Rio Bravo qWeek

Episode 194: Acute low back pain.  Future Dr. Ibrahim presents a clinical case to explain the essential points in the evaluation of back pain.  Future Dr. Redden adds information about differentiating between a back strain and more serious diseases such as cancer, and Dr. Arreaza shares information about returning to work after back strain.Written by Michael Ibrahim, MSIV. Editing and comments by Jordan Redden, MSIV, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Dr. Arreaza:Welcome back, everyone. Today's topic is one that every primary care provider, emergency doctor, and even specialist sees routinely: low back pain. It's so common that studies estimate up to 80% of adults will experience it at some point in their lives. But despite how frequent it is, the challenge is to identify which cases are benign and which demand urgent attention.Jordan:Exactly. Low back pain is usually self-limiting and mechanical in nature, but we always need to keep an eye out for the rare but serious causes: things like infection, malignancy, or neurological compromise. That's why a good history and physical exam are our best tools right out of the gate.Michael:And to ground this in a real example, let me introduce a patient we saw recently. John is a 45-year-old warehouse worker who came in with two weeks of lower back pain that started after lifting a 50-lb box. He describes it as a dull, aching pain that radiates from his lower back down the posterior left thigh into the calf. He says it gets worse with bending or coughing, but he feels better when lying flat. He also mentioned some numbness in his left foot, but he denies any bowel or bladder issues. His vitals are completely normal. On exam, he had lumbar paraspinal tenderness, a positive straight leg-raise at 40 degrees on the left and decreased sensation in the L5 dermatome, though reflexes were still intact.Dr. Arreaza:That's a great case. Let's take a minute and talk about the straight leg raise test. This is a bedside tool we use to assess for lumbar nerve root irritation often caused by a herniated disc. ***Here's how it works: the patient lies supine, and you slowly raise their straight leg. If pain radiates below the knee between 30° and 70°, that suggests radiculopathy, especially involving the L5 or S1 nerve roots. Pain at higher angles is more likely due to hamstring tightness or mechanical strain.Michael:Right. So, stepping back: what do we mean by "low back pain"? Broadly, it's any pain localized to the lumbar spine, but it's often classified by type or cause:Mechanical (like muscle strain or degenerative disc disease), Radicular (nerve root involvement), Referred pain (like from pelvic or abdominal organs), Inflammatory (AS), and Systemic or serious causes like infection or malignancy. Jordan:In John's case, we're thinking radicular pain, most likely from a herniated disc compressing the L5 nerve root. That's supported by the dermatomal numbness, the leg pain, and that positive straight leg test.Dr. Arreaza:Good reasoning. Now, anytime we see back pain, our brains should run a checklist for red flags. These help us pick up more serious causes that require urgent attention. Let's run through the red flags.Michael:Sure. For fracture, we think about major trauma or even minor trauma in the elderly, especially those with osteoporosis or on chronic steroids. Also, anyone over 70 years old.Jordan:Then we have infections, which could include things like discitis, vertebral osteomyelitis, or epidural abscess. Red flags include fever, IV drug use, recent surgery, or immunosuppression.Michael:Malignancy is another critical one, especially if there's a history of breast, prostate, lung, kidney, or thyroid cancer. Clues include unexplained weight loss, night pain, or constant pain not relieved by rest.Jordan:And don't forget about inflammatory back pain, like ankylosing spondylitis, which is often seen in younger patients with morning stiffness that lasts more than 30 minutes and improves with activity.Dr. Arreaza:And of course, we always rule out cauda equina syndrome: a surgical emergency. That's urinary retention or incontinence, saddle anesthesia, bilateral leg weakness, or fecal incontinence. Missing this diagnosis can be catastrophic.Michael:Thankfully, in John's case, we don't see any red flags. His presentation is classic for uncomplicated lumbar radiculopathy. But we must stay vigilant, because sometimes patients don't offer up key symptoms unless we ask directly.Jordan:And that's where associated symptoms help guide us. For example:Radicular symptoms like numbness or weakness follow dermatomal patterns. Constitutional symptoms like fever or weight loss raise red flags. Bladder/bowel changes or saddle anesthesia raise alarms for cauda equina. Pain that wakes patients up at night might point to malignancy. Dr. Arreaza:So when do we order labs or imaging?Michael:Not right away. For most patients with acute low back pain, imaging is not needed unless they have red flags. If infection is suspected, we'd get CBC, ESR, and CRP. For cancer, maybe PSA or serum protein electrophoresis. And if inflammatory back disease is suspected, HLA-B27 can be helpful.Jordan:Yes, imaging should be delayed for at least six weeks unless red flags or significant neurologic deficits are present. When we do image, MRI is our go-to especially for suspected radiculopathy or cauda equina. X-rays can help if we're thinking about fractures, but they won't show soft tissue or nerve root issues.Michael:In the example from our case, since the patient doesn't have red flags, we'd go with conservative management: start NSAIDs and recommend activity modification. As this is the acute setting, physical therapy would not be recommended.Jordan:For the acute phase, research shows no serious difference between those with PT and those without in the long term. However, physical therapy is really the cornerstone of management for chronic back pain. It's not just movement: it's education, body mechanics, and teaching patients how to move safely. And PT can actually reduce opioid use, imaging, and injections down the line for patient struggling with long term back pain.Dr. Arreaza:Yes, and PT is not one-size-fits-all. PT might include McKenzie exercises, manual therapy, postural retraining, or even neuromuscular re-education. The goal is always to build core stability, promote healthy movement patterns, and reduce fear of motion.Jordan:Let's take a minute to talk about the McKenzie Method, a physical therapy approach used to treat lumbar disc herniation by identifying a specific movement, (often spinal extension) that reduces or centralizes pain. A common exercise is the prone press-up, (cobra pose for yoga fans) where the patient lies face down and pushes the upper body upward while keeping the hips on the floor to relieve pressure on the disc. These exercises should be done carefully, ideally under professional guidance, and discontinued if symptoms worsen.Michael:For our case patient, our working diagnosis is mechanical low back pain with L5 radiculopathy. No imaging needed now, no red flags. We'll treat conservatively and educate him about proper lifting, staying active, and recovery expectations.Jordan:We also emphasized to him that bed rest isn't helpful. In fact, bed rest can make things worse. Keeping active while avoiding heavy lifting for now is key.Dr. Arreaza:Return-to-work recommendations should be individualized. For example, an office worker, positioning while working, or work hours may be able to return to work promptly. However, those with physically demanding jobs may need light duty or be off work.Ice: no evidence of benefit. Heat: may reduce pain and disability in pain of less than 3 months, although the benefit was small and short.And we should always teach safe lifting techniques: bend at the knees, keep the load close, avoid twisting. It's basic knowledge, but it is very effective in preventing recurrence.Jordan:Now, if a patient fails to improve after 6 weeks of conservative therapy, or if they develop new neurologic deficits, that's when we think about referral to spine specialists or surgical consultation.Michael:And as previously mentioned: in cases where back pain becomes chronic (lasting more than 12 weeks) a multidisciplinary approach works best. That can include:Physical therapy, Cognitive behavioral therapy (CBT) And sometimes pain management interventions. Jordan:We can't forget the psychological toll either. Chronic back pain is associated with depression, anxiety, and opioid dependence. Increased risk factors include obesity, smoking, sedentary lifestyle, and previous back injuries.Dr. Arreaza:Well said. So, let's summarize. Michael?Michael:Sure! Low back pain is common, and most cases are benign. But we have to know the red flags that point to serious pathology. A focused history and physical exam are more powerful than many people realize. And the first step in treatment is almost always conservative, with a strong emphasis on maintaining physical activity.Jordan:And don't underestimate the value of patient education. Helping patients understand their pain, set realistic expectations, and stay active is often just as important as the medications or therapies we offer.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478–491. https://doi.org/10.7326/0003-4819-147-7-200710020-00006Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102National Institute for Health and Care Excellence. (2020). Low back pain and sciatica in over 16s: Assessment and management (NICE Guideline No. NG59). https://www.nice.org.uk/guidance/ng59Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514–530. https://doi.org/10.7326/M16-2367UpToDate. (n.d.). Evaluation and treatment of low back pain in adults. Wolters Kluwer. https://www.uptodate.com (Access requires subscription)Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

Episode 193: Gestational Diabetes IntroJesica Mendoza (OMSIII) describes the pathophysiology of gestational diabetes and the right timing and method of screening for it. Dr. Arreaza adds insight into the need for culturally-appropriate foods, such as vegetables in Mexican cuisine.    Written by Jesica Mendoza, OMSIII, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.DefinitionGestational diabetes mellitus (GDM) is a condition that occurs to previously non-diabetic pregnant women, caused by glucose intolerance at around the 24th week of gestation. PathophysiologyGDM arises due to an underlying pancreatic beta cell dysfunction in the mother which leads to a decrease in the amount of insulin produced and thus leads to higher blood sugar levels during pregnancy. The placenta of the fetus will produce hPL (human placental lactogen) to ensure a steady supply of sugars to the fetus, creating an anti-insulin effect. However, hPL readily crosses the placental barrier causing the mothers insulin requirement to increase, when the mother's pancreas cannot increase production of insulin to that level needed to counter the effect of hPL they become diabetic, and this leads to gestational diabetes. So, basically the placenta is asking for more glucose for the baby and the mother's pancreas struggles to keep the glucose level within normal limits in the body of the mother. If left untreated, high levels of glucose in the mother can cause glucotoxicity in the mother.“Glucotoxicity” refers to the toxic effect of glucose. Glucose is the main fuel for cell functions, but when it is high in the bloodstream, it causes toxicity to organs. Prevalence of GDM.The CDC reports mean prevenance of GDM is 6.9%. In U.S. mothers the prevenance increased from 6.0% in 2016 to 8.3% in 2021. Many different factors have played a role in increasing gestational diabetes in American mothers, some of those being the ongoing obesity epidemic with excess body weight being a known risk factor for insulin resistance. Another being advanced maternal age (AMA) as more American women have children later in life their body becomes less sensitive to insulin and requires a higher insulin output on top of the insulin that is required for the fetus. The “American diet” is also something that has a big effect in diabetes development. With the increase of high-carb foods that are readily available, the diet of Americans has declined and is affecting the metabolic health of mothers as they carry and deliver their children. Despite ongoing awareness of GDM, 6% to 9% of pregnant women in the United States are diagnosed with gestational diabetes, and the prevalence continues to increase worldwide. It is estimated that in 2017 18.4 million pregnancies were affected by GDM in the world, which then continued to increase to 1 in 6 births to women with GDM in 2019. It was also found that women living in low-income communities were disproportionately affected due to limited healthcare access. Additionally, women with GDM had a 1.4-fold increase in likelihood of undergoing a c-section, with 15% increase in risk of requiring blood transfusion. Screening for GDMGestational diabetes is screened between the 24th to 28th week of gestation in all women without known pregestational diabetes. In women who have high-risk for GDM the screening occurs during the first trimester, these women usually have at least one of the following: BMI > 30, prior history of GDM, known impaired glucose metabolism, and/or a strong family history of diabetes. The screening during the first trimester is to detect “pregestational diabetes” because we have to keep a good glycemic control to improve outcomes of pregnancy. So, if it's positive, you start treatment immediately. If these women are found to have a normal glucose, they repeat the testing again as done normally, at 24-28 weeks of gestation. How do we screen?The screening itself consists of two types of approaches. The two-step approach includes a 50-gram oral glucose tolerance test (OGTT), where blood glucose is measured in an hour and if it is below 140 they are considered to not have GDM, however if the reading is greater than 140 they must then do a 3-hour, 100g oral glucose tolerance test. The 3-hour OGTT includes measuring the blood sugars at Fasting which should be less than 95, at 1 hour at less than 180, at 2 hours at less than 155, and at 3 hours at less than 140. If 2 or more of these values exceed the threshold the patient is diagnosed with gestational diabetes mellitus. The one-step approach includes 75g after an overnight fast. Blood glucose is measured while fasting which should be less than 92, at 1 hour less than 180 and at 2 hours less than 153. If any one of these values is exceeded, the patient is diagnosed with GDM.If the mother is found to be GDM positive during pregnancy she will also need continued screening post-partum to monitor for any development of overt diabetes. The testing is usually 75g 2-hour OGTT at 6-12 weeks postpartum. If this testing is normal, then they are tested using HbA1c every 3 years. If the post-partum testing shows pre-diabetes, annual testing is recommended using HbA1c measurements. Maternal complications Women with GDM are at an increased risk for future cardiovascular disease, T2DM, and chronic kidney disease. GDM is also associated with increased likelihood of developing pre-eclampsia following delivery. Pre-eclampsia is a complication seen in pregnancy characterized by high blood pressure, proteinuria, vision changes, and liver involvement (high LFTs). Pre-eclampsia can then progress to eclampsia or HELLP syndrome, both of which can include end organ damage. Additionally, she can develop polyhydramnios which leads to overstretching of the uterus and can induce pre-term labor, placental abruption, and or uterine atony, all of which additionally put the mother at increased risk for c-section. All of these maternal complications that stem from GDM lead to complications and extended hospitalization. Child's complications Although there is an increased set of risks for the mother, the neonate can also develop a variety of risks due to the increased glucose while in utero. While the fetus is growing, the placenta is the source of nutrition for the fetus. As the levels of glucose in the mother increase so does the amount of glucose filtered through the placenta and into the fetal circulation. Over time the glucose leads to oxidative stress and inflammation with activation of TGF-b which leads to fibroblast activation and fibrosis of the placenta. This fibrosis decreases the nutrient and oxygen exchange for the fetus. As the fetus attempts to grow in this restrictive environment its development is affected. The fetus can develop IUGR (intrauterine growth restriction) leading to a small for gestation age newborn which can then lead to another set of complications. The low oxygen environment can lead to increased EPO production and polycythemia at birth which can then lead to increased clotting that can travel to the newborn brain. Newborns can also be born with fetal acidosis due to the anerobic metabolism and lactic acid buildup in fetal tissues which can cause fetal encephalopathy leading to cerebral palsy and developmental delay. And the most severe of newborn complications to gestational diabetes can lead to fetal demise. Furthermore, the increase of glucose can also lead to macrosomia in the infant which can often lead to a traumatic delivery and delivery complications such as shoulder dystocia and brachial plexus injury. Brachial plexus injury sometimes resolves without sequela, but other times can lead to permanent weakness or paralysis of the affected arm. The baby can be born too small or too big.Additionally, once the fetus is born the cutting of the umbilical cord leads to a rapid deceleration in blood glucose in the fetal circulation and hypoglycemic episodes can occur, that often lead to NICU admission. The insulin that is created by the fetus in utero to accommodate the large quantities of glucose is known to affect lung maturation as well. The insulin produced inhibits surfactant production in the fetus. Upon birth some of the newborns also have to be placed on PEEP for ventilation and some children require treatment with surfactant to prevent alveolar collapse and/or progression to NRDS created by the low surfactant levels. Additionally, neonates who are macrosomic, which is usually seen in GDM mothers, are larger and stronger and when put on PEEP to help increase ventilation the newborn's stronger respiratory effort can lead to higher pulmonary pressures and barotrauma such as neonatal pneumothorax.Long term complications to the child of a mother with GDM also occur. As the child grows, they are also at an increased risk for developing early onset obesity because of the increased adipose storage triggered by the increase in insulin in response to the high glucose in utero. This then can lead to a higher chance of developing type 2 diabetes mellitus in the child. With diabetes, also comes an increase in cardiovascular risk as the child ages and becomes an adult. The effects of GDM go beyond the fetal life but continue through adulthood.What can be done?Gestational Diabetes Mellitus has many severe and lifelong consequences for both the mother and the child and prevention of GDM would help enhance the quality of life of both. Many of the ways to prevent GDM complications include patient education and dietary modifications with a diet rich in whole grains, fruits, vegetables and lean proteins. Benefits of some vegetables in the Mexican cuisine that may be beneficial: Nopales, Chayote, and Jicama. Those are good alternatives for highly processed carbs.Mothers are usually offered nutritional counseling to help them develop a tailored eating plan. This and 30 minutes of moderate exercise daily is recommended to increase insulin sensitivity and lower the post-prandial glucose levels. If within 2 weeks of implementing lifestyle changes alone the glucose measurements remain high, then medications like insulin can be put onboard to manage the GDM. If they require insulin, I think it is time to refer to a higher level of care, if available, high risk OB clinic.Conclusion: Now we conclude episode number ###, “[TITLE].” [summary here]. _____________________References:Eades CE, Burrows KA, Andreeva R, Stansfield DR, Evans JM. Prevalence of gestational diabetes in the United States and Canada: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2024 Mar 15;24(1):204. doi: 10.1186/s12884-024-06378-2. PMID: 38491497; PMCID: PMC10941381. https://pubmed.ncbi.nlm.nih.gov/38491497/QuickStats: Percentage of Mothers with Gestational Diabetes,* by Maternal Age — National Vital Statistics System, United States, 2016 and 2021. Weekly / January 6, 2023 / 72(1);16. https://www.cdc.gov/mmwr/volumes/72/wr/mm7201a4.htm?utmAkinyemi OA, Weldeslase TA, Odusanya E, Akueme NT, Omokhodion OV, Fasokun ME, Makanjuola D, Fakorede M, Ogundipe T. Profiles and Outcomes of Women with Gestational Diabetes Mellitus in the United States. Cureus. 2023 Jul 4;15(7):e41360. doi: 10.7759/cureus.41360. PMID: 37546039; PMCID: PMC10399637. https://pmc.ncbi.nlm.nih.gov/articles/PMC10399637/?utmPerlman, J. M. (2006). Summary proceedings from the neurology group on hypoxic-ischemic encephalopathy. Pediatrics, 117(3), S28–S33.DOI: 10.1542/peds.2005-0620C.Low, J. A. (1997). Intrapartum fetal asphyxia: definition, diagnosis, and classification. American Journal of Obstetrics and Gynecology, 176(5), 957–959.DOI: 10.1016/S0002-9378(97)70609-0.Hallman, M., Gluck, L., & Liggins, G. (1985). Role of insulin in delaying surfactant production in the fetal lung. Journal of Pediatrics, 106(5), 786–790.DOI: 10.1016/S0022-3476(85)80227-0.Sweet, D. G., Carnielli, V., Greisen, G., et al. (2019). European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update. Neonatology, 115(4), 432–450.DOI: 10.1159/000499361.Raju, T. N. K., et al. (1999). Respiratory distress in term infants: when to suspect surfactant deficiency. Pediatrics, 103(5), 903–909.DOI: 10.1542/peds.103.5.903.Burns, C. M., Rutherford, M. A., Boardman, J. P., & Cowan, F. M. (2008). Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics, 122(1), 65–74.DOI: 10.1542/peds.2007-2822.Dabelea, D., et al. (2000). Long-term impact of maternal diabetes on obesity in childhood. Diabetes Care, 23(10), 1534–1540.DOI: 10.2337/diacare.23.10.1534.Dashe, J. S., et al. (2002). "Hydramnios: Etiology and outcome." Obstetrics & Gynecology, 100(5 Pt 1), 957–962.DOI: 10.1016/S0029-7844(02)02279-6.Long-term cost-effectiveness of implementing a lifestyle intervention during pregnancy to prevent gestational diabetes mellitus: a decision-analytic modelling study. Diabetologia.American College of Obstetricians and Gynecologists. (2018). Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstetrics & Gynecology, 131(2), e49–e64. https://doi.org/10.1097/AOG.0000000000002501Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

Episode 192: ADHD Treatment.  Jordan Redden (MSIV) explains the treatment of ADHD. Dr. Bustamante adds input about pharmacologic and non-pharmacologic treatments. Dr. Arreaza shares the how stimulants were discovered as the treatment for ADHD. Written by Jordan Redden, MSIV, Ross University School of Medicine. Comments and edits by Isabelo Bustamante, MD, and Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.ADHD is a chronic neurodevelopmental condition characterized by inattention, impulsivity, and/or hyperactivity. While it's often diagnosed in childhood, symptoms can persist well in adulthood. The treatment for ADHD is multifaceted. It often includes medication, behavioral therapy, environmental modifications, and sometimes educational interventions which are especially effective in younger patients. Ongoing evaluation is needed during treatment. Treatment needs adjustments over time.Starting with medications: Stimulants are the most well-studied and effective pharmacologic treatment for ADHD. These include methylphenidate-based medications such as Ritalin, Concerta, and Focalin, and amphetamine-based options, like Adderall, Vyvanse, and Dexedrine. Discovery of stimulants for ADHD> Dr. Charles Bradley discovered stimulants as the treatment for ADHD around 1937. ADHD did not have a name at that time, but it was known that some children had behavioral problems related to poor attention and inability to control their impulses, but they were still intelligent. Dr. Bradley was a psychiatrist who was working in the Bradley Hospital (Rhode Island), he was studying these children and, as part of his experiments, they developed severe headaches. He gave “Benzedrine” (a decongestant) to his pediatric patients to treat severe headaches, and he discovered that Benzedrine improved academic performance and interest in school and improved disruptive behavior in some children.How do stimulants work.Stimulants work primarily by increasing dopamine and norepinephrine levels in the brain, which helps improve focus, attention span, and impulse control. They typically show a rapid onset of action and can lead to noticeable improvements within the first few days of use. Dosing is individualized and should start low with gradual titration. Side effects can include reduced appetite, insomnia, headaches, increased heart rate, and emotional lability.Types of stimulants. Stimulants come as short acting and long acting. They can come as a tablet, liquid, patch, or orally disintegrating tablet. After the discovery of Benzedrine as a possible treatment for ADHD, more research was done over the years, and Ritalin became the first FDA-approved medication for ADHD (1955). The list of medications may seem overwhelming, but there are only two types of stimulants used to treat ADHD: methylphenidate and amphetamine. Long-acting stimulant medications are often preferred for their consistent symptom control and lower potential for misuse. Vyvanse (lis-dexa-mfetamine) is a widely used long-acting amphetamine-based option. As a prodrug, it remains inactive until metabolized in the body, which results in a smoother onset and offset of action and may reduce the risk of abuse. This extended duration of effect can help patients maintain focus and regulate impulses throughout the day without the peaks and crashes sometimes seen with shorter-acting formulations. Of note, Vyvanse is also approved for Binge Eating Disorder. Many of these medications are Schedule II controlled substances, so to prescribe them you need a DEA license. Other long-acting options include Concerta, an extended-release methylphenidate, as well as extended-release versions of Adderall and Focalin. These are especially helpful for school-aged children who benefit from once-daily dosing, and for adults who need sustained attention during work or academic activities. The choice between short- and long-acting stimulants depends on individual response, side effect tolerance, and daily routine.For patients who cannot tolerate stimulants, or for those with contraindications such as a history of substance misuse or certain cardiac conditions, non-stimulant medications are an alternative. One of the most used is atomoxetine, which inhibits the presynaptic norepinephrine transporter (NET). This leads to increased levels of norepinephrine (and to a lesser extent dopamine). Guanfacine or clonidine are alpha-2A adrenergic receptor agonists that lead to reduced sympathetic outflow and enhanced prefrontal cortical function, improving attention and impulse control. These alpha agonists are particularly useful in younger children with significant hyperactivity or sleep disturbances.Non-pharmacologic treatments.Behavioral therapy before age 6 is the first choice, after that, medications are more effective than BH only, and as adults again you use CBT.Medication is often just one part of a broader treatment plan. Behavioral therapy, especially in children, plays a critical role. Parent-training programs, positive reinforcement systems, and structured routines can significantly improve functioning. And for adolescents and adults, cognitive-behavioral therapy (CBT) is particularly helpful. CBT can address issues like procrastination, time management, emotional regulation, and self-esteem which are areas that medication doesn't always touch.Using medications for ADHD can be faced with resistance by parents, and even children. There is stigma and misconceptions about mental health, there may be concerns about side effects, fear of addiction, negative past experiences, and some parents prefer to treat ADHD the “natural” way without medications or only with supplements. All those concerns are valid. Starting a medication for ADHD is the first line of treatment in children who are 6 years and older, but it requires a shared decision with parents and patients. Cardiac side effects are possible with stimulants. EKG may be needed before starting stimulants, but it is not required. Get a personal and family cardiac history, including a solid ROS. Benefits include control of current condition and treating comorbid conditions.The presentation of ADHD changes as the person goes through different stages of life. For example, you may have severe hyperactivity in your school years, but that hyperactivity improves during adolescence and impulsivity worsens. It varies among sexes too. Women tend to present as inattentive, and men tend to be more hyperactive. ADHD is often underdiagnosed in adults, yet it can significantly impact job performance, relationships, and mental health. In adults, we often use long-acting stimulants to minimize the potential for misuse. And psychotherapy, particularly CBT or executive functioning coaching, can be life-changing when combined with pharmacologic treatment. There are several populations where treatment must be tailored carefully such as pregnant patients, individuals with co-occurring anxiety or depression, and those with a history of substance use. For example, atomoxetine may be preferred in patients with a history of substance misuse. And in children with coexisting oppositional defiant disorder, combined behavioral and pharmacologic therapy is usually more effective than either approach alone.Comorbid conditions.Depression and anxiety can be comorbid, and they can also mimic ADHD. Consult your DSM-5 to clarify what you are treating, ADHD vs depression/anxiety.Treatment goes beyond the clinic. For school-aged children, we often work closely with schools to implement 504 plans or Individualized Education Programs (IEPs) that provide classroom accommodations. Adults may also benefit from workplace strategies like structured schedules, noise-reducing headphones, or even coaching support. Ongoing monitoring is absolutely essential. We assess side effects of medication, adherence, and symptom control. ***In children, we also monitor growth and sleep patterns. We often use validated rating scales, like the Vanderbilt questionnaire for children 6–12 (collect answers from two settings) or Conners questionnaires (collect from clinician, parents and teachers), to track progress. And shared decision-making with patients and families is key throughout the treatment process.To summarize, ADHD is a chronic but manageable condition. Effective treatment usually involves a combination of medication and behavioral interventions, tailored to the individual's needs. And early diagnosis and treatment can significantly improve quality of life academically, socially, and emotionally.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text rev. (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022. CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder). Understanding ADHD. Accessed May 2025. https://chadd.org National Institute for Health and Care Excellence (NICE). Attention Deficit Hyperactivity Disorder: Diagnosis and Management. NICE guideline [NG87]. Updated March 2018. Accessed May 2025. https://www.nice.org.uk/guidance/ng87 Pliszka SR; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894–921. doi:10.1097/chi.0b013e318054e724 Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4):e20192528. doi:10.1542/peds.2019-2528 Texas Children's Hospital. ADHD Provider Toolkit. Baylor College of Medicine. Accessed May 2025. https://www.bcm.edu Wolraich ML, Hagan JF Jr, Allan C, et al. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. UpToDate. Published 2024. Accessed May 2025.https://www.uptodate.comThe History of ADHD and Its Treatments, https://www.additudemag.com/history-of-adhd/Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

Episode 191: Diagnosis of ADHDFuture Dr. Granat explains how to diagnose Attention Deficit Hyperactivity Disorder. She explained the influence of social media in increasing awareness of ADHD. Dr. Arreaza added input about the validated tools for ADHD diagnosis and highlighted the importance of expert evaluation for the diagnosis of this disorder.  Written by Yen Stephanie Granat, MSIV. Ross University School of Medicine. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Steph: I love podcasts—many of us do—and if you, like me, spend any amount of your leisure time listening to podcasts, perusing the news, or scrolling social media; you've likely noticed an alarming trend in the number of discussions we seem to be having about ADHD. It has grown into a very hot topic over the past couple of years, and for some of us, it seems to have even begun sneaking into our “recommended videos” and across our news feeds! Naturally, for the average person this can spur questions like:“Do I have ADHD? Do we all have it? How can I be certain either way, and what do I do if I find myself relating to most of the symptoms that I'm seeing discussed?”Granted that there is a whirlpool of information circulating around this hot topic, I was hoping to spend a bit of time clearly outlining the disorder for anyone finding themselves curious. I believe that can best be achieved through outlining a clear, concise, and easy-to-understand definition of what ADHD is; outlining what it is not; and helping people sift through the fact and the fiction. As with many important things we see discussed on the internet, we're seeing is that there is much more fiction than fact. Arreaza: I'm so glad you chose this topic! I think it is challenging to find reliable information about complex topics like ADHD. Tik Tok, Instagram and Facebook are great social media platforms, but we have to admit that fake news have spread like a fire in recent years. So, if you, listener, are looking for reliable information about ADHD, you are in the right place. With ADHD, there aren't any obvious indicators, or rapid tests someone can take at home to give themselves a reliable “yes” or “no” test result. People's concerns with ADHD are valid, and important to address, so we will discuss the steps to identify some of signs and symptoms they are seeing on TikTok or their favorite podcaster. Steph: Healthcare anxiety is a vital factor to consider when it comes to large cultural conversations around our minds and bodies; so, I hope to sweep away some of the misconceptions and misinformation floating around about ADHD. In doing so, I want to help alleviate any stress or confusion for anyone finding themselves wondering if ADHD is impacting their lives! We might even be able to more accurately navigate these kinds of “viral topics” (for lack of a better term) next time we see them popping up on our news feeds.Arreaza: The first thing I want to say about ADHD is “the crumpled paper sign.”Steph: What is that?Arreaza: It is an undescribed sign of ADHD, I have noticed it, and it is anecdotal, not evidence based. When I walk into a room to see a pediatric patient, I have noticed that when the paper that covers the examination table is crumpled, most of the times it is because the pediatric patient is very active. Then I proceed to ask questions about ADHD and I have been right many times about the diagnosis. So, just an anecdote, remember the crumpled paper sign.  Steph: When you have patients coming to you asking for stimulants because they think they have ADHD, hopefully, after today, you can be better prepared to help those patients. So, for the average person—anyone wanting to be sure if this diagnosis applies to them—how can we really know?”Arreaza: So, let's talk about diagnosis.Steph: Yes, the clearest information we have is the DSM-5, which defines these disorders, as well as outlines the specific criteria (or “checkpoints”) one needs to meet to be able to have a formal diagnosis. However, this manual is best utilized by a trained professional—in this case, a physician—who can properly assess your signs and symptoms and give you a clear answer. Steph: ADHD stands for Attention Deficit Hyperactivity Disorder. It is among the most common neurodevelopmental disorders of childhood. That is not to say it does not affect adult—it does—and because it can be easy to miss, it's very possible for someone to have ADHD without knowing. Arreaza: I recently learned that ADD is an outdated term. Some people with ADHD do not have hyperactivity but the term still applies to them. Steph: Yes, there are multiple types that I will explain in just a bit. But overall the disorder is most simply characterized by a significant degree of difficulty in paying attention, controlling impulsive behaviors, or in being overly active in a way that the individual finds very difficult to control. (CDC)Arreaza: How common is ADHD?Steph: The most recently published data from The CDC estimates that 7 million (11.4%) of U.S. children between the ages of 3 and 17 have been diagnosed with ADHD. For adults, it is estimated that there are 15.5 million (6%) individuals in the U.S. who currently have ADHD. Arreaza: I suspected it would be more than that. [Anecdote about Boy Scout camp]. Steph: I totally agree. With short videos on TikTok, or paying high subscription fees to skip ads, it feels like as a society we all have a shorter attention span. Arreaza: Even churches are adapting to the new generation of believers: Shorter sermons and shorter lessons.Steph: When it comes to better understanding these numbers, it's also important to know that there are three distinct presentations of ADHD recognized by The CDC and The World Health Organization. Arreaza: The DSM-5 TR no longer uses the word “subtypes” for ADHD. Instead, it uses the word "presentation" to describe the different ways that ADHD may manifest in a person. That reminded me to update my old DSM-5 manual and I ordered it while reading today about ADHD. This means people with ADHD are no longer diagnosed as having a “subtype”. Instead, they are diagnosed with ADHD and a certain “presentation” of symptoms.Steph: These presentations are:Inattentive TypePeople often have difficulty planning or completing tasksThey find themselves easily distracted (especially when it comes to longer, focus-oriented tasks)They can often forget details and specifics, even with things that are part of their daily routineThis used to be referred to as “ADD” (you'll notice the absence of an “H”, segue).Hyperactive-Impulsive TypePeople often have a sense of intense “restlessness”, noticeable even in calm environments.They tend to be noticeably more talkative, and might often be seen interrupting others, or finishing their sentences.They find significant difficulty in being still for extended periods. Because of this, they are often unable to sit through a movie or class time, without fidgeting or getting up and moving around.With this category of ADHD, we often see an impulsiveness that unwittingly leads to risky behavior. Because of this, accidents and bodily injury are more common in individuals with this type of ADHD.Combined TypeThese are individuals who exhibit symptoms from both “Inattentive” and “Hyperactive-Impulsive” ADHD equally.Some listeners might have noticed that the categories are quite different, meaning that ADHD presents in different ways depending on the person! Two people who have ADHD can be in the same room and have vastly different presentations, whilst still having many of the same types of challenges. You also might have noticed what makes the discussion so interesting to the general public, which is also the thing that makes speaking to a professional to get formally tested so important:The diagnostic criteria rely heavily on patterns of behavior, or external variables; rather than on how a person might feel, or certain measurements taken from lab tests.Arreaza: Diagnosing ADHD requires evaluation by a professional who is properly trained for this. Fortunately, we have tools to assist with the diagnosis. The attention deficit must be noted in more than one major setting (e.g., social, academic, or occupational), that's why the information should be gathered from multiple sources, including parents, teachers, and other caregivers, using validated tools, such as:The Neuropsychiatric EEG-Based ADHD Assessment Aid (NEBA), recommended by the American Academy of NeurologyThe Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) and the Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS), recommended by the Society for Developmental and Behavioral Pediatrics.For adults: The validated rating scales include the Adult ADHD Self-Report Scale (ASRS) and the Conners Adult ADHD Rating Scales (CAARS).Steph: This is important because nearly everyone alive has experienced several, if not most, of these behavioral patterns at least once. Whether or not an individual has ADHD, I'm certain we could all think of moments we've had great difficulty focusing or sitting still. Perhaps some of us are incredibly forgetful, or act more impulsively than the average person might find typical. Getting a professional diagnosis is important because it is in skillfully assessing “the bigger picture” of a person's life, or their patterns of behavior, that a skilled physician, who understands the nuances and complexities in these disorders, can properly tell each of us whether we have ADHD, or not.Essentially, most of us could stand to use a bit more focus these days, but far fewer of us would meaningfully benefit from the kinds of treatments and therapies needed by individuals with ADHD to live healthier, more happy and regulated lives.Arreaza: I had a mother who came to discuss the results of the Vanderbilt Questionnaire. I think she left a little disappointed when she heard that, based on the responses from her and the teacher, her son did not have ADHD. Some kids may have behaviors such as being distracted during a meeting, forgetting about homework or having a lot of energy, but that does NOT mean necessarily that they have ADHD, right?Steph: Absolutely! The important thing to remember here is that these patterns of behavior outlined in the DSM-5 are merely an external gauge for a neurological reality. What the science is showing us is that the brains of people with ADHD are wired differently than that of the more “neurotypical” brain. Much like a check engine light would serve as a signal to a driver that something under the hood needs attention; these patterns of behavior, when they begin impeding our day to day lives, might tell us that it's time to see a professional (whether it be an auto mechanic or a trained physician). I think we all know someone who drives with their check engine light and not a care in the world. Arreaza: How serious/urgent is ADHD? Why should we care to make the diagnosis?Steph: Although we've yet to see anyone incur harm solely from having ADHD, it does lead to quite a range of more serious issues, some of which might prove more urgent. In the cases of ADHD, specifically, what we know is that there is a notable degree of dysregulation in some key neurotransmitters, like dopamine and norepinephrine. More plainly, what we are seeing in the brains of people with ADHD is a disruption, or alteration, of some of the brain's key chemicals.These neurotransmitters are largely responsible for much-needed processes like Motivation, Satisfaction, Focus, Impulse control, even things like energy and feelings of happiness. Many of these things serve as “fuel” for our day-to-day lives; things we'd call our “executive function”.  These are also what prove dysfunctional in those struggling with ADHD. It is in this sense that we might be able to bridge a meaningful gap between ADHD as being seen through patterns of behaviorthat signal a real, neurological reality.Steph: We often hear of the brain referenced as a kind of supercomputer. A more accurate assessment might be that the brain is more of a network of interconnected computers that run different processes and require continual communication with one another for our brain to function properly and seamlessly. What we're seeing in members of the population with this diagnosis, is a significant disruption in these lines of communication. Although this is a very broad oversimplification, for the purposes of our metaphor is to think of it like our brain chemicals getting caught in a traffic jam, or parts of our brain attempting to communicate to one another with poor cell signal. Arreaza: Making the diagnosis is critical to start treatment because having that level of dysfunction sounds like having a very difficult life.Steph: Yeah! I think that's why this conversation matters so much. There's a sense of urgency there, because much of life is, in fact, boring. Things like paying bills, exercising and eating well, work and school—these are all things that are vital to health and wellbeing in day-to-day life; and for the more neurotypical brain, these things might prove occasionally challenging. Yet, they are still doable. For those with ADHD however, this goes far beyond mere boredom or “laziness” (which proves to be a trigger term for many—more on that in just a bit).For folks listening, I wanted to offer some statistics that show why this is such a big concern for the public, whether one has a formal ADHD diagnosis or not. The facts are figures are:Children with ADHD are more than five times as likely as the child without ADHD to have major depression.A significant increase in the prevalence of anxiety is seen in ADHD patients, ranging from 15% to 35%, when accounting for overlap in symptoms.There are significant correlations in youth diagnosed with ADHD, and those diagnosed with what are known as “externalizing disorders”. These are things like Conduct Disorder, Disruptive Mood Dysregulation Disorder, and Oppositional Defiant Disorder.We are seeing a much higher rate of academic problems in kids who have ADHD, like reading disorder, impaired verbal skills, and visual motor integration.We're finding that many, if not most, of these connections are being made after diagnosis. In the case of the “internalized disorders”, like depression and anxiety, we're often seeing years between ADHD diagnoses and the diagnoses of major depressive disorder or anxiety disorders. Given this framework, much of the data is theorized to point towards what we call “negative environmental circumstances”, otherwise known as “ADHD-related demoralization”.For children, this often looks like struggling with sitting still during class, failing to get homework done (because they forgot, or couldn't focus on the tasks at hand), and struggling to focus their attention on what their teacher is saying during lecture. These things often lead to bad grades, discipline or forced time sitting still in detention. This can be seen in more problems at home, with children being disciplined often for behavior that they struggle immensely to control.For adults, this can mean forgetting to pay your bills, missing work meetings, having trouble making appointments, or having difficulty with day-to-day tasks, really anything that requires sustained attention. We often see adults with ADHD who are chasing normalcy with caffeine addictions or even struggling with substance use. Arreaza: Substance use disorder actually can be a way for some people living with ADHD to self-treat their symptoms. Steph: These differences between the individual's experience and the world around them can lead to really powerful feelings of failure or inadequacy. They can affect your social life, your sense of community, and even further limit your capacity to seek help.Literacy in these things is so important—not just for the individual who feels that they may have ADHD, but also for those who are likely to encounter people with ADHD in their own lives. Understanding why some of these patterns pop up, even those who might not have a formal diagnosis, can go a long way to properly approaching these behaviors with success and with empathy.Arreaza: Learning about ADHD is fundamental for primary care doctors. We talked about the high prevalence and the influence of the media in increasing awareness and sometimes increasing public panic. So, we have to be prepared to diagnose or undiagnosed ADHD. Steph: Whether we're the physicians in the room, or the patient in the chair, I think it's important to have a clear understanding of what ADHD is and how it can affect lives. Thanks for listening, I hope we were able to teach you a little more about ADHD. ______________Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _______________References:NICHQ-Vanderbilt-Assessment-Scales PDF: https://nichq.org/wp-content/uploads/2024/09/NICHQ-Vanderbilt-Assessment-Scales.pdfADHD: The facts. ADDA - Attention Deficit Disorder Association. (2023, January 11). https://add.org/adhd-facts/American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, Inc. https://doi.org/10.1176/appi.books.9780890425596.Gnanavel S, Sharma P, Kaushal P, Hussain S. Attention deficit hyperactivity disorder and comorbidity: A review of literature. World J Clin Cases. 2019 Sep 6;7(17):2420-2426. doi: 10.12998/wjcc.v7.i17.2420. PMID: 31559278; PMCID: PMC6745333.Staley BS, Robinson LR, Claussen AH, et al. Attention-Deficit/Hyperactivity Disorder Diagnosis, Treatment and Telehealth Use in Adults — National Center for Health Statistics Rapid Surveys System, United States, October – November 2023. CDC.Gov, MMWR Morb Mortal Wkly Rep 2024;73:890-895.Danielson ML, Claussen AH, Arifkhanova A, Gonzalez MG, Surman C. Who Provides Outpatient Clinical Care for Adults With ADHD? Analysis of Healthcare Claims by Types of Providers Among Private Insurance and Medicaid Enrollees, 2021. J Atten Disord. 2024 Jun;28(8):1225-1235. doi: 10.1177/10870547241238899. Epub 2024 Mar 18. PMID: 38500256; PMCID: PMC11108736. https://pubmed.ncbi.nlm.nih.gov/38500256/Mattingly G, Childress A. Clinical implications of attention-deficit/hyperactivity disorder in adults: what new data on diagnostic trends, treatment barriers, and telehealth utilization tell us. J Clin Psychiatry. 2024;85(4):24com15592. https://www.psychiatrist.com/jcp/implications-adult-adhd-diagnostic-trends-treatment-barriers-telehealth/Didier J. My four kids and I all have ADHD. We need telehealth options. STAT News. Published October 10, 2024. Accessed October 10, 2024. https://www.statnews.com/2024/10/10/adhd-medication-shortage-telehealth-dea-congress/.Hong J, Mattingly GW, Carbray JA, Cooper TV, Findling RL, Gignac M, Glaser PE, Lopez FA, Maletic V, McIntyre RS, Robb AS, Singh MK, Stein MA, Stahl SM. Expert consensus statement for telepsychiatry and attention-deficit hyperactivity disorder. CNS Spectr. 2024 May 20:1-12. doi: 10.1017/S1092852924000208. Epub ahead of print. PMID: 38764385. https://pubmed.ncbi.nlm.nih.gov/38764385/Gabor Maté: The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture. (2022). Youtube. Retrieved April 27, 2025, from https://www.youtube.com/watch?v=ttu21ViNiC0. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 190: Measles BasicsFuture Dr. Kapur explained the basics of measles, including the pathophysiology, diagnosis and management of this disease. Dr. Schlaerth added information about SPPE and told interesting stories of measles. Dr. Arreaza explained some statistics and histed the episode.  Written by Ashna Kapur MS4 Ross University School of Medicine. Comments by Katherine Schlaerth, MD, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.According to the CDC, as of April 24, 2025, a total of 884 confirmed measles cases were reported by 30 states, including California, and notably Texas. This is already three times more cases than 2024. There are 3 confirmed deaths so far in the US. What is measles?Measles is a disease that's been around for centuries, nearly eradicated, yet still lingers in parts of the world due to declining vaccination rates. Let's refresh our knowledge about its epidemiology, clinical features, diagnosis, management, and most importantly — prevention.Definition.Measles, also known as rubeola, is an acute viral respiratory illness caused by the measles virus. It's a single-stranded, negative-sense RNA virus belonging to the Paramyxoviridae family. It's extremely contagious with a transmission rate of up to 90% among non-immune individuals when exposed to an infected person.EpidemiologyBefore the introduction of the measles vaccine in 1963, nearly every child got measles by the time they were 15 years old. With the introduction of vaccination, cases and deaths caused by measles significantly declined. For example, in 2018, over 140,000 deaths were reported in the whole world, mostly among children under the age of 5.Measles is still a common disease in many countries, including in Europe, the Middle East, Asia, and Africa. Measles outbreaks have been reported recently in the UK, Israel, India, Thailand, Vietnam, Japan, Ukraine, the Philippines, and more recently in the US. So, let's take prevention seriously to avoid the spread of this disease here at home and abroad. How do we get measles, Ashna?Mode of Transmission:● Air: Spread primarily through respiratory droplets.● Surfaces: The virus remains viable on surfaces or in the air for up to 2 hours. (so, if a person with measles was in a room and you enter the same room within 2 hours, you may still get measles)● Other people: Patients are contagious from 4 days before until 4 days after the rash appears.PathophysiologyThe measles virus first infects the respiratory epithelium, replicates, and then disseminates to the lymphatic system.It leads to transient but profound immunosuppression, which is why secondary infections are common. It affects the skin, respiratory tract, and sometimes the brain, leading to complications like pneumonia or encephalitis.Clinical PresentationThe classic presentation of measles can be remembered in three C's:● Cough● Coryza (runny nose)● ConjunctivitisCourse of Disease (3 Phases):1. Prodromal Phase (2-4 days)○ High fever (can peak at 104°F or 40°C)○ The 3 C's○ Koplik spots: Small white lesions on the buccal mucosa.2. Exanthem Phase○ Maculopapular rash begins on the face (especially around the hairline), then spreads from head to toe. The rash typically combines into 1 big mass as it spreads, and the fever often persists during the rash.3. Recovery Phase○ Rash fades in the same order it appeared.○ Patients remain at risk for complications during and after rash resolution.Complications:● Pneumonia (most common cause of death in children)● Otitis media (most common overall complication)● Encephalitis (can lead to permanent neurologic sequelae)● Subacute sclerosing panencephalitis (SSPE): A rare, fatal, degenerative CNS disease that can occur years after measles infection.High-risk groups for severe disease include:● Infants and young children● Pregnant women● Immunocompromised individualsDiagnosisClinical diagnosis is sufficient if classic symptoms are present, especially in outbreak settings.Ashna: Laboratory confirmation:● Measles-specific IgM antibodies detected by serology.● RT-PCR from nasopharyngeal, throat, or urine samples.Notify public health authorities immediately upon suspicion or diagnosis of measles to limit spread. ManagementThere is no specific antiviral treatment for measles. Management is supportive:● Hydration (by mouth and only IV in case of severe dehydration)● Antipyretics (e.g., acetaminophen) for fever● Oxygen if hypoxicVitamin A supplementation:● Recommended for all children with acute measles, particularly in areas with high vitamin A deficiency. It has shown to reduce morbidity and mortality.Hospitalization may be necessary for:● Severe respiratory compromise● Dehydration● Neurologic complicationsPrevention: We live in perilous times and vaccination is under scrutiny right now. Before the measles vaccine, about 48,000 people were hospitalized and 400–500 people died in the United States every year. Measles was declared eradicated in the US in 2000, but the vaccination coverage is no longer 95%. How do we prevent measles?Vaccination is the cornerstone of prevention.● MMR vaccine (Measles, Mumps, Rubella):○ First dose at 12-15 months of age.○ Second dose at 4-6 years of age.○ 97% effective after 2 doses.The Advisory Committee on Immunization Practices (ACIP) has noted that febrile seizures typically occur 7 to 12 days after vaccination with MMR, with an estimated incidence of 3.3 to 8.7 per 10,000 doses. The Centers for Disease Control and Prevention (CDC) states that febrile seizures following MMR vaccination are rare and not associated with any long-term effects. The risk of febrile seizures is higher when the MMR vaccine is administered as part of the combined MMRV (measles, mumps, rubella, and varicella) vaccine compared to the MMR vaccine alone.Post-exposure prophylaxis:● MMR vaccine within 72 hours of exposure (if possible).● Immunoglobulin within 6 days for high-risk individuals (e.g., infants, pregnant women, immunocompromised).Herd immunity requires at least 95% vaccination coverage to prevent outbreaks.Key Takeaways● Measles is a highly contagious viral illness that can lead to severe complications.● Diagnosis is often clinical, but lab confirmation helps with public health tracking.● Treatment is mainly supportive, with Vitamin A playing a critical role in reducing complications.● Vaccination remains the most effective tool to eliminate measles worldwide.While measles might seem like a disease of the past, it can make a dangerous comeback without continued vigilance and vaccination efforts.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Centers for Disease Control and Prevention (CDC). Measles (Rubeola), Clinical Overview, July 15, 2024. Accessed on May 1, 2025. https://www.cdc.gov/measles/hcp/clinical-overview/index.html.World Health Organization (WHO). Measles, November 14, 2024. https://www.who.int/news-room/fact-sheets/detail/measlesGans, Hayley and Yvonne A. Maldonado, Measles: Clinical manifestations, diagnosis, treatment, and prevention, UpToDate, January 15, 2025. Accessed on May 1, 2025. https://www.uptodate.com/contents/measles-clinical-manifestations-diagnosis-treatment-and-preventionTheme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 189: Intermittent Fasting (Religious and Sports)Future Doctors Carlisle and Kim give recommendations about patients who are fasting for religious reasons, such as Ramadan. They also explain the benefits and risks of fasting for athletes and also debunked some myths about fasting. Dr. Arreaza add input about the side effects of fasting and ways to address them.    Written by Cameron Carlisle, MSIV (RUSM) and Kyung Kim, MSIV (AUC). Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: In the last episode on fasting (#179), we explored how intermittent fasting (IF) can help manage type 2 diabetes by improving insulin sensitivity, promoting weight loss, and lowering inflammation. We discussed the benefits of methods like 16:8 time-restricted eating and the 5:2 meal plan, and even compared IF to medications like metformin. Today, we're bringing that science into real life. We'll talk about how people fast for religious reasons, like during Ramadan, how athletes use IF to stay in shape, and how we can use IF as a tool in family medicine to support community health and A1c control.Intermittent Fasting in Religious PracticeRamadan just ended on 3/30/25, but this is a great time to talk about the broader role of fasting in religion and health. Many faiths incorporate fasting into spiritual practice and understanding this can help us better support our patients.Islam (Ramadan): Ramadan is a month where Muslims fast from dawn to sunset, focusing on spiritual reflection and self-control. No food or drink is consumed during daylight hours. Despite this, studies have shown that with good planning, fasting during Ramadan does not significantly impair physical performance or metabolic health.Key health tips for patients observing Ramadan:Hydrate well between iftar (sunset) and suhoor (pre-dawn).Break the fast with dates and water to gently replenish energy and electrolytes.Eat balanced meals with complex carbs, protein, and healthy fatsAvoid greasy, heavy foods right after fastingLight exercise (such as a walk) after iftar is beneficialReview medications with a healthcare provider, especially for those on insulin or sulfonylureas.For example: Metformin should be taken when you break your fast and then again before dawn. If its an extended-release metformin, take it at night. Metformin does not cause significant hypoglycemia and can be continued during Ramadan. Basal insulin is advised to be given at Iftar, and the dose should be reduced by 25-35% if the patient is not well managed. And regarding the fast-acting insulin, it requires a little more reading, so you can look it up and learn about it. Judaism: In Judaism, fasting is practiced on days like Yom Kippur and Tisha B'Av, typically lasting 25 hours without food or water. These fasts are spiritual and reflective, and patients with medical conditions may seek guidance on how to participate safely.Christianity: Many Christians fast during Lent, either by abstaining from certain foods or limiting meal frequency. Some practice partial-day fasts or water-only fasts for spiritual renewal.A branch of Christianity known as The Church of Jesus Christ of Latter-day Saintsoften observe a 24-hour fast on the first Sunday of each month, known as Fast Sunday, where they abstain from food and drink and donate the cost of meals to charity. This practice is both spiritual and communal.Cameron: Fasting for religious reasons, when done safely, can align with IF protocols and be culturally sensitive for diverse patients in family medicine.IF in Athletes and PerformanceIntermittent fasting is gaining popularity in the sports world. Athletes are using IF to improve body composition, increase fat oxidation, and enhance metabolic flexibility. A recent study, known as the DRIFT trial and published in Annals of Internal Medicine, found that fasting three non-consecutive days a week led to more weight loss than daily calorie restriction. Participants lost an average of 6.37 pounds more over 12 months.Why? Better adherence. People found the 3-day fasting schedule easier to stick to than counting calories every day.Benefits of IF for athletes:Encourages fat burning (via AMPK activation and GLUT4 upregulation, listen to ep. 179).Helps maintain lean muscle while reducing fat.No major drop in performance when meals and workouts are timed properly.What are some practical tips?Schedule workouts during or just before eating windows.Eat protein-rich meals post-workout.Avoid intense training during long fasts unless adapted.Stay hydrated, especially in hot environments or endurance sports.Broader Applications and Myths Around IFHormonal Effects of IF: In addition to improving insulin sensitivity, IF also affects hormones such as ghrelin (which stimulates hunger, remember it as growling) and leptin (which signals fullness). Over time, IF may help the body regulate appetite better and reduce cravings. IF can also decrease morning cortisol levels, the stress hormone. That's why it's important to monitor sleep, hydration, and stress levels when recommending IF.Circadian Rhythm Alignment: Emerging research shows that aligning eating times with natural light/dark cycles—eating during the day and fasting at night—can improve metabolic outcomes. This practice, known as early time-restricted eating (eTRE), has been shown to lower blood glucose, reduce insulin levels, and improve energy use. Patients who eat earlier in the day tend to have better results than those who eat late at night.Myths and Clarifications on IF:-“Fasting slows metabolism” In fact, short-term fasting may boost metabolism slightly due to increased norepinephrine. -“You can't exercise while fasting.” Many people can safely train during fasted states, especially for moderate cardio or strength training. -“Skipping breakfast is bad.” For some, skipping breakfast is a useful IF strategy—as long as total nutrition is maintained. You can break your fast at 2:00 pm, it does have to be at 7:00 AM.What to Eat When Breaking a FastBreaking a fast properly is just as important as fasting itself. Whether it's after a Ramadan fast or a 16-hour fast, the goal is to replenish energy gently and restore nutrients.Ideal foods to break a fast:Dates and water: provide quick energy, potassium, and fiberSoups: lentil or broth-based soups are gentle on digestionComplex carbs: whole grains like brown rice or oatsLean proteins: chicken, fish, eggs, legumesFruits and vegetables: hydrate and provide fiberHealthy fats: nuts, avocado, olive oilProbiotics: yogurt or kefir for gut supportBalanced meals with carbs, protein, and healthy fats help the body transition smoothly back to a fed state.Using IF in Family Medicine and Community HealthIntermittent fasting can be a practical, cost-effective strategy in family medicine. In areas with high rates of obesity and diabetes, like Kern County, IF offers a lifestyle-based tool to improve metabolic health, especially in underserved populations. IF is free!How IF can help in family medicine:Lower A1c levels: improves insulin sensitivity and glucose controlPromote weight loss: decreases insulin resistance and inflammationReduce medication dependence: fewer meds needed over time for some patientsEncourage patient engagement: flexible and easier to follow than strict calorie countingFit diverse lifestyles: aligns with religious and cultural practicesAddress food insecurity: structured eating windows can help patients stretch limited food resourcesHow to apply IF in clinic:Start the conversation by asking if the patient has heard of IFRecommend simple starting points: 12:12 or 14:10Emphasize hydration and nutrient-dense mealsMonitor labs and symptoms, especially in diabetic patientsAdjust medications to avoid hypoglycemiaProvide follow-up and patient education handouts if possibleWhat if a patient isn't ready to try fasting?For those not ready to commit to intermittent fasting, one effective alternative is walking after meals. A simple 10–20 minute walk post-meal can help stimulate GLUT4 receptors in skeletal muscle, promoting glucose uptake independent of insulin. This reduces the demand on pancreatic beta cells and may help improve blood sugar control over time. This strategy is particularly useful for patients with insulin resistance or early-stage type 2 diabetes.Conclusion: Intermittent fasting is not one-size-fits-all, but it can be a powerful tool for both individual and community health. From Ramadan to race day, IF has a place in family medicine when used thoughtfully. Encourage patients to work with their healthcare providers to find an approach that fits their lifestyle, medical needs, and personal values. IF is a cost-effective toolEven without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Academy of Family Physicians. (2022). "Intermittent Fasting: A Promising Treatment for Diabetes." AAFP Community Blog. https://www.aafp.org/pubs/afp/afp-community-blog/entry/intermittent-fasting-a-promising-treatment-for-diabetes.htmlHealthline. (2023). "What Breaks a Fast? Foods, Drinks, and Supplements." https://www.healthline.com/nutrition/what-breaks-a-fast.Sarri KO, Tzanakis NE, Linardakis MK, Mamalakis GD, Kafatos AG. Effects of Greek Orthodox Christian Church fasting on serum lipids and obesity. BMC Public Health. 2003 May 16;3:16. doi: 10.1186/1471-2458-3-16. PMID: 12753698; PMCID: PMC156653. https://pmc.ncbi.nlm.nih.gov/articles/PMC156653/.Shang, Y., et al. (2024). "Effects of Intermittent Fasting on Obesity-Related Health Outcomes: An Umbrella Review." eClinicalMedicine.https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00098-1.Abaïdia AE, Daab W, Bouzid MA. Effects of Ramadan Fasting on Physical Performance: A Systematic Review with Meta-analysis. Sports Med. 2020 May;50(5):1009-1026. doi: 10.1007/s40279-020-01257-0. PMID: 31960369. https://pubmed.ncbi.nlm.nih.gov/31960369/.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 188: RSV Management and PreventionDr. Sandhu and future Dr. Mohamed summarize the management of RSV and describe how to prevent it with chemoprophylaxis and vaccines. Dr Arreaza adds some comments about RSV vaccines.Written by Abdolhakim Mohamed, MSIV, Ross University School of Medicine. Comments by Ranbir Sandhu, MD, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is RSV? -The Respiratory syncytial Virus (RSV) is an enveloped, negative-sense, single-stranded RNA virus of the Orthopneumovirus genus within the Pneumoviridae family. -RSV is a major cause of acute respiratory tract infections, particularly bronchiolitis and pneumonia, in infants and young children, and it also significantly affects older adults and immunocompromised individuals. -RSV infections cause an estimated 58,000–80,000 hospitalizations among children younger than 5 years and 60,000–160,000 hospitalizations among adults older than 65 years each year.-RSV is highly contagious and spreads through respiratory droplets and direct contact with contaminated surfaces. The virus typically causes seasonal epidemics, peaking in the winter months in temperate climates and during the rainy season in tropical regions. -Virtually all children are infected with RSV by the age of two, and reinfections can occur throughout life, often with milder symptoms.-Per the 2014 Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis, from the American Academy of Pediatrics, the most common etiology of bronchiolitis is RSV. -About 97% of children are infected with RSV in the first 2 years of life, about 40% will experience lower respiratory tract infection during the initial infection. Other viruses that cause bronchiolitis include human rhinovirus, human metapneumovirus, influenza, adenovirus, coronavirus, and parainfluenza viruses.When is RSV season?-Classically, the highest incidence of infection occurs between December and March in North America. Per CDC, there were typical prepandemic RSV season patterns, but the COVID-19 pandemic disrupted RSV seasonality during 2020–2022. -Before we dive into the seasonality patterns, for context, in order to describe RSV seasonality in the US, data was gathered and analyzed from polymerase chain reaction (PCR) test results reported to the National Respiratory and Enteric Virus Surveillance System (NREVSS) during July 2017–February 2023. -Seasonal RSV epidemics were defined as the weeks during which the percentage of PCR test results that were positive for RSV was ≥3%. Per 2017–2020 data, RSV epidemics in the United States typically follow seasonal patterns, that began in October, peaked in December or January, and ended in April. -However, during 2020–21, the typical winter RSV epidemic did not occur. The 2021–22 season began in May, peaked in July, and ended in January. -The 2022–23 season started (June) and peaked (November) later than the 2021–22 season, but earlier than prepandemic seasons. CDC notes that the timing of the 2022–23 season suggests that seasonal patterns are returning toward those observed in prepandemic years, however, warn that clinicians should be aware that off-season RSV circulation might continue.Treatment of RSVSome key points of the 2014 pediatric guidelines from the American Academy of Pediatrics.-AAP strongly do not recommend beta agonists or steroids for viral associated bronchiolitis because of no significant improved outcomes. “Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).”-Epinephrine is not recommended for infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).-Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department (Evidence Quality: B; Recommendation Strength: Moderate Recommendation), but hypertonic saline may be administered when they are hospitalized (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings]).-Chest physiotherapy should not be used in infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).-Antibiotics should not be administered in bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one (Evidence Quality: B; Recommendation Strength: Strong Recommendation).-Oxygen therapy may not be administered if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low level evidence and reasoning from first principles]).-Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally (Evidence Quality: X; Recommendation Strength: Strong Recommendation).How do we prevent RSV?Infant Immuno-prophylaxis:A clinical trial in 2022 demonstrated that a single injection of nirsevimab (Beyfortus®), administered before the RSV season, protected healthy late-preterm and term infants from RSV-associated lower respiratory tract that required medical treatment. Nirsevimab is a monoclonal antibody to the RSV fusion protein that has an extended half-life.Additionally, on August 3, 2023, the Advisory Committee on Immunization Practices (ACIP) recommended nirsevimab for all infants younger than 8 months who are born during or entering their first RSV season and for infants and children between 8-19 months who are at increased risk for severe RSV disease and are entering their second RSV season. On the basis of pre-COVID-19 pandemic patterns, nirsevimab could be administered in most of the continental United States from October through the end of March.Maternal Vaccination: The CDC recommends the administration of the RSVPreF vaccine to pregnant women between 32 0/7 and 36 6/7 weeks of gestation. This vaccination aims to reduce the risk of RSV-associated lower respiratory tract infection in infants during the first 6 months of life.At this time, if a pregnant woman has already received a maternal RSV vaccine during any previous pregnancy, CDC does not recommend another dose of RSV vaccine during subsequent pregnancies.Older individuals: -Each year in the U.S., it is estimated that between 60,000 and 160,000 older adults are hospitalized and between 6,000 and 10,000 die due to RSV infection-ABRYSVO's approval will help offer older adults protection in the RSV season.-On June 26, 2024, ACIP voted to give these recommendations: all adults older than 75 years and adults between 60–74 years who are at increased risk for severe RSV disease should receive a single dose of RSV vaccine (Abrysvo®).Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Hamid S, Winn A, Parikh R, et al. Seasonality of Respiratory Syncytial Virus — United States, 2017–2023. MMWR Morb Mortal Wkly Rep 2023;72:355–361. DOI: http://dx.doi.org/10.15585/mmwr.mm7214a1Hammitt LL, Dagan R, Yuan Y, Baca Cots M, Bosheva M, Madhi SA, Muller WJ, Zar HJ, Brooks D, Grenham A, Wählby Hamrén U, Mankad VS, Ren P, Takas T, Abram ME, Leach A, Griffin MP, Villafana T; MELODY Study Group. Nirsevimab for Prevention of RSV in Healthy Late-Preterm and Term Infants. N Engl J Med. 2022 Mar 3;386(9):837-846. doi: 10.1056/NEJMoa2110275. PMID: 35235726.Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502. doi: 10.1542/peds.2014-2742. Erratum in: Pediatrics. 2015 Oct;136(4):782. doi: 10.1542/peds.2015-2862. PMID: 25349312.CDC, per their published article Seasonality of Respiratory Syncytial Virus — United States for 2017–2023, in the United StatesWhat U.S. Obstetricians Need to Know About Respiratory Syncytial Virus.Debessai H, Jones JM, Meaney-Delman D, Rasmussen SA. Obstetrics and Gynecology. 2024;143(3):e54-e62. doi:10.1097/AOG.0000000000005492.Maternal Respiratory Syncytial Virus Vaccination and Receipt of Respiratory Syncytial Virus Antibody (Nirsevimab) by Infants Aged

Episode 187: Autism FundamentalsFuture Dr. Ayyagari explains the recommended screenings for autism, how to diagnose it and sheds some light on the management. Dr. Arreaza mentions the Savant Syndrome and the need to recognize ASD as a spectrum and not a “black or white” condition.Written by Tejasvi Ayyagari, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction:Autism, or Autism Spectrum Disorder (ASD), is a neurodevelopmental disorder that affects how a person thinks, interacts with others, and experiences the world. It is characterized by deficits in social communication and interaction and restricted and/or repetitive behavior patterns, interests, and activities. Autism is considered a "spectrum" disorder because it encompasses a wide range of symptoms, skills, and levels of functioning, including Asperger's, Auditory processing disorder, Rett syndrome, etc. The exact causes of autism are not fully understood, but many question genetic and environmental factors at play.  What are some of the main characteristics of autism?1. Social difficulties: Individuals with autism may experience trouble understanding social cues or body language, leading to difficulty forming meaningful relationships. Children may display little interest in playing with others or engage in limited imaginative play (doll playing, pretend playing).2. Repetitive behaviors and interests: People with autism may engage in repetitive movements with their arms or hands and focus intensely on specific topics or activities. They may become distressed when routines are disrupted.3. Overstimulation: Individuals with autism may find multiple stimuli too overwhelming and gravitate towards either minimal stimulation or certain appealing stimulations best suited for their needs. 4. Intellectual variation: People with autism can have varying intellectual abilities, from severe mental disabilities to those who excel in specific disciplines, such as accounting or history (savants). Savant syndrome. It is a syndrome popularized by movies, TV shows and social media. The Good Doctor is a good example of it. Savant syndrome manifests by having a superior specific set of skills in a developmentally disabled person. Savants are like human supercomputers—while the rest of us are buffering, they can recall in 4K. We must not assume all people with autism are savants, unless we are particularly told about their exceptional talent.Another famous person with Savant syndrome was Kim Peek, portrayed by Dustin Hoffman in the 1988 movie The Rain Man. Kim Peek was later diagnosed with the FG syndrome and not autism spectrum disorder.What is the prevalence of autism?Worldwide, it is estimated that about 1 in 100 to 1 in 150 children are diagnosed with autism, though this number can vary based on the country and diagnostic practices. In the United States, according to the CDC, as of 2023, approximately 1 in 36 children are diagnosed with autism.  Some studies even claim that boys are 4x more likely to be diagnosed with autism than girls.It is a very prevalent condition, and we have some recommendations about screenings. I feel like most parents have a “feeling” that something may be wrong with their kid, but I think most parents may feel that way, especially when they have their first baby.The American Academy of Pediatrics recommends that all children should be screened for autism at 18 months and 24 months of age during routine well-child visits, using standardized tools like the Modified Checklist for Autism in Toddlers (M-CHAT) or other validated autism screening tools.   MCHAT is a two-step screening that requires a second visit if the first test shows moderate risk. Also, we must continue to follow up the development of kids in well child visits and be on the lookout for signs of autism, even outside of the recommended screening ages. How is autism diagnosed?Autism is typically diagnosed between the ages of 2 and 3, but it is often identified in early childhood. According to the DSM-5, there are two main clusters of symptoms for autism.- Cluster A: Involves social communication and interaction impairments in various settings.- Cluster B: Involves repetitive behavioral patterns, limited areas of interest, and atypical sensory behaviors/experiences.According to the DSM-5-TR criteria, a diagnosis of ASD requires that the following criteria are met:All three of the following Cluster A symptoms:- Social-emotional reciprocity: Difficulty engaging in mutually enjoyable conversations or interactions due to a lack of shared interests or understanding of others' thoughts and feelings.- Nonverbal communicative behaviors to socialize, such as using aspects with eye contact, facial expressions, gestures, and tone of voice, which makes communication more difficult.- Difficulty developing, understanding, and maintaining relationships: This could manifest as difficulty adjusting behavior to social settings, an inability to show expected social behaviors, a lack of interest in socializing, or difficulty making friends despite wanting to.Two or more of the following Cluster B symptoms:- Stereotyped or repetitive movements, use of objects, or speech: Echolalia or flapping the hands repeatedly.- Persistent sameness, where patients require adherence to routines or ritualized patterns of behavior, such as difficulty with transitions or a need to eat the same food each day.- Highly restricted, fixated interests: This may include an intense focus on specific objects (trains) or topics (such as dinosaurs or natural disasters).- Sensory response variations, including heightened or diminished responses to sensory input, such as adverse reactions to sounds, indifference to temperature, or excessive touching/smelling of objects.Additionally, the symptoms must:- Significantly impair social, academic/occupational, and daily functioning,- Not be better explained by intellectual disability or global developmental delay, and- Be present in early childhood. (However, symptoms may only become apparent when social demands exceed the child's capacity; in later life, they may be masked by learned strategies.)How can we go about managing autism?There is no "cure" for Autism. However, various therapies can help manage the condition. Treatment tailors to the individual's age, strengths, and weaknesses. Our main goal is to maximize function, encourage independence, and improve the patient's overall quality of life.During office visits as primary care doctors, we have to use different strategies to make the visits more focused on individual needs, making sure the caregivers are involved as well as the patient. We communicate with caregivers before and during the visit to optimize patient compliance, allow enough time for the family/caregiver to talk about the patient's history, allow the patient to play with instruments/materials provided, and use simple instructions. Sometimes, the physical exam can be the most challenging aspect of the exam because it is so overstimulating for the patient. Hence, allowing enough time for the patient to be comfortable is key.This is a multidisciplinary management that includes, family med, pediatricians, social workers, behavioral health, etc.Personal experiences interacting and managing patients with autism in the clinic or in the hospital:Dr. Arreaza: I have seen a lot of adult patients with autism.I see a challenge commonly found is agitation and the use of medications. I prefer to defer any prescriptions to psychiatry, if needed, but behavioral concerns can be successfully managed by behavioral health with participation of family, caregivers, and especial education.TJ:  Personal story with Auditory Processing Disorder (APD).Conclusions: Dr. Arreaza: Autism is a spectrum, not all persons with ASD are the same. They are not all geniuses, and they are not all developmentally delayed, they are not just black or white, but there are several shades of gray in between. TJ:  Not one doctor or one family will take care all responsibility, it requires a multifaceted approach.People with autism can live a long and meaningful lives.Thank you for listening to this week's episode on Autism. We will see you next time.  Have a nice day.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Centers for Disease Control and Prevention. Data and statistics on autism spectrum disorder. CDC.gov. Accessed on March 13, 2025. https://www.cdc.gov/autism/data-research/index.htmlWeissman Hale, Laura, “Autism spectrum disorder in children and adolescents: Overview of management and prognosis,” UpToDate, accessed on March 13, 2025. https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-management-and-prognosis.Volkers, N. (2016). Early Signs. The ASHA Leader.https://doi.org/10.1044/leader.ftr1.21042016.44Urquhart-White, Alaina, “'The Good Doctor' Puts The Spotlight On A Rare, Mysterious Syndrome,” Bustle, September 25, 2017. https://www.bustle.com/p/whats-real-about-savant-syndrome-is-something-the-good-doctor-should-explore-2439405Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

Episode 186: Exercise PrescriptionsDr. Sandhu and future Dr. Daoud explain the way to prescribe exercise, what are the general guidelines for exercise and how to overcome barriers to exercise. Dr. Arreaza emphasized the importance to screen our patients before exercise and using the term “physical activity” to improve receptivity by patients.  Written by Wessam Daoud, MSIV, Ross University School of Medicine. Edits and comments by Ranbir Sandhu, MD, and Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: I'm Dr. Arreaza, and today, we will talk about a topic that is both simple and powerful: exercise. Previous episodes: 158, 100 (sexercise), 95, We all know exercise is good for us, but how do we prescribe it like we do medications? How can we tailor exercise recommendations to our patients' needs and lifestyles? To help us unpack this, I'm joined today by Dr. Ranbir Sandhu, and Medical Student, Wessam Daoud, who has a passion for preventive medicine. Welcome to the show!Ranbir: Thanks, Dr. Arreaza! We're excited to be here and to discuss something so fundamental to health.Segment 1: Understanding Exercise PrescriptionArreaza: Let's start with the basics. In medicine, we prescribe medications with precise instructions—dosage, frequency, duration. But how do we apply this concept to exercise?Ranbir: Great question! Before we prescribe exercise, we have to make sure that it is not contraindicated. We can use a system to stratify our patients based on risk factors, such as older age, smoking, baseline level of activity, etc. For example, a patient who had a heart attack within the last 6 weeks should not exercise yet, a person with heart failure exacerbation, asthma exacerbation, uncontrolled heart arrhythmia, etc. Wes: Exercise prescription follows a structured approach, similar to medications. We use the FITTE mnemonics to guide recommendations: Frequency – How often?Intensity – How hard should the patient work?Time – How long should each session last?Type – What kind of exercise is best?Enjoyment – Does the patient enjoy this activity?By adjusting these components, we can tailor exercise to each patient's needs, whether it's improving cardiovascular health, managing chronic disease, or building strength.Segment 2: How Much Exercise Do Adults Need?Arreaza: Now, when we talk about exercise, there's a lot of conflicting advice out there. What do the official guidelines say about how much adults should exercise?Ranbir: The American College of Sports Medicine (ACSM) and CDC provide clear guidelines:Aerobic Exercise: At least 150 to 300 minutes of moderate-intensity exercise per week, OR 75 to 150 minutes of vigorous-intensity exercise (or a mix of both).Muscle Strengthening: At least two days per week of resistance training targeting major muscle groups.Balance & Flexibility: Particularly important for older adults to reduce fall risk.These guidelines are adaptable, meaning patients can break them into shorter sessions throughout the week.Arreaza: For weight regain, you may need to exercise a little bit more, about 300 minutes/week, and >2 days of resistance activity.Segment 3: Choosing the Right Type of ExerciseArreaza: With so many options—cardio, strength training, yoga—how do you guide patients in choosing the right type of exercise for them?Wes: It depends on the patient's goals, health conditions, and personal preferences. Here's how we might break it down:For cardiovascular health: Activities like brisk walking, jogging, cycling, or swimming.For strength and bone health: Resistance exercises, bodyweight exercises, or weightlifting.Ranbir: For flexibility and balance: Yoga, Pilates, or tai chi, especially for older adults.For chronic disease management: Customized plans—e.g., low-impact options for arthritis or supervised exercise for heart disease.The key is finding something they enjoy, because sustainability is the most important factor.Arreaza: We can use our physical therapy friends to design an appropriate plan for our patients.Segment 4: Overcoming Common Barriers to ExerciseArreaza: I hear this all the time in the clinic—patients want to exercise but struggle to stay consistent. What are the biggest barriers, and how do we help patients overcome those barriers?Wes: Absolutely. Some common barriers include:Lack of time: Patients think they need hours at the gym, but even short bouts of 10 minutes throughout the day add up.Low motivation: Encouraging goal setting and accountability, such as a workout buddy or an activity tracker, helps.Arreaza: Instagram post from Ranbir: Go to the gym even if you don't want to go. Wes: Pain or chronic illness: We can adapt exercises—low-impact options like swimming or chair exercises work well.No access to a gym: Many exercises require no equipment—walking, stair climbing, bodyweight exercises.Ranbir: As physicians, we need to normalize movement as part of daily life rather than an all-or-nothing approach.Segment 5: The Role of Healthcare Providers in Exercise CounselingArreaza: We often focus on medications and procedures, but exercise is one of the best treatments we have. What role should physicians play in promoting physical activity?Ranbir: Our role is critical! Exercise is preventive medicine and can reduce the risk of heart disease, diabetes, obesity, and even depression. As physicians, we can:-Ask about exercise levels at routine visits.-Provide specific, personalized exercise prescriptions rather than just saying 'you should exercise more.'-Address patient concerns by modifying recommendations to their abilities.-Follow up and reinforce progress like we would with any other treatment.-Even a brief conversation about physical activity can significantly impact patient motivation and adherence.Arreaza: Exercise vs physical activity. Ask your patients as a routine. Closing Thoughts & Call to ActionArreaza: Ranbir andWessam, this has been a fantastic discussion. Any final thoughts for our listeners?Ranbir: My biggest takeaway is that any movement is better than none. Exercise doesn't have to be perfect—it just has to be consistent. Start small, find an activity you enjoy, and build from there!Arreaza: Any take-home message, Wes?Wes: Same for me, find an activity you enjoy, start where you are, and keep moving!Arreaza: Great advice! If you found this episode helpful, share it with your colleagues and patients. Ranbir: Until next time—stay active and stay healthy!Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________Sources:Some information in this podcast was inspired by conferences from the Obesity Medicine Association, https://obesitymedicine.org/.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 186: Aging 101Dr. Schlaerth explained the physiology, how to slow down and how to prevent aging. Dr. Ayyagari inquired about how to fight ageism in our clinic and in our society. Dr. Arreaza highlights the importance of treating elderly patients with dignity and empathy. A new book written by Dr. Schlaerth is introduced (“The Ways our Bodies Age.”)  Written by Katherine Schlaerth, MD (Clinica Sierra Vista). Edits and comments by Hector Arreaza, MD (Clinica Sierra Vista), and Tejasvi Ayyagari, MSIV (Ross University School of Medicine.)You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.InterviewArreaza: Question 1: What are some early signs that may indicate that your body is aging? (Pain? Memory? Weight loss?)Schlaerth: Maximum bone mass, muscle strength and mass and general strength and endurance generally peak in the third and early fourth decades of life. However, genetics and environment play a big role in aging for each of us. People can have problems with visual accommodation in their early forties, if not before. Many people feel that a realization of the possibility of aging begins when they must have magnification to read very small print.  Women often complain of menopause as a benchmark for aging. Men don't really have such a well demarcated event in their lives. Arreaza: Sure, men do not have a specific event, but I think an undeniable sign of aging in men is urinary frequency. I normally tell my patients that the nose, the ears, and the prostate are organs that tend to grow with age. So, if a male patient complains that they must use the bathroom more frequently, that may be a sign that their prostate is growing, after ruling out other conditions, if needed, we can reassure the patient that this can be a normal sign with aging. We will not neglect the patient because “it is normal” but we must offer interventions when needed.Schlaerth: The bottom line may be that aging is multifactorial, involves everything from the demands of one's employment, through genetics, diet, and exercise right up to how many friends one has. It is also a stealth process, and all our body parts may even age at different rates! One individual may have great kidneys but an erratic thyroid, and another a shrinking liver but a superb array of teeth.Arreaza: (Humor) Plastic surgery and cosmetics can hide some signs of aging (not all). A wise woman said that you can hide your age, but your hands and neck will surely reveal it.Schlaerth: Many of us use external clues to measure aging. Teenage daughters accuse us of being behind the times, or new wrinkles and white streaks in our hair bring the reality of time passing to us. So, the realization of aging may be rather subjective, or it may be signaled by reduced energy, a falling off of the athletic skills we once had, or weight gain when we eat the same exact quantity and type of food we did at a younger age without gaining weight. So subjective aging mirrors incompletely the aging we are undergoing at a cellular and subcellular level.TJ: Question 2:How can we slow down aging?Schlaerth: One unpopular way would be to increase the age at which people are eligible for social security if in good health. WHY would this help? Because work adds a valuable dimension to the daily lives of seniors. It provides socialization, intellectual challenges, exercise and allows people to continue giving the results of their valuable life experience to others. Now there are issues here. Positions may have to change to accompany the changes of aging. People may choose different occupations from those held in adulthood. Part time work may compel employers to decrease salaries and to make accommodating changes in the workplace. Arreaza: I see your point. As you stay active, your aging slows down. Schlaerth: On the opposite side of the equation, social security may be saved from being turned into a funding responsibility of the federal government, raising taxes on younger workers and making them even less likely to be able to afford housing and even children. TJ: [In your experience Dr. Schlaerth, are professions, especially healthcare, moving in that direction to provide appropriate accommodations for aging workforce?] Schlaerth: There are variability. Schlaerth: To continue about slowing down aging, as an alternative, acquire a new skill or hobby that allows you to grow instead of vegetating in front of a TV or other screen, and brings you into contact with others, young and older, who share your interest.More popular ideas would include expanding opportunities to exercise and socialize within one's own community, with local initiatives geared to the specifics of the community's location and interests. But in the long run, education and motivation will be the biggest interventions. People need to know more about their bodies over time, because preparing for aging takes knowledge and starts in one's thirties or forties. This means establishing an exercise habit which will endure for decades and is consistent with one's responsibilities to one's family and one's job. It must work and be doable over time. Arreaza: So, we must develop an exercise routine that we enjoy, it's challenging, and sustainable over decades. Brain exercise also works (new ways to go to work, learning a new language, etc.)Schlaerth: -Eating habits must be changed, which will involve less eating out and more home cooking. TJ: [As much as I enjoy a good In-N-Out burger, nothing beats a home cooked meal. Aside from controlling the ingredients for individualized diets/spice levels, cooking for me is therapeutic and helps relieve stress, especially when I cook Indian food (my specialty).] Schlaerth: Choosing the right lifelong partner and staying married is a big help. That may also require a bit of education, starting in childhood! All studies show that being married prolongs life!Tongue in cheek, I would suggest choosing the right location to settle down. Los Angeles and New York City don't currently look like stress free places to live. That may change though.Arreaza: I guess if you have a good social support in those cities, it may work. What else can we recommend our patients?Schlaerth: People who are happy and optimistic and have lots of friends and family statistically do well. Join your local church, synagogue, temple, mosque, etc. Living according to your code of ethics and beliefs with others who share these is always reinforcing and offers support in times of trouble. One recently widowed octogenarian who had had a very strong and fulfilling marriage knew that she had to reinvent purpose in her life. So, she became the neighborhood unofficial social worker. Did a friend's child need a place to stay until he or she got their own apartment? Come on over, there's an extra bedroom. Was a trip to the doctor needed by someone who couldn't drive? Let's go! Another widow opened her home to students at a university, charging rent and becoming a “mother hen” to her student lodgers.A man who loved aeronautics served as a docent for a local museum and became a fount of information about the intricacies of World War II planes right down to structural details. All of these and similar strategies kept people interested and interesting, promoted exercise and took a bit of creativity and yes, energy.Arreaza: So, to slow down aging, stay physically, spiritually, and mentally active. Question 3:Why are people so afraid of aging? (TJ: There are some concepts we can introduce for discussion: -Gerascophobia is an abnormal or incessant fear of growing older or ageing. -Gerontophobia is the hatred or fear of the elderly. -Ageism refers to age discrimination) Schlaerth: There are very personal and idiosyncratic reasons for a fear of aging. One gentleman saw his wife die a painful death from cancer and this triggered his fear.Another saw his grandparents age and had to help care for them. Sometimes this kind of experience can engender love and respect for one's older family members, and sometimes the opposite. -One's teeth leave, food is no longer palatable, balanced precludes getting a kid's ball off your roof, constipation and aches are a daily struggle, even the TV shows you loved are now old reruns. You no longer feel welcome in this new world. And anyway, you can't drive at night, and you can't hear well enough in a crowd to join in a restaurant conversation.-But probably the biggest reasons include a loss of function and autonomy (the Bible even alludes to this fear!), loss of employment and loneliness when one's friends and especially one's lifelong partner are no longer there.-Cultural change can also be a factor. The community one grew up in no longer exists. Communication is by computer or cell phone and much too complicated to learn. The old lot where baseball was played so long ago is now a derelict and abandoned shopping center! -You don't look beautiful anymore.-A strong religious faith often mitigates a lot of these fears. TJ: Question 4:How can we fight age discrimination (ageism) in our clinics, hospitals, and society?Schlaerth: The humanity of each person needs to be recognized. It is said that people feel about 20 years younger than their chronologic age. This may not be true for children, teenagers, or young adults though. When interacting with older folk, the need for environmental issues like good illumination, comfort, clear and low-pitched speech, the absence of extraneous noise, eye contact should be addressed to facilitate communication. If a younger person accompanies the older person, address at least some comments specifically to the older person. Allow time for a slower gait or response to questions. If possible, add a small complement that acknowledges the senior's personality or accomplishment. For example, an older lady with her daughter was left out of a conversation about her health because she was deaf, spoke a language other than English, and couldn't recall the particulars of a recent visit to a specialist. However, she'd raised 13 children who were all gainfully employed raising their own children and assets to society. When she was praised for this monumental accomplishment in the face of scanty resources, she brightened up like a wilted flower given water. -In society, again let older people perform when they have the capacity, be this in the workplace, the home, or in a social situation. Recognize everyone's humanity, even if it means just smiling at an elderly man in a wheelchair. And if the old lady can cross the street by herself, let her do so, even if you are a boy scout!Arreaza: In summary, treat your elderly patients with dignity and acknowledge them. Question 5.Give us three fundamentals of aging for primary care.Schlaerth:Help people in their thirties and forties prepare for old age by evaluating genetic and other risk factors, attacking the early stages of chronic diseases, encouraging lifelong good habits and working on eliminating bad ones, and vaccinate early.Help people maintain function as long as possible, even if total cure is no longer possible. Recognize the humanity and need for recognition in every person no matter how old and frail.TJ: Let's talk about your book: What was your motivation to write it? Arreaza: What is the basic message of your book? TJ: Give advice to new or aspiring writers or medical authors. Arreaza: The book can be found in Amazon: The Ways our Bodies Age by Katherine Schlaerth, MD.Conclusions:Arreaza: My take-home point for this episode is that aging is a physiologic process that takes place at a different pace in every individual. We can slow down or speed up the process depending on many factors, such as genetics, diet, occupation, and physical activity. We all will undergo the process of aging. So, let's be prepared and prepare our patients for that process with the advice given by Dr. Schlaerth.TJ: I want to have smooth conversation with our patients about aging._____________________References:Schlaerth, Katherine R., The Ways Our Bodies Age, Archway Publishing, 2025. Available for purchase at Amazon.com.Theme song, Works All The Time, by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 184: Multiple Myeloma BasicsSub-Interns and future Drs. Di Tran and Jessica Avila explain the symptoms, work up and treatment of multiple myeloma. Written by Di Tran, MSIV, Ross University School of Medicine; Xiyuan Yang, MSIV, American University of the Caribbean. Comments by Jessica Avila, MSIV, American University of the Caribbean. Edits by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Di: Hi everyone, this is Di Tran, 4th year medical student from Ross university.  It's a pleasure to be back.  To be honest, this project is a part of teamwork of two medical students, myself and another 4th year, her name is XiYuan.  She came from the AUC. Unfortunately, due to personal matters she was unable to make it to the recording today which makes me feel really sad. Jessica: My name is Jessica Avila, MSIV, American University of the Caribbean.Di: The topic we will present today is Multiple Myeloma. Multiple myeloma is typically a rare disease and it's actually a type of blood cancer that affects plasma cells in the bone marrow.Jessica: Let's start with a case: A 66-year-old male comes to his family doctor for an annual health checkup. He is not in any acute distress but he reports that he has been feeling tired and weaker than usual for the last 3 months. He also noticed that he tends to bruise easily. He has a history of arthritis and chronic joint pain, but he thinks his back pain has gotten worse in the last couple of months. Upon checking his lab values, his family doctor found that he has a calcium level of 10.8 and a creatinine level of 1.2, which has increased from his baseline. Given all that information, what do you think his family doctor is suspecting? And what kind of tests she can order for further evaluation?Di: Those symptoms sound awfully familiar – are we talking about the CRAB? You know, the diagnostic criteria for Multiple Myeloma.Jessica: Exactly! Those are called “myeloma-defining events.” Do you remember what those are?Di: CRAB criteria comes in 4 flavors.  It's HYPERCALCEMIA with >1mg/dL, RENAL INSUFFICIENCY with serum creatinine >2mg/dL, ANEMIA with hemoglobin value 10% plasma cells, PLUS any one or more of the CRAB features, we can make the official diagnosis of multiple myeloma. Di:  Before we go deeper, let's back up a little bit and do a little background.  So, what do we know about the immunoglobulins, also known as antibodies? Back from years of studying from medical school, we know that the plasma cells are the ones that producing the antibodies that help fight infections.  There  are various kinds that come with various functions.  Each antibody is made up of 2 heavy chains and 2 light chains.  For heavy chains, we have A, D, E, G, M and for light chains we have Kappa and Lambda.Jessica: Usually, the 5 possible types of immunoglobulins for heavy chains would be written as IgG, IgA, IgD, IgE, and IgM.  And the most common type in the bloodstream is nonetheless the IgG. Di: What is multiple myeloma? In myeloma, all the abnormal plasma cells make the same type of antibody, the monoclonal antibody.  The cause of myeloma is unknown, but there are lots of studies and evidence that show a number of potential etiologies, including viral, genetic, and exposure to toxic chemicals, especially the Agent Orange, which is a chemical used as herbicide and defoliant. It was used as a chemical warfare by the U.S. military during the Vietnam War from 1961 to 1971.Jessica: We need to order some specific blood tests to see if there is elevated monoclonal proteins in the blood or urine. So, to begin with we'll need to take a very thorough history and physical exam. Next, we'll do labs, such as CBC, basic metabolic panel, calcium, serum beta-2 microglobulin, LDH, total protein, and some not so common tests: serum protein electrophoresis (SPEP), immunofixation of blood or urine (IFE), quantitative immunoglobulins (QIg), serum free light chain assay, and serum heavy/light chain ratio assay.If any of the results is abnormal, we should consider referring our patient to an oncologist.Di: Interesting! I read that Multiple Myeloma symptoms vary in different patients.  In fact, about 10-20% of patients with newly diagnosed myeloma do not have any symptoms at all.   Otherwise, classic symptomatic presentations are weakness, fatigue, increased bruising under the skin, reduced urine output, weakened bones that is likely prone to fractures, etc. And if multiple myeloma is highly suspected, a Bone Marrow biopsy should be done with testing for flow cytometry and fluorescent in situ hybridization (FISH). Actually, if any of the “Biomarkers of malignancy (SLIM)” is met we can also diagnose multiple myeloma even without the CRAB criteria. Jessica: The diagnosis is made if one or more of the following is found: >= 60% of clonal plasma cells on bone marrow biopsy, > 1 lytic bone lesion on MRI that is at least 5mm in size, or a biopsy confirmed plasmacytoma. Di: Imaging comes in at the final step especially if we able to find one or more sites of osteolytic bone destruction > 5mm on an MRI scan.Jessica: What if the bone marrow biopsy returns > 10% of monoclonal plasma cells, but our patient doesn't have either the CRAB or the Biomarker criteria? Di: That's actually a very good question, since Multiple Myeloma is part of a spectrum of plasma cell disorders. That's when smoldering myeloma comes into play. It is a precursor of active multiple myeloma. Smoldering myeloma is further categorized as high-risk or low-risk based on specific criteria.A less severe form is called Monoclonal Gammopathy of Undetermined Significance, or simply MGUS, with < 10% bone marrow involvement. Those are diagnoses we give once we rule out actual multiple myeloma, which are defined by the amount of M-protein in the serum.Jessica:  When to get started on treatment? Multiple Myeloma is on a spectrum of plasma cells proliferative disorders, starting from MGUS to Smoldering Myeloma, to Multiple Myeloma and to  Plasma Cell Leukemia.  Close supervision/active watching is enough for MGUS and low risk Smoldering Myeloma. But once it has progressed to high-risk smoldering myeloma or to active Multiple Myeloma, chemotherapy is usually required. Some situations may require emergent treatment to improve renal function, reduce hypercalcemia, and to prevent potential infections.Di: As of 2024, treatment of Multiple Myeloma comprises the Standard-of-Care approved by the FDA. In fact, the quadruple therapy is a combination of 4 different class of drugs that include a monoclonal antibody, a proteasome inhibitor, an immunomodulatory drug, and a steroid. Jessica: They are Darzalex (daratumumab), Velcade (bortezomib), Revlimid (lenalidomide) and dexamethasone.  Other treatment plans for Multiple Myeloma include chemotherapy, immunotherapy, radiation therapy (for plasmacytomas) and stem cell transplants. The patient will also be on prophylaxis acyclovir and Bactrim while on chemotherapy. Sometimes anticoagulants are also considered because the chemo increases the risk of venous thromboembolic events.Di: Although the disease is incurable, but with the advancing of novel therapies and clinical trials patients with multiple myeloma are able to live longer.  Problem is the majority of patients diagnosed with Multiple Myeloma are older adults (>65), the risk of falling is adding to multiple complications of the disease itself, such as bone density loss, pain, neurological compromises, distress and weakness.  Palliative care may come in help at any point in time throughout the course of treatment but is most often needed at the very end of the course. Jessica, can you give us a conclusion for this episode?Jessica: Multiple Myeloma may not be the most common cancer, but we have to be aware of the symptoms and keep it in our differential diagnosis for patients with bone pain, easy bruising, persistent severe headaches, unexplained renal dysfunction, and remember the CRAB: HyperCalcemia, Renal impairment, Anemia and Bone lesions.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:International Myeloma Foundation. (n.d.). International Myeloma Working Group (IMWG) criteria for the diagnosis of multiple myeloma. https://www.myeloma.org/international-myeloma-working-group-imwg-criteria-diagnosis-multiple-myeloma Laubach, J. P. (2024, August 28). Patient education: Multiple myeloma symptoms, diagnosis, and staging (Beyond the Basics). UpToDate. https://www.uptodate.com/contents/multiple-myeloma-symptoms-diagnosis-and-staging-beyond-the-basics.University of California San Francisco. (n.d.). About multiple myeloma. UCSF Helen Diller Family Comprehensive Cancer Center. https://cancer.ucsf.edu/research/multiple-myeloma/about Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 183: Colorectal Cancer in Young AdultsFuture Dr. Avila and Dr. Arreaza present evidence-based information about the screening and diagnosis of colorectal cancer and explain the increasing incidence among young adult and the importance to screen early in high risk groups.  Written by Jessica Avila, MS4, American University of the Caribbean School of Medicine. Edits and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.IntroductionJessica: Although traditionally considered a disease only affecting older adults, colorectal cancer (CRC) has increasingly impacted younger adults (defined as those under 50) at an alarming rate. According to the American Cancer Society, CRC is now the leading cause of cancer-related death in men under 50 and the second leading cause in women under 50 (American Cancer Society, 2024). Arreaza: Why were you motivated to talk about CRC in younger patients?Jessica: Because despite advancements in early detection and treatment, younger patients are often diagnosed at later stages, resulting in poorer outcomes. We will discuss possible causes, risk factors, common symptoms, and why early screening and prevention are important. Arreaza: This will be a good reminder for everyone to screen for colorectal cancer because 1 out of every 5 cases of colorectal cancer occur in adults between the ages of 20 and 54. The Case of Chadwick BosemanJessica: Many people know Chadwick Boseman from his role as T'Challa in Black Panther. His story highlights the worrying trend of increasing CRC in young adults. He was diagnosed with stage III colorectal cancer at age 39. This diagnosis was not widely known until he passed away at 43. His case shows how silent and aggressive young-onset CRC can be. Like many young adults with CRC, his symptoms may have been missed or thought to be less serious issues. His death drew widespread attention to the rising burden of CRC among young adults and emphasized the critical need for increased awareness and early screening efforts.Arreaza: Black Panther became a hero not only in the movie, but also in real life, because he raised awareness of the problem in young AND in Black adults. EpidemiologyJessica: While rates of CRC in older populations have decreased since the 1990s, adults under 50 have seen an increase in CRC rates of nearly 50%. (Siegel et al., 2023). Currently, one in five new CRC diagnoses occurs in individuals younger than 55 (American Cancer Society, 2024).Arreaza: What did you learn about the incidence by ethnic groups? Are there any trends? Jessica: Yes, certain ethnic groups are shown to have higher rates of CRC. Black Americans, Native Americans, and Alaskan Natives have the highest incidence and mortality rates from CRC (American Cancer Society, 2024). Black Americans have a 20% higher incidence and a 40% higher mortality rate from CRC compared to White Americans, primarily due to disparities in access to screening, healthcare resources, and early diagnosis. Hispanic and Asian American populations are also experiencing increasing CRC rates, though to a lesser extent.Arreaza: It is important to highlight that Black Americans have the highest rate of both diagnoses and deaths of all groups in the United States. Who gets colorectal cancer?Risk FactorsJessica: Anyone can get colorectal cancer, but some are at higher risk. In most cases, environmental and lifestyle factors are to blame, but early-onset CRC are linked to hereditary conditions. Arreaza: There is so much to learn about colorectal cancer risk factors. Tell us more.Jessica: The following are key risk factors:Modifiable risk factors:Diet and processed foods: A diet high in processed meats, red meat, refined sugars, and low fiber is strongly associated with an increased risk of CRC. Fiber is essential for gut health, and its deficiency has been linked to increased colorectal cancer risk (Dekker et al., 2023).Obesity and sedentary lifestyle: Obesity and physical inactivity contribute to CRC risk by promoting chronic inflammation, insulin resistance, and metabolic disturbances that promote tumor growth (Stoffel & Murphy, 2023).Gut microbiome imbalance: Disruptions in gut microbiota, especially an overgrowth of Fusobacterium nucleatum, have been noted in CRC pathogenesis, potentially causing tumor development and progression (Brennan & Garrett, 2023).Arreaza: As a recap, processed foods, obesity, sedentarism, and gut microbiome. We also have to mention smoking and high alcohol consumption as major risks factors, but the strongest risk factor is a family history of the disease.Non-modifiable risk factors:Genetic predisposition: Although only 20% of early-onset CRC cases are linked to hereditary syndromes such as Lynch syndrome and familial adenomatous polyposis (FAP), individuals with a first-degree relative with CRC are at a significantly higher risk and should undergo earlier and more frequent screening (Stoffel & Murphy, 2023).Arreaza: Also, there is a difference in incidence per gender assigned at birth, which is also not modifiable. The rate in the US was 33% higher in men (41.5 per 100,000) than in women (31.2 per 100,000) during 2015-2019. So, if you are a man, your risk for CRC is slightly higher. Protective factors, according to the ACS, are physical activity (no specification about how much and how often) and dairy consumption (400g/day). Jessica, let's talk about how colon cancer presents in our younger patients.Clinical Presentation and Challenges in DiagnosisJessica: Young-onset CRC is often diagnosed at advanced stages due to delayed recognition of symptoms. Common symptoms include:Rectal bleeding (often mistaken for hemorrhoids)Young individuals may ignore it, believe they do not have time to address it, or lack insurance to cover a comprehensive evaluation.Unexplained weight lossFatigue or weaknessChanges in bowel habits (persistent diarrhea or constipation)This may also be rationalized by dietary habits.Abdominal pain or bloatingIron deficiency anemia.Arreaza: All those symptoms can also be explained by benign conditions, and colorectal cancer can often be present without clear symptoms in its early stages. Jessica: Yes, in young adults, symptoms may be dismissed by healthcare providers as benign conditions such as irritable bowel syndrome (IBS), hemorrhoids, or dietary intolerance, leading to significant diagnostic delays. Arreaza: We must keep a low threshold for ordering a colonoscopy, especially in patients with the risks we mentioned previously. Jessica: We may also be concerned about the risk/benefit of colonoscopy or diagnostic methods in younger adults, given the traditional low likelihood of CRC. Approximately 58% of young CRC patients are diagnosed at stage III or IV, compared to 43% of older adults (American Gastroenterological Association, 2024). Early recognition and prompt evaluation of persistent symptoms are crucial for improving outcomes. Empowering and informing young adults about concerning symptoms is the first step in better recognition and better outcomes for these individuals.Arreaza: This is when the word “follow up” becomes relevant. I recommend you leave the door open for patients to return if their common symptoms worsen or persist. Let's talk about screening. Screening and PreventionJessica: Due to the trend of CRC being identified in younger populations, the U.S. Preventive Services Task Force (USPSTF) lowered the recommended screening age for CRC from 50 to 45 in 2021 (USPSTF, 2021). Off the record, some Gastroenterologists also foresee the USPSTF lowering the age to 40. Arreaza: That is correct, it seems like everyone agrees now that the age to start screening for average-risk adults is 45. It took a while until everyone came to an agreement, but since 2017, the US Multi-Society Task Force had recommended screening at age 45, the American Cancer Society recommended the same age (45) in 2018, and the USPSTF recommended the same age in 2021. This podcast is a reminder that the age of onset has been decreased from 50 to 45, for average-risk patients, according to major medical associations.Jessica: For individuals with additional risk factors, including a family history of CRC or chronic gastrointestinal symptoms, screening starts at age 40 or 10 years before the diagnosis of colon cancer in a first-degree relative. Dr. Arreaza, who has the lowest and the highest rate of screening for CRC in the US? Arreaza: The best rate is in Massachusetts (70%) and the lowest is California (53%). Let's review how to screen:Jessica: Recommended Screening Methods:Colonoscopy: Considered the gold standard for CRC detection and prevention, colonoscopy allows for identifying and removing precancerous polyps.Fecal Immunochemical Test (FIT): A non-invasive stool test that detects hidden blood, recommended annually.Stool DNA Testing (e.g., Cologuard): This test detects genetic mutations associated with CRC and is recommended every three years.Arreaza: Computed tomographic colonography (CTC) is another option, it is less common because it is not covered by all insurance plans, it examines the whole colon, it is quick, with no complications. Conclusion:Colorectal cancer is rapidly emerging as a serious health threat for young adults. The increase in cases over the past three decades highlights the urgent need for increased awareness, early symptom detection, and proactive screening. While healthcare providers must weigh the risk/benefit of testing for CRC in younger adults, patients must also be equipped with knowledge of concerning signs so that they may also advocate for themselves. Early detection remains the most effective tool in preventing and treating CRC, emphasizing the importance of screening and risk factor modification.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Cancer Society. (2024). Colorectal Cancer Statistics, 2024. Retrieved fromhttps://www.cancer.orgAmerican Gastroenterological Association. (2024). Delays in Diagnosis of Young-Onset Colorectal Cancer: A Systemic Issue. Gastroenterology Today.Brennan, C. A., & Garrett, W. S. (2023). Gut Microbiota and Colorectal Cancer: Advances and Future Directions. Gastroenterology.Dekker, E., et al. (2023). Colorectal Cancer in Adolescents and Young Adults: A Growing Concern. The Lancet Gastroenterology & Hepatology.Siegel, R. L., et al. (2023). Colorectal Cancer Statistics, 2023. CA: A Cancer Journal for Clinicians.Stoffel, E. M., & Murphy, C. C. (2023). Genetic and Environmental Risk Factors in Young-Onset Colorectal Cancer. JAMA Oncology.U.S. Preventive Services Task Force. (2021). Colorectal Cancer Screening Guidelines.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 182: HPV VaxFuture Dr. Zuaiter and Dr. Arreaza briefly discuss HPV infection but pocus on the prevention of the infection with the vaccine. Dr. Arreaza mentions that HPV vaccine is also recommended by ASCCP to medical professionals. Written by Amanda Zuaiter, MS4, Ross University School of Medicine. Edits and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Human Papilloma Virus (HPV).According to the World Health Organization, cervical cancer is the 4th most common cancer affecting women globally. Annually, there are over 600,00 new cases and more than 300,000 deaths. The leading cause of cervical cancer is HPV. HPV, or human papillomavirus, is a prevalent virus that is spread through close skin-to-skin contact, mainly by sexual intercourse. It is the most common sexually transmitted disease in the United States. The term STI and STD are used indistinctively, but some people make a difference, such as Dr. Cornelius Reitmeijer. STI refers to sexually transmitted infection, which can be asymptomatic, and STD stands for sexually transmitted disease, which are the signs and symptoms caused by the multiplication of the infectious agent and disruption of bodily functions. STI is the preferred term, as recommended by experts during the last few years.  Low risk vs High risk HPV.There are over 200 strains of HPV which fall into two categories: low risk and high risk. The low-risk types, HPV 6 and 11, cause warts around the genitals, anus, mouth or throat. The high-risk types, HPV 16 and 18, are linked to cervical, vaginal, anal, and other cancers. Persistent infection with high-risk HPV types is the primary cause of cervical cancer, accounting for 70% of cervical cancer cases. While often asymptomatic, persistent HPV infections can develop into papular lesions which can cause bleeding and pain or cause sore throat and hoarseness if warts develop in the throat.Not all warts will turn into cancer, but the risk of a wart turning into cancer is higher than normal skin or mucosa that has not been infected by HPV.Even though cervical cancer is the most well-known condition linked to HPV, it's important to note that HPV isn't just a women's health issue. It can also cause cancers in men, such as throat, penile and anal cancers. Men, however, are not screened for HPV if they have no signs or symptoms of infection.HPV Prevention: General measures that can be taken are maintaining a healthy immune system by exercising regularly and a balanced diet and quitting smoking.Male circumcision has been shown to reduce the risk of penile cancer in men and their sexual partners may have a lower risk of cervical cancer. Screening: Women should undergo regular pap smears with HPV screening. Pap smear screening begins at the age of 21 and is recommended every 3 years. From ages 30-65, co-testing should be done every 5 years, according to the guidelines by the American College of Obstetrics and Gynecology. Also, HPV test self-collection is now available in the US since May 2024, and it is useful especially in rural areas.The most effective ways to prevent the transmission of HPV is to practice safe sex, using condoms, and getting vaccinated. HPV vaccine. For medical providers: It was announced only to ASCP (American Society for Colposcopy and Cervical Pathology) members in the middle of the pandemic. On February 19, 2020, ASCCP recommended HPV vaccination for clinicians routinely exposed to the virus.This recommendation encompasses the complete health care team, including but not limited to, physicians, nurse practitioners, nurses, residents, and fellows, as well as office and operating room staff in the fields of obstetrics and gynecology, family practice, gynecologic oncology, and dermatology. Let's remember that in 2018, the FDA a supplemental application for Gardasil 9 to include persons aged 27 to 45 years old. The ASCCP letter states “While there is limited data on occupational HPV exposure, ASCCP, as well as other medical societies, recommend that members actively protect themselves against the risks” among medical providers. For patients: The vaccine is given to prevent the types of HPV that are most likely to cause cancer and other health problems. It works by training the immune system to recognize and fight HPV before an infection can take hold. Gardasil-9® is the brand name that is offered in the US. The 9 means it targets 9 strains of the virus (6, 11, 16, 18, 31, 33, 45, 52, and 58). It's important to note that the vaccine is preventative, and it is not considered a treatment. This means it's most effective when given BEFORE any exposure to HPV, ideally during adolescence. The HPV vaccine is recommended for boys and girls ages 11-12 but can be started as early as the age of 9. We need to be prepared to manage vaccine hesitancy because some parents may be concerned when you explain the vaccine to them. A study done in Scotland found that there were NO cases of invasive cervical cancer in adults who received any doses of the HPV vaccine at 12 to 13 years of age. To get to that conclusion, they reviewed the cancer data of 447,845 women who were born between 1988 and 1996. The data demonstrated that the HPV vaccine prevents invasive cervical cancer, especially when given between 12 to 13 years of age. When the vaccine is given later in life, it tends to be less effective. AmandaHow is HPV vaccine given?The vaccine schedule is as follows: -For ages 9-14, two shots are given with the second dose 6-12 months after the first. -For those ages 15-26, three shots are given. After the first shot, the second is given after 1-2 months, and the third shot 6 months after the first. This is the same schedule for immunocompromised people regardless of their age. -People over the age of 26 can still receive the vaccine, as the FDA has approved the vaccine for individuals up to the age of 45. With that being said, those over the age of 26 may not fully benefit from the vaccine due to the fact they may have already been exposed to HPV. Still, vaccination can provide protection against other strains of the virus.Other HPV Vaccine considerations:Is HPV vaccine effective?-Studies have shown that the HPV vaccine is nearly 100% effective at preventing cervical pre-cancers caused by HPV 16 and 18.Are boosters needed?-The vaccine provides protection for at least 10 years and boosters are not required. The vaccine is recommended for boys too, as they are also at risk for HPV causing cancers, and administration of the vaccine helps to reduce the spread of the virus. It is safe to administer the HPV vaccine with all other age-appropriate vaccinations. What if my patient misses a dose?-If a dose is missed, it can be resumed at any time without restarting the series. There are no known severe side effects or reactions to the vaccine. The vaccine can be given even if the person has already been exposed to HPV as it can protect against the other types of HPV.Conclusion: HPV is a common cause of cervical cancer, and the benefits of the HPV vaccine are profound. Countries with high vaccination rates have already seen significant drops in HPV infections, genital warts, and cervical pre-cancers. Vaccination protects individuals and helps achieve herd immunity, benefiting entire communities.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Sabour, Jennifer, “The Difference Between STD and STI,” Verywell Health, August 22, 2024, https://www.verywellhealth.com/std-vs-sti-5214421. ASCCP Letter, February 19, 2020, https://www.asccp.org/hpv-vaccinationBarry HC. Scottish Screening: No Cases of Invasive Cervical Cancer in Women Who Received At least One Dose of Bivalent HPV Vaccine at 12 or 13 Years of Age. Am Fam Physician. 2024 Aug;110(2):201-202. PMID: 39172683. https://pubmed.ncbi.nlm.nih.gov/39172683/World Health Organization. “Cervical Cancer,” March 5, 2024, www.who.int/news-room/fact-sheets/detail/cervical-cancerACOG, “Cervical Cancer Screening FAQ,” www.acog.org/womens-health/faqs/cervical-cancer-screening. Accessed January 9, 2025.ACOG, “HPV Vaccination FAQ,” www.acog.org/womens-health/faqs/hpv-vaccination. Accessed January 9, 2025.Cox, J. Thomas and Joel M Palefsky, UpToDate, www.uptodate.com/contents/human-papillomavirus-vaccination, accessed January 9, 2025.National Cancer Institute. “HPV and Cancer.” National Cancer Institute, 18 Oct. 2023, www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer .Theme song, Works All the Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 181: Cannabinoid Hyperemesis SyndromeFuture Dr. Johnson explains the pathophysiology, assessment, and management of Cannabinoid Hyperemesis syndrome. Dr. Arreaza adds some insights on the topic.  Written by Tyler Johnson, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic abdominal pain, vomiting, or nausea in older adolescents and adults who have chronic ϲаnոаbis use.The term “marijuana” is considered racist by some people. In the 1930s, American politicians popularized the term “marijuana” in the U.S. to portray the drug as a “Mexican vice” and to have a justification to persecute Mexican immigrants. Epidemiology The overall prevalence of cannabinoid hyperemesis syndrome is unknown due to a lack of definitive criteria or diagnostic tests. It occurs in a population that may not disclose substance use. One study conducted in 2015 in a United States urban emergency department not named, found one-third of patients with near-daily cannabis use met criteria for having had CНЅ in the prior six months.Why are rates of CHS increasing?Between 2005-2014 hospitalizations cyclic vomiting syndromes increased by 60 %. concurrent cannabis use in hospitalized patients increasing from 2 to 21 percent. 7 years after the commercialization of cannabis in Canada, the Canadian health services found a 13-fold increase in cyclic vomiting syndromesPotential correlations for the increase in CHS are increased legalization and commercialization of cannabis, higher tetrahydrocannabinol concentrations in cannabis products, and increased recognition of the syndrome.Legal status of Cannabis in the USCannabis is legal in 24 states: Alaska, Arizona, California, Colorado, Connecticut, Delaware, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, Virginia, and Washington. It is also legal in Washington, D.C. Cannabis is approved for medical use in 38 states.Federal level: Cannabis is a Schedule I drug, under the Controlled Substance Act (added in 1970) in the group of Hallucinogenic or psychedelic substances. Tetra-hydro-cannabinol (THC, a “mind-altering substance in cannabis”) is on the same list. However, cannabidiol (CBD, derived from hemp or non-hemp plants) was removed from the Controlled Substances Act in 2018. CBD is FDA-approved (under the name of Epidiolex®) to treat rare seizure disorders. CBD is still on the list of controlled substances in some states. I see THC as a problem.THC increased concentration As recreational Cannabis becomes more normalized, innovators look to find new ways to differentiate their product and increasing THC has become a common way to perform this similar to alcohol content in the beer, wine, and liquor industry. An article by Yale School of Medicine titled “Marijuana: Rising THC Concentrations in Cannabis Can Pose Health Risks” states, “In 1995, the average THC content in cannabis seized by the Drug Enforcement Administration was about 4%. By 2017, it had risen to 17% and continues to increase. Beyond the plant, a staggering array of other cannabis products with an even higher THC content like dabs, oils, and edibles are readily available—some as high as 90%.”Recently, cannabis-infused water started to be sold in some grocery stores.Pathophysiology of CHSIt is not entirely understood. Some suggest multifactorial involving cannabinoid metabolism, exposure dose and tolerance modifying receptor regulation, complex pharmacodynamics at Cannabinoid receptors, and even changes in genetics and cannabinoid variation in plants. CB1 receptors are involved in gastric secretion, sensation, motility, inflammation, and lipogenesis. The activation of CB1 and CB2 receptors has been suggested as the possible cause of CHS.Risk FactorsCHS can occur after acute or acute on chronic use but many report daily 3-5x cannabis use cannabis use over one year and many over at least two years. Median age 24 years. Interesting factsMedical visits for inhaled cannabis are more likely associated with CHS while edibles are more likely for acute psychiatric reactions.Also, CHS is a paradoxical effect since cannabis and cannabinoid receptor agonists are known antiemetics (as seen in nabilone and dronabinol (synthetic analogs of THC)) and prescribed by some physicians to combat chemotherapy effects.Clinical Features of CHSCyclical pattern with abdominal pain, severe nausea, and vomiting up to 30 episodes daily. Pain is intense and even referred to as “scromiting” due to its intense nature, causing patients to scream and vomit concurrently.Typically, it presents with 2 or more episodes over a 6-month period with no symptoms in between. It starts within 24 hours of last cannabis use (differentiating from cannabis withdrawal) and occurs at day or night. There is a gradual symptom resolution of nausea and vomiting after several days of cannabis cessation. Some patients had symptoms 2 days to 2 weeks after cessation. Diagnosis of CHSClinical diagnosisRule out neurological symptoms such as migraine headaches, acute abdomen, motion sickness, and medications, such as recent antibiotics and chemotherapy.Often the diagnosis is discovered with a thorough history reporting a decrease in symptoms with hot showers/baths.Management of CHS AcuteRehydrate with Fluids Dopamine Antagonists– Droperidol (0.625 or 1.25mg) /Haloperidol (0.05 to 0.1mg/kg with max dose of 5mg initially) favored over typical antiemetics like Zofran or Reglan.If needed, combine with an antiemetic like metoclopramide IM or ondansetron IV and consider patients' dehydration status likely requiring US-guided IV.Topical capsaicin cream 0.025 – 0.1% on the abdomen. Long term97% resolution of symptoms completely in a systematic review of patients who stopped cannabis use.Reinforce it may take several weeks of abstinence for symptoms to resolve and symptoms can worsen if cannabis is resumed. It is unknown if a reduction in use can prevent recurrence.Approaches in the clinicEducate patients on the etiology of their symptoms with complete cessation of cannabis use.Consider referral to counseling for cannabis use disorder and abstinence support for treatment-seeking cannabis users. Approach topics such as changing one's environment, seeking social support, and using self-help techniques to non-treatment-seeking individuals.Consider referring patients with polysubstance use and significant comorbidities to a supervised withdrawal management setting. Conclusion: Cannabis use is increasing with legalization and commercialization across the United States. With increased use, Cannabinoid hyperemesis syndrome incidence increases. Often it can be diagnosed with a thorough history including chronic cannabis consumption and symptomatic relief by showers. Physicians will need to develop counseling approaches to better understand CHS patients and how to approach an often-difficult topic.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Angulo MI. Cannabinoid Hyperemesis Syndrome. JAMA. 2024;332(17):1496. doi:10.1001/jama.2024.9716. Link: https://jamanetwork.com/journals/jama/fullarticle/2824833#:~:text=Cannabinoid%20hyperemesis%20syndrome%20(CHS,last%20less%20than%201%20week.Backman, Isabella, Marijuana: Rising THC Concentrations in Cannabis Can Pose Health Risks, Yale School of Medicine, August 30, 2023. https://medicine.yale.edu/news-article/not-your-grandmothers-marijuana-rising-thc-concentrations-in-cannabis-can-pose-devastating-health-risks/Buchanan, Jennie A and George Sam Wang, Cannabinoid Hyperemesis Syndrome, Up To Date, updated July 17, 2024. https://www.uptodate.com/contents/cannabinoid-hyperemesis-syndromeTheme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 180: Pediatric Hip PainFuture Dr. Pena-Brockett explains the differential diagnosis in a 14-year-old patient who has a new onset of left hip pain. Dr. Arreaza adds comments and explains toxic synovitis.  Written by Natalie Pena-Brockett, MSIV, California Health Sciences University. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Having a limping kid can be terrifying. Many questions may cross your mind: Is this a permanent damage? What is going on here? Where is the pain located? Do I need to send this child to the hospital? Today, hopefully, we can help you ease some of your fears. Case: This is a 14-year-old boy with no past medical history, no trauma, presents to the family medicine clinic with a complaint of left-sided hip pain. Mom notes that her son has been limping for the last week and complaining of pain in his left hip and knee when he walks. He has never experienced this pain before this week. He does not take any medications. Physical exam: He is afebrile and all of his vitals are within normal limits. On exam, you note that his BMI is at the 90th percentile (overweight), and has an antalgic gait where he is favoring the right side and has tenderness on his left groin. His left foot is turned outward while standing up straight. His left knee has negative findings on specialized tests, but he has restricted movement of the left hip. Discussion: This is a common topic that you will see on board exams or limping into your office. Although pediatric hip pain may seem like a benign musculoskeletal concern, taking the time to take a complete history and perform a thorough physical exam is critical to assess the severity of the patient's concern.Physical Exam for Pediatric Hip Pain.Observation: Every physical exam begins the moment you first see the patient. This allows you to gauge the patient's comfort level, the natural stature, length, and positioning of the patient's extremities, skin changes, gait, and ability to bear weight. Palpation: In medicine, our hands are one of our greatest tools for evaluating patients, especially those with musculoskeletal concerns. This is the time to palpate the area for any tenderness or gross deformities of the pelvis, hip, knee, or leg. Special Tests: In the world of MSK, we have all sorts of tests to evaluate the range of movement of our joints and tendons. When specifically evaluating the hip, the most common are the FABER(flexion, abduction, external rotation),test to assess the sacroiliac joint, Ober's Test to assess the iliotibial band, and Straight Leg Raise to assess for lumbar radiculopathy.Legg-Calve Perthes Disease-Legg-Calve Perthes disease is an idiopathic avascular necrosis of the femoral head. -It is most commonly observed in patients between the ages of 2-12 years and in a higher ratio of males to females 1. -It often manifests as an atraumatic limp with limited movement in abduction and internal rotation. -X-ray imaging may demonstrate a widening of the joint space and sclerosis of the femur, and MRI will confirm osteonecrosis of the femoral head. -Early diagnosis is key to minimizing the risk of developing osteoarthritis of the hip. -The goal of treatment is to maintain the shape of the femoral head and the range of motion of the hip. -The first-line treatment includes managing pain with NSAIDs, limiting weight-bearing activity, and physical therapy for range of motion.-If the disease progresses, bracing and casting can be used to retain the femoral head within the acetabulum to keep the shape and integrity of the femoral head. In more serious cases, a surgical osteotomy may be done to cut and realign the bones. Developmental Dysplasia of the Hip (DDH)-Developmental Dysplasia of the Hip (DDH) is a pediatric condition that results in unilateral or bilateral instability of the hip due to the abnormal development of the acetabulum or femur. -This is most commonly seen in newborns, especially those which develop in a breech position. -These patients often present with a shortened leg or asymmetric gluteal creases and a Trendelenburg gait when walking. -The Trendelenburg gait is an abnormal gait caused by weak hip abductor muscles. The person's trunk shifts over the affected hip during the stance phase of walking and away from it during the swing phase, making it look like the person is missing steps or limping. -On physical exam, hip joint laxity can be evaluated with the Ortolani and Barlow maneuvers to apply pressure to the proximal femur to assess dislocatability of the hip joints. These maneuvers would both be considered positive if a “clunk” is felt over the hip as this means that the hip is dislocated with pressure. Due to the patient's age usually being under 6 months old, ultrasound is the most common imaging modality to confirm the diagnosis, otherwise, an X-ray can be used. -The treatment in patients under 18 months old, a Pavlik Harness is often used to treat patients to maintain the placement of the hip within the acetabulum. -Patients between the ages of 18 months and 9 years old, are most often treated with open or closed reduction of the hip. -There is generally less success in reduction treatment of children older than 9 years old as they have likely developed femoral head deformities and are at greater risk of osteonecrosis. -Children with DDH should continue to be monitored with regular imaging to evaluate for complications. These patients should also be made aware that they are also at increased risk of requiring a hip replacement, especially if their treatment included a reduction. 2Slipped Capital Femoral Epiphysis (SCFE)-Slipped Capital Femoral Epiphysis (SCFE) is one of the most common pediatric hip pathologies in which the capital femoral epiphysis is anterolaterally displaced from the femoral neck. -Although slightly more common in males than females between the ages of 10 to 16, the greatest risk factor for an SCFE is childhood obesity 3. -Common symptoms include an insidious onset of unilateral hip pain and a change in gait due to the displacement of the hip from the acetabulum. In some instances of chronic SCFE, some patients will experience ipsilateral knee pain due to compensation. -A SCFE can be evaluated with an AP radiograph which will demonstrate a widened physis in the early stages or the classic “slipped ice cream cone sign” which is the posterior displacement of the femoral epiphysis. -Management of a SCFE includes limiting weight-bearing activities as well as screw fixation by an orthopedic surgeon to stabilize the hip.Patients should consider pinning the contralateral hip due to increased risk of developing a future SCFE. Early diagnosis is critical as untreated SCFE can lead to osteonecrosis.Osgood-Schlatter-Osgood-Schlatter is a repetitive-use pediatric condition as a result of traction to the growth plate of the tibial tubercle. -This pathology is most common in male children between the ages of 9 to 14 years old 4. -Active athletes or children with rapid growth spurts are at greater risk of developing Osgood-Schlatter than non-active children.-These children often present with an achy knee pain that can lead to a unilateral limping gait.  On physical exam, these patients often have a bony prominence over the tubercle that is tender to palpation with greater tenderness over the patellar tendon. -The knee will have full range of motion and stability, but will likely have a warmth and erythema over the knee.  Imaging of the knees can have nonspecific findings and diagnosis is made clinically. -For management, it is recommended that children continue their regular activities and rest with NSAIDs for pain management as needed 5. Physical therapy can be prescribed to prevent deconditioning as this can result in recurrence or additional injuries.Arreaza: It seems like the pain is more localized to the knee, but it can be referred to the hip. If you have tenderness on the tibial tubercle, you got the diagnosis. Juvenile Idiopathic Arthritis (JIA)-Juvenile Idiopathic Arthritis (JIA) is a systemic rheumatologic condition in children that often presents as a polyarticular pain. The onset of disease is often bimodal with peaks between 2 to 5 years old and 10 to 14 years old. 6-Patients will often complain of minor symmetric joint pain and stiffness until an infection causes an inflammatory reaction that exacerbates the joint pain or can increase joint involvement. Small joints are the most likely to be involved, but hips and knees can also be affected. -Lab evaluation will demonstrate inflammation with an elevated ESR, low hemoglobin, and a positive ANA. -Disease management starts with NSAIDS for pain control and can escalate to immunosuppressive measures for moderate disease7.Toxic Synovitis-Toxic synovitis, also known as transient synovitis, is the leading cause of acute hip pain and limping in children aged 2–12, more commonly affecting boys. -This self-limited inflammatory condition, often confused by its name as "toxic," has no relation to a toxic state. It typically arises after an upper respiratory or other viral infection (e.g., rubella or coxsackie virus).-Children with toxic synovitis may show mild to moderate hip pain, limp, and keep their hip in abduction and external rotation. Movement is usually possible within a limited range, and weight-bearing is often maintained.-Evaluation: A thorough history and physical exam are key, as laboratory tests like CBC, ESR, and CRP are often normal, mainly used to rule out other conditions like septic arthritis. X-rays typically show no abnormalities, although small changes may appear. Ultrasound can help detect joint effusion and rule out septic arthritis if no effusion is present.Arreaza: DDX: DDH, SCFE, Osgood Schlatter, and toxic synovitis.Osteopathic Manipulative Treatment in Pediatric Hip PathologiesSacroiliac Articulatory Technique- this is a technique in which you move the joint into an out of its barrier to reduce restriction and improve movementCounterstrain of Tender points (psoas, piriformis, hip adductors)- in this technique we shorten the muscle to decrease tension.  This allows the muscle to increase blood lymphatic flow to reduce nociceptive and proprioceptive activity of the muscleBalanced Ligamentous Tension of the Innominate- with this technique, we manipulate the joint in a way that moves the ligaments into neutral position so that there is balance in all planes of motion.  The goal is to again release tension within the muscles and the jointClinical Decision Making Now that we have covered the most common differential diagnoses for pediatric hip pain, let's revisit our patient presentation and identify the key characteristics to determine which diagnosis he most likely has.The patient is 14 years old.  This makes DDH and Legg-Calve Perthe less likely, and SCFE more likely.He has been complaining of symptoms for 1 week, which indicates that is not likely a chronic condition. This makes DDH and Osgood-Schlatter less likely.The patient has never experienced joint pain like this before.  This makes JIA, DDH, and Osgood-Schlatter less likely.The patient is overweight. This makes SCFE more likely.The unilateral hip tenderness and no knee pain.      This makes Osgood-Schlatter and JIA less likely.The patient has antalgic gait and limited internal rotation of the foot. This makes Legg-Calve Perthes and SCFE more likely. Now when we take the epidemiological factors, the history of the present illness, and the physical exam findings into account, this patient's presentation best aligns with a SCFE. We would order a bilateral AP and Frog-leg views of the hips. If either imaging shows a widened physis or the classic “ice cream cone sign”, this is when we would start the referral process for an orthopedic surgery consultation for internal fixation. As family medicine physicians, we would give instructions for strict non-weight bearing activities and analgesics or anti-inflammatories for pain management.Keep in mind some of the DDX: Calve Legg-Perthes disease, Developmental Dysplasia of the Hip (DDH), Juvenile Idiopathic Arthritis (JIA), Osgood Schlatter, toxic synovitis, and Slipped Capital Femoral Epiphysis (SCFE). Hopefully, the next time you have a pediatric patient present with a complaint of hip pain, you'll feel more comfortable evaluating and working up the case._________________________This week we thank Hector Arreaza and Natalie Pena-Brockett. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Osteonecrosis of the femoral head / Legg-Calvé-Perthes disease | Time of Care. Accessed October 27, 2024. https://www.timeofcare.com/osteonecrosis-of-the-femoral-head-legg-calve-perthes-disease/Scott EJ, Dolan LA, Weinstein SL. Closed Vs. Open Reduction/Salter Innominate Osteotomy for Developmental Hip Dislocation After Age 18 Months: Comparative Survival at 45-Year Follow-up. J Bone Joint Surg Am. 2020;102(15):1351-1357. doi:10.2106/JBJS.19.01278. https://europepmc.org/article/med/32769602Perry DC, Metcalfe D, Costa ML, Van Staa T. A nationwide cohort study of slipped capital femoral epiphysis. Arch Dis Child. 2017;102(12):1132-1136. doi:10.1136/archdischild-2016-312328. https://pubmed.ncbi.nlm.nih.gov/28663349/Haines M, Pirlo L, Bowles K-A, Williams CM. Describing Frequencies of Lower-Limb Apophyseal Injuries in Children and Adolescents: A Systematic Review. Clin J Sport Med. 2022;32(4):433-439. doi:10.1097/JSM.0000000000000925. https://pubmed.ncbi.nlm.nih.gov/34009802/Wall EJ. Osgood-Schlatter disease: practical treatment for a self-limiting condition. Phys Sportsmed. 1998;26(3):29-34. doi:10.3810/psm.1998.03.802. https://pubmed.ncbi.nlm.nih.gov/20086789/Oberle EJ, Harris JG, Verbsky JW. Polyarticular juvenile idiopathic arthritis - epidemiology and management approaches. Clin Epidemiol. 2014;6:379-393. doi:10.2147/CLEP.S53168. https://pubmed.ncbi.nlm.nih.gov/25368531/Beukelman T, Patkar NM, Saag KG, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken). 2011;63(4):465-482. doi:10.1002/acr.20460. https://pubmed.ncbi.nlm.nih.gov/21452260/Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 179: Impact of intermittent fasting Impact on T2DMFuture Dr. Carlisle explains the physiology of fasting and how it can help revert type 2 diabetes. Dr. Arreaza adds details on how to do intermittent fasting. Written by Cameron Carlisle, MSIV, Ross University School of Medicine. Comments and edits by Hector Arreaza, MD, FAAFP.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is type 2 Diabetes Mellitus (T2DM)?-Type 2 Diabetes Mellitus (T2DM) is a metabolic disorder characterized by insulin resistance and impaired glucose regulation. -This impaired regulation can lead to hyperglycemia, contributing to complications in a myriad of organs: heart, kidneys, eyes, nerves, etc. (target organs). According to the CDC, more than 38 million Americans have T2DM (about 1/10 people). -Multiple mechanisms are believed to contribute to insulin resistance in obese patients with T2DM, such as increased lipid deposition throughout the body and systemic inflammation.What is Intermittent Fasting (IF)? Intermittent fasting (IF) has recently gained popularity as a dietary approach for health benefits, but it has been around for thousands of years. IF is an eating pattern that alternates between eating and fasting (no calories consumed) over a specific period of time. When you are fasting, you are allowed and encouraged to keep drinking water and non-caloric drinks, like coffee, tea, and even homemade bone broth.-According to the International Food Information Council Foundation (IFIC), 10% of Americans engage in IF daily. -According to Mark Mattson, a neuroscientist and IF expert for over 25 years, a mechanism called “metabolic switching” is seen with IF. This is when your body runs out of glucose and starts burning fat (i.e., fatty oxidation). These metabolic changes can help protect your organs and reduce the risk of chronic conditions, like T2DM. Common IF methods: Time-restricted eating: Most common method, involves eating within a specific time frame (e.g., the 16:8, 18:6, 12:12 method is also common.  [16:8 means you have 16 hours of fasting and 8 hours of eating.]Alternate-day fasting: Alternating between fasting days and normal eating days.  [Find more info in The Complete Guide to Fasting, by Jason Fung, who is a nephrologist, he explains that alternate-day is basically eating every other day, which would give 36 hours of fasting, but if you are a beginner you can try a 24 hours fasting, in short, not eating breakfast any day of the week and having lunch 4 days a week, and dinner every night.]5:2 diet (aka periodic fasting): Maintaining a normal diet for 5 days, with 2 days (usually non-consecutive) of caloric restriction (25% of normal caloric intake; e.g., 500 calorie meal). IF is strongly believed to improve metabolic health in individuals with T2DM by reducing insulin resistance via increasing insulin sensitivity, promoting weight loss (patients with obesity and DM… AKA patients with diabesity), and enhancing lipolysis via fat oxidation.While fasting, the body goes through several phases that affect how energy is metabolized. Between 0 and 4 hours after eating, the body enters a feeding state, using glucose as its main energy source. After fasting for 12-16 hours, the body enters ketosis and starts to use fat for energy. Within 24-36 hours, autophagy begins, a process that recycles damaged cells and allows for cellular repair. This process can have great benefits for people with T2DM, such as improved insulin sensitivity and glucose regulation. Pathophysiology of Implementing IF in T2DM. -IF is thought to increase insulin sensitivity by decreasing fatty tissue in the body (i.e., visceral adipose tissue), which is correlated to insulin resistance. Insulin resistance is defined as higher than normal circulating insulin levels needed for a glucose lower response, which is thought to be the culprit for the generation of T2DM. It means you need high levels of insulin to keep glucose normal. -Obesity is an important risk factor for T2DM. Visceral adipose tissue functions as an organ via the secretion of adipokines (cytokines or cellular messengers produced by adipose tissue): leptin and adiponectin. Leptin: proinflammatory, leading to chronic inflammation. Patients with higher BMI levels and increased insulin resistance were found to have increased leptin levels.[Leptin is a good hormone at normal levels, but there is leptin resistance] Adiponectin: anti-inflammatory and antidiabetic effects. Higher adiponectin levels result in decreased hepatic gluconeogenesis, enhanced glucose absorption, and enhanced skeletal muscle and hepatic fatty acid oxidation. Levels drop as visceral fat increases. -Dr. López-Jaramillo, a Colombian endocrinologist and researcher, and colleagues published a review in 2014 examining the imbalance in the levels of leptin and adiponectin in individuals with metabolic syndrome. This imbalance (increase in leptin and decrease in adiponectin) is linked to obesity and insulin resistance, which has been shown to increase the risk of T2DM. It has been shown that IF has resulted in the reduction of leptin levels and increased levels of adiponectin, which leads to decreased insulin resistance and increased insulin sensitivity. -IF allows pancreatic beta-cells to rest by not having to secrete insulin constantly. This allows the beta-cells of the pancreas to improve in function over time. In addition, IF has been shown to lead to noticeable weight loss and loss in body fat, both of which play an important contribution in managing T2DM. Research demonstrates that this weight loss increases insulin sensitivity and decreases the need for insulin therapy, making IF a powerful approach for improving metabolic health. AMP-Activated Protein Kinase (AMPK) and Its Role in IF and T2DM Recent research has highlighted an important enzyme seen in IF, AMP-activated protein kinase (AMPK), which plays a vital role as an important energy sensor in cells. It is activated when cellular energy levels are low, such as during IF. A 2020 research study in Nature Reviews Endocrinology explains that activation of AMPK aids in suppressing gluconeogenesis and stimulates fatty acid oxidation, leading to optimal energy balance and reduction of visceral adipose tissue accumulation, a major contributor to insulin resistance and T2DM progression. AMPK is upregulated during fasting, which enhances glucose metabolism and reduces insulin resistance. This is imperative in managing T2DM, as it counters the effects of insulin resistance associated with T2DM.Exercise, which also promotes AMPK activation, complements IF and can promote a synergistic effect in improving insulin sensitivity and promoting fat burning, New Research Findings on IF and T2DM -The EARLY (Exploration of Treatment of Newly Diagnosed Overweight/Obese Type 2 Diabetes Mellitus) study is a randomized clinical trial published in JAMA Network Open (2024). Findings In this randomized clinical trial study found that a time-restricted eating window significantly improved fasting glucose levels and HbA1c levels in individuals with T2DM. The study examined the effect of a 16-week 5:2 meal replacement (5:2 MR) fasting plan that consisted of five days of normal eating and 2 days, nonconsecutive of restricted diet (500-600 calories). This group was examined alongside a group of patients who took metformin 0.5 g BID and empagliflozin 10 mg QD. The study wanted to investigate the changes in HbA1c in Chinese adults with early T2DM.-The study was a randomized clinical trial of 405 adults, and a study showed that the 5:2 MR approach led to better glycemic control at 16 weeks compared to the counter treatments with metformin and empagliflozin. The 5:2 MR group had the greatest reduction in HbA1c (-1.9%), followed by metformin (-1.6%), and empagliflozin (-1.5%). The 5:2 MR plan also revealed the greatest weight loss (-9.7 kg), followed by empagliflozin (-5.8 kg), and metformin (-5.5 kg). -This research suggests IF, such as 5:2 MR, can be a powerful tool in the management of T2DM and improving metabolic health. This study can potentially open doors for healthcare providers to provide the 5:2 MR approach for individuals as an effective initial lifestyle intervention. However, follow-up studies are needed to assess the effectiveness and durability of the 5:2 MR.Safety and Risks of IF in T2DM. -IF when combined with glucose-lowering medications (e.g., insulin, sulfonylureas, GLP-1 agonists) can increase the risk of hypoglycemia. Also, prolonged fasting can lead to nutrient deficiencies if not planned carefully. Patients should be counseled on maintaining a balanced, nutritious diet during non-fasting days. -IF is not suitable for everyone. Children under the age of 18 should not try IF due to needing proper calories for adequate development and proper growth. Also, it is recommended that pregnant or breastfeeding women do not undergo IF. It is advised that people with eating disorders should not try IF. -Individuals with certain medical conditions, such as kidney stones or gastroesophageal disease should speak with their doctor before trying IF. Also, patients on insulin or other glucose-lowering medications should adjust their dose and talk with their healthcare providers to prevent hypoglycemia during fasting. It is recommended that each person speak with their doctor to discuss the safety and risks of IF and see if it would benefit the individual before starting IF. -Many studies have explored the benefits of IF at the micro level revealing its cellular benefits and on a macro level of the body as a whole. However, more research is needed to confirm the long-term effects of IF on glycemic control and its sustainability as a therapeutic approach for T2DM. Conclusion:-IF shows potential for improving glycemic control, promoting weight loss, and enhancing metabolic health in individuals with T2DM. Despite its benefits, IF may present with risks, such as hypoglycemia, nutrition deficiencies, or dehydration in certain patients. Therefore, it may not be suitable for all individuals. It's important to monitor patients who engage in IF, especially for patients with T2DM. Patients should follow up with their doctor for individualized IF plans in patients with T2DM. ______________This week we thank Hector Arreaza and Cameron Carlisle. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Albosta, Michael, and Jesse Bakke. “Intermittent Fasting: Is There a Role in the Treatment of Diabetes? A Review of the Literature and Guide for Primary Care Physicians - Clinical Diabetes and Endocrinology.” BioMed Central, BioMed Central, 3 Feb. 2021, doi.org/10.1186/s40842-020-00116-1.Blumberg, Jack, et al. “Intermittent Fasting: Consider the Risks of Disordered Eating for Your Patient - Clinical Diabetes and Endocrinology.” BioMed Central, BioMed Central, 21 Oct. 2023, https://clindiabetesendo.biomedcentral.com/articles/10.1186/s40842-023-00152-7.De Cabo, Rafael, and Mark P. Mattson. “Effects of intermittent fasting on health, aging, and disease.” New England Journal of Medicine, vol. 381, no. 26, 26 Dec. 2019, pp. 2541–2551, https://doi.org/10.1056/nejmra1905136.Guo, Lixin, et al. “A 5:2 intermittent fasting meal replacement diet and glycemic control for adults with diabetes.” JAMA Network Open, vol. 7, no. 6, 21 June 2024, https://doi.org/10.1001/jamanetworkopen.2024.16786.Herz, Daniel, et al. “Efficacy of Fasting in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review.” Nutrients, U.S. National Library of Medicine, 10 Aug. 2023, www.ncbi.nlm.nih.gov/pmc/articles/PMC10459496/. Herzig, S., & Shaw, R. J. (2018). AMPK: Guardian of metabolism and mitochondrial homeostasis. Nature Reviews Molecular Cell Biology, 19(2), 121-135.Longo, V. D., & Mattson, M. P. (2014). Fasting: Molecular mechanisms and clinical applications. Cell Metabolism, 19(2), 181-192. https://doi.org/10.1016/j.cmet.2013.12.008López-Jaramillo P, Gómez-Arbeláez D, López-López J, et al. The role of leptin/adiponectin ratio in metabolic syndrome and diabetes. Hormone Molecular Biology and Clinical Investigation. 2014;18(1):37–45.Mattson, Mark P., et al. “Impact of intermittent fasting on health and disease processes.” Ageing Research Reviews, vol. 39, Oct. 2017, pp. 46–58, https://doi.org/10.1016/j.arr.2016.10.005. Patikorn, Chanthawat, et al. “Intermittent fasting and obesity-related health outcomes.” JAMA Network Open, vol. 4, no. 12, 17 Dec. 2021, https://doi.org/10.1001/jamanetworkopen.2021.39558.Sharma, Suresh K, et al. “Effect of Intermittent Fasting on Glycaemic Control in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.” TouchREVIEWS in Endocrinology, U.S. National Library of Medicine, May 2023, www.ncbi.nlm.nih.gov/pmc/articles/PMC10258621/#:~:text=In%20IF%2C%20eating%20habits%20are,the%20risk%20of%20developing%20T2DM.Xiaoyu, Wen, et al. “The effects of different intermittent fasting regimens in people with type 2 diabetes: A network meta-analysis.” Frontiers in Nutrition, vol. 11, 25 Jan. 2024, https://doi.org/10.3389/fnut.2024.1325894. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 178: Social Media in MedicineDr. De Luna and Dr. Song explain the role of social media in medical education and how online journal clubs have become more useful in recent years.  Dr. Arreaza offers insights into our role as educators and sources of truth.Written by Patrick De Luna, MD. Comments by David Zheng Song, MD, and Hector Arreaza, MDYou are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Intro to episode (voiceover): Get ready to listen to a great conversation between three doctors diving into the impact of social media on medicine. It's no secret that social media shapes our lives—not just as professionals, but also as humans and members of our society. Every second, new information floods our feeds, and with the rise of artificial intelligence, it's becoming harder to separate fact from fiction. As doctors, we have a crucial role in clearing up confusion and supporting evidence-based practices. You'll hear insightful tips from Dr. De Luna, Dr. Song, and Dr. Arreaza—but remember, you also have a role in spreading the truth, you must be a reliable source of online truth and correct misinformation quickly. Also, use reliable sources, recommend fact-check websites, including Snopes, and FactCheck.org, and avoid “back-and-forth” arguing about fake news online, because as you keep arguing, fake news will continue to spread.Social Media in Medicine.Patrick: Social media has helped both physicians and patients obtain and expand their knowledge of medicine. This role in medical knowledge expansion has been more prevalent since the COVID-19 pandemic, especially in the form of podcasts (like this one), medical content creators, and personalities.  This growing medium has helped physicians to deliver medical knowledge in an efficient, but layman, format which can become a great outreach and educational tool. Arreaza: This podcast was created 3 days before the lockdown. It has been an educational tool for those who record and hopefully for those who listen to us.Patrick: In today's episode, we will explore a little about how this more accessible approach to medical learning has shaped our medical education landscape. We'll explore a recent study that shows the breakdown of how social media is used among medical professionals and the concerns that physicians have about medical education through social media. We will discuss how platforms such as X/Twitter have “Journal Club” threads and their implications. Furthermore, will discuss how online personalities have been able to bring medical education discussion to the broader population, and what we can learn from their work. David: Who is your favorite medical educator?Patrick: Dr. Mike (YouTube FM), Dr. Glaucomflecken (ophthalmologist comedian), and HealthyGamerGG (gamer), and yours?David: Curbsiders (THE internal medicine podcast)Arreaza: I like Dr. Glaucomflecken as well. He is a comedian but he is becoming a little more political. The AFP podcast is my favorite.David: We will explore and discuss how we could make quality and accurate medical education content and, hopefully, mitigate concerns about creating future educational content for physicians and patients alike. Analysis of Healthcare Professional Social Media UsePatrick: Social media has traditionally been used to share about your social life (posting pictures of your cat and family vacation), stay up to date on news and what is happening among your peers, as well as (for some select folks) a platform for content creation and a means of a career. Healthcare professionals also participate in social media in the same manner. David: Some social media users are called “influencers”. Arreaza: The term “influencer” is becoming a somewhat negative term online because many “influencers” are giving a bad reputation to that term, to the point that many prefer to be called “content creator.”Patrick: In a recent study published in Taylor and Francis' Medical Education Online, 72.1% of the participants reported use of social media to some degree. Out of the 72%, 11.5% of the surveyed report using social media sites exclusively for professional purposes, 22.8% for strictly personal use, and 65.7% for both. David: The most used social media platforms among healthcare workers were Facebook at 70%, YouTube 58%, LinkedIn 52%, Instagram 42%, Twitter (now called X) 27%, TikTok 10%, and Reddit at 5% among those surveyed. Those are 6 different media, which ones do you currently use, Patrick?Patrick: [Add response]. 20.4% of the surveyed indicated they use clinically focused social media platforms as well. This same survey found that respondents specializing in addiction medicine, family medicine, pediatrics, and psychiatry were more likely to use social media for continued professional development as compared to other specialties. David: Social media among the participants was highly used for staying informed with medical news and actively participating in medical discussions online, especially about medical management and treatments. Of note, the data is based on a population that skews more toward physicians and medical professionals who have practiced for more than 15 years. Arreaza: Doximity is one of those platforms that I have used in the past, and it contains interesting articles but they have to be read “with a grain of salt,” because they are editorials.The “New Journal Club” OnlinePatrick: Multiple residency programs report using social media as a form of engagement about published journal articles and updates to medical practice. Medical education may benefit from the implementation of social media and similar platforms as a medium for professional development, according to an analysis performed by Medical Education Online. The use of social media among many physicians has changed from content consumption (passive) to active participation in furthering medical education. David: This is reflected heavily in how platforms such as X (formerly known as Twitter), have become a forum towards a new form of “Journal Club”.Tweet Threads can now be utilized for further publication discussion in an open online space.  Good examples of this can be found among Twitter feeds from publication sites like the New England Journal of Medicine or #IDJClub (Before their move to Meta's Threads in November 2023). The Infectious Disease Journal Club, using the handle @IDJClub, published a study in May 2022 highlighting the impact of 20 months of journal club hosting through Twitter.Patrick: The authors of the study state that it may be harder for physicians outside of academic circles to have opportunities for well-scaffolded discussions and continued maintenance of critical appraisal skills. Due to an explosion of questionable medical literature during to COVID-19 pandemic (AKA fake news), they report a higher need for avenues to keep the practice of critical appraisal, thus we need to expand journal club access outside of academic sites.Arreaza: From May 19, 2019 – August 7, 2021, the @IDJClub account was followed by almost 9,500 followers from 114 countries and hosted 31 journal club posts and discussions. During the study, they found data that shows a decrease in participation in journal clubs use in residencies, as well as a lack of expert hosts to lead those discussions. Patrick: In addition to the increased accessibility, the survey makes a case that online interdisciplinary journal clubs can be an effective tool to update medical professionals and for practicing critical appraisal of the research studies. 75% of respondents believed that they learned more from these #IDJClub discussions than in their traditional journal club forums (if such forums were available to their respective programs). A case is made where it could be reflective of easier access, the make-up of how the publication is presented, and how the overall journal club is run. Concerns and Challenges to AvoidDavid: As well-intended and useful as these platforms for medical education can be, some authors from AAFP recommend that we be mindful of problems that can occur from misapplied use. Patrick: One problem that has been brought to the AAFPs' attention is potential society and licensing board actions. Medical boards, such as our own California Medical Board, can sanction physicians, uphold practice restrictions, or even take away physician licenses due to unprofessional behavior in social media content creation. This is especially worrisome if posting scientifically misleading or untrue claims.David: One example was an incident here in Bakersfield where 2 physicians used YouTube to post the results of COVID-19 tests at their urgent care during the peak of the pandemic. They misled the public in stating the disease did not have serious ramifications as the CDC stated. Due to the large number of viewers, the physicians were censured by medical societies due to their distribution of biased and unfounded information to the public. Patrick: AAFP authors suggest that for medical statements and discussions posted on social media for general patient education, it is recommended to add hyperlinks or direct sources with any online interaction in-so-that it better qualifies accuracy. If it's unverifiable, it would be best to add written caveats about the information's non-verifiability or that it is in the process of continued research. Patrick: At this time, there is some effort made by social media platforms to help indicate that the post is made by a reputable source. For example, when a licensed medical professional posts on YouTube, there are information panels that appear that will give context to the health content that is viewed. At the time of this episode, YouTube also currently allows channels to apply to be indicated as a licensed medical professional in the channel's posts. The applicants are examined by three different medical societies: the Council of Medical Specialty Societies (CMSS), the National Academy of Medicine (NAM), and the World Health Organization (WHO) to standardize how health education should be shared online. David: An example being Dr. Lin of Common Sense Family Doctor, an online medical blog for patients and physician education. In his statement to AAFP, he states that he wanted to post educational content twice a week, however, it required 3 to 4 hours a week to create. This can be time-consuming and distracting from other responsibilities.Arreaza: Social media can change mind. What other concerns do you think should be considered when physicians try to educate patients in an online environment?Social Media Platforms to Teach Medicine to the Greater Public Patrick: In general, social media platforms can be used to educate the public. One AAFP panel of authors wrote that some key points are important to consider when creating online content that is meant for public use.We must define our goals toward the subset population we are directing the education towards. Is it providing general health education? Is it promoting a practice? Is this used to advocate for a cause?We must consider who our audience is. For example, if our goal is to create a professional message to incite political or societal change towards public health policy, it would be best to utilize platforms that involve policymakers, political leaders, and/or patients that can inform them of what we want to achieve. Focus on general topics. These can include topics such as viral medical discussion trends on platforms like TikTok (ex. Ozempic), fitness and wellness, nutrition, or topics that you yourself have interest or expertise in. This can lead to the production of original content such as informatic YouTube series', podcasts such as this one, or discussion threads. AAFP recognizes that this can become a creative outlet for physicians and can reduce burnout.ConclusionPatrick: We can see the transformative impact of social media on medical education, and how it's further evolved since the COVID-19 pandemic. We explored how platforms like Twitter have redefined traditional journal clubs, making scholarly discussions more accessible across global medical communities. Moreover, we examined the role of influential medical content creators in bridging the gap between healthcare professionals and the general public. Patrick: While social media presents unprecedented opportunities for disseminating medical knowledge, our discussion also highlighted the challenges, including the need for accuracy in content, navigating professional conduct, and addressing algorithmic biases that can influence online interactions.Patrick As we conclude, it's evident that social media has revolutionized medical education by fostering broader engagement and democratizing access to knowledge. However, both physicians and content creators must uphold ethical standards and ensure the accuracy of information shared online. By navigating these challenges thoughtfully, we can harness its full potential as a powerful tool for advancing medical education and improving health outcomes in our local communities. ____________________This week we thank Hector Arreaza, Patrick De Luna, and David Zeng Song. Audio editing by Adrianne Silva. Intro by Raj Ajudia, MSIII. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________Links:Topf, Joel M., Introduction: Social Media and Medical Education Come of Age, Seminars in Nephrology, Volume 40, Issue 3, 247 – 248. https://www.seminarsinnephrology.org/article/S0270-9295(20)30043-7/fulltextNguyen BM, Lu E, Bhuyan N, Lin K, Sevilla M. Social Media for Doctors: Taking Professional and Patient Engagement to the Next Level. Fam Pract Manag. 2020;27(1):19-14. https://www.aafp.org/pubs/fpm/issues/2020/0100/p19.htmlIserson KV, Derse AR, Delpier M. Navigating the Hazards of Social Media. Fam Pract Manag. 2022;29(3):15-20. https://www.aafp.org/pubs/fpm/issues/2022/0500/p15.htmlVan Ravenswaay L, Parnes A, Nisly SA. Clicks for credit: an analysis of healthcare professionals' social media use and potential for continuing professional development activities. Med Educ Online. 2024 Dec 31;29(1):2316489. doi: 10.1080/10872981.2024.2316489. Epub 2024 Feb 15. PMID: 38359156; PMCID: PMC10877644. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10877644/Doctor Mike, YouTube Channel, https://www.youtube.com/@DoctorMikeDr. Glaucomflecken, YouTube Channel, https://www.youtube.com/@DGlaucomfleckenHealthyGamerGG, YouTube Channel, https://www.youtube.com/@HealthyGamerGGGet info on health-related content, Google Support, https://support.google.com/youtube/answer/9795167Apply to be a source in YouTube health features, YouTube Help, https://support.google.com/youtube/answer/12796915Theme Song: Works All The Time by Dominik Schwarzer, License #5924333, PremiumBeat.com.  

Episode 177: Urinary Incontinence in Older AdultsFuture Dr. Nguyen explains the evaluation and treatment of older adults with urinary incontinence.  Dr. Arreaza adds insights into the conservative management of urinary incontinence.Written by Vy Nguyen, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition of urinary incontinence. The International Continence Society (ICS) defines it as any involuntary urine leakage. Epidemiology of urinary incontinence. Data analysis from the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2018 shows that more than 60% of adult women which is equivalent to around 78,000,000 females living in the United States experience urinary incontinence with 32.4% reporting symptoms monthly. More data analysis shows the strongest association with urinary incontinence include age greater than 70, prior vaginal delivery, and BMI of 40 or greater. Despite urinary incontinence commonly affecting the senior population, this medical condition can also affect the quality of life of younger adult females and males. On top of that, urinary incontinence is often underestimated due to the low report level for various reasons and the obtained data might not accurately reflect the true prevalent rate. Types and etiology.Urinary incontinence is divided into 5 categories: stress, urge, mixed, overflow, and functional. Stress urinary incontinence has the highest prevalence of 37.5% followed by mixed urinary incontinence at 31.3%, urgency at 22%, and unspecified urinary incontinence at 9.2%. Due to time constraints, we will discuss the most prevalent type which is stress urinary incontinence.In females, stress urinary incontinence is often due to urethral sphincter hypermobility caused by weakened pelvic floor muscles. It can also be caused by dysfunction of the sphincter muscle that is exacerbated by increased intraabdominal pressure from coughing, sneezing, or physical exertion. This type of incontinence is commonly seen in pregnant women, those who experienced childbirth, and young women active in sports. In males, the most common etiology for stress urinary incontinence in males is prostate surgery such as radical prostatectomy which can damage the external urethral sphincter. Another cause is spinal cord injury or disease that can interfere with sphincter function. Evaluation. Urinary incontinence is first evaluated by a thorough history taking that includes inquiries about the type, severity, burden, and duration of incontinence. The initial evaluation includes a voiding diary that can provide clarity and help distinguish between the different types of incontinence or identify the dominating type in the case of mixed incontinence. Examples of voiding diary can be found on the websites of International Urogynecological Association (IUGA). Medical conditions such as COPD and asthma can induce cough; heart failure can cause volume overload; neurological disorders and musculoskeletal conditions can interfere with bladder emptying and urinary retention and thus should also be investigated. It is also helpful to ask about medication and substance use as the adverse effects can directly or indirectly contribute to urinary incontinence. For our female-identifying patients, a gynecological and obstetrical history such as birth history (vaginal versus c-section), current pregnancy as well as low estrogen (menopause) can contribute to reversible urinary incontinence. Management. There are various treatment modalities for stress urinary incontinence ranging from conservative to more invasive surgical management. Conservative treatment: -Initial treatment includes pelvic floor strengthening exercises and bladder training with scheduled void. -Pelvic floor muscle training (PFMT) is very effective, and it is proven to help achieve cure and improve the quality of life in women with ALL types of urinary incontinence. -For stress urinary incontinence, the median cure rate is around 58.8% for women after 12 months and 78.8% for men at 6 months of supervised pelvic floor muscle training (PFMT). -Certain behavioral modifications such as fluid intake management (

Episode 176: Self-sampling for HPV screeningFuture Dr. Markarian explains the importance of HPV screening for the prevention of cervical cancer. Dr. Arreaza adds some insight about cervical cancer.Written by Chantal Markarian, MSIV, American University of the Caribbean. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Insights into Cervical Cancer.Chantal: Cervical cancer stands as the most prevalent form of cancer in women globally costing the lives of approximately 350,000 women annually. About 4,000 women die of cervical cancer a year in the US. Cervical cancer is initially asymptomatic, allowing it to advance to a more severe stage if not detected early. The positive news is that cervical cancer is highly preventable through screening for precancerous lesions or the presence of HPV —the primary culprit behind most cases.The role of HPV: Human Papilloma Virus, according to the World Health Organization, caused an estimated 620,000 cancer cases in women and 70,000 cancer cases in men.Cervical cancer is more prevalent in certain regions. In regions with established screening initiatives, the incidence rate and mortality rate of cancer are lower than in resource-limited areas. This highlights that resource-constrained countries continue to bear a burden of this disease. In nations like the United States, access to the HPV vaccine along with routine screenings, like Pap smears and HPV tests has significantly decreased the prevalence of cervical cancer.Screening recommendations from the US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS).The U.S Preventive Services Task Force advises that women aged 21 to 29 undergo a Pap test every three years while those aged 30 to 65 should opt for co-testing (Pap and HPV tests) every five years. These examinations are usually conducted in outpatient facilities, where a medical professional collects a sample of cervical cells that are later examined under a microscope.A normal result states that the sample was adequate for evaluation, in other words, that endocervical/transformation zone components are present, and that the patient is “Negative for intraepithelial lesion or malignancy.” ACS recommends cervical cancer screening begin at age 25 for women and people with a cervix. Those aged 25 to 65 should have a primary HPV test every 5 years. (A primary HPV test means the HPV test is done without cytology; follow-up screening can be done with a Papanicolaou (Pap) test if needed.) If primary HPV testing is not available, screening may be done with either a co-test every 5 years, which combines an HPV test with a Papanicolaou (Pap) test, or a Pap test alone every 3 years. How is Cervical Cancer Classified?Two systems categorize lesions: the Cervical Intraepithelial Neoplasia (CIN) scale and the Bethesda system.The CIN scale categorizes lesions based on the degree of involvement of the cervical lining ranging from mild (CIN I) to moderate (CIN II) to severe dysplasia (CIN III).The Bethesda system emphasizes cytological findings organizing results into categories such as atypical squamous cells, low-grade lesions (LSIL), and high-grade lesions (HSIL).ASCUS (Atypical Squamous Cells of Undetermined Significance) is the most common abnormality seen in pap smears. It may or may not indicate a problem, you have to make a decision based on the patient. Cervical cancer is largely linked to high-risk HPV (hrHPV), mostly HPV 16 and 18, and scientists are investigating tests that identify hrHPV DNA or RNA. These tests may provide a more accurate evaluation of cancer risk compared to traditional cytology. Examples include DNA amplification tests like Cobas test and the Xpert HPV test.Obstacles to Screening.Despite the efficacy of cervical cancer screening, many women face many obstacles to testing. In regions with limited resources, fear, embarrassment, lack of awareness, and restricted healthcare access pose challenges to screening.In Nigeria, a study revealed that women often avoid Pap smears due to a lack of awareness. Similarly, healthcare providers in Ecuador highlighted issues like the absence of screening programs and inadequate health promotion efforts. Women in Peru face obstacles such as long waiting times preferences for female healthcare providers and limited access to health facilities. In 2022, 31% of minority women in the US did not undergo Pap smears in the past three years; many of these women were uninsured, unemployed, or low-income. These challenges contribute to higher rates of cervical cancer among women who do not follow recommended screening guidelines.We must mention the cultural obstacle as well. Some cultures do not allow any kind of pelvic exams before marriage. They put a major emphasis on being a “virgin,” and placing a speculum in the vagina may be considered culturally unacceptable. In those cases, the doctor has to use their best persuasion skills to accomplish the goals of care. For example, they may suggest having the mother in the room during the pap smear, using the smallest speculum possible, or other techniques.Self-sampling.In 2020, the World Health Organization (WHO) introduced a global initiative to combat cervical cancer worldwide. The initiative aims to:Vaccinate 90% of girls by age 15.Screen 70% of women by age 35.Treat 90% of women with lesions and invasive cancer by 2030.To achieve these goals, self-sampling for HPV testing has been introduced as a viable option for cervical cancer screening. Self-sampling for HPV testing is seen as an alternative for cervical cancer screening that addresses barriers associated with traditional methods. This approach enables women to take samples themselves using swabs or brushes removing the necessity for a pelvic examination. The option to mail in samples and receive results within two weeks enhances the convenience, privacy, and accessibility of the process giving individuals control over their health.While self-sampling for hrHPV detection is not currently standard practice in the United States, it has been successfully implemented in countries across Europe, Africa, and South America. Pilot studies are ongoing in nations like Canada and New Zealand to assess its effectiveness offering promise for its impact.In May 2024, the Food and Drug Administration (FDA) approved primary HPV self-collection for cervical cancer screening in a health-care setting. That means, the patient still has to go to a clinic to self-collect her sample. How Effective is HPV Self-Sampling?Research supports the accuracy of HPV self-sampling. A study conducted by Polman et al., which involved a randomized controlled trial, demonstrated that HPV tests on self-collected samples were just as precise as those done on samples collected by clinicians in detecting high-grade lesions (CIN II and CIN III). Similarly, a meta-analysis conducted by Arbyn et al. showed no difference in sensitivity or specificity between self-sampled and clinician-sampled tests for detecting CIN grade II or higher.These results indicate that self-sampling could be an adequate screening method for cervical cancer. This reassurance may motivate women to partake in screenings knowing they have a convenient and effective option. Ok, let's say a patient has collected her sample or the sample was collected by a clinician, what is next?Management of Cervical Cancer Screening Results.The process of managing cervical cancer screening results involves evaluating a patient's immediate and five-year risk of developing cervical abnormalities (CIN 3+) following guidelines from the American Society for Colposcopy and Cervical Pathology (ASCCP).The ASCCP app is the best investment you can make in primary care. It is only $9.99, but it can save you a lot of time in clinic. Estimating risk is a process that considers factors such as current HPV test results, past screening outcomes, the patients' age, and whether they've had a hysterectomy or not. When Risk is Elevated, Prompt Action.If a patient's immediate risk of developing CIN 3 exceeds 4%, expedited treatment is typically recommended. This treatment may entail one of several procedures aimed at removing abnormal cervical tissue.Loop Electrosurgical Excision Procedure (LEEP): A common method that removes tissue using an electric wire loop. Cold Knife Conization: In this procedure, a scalpel removes a cone-shaped section of the cervix.Laser Cone Biopsy: This technique involves removing a cone-shaped section of tissue using a laser.Alternatively, healthcare providers may opt for treatment methods such, as cryotherapy, thermos-ablation, and laser ablation to eliminate abnormal tissue.And those procedures are typically out of the scope of family medicine, but many family doctors may perform them with the proper training and experience.When the risk is deemed low, Surveillance.Patients with a risk of CIN 3 below 4% are typically advised to undergo surveillance with HPV testing every 1-5 years. If HPV testing is not available cytology alone (Pap test) is considered acceptable.Special considerations for women.For women under 25, a cautious approach is taken. If a low-grade lesion (LSIL) is identified through cytology, it is recommended to repeat the test annually for two years. If two consecutive tests show normal results the patient can resume screening intervals based on age. However, if a high-grade lesion (HSIL) is detected, a colposcopy and biopsy are recommended. It should be noted that expedited treatment is generally not advised for this age group since many high-grade lesions may resolve spontaneously.For women over 25, the presence of low-grade lesions or persistent high-risk HPV often leads to recommendations for colposcopy and cervical biopsy.When a cervical biopsy shows adenocarcinoma in situ it is suggested to perform an excisional procedure to rule out invasive cancer. The next steps depend on the margins of the excised tissue; If the margins show positive results (indicating abnormal tissue remains) further excision is necessary to ensure clear margins. This may be followed by a hysterectomy due to the risk of residual disease. For individuals who have been treated for high-grade lesions there is still a risk of developing cervical cancer. Therefore, long-term surveillance is essential. Women over 25 should undergo HPV testing six months after treatment, then annually until three consecutive negative tests are obtained. Subsequently testing every three years is advised for 25 years. As for women under 25, cervical cytology should be done six months post-treatment. Then at six-month intervals until three consecutive negative results are achieved. Once they reach 25 years old, they should switch to HPV testing.As summary, HPV is the most common cause of cervical cancer, and screening must be implemented no matter what your zip code is because adequate screening can lead to a lower mortality. Remember that self-collection is an alternative for your patients, and it is FDA-approved if it is done in a healthcare setting. The ASCCP guidelines are very useful but difficult to memorize, so you can invest in the ASCCP phone app to provide accurate care for your patients. Thanks!References: 1. World Health Organization. HPV and Cervical Cancer Fact Sheet. 2024. Available online: https://www.who.int/en/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer (accessed on 10 August 2024).2. Arbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. 2020;8(2):e191-e203.3. Serrano B, Ibáñez R, Robles C, Peremiquel-Trillas P, de Sanjosé S, Bruni L. Worldwide use of HPV self-sampling for cervical cancer screening. Preventive Medicine. 2022;154:106900.4. Gupta S, Palmer C, Bik EM, et al. Self-sampling for human papillomavirus testing: increased cervical cancer screening participation and incorporation in international screening programs. Front Public Health. 2018;6:345033.5. Ubah C, Nwaneri AC, Anarado AN, Iheanacho PN, Odikpo LC. Perceived barriers to cervical cancer screening uptake among women of an urban community in South-eastern Nigeria. Asian Pac J Cancer Prev. 2022;23(6):1959-1965.6. Vega Crespo, B., Neira, V.A., Ortíz Segarra, J. et al.Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals. BMC Public Health 22, 2144 (2022). https://doi.org/10.1186/s12889-022-14601-y7.Olaza-Maguiña AF, De la Cruz-Ramirez YM. Barriers to the non-acceptance of cervical cancer screenings (Pap smear test) in women of childbearing age in a rural area of Peru. Ecancermedicalscience. 2019;13:901.8. Sharma M, Batra K, Johansen C, Raich S. Explaining correlates of cervical cancer screening among minority women in the United States. Pharmacy. 2022 Feb 15;10(1):30.9. Polman NJ, Ebisch RMF, Heideman DAM, et al. Performance of human papillomavirus testing on self-collected versus clinician-collected samples for the detection of cervical intraepithelial neoplasia of grade 2 or worse: a randomised, paired screen-positive, non-inferiority trial. The Lancet Oncology. 2019;20(2):229-238.10. Costa S, Verberckmoes B, Castle PE, Arbyn M. Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening. British Journal of Cancer. 2023 Mar 23;128(5):805-13.11. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2020;24(2):102-131.12. Straughn, Jr, J Michael, and Catheryn Yashar. “Management of Early-Stage Cervical Cancer.” Www.uptodate.com, 2 Aug. 2024, https://www.uptodate.com/contents/management-of-early-stage-cervical-cancer. Accessed 13 Aug. 2024.13. AMBOSS GmbH.Cervical cancer screening. https://amboss.com/. Accessed August 18, 2024.14. Royalty-free music used for this episode: Lofi-Chilly by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 175: Alcohol Use Disorder Basics   Future Dr. Sangha explains the clinical presentation, diagnosis, and fundamentals of the treatment of alcohol use disorder (AUD). Dr. Arreaza offers insights about the human aspect of the treatment of AUD.    Written by Darshpreet Sangha, MS4, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is Alcohol Use Disorder?AUD is characterized as the inability to stop or control alcohol use despite adverse physical, social and occupational consequences. According to DSM-5, it is a pattern of alcohol use that, over 12 months, results in at least two of the following symptoms, indicating clinically substantial impairment or distress: Alcohol is frequently used in higher quantities or for longer periods than planned.There is a persistent desire or unsuccessful attempt to reduce or manage alcohol use.Activities that are required to get alcohol, consume alcohol, or recuperate from its effects take up a lot of time.A strong need or desire to consume alcohol—a craving.A pattern of drinking alcohol that prevents one from carrying out important responsibilities at work, school, or home.Sustained alcohol consumption despite ongoing or recurring interpersonal or social issues brought on by or made worse by alcohol's effects.Alcohol usage results in the reduction or cessation of important social, professional, or leisure activities.Frequent consumption of alcohol under risky physical circumstances.Continuing to drink even when one is aware of a chronic or recurrent health or psychological issue that may have been brought on by or made worse by alcoholTolerance: requiring significantly higher alcohol intake to produce the same intended effect. Withdrawal: Characterized by the typical withdrawal symptoms or a noticing relief after taking alcohol or a closely related substance, such as benzodiazepine.How can we determine the severity of AUD? Mild: 2–3 symptomsModerate: 4–5 symptomsSevere: >/= 6 symptomsWho is at risk for AUD?Note: Ancestry offers a DNA analysis to find out about your heritage. You can also send that DNA to a third party to learn about your risks for diseases and conditions (for example, Prometheus.) Anyone can find out about their risk for alcoholism by doing a DNA test. The risk factors for AUD are: Male genderAges 18-29Native American and White ethnicitiesHaving Significant disabilityHaving other substance use disorderMood disorder (MDD, Bipolar)Personality disorder (borderline, antisocial personality)What is heavy drinking?According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), heavy alcohol use is characterized as: Males who drink > 4 drinks daily or > 14 drinks per week Females who drink > 3 drinks on any given day or > 7 drinks per weekPathophysiology of AUD.The pathogenesis of AUD is not well understood, but factors that may play a role are genetics, environmental influences, personality traits, and cognitive functioning. Also, genetic factors may decrease the risk of AUD, i.e., the flushing reaction, seen in individuals who are homozygous for the gene that encodes for aldehyde dehydrogenase, which breaks down acetaldehyde. Who should be screened?A person with AUD may not be easy to diagnose in a simple office visit, but some clues may point you in that direction. First of all, patients with AUD may present to you during their sober state, that´s why ALL adults (including pregnant patients) must be screened for AUD in primary care )Grade B recommendation). The frequency has not been determined but as a general rule, at least in Clinica Sierra Vista, we screen once a year. The USPSTF has concluded that there is insufficient evidence to recommend screening adolescents between 12-17 years old. What are the clinical manifestations of AUD?Some symptoms may be subtle, including sleep disturbance, GERD, HTN, but some may be obvious, such as signs of advanced liver disease (ascites, jaundice, bleeding disorders, etc.)If you draw routine labs, you may find abnormal LFTs (AST:ALT ratio >2:1), macrocytic anemia (MCV >100 fL), and elevated Gamma-glutamyl transferase (GGT). All these findings are highly suggestive of AUD. Patients with AUD may present in either an intoxication or withdrawal state. Signs and symptoms of acute intoxication may include “slurred speech, nystagmus, disinhibited behavior, incoordination, unsteady gait, hypotension, tachycardia, memory impairment, stupor, or coma.” Signs and symptoms of withdrawal range from tremulousness to hallucinations, seizures, and death. They are seen between 4 and 72 hours after the last drink, peaking at 48 hours, and can last up to 5 days. Alcohol withdrawal is one of the few fatal withdrawal syndromes that we know in medicine, and the symptoms can be assessed using a CIWA assessment. Treatment of AUD.There are factors to consider before starting treatment: Evaluating the severity of AUD Establishing clear treatment goals is associated with better treatment outcomesAssessing readiness to change: It can be done by motivational interviewing and using the stages of change model, which are, Pre-contemplation, contemplation, preparation, action, maintenance, and relapse.Discussing treatment of withdrawal.Treatment may be done as outpatient or it may require hospitalization. Dr. Beare sent an email with this information: “The approach to treating patients with AUD can be broken into two parts - the first is withdrawal management and the second is the long-term maintenance part. You MUST have a good plan for withdrawal treatment as it can be fatal if it's not addressed properly.” “Patients with any history of seizures due to withdrawal or a history of delirium tremens need inpatient management. If their withdrawal symptoms are typically mild (agitation, tremors, sleeplessness, anxiety) then outpatient management may be appropriate, typically with a long-acting benzodiazepine such as Librium or Ativan.”According to Dr. Beare, “the human aspect isa key element in treating alcohol use disorder. These patients arrive with tremendous amounts of suffering, shame, guilt, and fear. The relationship between the patient and provider needs to be built with compassion and understanding that this disease is horrible from the patient's perspective and using an algorithmic and calculated approach can cause significant harm to the rapport-building process, leading to lower success rates.”Treatment requires a lot of motivation and willpower. Hopefully, we can use some tools to assist our patients to be successful.-For mild disorder, Psychosocial interventions like motivational interviewing and mutual help groups like AA meetings may be enough to help our patient quit drinking.-For moderate or severe disorder: 1st line treatment is Meditation and structured, evidence-based psychosocial interventions (CBT, 12-step facilitation); which leads to better outcomesFor patients who lack motivation, motivational interviewing can be a useful initial interventionFor motivated patients: medical management, combined behavioral intervention, or a combination of both can be utilizedFor patients with limited cognitive abilities, 12-step facilitation, or contingency management can be helpful For patients who have an involved partner: Behavioral couples therapy can be utilizedMedications for AUD.The first-line pharmacological treatment is Naltrexone. It is given as a daily single dose and can be started while the patient is still actively drinking. There is a monthly dose of long-acting injectable naltrexone as well. Naltrexone is contraindicated in individuals taking opioids, and patients with acute hepatitis or hepatic failure. Alternative 1st line treatment is Acamprosate which can be used in people with contraindications to Naltrexone.AUD is a chronic problem and requires a close follow-up to evaluate response to treatment and complications. Medications need to be used along with psychotherapy and support, and medications may need to be changed or adjusted depending on the patient. It is an individualized therapy that requires full engagement of the doctor, the patient, and their families or social support. In conclusion, I would just like to add that, be compassionate because AUD is not a choice. AUD is a chronic problem like diabetes and HTN and may require a long road to recovery. Treatment includes psychotherapy, medications, and regular follow-up.Thank you for listening!Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Risky drinking and alcohol use disorder: Epidemiology, clinical features, adverse consequences, screening, and assessment, https://www.uptodate.com/contents/risky-drinking-and-alcohol-use-disorder-epidemiology-clinical-features-adverse-consequences-screening-and-assessment, accessed on August 18, 2024.Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry, Accessed on August 18, 2024.Alcohol use disorder: Treatment overview, https://www.uptodate.com/contents/alcohol-use-disorder-treatment-overview, assessed on August 18, 2024. Royalty-free music used for this episode, Grande Hip-Hop by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 174: GERD in AdultsCommon and atypical symptoms are presented. Pathophysiology, diagnosis, and management are discussed. H. pylori's role is discussed during this episode. Written by Jacquelyn Garcia MS4 Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definitions: Gastroesophageal reflux (GER): occasional backflow of stomach acid into the esophagus. It's a common physiological process that happens to many people, especially after meals. Occurs less than twice a week. Associated with mild and temporary symptoms such as heartburn or regurgitation. Gastroesophageal reflux disease (GERD): a chronic and more severe form of GER. It occurs when acid reflux happens frequently, typically more than twice a week, and/or causes esophageal injury/complications. -Non-erosive reflux disease (NERD)= GER without evidence of esophageal injury on endoscopy. -Erosive reflux disease (ERD)= GER with evidence of esophageal injury on endoscopy.AFP Journal, January 2024: “Nonerosive GERD does not increase the likelihood of esophageal cancer. However, erosive GERD is associated with a doubled, but still low, risk of developing cancer, with the likelihood increasing over time.”Pathophysiology:The main pathophysiology behind GERD is lower esophageal sphincter (LES) dysfunction which can occur due to the following:-LES Pressure: The LES is a muscular ring at the junction of the esophagus and stomach. It normally maintains a high-pressure zone to prevent reflux. In GERD, the intragastric pressure is higher than the pressure created by the LES. The tone of the LES can be reduced by caffeine, nitroglycerin, and scleroderma. -Transient LES Relaxations (TLESRs): These are normal relaxations of the LES that occur independently of swallowing. In GERD, these relaxations are more frequent or prolonged, allowing acid to reflux into the esophagus.-Anatomic abnormalities: A hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity. This disrupts the normal anatomy of the gastroesophageal junction, reducing the pressure barrier and promoting reflux.Epidemiology: It affects 10-20% of adults in Western cultures and less than 5% in Asia. Prevalence in the US ranges from 18.1% to 27.8% with a slightly higher rate in men. Risk factors: -Obesity, pregnancy, scleroderma, hiatal hernia; smoking, caffeine, alcohol, stress, fatty/fried/spicy foods. Spicy foods can be a challenge in some cultures (e.g. Mexican and Indian.) Sometimes, patients may ask for “something” to stop GERD but all they may need is dietary modification. -Medications: -aspirin, ibuprofen, clindamycin, tetracycline, bisphosphonates (irritate the esophagus and cause heartburn pain similar to GERD) -anticholinergics, TCA's, CCB's, ACEi, statins, benzodiazepines, theophylline, opioids, progesterone (increase acid reflux and worsen GERD)Clinical features: Typical symptoms: -heartburn (burning retrosternal pain) -regurgitation (acidic stomach contents)Atypical symptoms: -chest pain (can mimic angina pectoris, squeezing/burning substernal, radiates to back/neck/jaw/arm) -water brash (hypersalivation)-globus sensation (lump in throat)-nausea -belching-bloating Alarm features in GERD: -dysphagia-odynophagia (pain with swallowing)-new onset of dyspepsia in ≥60yo -weight loss-GI bleeding-vomiting-anemia Diagnosis: -There is no gold standard test -Patient with typical symptoms: diagnosis can be based on clinical symptoms alone -Patient with atypical symptoms: these symptoms can be seen in GERD but are not sufficient for diagnosis of GERD in the absence of typical symptoms. Need to rule out other disorders before associating the symptoms with GERD. (ex: chest pain r/o other causes such as MI with ECG) -Patient with alarm features: refer to GI for upper GI endoscopy. Complications: -Esophagitis: Erosive reflux disease (ERD) = GER with evidence of esophageal distal injury on endoscopy; in untreated GERD 30% have esophagitis. -Iron deficiency anemia: due to mucosal ulcerations -> chronic bleeding.-Esophageal stricture: narrowing near GE junction, solid food dysphagia.-Barrett Esophagus: intestinal metaplasia of esophagus due to chronic GERD (stratified squamous epithelium replaced by columnar epithelium)-Risk factors: GERD for 5-10 years, >50yo, males, obesity, Caucasian, Tobacco use, family history                 -Predisposes to esophageal adenocarcinoma Role of H. pylori.Sometimes we tend to think that H. pylori is the cause of GERD. “H. pylori infection appears to protect the esophagus from gastroesophageal reflux disease, Barrett's esophagus, dysplasia in Barrett's esophagus, and esophageal adenocarcinoma, perhaps by causing chronic gastritis that interferes with acid production.”It is unclear whether long-term use of PPIs heightens the risk of atrophic gastritis in patients with H. pylori. Consequently, routine screening for H. pylori infection and empiric eradication of H. pylori are NOT advised for patients with GERD. However, if H. pylori is diagnosed in the setting of GERD, eradication of H. pylori has been associated with an improvement of symptoms in patients with antral-predominant gastritis. Treatment: Two categories: Mild/intermittent symptoms (

Episode 173: Acute OsteomyelitisFuture Dr. Tran explains the pathophysiology of osteomyelitis and describes the presentation, diagnosis and management of acute osteomyelitis. Dr. Arreaza provides information about    Written by Di Tran, MSIII, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is osteomyelitis?Osteomyelitis, in simple terms, is an infectious disease that affects both bone and bone marrow and is either acute or chronic.  According to archaeological findings of animal fossils with a bone infection, osteomyelitis was more than likely to be known as a “disease for old individuals”.Our ancestors over the years have used various vocabulary terms to describe this disease until a French surgeon, Dr. Nelaton, came up with the term “Osteomyelitis” in 1844. This is the beauty of medical terms, Latin sounds complicated for some people, but if you break up the term, it makes sense: Osteo = bone, myelo = marrow, itis = inflammation. So, inflammation of the bone marrow.Traditionally, osteomyelitis develops from 3 different sources:First category is the “hematOgenous” spread of the infection within the bloodstream, as in bacteremia. It is more frequent in children and long bones are usually affected. [Arreaza: it means that the infection started somewhere else but it got “planted” in the bones]Second route is “direct inoculation” of bacteria from the contiguous site of infection “without vascular insufficiency”, or trauma, which may occur secondary to fractures or surgery in adults.  In elderly patients, the infection may be related to decubitus ulcers and joint replacements.And the third route is the “contiguous” infection “with vascular insufficiency”, most seen in a patient with a diabetic foot infection.Patients with vascular insufficiency often have compromised blood supply to the lower extremities, and poor circulation impairs healing. In these situations, infection often occurs in small bones of the feet with minimal to no pain due to neuropathy.They can have ulcers, as well as paronychia, cellulitis, or puncture wounds.Thus, the importance of treating onychomycosis in diabetes because the fungus does not cause a lot of problems by itself, but it can cause breaks in the nails that can be a port of entry for bacteria to cause severe infections. Neuropathy is an important risk factor because of the loss of protective sensation. Frequently, patients may step on a foreign object and not feel it until there is swelling, purulent discharge, and redness, and they come to you because it “does not look good.”Acute osteomyelitis often takes place within 2 weeks of onset of the disease, and the main histopathological findings are microorganisms, congested blood vessels, and polymorphonuclear leukocytes, or neutrophilic infiltrates.What are the bugs that cause osteomyelitis?Pathogens in osteomyelitis are heavily depended on the patient's age.  Staph. aureus is the most common culprit of acute hematogenous osteomyelitis in children and adults.  Then comes Group A Strep., Strep. pneumoniae, Pseudomonas, Kingella, and methicillin-resistant Staph. aureus.  In newborns, we have Group B Streptococcal. Less common pathogens are associated with certain clinical presentations, including Aspergillus, Mycobacterium tuberculosis, and Candida in the immunocompromised.Salmonella species can be found in patients with sickle cell disease, Bartonella species in patients with HIV infection, and Pasteurella or Eikenella species from human or animal bites.It is important to gather a complete medical history of the patient, such as disorders that may put them at risk of osteomyelitis, such as diabetes, malnutrition, smoking, peripheral or coronary artery disease, immune deficiencies, IV drug use, prosthetic joints, cancer, and even sickle cell anemia. Those pieces of information can guide your assessment and plan.What is the presentation of osteomyelitis?Acute osteomyelitis may present symptoms over a few days from onset of infection but usually is within a 2-week window period.  Adults will develop local symptoms of erythema, swelling, warmth, and dull pain at the site of infection with or without systemic symptoms of fever or chills.Children will also be present with lethargy or irritability in addition to the symptoms already mentioned.It may be challenging to diagnose osteomyelitis at the early stages of infection, but you must have a high level of suspicion in patients with high risks. A thorough physical examination sometimes will show other significant findings of soft tissue infection, bony tenderness, joint effusion, decreased ROM, and even exposed bone. Diagnosis.As a rule of thumb, the gold standard for the diagnosis of osteomyelitis is bone biopsy with histopathology findings and tissue culture. There is leukocytosis, but then WBC counts can be normal even in the setting of acute osteomyelitis.Inflammatory markers (CRP, ESR) are often elevated although both have very low specificity. Blood cultures should always be obtained whenever osteomyelitis is suspected.  A bone biopsy should also be performed for definitive diagnosis, and specimens should undergo both aerobic and anaerobic cultures.  In cases of osteomyelitis from diabetic foot infection, do the “probe to bone” test. What we do is we use a sterile steel probe to detect bone which is helpful for osteomyelitis confirmation.Something that we can't miss out on is radiographic imaging, which is quite important for the evaluation of osteomyelitis.  Several modalities are useful and can be used for the work-up plan; plain radiographs often are the very first step in the assessment due to their feasibility, low cost, and safety.  Others are bone scintigraphy, CT-scan, and MRI.  In fact, the MRI is widely used and provides better information for early detection of osteomyelitis than other imaging modalities.  It can detect necrotic bone, sinus tracts, and even abscesses. We look for soft tissue swelling, cortical bone loss, active bone resorption and remodeling, and periosteal reaction.  Oftentimes, plain radiography and MRI are used in combination. Treatment:Treatment of osteomyelitis actually is a teamwork effort among various medical professionals, including the primary care provider, the radiologist, the vascular, the pharmacist, the podiatrist, an infectious disease specialist, orthopedic surgeons, and the wound care team.Something to take into consideration, if the patient is hemodynamically stable it is highly recommended to delay empirical antibiotic treatment 48-72 hours until a bone biopsy is obtained.  The reason is that with percutaneous biopsy ideally done before the initiation of antibiotic treatment, “the microbiological yield will be higher”.We'll have a better idea of what particular bugs are causing the problem and guide the treatment appropriately. The choice of antibiotic therapy is strongly determined by susceptibilities results.  The antibiotic given will be narrowed down only for the targeted susceptible organisms.  In the absence of such information, or when a hospitalized patient presents with an increased risk for MRSA infection, empiric antibiotic coverage is then administered while awaiting culture results. It should be broad-spectrum antibiotics and include coverage for MRSA, broad gram-negative and anaerobic bacteria.  For example, vancomycin plus piperacillin-tazobactam, or with broad-spectrum cephalosporin plus clindamycin.  Treatment will typically be given for 4 to 6 weeks.The duration between 4-6 weeks is important for complete healing, but a small study with a small sample showed that an even shorter duration of 3 weeks may be effective, but more research is needed. In certain situations, surgery is necessary to preserve viable tissue and prevent recurrent infection, especially when there are deep abscesses, necrosis, or gangrene, amputation or debridement is deemed appropriate. If the infected bone is completely removed, patients may need a shorter course of antibiotics, even a few days only. Amputation can be very distressing, especially when we need to remove large pieces of infected bone, for example, a below-the-knee amputation. We need to be sensitive to the patient's feelings and make a shared decision about the best treatment for them.In patients with diabetes, additional care must be taken seriously, patient education about the need for compliance with treatment recommendations, with careful wound care, and good glycemic control are all beneficial for the healing and recovery process. Because this is a very common problem in the clinic and at the hospital, we must keep our eyes wide open and carefully assess patients with suspected osteomyelitis to detect it promptly and start appropriate treatment. Adequate and timely treatment is linked to fewer complications and better outcomes._________________________Conclusion: Now we conclude episode number 173, “Acute Osteomyelitis.” Future Dr. Tran explained the pathophysiology, diagnosis, and management of osteomyelitis. A bone biopsy is the ideal method of diagnosis. Delaying antibiotic treatment a few days until you get a biopsy is allowed if the patient is stable, but if the patient is unstable, antibiotics must be started promptly. Dr. Arreaza mentioned the implications of amputation and that we must discuss this treatment empathically with our patients. This week we thank Hector Arreaza and Di Tran. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Bury DC, Rogers TS, Dickman MM. Osteomyelitis: Diagnosis and Treatment. Am Fam Physician. 2021 Oct 1;104(4):395-402. PMID: 34652112.Cunha BA. Osteomyelitis in elderly patients. Clin Infect Dis. 2002 Aug 1;35(3):287-93. doi: 10.1086/341417. Epub 2002 Jul 11. PMID: 12115094.Fritz JM, McDonald JR. Osteomyelitis: approach to diagnosis and treatment. Phys Sportsmed. 2008 Dec;36(1):nihpa116823. doi: 10.3810/psm.2008.12.11. PMID: 19652694; PMCID: PMC2696389.Hatzenbuehler J, Pulling TJ. Diagnosis and management of osteomyelitis. Am Fam Physician. 2011 Nov 1;84(9):1027-33. PMID: 22046943.Hofstee MI, Muthukrishnan G, Atkins GJ, Riool M, Thompson K, Morgenstern M, Stoddart MJ, Richards RG, Zaat SAJ, Moriarty TF. Current Concepts of Osteomyelitis: From Pathologic Mechanisms to Advanced Research Methods. Am J Pathol. 2020 Jun;190(6):1151-1163. doi: 10.1016/j.ajpath.2020.02.007. Epub 2020 Mar 16. PMID: 32194053.Momodu II, Savaliya V. Osteomyelitis. [Updated 2023 May 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532250/Royalty-free music used for this episode: Trap Chiller by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net 

Episode 172: NAFLD and ObesityFuture Dr. Nguyen explains the pathophysiology of non-alcoholic fatty liver disease and how it relates to obesity. Dr. Arreaza gives information about screening and diagnosis of NAFLD. Written by Ryan Nguyen, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction/PathophysiologyNonalcoholic fatty liver disease (NAFLD) refers to the buildup of excess fat in liver cells, occurring without the influence of alcohol or drugs. Nonalcoholic steatohepatitis (NASH) represents a more severe form of NAFLD, characterized by inflammation and liver cell injury due to fat accumulation. If left untreated, NASH can progress to liver fibrosis or cirrhosis. Typically, NAFLD/NASH is diagnosed after other liver conditions are ruled out, making it a diagnosis of exclusion.NAFLD -> NASH -> Cirrhosis -> Liver failure. Another term for NAFLD is metabolic dysfunction-associated steatotic liver disease. Fatty liver disease is identified when more than 5% of liver weight consists of fat, whereas, NASH is diagnosed when this fat accumulation is accompanied by inflammation and liver cell injury, sometimes leading to fibrosis. Understanding these distinctions is crucial in recognizing and managing the spectrum of liver conditions associated with obesity and metabolic syndrome.BMI serves as a tool to gauge body fat levels: individuals are categorized as normal weight if their BMI falls between 18.5 and 24.9, overweight if it ranges from 25 to 29.9. Class I obesity is diagnosed with a BMI of 30 to 34.9, class II obesity between 35 and 39.9, and class III obesity when BMI exceeds 40.Obesity puts you at risk of NAFLD, but you can also see NAFLD in non-obese patients, but the prevalence is very low, about 5%. What did you learn about the demographics of NAFLD?NAFLD is most widespread in regions like South Asia, the Middle East, Mexico, Central and South America, with prevalence rates exceeding 30%. In the United States, prevalence varies with approximately 23-27%, notably higher among Asians at 30%, followed by Hispanic individuals at 21%, White individuals at 12.5%, and Black individuals at 11.6%. Across all racial groups, obesity plays a significant role, affecting more than two-thirds of individuals diagnosed with NAFLD. Understanding these demographics underscores the global impact of obesity on NAFLD prevalence.Diagnosis: Screening/Labs/Imaging/ToolsThe American Association for the Study of Liver Diseases does not recommend screening for NAFLD, but if it is discovered an appropriate workup is warranted. AST/ALT RatioLiver health can be assessed by a series of tests aimed at assessing fat accumulation, inflammation, and fibrosis. Initial screening often includes laboratory tests such as measuring the ratio between aspartate transaminase (AST) and alanine transaminase (ALT), where a ratio less than 1 may suggest possible NAFLD, although it is not diagnostic on its own. Normally, AST is slightly more elevated than ALT. So, if the AST/ALT ratio is lower, then means that ALT is higher than AST. FibroSure®.Additionally, you can measure indirect markers of fibrosis with tests such as FibroSure or FibroTest blood tests that combine several biomarkers including age, sex, gamma-glutamyl-transferase (GGT), total bilirubin, alpha-2-macroglobulin, apolipoprotein A1, haptoglobin, and ALT to provide insights into liver health.Some people may be more familiar with FibroSure before Hepatitis C treatment. You can get a fibrosis score (F0-F4), and it is considered significant fibrosis if the score is > or equal to F2. Imaging plays a crucial role in diagnosing NAFLD without the need for invasive procedures like liver biopsy. Vibration-controlled transient elastography (Fibroscan) uses ultrasound to measure liver stiffness, indicating potential fibrosis and inflammation. While noninvasive and portable, it focuses solely on liver ultrasound and may not be universally accessible. MRI with proton density fat fraction (MRI-PDFF) offers a comprehensive assessment of liver fat content, commonly used in clinical and research settings for NAFLD and NASH evaluation.For evaluating hepatic fibrosis in patients with suspected NAFLD, tools like the Fibrosis-4 Index (FIB-4) incorporate age, AST, ALT, and platelet count to estimate the likelihood of liver disease progression. These screening methods collectively aid in diagnosing and monitoring NAFLD, particularly in individuals at risk due to factors like prediabetes, type 2 diabetes, obesity, and abnormal liver enzyme ratios. With the FIB-4 you can get a faster answer than FibroSure because you only need 4 elements: Age, platelet count, AST and ALT. Cirrhosis is less likely if FIB-4 is 3.25. Understanding these diagnostic approaches is essential for early detection and management of NAFLD in clinical practice.Some researchers are invested in diagnosis and treating NAFLD while others recommend against labeling patients with NAFLD. A 2018 Lancet article concluded that the risks of over-diagnosing and overtreating NAFLD exceed the benefits of screening or periodic imaging because of “the low hepatic mortality, high false-positive rate of ultrasonography, selection bias of current studies, and lack of viable treatment.” However, patients who suffer from metabolic syndrome should be counseled about dietary modification and physical activity regardless of their liver condition. NAFLD and obesityFatty liver disease is often caused by multiple insults towards either genetically or environmentally predisposed individuals. Family history of NAFLD and having specific genetic variants are important risk factors for NAFLD. Those with prior health conditions can have increased susceptibility to NAFLD including T2DM leading to insulin resistance, metabolic syndrome, sleep apnea, hepatitis C, and cardiovascular or chronic kidney disease. A sedentary lifestyle and unhealthy nutrition (especially high intake of processed carbohydrates) cause an increase in free fatty acids leading to hepatic fat deposition → ballooning of hepatocytes → leading to hepatocyte injury/death → inflammation with fibroblast recruitment → end result of fibrosis/cirrhosis. Just a quick reminder, NAFLD is defined as fatty liver with >5% hepatic fat and NASH is defined as fatty liver with >5% hepatic fat with inflammation, hepatocyte injury, with or without fibrosis that we can determine through imaging. A leading concern for the development of NAFLD is the consumption of high fructose corn syrup.  High fructose corn syrup (HFCS), commonly found in candy, processed sweets, soda, fruit juices, and other processed foods, is linked to non-alcoholic fatty liver disease (NAFLD). Unlike natural whole fruits, which contain fiber and are generally healthier due to their slower absorption, HFCS lacks fiber and is quickly absorbed, leading to rapid transport to the liver. This process contributes to NAFLD by increasing the hepatic synthesis of lipids and interfering with insulin signaling. To avoid HFCS, individuals are encouraged to consume whole fruits rather than fruit juices and adopt diets rich in whole grains, lean meats, plant-based proteins, fruits, and vegetables, such as the Mediterranean or DASH diets, which are less likely to promote NAFLD, especially in those with healthy body weight.NAFLD treatment.Avoiding alcohol seems very obvious, but we need to mention it. Avoiding heavy alcohol consumption is recommended and complete abstinence is suggested.Weight loss is crucial; even a modest reduction of 3–5% in body weight can alleviate hepatic steatosis, with greater improvements typically seen with 7–10% weight loss, particularly beneficial for addressing histopathological features of NASH, such as fibrosis. We must focus on tailored medical nutrition therapy and regular physical activity. A strategic meal plan is essential, emphasizing achieving a healthy body weight while limiting trans fats and ultra-processed carbohydrates. Options like the Mediterranean diet, which balances lean proteins and restricts processed carbohydrates have shown promise. Dynamic aerobic and resistance exercises play a significant role in managing NAFLD. They help maintain a healthy weight and enhance peripheral insulin sensitivity, reduce circulating free fatty acids and glucose levels, and boost intrahepatic fatty acid oxidation while curbing fatty acid synthesis. These benefits contribute to mitigating liver damage associated with NAFLD, offering therapeutic advantages beyond mere weight reduction.Exercise may not be a great tool for weight loss, but it is a great tool for weight maintenance, liver health, and overall health as well. “Most patients with NAFLD die from vascular causes, but NAFLD puts patients at increased risk of cardiovascular death”. Medications for NAFLD.Regarding pharmacotherapy, while no medications are currently FDA-approved specifically for NAFLD treatment, some options show promise in clinical settings. Vitamin E supplementation at 800 IU (international units) daily has demonstrated biochemical and histological improvements in NASH cases without diabetes or cirrhosis, though long-term use may elevate prostate cancer risks. It is important to make a shared decision with the patient before starting Vitamin E supplementation. Medications like pioglitazone can reduce liver fat and improve NASH, even as they may increase body weight. But our favorite, GLP-1 receptor agonists, such as liraglutide and semaglutide, also show potential in reducing liver fat and improving NASH symptoms, and this is an emerging therapeutic option for managing this condition.If you decide to treat, then you should monitor as part of the treatment. An aminotransferase check is recommended 6 months after starting a weight loss program. If levels do not improve or do not return to normal after 5-7% of weight loss, another cause of elevated transaminases needs to be investigated.You also need to monitor fibrosis in patients with >F2. If fibrosis has been proven by liver biopsy, you can order FibroSure every 3-4 years. Having a fatty liver may be a red flag that your patient has a metabolic problem. If you discover it, start interventions that would benefit not only the liver but the whole metabolic profile of your patient. The Obesity Medicine Association (OMA) issued a Clinical Practice Statement (CPS) regarding NAFLD and obesity stating that patients with obesity are at increased risk for NAFLD and NASH. It recommends that clinicians strive to understand the etiology, diagnosis, and optimal treatment of NAFLD with a goal to prevent NASH in their patients.Regular exercise, even walking 30 minutes a day can show many benefits in curbing fatty accumulation in the liver. Having a proper diet with avoidance of high fructose corn syrup can overall help in reducing NAFLD/NASH. _____________________Conclusion: Now we conclude episode number 172, “NAFLD and Obesity.” Future Dr. Nguyen explained that NAFLD and obesity are closely related and NAFLD can lead to NASH and cirrhosis in some patients. Dr. Arreaza explained that screening may not be recommended by some medical societies, but others are in favor of screening and treating this disease. However, most people agree that NAFLD is a sign of metabolic disease and a good reason to talk about healthy eating and physical activity with our patients. There are no FDA-approved medications to treat NAFLD, but some evidence suggests that Vitamin E can improve it and GLP-1 receptor agonists are a promising option. This week we thank Hector Arreaza and Ryan Nguyen. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Karjoo S, Auriemma A, Fraker T, Edward H. Nonalcoholic fatty liver disease and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022. https://doi.org/10.1016/j.obpill.2022.100027.Curry M, Afdhal N. Noninvasive assessment of hepatic fibrosis: Overview of serologic tests and imaging examinations.  https://www.uptodate.com/contents/noninvasive-assessment-of-hepatic-fibrosis-overview-of-serologic-tests-and-imaging-examinationsRoyalty-free music used for this episode: Cool Groove (Alt-Mix) by Videvo, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 171: Postpartum Blues, Depression, and PsychosisFuture Dr. Nguyen defines and explains the difference between baby blues, depression, and psychosis. Dr. Arreaza added comments about screening and management of these conditions. Written by Vy Nguyen, OMSIII, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.Pregnancy is one of the most well-celebrated milestones in one's life. However, once the baby is born, the focus of the family and society quickly shifts to the new member. It is important to continue to care for our mothers and offer them support physically and mentally as they begin their transition into their role. Peripartum mood disorders affect both new and experienced mothers as they navigate through the challenges of motherhood. The challenges of motherhood are not easy to spot, and they include sleep deprivation, physical exhaustion, dealing with pain, social isolation, and financial pressures, among other challenges. Let's focus on 3 aspects of the postpartum period: Postpartum Blues (PPB), Post-partum Depression (PPD) and Post-partum Psychosis (PPP). By the way, we briefly touched on this topic in episode 20, a long time ago. Postpartum blues (PPB) present as transient and self-limiting low mood and mild depressive symptoms that affect more than 50% of women within two or three days of childbirth and resolve within two weeks of onset. Symptoms vary from crying, exhaustion, irritability, anxiety, appetite changes, and decreased sleep or concentration to mood lability. Women are at risk for PPB.Several factors are thought to contribute to the increased risk of postpartum blues including a history of menstrual cycle-related mood changes, mood changes associated with pregnancy, history of major depression, number of lifetime pregnancies, or family history of postpartum depression. Pathogenesis of PPB: While pathogenesis remains unknown, hormonal changes such as a dramatic decrease in estradiol, progesterone, and prolactin have been associated with the development of postpartum blues. In summary, PPB is equivalent to a brief, transient “sad feeling” after the delivery. Peripartum depression (PPD) occurs in 20% of women and is classified as depressive symptoms that appear within six weeks to 1 year after childbirth. Those with baby blues have an increased risk of developing postpartum depression. About 50% of “postpartum” major depressive episodes begin before delivery, thus the term has been updated from “postpartum” to “peripartum” depressive episodes. Some risk factors include adolescent patients, mothers who deliver premature infants, and women living in urban areas. Interestingly, African American and Hispanic mothers are reported to have onset of symptoms within two weeks of delivery instead of six like their Caucasian counterparts. Additional risks include psychological risks such as a personal history of depression, anxiety, premenstrual syndrome, and sexual abuse; obstetric risks such as emergency c-sections and hospitalizations, preterm or low birth infant, and low hemoglobin; social risks such as lack of social support, domestic violence in form of spousal physical/sexual/verbal abuse; lifestyle risks such as smoking, eating sleep patterns and physical activities. Peripartum depression can present with or without psychotic features, which may appear between 1 in 500 or 1 in 1,000 deliveries, more common in primiparous women. Pathogenesis of PPD: Much like postpartum blues, the pathogenesis of postpartum depression is unknown. However, it is known that hormones can interfere with the hypothalamic-pituitary-adrenal axis (HPA) and lactogenic hormones. HPA-releasing hormones increase during pregnancy and remain elevated up to 12 weeks postpartum. The body receptors in postpartum depression are susceptible to the drastic hormonal changes following childbirth which can trigger depressive symptoms. Low levels of oxytocin and prolactin also play a role in postpartum depression causing moms to have trouble with lactation around the onset of symptoms. The USPSTF recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. Edinburgh Postnatal Depression Scale (EPDS) can be used in postpartum and pregnant persons (Grade B recommendation).Postpartum psychosis (PPP) is a psychiatric emergency that often presents with confusion, paranoia, delusions, disorganized thoughts, and hallucinations. Around 1-2 out of 1,000 new moms experience postpartum psychosis with the onset of symptoms as quickly as several days and as late as six weeks after childbirth. Given the high risk of suicide and harm, individuals with postpartum psychosis require immediate evaluation and treatment. Postpartum psychosis is considered multifactorial, and the single most important risk factor is first pregnancy with family or personal history of bipolar 1 disorder. Other risk factors include a prior history of postpartum psychosis, family history of psychosis, history of schizoaffective disorder or schizophrenia, or discontinuation of psychiatric medications. Studies show that patients with a history of decreased sleep due to manic episodes are twice as likely to have postpartum psychosis at some point in their lives. However, approximately 50% of mothers who experience psychosis for the first time do not have a history of psychiatric disorder or hospitalization. Evaluation.Symptoms of postpartum blues should not meet the criteria for a major depressive episode and should resolve in 2 weeks. The Edinburg Postpartum Depression Scale which is a useful tool for assessing new moms with depressive symptoms. Postpartum depression is diagnosed when the patient presents with at least five depressive symptoms for at least 2 weeks. According to the DSM5, postpartum depression is defined as a major depressive episode with peripartum onset of mood symptoms during pregnancy or in the 4 weeks following delivery. Symptoms for diagnosis include changes in sleep, interest, energy, concentration, appetite, psychomotor retardation or agitation, feeling of guilt or worthlessness, and suicidal ideation or attempt. These symptoms are not associated with a manic or hypomanic episode and can often lead to significant impediments in daily activities. Peripartum-onset mood episodes can present with or without psychotic features. The depression can be so severe that the mother commits infanticide. Infanticide can happen, for example, with command hallucinations or delusions that the infant is possessed.While there are no standard screening criteria in place of postpartum psychosis, questionnaires mentioned earlier such as the Edinburg Postpartum Depression Scale can assess a patient's mood and identify signs of depression and mania. It is important after a thorough history and physical examination to order labs to rule out other medical conditions that can cause depressive and psychotic symptoms. Disorders like electrolyte imbalance, hepatic encephalopathy, thyroid storm, uremia, substance use, infections, and even stroke can mimic a psychiatric disorder. So, How can we treat patients who are diagnosed with a peripartum mood disorder?Management.On the spectrum of peripartum mood disorders, postpartum blues are the least severe and should be self-limiting by week 2. However, patients should be screened for suicidal ideation, paranoia, and homicidal ideation towards the newborn. Physicians should provide validation, education, and resources especially support with sleep and cognitive therapy and/or pharmacotherapy can be recommended if insomnia persists. Regarding postpartum depression, the first-line treatment includes psychotherapy and antidepressants. For those with mild to moderate depression or hesitant to start on medications, psychosocial and psychotherapy alone should be sufficient. However, for those with moderate to severe symptoms, a combination of therapy and antidepressants, such as selective serotonin reuptake inhibitors, is recommended. Once an effective dose is reached, patients should be treated for an additional 6 to 12 months to prevent relapse. In severe cases, patients may need to be hospitalized to treat their symptoms and prevent complications such as self-harm or infanticide.Most SSRIs can be detected in breast milk, but only 10 percent of the maternal level. Thus, they are considered safe during breastfeeding of healthy, full-term infants. So, you mentioned SSRIs, but also SNRIs, bupropion, and mirtazapine are reasonable options for treatment. In patients who have never been treated with antidepressants, zuranolone (a neuroactive steroid) is recommended. Zuranolone is easy to take, works fast, and is well tolerated. Treatment with zuranolone is consistent with practice guidelines from the American College of Obstetricians and Gynecologists.While there are no current guidelines to manage postpartum psychosis, immediate hospitalization is necessary in severe cases. Patients can be started on mood stabilizers such as lithium, valproate, and lamotrigine, and atypical antipsychotics such as quetiapine, and olanzapine, to name a few. Medications like lithium can be eliminated through breast milk and can expose infants to toxicity.The use of medications such as SSRIs, carbamazepine, valproate, and short-acting benzodiazepines are relatively safe and can be considered in those with plans to breastfeed. Ultimately, it is a decision that the patient can make after carefully discussing and weighing the pros and cons of the available medical management. While the prognosis of peripartum mood disorders is relatively good with many patients responding well to treatments, these disorders can have various negative consequences. Individuals with a history of postpartum blues are at increased risk of developing postpartum depression. Similarly, those with a history of postpartum psychosis are at risk of experiencing another episode of psychosis in future pregnancies. Additionally, postpartum depression can have a detrimental effect on mother-infant bonding and affect the growth and development of the infant. These children may have difficulties with social interactions, cognitive development, and depression. In summary, following the birth of a baby can pose new challenges and often is a stressful time for not only the mother but also other family members. Validation and reassurance from primary care physicians in an empathetic and understanding manner may offer support that many mothers may not have in their close social circle. As the first contact, primary care physicians can identify cues and offer support promptly that will not only improve the mental well-being of mothers but also that of the growing children.___________________________Conclusion: Now we conclude episode number 171, “Postpartum blues, depression, and psychosis.” These conditions may be more common than you think. So, be alert during your prenatal and postpartum visits and start management as needed. Psychotherapy and psychosocial therapy alone may be effective but do not hesitate to start antidepressants or antipsychotics when necessary. Make sure you involve the family and the patient in the decision-making process to implement an effective treatment.This week we thank Hector Arreaza and Vy Nguyen. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Raza, Sehar K. and Raza, Syed. Postpartum Psychosis. National Library of Medicine. Last updated Jun 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK544304/Balaram, Kripa and Marwaha, Raman. Postpartum Blues. National Library of Medicine. Last updated Mar 6, 2023. https://www.ncbi.nlm.nih.gov/books/NBK554546/Mughal, Saba, Azhar, Yusra, Siddiqui, Waquar. Postpartum Depression. National Library of Medicine. Last updated Oct 7, 2022. https://www.ncbi.nlm.nih.gov/books/NBK519070/Royalty-free music used for this episode: Good Vibes by Simon Pettersson, downloaded on July 20, 2023, from https://www.videvo.net/royalty-free-music/.

Episode 170: Schizophrenia: An OverviewFuture Dr. Chng explains the diagnostic criteria and describes how to treat schizophrenia. Dr. Arreaza mentions additional risk factors and social aspects of schizophrenia.  Written by Tiffanny Chng, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Schizophrenia may be an intriguing disease for many, even for health care providers. Schizophrenia is frequently misunderstood and stigmatized. Receiving a diagnosis of schizophrenia can be life-altering and cause significant distress in patients and their families, but it can also impact their work, relationships, and even their communities.Epidemiology of schizophrenia: Schizophrenia has a prevalence of about 1% worldwide, and a prevalence of about 0.6% in the US. Although the distribution between males and females is comparable, males will typically present with their first episode, sometimes known as a “psychotic break” in the early 20's as opposed to women who may present in their late 20s or early 30s. Despite having a low prevalence, the NIH lists schizophrenia as one of the top 15 leading causes of disability and disease burden in the world. In 2019 the economic burden of schizophrenia in the US was $343 billion. For comparison, in 2019, diabetes had an economic burden of $760 billion in the US, however, the prevalence of diabetes that year was 11.6%, more than 10 times that of schizophrenia. Patients who are diagnosed with schizophrenia are also at increased risk of a multitude of co-occurring medical conditions: alcohol and substance abuse disorders, mood disorders, and metabolic disturbances (diabetes, hyperlipidemia, and obesity, which may be exacerbated with the use of antipsychotics). These patients have a two-to-four-fold increased risk of premature mortality with an estimated potential life loss of ~28.5 years. Of note, 4-10% of patients with schizophrenia die secondary to suicide.Pathogenesis:The exact pathogenesis of schizophrenia is unknown, but we do know that it is a combination of genetic, neurological, and environmental factors. Genetics: Twin studies conducted in mono and dizygotic twins have shown that schizophrenia is highly inheritable (~80%). Although there are no specific genes that directly cause the disease state, genome-wide association studies have shown polygenic additive effects of 108 single nucleotide polymorphisms. This includes genes involved in the dopaminergic and glutamate pathways, which are the basis of antipsychotic medications. Epigenetics: Studies have also shown that epigenetics is a potential factor that plays into the risk of developing schizophrenia. Having a history of obstetric complications, for example, has an almost two-fold increased risk of schizophrenia in the child during early adulthood. Such complications include maternal infections, preterm labor, and fetal hypoxia. Certain infections and pro-inflammatory disease states, such as Celiac and Graves' disease have also been associated with schizophrenia. The suggested pathophysiology is thought to involve pro-inflammatory cytokines crossing the blood-brain barrier inducing or exacerbating psychosis or cognitive impairment. Trauma: As in many other psychiatric conditions, childhood trauma or severe childhood adversities, especially emotional neglect, have also been shown to increase the risk of schizophrenia later in life.Cannabis and Immigration: So, you mentioned the role of genetics, epigenetics, and inflammation. I'd like to mention the use of cannabis as a risk factor for developing psychosis as well, more specifically the THC component of cannabis. Something to keep in mind during these times when cannabis is being studied in more detail. Also, this is interesting: immigration puts you at risk for schizophrenia, and the risk can be as high as four-fold, depending on the study. Some explanations for this are increased discrimination, stress, and even low vitamin D. Tiffany, how do we diagnose schizophrenia?DSM-5 Diagnostic Criteria: The DSM-5 identifies 5 diagnostic criteria for schizophrenia: Patient must have two or more active phase symptoms for one month or longer: (1) Delusions, (2) Hallucinations (auditory, visual, or tactile) (3) Disorganized speech, (4) Negative symptoms (flat affect, avolition, social withdrawal, anhedonia), or (5) Catatonic behavior (which can be a collection of abnormal physical movements, the lack of movement or resistance to movement, psychomotor agitation). For the first criterion to be met, the patient must have delusions, hallucinations, or disorganized speech as one of their two presenting symptoms. Arreaza: The 1-month duration can be less if the patient is successfully treated.The symptoms experienced by the patient must impair their level of functioning in one or more major areas (professional career, relationships, and self-care). In addition, the disruption must be present most of the time since the onset of symptoms. There must be continuous signs of disturbance for at least 6 months. Within these 6 months, there must be at least 1 month where the patient experiences symptoms mentioned in the first criteria (delusions, hallucinations, disorganized speech, negative symptoms, or catatonic behavior). The disturbance may only be negative symptoms or attenuated positive symptoms (unusual perceptual experiences, odd beliefs, etc.)Mood disorders must be ruled out. This includes bipolar disorder with psychotic features, depressive disorder with psychotic features, and schizoaffective disorder. The behavioral disturbances must not be attributable to any substance use or medical conditions. After the diagnosis of schizophrenia has been made for 1 year or more, specifiers can be added to further categorize the disease state, according to the DSM-V: Acute episode: a period in which all symptomatic criteria are met.Partial remission: a period in which symptomatic criteria are only partially met and symptoms are improved from a previous episode.Full remission: a period in which no symptomatic criteria are met (for a minimum of 6 months).Continuous: symptoms prevalent for the majority of the illness course.Goals of Treatment: Reduce acute symptoms to allow patients to return to their baseline level of functioning. Prevent recurrence and maximize a patient's quality of life using maintenance therapy.There are 2 components of treatment: Pharmacotherapy and Psychosocial Intervention.Pharmacotherapy.Pharmacotherapy is initiated with second-generation antipsychotics as first-line agents due to their decreased risk of extrapyramidal side effects, compared to our first-generation antipsychotics. Commonly used medications include aripiprazole (Abilify), lurasidone (Latuda), risperidone (Risperdal), and quetiapine (Seroquel). These antipsychotics also have a more favorable side effect profile, showing a lower incidence of seizures, orthostatic hypotension, QT prolongation, weight gain, impaired glucose metabolism, and hyperlipidemia. Of note, younger patients being treated for their first psychotic episode are more likely to experience metabolic side effects while on antipsychotics. Hence, it is important to start at lower doses in these patients and slowly titrate to a therapeutic dose. Antipsychotics are implicated in the development of obesity, and obesity is one of my favorite topics. As a PCP, you need to have close communication with the psychiatrist before you change any doses of any antipsychotics, in my case, I just avoid making changes.Older patients, who are likely on other medications should be started at doses that are ¼ to ½ the adult dose initially to monitor for any potential drug interactions. After therapy initiation, routine monitoring for symptomatic response is done weekly for the first 3 months. Signs of any extrapyramidal symptoms should also be evaluated at each visit. Special care must be taken to patients with risk factors, for example, a metabolic profile should be ordered every 6 to 12 weeks depending on a patient's comorbidities, and an EKG should be done before and 3 months after therapy initiation to monitor for QT prolongation.QT prolongation is higher with ziprasidone, quetiapine, chlorpromazine, and intravenous (IV) haloperidol. Normal QTc intervals: Before puberty: NORMAL

Episode 169: Food insecurity and Obesity in Kern CountyFuture Dr. Kim presents the problem of food insecurity in Kern County and how it is linked to obesity and liver disease. She shared several resources available to address food insecurity. Dr. Arreaza reminds us of the importance of improving access to fresh and healthy foods.  Written by Judy Kim, OMS3; Mira Patel, OMS3; and Vy Nguyen, OMS3. Western University of Health Sciences. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: Why did you pick this topic?Judy: While Kern County is known as one of the top-producing agricultural counties in the country, food insecurity is a major health disparity within this county. In order to dissect the problem of food insecurity in Kern County, we must first discuss the demographics and significance of this current topic. Among residents of Kern County, 23.1% are at or below 100% of the federal poverty level (FPL) and 47.7% are low-income (200% of FPL or below), which is higher than that of California.  Arreaza: What is food insecurity? In February 2023, we discussed the definition in Episode 128, but it is important to remember what it is. “Food insecurity is having limited, uncertain, or inconsistent access to the food necessary for a healthy life.” Another interesting fact is that it is estimated that 45% of undocumented immigrants in California are affected by food insecurity, including 64% of undocumented children (Source: 2021 CHIS).Judy: Food insecurity is strongly tied to numerous conditions such as hypertension, coronary artery disease, diabetes, hepatitis, stroke, cancer, asthma, arthritis, chronic obstructive pulmonary disease, and kidney disease. Thus, this problem must be explored and discussed to find ways to improve health outcomes. However, the first steps must focus on bridging gaps in accessing healthy and affordable foods. For example, consumers have consistently noted that reliable transportation is a barrier when even applying for assistance before accessing their benefits. Oftentimes, families experiencing poverty, a large number of residents in Kern County, are part of the migrant community, move frequently, and experience difficulties even completing the necessary paperwork for programs such as the Migrant Childcare Alternative Payment program. Arreaza: It may be off-topic, but I had to search what MCAP is. The Migrant Childcare Alternative Payment (MCAP) Program provides childcare services to migrant farm worker families in Kern and other counties in California, such as Merced and Fresno. MCAP allows parents to work while children are taken care of by licensed childcare centers, licensed family childcare homes, license-exempt (relatives), and in-home providers. I think many families may not be aware of this program. This is a reminder for our residents and students that this is available for your patients. Judy: Going back to food insecurity, when looking at the distribution and locations of large supermarkets in the greater Bakersfield area, such as Albertsons, Smart & Final, and Vallarta, the northwest area has many large stores and without a high density of households in poverty. In contrast, Oildale, the southwest and southeast areas do not have many large markets nearby. Thus, it is also important to examine how and where our patients can access healthy and affordable food.Obesity and Fatty Liver Disease in Kern County.Judy: I would like to describe the relationship between food insecurity with liver disease. The food insecurity that is prevalent in Kern County contributes to the increasing number of overweight and obese populations we see here. Almost 78% of adults in Kern County are considered either overweight or obese. This is concerning because increased rates of obesity are correlated with higher rates of liver disease. As we know, the liver is responsible for breaking down fats, creating new small and medium-chain fatty acids, and transporting fats. With obesity, fat tends to accumulate in the liver since it is unable to properly break down the fat. This leads to steatosis. Short-term fatty liver disease does not have many clinical findings associated with it, but long term if left uncontrolled it can lead to cirrhosis and death. Arreaza: According to a review of the liver transplant list done in 2022, Non-alcoholic steatohepatitis (NASH) is currently the second leading cause of liver transplant overall, and in females, it is the number-one cause. In California, we see about 13.8 deaths per 100,000 persons from liver-related disease, but Kern County has a high 15.9 deaths per 100,000 persons, which exceeded the Healthy People 2020 objective for liver disease deaths of 8.2 per 100,000 persons. Judy: This was found in Kern Medical Community Needs assessments so these deaths could be correlated to NAFLD, NASH, fatty liver, autoimmune hepatitis, etc. but it is still concerning that the number of deaths from liver disease is about 2x the goal of maximum deaths we would want. Arreaza: So, you are linking food insecurity to obesity, and obesity to fatty liver disease, I see the correlation. Tell us about the local resources to address the problem of food insecurity. Local Resources Judy: As patients walk through our doors, we recognize the social determinants for health and quality of life of our patients. Besides providing affirmations and words of encouragement, it's helpful for the physician and medical staff to offer specific local resources that one can refer to. We collected a list of available resources, please keep in mind that this is not an exhaustive list of the support available in Kern County. Rely on resources around you such as local organizations like Community Action Partnership of Kern (CAPK) and social workers in conjunction with your research to have a comprehensive understanding of what's available for your patients. Arreaza: The first notable resource you guys found is the Commodity Supplemental Food Program, for our unique population– the elderly. It's a USDA-sponsored program that provides a 30-lb monthly food box for seniors 60 years and older who also fall below the federal income guidelines. Judy: The Golden Empire Gleaners also offer support to eligible seniors via a program called  Senior Sack, which has established over 20 sites throughout Kern County. Twice a month, each registered  senior will pick up 10-12 items of fresh fruits, vegetables, canned food, bread, and boxed staples at a local site. Upon arrival, they also engage in interactive activities with the staff and learn more about other local services available.Arreaza: Another resource is the Food Bank, provided by several nonprofit organizations such as Community Action Partnership of Kern, Golden Empire Gleaners,  where individuals of any age can come and receive nutritious food every month. Home delivery and emergency food boxes for seniors are also available. Judy: There are also farmers markets such as F Street Farmers Market, which operates year-round every Saturday from 7:45 am to noon. What's unique about F Street is they offer Market Match which matches program assistance's benefits such as that of CalFresh and eWIC to the farmers' markets and other farm-directed sites. How it works is when individuals use their benefits, Market Match will match that fund so the person can buy even more fruits and vegetables. For example, if I use $10 of CalFresh benefits at the farmers' market, I will also receive another $10 for a total of $20 to spend on any fresh produce. F Street Farmers Market will match up to $20 per visit year-round which increases access to fresh fruits and vegetables, as well as provides an incentive for the locals to support family farms and their businesses. To find other farmers' markets that offer other benefits, please visit Farmers Market Finder by Ecology Center or call CAPK for other free food distribution sites. Arreaza: I have to mention this wonderful initiative which I have participated in many times. It is called the bishop's storehouse, sponsored by The Church of Jesus Christ of Latter-day Saints. It is a place where those in need can go to obtain food and other supplies at the recommendation of their bishop. So, it requires a “ticket” from a bishop, who is the leader of a congregation, to receive goods for free. People of any faith can request this help by going to any church location. So, we mentioned the Commodity Supplemental Food Program, Golden Empire Gleaners, Food Bank, F Street Farmers Market, and the bishop's storehouse. Judy, thanks for sharing this relevant information. Please give us a conclusion to wrap up this episode.Judy: As primary care doctors we are in a special position to prevent and treat many diseases. By addressing food insecurity, you may have a significant impact on your community. By providing appropriate nutrition, we can fight and prevent many diseases, such as fatty liver disease among others. We should share these resources with patients to improve their access to healthy food.___________________________Conclusion: Now we conclude episode number 169, “Food Insecurity and Obesity in Kern County.” Future Dr. Kim explained that food insecurity is linked to multiple chronic conditions, and she mentioned particularly obesity and fatty liver disease. Food insecurity can be partially addressed by sharing with our patients the resources in our community, and today you heard some of them, but we encourage you to keep looking for many others and share them with your patients. This week we thank Hector Arreaza, Judy Kim, Vy Nguyen, and Mira Patel. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Food Bank - CAPK: Community Action Partnership of Kern. CAPK. (2024, February 27). https://www.capk.org/seniorfood/Kern Food Insecurity Needs Assessment. CAPK. (2023, August). https://feedingkern.org/wp-content/uploads/2023/09/CAPK-Food-Insecurity-Needs-Assessment-Report-revised-with-copyedits-9-11-2023.pdfMarket Match Program Helps Residents Double Their CalFresh Dollars. Department of Public Social Services. (n.d.)https://dpss.lacounty.gov/en/news/2021/05/calfresh-market-match.htmlSenior Sack. Golden Empire Gleaners. (n.d.). https://www.goldenempiregleaners.com/programsSenior food program - CAPK: Community Action Partnership of Kern. CAPK. (2024, February 27). https://www.capk.org/seniorfood/Fabbrini E, Sullivan S, Klein S. Obesity and nonalcoholic fatty liver disease: biochemical, metabolic, and clinical implications. Hepatology. 2010 Feb;51(2):679-89. doi: 10.1002/hep.23280. PMID: 20041406; PMCID: PMC3575093.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575093/Know your numbers. Kern County Public Health. (2024, April 1). https://kernpublichealth.com/knowyournumbers/CAPK feeding Kern - feeding Kern. CAPK Food Assessment Report. (2024, March 15). https://feedingkern.org/Community Health Needs Assessment. (n.d.). https://www.kernmedical.com/documents/Kern-Medical-2019-CHNA-Report-Final.pdfDepartment of Health & Human Services. (2007, November 28). Liver - fatty liver disease. Better Health Channel. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/liver-fatty-liver-disease#Noureddin M, Vipani A, Bresee C, et al. NASH Leading Cause of Liver Transplant in Women: Updated Analysis of Indications For Liver Transplant and Ethnic and Gender Variances. Am J Gastroenterol. 2018;113(11):1649-1659. doi:10.1038/s41395-018-0088-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9083888/The Bishops' Storehouse, Provident Living, The Church of Jesus Christ of Latter-day Saints, https://providentliving.churchofjesuschrist.org/bishops-storehouse?lang=eng.Royalty-free music used for this episode: Good Vibes by Simon Pettersson, downloaded on July 20, 2023, from  https://www.videvo.net/royalty-free-music

Episode 168: UTI in MalesFuture Dr. Tran gives a summary of UTIs in Males, including epididymitis, orchitis, urethritis, prostatitis, and pyelonephritis. Diagnosis and treatment were briefly described and some differences with female patients were mentioned by Dr. Arreaza.  Written by Di Tran, MS-3, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.WHAT ARE URINARY TRACT INFECTIONS?Urinary Tract Infection (UTI) is an infection of any part of the urinary tract system. It may involve any part of the renal system, the kidneys, the ureters, the bladder, the prostate, and the urethra.  Different from men, a woman may get a UTI more easily due to their anatomical difference. A woman's urethra is shorter and lies close in proximity to both the vagina and the anus, which allows easy access for bacteria to travel up to the bladder.UTI is further subdivided into two different categories, depending on where the infection takes place within the urinary tract:Lower Tract Infection – cystitis and urethritis when the infection occurs on the bladder and the urethra, respectively.  Common infections are a result of bacteria migrating from the skin (and also from sexual organs) to the urethra and ending up in the bladder.In males, other forms of lower tract infection can result in prostatitis, epididymitis, and orchitis.Upper Tract Infection - aka pyelonephritis, is a more concerning infection that involves the upper parts of the urinary system, in other words, the ureters, and kidneys.AGE DIFFERENCES IN UTI FOR MEN:For men, the incidence of UTI increases with age. Dr. John Brusch reports UTI rarely develops in young males and the prevalence of bacteriuria is 0.1% or less.  Men who are 15-50 years of age often have urethritis due to sexually transmitted infection (STI), mainly by Neisseria gonorrhoeae and Chlamydia trachomatis.  Symptoms include frequency, urgency, and dysuria (most common).Men who are 50 years or older, especially those with prostatic hyperplasia, will have signs and symptoms of incomplete bladder emptying, hesitancy, slow stream, difficulty initiating urination, and dribbling after urinating. Due to the enlargement of the prostate gland, there will be partial blockage of urine flow from the bladder, which in turn, creates a reservoir where bacteria can grow and cause an infection. The most common offending microorganism for this age group is Escherichia coli.Interestingly, while UTIs are rare among men under 60, by the age of 80, both women and men have similar incidence rates. The bladder tends to have a higher residual volume in older males because the prostate grows no matter what, it´s just a part of aging for males. Some may end up with more or less lower urinary tract symptoms, but the prostate is enlarged in general.Other risk factors for UTI in males are men who are not circumcised, urethral strictures, fistulas, hydronephrosis (or dilated ureters overfilled with urine due to failure of drainage to the bladder), and the use of urinary catheters. DIFFERENT TYPES OF UTIs IN MALES:EPIDIDYMITIS:The infection starts from the retrograde ascending route from the prostatic urethra, backing up to the vas deferens, and eventually ending in the epididymis.In men who are younger than 35 years of age, the usual pathogens are C. trachomatis and N. gonorrhoeae (sexually transmitted).In men who are older than 35 years of age, the usual offending agents are Enterobacteriaceae and gram-positive cocci (E. coli as mentioned previously).ORCHITIS:This unique UTI is caused by viral pathogens, such as mumps, coxsackie B, Epstein-Barr (EBV), and varicella (VZV) viruses.  Several studies have shown that patients having orchitis have a history of epididymitis. Fortunately, this infection is uncommon, and it was the main reason to develop the MMR vaccine. It is caused by viruses other than mumps, so you can still have orchitis even if you are vaccinated. Antibiotics are not prescribed for viral orchitis.BACTERIAL CYSTITIS:Having a similar pathophysiology of ascending infection mechanism, male patients in this category often present frequency, urgency, dysuria, nocturia, and suprapubic pain. On a side note, having hematuria is concerning, especially without symptoms, because it's automatically a red flag that should prompt an immediate evaluation in search of other causes besides infection, such as underlying malignancy. Possible etiologies are calculi, glomerulonephritis, and even schistosomiasis infection that can ultimately result in squamous cell carcinoma of the bladder. Arreaza: Let me share a little anecdote about hematuria. One Sunday when I was a resident I woke up with hematuria. Of course, I immediately went to urgent care, knowing hematuria means trouble in men. I had a urine dipstick test, which was normal. The first thing the nurse practitioner asked me was, “Did you eat any beets?”, and I never eat beets, but that day I had a full bag of beet chips. So, yes, that was the cause of my pseudo-hematuria. Lesson learned: Always ask about beets when you have a patient with painless hematuria with a normal dipstick. PROSTATITIS:This is an infection of the prostate gland. The most common offending agent is E. coli. Acute prostatitis will present with signs of “acute” infection, such as fever, chills, and suprapubic pain. On rectal exam, we will find a prostate that is warm, swollen, boggy, and very tender. Make sure you perform a gentle prostate exam as you may spread bacteria to the blood and cause bacteremia and potentially sepsis. Patients are normally very sick and it is not your typical cystitis, but it is more severe. Chronic Prostatitis can arise from different causes, ranging from retrograde ascending infection, “chronic” exposure to urinary pathogens, and even autoimmune etiologies. The majority of patients often are asymptomatic.   URETHRITIS:This infection is further classified into two groups, gonococcal and non-gonococcal. For gonococcal urethritis, N. gonorrhoeae is the most common pathogen. Agents of non-gonococcal urethritis include C. trachomatis, Ureaplasma, trichomonas, and Herpes Simplex Virus (HSV).  Patients often present symptoms of dysuria, pruritus, and purulent penile discharge.PYELONEPHRITIS:Following a retrograde ascending mechanism, an infection may travel from the bladder and make its way to the kidney, causing damage and inflammation to the renal parenchyma. According to Dr. John Brusch, E. coli is responsible for approximately 25% of cases in males. Pyelonephritis presents with chills, fever, nausea/vomiting, flank pain/costovertebral angle tenderness, and dysuria.  Other findings include pyuria and bacteriuria.  Pyelonephritis is a common cause of sepsis. Diagnosis of UTIs.URINE STUDIES: Urine culture remains the gold standard for diagnosis of UTI. Other studies include suprapubic aspiration, catheterization, midstream clean catch, and Gram stain. Imaging studies are not always needed, but you may order plain films, ultrasonography, CT scans, and MRIs.  It will depend on the severity of your case and your clinical judgment.UTIs in women: In males, we should perform urine culture and susceptibility studies. However, in women, urine studies are not needed all the time, they should be reserved for women with recurrent infection, treatment failure, history of resistant isolates, or atypical presentation. This is done to confirm the diagnosis and guide antibiotic selection.Interestingly, in a recent evidence review, published in the American Family Physician journal, women can self-diagnose their uncomplicated cystitis. All that is needed is having typical symptoms (frequency, urgency, dysuria/burning sensation, nocturia, suprapubic pain), without vaginal discharge. If you have those elements, you have enough information to diagnose, or even the patient can self-diagnose, an uncomplicated UTI without further testing, but in males, you should ALWAYS perform urine studies.TREATMENTS:Men with UTI should ALWAYS receive antibiotics, with urine culture and susceptibility results guiding the antibiotic choice. Laboratory results will help us determine the best treatment plan. UTIs are often treated with a variety of antibiotics.  Dr. Robert Shmerling, of Harvard Medical School, states that most uncomplicated lower tract infections can be eradicated with a week of treatment with antibiotics. Common antibiotics for UTI are fluoroquinolones, trimethoprim-sulfamethoxazole (TMP-SMZ), minocycline, or nitrofurantoin.On another hand, if it's an upper tract infection or prostatitis, the course of treatment can be extended for longer periods. For those patients who are hemodynamically unstable or have severe upper UTI, hospital admission is required to monitor for complications and IV antibiotics.UTIs in males are less frequent than UTIs in females, except when patients are 80 years and older when the incidence is similar in both sexes. UTIs in males must prompt further evaluation because if left untreated, they can have detrimental effects on your patients' health. As a take-home point, UTI in males is less common than in females, and it requires urine studies or other studies to identify the etiology and guide treatment. Antibiotics are always used, and you may guide your treatment depending on the results. Imaging is not always needed, but use your clinical judgment to make a more specific diagnosis and detect complications promptly. __________Conclusion: Now we conclude episode number 168, “UTI is Males.” Future Dr. Tran described the different anatomical areas that can be infected in males with UTI. She reminded us that UTIs in males always need to be treated with antibiotics and urine cultures are done to guide treatment. Dr. Arreaza mentioned a few differences in the diagnosis and treatment of UTIs in females. For example, women can self-diagnose an uncomplicated cystitis, and urine studies or antibiotics are not always needed in women. This week we thank Hector Arreaza and Di Tran. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Shmerling, R. H. (2022, December 5). Urinary tract infection in men. Harvard Health Publishing. https://www.health.harvard.edu/a_to_z/urinary-tract-infection-in-men-a-to-z.Brusch, J. L. (2023a, March 27). Urinary tract infection (UTI) in males. emedicine.medscpae.com. https://emedicine.medscape.com/article/231574-overview.Kurotschka PK, Gágyor I, Ebell MH. Acute Uncomplicated UTIs in Adults: Rapid Evidence Review. Am Fam Physician. 2024;109(2):167-174. https://www.aafp.org/pubs/afp/issues/2024/0200/acute-uncomplicated-utis-adults.htmlRoyalty-free music used for this episode: Tropicality by Gushito, downloaded on July 20, 2023, from https://www.videvo.net/royalty-free-music/

Episode 167: Aspirin in PregnancyDr. Marquez explains the use of aspirin during pregnancy to prevent preeclampsia. Dr. Arreaza adds comments and questions and clarifies that aspirin is not used for the treatment of preeclampsia.Written by Verna Marquez, MD, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction to the topic: Pregnancy is a special time in a woman's life, and we want to make sure that both the mother and the baby are safe and healthy. 1. What is aspirin? Aspirin is one of the most ancient medications in history, it is known as acetyl-salicylic acid (ASA) and it belongs to the family of non-steroidal anti-inflammatory drugs (NSAID), and it is also an anti-platelet, among other properties that may be unknown. It is widely used for pain, fever, and inflammation, but due to adverse effects during viral illness (i.e. Reye Syndrome), it is used less frequently during viral infections. As we know, aspirin is widely used to treat myocardial infarction and ischemic stroke, and especially for secondary prevention. The use of aspirin for primary prevention of cardiovascular disease has become less popular, but we are going to leave that discussion for another episode because today we will talk about the use of aspirin in pregnancy!2. Why should we use aspirin in pregnancy?Low-dose aspirin in pregnancy is most commonly used to prevent or delay the onset of preeclampsia. Aspirin lowers the risk of preeclampsia by 10% and its consequences (such as growth restriction and preterm birth). Several organizations have agreed on the risk factors we will mention briefly. These organizations are ACOG (American College of Obstetricians and Gynecologists), USPSTF (US Preventive Services Task Force), and SMFM (Society for Maternal-Fetal Medicine).3. Who should we start on aspirin in pregnancy? Aspirin is not for every pregnant patient, for example, a healthy nulliparous or any patient who had an uneventful, full-term delivery previously, is considered low risk and should NOT be started on aspirin because there is no benefit in preventing any condition. Low-dose aspirin is recommended for women who have at least a high-risk factor because the incidence of preeclampsia is about 8% in these patients. The risk factors are:•Previous pregnancy with preeclampsia (especially early onset and with an adverse outcome)•Type 1 or 2 diabetes mellitus.•Chronic hypertension.•Multifetal gestation.•Kidney disease.•Autoimmune disease with potential vascular complications (antiphospholipid syndrome, systemic lupus erythematosus).Your patient only needs 1 high-risk factor to be put on aspirin in pregnancy. 4. What are the moderate risk factors?A patient needs to have more than 1 moderate risk factor to meet the criteria for prenatal aspirin.•Nulliparity.•Obesity (BMI >30).•Family history of preeclampsia in mother or sister.•Age ≥35 years.•Sociodemographic characteristics (Black persons, lower income level [recognizing that these are not biological factors]).•Personal risk factors (for example, previous pregnancy with low birth weight or small for gestational age newborn, previous adverse pregnancy outcome [such as stillbirth], interval >10 years between pregnancies). However, low-dose ASA prophylaxis is not recommended solely for the indication of prior unexplained stillbirth in the absence of risk factor for preeclampsia.•In vitro conception.USPSTF/ACOG may also suggest aspirin in selected patients with only one moderate risk factor, but it would require consultation with a specialist in obstetrics. 5. When should we start aspirin?After 12 weeks of gestation, ideally before 16-20 weeks of gestation. If a patient is more than 16 weeks pregnant, aspirin can be started but most of the benefit has been noted when initiated before 16 weeks because many of the abnormalities that cause preeclampsia are developed early in pregnancy. It is not recommended to start before 11 weeks.It is important to mention also that low-dose aspirin appears to have little or no benefit in patients who already have developed preeclampsia. Starting aspirin in preeclampsia can even cause damage such as bleeding in cases of thrombocytopenia. 6. What is the dose?The dose is between 75 to 162 mg daily. Conveniently, we have an 81 mg presentation in the United States, and it falls within the recommended range. It can be taken in the morning or at night, and adherence of >90% is associated with better prevention.7. When do we stop aspirin?Expert opinion recommends stopping aspirin at the time of delivery. 8. What are the contraindications to ASA use during pregnancy?Absolute contraindications to aspirin: -Patients with a history of ASA allergy (urticaria) or hypersensitivity to other salicylates are at risk of anaphylaxis and should not receive low-dose ASA. -Because of significant cross-sensitivity between ASA and other NSAIDs, low-dose ASA is also contraindicated with known HPS to NSAIDs. -Exposure to low-dose ASA in patients with nasal polyps may result in life-threatening bronchoconstriction and should be avoided.Relative contraindications are history of GI bleed, active peptic ulcer disease, other sources of GI or GU bleeding, and severe hepatic dysfunction.Aspirin is an excellent way to prevent preeclampsia in patients who are at high or moderate risk. Remember to think about the high-risk factors, and if your patient has only 1 positive, then aspirin needs to be started. Mainly, previous preeclampsia, diabetes, hypertension, multifetal gestation, and kidney or autoimmune disease. Look for moderate risk factors and start aspirin if the patient has 2 or more of those risk factors. _________________Conclusion: Now we conclude episode number 167, “Aspirin in Pregnancy.” Dr. Marquez explained that aspirin is started between 12-16 weeks of gestation to prevent preeclampsia in patients with at least 1 high-risk factor or patients with 2 or more moderate-risk factors. Dr. Arreaza also mentioned that aspirin is not for low-risk patients or for patients who already developed preeclampsia. As you know, preeclampsia can result in severe consequences for the fetus and the mother, but by preventing it, we can improve the chances of having a positive outcome in pregnancy. This week we thank Hector Arreaza and Verna Marquez. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:August, Phyllis and Arun Jeyabalan, Preeclampsia: Prevention. UpToDate, Last updated Feb 16, 2024. https://www.uptodate.com/contents/preeclampsia-prevention.Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication, September 28, 2021, United States Preventive Services Taskforce https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication.Royalty-free music used for this episode: Tropicality by Gushito, downloaded on July 29, 2023, from https://www.videvo.net/royalty-free-music/. 

Episode 166: Naturopathic Medicine InsightsFuture Dr. Luong talked about what she learned about naturopathic doctors (NDs). She discussed the principles of naturopathic medicine and mentioned some differences in regulations across states in the US. Dr. Arreaza shared his opinion about the pros and cons of naturopathic medicine.  Written by Teresa Luong, MSIV, American University of the Caribbean. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: This may be a controversial topic. The term “natural” in medicine triggers strong reactions among allopathic doctors like me. Today we have a medical student who took up the challenge to talk about Naturopathic Doctors. Teresa:I am providing information based on research and living in Washington state, which is considered one of the birthplaces of modern naturopathic medicine, boasts the highest population of naturopathic doctors and a wide range of practice specialties. It's important to note that my responses are not personal opinions but rather informed insights. There are about 8,500 licensed naturopathic doctors in North America. Naturopathic Doctors may not use the title of physicians in California. What is a Naturopathic Doctor?While it's true that in California naturopathic doctors are not legally permitted to use the term ”physician” to describe themselves, some still choose to refer to themselves as “naturopathic physicians” colloquially or in their practice branding. So, confusion can arise because naturopathic doctors, while legally not recognized as physicians in California, can function as primary care providers, this overlap in roles can lead to the informal use of terms like ”naturopathic physician.“ However, it's important to recognize that legally, they are not recognized as physicians in this state. Naturopathic doctors (NDs) are healthcare professionals who embrace a holistic approach to healing, focusing on natural and non-invasive therapies to support the body's inherent ability to heal itself. Naturopathic medicine has its roots in traditional healing practices from around the world, blending ancient wisdom with modern scientific knowledge. The philosophy of naturopathy emphasizes the importance of treating the whole person—mind, body, and spirit—rather than just addressing isolated symptoms or diseases.What is an allopathic approach vs a holistic approach?Allopathic medicine: Allopathic medicine focuses on diagnosing and treating specific symptoms or diseases using pharmaceutical drugs, surgery, and other conventional interventions. Treatment is often targeted at managing symptoms or eradicating pathogens.Holistic medicine: Holistic medicine takes a broader approach, considering the whole person and aiming to address the root causes of illnesses. Treatment may involve a combination of conventional therapies and alternative modalities such as nutrition, herbal medicine, acupuncture, and lifestyle modifications. The focus is on promoting overall health and well-being rather than just treating isolated symptoms.Core Principles Naturopathic Practitioners: The six core principles of naturopathic medicine serve as guiding tenets for both diagnosis and treatment. These principles include: -first, do no harm. -the healing power of nature -identify and treat the root cause -treat the whole person, -the physician as a teacher; -and prevention as the best cure. Treatment modalities: Naturopathic doctors employ a wide range of therapeutic modalities to address the unique needs of each individual, such as:-Clinical nutrition, which focuses on using “food as medicine” to promote healing and prevent disease. -Herbal medicine utilizes the medicinal properties of plants to support various bodily systems and restore balance. -Acupuncture, everybody is familiar with acupuncture. -Other modalities may include hydrotherapy, homeopathy, physical medicine (such as massage and manipulation), and lifestyle counseling.The role of allopathic medications (NSAIDs, antibiotics) and surgical procedures.Naturopathic doctors typically prioritize natural therapies and lifestyle intervention, but may also integrate conventional medicine when necessary. Their views on traditional medications, such as NSAIDs, antibiotics, and surgical procedures vary depending on the individual practitioner and their approach to healthcare. Some may recommend them when appropriate, while others may prefer to explore alternative options first. Ultimately, their goal is often to promote holistic health and well-being. Education and Training: Pre-Medical Requirements: Aspiring naturopathic doctors typically complete undergraduate coursework in pre-medical sciences, including Biology, Chemistry, Physics, and Psychology.Naturopathic Medical Program:Naturopathic doctors must graduate from a four-year accredited naturopathic medical school. The forst two years are basic sciences courses and the last 2 years are clinical courses.After completing their naturopathic medical education, graduates must pass the Naturopathic Physicians Licensing Examinations (NPLEX) to become licensed practitioners. MDs need a residency, and NDs can start working immediately after school in some states, or they can do some additional training.Scope of Practice: The scope of practice for naturopathic doctors varies depending on the regulations in each jurisdiction. In general, NDs are trained to:- Prescribe natural therapies such as nutritional supplements, herbal remedies, and homeopathic medicines.- Prescribe prescription medications, including some, but not limited to, controlled substances.- Provide dietary counseling and lifestyle interventions tailored to individual health needs.- Provide Primary Care, such as, performing physical exams, administering vaccinations, ordering laboratory tests,- Offer acupuncture.- They can use detoxification protocols and intravenous (IV) nutrient therapy into treatment plans.- Utilize mind-body techniques like meditation, mindfulness, and relaxation exercisesIn January 2022, the recognition of naturopathic doctors (NDs) and the extent of their scope of practice vary significantly from state to state within the United States. Here's an overview of states where NDs are recognized and their scope of practice:Licensed States: In these states, naturopathic doctors are licensed to practice independently and have a broad scope of practice, including diagnosis, treatment, and prescription of medications and natural remedies within their scope. Some states may have specific restrictions or additional requirements.-California: NDs are licensed and regulated by the California Naturopathic Medicine Committee. They have a comprehensive scope of practice, including the prescription of certain medications.-Washington: NDs are licensed and regulated by the Washington State Department of Health. They have a limited formulary for prescription medications.Unlicensed States (for example, Georgia and Virginia): In states where naturopathic medicine is not regulated, NDs have to work as healthcare consultants or working alongside other licensed healthcare providers, like MDs. The scope of practice in these states may be more limited, and NDs may not have the authority to diagnose, treat, or prescribe medications independently.Pros:Naturopathic doctors utilize natural and holistic therapies, which may have fewer side effects compared to conventional medications. These therapies can complement conventional treatments, especially if they are collaborating with an MD.If Naturopathic doctors work collaboratively, it can offer complementary care options to patients, which can provide patients with treatment modalities and perspectives beyond conventional medicine. This can be particularly beneficial for patients who are a bit apprehensive to traditional medicine for whatever reason.Naturopathic medicine emphasizes preventive care and strategies to promote health and prevent disease. So they try to catch underlying imbalances and risk factors early, and see patients multiple times a week, which can help patients reduce their risk of developing chronic illnesses and improve their overall quality of life. By seeing a patient this frequently, it promotes stronger doctor-patient relationships and improves patient satisfaction.Cons:Lack of Regulation and Standardization: Naturopathic medicine is not regulated to the same extent as conventional medicine, and there may be variability in the education, training, and qualifications of naturopathic doctors. This lack of regulation and standardization can raise concerns about the quality and safety of naturopathic care.Limited Scientific Evidence: Some naturopathic treatments  lack rigorous scientific evidence supporting their efficacy and safety. Without robust clinical research, it can be challenging to assess the effectiveness of certain naturopathic interventions and differentiate between evidence-based practices and unproven therapies.Potential for Harmful Practices: In some cases, naturopathic doctors may recommend treatments or interventions that have the potential to be harmful, particularly if they lack scientific support or are based on unfounded beliefs. Patients may be at risk of receiving ineffective or unsafe treatments without proper oversight and regulation.Delayed Access to Conventional Care: So if a patient relies solely on naturopathic care, it may delay access to conventional medical treatments that are necessary for managing serious or life-threatening conditionsCost and Insurance Coverage: Naturopathic services may not be covered by health insurance plans, or coverage may be limited compared to conventional medical services. This lack of insurance coverage can make naturopathic care inaccessible to some patients, particularly those with limited financial resources.This information is provided to increase your knowledge on this topic, it is not intended to convince you to go against or support naturopathic medicine. Our goal is to inform you and you can draw your own conclusions about it. It is important to educate ourselves on this topic because naturopathic doctors are rising in California and we may encounter them in our future practices. ________________________________Conclusion: Now we conclude episode number 166, “Naturopathic Medicine Insights.” Future Dr. Luong explained that naturopathic doctors receive training in naturopathic medical schools and receive a degree before they sit for a board exam. Many NDs may be working in outpatient primary care or even in hospital care. Dr. Arreaza shared his opinion about the pros and cons of having naturopathic medicine available for patients.This week we thank Hector Arreaza and Teresa Luong. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! Links: American Association of Naturopathic Physicians:aanp.org. Complementary, Alternative, or Integrative Health: What's In a Name? NIH National Center for Complementary and Integrative Health, https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name. Accessed March 21, 2024. Bastyr University:bastyr.eduNational University of Natural Medicine (NUNM):nunm.eduFleming SA, Gutknecht NC. Naturopathy and the primary care practice. Prim Care. 2010;37(1):119-136. doi:10.1016/j.pop.2009.09.002. https://pubmed.ncbi.nlm.nih.gov/20189002/Atwood KC 4th. Naturopathy: a critical appraisal. MedGenMed. 2003;5(4):39. Published 2003 Dec 30. https://pubmed.ncbi.nlm.nih.gov/14745386/Public Notification: Artri King contains hidden drug ingredients, U.S. Food & Drug Administration (FDA), April 20, 2022. https://www.fda.gov/drugs/medication-health-fraud/public-notification-artri-king-contains-hidden-drug-ingredientsRoyalty-free music used for this episode: My Dinner with the Diablo by Tropicalia, downloaded on July 20, 2023 from  https://www.videvo.net/. 

Episode 165: Early-Onset Sepsis Part 2Dr. Lovedip Kooner explains how to use the Kaiser Permanente early-onset sepsis calculator and explains other useful tools to assist in the diagnosis of EOS. Dr. Arreaza adds comments about the usefulness of this calculatorWritten by Lovedip Kooner, MD. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: As a recap, Early-onset sepsis is diagnosed within 72 hours (or within 7 days, according to some experts) after birth. We talked about GBS as the main culprit of EOS. 28% of EOS by GBS are babies born 2 hours to maintain oxygen saturations > 90% (outside of the delivery room)After all that information is entered into the Kaiser Permanente calculator, the options for management are clinical monitoring, laboratory evaluation, or antibiotic administration. Example: -Incidence: 0.5/1,000 live births -Gestational age: 36 6/7 weeks-Highest maternal antepartum temperature: 102 F-ROM: 5 hours-Maternal GBS: Positive-Intrapartum antibiotics: Broad spectrum 3 hours prior to birth-RESULT: EOS risk at birth 2.34.Recommendations based on physical exam:1. Well-appearing baby, risk 0.96, RECOMMENDATIONS: No culture, no antibiotics, vitals every 4 hours for 24 hours.2. Equivocal, risk 11.61, RECOMMENDATIONS: Start empiric antibiotics and vitals per NICU.3. Clinical Illness, risk 47.46, RECOMMENDATIONS: Start empiric antibiotics and vitals per NICU.The Kaiser Permanente neonatal early-onset sepsis calculator was analyzed in a meta-analysis, as published in the American Family Physician in 2021. Six high-quality, non-randomized controlled trials were evaluated, including more than 170,000 neonates. The calculator was compared to the standard approach recommended by the CDC guidelines. The analysis showed there was a statistically significant reduction in antibiotic use, a reduction in the number of laboratory tests, and a reduction in NICU admission in neonates who were managed following the sepsis calculator compared with the standard approach. There was no difference in readmission rates to NICU and no difference in culture-positive sepsis between neonates treated using the sepsis calculator and those treated with the standard approach. In summary, I recommend using the Kaiser Permanente calculator as part of your evaluation. BTW, I received no money from KP. It is important to know that depending on resources and institutional policies, your management may change.Use of CBC and CRP.CBC interpretation in neonates: Remember that CBC in newborns needs to be evaluated following the normal parameters for neonates. For example, WBC up to 30,000 per mm3, and hemoglobin up to 19.9 gm/dL can be normal in neonates. Serial white blood cell counts and immature–to–total neutrophil ratio (I/T ratio) generally greater than or equal to 0.2 by some experts is considered positive for sepsis. Complete blood cell counts taken 12-24 hours after birth are associated with increased sensitivity and negative predictive value compared to a sample taken 1-7 hours after birth. C-reactive protein (CRP) is also often used and it rises within 6 hours of infection and peaks at 24 hours. Two normal CRP levels, one taken between 8-24 hours of age and the second 24 hours later, have an over 99% negative predictive value. Single values of CRP or procalcitonin obtained after birth to assess the risk of EOS are neither sensitive nor specific to guide EOS care decisions.Procalcitonin: Procalcitonin may be difficult to interpret within the first 3 days after birth due to elevations caused by noninfectious etiologies and the physiologic rise after birth. It is important to note that neither single values of CRP nor procalcitonin after birth should be used to guide the management plan of infants undergoing evaluation for EOS>.Extreme values in CBC: Extreme values (total WBC count 0.3; ANC

Episode 164: More Than Just A HeadacheDr. Song presents a case of a subacute headache that required an extensive workup and multiple visits to the hospital and clinic to get a diagnosis. Dr. Arreaza added comments about common causes of subacute headaches.    Written by Zheng (David) Song, MD. Editing and comments by Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction to the episode: We are happy to announce the class of 2027 of the Rio Bravo / Clinica Sierra Vista Family Medicine Residency Program. Our new group will be (in alphabetical order): Ahamed El Azzih Mohamad, Basiru Omisore, Kenechukwu Nweke, Mariano Rubio, Nariman Almnini, Patrick De Luna, Sheila Toro, and Syed Hasan. We welcome all of you. We hope you can enjoy 3 enriching and fulfilling years. During this episode, you will hear a conversation between Dr. Arreaza and Dr. Song. Some elements of the case have been modified or omitted to protect the patient's confidentiality. 1. Introduction to the case: Headache. A 40-year-old male with no significant PMH presents to the ED in a local hospital due to over a month history of headaches. Per the patient, headaches usually start from the bilateral temporal side as a tingling sensation, and it goes to the frontal part of the head and then moves up to the top of the head. 8 out of 10 severities were the worst. Pt reports sometimes hypersensitivity to outdoor sunlight but not indoor light. OTC ibuprofen was helpful for the headache, but the headache always came back after a few hours. The patient states that if he gets up too quickly, he feels slightly dizzy sometimes, but it is only for a short period of time. There was only one episode of double vision lasting a few seconds about 2 weeks ago but otherwise, the patient denies any other neurological symptom. He does not know the cause of the headache and denies any similar history of headaches in the past. The patient denies any vomiting, chest pain, shortness of breath, cough, abdominal pain, or joint pain. The patient further denies any recent traveling or sick contact. He does not take any chronic medication. The patient denies any previous surgical history. He does not smoke, drink, or use illicit drugs. What are your differential diagnoses at this moment? Primary care: Tension headache, migraines, chronic sinusitis, and more.2. Continuation of the case: Fever and immigrant.Upon further inquiries, the patient endorses frequent “low-grade fever” but he did not check his temperature. He denies any significant fatigue, night sweats, or weight loss. He migrated from Bolivia to the U.S. 12 years ago and has been working as a farm worker in California for the past 10 years. He is married. His wife and daughter are at home in Bolivia. He is currently living with friends. He is not sexually active at this moment and denies having any sexual partners. Differential diagnoses at this moment?  Tension headache, migraine, infections, autoimmune disease, neurocysticercosis. 3. Continuation of the case: Antibiotics and eosinophilia. As we kept asking for more information, the patient remembered he visited a clinic about four months ago for a dry cough and was told he had bronchitis and was given antibiotics and the cough got better after that. He went to another local hospital ED one month after that because the cough came back, now with occasional phlegm and at that time he also noticed two “bumps” on his face but nothing significant. After a CXR at the ED, the patient was diagnosed with community-acquired pneumonia and sent home with cough medication and another course of antibiotics. His cough improved after the second round of antibiotics. We later found on the medical record that the CXR showed “mild coarse perihilar interstitial infiltrates of unknown acuity”. His blood works at the ED showed WBC 15.2, with lymphocyte 21.2%, monocyte 10.1%, neutrophil 61.7%, eosinophil 5.9% (normally 1-4%), normal kidney, liver functions, and electrolytes, and prescribed with benzonatate 100mg TID and doxycycline 100mg bid for 10 days. He went to the same ED one month before he saw us for headache and fever (we reviewed his EMR, and temp was 99.8F at the ED). After normal CBC, CMP and chest x-ray. The patient was diagnosed with a viral illness and discharged home with ibuprofen 400mg q8h.Due to the ongoing symptoms of headache and fever, the patient went back to the same clinic he went to four months ago for a dry cough and requested a complete physical and blood work. The patient was told he had a viral condition and was sent home with oseltamivir (Tamiflu®) for five days. However, the provider did order some blood work for him. Differential diagnoses at this moment?  Patients with subacute meningitis typically have an unrelenting headache, stiff neck, low-grade fever, and lethargy for days to several weeks before they present for evaluation. Cranial nerve abnormalities and night sweats may be present. Common causative organisms include M. tuberculosis, C. neoformans, H. capsulatum, C. immitis, and T. pallidum. At his physical exam visit, the patient actually asked the provider specifically to check him for coccidiomycosis because of his job as a farm worker and he heard from his friends that the infection rate is pretty high in the Central Valley of California. His serum cocci serology panel showed positive IGG and IGM with CF titer of 1:128. His HIV, syphilis, HCV, HBV are all negative. The patient was told by that clinic to come to ED due to his history of headache, fever, and very high serum coccidiomycosis titer.  The senior and resident intern were on the night shift that night and we were contacted by the ED provider at around 9:30 pm for this patient. When reviewing his ED record, his vitals were totally normal at the ED, the preliminary ED non-contrast head CT showed no acute intracranial abnormality. A lumbar puncture was performed by the ED provider, which showed WBCs (505 - 71%N, 20%L, 7%M), RBC (1), glucose (19), and protein (200). CSF: High Leukocytes, low glucose, and high protein.On the physical exam, the patient was pleasant and cooperative, he was A&O x 4, he had a normal examination except for two brown healing small nodules on his forehead and left cheek and slight neck stiffness. At that point, we knew the patient most likely had fungal meningitis by cocci except for the predominant WBC in his CSF fluid was neutrophil not the more typical picture of lymphocyte dominant. And because of his very benign presentation and subacute history, we were not 100% sure if we had a strong reason to admit this patient. We thought this patient could be managed as an outpatient with oral fluconazole and referred to infectious disease and neurology. 4. Continuation of case: Admission to the hospital.Looking back, one thing that was overlooked while checking this patient in the ED was the LP opening pressure. Later, the open pressure was reported as 340mm H2O (very high). The good thing was, after speaking to the ED attending and our attending, the patient was admitted to the hospital and started on oral fluconazole.  Three hours after the admission, a rapid response was called on him. While the floor nurses were doing their check-in physical examination, the patient had a 5-minute episode of seizure-like activity which included bilateral tonic arm/hand movements, eye deviation to the left, LOC unresponsive to sternal rub, and the patient desaturated to 77%. He eventually regained consciousness after the seizure and pulse oximetry increased to 100% on room air. The patient was started on Keppra and seen by a neurologist the following day. His 12-hour EEG was normal, but his head MRI showed “diffuse thickening and nodularity of the basal meninges are seen demonstrating enhancement, suggesting chronic meningitis, possibly related to cocci. Other etiologies including sarcoidosis and TB meningitis and/or infiltration by metastatic process/lymphoma are not excluded. The ventricles are slightly prominent in size”. MRI of the cervical, thoracic, and lumbar spines also showed extensive diffuse leptomeningeal thickening, extensive meningitis, and nodular dural thickening. Also, his chest x-ray showed “some heterogeneity and remodeling of the distal half of the left clavicle. Metabolic bone disease, infectious etiology and/old trauma considered”. This could also be due to disseminated cocci infection. The infectious disease doctor saw this patient and recommended continuing with fluconazole, serial LPs until opening pressure is less than 250 mmH2O and neurosurgery consultation for possible VP shunt placement. The neurologist recommended the patient continue with Keppra indefinitely in the context of structural brain damage secondary to cocci meningitis.Take home points: Suspect cocci meningitis in patients with subacute headache associated with respiratory symptoms, new skin lesions, photophobia, neck stiffness, nausea, vomiting, eosinophilia, erythema nodosum (painful nodules on the anterior aspect of legs). Other symptoms to look for include arthralgias, particularly of the ankles, knees, and wrists.____________________Brief summary of coccidiomycosis. Etiology Coccidioidomycosis, commonly known as Valley fever, is caused by dimorphic soil-dwelling fungi of the genus Coccidioides (C. immitis and C. posadasii). They are indistinguishable in clinical presentation and routine laboratory test results.1, 2, 3, 5Epidemiology In the United States, endemic areas include the southern portion of the San Joaquin Valley of California and the south-central region of Arizona. However, infection may be acquired in other areas of the southwestern United States, including the southern coastal counties in California, southern Nevada, southwestern Utah, southern New Mexico, and western Texas (including the Rio Grande Valley). There are also cases in eastern Washington state and in northeastern Utah. Outside the United States, coccidioidomycosis is endemic to northern Mexico as well as to localized regions of Central and South America.1, 2Overall, the incidence within the United States increased substantially over the 1998-2019, most of that increase occurred in south-central Arizona and in the southern San Joaquin Valley of California. From 1998 to2019, reported cases in California increased from 719 to 9004.1, 6The risk of infection is increased by direct exposure to soil harboring Coccidioides. Past outbreaks have occurred in military trainees, archaeologists, construction or agricultural workers, people exposed to earthquakes or dust storms. However, in endemic areas, many cases of Coccidioides infection occur without obvious soil or dust exposure and are not associated with outbreaks. Change in population, climate change, urbanization and construction activities, and increased awareness and reporting, are possible contributing factors.1, 2, 5 Pathology In the soil, Coccidioides organisms exist as filamentous molds. Small structures called arthroconidia from the hyphae may become airborne for extended periods. Arthroconidia are usually 3-5 μm—small enough to evade bronchial tree mucosal mechanical defenses and reach deep into the lungs.1, 3Once inhaled by a susceptible host into the lung, the arthroconidia develop into spherules (theparasitic existence in a host), which are unique to Coccidioides. Endospores from ruptured spherules can themselves develop into spherules, thus propagating infection locally.1, 3, 5Although rare cases of solid organ donor-derived or fomite transmitted infections have been reported, coccidioidomycosis does not occur in person-to-person or zoonotic contagion, and transplacental infection in humans has never been documented.2, 5Cellular immunity plays a crucial role in the host's control of coccidioidomycosis. Among individuals with decreased cellular immunity, Coccidioides may spread locally or hematogenously after an initial symptomatic or asymptomatic pulmonary infection to extrathoracic organs.1, 3, 7Clinical manifestationThe majority of infected individuals (about 60%) are completely asymptomatic. Symptomatic persons (40% of cases) have symptoms that are related principally to pulmonary infection, including cough, dyspnea, and pleuritic chest pain. Some patients may also experience fever, headache (common finding in early-stage infection and does not represent meningitis), fatigue, night sweats, rash, myalgia.1, 2, 3, 5In most patients, primary pulmonary coccidioidomycosis usually resolves in weeks without sequelae and lifelong immunity to reinfection. However, some patients may develop chronic pulmonary complications, such as nodules or pulmonary cavities, or chronic fibrocavitary pneumonia. Some individuals with intense environmental exposure or profoundly suppressed cellular immunity (e.g., in patients with AIDS) may develop a primary pneumonia with diffuse reticulonodular pulmonary process in association with dyspnea and fever.1, 3, 5Fewer than 1% of infected individuals develop extrathoracic disseminated coccidioidal infection. Common sites for dissemination include joints and bones, skin and soft tissues, and meninges. One site or multiple anatomic foci may be affected. 1, 2, 3, 7It is estimated that coccidioidal meningitis, the most lethal complication of coccidioidomycosis, affects only 0.1% of all exposed individuals. Patients with coccidioidal meningitis usually present with a persistent headache (rather than a self-limited headache in some patients with primary pulmonary infection), with nausea and vomiting, and sometimes vision change. Some may also develop altered mental status and confusion. Meningismus such as nuchal rigidity, if present, is not severe.Hydrocephalus and cerebral infarction may develop in some cases. Papilledema is more commonly observed in pediatric patients.1, 3, 4, 5, 7When meningitis develops, most patients may not have any respiratory symptoms nor radiographic manifestation of pulmonary infection. However, a large number of these individuals also present with other extrathoracic lesions.7DiagnosisAlthough early diagnosis carries obvious benefits for patients and the health care systems as a whole (e.g., decreases patient anxiety, reduces the cost of expensive and invasive tests, removes the temptation for empirical antibacterial or antiviral treatments, and allows for early detection of complications), considerable diagnostic delays up to several weeks to months are common in both endemic areas and non-endemic areas.3, 7 Most symptomatic persons with coccidioidal infection present with primarily pulmonary symptoms and are often misdiagnosed as community-acquired bacterial pneumonia and treated with antibiotics. In endemic areas like south-central Arizona, previous studies found up to 29% of community-acquired pneumonia is caused by coccidioidomycosis. Healthcare providers thus should maintain a high clinical suspicion for coccidioidomycosis when evaluating persons with pneumonia who live in or have traveled to endemic areas recently. Elevated peripheral-blood eosinophilia of over 5%, hilar or mediastinal adenopathy on chest radiography, marked fatigue, and failure to improve with antibiotic therapy should prompt suspicion and testing for infection with coccidioidomycosis in endemic areas.1, 3, 5Serological testing plays an important role in establishing a diagnosis of coccidioidomycosis. Enzyme immunoassay (EIA) to detect IgM and IgG antibodies is highly sensitive and therefore commonly used as the screening tool. Immunodiffusion is more specific but less sensitive than enzyme immunoassay. It is used to confirm the diagnosis of positive EIA test results. Complement fixing (CF) test, which indirectly detects the presence of coccidioidal antibodies by testing the consumption of serum complement, are expressed as titers. Serial measurements of titers are of not only diagnostic but also prognostic value.1, 2, 3, 5Other methods, including culture, microscopic, or polymerase chain reaction (PCR) exam on tissue or respiratory specimens, are limited by their availability, sample obtaining and handling, or lack of sufficient evaluation.1, 2, 3, 5Cerebrospinal fluid (CSF) examination in coccidioidal meningitis usually demonstrates lymphocyte dominated elevation of leukocytes, although polymorphonuclear leukocyte dominance can also be seen in the early stage of the infection. Profound hypoglycorrhachia and elevated protein levels in CSF examination are also very common in coccidioidal meningitis.1, 7Although isolating Coccidioides from CSF or other CNS specimens are diagnostic for coccidioidal meningitis, in practice, diagnoses are often made based on the combination of clinical presentation, CSF examination that suggesting fungal infection, and positive Coccidioides antibodies found in CSF.7Imaging, especially enhanced magnetic resonance imaging (MRI), can help in diagnosing coccidioidal meningitis. Basilar leptomeningeal enhancement is a more common finding even though hydrocephalus, cerebral infarction, and vertebral artery aneurysm can also be seen.7TreatmentMost patients with focal primary pulmonary coccidioidomycosis do not require antifungal therapy. According to 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline, antifungal therapy should be considered in patients with concurrent immunosuppression that adversely affect cellular immunity (e.g., organ transplant patients, AIDS in HIV-infected patients, and patients receiving anti–tumor necrosis factor therapy) and those with significantly debilitating illness, extensive pulmonary involvement, with concurrent diabetes, pregnant women, or who are otherwise frail because of age or comorbidities. Some experts would also include African or Filipino ancestry as indications for treatment. Conversely, humoral immunity comprise splenectomy, hypocomplementemia, or neutrophil dysfunction syndromes are not major risk factors for this disease.1, 2, 3, 4, 5Triazole antifungals (fluconazole or itraconazole) are currently considered as the first-line medications used to treat most cases of coccidioidomycosis. Amphotericin B is reserved for only the most severe cases of dissemination and patients with coccidioidal meningitis in whom triazole antifungal therapy has failed. It is also the choice of therapy for coccidioidomycosis in pregnant women during the first trimester because of the possible teratogenic effect of high-dose triazole therapy during this period of time.1, 3, 4, 5Treating coccidioidal meningitis (CM) poses a special challenge because untreated meningitis is nearly always fatal. Lifelong therapy is recommended for CM because the majority 80% patients with CM experience relapse when therapy is stopped despite initial response to antifungal treatment. Shunting of CSF is required in cases of meningitis complicated by hydrocephalus.1, 3, 4, 5, 7Prevention Avoidance of direct contact with contaminated soil in endemic areas (e.g., respirator use by construction workers) may reduce disease risk, although clear evidence of its benefit is lacking.1, 5Some special population groups may benefit from prophylactic use of antifungals, such as those about to undergo allogeneic solid-organ transplantation or patients with a history of active coccidioidomycosis or a positive coccidioidal serology in whom therapy with tumor necrosis factor α antagonists is being initiated. The administration of prophylactic antifungals is not recommended for HIV-1-infected patients even if they live in an endemic region.1, 5Conclusion: Now we conclude episode number 164, “More than just a headache.” Dr. Song explained that a headache with an indolent course, accompanied by subacute respiratory symptoms, nausea, vomiting, photophobia, neck stiffness, and skin lesions can be secondary to Valley Fever. The Central Valley of California, as well as other areas with dry climate, are endemic and we need to keep this disease in our differential diagnosis.This week we thank Hector Arreaza and Zheng (David) Song. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Roos KL, Tyler KL. Acute Meningitis. McGraw Hill Medical. Published 2023. Accessed August 18, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=192020493Information for Healthcare Professionals. Published 2023. Accessed August 18, 2023. https://www.cdc.gov/fungal/diseases/coccidioidomycosis/health-professionals.html#printValley Fever (Coccidioidomycosis) a Training Manual for Primary Care Professionals. Accessed August 18, 2023. https://vfce.arizona.edu/sites/default/files/valleyfever_training_manual_2019_mar_final-references_different_colors.pdfAmpel NM. Coccidioidomycosis. Idsociety.org. Published July 27, 2016. Accessed August 18, 2023. https://www.idsociety.org/practice-guideline/coccidioidomycosis/Herrick KR, Trondle ME, Febles TT. Coccidioidomycosis (Valley Fever) in Primary Care. American Family Physician. 2020;101(4):221-228. Accessed August 18, 2023. https://www.aafp.org/pubs/afp/issues/2020/0215/p221.htmlValley Fever Statistics. Published 2023. Accessed August 18, 2023. https://www.cdc.gov/fungal/diseases/coccidioidomycosis/statistics.htmlUpToDate. Uptodate.com. Published 2023. Accessed August 18, 2023. https://www.uptodate.com/contents/coccidioidal-meningitis?search=7%20Coccidioidal%20meningitis&source=search_result&selectedTitle=1~10&usage_type=default&display_rank=1Royalty-free music used for this episode: Tropicality by Gushito, downloaded on July 20, 2023, from  https://www.videvo.net/

Episode 163: Vascular Dementia      Future Dr. Ruby explains gives a definition of vascular dementia and concisely explains the pathophysiology and presentation of this disease. Dr. Arreaza reminds us of the importance of treating diabetes to prevent dementia.  Written by Carmen Ruby, MSIV, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is vascular dementia?Vascular dementia is a condition that arises due to damage to blood vessels that reduce or block blood flow to the brain. A stroke can block an artery and result in various symptoms, such as changes in memory, thinking, or movement. Other conditions like high blood pressure or diabetes can also damage blood vessels and lead to memory or thinking problems over time.Vascular dementia (VaD) is a type of dementia that slowly worsens cognitive functions and is thought to be caused by vascular disease within the brain. Patients with VaD often exhibit symptoms similar to Alzheimer's disease (AD) patients. However, the changes in the brain are not due to Alzheimer's disease pathology (amyloid plaques and neurofibrillary tangles) but due to a chronic reduction in blood flow to the brain, eventually leading to dementia. Alzheimer's disease pathophysiology is very complex, and studies have shown that patients with AD can experience simultaneously several vascular issues that can affect cognitive function. For example, patients with AD may experience mini-strokes and have a reduction of the flow of oxygen and nutrients to the brain tissue. So, AD can be worsened by vascular factors as well, but the vascular factors are not the main problem in AD.Clinically, patients with VaD can appear very similar to those with AD, which makes it difficult to distinguish between the two diseases. Nevertheless, some clinical symptoms and brain imaging findings suggest that vascular disease is contributing to, if not entirely explaining, a patient's cognitive impairment.Epidemiology.In the US, VaD is the 2nd most common type of dementia (15-20% of cases). Prevalence increases with age (∼ 1–4% in patients ≥ 65 years.) People affected by vascular dementia typically start experiencing symptoms after age 65, although the risk is significantly higher for people in their 80s and 90s.EtiologyVaD may occur as a result of prolonged and severe cerebral ischemia of any etiology, primarily:Large artery occlusion (usually cortical ischemia) *Acute*Lacunar stroke (small vessel occlusion resulting in subcortical ischemia) *Acute/Subacute**Chronic* subcortical ischemiaRisk factors:Advanced ageHistory of strokeUnderlying conditions associated with cardiovascular disease:Chronic hypertensionDiabetesDyslipidemiaObesitySmokingClinical Features:Symptoms depend on the location of ischemic events and, therefore, vary widely amongst individuals, but a progressive impairment of daily life is common. Because of the diverse clinical picture, the term "vascular cognitive impairment" is gaining popularity over Vascular Dementia.Dementia due to small vessel disease:Symptoms tend to progress gradually or in a stepwise fashion and comparatively slower than in multi-infarct dementia.Generally associated with signs of subcortical pathology:Dementia due to large vessel disease Usually, sudden onsetMulti-infarct dementia: typically, stepwise deterioration Generally associated with signs of cortical pathology:Early symptomsReduced executive functioningLoss of visuospatial abilitiesConfusion ApathyMotor disorders (e.g., gait disturbance, urinary incontinence)Later symptomsImpaired memoryFurther cognitive decline: loss of judgment, disorientationMood disorders (e.g., euphoria, depression)Behavioral changes (e.g., aggressiveness)Advanced stages: further motor deterioration: dysphagia, dysarthriaDementia due to large vessel disease Usually, sudden onsetMulti-infarct dementia: typically, stepwise deterioration Generally associated with signs of cortical pathology:Cognitive impairment in combination with asymmetric or focal deficits (e.g., unilateral visual field defects, hemiparesis, Babinski reflex present)Overall, the symptoms vary depending on which areas of the brain are affected.Management and TreatmentThere is hope when it comes to managing the symptoms of vascular dementia. Although there is no cure for the condition, there are medications available that can help make life easier for those living with it. Additionally, there are drugs commonly used to treat memory issues in Alzheimer's disease that may be effective for individuals with vascular dementia. Sometimes, people with vascular dementia may experience mood changes, such as depression or irritability. These changes can be managed with medications used for depression or anxiety.Vascular risk modification: If your patient is experiencing cognitive impairment and has clinical or radiologic evidence of cerebrovascular pathology, getting screened for vascular risk factors, especially hypertension, is essential. Treatment can help prevent dementia, but it may not be as effective in reversing it. Statins are given after a stroke regardless of lipid levels.Antithrombotic therapy: For patients with vascular dementia who have had a clinical ischemic stroke or transient ischemic attack, they must receive the appropriate antithrombotic therapy based on the specific stroke subtype to help prevent any future ischemic strokes.When considering antiplatelet therapy for patients with vascular dementia who have not had a clinical ischemic stroke or TIA, it is important to make an individualized decision. For instance, we may prescribe aspirin at a dosage of 50-100 mg daily for patients with an infarction seen on brain imaging but not for those with only white matter lesions.Cholinesterase inhibitor therapy: It is recommended to start cholinesterase inhibitor therapy, such as donepezil or galantamine, for patients with vascular dementia who have a gradual cognitive decline that is not a direct result of a stroke. The evidence suggests that this treatment may offer a small cognitive benefit, but the clinical significance is unclear. Experts do not recommend cholinesterase inhibitors for patients with dementia diagnosed after a stroke if there is no gradual cognitive decline.Antipsychotics: We can briefly mention antipsychotics. They may be used but we have to remember they may increase mortality in the elderly, and the patient and family must be aware of this risk. Some examples are risperidone, quetiapine, and olanzapine, use them cautiously. Let's talk beyond medications, what other treatments can we offer? Non-pharmacologic options: In addition to medications, there are various ways to help a person with vascular dementia. Research has shown that physical exercise, sleep hygiene, and maintaining a healthy weight can not only enhance brain health but also reduce the risk of heart problems, stroke, and other diseases that affect blood vessels. Patients must be encouraged to eat a balanced diet, get enough sleep,limit alcohol intake, and encouraged to quit smoking, as these are other crucial ways to promote good brain health and reduce the risk of heart disease. Additionally, comorbid conditions such as diabetes, high blood pressure, or high cholesterol, must be treated, because they affect brain function and quality of life overall.It is essential to understand that emotional outbursts and personality changes can be caused by underlying brain disease and are not always intentional responses or reactions. When behavior problems overwhelm an individual, their family members, or friends, it is critical to seek support. Patient and caregiver support groups are helpful, offering a space to vent, grieve, and gain practical advice from others experiencing similar challenges. Exploring other sources of support, such as adult day programs, can also benefit caregivers and individuals affected by vascular dementia. Conclusion: Now we conclude episode number 163, “Vascular dementia basics.” Future Dr. Ruby explained that vascular dementia is mainly caused by an impaired circulation of blood and oxygen to certain areas in the brain. This can be a result of large or small vessel disease. Dr. Arreaza reminded us of the importance of treating diabetes as a way to prevent dementia. This week we thank Hector Arreaza and Carmen Ruby. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Smith, MD EE, Wright, MD, MS CB. Treatment of Vascular Cognitive Impairment and Dementia. Wilterdink, MD JL, ed. UpToDate. Published online May 24, 2022. Accessed February 27, 2024. https://www.uptodate.comVascular Dementia. Memory and Aging Center. Published 2020. https://memory.ucsf.edu/dementia/vascular-dementiaVascular dementia. AMBOSS. Published online June 29, 2023. Accessed February 28, 2024. https://www.amboss.com/usWhat Happens to the Brain in Alzheimer's Disease? National Institute on Aging, https://www.nia.nih.gov/health/alzheimers-causes-and-risk-factors/what-happens-brain-alzheimers-disease. Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/. 

Episode 162: Early-Onset Sepsis      Dr. Kooner explains how to diagnose early-onset sepsis by using clinical evaluation and clinical tools. Dr. Schlaerths describes the signs and symptoms of sepsis in neonates, and Dr. Arreaza adds comments about GBS bacteriuria.  Written by Lovedip Kooner, MD, editing Hector Arreaza, MD, and comments by Katherine Schlaerth, MD. Rio Bravo Family Medicine Residency Program.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction:Neonatal sepsis is defined as pathogenic bacterial growth from blood or cerebral spinal fluid culture within the first 28 days of life. Neonatal sepsis can be divided into two categories: early-onset sepsis (EOS) and late-onset.  EOS is neonatal sepsis within 72 hours or 7 days after birth, depending on the specialist. How common is early-onset sepsis (EOS)?According to the CDC, the infant mortality rate rose for the first time in 20 years in the USA. In the U.S., the incidence of EOS is 0.5 in 1,000 live births and carries a mortality rate of about 3%. What causes EOS?Most infections are due to ascending lower vaginal tract flora. Other causes include intra-amniotic infections and maternal hematogenous spread of systemic infections. Group B streptococcus (S. agalactiae) accounts for about 1/3 of the infectious organisms, followed by E. coli which accounts for about 1/4, and Viridans streptococci account for about 1/5 of infections. Cases of E. coli are seen more often with prolonged rupture of membranes and intrapartum antibiotic exposure. Other notable infections are Listeria monocytogenes, coagulase-negative staphylococci (CoNS), herpes simplex virus, and enteroviruses. The role of GBS.Approximately 30% of women have vaginal and rectal GBS colonization and 50% will transmit it to the newborn. Without maternal antibiotic treatment, 1-2% of those infants will develop EOS. The American College of Obstetricians and Gynecologists (ACOG) recommends universal culture-based screening for GBS at 36-37 weeks and 6 days regardless of mode of delivery. GBS bacteriuria: Treat it (symptomatic and asymptomatic) if >105 CFU/mL. Do not treat it in asymptomatic patients if GBS 18 hours, intrapartum fever, or GBS positive in previous pregnancy.Nucleic acid amplification test: NAAT in pregnancy is not recommended to determine colonization status. However, if NAAT is obtained in the intrapartum period, give IAP if positive. But, you must also give IAP if negative + mentioned risk factors (18h, Maternal fever >100.4F)What is considered adequate intrapartum antibiotic prophylaxis? Penicillin and ampicillin are the recommended antibiotics for prophylaxis. Cefazolin can be given if there is a penicillin-allergy with a low risk for anaphylaxis. Clindamycin and vancomycin are reserved for cases of maternal penicillin allergy. Specifically, clindamycin can be used only if GBS is known to be sensitive to clindamycin. Vancomycin must be used if GBS is resistant to clindamycin. Do not use erythromycin. You will Administered at least 4 hours before delivery.IAP is believed to reduce neonatal GBS disease by: (1) temporarily reducing maternal vaginal GBS colonization; (2) preventing colonization of the fetus or newborn's surfaces and mucous membranes; and (3) achieving antibiotic levels in the newborn's bloodstream sufficient to surpass the minimum inhibitory concentration (MIC) for eliminating group B streptococci.Diagnosis of EOS:Clinical presentation: Tachycardia, tachypnea, temperature instability, supplemental oxygen requirement, and lethargy. Hypoglycemia should not be considered a sign of EOS.Diagnosing early-onset sepsis is achieved through blood or cerebrospinal fluid (CSF) cultures. Not effective methods for diagnosing EOS include laboratory tests, such as a complete blood cell count or C-reactive protein (CRP), as well as surface cultures, gastric aspirate analysis, or urine culture.Most infants will generally show signs of EOS GBS infection within the initial 24 hours of birth, with approximately 85% exhibiting symptoms during this timeframe.Waiting for cultures and/or signs can delay lifesaving treatment.Management:According to the American Academy of Pediatrics (AAP), the management of term and late-term infants is undertaken via the clinical condition assessment, the categorical risk factor assessment, and the multivariate risk assessment. As a part of the 2015 AAP guidelines, the Categorical Risk Factor Assessment is more of an algorithmic approach based on the presence or absence of specific risk factor threshold values such as:Ill-appearing infant. Mother diagnosed with chorioamnionitis.Mother GBS positive with inadequate intrapartum prophylaxis.ROM >18 hours.Birth before 37 weeks of gestation.Antibiotics are not always needed, and they can even cause damage. Information taken from the American Academy of Pediatrics, “Management of Neonates Born at ≥35 0/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis,” published on December 1, 2018:(1) Any newborn infant who is ill-appearing or (2) when the mother has a clinical diagnosis of chorioamnionitis -> laboratory testing must be ordered, and empirical antibiotic therapy should be started.(3) A mother who is colonized with GBS and who received inadequate intrapartum antibiotic prophylaxis, with a duration of ROM being >18 hours or birth before 37 weeks' gestation -> laboratory testing should be ordered.(4) A mother who is colonized with GBS who received inadequate IAP but with no additional risk factors -> observation in the hospital for ≥48 hours.______________________________Conclusion: Now we conclude episode number 162, “Early-onset Sepsis Introduction.” Dr Kooner explained the role of GBS in the pathophysiology of EOS, Dr. Schlaerth discussed the importance of clinical evaluation and Dr. Arreaza explained that GBS screening in the third trimester is not needed when there is a GBS positive urine culture early in pregnancy. Don't miss part 2 of this discussion. By the way, we do not recommend using feces to prevent or treat sepsis, we just shared anecdotal information to end with a funny note.This week we thank Hector Arreaza, Lovedip Kooner, and Katherine Schlaerth. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Neonatal Early-Onset Sepsis Calculator by Kaiser Permanente, available at: https://neonatalsepsiscalculator.kaiserpermanente.org/.Espinosa K, Brown SR. Neonatal Early-Onset Sepsis Calculator. Am Fam Physician. 2021;104(6):636-637.https://www.aafp.org/pubs/afp/issues/2021/1200/p636.html.Puopolo KM, Benitz WE, Zaoutis TE; COMMITTEE ON FETUS AND NEWBORN; COMMITTEE ON INFECTIOUS DISEASES. Management of Neonates Born at ≥35 0/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics. 2018 Dec;142(6):e20182894. doi: 10.1542/peds.2018-2894. PMID: 30455342. https://pubmed.ncbi.nlm.nih.gov/30455342/.Briggs-Steinberg C, Roth P. Early-Onset Sepsis in Newborns. Pediatr Rev. 2023 Jan 1;44(1):14-22. doi: 10.1542/pir.2020-001164. PMID: 36587021. https://pubmed.ncbi.nlm.nih.gov/36587021/.Flannery DD, Puopolo KM. Neonatal Early-Onset Sepsis. Neoreviews. 2022 Nov 1;23(11):756-770. doi: 10.1542/neo.23-10-e756. PMID: 36316253. https://pubmed.ncbi.nlm.nih.gov/36316253/.Polin RA; Committee on Fetus and Newborn. Management of neonates with suspected or proven early-onset bacterial sepsis. Pediatrics. 2012 May;129(5):1006-15. doi: 10.1542/peds.2012-0541. Epub 2012 Apr 30. PMID: 22547779. https://pubmed.ncbi.nlm.nih.gov/22547779/.Royalty-free music used for this episode: Good Vibes_Adventure Time by Simon Pettersson, downloaded on July 20, 2023, from https://www.videvo.net/  

Episode 161: Depression FundamentalsFuture doctors Madeline Tena and Jane Park define depression and explain different methods to diagnose it. Non-pharmacologic and pharmacologic treatment is mentioned briefly at the end.  Written by Madeline Tena, MSIII, and Jane Park, MSIII. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Per the language of Mental Health, depression can be defined as a mood, a symptom, a syndrome of associated disorders, or a specific mental disorder. As a state of mood, depression is associated with feelings of sadness, despair, emptiness, discouragement, and hopelessness. The sense of having no feelings or appearing tearful can also be a form of depressed mood. A depressed mood also can be a part of a collection of symptoms that explain a syndrome. Depression as a mental disorder can encompass depressive syndromes. Per the American Psychiatric Association DSM-5-TR, depressive disorders commonly include sad, empty, irritable mood, accompanied by changes in one's functional capacity. They can be classified by severity and recurrence, and associated with hypomania, mania, or psychosis. Depressive disorders include major depressive disorder (including major depressive episodes), persistent depressive disorder, premenstrual dysphoric disorder, substance-induced depressive disorder, depressive disorder due to medical condition, other specified depressive disorder, and unspecified depressive disorder.Today, we will cover unipolar depressive disorder, also known as major depressive disorder. MDD.Major depressive disorder is a mood disorder primarily characterized by at least one major depressive episode without manic or hypomanic episodes. Depressive episode is a period of at least 2 weeks of depressed mood or anhedonia in nearly all activities for most of the day nearly every day, with four or more associated symptoms in the same 2 weeks. We will discuss specific symptoms for diagnosis further on. Epidemiology of depression.Nationally or regionally representative surveys in 21 countries estimate that the 12-month prevalence of major depressive disorder across all countries is 5 percent. Furthermore, the prevalence of major depressive disorder plus persistent depressive disorder in developed countries (United States and Europe) is approximately 18 percent. Multiple studies consistently indicate that in the general population of the United States, the average age of onset for unipolar major depression and for persistent depressive disorder (dysthymia) is approximately 30 years old. During 2020, approximately ⅕ US adults have reported receiving a diagnosis by a healthcare provider, with the highest prevalence found among young adults age (18-24 year age… generation Z). Within the US there was considerable geographic variation in the prevalence of depression, with the highest state and county estimates of depression observed along the Appalachian and southern Mississippi Valley regions. Why do we care about depression?Because depression is associated with impaired life quality. It can impair a patient's social, physical, and psychological functioning. Also, depression is associated with mortality. A study done by UPenn Family Practice and Community Medicine in 2005 showed that among older, primary-care patients over a 2-year follow-up interval, depression contributed as much to mortality as did myocardial infarction or diabetes. A prospective study from 2005-2017 that followed 186 patients for up to 38 years further showed that patients with major depressive disorder had 27 times higher incidence rate of suicide than the general population. (1, 2). Also, patients dying by suicide visit primary care physicians more than twice as often as mental health clinicians. It is estimated that 45% of patients who died by suicide saw their primary care physician in the month before their death. Only 20% saw a mental health professional a month before their death. (3)Suicidality in depression.It seems that primary care physicians often do not ask about suicidal symptoms in depressive patients. A 2007 study by Mitchell Feldman at the University of California San Francisco showed that 152 family physicians and internists who participated in a standardized patient with antidepressants, suicide was explored in only 36% of the encounters. (4)Physicians, including primary care physicians, should ask patients with depression about suicidality with questions such as: Do you wish you were dead? In the past few weeks, have you been thinking about killing yourself? Do you have a plan to kill yourself? Have you ever tried to kill yourself? (5) Screening for depression.The USPSTF recommends screening for depression in all adults: 18 years old and over regardless of risk factors. Some factors increase the risk of positive screening, such as temperament (negative affectivity/neuroticism), general medical illness, and family history. First-degree family members of people with MDD have a 2-4 times higher risk of MDD than the general population. Furthermore, social history can increase risk as well: sexual abuse, racism, and other forms of discrimination.It is important to highlight the risk in women because they may also be at risk related to specific reproductive life stages (premenstrual period, postpartum, perimenopause). The USPSTF includes pregnant individuals and patients in the postpartum period to be screened for depression. Screening tools. The US Preventive Services Task Force recommends depression screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years (grade B). Similarly, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) has also recommended annual screening for depression in children aged 12 and older. (6) Some tools used for screening in this age group are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI). For the general adult population, it is recommended that all patients not currently receiving treatment for depression be screened using the Patient Health Questionnaire-2 (PHQ-2) (7)PHQ 2 is a survey scored 0-6. The survey asks two questions: Over the last 2 weeks, how often have you been bothered by any of the following problems?Little interest or pleasure in doing things.Feeling down, depressed, or hopeless.Answers should be given in a numerical rating. 0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day. A score ≥ 3 is considered positive, and a follow-up full clinical assessment is recommended. The PHQ-2 has a sensitivity of 91% and a specificity of 67% when compared to a semi-structured interview. Keep in mind that the PHQ-2 may be slightly less sensitive to older individuals. Individuals who screen positive with PHQ-2 should have additional screening with the PHQ-9, which is a nine-item, self or clinician-administered, brief questionnaire that is specific to depression. (8) Its content maps directly to the DSM-5 criteria for major depression. (9)The PHQ-9 is a set of 9 questions. The answers are scored similarly to PHQ-2, with a numerical scoring between 0 and 3. (0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day). Dr. Arreaza, you will be my patient today, are you ready? It's important that you think about the last 2 weeks.Over the last 2 weeks, how often have you been bothered by any of the following problems?Little interest or pleasure in doing things. [Dr. Arreaza answers, “sometimes”. Jane asks, “is it several days or nearly every day?”. Dr. Arreaza answers, “nearly every day” 3]Feeling down, depressed or hopeless [Dr. Arreaza: every day 3]Trouble falling or staying asleep, or sleeping too much [Dr. Arreaza: not at all 0]Feeling tired or having little energy [Dr. Arreaza: not at all 0]Poor appetite or overeating [Dr. Arreaza: every day 3]Feeling bad about yourself- or that you are a failure or have let yourself or your family down [Dr. Arreaza: several days 1]Trouble concentrating on things, such as reading the newspaper or watching television [Dr. Arreaza: Several days 2]Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. [Dr. Arreaza: Not at all 0]Thoughts that you would be better off dead, or of hurting yourself [Not at all 0]Jane: Your score is 12.Maddy: Regarding severity, a total score of 1-4 suggests minimal depression. 5-9 suggests mild, 10-14 moderate, 15-19 moderately severe, and 20-27 severe depression. PHQ-9 with patients' scores over 10 had a specificity of 88% and sensitivity of 88% for MDD. (10)But if there are at least 4 non-zero items, including question #1 or #2, consider a depressive disorder and add up the scores. If there are at least 5 non-zero items including questions #1 or #2, consider major depressive disorder specifically. The questionnaire is the starting point for a conversation about depression.A couple of things to note: 1. Physicians should make sure to verify patient responses given the questionnaire can be self-administered. Diagnosis also requires impairment in the patient's job, social, or other important areas of functioning. 2. Diagnosis requires a ruling-out of normal bereavement, histories of manic episodes, depressive episodes better explained by schizoaffective disorder, any superimposed schizophrenia, a physical disorder, medication, or other biological cause of depressive symptoms.Once a patient is newly diagnosed and/or started on treatment, a regular interval administration (e.g. 2 weeks or at every appointment) of PHQ-9 is recommended. The PHQ-9 has good reliability, validity, and high adaptability for MDD patients in psychiatric hospitals for screening and evaluation of depression severity. (12) Other than PHQ-9, there is also Geriatric Depression Scale-15 for older patients with mini mental status exam (MMSE) that scored over 10. (13)For postpartum depression, the preferred screening tool is the Edinburgh postnatal depression scale[Click here (stanford.edu)].Non-pharmacologic and pharmacologic treatment.Now that we have diagnosed the patient, we have to start management. Patients can consider non-pharmacologic treatment such as lifestyle modifications. This can include sleep hygiene, reduction in drug use, increased social support, regular aerobic exercise, finding time for relaxation, and improved nutrition. Furthermore, based on severity, patients can start psychotherapy alone or psychotherapy + pharmacotherapy. Admission is required for pts with complex/severe depression or suicidality. There should be an assessment of efficacy at 6 weeks.There is a warning about patients aged 18-24 who are at increased risk of suicide when taking SSRI within the first couple weeks of treatment. Mediations: SSRI, SNRI, tricyclic antidepressants, MAOIs, and Atypical antidepressants: including trazodone, mirtazapine (Remeron), bupropion (Wellbutrin SR). More research is being done on psychedelic drugs such as ketamine and psilocybin as possible treatments. There are therapies such as ECT available too.Potential Harm of Tx: Potential harms of pharmacotherapy: -SNRI:  initial increases in anxiety, insomnia, and restlessness, and possible sexual dysfunction and headaches as well. Compared with the SSRI class, the SNRI class tends to induce more nausea, insomnia, dry mouth, and in rare cases hypertension.-Tricyclic: Cause of numerous side effects, very infrequently prescribed unless the patient is not responding to other forms of treatment. Side effects that are included are: dry mouth. slight blurring of vision, constipation, problems passing urine, drowsiness, dizziness,  weight gain, excessive sweating (especially at night). Avoid TCAs in elderly patients.-MAOIS: MAO-IS can cause side effects too, including dizziness or lightheadedness, dry mouth, nausea, diarrhea or constipation, drowsiness, and insomnia. Furthermore, other less common side effects can include involuntary muscle jerks, hypotension, reduced sexual desire/ ability to orgasm, weight gain, difficulty starting urine flow, muscle cramps, and paresthesia.Remember to screen your patients. In case you establish a diagnosis, discuss treatments, including non-pharmacologic and pharmacologic options. Warn your patients about side effects and the timing to see the benefits of the medication, usually after 6 weeks. __________________Conclusion: Now we conclude episode number 161, “Depression Fundamentals.” Future doctors Park and Tena discussed depression and its risk factors, screening, and treatment. They went through the PHQ2 and PHQ9 as screening tools, as well as commonly used treatments and their side effects, such as SSRIs. Dr. Arreaza also highlighted the importance of asking about suicidality in your depressed patients, there is a lot of room for improvement in that aspect. This week we thank Hector Arreaza, Madeline Tena, and Jane Park. Audio editing by Adrianne Silva.Talk_OutroEven without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Angst F, Stassen HH, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34-38 years. J Affect Disord. 2002;68(2-3):167-181. doi:10.1016/s0165-0327(01)00377-9. https://pubmed.ncbi.nlm.nih.gov/12063145/Miron O, Yu KH, Wilf-Miron R, Kohane IS. Suicide Rates Among Adolescents and Young Adults in the United States, 2000-2017. JAMA. 2019;321(23):2362-2364. doi:10.1001/jama.2019.5054. https://pubmed.ncbi.nlm.nih.gov/31211337/ Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Let's not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007;5(5):412-418. doi:10.1370/afm.719. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000302/.Brief Suicide Safety Assessment,National Institute of Mental Health (NIMH), July 11, 2020. https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/adult-outpatient/bssa_outpatient_adult_asq_nimh_toolkit.pdfBeck A, LeBlanc JC, Morissette K, et al. Screening for depression in children and adolescents: a protocol for a systematic review update. Syst Rev. 2021;10(1):24. Published 2021 Jan 12. doi:10.1186/s13643-020-01568-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802305/Williams, John; Nieuwsma, Jason. Screening for depression in adults, UpToDate, updated on November 30, 2023. https://www.uptodate.com/contents/screening-for-depression-in-adults.Instrument: Patient Health Questionnaire-9 (PHQ-9), National Institute on Drug Abuse, https://cde.nida.nih.gov/instrument/f226b1a0-897c-de2a-e040-bb89ad4338b9.Lowe B, et al. Monitoring depression-treatment outcomes with the Patient Health Questionnaire-9 (PHQ-9). Med Care, 42, 1194-1201, 2004.Sun, Y., Fu, Z., Bo, Q. et al.The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BMC Psychiatry20, 474 (2020). https://doi.org/10.1186/s12888-020-02885-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701937/Conradsson M, Rosendahl E, Littbrand H, Gustafson Y, Olofsson B, Lövheim H. Usefulness of the Geriatric Depression Scale 15-item version among very old people with and without cognitive impairment. Aging Ment Health. 2013;17(5):638-645. doi:10.1080/13607863.2012.758231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701937/.Royalty-free music used for this episode: Old Mexican Sunset by Videvo, downloaded on Nov 06, 2023 from https://www.videvo.net

Episode 160: Artificial Intelligence in Primary Care.      Future Dr. Manophinives explains the present and future of AI in diagnosing and treating diseases.    Written by Rosalynn Manophinives, MS-IV, American University of the Caribbean. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today, we embark on an intriguing journey at the crossroads of technology and healthcare: The Future of Healthcare in Artificial Intelligence (AI) and Machine Learning (ML). Let's start by establishing the groundwork for AI and ML. Artificial Intelligence involves machines mirroring cognitive functions like learning and problem-solving, while machine learning empowers machines to learn from data and refine their capabilities over time. In healthcare, these technologies aim to elevate diagnostic precision and treatment effectiveness which are pivotal aspects in primary care medicine.Accurate diagnosis is the cornerstone of effective patient care in all forms of medicine because an accurate diagnosis guides treatment decisions and influences patient outcomes. This is why the integration of AI and ML holds immense promise in this field.Section 1: AI in Diagnostic Assistance (4 mins)Let's explore how AI utilizes algorithms to analyze extensive datasets, enhancing diagnostic accuracy significantly.AI serves as a revolutionary force in analyzing a large amount of data, particularly in medical imaging. Imagine AI algorithms as super brains, employing machine learning to decipher intricate details from X-rays, MRIs, and CT scans. Notably, studies have demonstrated their precision matching and even surpassing that of human experts. For instance, research published in the Journal of the American Medical Association revealed AI algorithms outperforming radiologists in detecting conditions like breast cancer.AI's skills extend beyond images. It digs into genetic information, medical history, and treatment outcomes, acting as a detective to spot patterns, predict responses, and customize interventions. Studies support this, showcasing AI models outperforming dermatologists in diagnosing skin cancer from images. Will AI replace doctors?The beauty of AI is that it does not replace doctors but acts as a super investigator in your healthcare corner, expediting diagnoses, and refining treatments. So, AI isn't merely accelerating processes; it's enhancing healthcare outcomes, making diagnoses quicker, and treatments more precise, and minimizing errors. The future appears very promising with AI leading the way to more precise and tailored healthcare.Section 2: Case Studies in Diagnosis (4 mins):Help in research: Let's delve into real-life examples of AI in action, further amplifying diagnostic accuracy. In a research study, Rajkomar and collaborators crafted an AI algorithm predicting patient deterioration within hours, leveraging electronic health record data. This tool allowed for proactive care, identifying potential issues before they escalated. Taking it up a notch, Aliper and collaborators compared AI to human researchers, resulting in AI outsmarting human brains in designing drugs targeting age-related diseases. These experiments underscore AI's potential in diagnostics, from catching issues early to designing groundbreaking drugs.AI here enhances doctors' capabilities and acts as an additional set of eyes, boosting their superpowers, spotting nuances, and proposing game-changing solutions in medicine.Section 3: AI in Risk Prediction (4 mins):Let's shift our focus to AI's role in predicting risks and prognosis, particularly in conditions like COPD.AI employs sophisticated algorithms to analyze patient data comprehensively, including demographics, hospital visits, diagnoses, prescribed medications, and lab results. In COPD, AI not only predicts mortality but also anticipates hospital readmissions for respiratory issues or flare-ups. By scrutinizing various markers, AI resembles Sherlock Holmes, unraveling clues within data.And AI doesn't stop there, AI integrates risk predictions into medical practices, which fosters personalized care tailored to individual risk factors. A study led by Choi and their team analyzed retrospective patient data and they were able to identify individuals at risk of undiagnosed COPD, emphasizing the significance of catching potential issues early, finding those who might slip through the cracks otherwise, which is huge! Section 4: AI in Treatment Planning (4 mins):Let's now explore how AI is revolutionizing treatment planning within medicine.AI, equipped with machine learning algorithms, tailors treatments by analyzing patient-specific data and medical history. In cancer, for example, AI analyzes biopsy images and quantifies biomarkers, facilitating personalized treatments. Beyond cancer, AI extends its reach to cell therapies, predicting their effectiveness through genomic information and drug responses.And here's the techie part: AI employs various smart algorithms like Convolutional Neural Networks (CNN) and Recurrent Neural Networks (RNN) to provide personalized treatment recommendations. It's like having personalized treatment recommendations by experts that fit you like a glove, catering to individual needs. Section 5: Fuzzy Cognitive Maps and Reduction of Medical Errors (4 mins):Lastly, let me tell you about the impact of AI-driven treatment planning, specifically in reducing medical errors. Imagine this—medical decisions? They're tough. Sifting through tons of data, inaccessible medical records, physicians' lack of experience, and loads of conflicting info, makes the decision often not crystal clear. This is where a high percentage of medical errors occur, which is where Fuzzy Cognitive Maps (FCMs) come in.  FCMs are like a super-smart tool that mimics human reasoning, tackling the messiness of medical data with grace.FCMs are all about modeling complex systems, by combining fuzzy logic and neural networks, just like our brain does—connecting the dots between concepts and their cause-and-effect relationships. From patient records to test results, they make sense of it all.And FCM is not just theory—FCMs are the real deal and they're not the newbies in town; they've been around for a while, evolving from their early days. They've proven their worth in various medical areas too – in radiotherapy planning, diagnosing language impairments, and even in grading tumors!So, in a nutshell, FCMs are useful tools for medical decision support by taking on the complexities of diagnosing and treatment planning.Closing:In conclusion, the integration of Artificial Intelligence and Machine Learning in healthcare is a thrilling frontier, offering invaluable tools to enhance diagnostic accuracy and patient outcomes. As we evolve, responsible use of these advances is paramount, ensuring they optimize rather than replace the indispensable human touch in healthcare.Thank you for joining me in exploring the future of healthcare in AI and Machine Learning. I trust this discussion has sparked curiosity and appreciation for the transformative potential of technology in healthcare. -----------------------------------Conclusion: Now we conclude episode number 160, “Artificial Intelligence in Primary Care.” This is a new and somewhat unknown field of medicine that is rapidly evolving these days. Future Dr. Manophinives explained that AI and ML can be a useful tool in the diagnosis of diseases by, for example, interpreting images accurately. AI also can help develop plans of care by interpreting large amounts of complex data and predicting trends, possible complications, and the effectiveness of multiple treatments. Keep your eyes and mind wide open to learn more about this advancing technology that will continue to support our efforts to bring health and well-being to our communities.This week we thank Hector Arreaza and Rosalynn Manophinives. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Obermeyer Z, Emanuel EJ. Predicting the Future - Big Data, Machine Learning, and Clinical Medicine. N Engl J Med. 2016;375(13):1216-1219. doi:10.1056/NEJMp1606181. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070532/.Rajkomar, Alvin, et al. "Scalable and accurate deep learning with electronic health records." npj Digital Medicine, 08 May 2018. https://www.nature.com/articles/s41746-018-0029-1Choi, Ellen, et al. "Retrospective analysis of real-world data to identify patients at risk for undiagnosed chronic obstructive pulmonary disease." PLoS ONE, 2020.Choi, Ellen, et al. "Machine Learning in Primary Care: Predicting Hospitalizations and Critical Events." AMIA Annual Symposium Proceedings, 2018.Beam AL, Kohane IS. Translating Artificial Intelligence Into Clinical Care. JAMA. 2016;316(22):2368-2369. doi:10.1001/jama.2016.17217. https://pubmed.ncbi.nlm.nih.gov/27898974/Johnson, Kipp W., et al. "Automated Fuzzy Cognitive Maps Generation for Supporting Clinical Decisions in Primary Care." IEEE Transactions on Fuzzy Systems, 2020.Royalty-free music used for this episode: Gushito, “Gista Mista”, downloaded on November 16th, 2023, from https://www.videvo.net/

Episode 159: Transcranial Magnetic Stimulation BasicsFuture Dr. Ameri explains how transcranial magnetic stimulation can be useful in the treatment of certain mental conditions.  Written by Omeed Ameri, MS-IV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Transcranial Magnetic Stimulation (TMS)TMS is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and Obsessive-compulsive disorder (OCD). TMS uses the principles of electromagnetic inductions as described by Faraday's Law. When an electric current passes through the TMS coil, it creates a rapidly charging magnetic field, which passes unimpeded through the scalp and skull, inducing a secondary current in neural tissues of the brain, causing depolarization of neuronal membranes in targeted brain regions, mainly in the superficial layers of the cortex 1.5 to 2.5 cm beneath the coil.How it works.Depending on the frequency and pattern of magnetic pulses, TMS can either increase or decrease cortical excitability. High-frequency TMS (Generally > 1 Hz) is associated with increased cortical excitability and is often used for depression treatment. In contrast, low-frequency TMS (< 1 Hz) is typically used for anxiety and pain.This stimulation alters neurotransmitter release such as dopamine, serotonin, and norepinephrine. The repeated stimulation over sessions promotes synaptic plasticity, leading to more lasting changes in brain activity patterns associated with improved clinical outcomes. This is thought to have cascading effects throughout brain networks, and modulate dysfunctional circuits implicated in depression and restoring normal function. Effectiveness.The effectiveness of TMS can vary widely between individuals due to differences in anatomy, age, and specific conditions being treated. As such, ongoing research into how to personalize and optimize TMS parameters is ongoing. Research supporting the use of TMS in treatment-resistant depression.Research into the effectiveness of TMS and other therapy modalities targeting Treatment-Resistant Depression has been an ongoing effort for many years. In 2009, the American Academy of Family Physicians published Dr. Little's article titled “Treatment-Resistant Depression,” which noted that there was little evidence that TMS could significantly treat patients with treatment-resistant depression. Since that time, the American Journal of Psychiatry published a groundbreaking study in 2020, led by Dr. Cole, which explores the effectiveness of a novel treatment for treatment-resistant depression. This trial, known as Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT, which demonstrates promising results in combating depression where traditional methods have failed. It was an open-label study that provides a new perspective on depression treatment, emphasizing rapid and targeted intervention. Twenty-two participants received 50 intermittent theta burst stimulation (iTBS), which is a more recent protocol for TMS treatment, over the course of five days. Each session included 1,800 pulses per session, with a 50-minute intersession interval, ten times a day. As a result of this intensive regimen, one participant withdrew from treatment, and 19 of the remaining 21 met remission criteria, with a score of less than 11 on the Montgomery-Asberg Depression Rating Scale. There were no serious adverse events reported, the participant who withdrew did so due to anxiety. Side effects included fatigue and some discomfort. 70% of participants continued to meet response criteria one-month post-treatment.TMS application for patients with OCD. Studies have shown promising results for the treatment of OCD with TMS. Typically, OCD is difficult to manage and requires the highest doses of SSRIs. In 2019, The American Journal of Psychiatry published Dr. Carmi's Article titled: “Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial”, which presents a comprehensive study on the effectiveness of dTMS in treating OCD. This multicenter, randomized, double-blind, placebo-controlled trial involved 99 OCD patients across 11 centers, who were treated with either high-frequency dTMS or sham dTMS, and focused on changes in the Yale-Brown Obsessive Compulsive Scale (YBOCS) scores.The treatment phase extended to 6 weeks with a total of 29 treatment sessions, following a 3-week screening phase and a 4-week follow-up phase. Patients were aged 22-68, with YBOCS scores greater than or equal to 20. At the start of the study, patients were already on a maintenance treatment with therapeutic dosages of SSRIs, or previously failed an SSRI and were currently being treated with Cognitive Behavioral Therapy. The results revealed that dTMS treatment participants showed a significantly greater reduction in YBOCS score compared to sham treatment (6.0 points vs. 3.3 points). The most frequent adverse effect was headaches. There was one incident of severe suicide ideation. On investigation, it was revealed that the suicide ideation preceded the treatment and required hospitalization for the patient. TMS therapy has shown promising results in treating both treatment-resistant depression and OCD. More research is required to assess the long-term viability of the treatment modality, and which treatment regimens have the greatest efficacy for various psychiatric disorders. I hope our listeners will keep TMS in mind when confronted with treatment-resistant depression and OCD.___________________Conclusion: Now we conclude episode number 159, “Transcranial Magnetic Stimulation,” also known as TMS. We learned from future Dr. Ameri that TMS has proven to be an effective option for treatment-resistant depression and Obsessive-compulsive disorder. When medications and therapy are not enough, you may consider this therapy for your patients. This week we thank Hector Arreaza and Omeed Ameri. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Cole, E., Stimpson, K. H., Bentzley, B. S., Gulser, M., Cherian, K., Tischler, C., Nejad, R., Pankow, H., Choi, E., Aaron, H., Espil, F. M., Pannu, J., Xiao, X., Duvio, D., Solvason, H. B., Hawkins, J., Guerra, A. T., Jo, B., Raj, K. S., . . .Williams, N. (2020). Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression. American Journal of Psychiatry, 177(8), 716–726. https://doi.org/10.1176/appi.ajp.2019.19070720Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., Ward, H. E., Lapidus, K., Goodman, W. K., Casuto, L., Feifel, D., Barnea‐Ygael, N., Roth, Y., Zangen, A., & Zohar, J. (2019). Efficacy and Safety of Deep transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A prospective multicenter randomized Double-Blind Placebo-Controlled Trial. American Journal of Psychiatry, 176(11), 931–938. https://doi.org/10.1176/appi.ajp.2019.18101180Little, A. (2009, July 15). Treatment-Resistant depression. AAFP. https://www.aafp.org/pubs/afp/issues/2009/0715/p167.htmlRoyalty-free music used for this episode: If You Were the One, downloaded on November 15, 2023, from https://www.videvo.net/ 

Episode 158: Strength Training PrinciplesFuture Dr. Hasan explains the importance of adding muscle strength exercises to our routine physical activity. Dr. Arreaza asked questions about some terminology and reminded us of the physical activity guidelines for Americans.    Written by Syed Hasan, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.An Introduction to Strength Training Principles.Arreaza: Hello, everyone. Welcome to episode 158. [Introduce myself]. We are recording this episode right before Christmas but by the time you listen to this episode it will be 2024, so Happy New Year! It has been a busy time in our residency, we had lots of interviews, parties, and, of course, lots of learning and teaching. I apologize for our absence in the last few weeks, but we are back for good. We have Syed today, hi, Syed, please introduce yourself.Syed: Hi Dr. Arreaza, and hello everybody. My name is Syed. I am a fourth-year medical student at Ross University School of Medicine. I'm also a lifting enthusiast. One of my many goals in life is to look like I lift. Until I reach that goal, I will take solace in the fact that at least I sound like I lift. Arreaza: You are getting there, keep going! Give us an intro for today's episode. Syed: (laughs) Thanks! Well, today, I want to present a framework with which to approach resistance training. The benefits of weight training are well-known, and a quick Google search gives us plenty to learn about them. But a clear framework for resistance training is a bit more difficult to come by. So, in this podcast, I will attempt to provide you, the listeners, with such a framework. By the end of the episode, my goal is to get most of you to start thinking about strength training seriously. Arreaza: I'm excited to hear it. I'm ready to learn more. I exercise, but I have to confess that I need to add more lifting to my routines. I enjoy cardio exercise, especially if I'm listening to my favorite music or watching a Netflix show. So, today I will go to bed being a little wiser. I have low gym literacy, but I think many of our listeners will appreciate my silly questions. Syed: (laughs) If you're thinking it, it's not a silly question, Dr. Arreaza! Before we begin though, some housekeeping. Because there is some technical stuff like names of muscles, their function, and exercises to target them, we will add a quick glossary at the end of the attached transcript. I will also include sources for the information I present. As well, a lot of other sources on hypertrophy training and exercise science. Arreaza: So, let's start with the definition of strength training, Syed. Syed: Yeah. So put simply, any exercise where you produce force against a resistance can be thought of as a resistance training exercise. Doing this kind of exercise over a long period of time is what causes strength and muscle gain. By the way, strength and muscle gains are like chicken and eggs. Scientists are not sure which comes first, just that both are correlated. Practically, it means that when we look at two people, the person with bigger muscles is probably going to be stronger.Arreaza: On the Physical Activity Guidelines for Americans, available online at health.gov, we find that it is recommended that adults engage in “muscle-strengthening activities of moderate or greater intensity… [involving] all major muscle groups on 2 or more days a week,” and that's ON TOP of the 150-300 minutes of moderate physical activity a week for general health benefits.Syed: Yeah, and we are talking about it today because a lot of times it's unclear to people what such exercise entails. Some common examples are bodyweight exercises like push-ups, pull-ups, and squats. Syed: In these exercises, our body is the resistance against which our muscles are producing force. So, in push-ups, it is our chest and triceps that are mostly involved. In pull-ups, it is our back and biceps that work the hardest. When it comes to squats, it is our quads and glutes that are used most. Quads are the muscles in the front part of the thighs, and glutes are the buttock muscles. Arreaza: Push-ups, pull-ups, and squats are examples of bodyweight exercises. Syed: Yeah, so now let's talk about free weight exercises. Just like in body weight exercises, we are using our body weight as resistance, in free weight exercises we use free weights, like barbells or dumbbells, as resistance. So, instead of a push-up, we could do a bench press with a barbell or dumbbell, for example. Arreaza: Barbells and dumbbells. What's the difference?Syed: The difference is the size, dumbbells fit in your hand and barbells are larger. Bench press with them is a substitute for push-ups. These would target the chest and triceps just like push-ups. For pull-ups, the substitute would be barbell rows or dumbbell rows, to target the upper back. And the free-weight version of bodyweight squats is simply having a barbell on the upper back/shoulders and do squats. This exercise is called barbell squat. If we don't have barbells but have dumbbells, we can grab one, hold it with both hands in front of our chest, and do squats. That is called a goblet squat.Arreaza: And don't forget the kettlebells that can be used for squats too.Syed: That's right. So far in our discussion, some themes have emerged. There are big muscle groups that work together, like the back and biceps, chest and triceps, and quads and glutes.There are exercise groups that target these muscle groups.These big muscle groups are either part of the trunk or are nearest to the trunk of the bodyMost people know what trunk is, but I'll describe it as the area between the neck and groin. You can imagine our limbs and neck sprouting from our trunk just as branches sprout from a tree trunk.So, chest is part of the trunk, and biceps are near the trunk; back is part of the trunk, and triceps are near the trunk. For our lower body, quads and glutes are near the trunk.Now, let's also summarize the muscle groups and exercise groups mentioned so far. Chest and triceps: Can be targeted with push-ups, bench press (when using barbells), or dumbbell press (when using dumbbells).By the way, in the world of lifting, the same exercise might have different names. I don't want anyone to be married to the names. Understanding the movement pattern is the important thing.So, again, reiterate #1Back and biceps can be targeted with pull-ups, barbell rows, or dumbbell rows. There is also an exercise called lat pull-down that is like the movement pattern of pull-ups (basically starting with arms above our body and then bringing our elbows towards the ribs). But a lat-pull down uses a cable machine found at most gyms.So again, for back and biceps, we can do pull-ups, barbell or dumbbell rows, or lat pull-downs, depending on what we have access to.Finally, we talked about quads that can be targeted with body weight squats, barbell, or dumbbell squats. To these exercises, we can also add lunges, that can be done with bodyweight, dumbbells, or barbells.Arreaza: What are lunges?Syed: Lunges are like walking but you lower your hips and bend your knees with every step. And you do this with dumbbells in hands or a barbell on the back. You can also do it with just body weight. Arreaza: You said these muscle and exercise groups cover the big muscles on or nearest to the trunk. You have not mentioned the shoulders and the back of the thighs. Syed: To that, I would say, thank you for listening so closely! All of these exercises have been compound movements, meaning they target more than one muscle group. These are the exercises that give you the biggest bang for your buck, that is time.Syed: The compound exercises for back of the thigh is deadlifts. Muscles in the back of the thigh are called hams (short for hamstrings). The bread-and-butter compound exercise for hams is the deadlift. It can be done with a barbell or dumbbells. On top of targeting your hams, it also makes your erector muscles work hard. Erectors are also called erector spinae. These are a group of muscles in the back that work hard to keep your spine stable and help us stand straight. They also allow us to bend our spine side to side and even backwards a bit. So the deadlift is done with the lifter bending at the hips and knees, keeping the back straight. And reversing that movement to stand back up.Arreaza: It is important to exercise your erectors. Deadlifts for your hams. And for your shoulders?Syed: For shoulders, the go-to compound lift is the shoulder press (and again, this can be done with a barbell or dumbbell). It targets your delts, short for deltoids. Shoulder press also targets our triceps, traps, and upper chest. Syed: The thing with both deadlifts and shoulder press is that they are taxing on your spine. It's true for squats too, but squats are a relatively simple movement compared to deadlifts and shoulder press. With deadlifts and shoulder press, you have to pay special attention to keeping a neutral spine, and that does not come intuitively. Often the best way to master these movements without putting your spine in a compromised position is under expert supervision, at least when learning the movement. Don't get me wrong; it can be learned by paying close attention to exercise videos online as well. But yeah, it takes practice.Arreaza: So we have covered all big muscles groups that can be trained together using compound movements: back and biceps; chest and triceps; hams, erectors, and glutes; quads and glutes. Syed: Yes, glutes and abs are freebies. They get worked in a lot of movements. More directly in some exercises and less in others. So, these muscle groups really don't need extra attention in most cases, at least not at the beginner level. So, now we know the muscle groups and the compound exercises to target these muscle groups. The final piece is how much and how often to train them. The recommended frequency, in general, for strength training is two days or more per week. Syed: How many exercises in a session? Generally, 3-5. Syed: How many sets for each exercise? The standard answer is 2-5 sets of 5-15 reps per exercise. Stopping 2-3 reps shy of failure (this is called the reps-in-reserve or RIR model). Make sure to take plenty of rest between sets. Arreaza: How much is plenty? Syed: 1) your muscles feel sufficiently recovered, 2) your breathing is back to normal or almost normal, and 3) your will to push for another set is back. You can use this 3-point checklist for both rest periods between sets and rest periods between training sessions. Between sets, the rest time may be 2 minutes; it may be 5 minutes. It may go from 5 to 2 minutes as your cardio improves over time. But the most important thing is, listening to our body.  Not overexerting. Otherwise, our subconscious is going to tell us, you just punish me when exercising. So, now it is going to rebel. And before we know it, weeks have passed between training sessions, we have lost the momentum for training, and we missed out on potential gains. Arreaza: My patients talk about being afraid of injuries when lifting. Can you talk about that? Syed: Anything in life has risks and benefits. I heard a resident at Rio Bravo once say, “being alive has its risks.” The good news is, resistance training of any kind, whether it is Olympic lifting, powerlifting, or bodybuilding, carries a lot less risk of injury compared to any other sport. And the benefits, physical, mental, and reduced all-cause mortality far outweigh the risks. I have never regretted a training session. This is something you will hear most people who lift say. And for good reason. The only thing is, start slowly, and increase weights slowly over time. Arreaza: Injury prevention is important. You need to make sure you are keeping a correct posture and body positioning during weight-lifting. A personal trainer can be a way to prevent injuries but if you are very motivated, you can find videos to guide you. Do you have any recommendations on sources where our listeners can learn more about this?Syed: To learn about the principles of muscle hypertrophy, the people I benefited the most from are Dr. Eric Helms, Dr. Mike Israetel,  Dr. Milo Wolf, and Barbell Medicine (Drs. Baraki and Feigenbaum whose articles I referred to when preparing for this podcast). All these people have tons of sources available in the forms of books, articles, YouTube videos, and Instagram posts. In other words, they are everywhere trying to teach us!. I can link some of the playlists for exercises by muscle groups.Arreaza: Thanks.Syed: Thank you for listening, I hope this episode gives us a better idea to guide our patients or ourselves in strength training. GlossaryCompound exercise A strength training exercise that involves the use of multiple muscle groups and joints to perform the movement. Chest Pecs or pectoralis muscles (major and minor)The pecs work to help us push things away in front of us.  Compound exercises targeting chest also work the front delts.  Triceps Tris (pronounced “tries”)The triceps help us straighten our arms.Chest and tris can be thought of as pushing muscles. ShouldersDelts or deltoids (front, medial, and rear) The delts raise arms up to around shoulder level, although some evidence suggests they work even when the arm has crossed the 90-100 degree mark. Back  Lats or latissimus dorsi helps us bring elbow close to our body (either from in front of us in a horizontal plane or from above us in a vertical plane). Most back exercises also work other muscles in the back like rear delts, traps, and erectors.GlutesGluteal muscles (gluteus maximus, medius, and minimus)Have many functions including pelvic stability, overall posture, force production in athletic movements, and so much more. Involved heavily in exercises for the quads and hams.  AbsCore or Abdominal muscles (rectus abdominis, internal and external obliques, and transverse abdominis)A group of muscles in the front of the torso. When body fat is low (10-15% in men and 15-25% in women), they lead to the appearance of the “six packs” (the rectus abdominis). They are used in most exercises when we brace before executing the movements.  Note: In most cases, being leaner than the percentages mentioned above is not good for overall hormonal health.   _____________________Conclusion: Now we conclude episode number 158, “Strength Training Principles.” Future Dr. Hasan explained how to strengthen groups of muscles by adding bodyweight and free weight exercises. He answered some questions about basic terminology and Dr. Arreaza added a few words about injury prevention. This week we thank Hector Arreaza and Syed Hasan. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Baraki A, Feigenbaum J, et al. Practical guidelines for implementing a strength training program for adults. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.). https://www.uptodate.com/contents/practical-guidelines-for-implementing-a-strength-training-program-for-adultsFranklin BA, Sallis RE, et al. Feigenbaum J, et al. Exercise prescription and guidance for adults. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.) https://www.uptodate.com/contents/exercise-prescription-and-guidance-for-adultsSullivan J, Feigenbaum J, et al. Strength training for health in adults: Terminology, principles, benefits, and risks. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.) https://www.uptodate.com/contents/strength-training-for-health-in-adults-terminology-principles-benefits-and-risksRoyalty-Free Music: Sur-La-Tabla_Beat. Downloaded on May 19th, 2023, from  https://www.videvo.net/Suggested Reading:Helms, E., Morgan, A., & Valdez, A. (2019). The Muscle & Strength Pyramid: Training. Muscle and Strength Pyramids, LLC.Helms, E., Morgan, A., & Valdez, A. (2019a). The Muscle & Strength Pyramid: Nutrition. Muscle and Strength Pyramids.Israetel, M. (2021). Scientific principles of hypertrophy training. Renaissance Periodization. Schoenfeld, B. (2021).Science and development of muscle hypertrophy. Human Kinetics.

Episode 157: Urine TestingThis episode includes the pitfalls of urine tests, how to detect adulterated urine, and more.  Written by Janelli Mendoza, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD. Comments by Carol Avila, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: Urine drug screenings are valuable tools used every day by physicians to monitor illicit substance use, as well as proper use or misuse of prescription drugs. However, studies suggest that physicians using “clinical judgment” on who and when to test is often wrong and confounded by implicit racial bias. The implications of this are an inappropriate discontinuation of treatment.For example, a study by Gaither, Gordon, and Crystal et. al found that compared to white patients, black patients were 10% more likely to undergo urine drug screening. In addition, they were 2-3 times more likely to have long-term opioid medication abruptly discontinued as a result of a UTOX positive for marijuana.False positive urine tests:Before getting into the current guidelines, let's discuss the interpretation of Urine Drug Screenings. It's important to be aware of prescription drugs that may cause false positives:· Bupropion, labetalol, pseudoephedrine, trazodone → Amphetamines· HIV antivirals, sertraline → Benzodiazepines· HIV antivirals, NSAIDs, PPI's → Cannabinoids· Diphenhydramine, Naloxone, Quetiapine, Quinolones, Verapamil → Opioids· Dextromethorphan, diphenhydramine, ibuprofen, tramadol, venlafaxine → PhencyclidineTampering of urine: Other factors to consider are the tampering of collected urine. The tampering of collected urine may include diluting the urine, or adding other chemicals and substances. Laboratory results that should prompt consideration of adulteration are: Creatinine

Episode 156: Obesity, Fertility, and PregnancyFuture Dr. Hamilton defines obesity and explains the pathophysiology of obesity and its effects on fertility and pregnancy. Dr. Arreaza adds some input about the impact of epigenetics on newborn babies.  Written by Shelby Hamilton, MS3, American University of the Caribbean School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition of obesityObesity is a multifactorial chronic disease that is increasing in prevalence across the globe. It can be defined as a body mass index (or BMI) greater than 30 kg/m2. According to the CDC from 2017-March 2020, the prevalence of obesity in United States adults was 41.9%.Classification of obesity by BMI.Obesity can further be divided into three classes: class I which is a BMI between 30-34.9; class II which is a BMI between 35-39.5; and class III which is a BMI greater than 40. We recommend avoiding the term “morbid obesity” because of the negative connotation of the word “morbid.” Class III or severe are better terms in those cases. This classification is based on the individual risk of cardiovascular disease. One of the greatest health consequences affecting individuals with obesity is the cardiovascular effects including hypertension, dyslipidemia, and coronary artery disease. Other effects include insulin resistance and diabetes, cholelithiasis, non-alcoholic fatty liver disease, osteoarthritis, and even depression.How Does Obesity Affect Fertility?Obesity can have an extensive effect on the overall health of an individual. In addition to these commonly discussed effects, obesity can also influence a person's fertility. This is especially observed in women with polycystic Ovary Syndrome (PCOS) who have a greater BMI and also have symptoms of anovulation. Excess adipose tissue plays a role in the effects that obesity has on fertility. White adipose tissue can secrete a specific group of cytokines known as ‘adipokines'. These adipokines include leptin, ghrelin, resistin, visfatin, chemerin, omentin, and adiponectin. With a greater percentage of adipose tissue, there are higher rates of hypothalamic gonadotropin hormonal dysregulation, which can be combined with insulin-related disorders, low sex hormone binding proteins, and high levels of androgens. The combination of these factors can result in decreased ovarian follicle development and decreased progesterone levels.Hormonal changesObesity is an endocrine disorder. One specific adipokine that affects the hypothalamic-gonadotropin axis is chemerin. Chemerin impairs the release of follicle-stimulating hormone (FSH) from the pituitary gland. This reduction in FSH release consequently leads to anovulation, meaning that no egg will be released from an ovarian follicle, contributing to infertility. Shelby: Another adipokine affecting fertility is adiponectin. The receptors of adiponectin are predominantly expressed in reproductive tissues, including the ovaries and endometrium. In individuals with a greater BMI, a decrease in adiponectin secretion has been observed, resulting in decreased stimulation of its receptors, especially in the endometrium, which has been linked to recurrent implantation failure. Adiponectin has also been shown to affect glucose uptake in the liver. With reduced adiponectin levels, there is reduced hepatic glucose uptake, leading to insulin resistance. As tissues become less sensitive to insulin, the body compensates by secreting higher amounts of insulin, leading to hyperinsulinemia. Higher levels of circulating insulin have also been proven to cause hyperandrogenemia in women by blocking the hepatic production of sex hormone-binding globulin. Insulin can also act on the IGF-1 receptors in the theca cells, increasing steroidogenesis, and thus, increasing androgens. With hyperandrogenemia, there is also increased granulosa cell apoptosis as well as increased peripheral conversion of androgens into estrogen. This creates negative feedback to the hypothalamic-pituitary axis to decrease the release of gonadotropins such as FSH which are critical in ovulation.Leptin is another adipokine that is shown to be increased in obesity. Studies on mice have shown that leptin impairs the development of ovarian follicles, resulting in a decrease in ovulation. In these studies, it was also observed that leptin reduces the production of estriol by the granulosa cells in the ovarian follicles as well as increases the rate of apoptosis in granulosa cells, both of which affect ovulation. Leptin decreases hunger, but persons with obesity may be resistant to its effects and that's why they have higher levels than a person with normal weight. They have high levels of leptin but are still hungry because they have leptin resistance.Studies have also shown that the fatty acid composition of follicular fluid found in ovarian follicles also plays a role in fertility. In individuals with a high BMI, this fluid contains high levels of oleic acid, which can cause embryo fragmentation after fertilization occurs. Stearic acid is another fatty acid found in elevated levels in the follicular fluid of women with a greater BMI, which can also affect the quality of the embryo while in the blastomere stage.The bottom line is obesity decreases fertility. It does not mean that patients with obesity will not get pregnant, but it can make it harder to get pregnant. Female patients who are losing weight must be warned about their improved fertility once they start to lose weight.What effect does obesity have on pregnancy?While obesity may make it more difficult for a woman to get pregnant, it is not impossible. However, there are potential risks both to the mother's health as well as the baby's health. Therefore, it is very important to monitor these patients even more carefully.Women who have a greater BMI pre-pregnancy are at a greater risk of developing gestational hypertension. Gestational hypertension is defined as blood pressure greater than 140/90 on more than one reading in the second half of pregnancy. Hypertension during pregnancy can also have serious complications such as kidney failure, stroke, myocardial infarction, or even heart failure. Gestational hypertension can also result in preterm birth or low birth weight.Treatment of mild hypertension in pregnancyRecent studies published in the AFP Journal support the treatment of mild hypertension in pregnancy. It states that “evidence and expert opinion support treating mild chronic hypertension in pregnancy with approved antihypertensives, with a strength of recommendation: B”. There was a randomized control trial with about 2,000 women who were randomized to receive antihypertensive treatment vs no treatment. The treatment group had a lower incidence of preeclampsia with severe features, preterm birth, placental abruption, and neonatal or fetal death. There was not an increase in fetal growth restriction or maternal or neonatal complications. So, it is advisable to treat chronic, mild hypertension in pregnancy, according to the AFP Journal.PreeclampsiaPreeclampsia is another condition that is at a higher risk in women with obesity, which is a more serious manifestation of hypertension in the second half of pregnancy. Along with high blood pressure, there are also effects on the kidneys and liver. Hypertension accompanied by proteinuria is indicative of preeclampsia and should be taken seriously. Preeclampsia can become eclampsia, where the patient also experiences seizures. There is also the risk for stroke, HELLP syndrome, placenta abruption, preterm birth, and fetal growth restriction.Gestational diabetesAnother risk is gestational diabetes. Elevated blood glucose during pregnancy can result in a larger baby and delivery by cesarean. There may also be a greater risk of the mother and child developing diabetes mellitus later on in life.OSAWomen with a greater BMI may also be at risk of developing obstructive sleep apnea during pregnancy. Not only can this result in fatigue but can also contribute to the development of gestational hypertension and preeclampsia.Effect of obesity on the fetusAs mentioned, there are some risks to the fetus in women with a greater pre-pregnancy BMI. There is a greater risk for these babies to be born with birth defects such as congenital heart defects and neural tube defects. Another risk previously discussed is macrosomia, or large for gestational age. Larger babies are also at increased risk for shoulder dystocia during delivery as well as resulting clavicle fractures, brachial plexus injuries, and nerve palsies. Preterm birth is another risk, which also increases the risk of short-term and long-term health complications. Lastly, a higher BMI is directly correlated with the risk of spontaneous abortion or stillbirth.SummaryAs the prevalence of obesity increases, it is important to discuss the health risks that are associated with this disease. In our patients of childbearing age and who may be hoping to conceive, it is even more important to discuss how a higher BMI may affect fertility and pregnancy. While discussing these topics with patients, it is important to try our best to build rapport with the patient so that the discussion is seen more as one of concern and support rather than one of criticism regarding their weight. We may want to help by not only telling patients to “lose weight” or “diet”, but we can also provide them with resources regarding dietary adjustments and ways they can incorporate physical activity into their lives without just telling them to eat less and move more. Stay tuned for our episode on the management of obesity in pregnancy.ConclusionNow we conclude episode number 156, “Obesity, fertility, and pregnancy.” Future Dr. Hamilton explained how obesity affects the hormonal regulation of fertility. She also explained the obstetrical risks associated with obesity. Primary care professionals need to educate our patients about the benefits of preconception weight control. Dr. Arreaza explained that hypertension is a common condition in pregnant patients with obesity and mentioned the benefits of treating mild hypertension in pregnancy. We hope to bring you an episode on the management of obesity in pregnancy soon, so stay tuned! This week we thank Hector Arreaza and Shelby Hamilton. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Gautam, D., Purandare, N., Maxwell, C., Rosser, M., O'Brien, P., Mocanu, E., McKeown, C., Malhotra, J., & McAuliffe, F. (2023) The challenges of obesity for fertility: A FIGO literature review. International Journal of Gynecology & Obstetrics, 160(S1), 50-55. https://doi.org/10.1002/ijgo.14538Pandey, S., Pandey, S., Maheshwari, A., & Bhattacharya, S. (2010). The impact of female obesity on the outcome of fertility treatment. Journal of Human Reproductive Science, 3(2), 62-67. https://doi.org/10.4103/0974-1208.69332.Perreault L. Obesity in adults: Prevalence, screening, and evaluation. In: UpToDate, Pi Sunyer FX (Ed) Wolters Kluwer. https://www.uptodate.com (Accessed on October 6, 2023).Obesity and Pregnancy FAQ, The American College of Obstetricians and Gynecologists (ACOG), https://www.acog.org/womens-health/faqs/obesity-and-pregnancy, Accessed on October 10, 2023.Adult Obesity Facts, Centers for Disease Control and Prevention (CDC), https://www.cdc.gov/obesity/data/adult.html, Accessed on October 7, 2023. Dresang L, Vellardita L. Should Medication Be Prescribed for Mild Chronic Hypertension in Pregnancy?. Am Fam Physician. 2023;108(4):411-412. Royalty-free music used for this episode: "I Think We Have a Chance."  downloaded on November 11, 2023,  from https://www.videvo.net/.

Episode 155: Diabetic Foot Infection GuidelinesFuture Dr. Perez presents the updates on lung cancer screening by the American Cancer Society. Future Dr. Danusantoso explains the classification, diagnosis, and treatment of diabetic foot infections according to the guidelines published by the International Working Group on the Diabetic Foot (IWGDF). Dr. Arreaza adds comments and anecdotes.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Intro: Lung cancer screening update.Written by Luz Perez, MSIII, Ross University School of Medicine. Editing by Hector Arreaza, MD.Hello, my name is Luz Perez and today I will talk about lung cancer screening.As a reminder, lung cancer is the top cause of cancer-related death in men and women worldwide. In the United States, lung cancer causes the death of about 154,000 people each year[4]. Smoking is the most significant risk factor for developing lung cancer, a risk that directly correlates to how much and how long a person has smoked[2]. Despite the efforts to decrease lung cancer-related deaths, which include screening of patients at risk and counseling on smoking cessation, many patients go undiagnosed in part because lung cancer can be asymptomatic but also because many people at risk did not meet the criteria for screening, according to previous guidelines… BUT On November 1, 2023, the American Cancer Society updated its guidelines for lung cancer screening to decrease mortality by lung cancer in the US. The updated lung cancer screening guidelines were published in November, which is Lung Cancer Awareness Month. This guideline aims to expand eligibility criteria for lung cancer screening. Previously, the guidelines covered people only between the ages of 55-74 who were current smokers or had quit within the past 15 years and had a 30 or more pack-year smoking history[3].The new guidelines recommend annual screening with low-dose CT (LDCT) scan for people who are 50-80 years old who are current or former smokers and who have a 20 or more pack-year of smoking history [1]. This change means that about 5 million people who would previously not qualify for screening are now eligible for this potentially lifesaving screening exam.Additionally, the American Cancer Society emphasizes the significance of shared decision-making between patients and healthcare providers on lung cancer screening and smoking cessation. This includes ways to help patients stop smoking by providing counseling and interventions including medications. For patients who are eligible for screening, having a full discussion of the lung cancer screening process including the purpose of the procedure, risks and benefits of low-dose CT, and recommendations from other organizations, is key in the shared decision-making process[1]. Perhaps, the most important step in the implementation of these new guidelines is ensuring that medical professionals talk to their patients about them and make them aware of the importance of screening for lung cancer. In this way, we can reduce mortality and other consequences of this devastating disease. Written by Maria Danusantoso, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.Update to Guidelines for Treatment of Diabetic Foot InfectionsIntroductionIn October 2023, the International Working Group on the Diabetic Foot (IWGDF) and the Infectious Disease Society of America (IDSA) collaborated and published an update to the 2019 guideline on the diagnosis and management of infections of the foot in persons with diabetes mellitus.The present guidelines include a list of 25 recommendations for diagnosis and management and clinically useful figures and tables including a treatment algorithm, a classification system for defining diabetic foot infections, and empirical antibiotic therapy according to clinical presentation and microbiological data.The goal of this episode is not to provide an exhaustive review of the updated guidelines and algorithms but to highlight what I believe are the most important recommendations. I hope this brief presentation is viewed as an introduction and that this encourages you, the listener, to independently read the guidelines in full and implement them into your own clinical practice.Wound Colonization Versus Wound InfectionBefore jumping into some of the recommendations, I want to take some time to discuss briefly how to classify diabetic foot infections. Most clinicians, including myself, will see a patient with diabetes with a foot ulcer or wound and want to treat it with antibiotics or admit the patient to the hospital. However, the updated guidelines propose that antibiotics and/or admission are not always indicated. For clinicians, there needs to be an awareness that wound colonization and wound infection are not the same. Wound colonization by bacteria is defined by the presence of bacteria on a wound surface without evidence of invasion of the host tissues. Colonization, then, can be considered a constant phenomenon as we live in a bacteria-filled world. Comment: If we culture our intact skin, we may find pathogens, that's why wound cultures even if they are positive, do not indicate there is infection. Tell us about infection.In contrast, wound infection is a disease state caused by the invasion and multiplication of microorganisms in host tissues that induce an inflammatory response in the host, usually followed by tissue damage. Therefore, since all wounds are colonized – often with potentially pathogenic microorganisms – we cannot define wound infection using only the results of wound cultures. Instead, diabetic foot infections are a clinical diagnosis based on the presence of manifestations of an inflammatory process involving a foot wound located below the malleoli. These signs and symptoms of inflammation may be masked in persons with diabetes especially if they have some level of baseline peripheral neuropathy, peripheral artery disease, or immune dysfunction.Classification of Diabetic Foot Infections.To assist with the classification of diabetic foot infections, the updated guidelines include a table for defining the presence and severity of an infection of the foot in a person with diabetes. Again, diabetic foot infections are a clinical diagnosis, and the clinical classification of infection can be described as: 1) uninfected, 2) mild, 3) moderate +/- O if osteomyelitis is present, 4) severe +/- O if osteomyelitis is present. Uninfected has no systemic or local symptoms or signs of infection. Mild infection is when at least two of the following are present: local swelling or induration, erythema between 0.5-2 cm around the wound in any direction, local tenderness or pain, local increased warmth, purulent discharge, and there is no other cause of an inflammatory response of the skin present (e.g., trauma, gout, acute Charcot neuro-arthropathy, fracture, thrombosis, or venous stasis).Moderate infection is without systemic manifestations and involves erythema extending 2 cm or more from the wound margin and/or involves tissue deeper than skin and subcutaneous tissues (e.g., tendon, muscle, joint, and bone) +/- the presence of osteomyelitis. The surrounding erythema and the depth of wound are key element in the classification of the wounds. Severe infection is associated with systemic manifestations and meets systemic inflammatory response syndrome (SIRS) criteria as manifested by 2 or more of the following: temperature below 36°C or above 38°C, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute, white blood cell count greater than 12,000/mm3 or greater than 10% immature (band) forms +/- presence of osteomyelitis. Features of Osteomyelitis on Plain X-RayWe have mentioned osteomyelitis quite a few times in this episode, so what are some ways we can diagnose osteomyelitis? Most commonly, osteomyelitis is diagnosed via imaging either with plain X-rays  or MRI. When looking at plain X-rays, there are a few features that are characteristic of diabetes-related osteomyelitis of the foot of which we should be aware regardless of our status as radiologists. Some of these features include bone sclerosis with or without erosion, abnormal soft tissue density or gas density in the subcutaneous fat, or new or evolving radiographic features on serial images spaced several weeks apart such as loss of bone cortex, focal demineralization, periosteal reaction or elevation. Changes in x-ray may be a late finding and indicate that the osteomyelitis is established.General Treatment Recommendations for Diabetic Foot InfectionsIn the updated guidelines, recommendation 11 states to not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy when the goal is to reduce the risk of new infection or to promote ulcer healing. As previously said, diabetic foot infections are a clinical diagnosis. So if clinically the wound does not meet criteria to be classified as a mild, moderate, or severe infection, this recommendation proposes that no antibiotic treatment is the best treatment so as not to expose patients to potentially unnecessary and harmful treatment and to not promote antibiotic resistance in patients, which would potentially make treating diabetic foot infections more challenging in the future. We still want to very closely monitor the wound every 2-7 days and promote wound healing with pressure offloading, keeping the wound and the surrounding skin clean and dry, and other non-antibiotic management for local wound care.What are some common bacteria?.When it is indicated to treat diabetic foot infections per the guidelines, recommendation 14 states to target aerobic gram positive pathogens only for people with a mild diabetes related foot infection. These pathogens include beta hemolytic streptococci and Staphylococcus aureus including methicillin-resistant strains if indicated. Additionally, recommendation 15 advises not to empirically target antibiotic therapy against Pseudomonas aeruginosa in cases of diabetes-related foot infection in temperate climates. However, it is appropriate to use empirical treatment of P. aeruginosa if it has been isolated from cultures of the affected site within the previous few weeks or in a person with moderate or severe infection who resides in tropical/subtropical climates.Antibiotic Treatment Duration RecommendationThe final recommendation we have time to discuss in this episode is regarding antibiotic treatment duration. For mild infections, oral antibiotics (such as cephalexin or Bactrim) for a duration of 1-2 weeks is appropriate. However, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease, it is reasonable to consider extending treatment for up to 3-4 weeks.For moderate or severe infections without osteomyelitis, a total treatment duration of 2-4 weeks is recommended starting initially with IV antibiotics before transitioning to oral antibiotics. Antibiotic selection will depend on multiple factors, such as recent antibiotic use, or MRSA risk factors. For example, if the patient took antibiotics recently, they could receive Zosyn® and ceftriaxone. If osteomyelitis is present, antibiotic treatment duration can be anywhere from 2 days to 6 weeks depending on the amount of source control achieved. Ideally, we should wait to have bone resection before giving antibiotics, but we know that antibiotics are given promptly in the ER.In the cases of a resected infected bone or joint (when complete source control is achieved), a duration of 2-5 days is recommended, starting with IV antibiotics before transitioning to oral antibiotics. If there is minor amputation of the infected foot but there remains a positive wound culture or positive margins are seen on pathology (inflammatory cells are seen at the proximal margin of the amputated section), a 3-week antibiotic treatment duration is recommended, again starting with IV before transitioning to oral antibiotics.For diabetes-related foot osteomyelitis without bone resection or amputation, a 6-week course of antibiotics is recommended, again initially with IV antibiotics before transitioning to oral. In all the situations where there is a transition from IV to oral antibiotics, this transition may only occur once there are clinical signs of improvement, for example, improving erythema surrounding the wound, resolution of tenderness or purulent drainage, or SIRS criteria is no longer met.Summary: For more details regarding the 2023 update to the guidelines on the diagnosis and treatment of foot infection in persons with diabetes, please refer to the complete guidelines which can be accessed on the IWGDF Guidelines website and via the citations listed in the References. As a reminder, this podcast episode is not an exhaustive review of the guidelines, but, instead, a brief introduction to some of the recommendations. Thank you for listening and I hope you learned something new!_____________________________Conclusion: Now we conclude episode number 155 “Diabetic foot guidelines.” Future Dr. Perez started this episode with an introduction about the new guidelines to screen for lung cancer, then future Dr. Danusantoso gave an excellent summary about the classification and treatment of diabetic foot infections. Our patients with diabetes must have foot self-awareness and report any concerns to their family physicians or podiatrists so they can get prompt treatment.This week we thank Hector Arreaza, Luz Perez, and Maria Danusantoso. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:McDowell, Sandy, New Lung Cancer Screening Guideline Increases Eligibility. American Cancer Society, published on November 1, 2023, Cancer.org. https://www.cancer.org/research/acs-research-news/new-lung-cancer-screening-guidelines-urge-more-to-get-ldct.htmlWolf AMD, Oeffinger KC, Shih TY, et al. Screening for lung cancer: 2023 guideline update from the American Cancer Society [published online ahead of print, 2023 Nov 1]. CA Cancer J Clin. 2023;10.3322/caac.21811. doi:10.3322/caac.21811. Link: https://pubmed.ncbi.nlm.nih.gov/37909877/Moniuszko, Sara. Lung cancer screening guidelines updates by American Cancer Society to include more people. CBS News, updated on November 3, 2023. https://www.cbsnews.com/news/lung-cancer-screening-guideline-american-cancer-society-update/Deffebach, M. E., & Humphrey, L. (2023). Screening for lung cancer. UpToDate. Retrieved November 6, 2023, UpToDate. https://www.uptodate.com/contents/screening-for-lung-cancerÉric Senneville, Zaina Albalawi, Suzanne A van Asten, Zulfiqarali G Abbas, Geneve Allison, Javier Aragón-Sánchez, John M Embil, Lawrence A Lavery, Majdi Alhasan, Orhan Oz, Ilker Uçkay, Vilma Urbančič-Rovan, Zhang-Rong Xu, Edgar J G Peters, IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023), Clinical Infectious Diseases, 2023; ciad527, https://doi.org/10.1093/cid/ciad527Senneville, Éric et al. 2023. “IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Foot Infection in Persons with Diabetes.” IWGDF Guidelines. Retrieved November 6, 2023 (https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-2023-04-Infection-Guideline.pdf). Royalty-free music used for this episode: Gushito, “Gista Mista”, downloaded on November 16th, 2023, from https://www.videvo.net/ 

Episode 154: Heart Failure and GDMTDr. Malave explains the four main medications that are part of the guideline-directed medical therapy of heart failure with reduced ejection fraction. Dr. Arreaza added comments and questions.  Written by Maria Fernanda Malave, MD. Edits by Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Brief introduction: Heart failure (HF) is a common condition that affects about 23 million people in the world, and it is estimated that 50% of cases are due to heart failure with reduced ejection fraction (HFrEF). It is a major public health concern because of the high morbidity and mortality with a 5-year survival rate of 25% after hospitalization due to HFrEF.In recent years, the management of HFrEF has evolved due to increased evidence in favor of certain medications. Guideline-directed medical therapy (GDMT) is the foundation of medical therapy for these patients, and it is the result of multiple randomized controlled trials and reviews favoring four main drug classes: 1. renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors -ACEi- and angiotensin receptor blockers -ARB), 2. evidence-based β-blockers, 3. mineralocorticoid inhibitors, and 4. sodium-glucose cotransporter 2 inhibitors -SGLT-2i-. The benefit of this therapy is mostly seen when these four groups of medications are used in conjunction. During this episode, we will provide some key elements about the prescription of these medications, but this is only an overview, and you are invited to continue learning from reputable sources.Definitions: HF is defined as the impairment of the heart to meet the metabolic demands of the body. It can be caused by multiple conditions that interfere with the filling up of the heart or conditions that prevent an effective ejection of blood out of the heart. Classification of HFrEF: Based on the EF by echocardiogram, heart failure can be classified as:Heart failure with preserved ejection fraction (HFpEF) when the EF is 50% or more.Heart failure with mildly reduced ejection fraction when EF ranges between 41-49%.Heart failure with reduced ejection fraction (HFrEF) when EF is 40% or less.GDMT: Once we make the diagnosis of HF, it is key to educate our patients and re-educate them every single visit about the importance of guideline-directed medical therapy (GDMT) and lifestyle modifications, because this can change the prognosis and exacerbation rates. Many patients think that since they are feeling well after starting GDMT they can stop it, but that's going to increase exacerbations, hospitalizations, and decrease quality of life. Key points to discuss with patients.First, discuss that GDMT are disease-modifying drugs that regulate the neurohormonal system to stop the progression of the disease. We should explain to our patients that medications should be taken despite feeling well. Also, patients should be educated about regular follow-ups and medication titration. We can even instruct our patients about increasing their furosemide dose if they observe signs of overload, such as a weight increase of 2-3 kgs in 3-4 days, tight rings, socks or bracelets, also Paroxysmal nocturnal dyspnea, dyspnea on exertion, and more.  Second, lifestyle modifications such as: quit smoking and alcohol. Additionally, in general, water restriction between 1.2-1.5L daily, salt restriction (there is no official recommendation about how many grams, but in general we recommend less than 2g daily). Third, it is highly recommended to do aerobic exercise that produces mild dyspnea since this improves cardiovascular capacity and decreases hospitalization risk. Patients should be encouraged to have their annual influenza vaccine and pneumococcal vaccine according to their own immunization schedule. According to the AFP journal, in September 2022, researchers found a clinically and statistically significant reduction in all-cause mortality for patients who received an influenza vaccine right after an MI, with a number needed to treat of 50, the effectivity of the vaccine may vary by season.GDMT, groups of medications:What are the basic medications any patient with HF should be on? At least, patients should be on angiotensin receptor blockers ARBs/ACEIs and Beta-blockers. Let's keep in mind that beta-blockers should be given cautiously in cases of exacerbation, but in general low doses are safe. We also have the angiotensin receptor/neprilysin inhibitors (ARNIs), a group of medications whose representative is the combination of sacubitril/valsartan, aka Entresto®. This medication should be the target once ARBs/ACEIs are tolerated. ARBs/ACEIs/ARNIs should be discontinued in the setting of advanced CKD, with a GFR of 30 or less. This applies to other medications used in HF such as SGLT-2 and mineralocorticoid receptor antagonist (MRA, such as spironolactone/eplerenone). Remember that SGLT-2 inhibitors should be started regardless diabetes status, and BB are safe in the setting of CKD. We also have other groups that are considered safe in patients with advanced CKD such as hydralazine/isosorbide dinitrate (combined or not), which are used in African Americans whose BP and HF symptoms do not improve with maximally tolerated dose of ARBs/ACEIs + BB.Ivabradine: Let's not forget about ivabradine, which is an SA node inhibitor like BB. Patients need to meet criteria such as a maximally tolerated dose of beta-blocker, heart rate of a least 70 or more and being on normal sinus rhythm to be started on this medication. Ivabradine does not improve survival as BB do, so even though they are not contraindicated in HF exacerbation, BB are still preferred since ivabradine does not decrease mortality.Titration and follow-ups in the HF management:-ARBs/ACEIs/ARNIs should be titrated approx. Q2 weeks until the maximally tolerated dose is achieved, ARNI should be titrated up Q2-4weeks. With these medications, we should monitor BP, potassium levels and Glomerular Filtration Rate (GFR). -BB can also be titrated up Q2weeks until the maximally tolerated dose is achieved. HR, BP and signs of congestion should be observed in patients on BB. Same for hydralazine/isosorbide, with BP follow-up. -MRA, such as spironolactone/eplerenone, these meds can be added in patients who remain symptomatic despite maximally tolerated doses of “ARBs or ACEIs or ARNIs” plus Beta-blockers. For MRA, potassium level, and GFR should be monitored every 2-3 days after initiation, 7 days after titration, monthly for 3 months, and then Q3 months. To start a patient on MRA, K+ must be lower than 5.Patients with HF should be followed up at least in a 2-week interval either via telephone, telemedicine, or clinic visit to assess symptoms, vital signs, bloodwork and to perform a physical exam. Monitoring EF: After 3-6 months of the patient´s stabilization, we should reorder an echo, EKG, BNP and Basic Metabolic Panel. The ejection fraction improves in all patients after GDMT initiation and compliance, and in some patients, this improvement is very significant, so we need to reassess EF after stabilization. Comorbidities: Also, let´s keep in mind that most of the patients have associated comorbidities such as Afib, diabetes, valve disease, or anemia. These comorbidities must be addressed either by starting anticoagulation, adjusting anti-diabetes medications, starting iron, or referring to cardiology if a valve replacement is needed.When to refer to Cardiology? Some patients will qualify for device therapy (ICD) as a primary prevention for ventricular arrhythmias that can degenerate either into torsades or ventricular fibrillation. These patients must be symptomatic, at least in 3 months of maximally tolerated GDMT, and EF between 30-35%. Symptomatic

Episode 153: Sudden Infant Death Syndrome.    Future doctors Nisha and Afolabi explain the way to prevent sudden infant death syndrome and Dr. Arreaza adds comments about prevention through vaccines.  Written by Selena Nisha, MS4; and Oluwatoni Afolabi, MS4. Ross University School of Medicine. Comments by Hector Arreaza, MDYou are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today, we are going to talk about sudden infant death syndrome, also known by its acronym SIDS. This topic is a heavy one and it may be triggering for some parents or those who may personally know a family member affected by SIDS, so please refrain from listening to this podcast at any point you see fit. First and foremost, we tend to hear a lot about SIDS in the news or social media outlets that cover these tragic incidents, but let's define what exactly sudden infant death syndrome is. Sudden Infant Death Syndrome, or SIDS, is the abrupt and unexplained death of an infant

Episode 152: ALS FundamentalsFuture Dr. Rodriguez explains the symptoms of ALS, including UMN and LMN symptoms. Dr. Arreaza discusses the principles of symptomatic treatment by primary care. This is a brief introduction to ALS.  Written by Adraina Rodriguez, MSIV, Ross University School of Medicine.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: It is rare but you may encounter it and you should be able to identify the most common symptoms. ALS Challenge in 2014: Ice bucket challenge. Adriana: Patrick Quinn was an ALS patient and activist who created the ICE Bicket Challenge and helped raise US$220 million for medical research.Arreaza: What is ALS?Adriana: ALS stands for Amyotrophic Lateral Sclerosis, formerly known as Lou Gehrig's Disease. It is the most common form of acquired motor neuron disease. ALS is a progressive, incurable neurodegenerative motor neuron disorder with Upper motor neuron (UMN) and/or Lower motor neuron symptoms that cause muscle weakness, disability, and eventually death. There is no single diagnostic test that can confirm or entirely exclude the diagnosis of motor neuron disease. Arreaza: When should you suspect ALS in a patient?Adriana: The classic patient presentation is insidious, slowly progressive, and unremitting UMN and/or LMN symptoms present in one of four body segments - cranial/bulbar, cervical, thoracic, and lumbosacral - followed by spread to other segments over a period of months to years. Arreaza: What would you see on the physical exam when the Patient is in the clinic? There is a system to send signals from your brain to your muscles. It involves basically two neurons: Upper and lower motor neurons. The UMN goes from your cerebral cortex to your spinal cord and there it connects to a lower motor neuron through synapsis. The LMN then sends the signal to your muscles, causing contraction or relaxation. Tell us about the UMN and LMN symptoms.Adriana:LMN Symptoms: Weakness, Fasciculations, Muscular atrophy, Decreased muscle tone (flaccidity) and reduced or absent reflexes. UMN Symptoms: Increased tone and increased extremity deep-tendon reflexes, presence of any reflexes in muscles that are profoundly weak and wasted, pathological reflexes (crossed adductors, jaw jerk, Hoffman sign, Babinski sign 50%), syndrome of pseudobulbar affect (inappropriate laughing, crying, forced yawning).Arreaza: What are important factors to help narrow your differential to ALS?Multifocal motor neuropathy, cervical radiculomyelopathy, benign fasciculations, inflammatory myopathies, post-polio syndrome, monomelic amyotrophy, hereditary spastic paraplegia, spinobulbar muscular atrophy, myasthenia gravis, hyperthyroidism, and many others.There are pertinent negatives to look out for: Usually negative neuropathic or radiculopathic pain, sensory loss, sphincter dysfunction, ptosis, or extraocular muscle dysfunction (20-30% positive sensory symptoms or “pins and needles” and “electricity” in the affected limbs).Note: Cognitive dysfunction does not exclude ALSArreaza: What are the diagnostic criteria for ALSAdriana: Gold Coast Criteria 2019 proposed over El Escorial criteria:Progressive upper and lower motor neuron symptoms and signs in one limb or body segment, ORProgressive lower motor neuron symptoms and signs in at least two body segments, ANDAbsence of electrophysiologic, neuroimaging, and pathologic evidence of other disease processes that might explain the signs of lower and/or upper motor neuron degeneration.Arreaza: What diagnostic tests should be ordered for further evaluation?Adriana: Electrodiagnostic studies: Electromyogram and nerve conduction studies (EMG and NCS)Laboratory testing: creatine phosphokinase up to 1000u/LNeuroimaging: to exclude other causes mainly. Brain MRI whenever bulbar disease is present. Cervical and lumbosacral spine MRI for LMN findings in the arms and legs.Genetic testing: FALS 10% of ALS defect in C9ORF72 gene that makes motor neuron and brain nerve cell protein, the exact cause is unknown. Arreaza: Finally, how do you treat ALS?Adriana: Disease-modifying treatment: Riluzole is recommended for all patients with ALS. Shown to prolong survival and slow functional deterioration. The mechanisms of action that reduce glutamate-induced excitotoxicity: 1) inhibit glutamic acid release, 2) non-competitive block of N-methyl-D-aspartate (NMDA) receptor-mediated responses, 3) direct action on the voltage-dependent sodium channel. Arreaza: Riluzole is given 50 mg by mouth twice a day. It may cause drowsiness or somnolence, hepatic injury: Not recommended for patients with elevation of transaminases >5 times the upper limit of normal. It is recommended to monitor for hepatic injury and discontinue if there is evidence of liver dysfunction, such as hyperbilirubinemia.Adriana: Symptom-based management is the mainstay of treatment. You may involve a multidisciplinary team to treat the symptoms. For example: palliative, hospice, respiratory function management (Noninvasive Positive Pressure Ventilation vs mechanical ventilation.Arreaza: PCPs may be in charge of managing symptoms because you are the closest provider to the patient. Wherever available, it is recommended to refer your ALS patients to a specialized center. Many patients do not have availability to an ALS center or a neurologist, but they have you to manage their symptoms or complications.Adriana: Dysphagia: It is a common and distressing symptom. It is suggested PEG tube placement for patients with ALS with normal or moderate respiratory function who have dysphagia. It is controversial, some studies found no benefit on survival or quality of life and other studies suggest that it is safe to give a high-carb, hypercaloric diet to ALS patients. Arreaza: Spasticity: Use medications such as baclofen and tizanidine may be helpful, and botulinum injections are an option for those who are not responding to oral muscle relaxants. Adriana: Sialorrhea: Use medications such as atropine, hyoscyamine, amitriptyline, and scopolamine. If these medications are not effective or tolerated, used botox injections into the salivary glands. It is considered safe and useful for treating sialorrhea in patients with ALS. Botox is not only for wrinkles!Arreaza: There are many other symptoms that will require management, but you are invited to review your preferred source of information such as Up to Date, AAFP, or the ALS Association website. ______________________________Conclusion: Now we conclude episode number 152, “ALS Fundamentals.” You heard from future Dr. Rodriguez that ALS can present with upper motor neuron symptoms, such as spastic muscles and hyperreflexia; or lower motor neuron symptoms, such as flaccid and weak muscles. Some other symptoms include dysphagia, shortness of breath, difficulty talking, fatigue, thick mucus, and pseudobulbar affect. Dr. Arreaza explained that primary care physicians are in a special situation to help diagnose and treat the symptoms of ALS, especially in communities with limited access to an ALS center. You may need to involve a multidisciplinary team to improve the quality of life and possibly the survival of ALS patients. This week we thank Hector Arreaza and Adriana Rodiguez. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Galvez-Jimenez, Nestor and Colin Quinn, Symptom-based management of amyotrophic lateral sclerosis, Up To Date, updated on July 31, 2023. https://www.uptodate.com/contents/symptom-based-management-of-amyotrophic-lateral-sclerosis. Royalty-free music used for this episode: Good Vibes: Sky's The limit, downloaded on July 20, 2023 from https://www.videvo.net/ 

Episode 151: Martian Medicine 102Future Dr. Collins discussed with Dr. Arreaza two common complications of astronauts in a hypothetical travel to Mars: Spaceflight-Associated Neuro-ocular Syndrome and mental illness.  Written by Wendy Collins, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: We are back for another episode of Martian Medicine! A couple months ago we published the episode Martian Medicine 101. We talked about radiation and its health risks for astronauts going beyond Low Earth Orbit such as a crew going to Mars. Today, we are going to be covering Martian Medicine 102, where we discuss some more risks from the article “Red risks for a journey to the red planet”. So, let's just jump into it! The next risk we are going to talk about is Spaceflight-Associated Neuro-ocular Syndrome or SANS.  Wendy: Yes, so this used to be called Vision Impairment Intracranial Pressure because the syndrome affects astronauts' eyes and vision and can appear like idiopathic intracranial hypertension. But the name changed to SANS because is not associated with the classic symptoms of increased intracranial pressure in idiopathic intracranial hypertension such as severe headaches, transient vision obscurations, double vision, and pulsatile tinnitus. Also, it has never induced vision changes that meet the definiti on of vision impairment, as defined by the National Eye Institute. Its name change also reflects that the syndrome can affect the CNS well beyond the retina and optic nerve. Arreaza: Let's talk about SANS some more. SANS presents with an array of signs including edema of the optic disc and retinal nerve fiber, and what else?Wendy: Edema of chorioretinal folds, globe flattening, and refractive error shifts. Flight duration is thought to play a role in the pathogenesis of SANS, as nearly all cases have been diagnosed during or immediately after long-duration spaceflight such as missions of 30 days duration or longer. But signs have been discovered as early as mission day 10. SANS has been studied in ISS crewmembers who are tested with optical coherence tomography (OCT), retinal imaging, visual acuity, a vision symptom questionnaire, Amsler grid, and ocular ultrasound.Arreaza: About 69% of the US crewmembers on the ISS experience an increase in retinal thickness in at least one eye, indicating the presence of optic disc edema. This can cause an astronaut to experience blind spots and reduced visual function. Fortunately, to date, blind spots are uncommon and have not had an impact on mission performance.Wendy: And chorioretinal folds if severe enough and located near the fovea, an astronaut can experience visual distortions or reduced visual acuity that cannot be corrected with glasses or contact lenses. Fortunately, and despite a prevalence of 15–20% in long-duration crewmembers, chorioretinal folds have not yet impacted astronauts' visual performance during or after a mission.  Arreaza: A change in your glasses prescription is due to a change in the distance between the cornea and the fovea, and it occurs in about 16% of crewmembers during long-duration spaceflight. This risk is reduced by giving crewmembers with several pairs of “Space Anticipation Glasses” (or contact lenses). The crewmember can then select the appropriate lenses to correct visual acuity. Wendy: From a longer-term perspective, SANS presents two main risks to crewmembers: optic disc edema and chorioretinal folds. It is unknown if a multi-year spaceflight like that to Mars will be associated with a higher prevalence, duration, and/or severity of optic disc edema compared to what has been experienced onboard the ISS. Since the retina and optic nerve are part of the CNS, if optic disc edema is severe enough, the crewmember risks a permanent loss of optic nerve and retinal nerve fiber tissue and thus, a permanent loss of visual function. But again, no astronaut has experienced SANS-related permanent vision loss and choroidal folds usually improved post-flight in affected crewmembers. Arreaza: It is important to understand the pathogenesis of SANS. In microgravity, fluid can distribute uniformly. The fluid that normally pools in your legs due to gravity can now move to your head and cause congestion of the cerebral veins. The pathophysiology of SANS is that CSF outflow can be blocked, which increases intracranial pressure. Wendy: There can be confounding variables such as exercise, high-sodium dietary intake, and high carbon dioxide levels. It is difficult to know much about SANS because there are not many crewmembers who have completed long-duration spaceflight. There is now enough evidence to state that SANS is not a male-only syndrome. Optical Coherence Tomography (OCT) has been used on the ISS since 2013, and it has allowed NASA to build a database of retinal and optic nerve images to understand SANS better. Research from this has shown that most long-duration astronauts present with some level of optic disc edema.Arreaza: Now all NASA crewmembers receive pre- and post-flight MRIs of the brain. There is evidence that brain changes structure with longer space flights. For example, the ventricles of the brain enlarge with 2–3 mL of CSF in astronauts. Luckily, there has been no cognitive problems with this. Like with most space health concerns, more research is needed. Wendy: In summary, SANS is a red risk and top priority to NASA and the human research program. The main concern with SANS is optic disc edema because it could lead to permanent vision impairment. And choroidal folds are also concerning for both short- and long-term flights. But for now, loss of visual acuity is successfully combatted with glasses. Certainly, the more astronauts and flights we take, the more we will learn about SANS.Wendy: Sorry we took so long on SANS, it's probably one of my favorites of all the red risk. Now let's move onto the red risk that includes behavioral health and performance. Future long duration mission in which you are in an isolated and confined space such as a space craft surrounded by an inhospitable environment which humans are not meant to survive could be a problem for the crew's behavioral and mental health. Arreaza: This could affect the astronauts and their ability to complete their mission. Typically, astronauts enjoy space and report it is a positive experience. But psychological changes from being in space for a long time will likely be even more challenging. Wendy: In the past, astronauts have reported ‘hostile' and ‘irritable' crew and symptoms of depression. Arreaza: Stressors to the ISS include long work hours and high workload, and the discomfort of space motion sickness. No one likes vomiting.  Wendy: Being on the ISS, you are close to Earth, and it is easy to communicate with family and friends when needed. Going to Mars there will be communication delay and will make support more difficult. Astronauts on the ISS also have routinely received care packages, which will also not be available to boost morale. Crew members can also change by swapping out astronauts over a certain period, but the crew to Mars will also not have this ability to work with new people.  Arreaza: There are simulation projects to test human resilience. NASA does these kinds of testing at the Johnson Space Center. There is also research in Antarctica that has shown decreased mood and increased stress for scientists in extreme environments. There is also the Mars 500 mission.  Wendy: Yes, the Mars 500 mission was where a crew of 6 went into isolation in Moscow for 520 days to simulate a trip to Mars. The astronauts had to complete behavioral questionnaires weekly. One of the six reported depressive symptoms based on the Beck Depression Inventory. Two crew members who had the highest ratings of stress and exhaustion, also reported conflicts and sleep difficulties. Two crew members reported no adverse behavioral symptoms during the mission.Wendy: So, I believe we're done. We've covered Radiation, SANS, and behavioral health. I know this topic is probably unique for qWeek, but a lot of what we learn medically from our time in space does have applications to us on Earth. As a medical student advice, I have gotten from others in the field is pursue what you're passionate about. Aerospace medicine is a growing field for clinicians from all specialties, so there's no golden path to take. If you are interested more in this field, I highly recommend joining relevant associations specifically AsMA and AMRSO. And if you ever want to discuss aerospace medicine further, feel free to reach out to me at my Ross email!______________________Conclusion: Now we conclude episode number 151, “Martian Medicine 102.” Future Dr. Collins explained that ocular issues are a potential problem when astronauts go to Mars, including Spaceflight-Associated Neuro-ocular Syndrome and vision impairments that would require changes in glass prescription, so, don't forget to take extra pairs of glasses when you go to the red planet. Dr. Arreaza also joined the conversation by talking about the mental health challenges that many astronauts may face as they embark on a long trip to Mars in a secluded spacecraft. We look forward to more information on Martian Medicine as primary care on Mars may look surprisingly similar to primary care on Earth.This week we thank Hector Arreaza and Wendy Collins. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Patel, Z.S., Brunstetter, T.J., Tarver, W.J. et al. Red risks for a journey to the red planet: The highest priority human health risks for a mission to Mars. npj Microgravity 6, 33 (2020). https://doi.org/10.1038/s41526-020-00124-6Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022, from https://freemusicarchive.org/music/Scott_Holmes/. 

Episode 150: Re-update on COVID Vaccines and Cervical CancerCOVID vaccines have been updated (again). The bivalent m-RNA COVID-19 vaccines are no longer authorized in the US. Sabrina explains that the monovalent COVID-19 vaccines will be available soon to target XBB lineage and more. Future Dr. Rodriguez explains the USPSTF cervical cancer screening guidelines. Dr. Arreaza adds comments and insight.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Celebrating our episode 150.Written by Hector Arreaza, MD.In our previous episode, we gave you an update on COVID-19 vaccines, but we need to give a new update. This is the risk you take when you try to become a news agency instead of an educational podcast, so you need to keep giving updates, and we'll tell you about the newest change in COVID-19 vaccines in a few minutes. This is episode number 150! And I wanted to take a moment to celebrate this milestone. Our first episode was released a few days before the lockdown for COVID-19 on March 3, 2020. Those were gloomy days. I was excited about having a weekly podcast, but I also was overwhelmed by COVID-19. I remember considering putting a hold on the podcast, but I decided to continue. We had a few episodes about COVID-19 and, as expected for a novel disease, we made some mistakes. For example, we gave the wrong recommendations to not wear a mask at the very beginning of the lockdown, but that was the initial recommendation. However, I got to accentuate the positive, I'm proud that we were probably the first place to report hiccups as a symptom of COVID. Soon I realized it would be impossible to keep up with the daily changes in recommendations and updates on COVID, so we focused on other topics, and it has been a great experience so far. This podcast was created for the Rio Bravo residents, and thankfully the medical students have become the main collaborators of this program. I have enjoyed every second I have spent with all our guests, including residents, nurses, medical assistants, specialists, scientists, and of course medical students. I feel very fortunate to have reviewed many relevant topics of family medicine with you. A colleague once mentioned to me that I may run out of topics, but I think it is impossible to run out of topics in family medicine, don't you think? So, I'm hoping to continue bringing to you brief discussions and pearls of knowledge every week. Now, let's listen to Sabrina.Re-update on COVID-19 Vaccines.Written by Sabrina Hawatmeh, MSIII, Ross University School of Medicine.Hi, my name is Sabrina Hawatmeh, I'm a 3rd-year medical student from Ross University School of Medicine. I'm so excited to be here today, huge thank you to Dr. Arreaza for having me here today! As mentioned by Dr. Arreaza, during our episode 149 we gave you an update on COVID-19 vaccines and now today it's time for a new update. Most recently, Pfizer/BioNTech and Moderna have updated their vaccines to target specific strains of the virus, and the American Academy of Family Physicians has given its approval to federal actions allowing the use of these updated vaccines for the Fall/Winter of 2023. The decision follows FDA approval for these vaccines for children and adults aged 12 and older, as well as CDC recommendation of emergency use authorization for children aged 6 months to 11 years. The AAFP's Board Chair, Sterling Ransone, M.D., accepted the recommendation to approve these actions as of September 14th, 2023. The vaccines may be available soon for administration. Bivalent vaccines were the most recent formula administered for immunization. Studies had shown that there was continued protection against circulating sublineages of Omicron and XBB.1.5. However, the vaccine effectiveness against Omicron decreases over time. Neutralizing antibody titers against XBB sublineages via bivalent vaccines are lower compared to titers induced by the matched BA.4/BA.5 sublineage. So, it makes sense that all this data suggested that vaccine modification be directed toward more closely matched strain composition to current circulating sublineages. I also think it's worth noting that the original version of Omicron is no longer circulating—neither is the original strain of the SARS-CoV-2 virus. For that reason, updated vaccines were created by Moderna and Pfizer/BioNTech, so the bivalent vaccines are no longer authorized for use in the United States. The updated vaccine recommendations include eligibility criteria for different age groups, regardless of previous vaccination status, and specify the number of doses needed. The CDC has also updated its vaccine recommendations, especially for moderately or severely immunocompromised individuals. The new vaccines are monovalent mRNA vaccines, designed to protect against omicron subvariant, XBB 1.5. While the subvariant XBB.1.5 is the target of the vaccines, the expectation is that they will offer immunization against multiple current strains. (XXB lineage, EG.5.1 (Eris), Fl.1.5.1 (Fornax), BA.2.86). Moderna (randomized controlled trial of 101 individuals) and Pfizer (mouse studies) evidence suggests that the vaccines will also serve to protect against the new mutated subvariant that has recently sparked some concern, BA.2.86. As a reminder, FDA granted emergency use authorization for Novavax COVID-19 vaccine, Adjuvant in July 2022 for the prevention of COVID-19 pneumonia in patients aged 12 and older. Now the updated Novavax formula for 2023-2024 (targeting the XBB strain) was authorized by CDC on September 12, 2023, but it is still under review by the U.S. FDA for emergency use authorization for individuals aged 12 and older. When authorized, Novavax's protein-based vaccine will be the only non-mRNA COVID vaccine available in the U.S. These updated vaccines are expected to be covered by most public and private insurance plans, but concerns have been raised about uninsured individuals having to pay out of pocket for the vaccines, which cost $120 to $130. The AAFP urged the government to ensure equitable access and financial support for primary care practices offering these vaccines.Cervical Cancer Screening Guidelines. Written by Adriana Rogriguez, MSIV, Ross University School of Medicine.Arreaza: Cervical canceris the 3rd most common gynecological cancer in the US. For 2023, the American Cancer Society estimates that about 13,000 new cases of cervical cancer will be diagnosed, and more than 4,000 women will die this year. Cervical cancer was once one of the most fatal types of cancer in women, but the mortality rate has been significantly decreased with the increased use of pap smears and the HPV test. Adriana: Another fun fact is that cervical cancer is the only cancer preventable by a vaccine—the HPV vaccine.Arreaza: Why is cervical cancer screening important?Adriana: Cervical Cancer screening is very important as it reduces mortality due to cervical disease. Intervention at early stages reduces the development of squamous cell carcinoma or adenocarcinoma of the cervix due to HPV. In fact, studies have shown that in resource-poor settings, one cervical screening reduces the incidence of cervical cancer by up to 50%. Arreaza: What would prevent a patient from wanting to get a Pap smear?Adriana: Many things can and do deter a patient from obtaining their cervical cancer screening. Patient discomfort and the psychosocial consequences of performing these screenings such as anxiety should be taken into consideration. Personal example. Also, a patient may be concerned about the costs, the effects of false-positive results, the risks of treatment during pregnancy (ex., increased risk/o 2nd-trimester pregnancy loss, PPROM, preterm delivery, perinatal mortality). Arreaza: We should mention the cultural implications of a pap smear in a 21-year-old who is considered a “virgin”. Some cultures try to preserve the hymen intact as a sign of purity. You can address this concern with your patients and explain that a hymen is not always present, it may be easily ripped by sports, biking, tampon use, and more. A small speculum may be used for your patients who have never been sexually active at age 21. Arreaza: We perform screening BEFORE we diagnose a disease. The age of diagnosis of cervical cancer is age 50, most patients fall between 35 and 45 years old. How can we determine who is at risk and needs a pap smear? Adriana: When looking at cervical screening guidelines and recommendations, we are looking at the patient who is: At average risk for cervical disease – a patient who is asymptomatic, immunocompetent, and has had all previous cervical cancer screening results within normal limit.At sufficiently low-risk for cervical disease and can return to routine age-based screening: 

Episode 149: COVID Vaccines UpdateFuture Dr. Williams presented an update on COVID-19 vaccines. This update is only for immunocompetent individuals, and it was recorded on August 24, 2023. Dr. Arreaza added comments and insight.  Written by John Williams, MS4, Ross University School of Medicine. Editing by Hector Arreaza, M.D.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Currently, there are two types of vaccines that have been approved by the FDA:Moderna and Pfizer developed mRNA vaccines.Novavax developed a lesser-known protein subunit vaccine.As of May 6, 2023, the vaccine developed by Johnson & Johnson has expired and is not available in the U.S.Novavax: This vaccine contains pieces (proteins) of the virus that causes COVID-19, the spike protein plus an adjuvant. It works by activating the immune system against the spike protein, so it will be ready to fight the actual virus when you get infected. Regardless of vaccine type, the shots are administered in the upper arm and have been demonstrated, for most people, to be safe and effective. There have now been hundreds of million vaccines administered in the US alone and the effectiveness of the vaccine to reduce the risks of severe illness, hospitalization, and death has been well documented. The most common side effects consist of mild to moderate cases of fever, chills, headache, and tiredness that are self-resolving.What is new about COVID-19 Vaccines?The updated vaccine is known as “bivalent”. This term is important because it refers to the vaccine's ability to confer protection against both the original COVID-19 virus as well as new variants Omicron BA.4 and BA.5. Rollout of the updated vaccine began in September 2022 for those aged 12 years and older and became widespread in March 2023 with approval granted for use in children aged 6 months – 4 years. Selected individuals over age 65 or those who are immunocompromised may receive additional doses to provide comparable and safe protection. The receipt of the updated vaccine supersedes any previous doses and provides coverage against the most recent known variants determined to be either most widespread or that have been projected to be more prevalent.Children aged 6 months – 4 years who received the original Pfizer vaccineThose who received either 2 or 3 doses of the original vaccine should receive 1 dose of the updated vaccine.Those who received 1 dose of the original vaccine should receive 2 doses of the updated vaccine.You are considered up to date if you have received 3 vaccine doses, including at least 1 updated dose.Children aged 5 years who received the original Pfizer vaccineThose who received 1+ doses of the original vaccine should receive 1 dose of the updated vaccine.You are considered up to date if you have received at least 1 updated dose.Children aged 6 months – 4 years who received the original Moderna vaccineThose who received either 2 or 1 dose(s) of the original vaccine should get 1 updated vaccine.Children aged 5 years who received the original Moderna vaccineThose who received either 2 or 1 dose(s) of the original vaccine should get 1 updated vaccine.Unvaccinated children 6 m-4 years should receive the new bivalent vaccine, 2 doses ofModerna or 3 doses of Pfizer, but if you are 5 years old and unvaccinated, you will receive 1 dose of Pfizer or 2 doses of Moderna.For 6-11 yo patients who have been vaccinated with 1 or more doses of monovalent (Moderna or Pfizer) will receive 1 dose of Bivalent Moderna or Pfizer. If you already received 2 monovalent doses and 1 bivalent dose, you are done, no more vaccines are needed. If you have not received any COVID-19 vaccine and you are in this age group (6-11 yo), you only need 1 bivalent dose, and you are done.>12 yo and Adults. If you received 1 or more doses of monovalent or if you are not vaccinated, you need 1 dose of bivalent (Pfizer or Moderna). If you already had 2 doses of monovalent and 1 dose of bivalent, you are done!An FDA advisory committee convened on June 15, 2023, to discern the importance for additional updates to the most recent COVID-19 vaccine series. It was determined that the latest circulating variant currently making rounds is from the Omicron group known as XBB. The committee decided it is prudent to proceed with a preference for the XBB 1.5 variant. The updated vaccine will be a monovalent version available in the Fall of 2023. As with the previous version, the FDA will provide strict oversight and safety monitoring of the vaccine._______________________________Conclusion: Now we conclude episode number 149, “COVID Vaccines Updates.” Future Dr. Williams explained that the bivalent COVID vaccines are currently recommended for unvaccinated patients, or for those who were previously vaccinated with monovalent vaccines. This episode focused on patients who are NOT immunocompromised. We encourage our audience to check the CDC website for recommendations about patients who are immunocompromised.As a clarification, our sub-intern, John Williams, has a great sense of humor and he claimed to be the composer of the music for many famous Hollywood movies. We don't doubt his musical talent, but we must make clear that it was a joke! This week we thank Hector Arreaza and John Williams. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Tin, Alexander, New COVID vaccine and booster shots for this fall to be available by end of September, CBS Texas, published online on August 9, 2023. https://www.cbsnews.com/texas/news/covid-vaccine-booster-xbb-variants-september-2023/, accessed on September 7/, 2023.Center for Disease Control and Prevention, Overview of COVID-19 Vaccines, updated May 23, 2023, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/overview-COVID-19-vaccines.html, accessed on September 7, 2023.Updated COVID-19 Vaccines for Use in the United States Beginning in Fall 2023, United States Food and Drug Administration. https://www.fda.gov/vaccines-blood-biologics/updated-covid-19-vaccines-use-united-states-beginning-fall-2023, accessed on September 7, 2023.Royalty-free music used for this episode: Gushito - Latin Chill. Downloaded on July 29, 2023, from https://www.videvo.net/  

Episode 148: Leg CrampsFuture Dr. Weller explains the pathophysiology, management, and prevention of leg cramps. Hector Arreaza adds comments and anecdotes about leg cramps.  Written by Olivia Weller, MS4, American University of the Caribbean School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition: Known also as “Charlie horses,” leg cramps are defined as recurrent, painful, involuntary muscle contractions. They can last anywhere from seconds to several minutes, with an average of nine minutes per episode. They are usually nocturnal and thus may be associated with secondary insomnia. Location: A muscle cramp can happen in any muscle in the body, but they occur most commonly in the posterior calf muscles, but they can also involve the thighs or feet. They are more common in women than men and the risk increases with age.Although they are experienced by 7% of children and up to 60% of adults, the exact mechanism remains unknown and there is no definitive treatment at this time. PathophysiologyThere is one leading hypothesis for nocturnal cramps that occur in the posterior calf muscles, and it is related to your sleeping position. When you are laying down in bed your toes are pointed which causes passive plantar flexion while the muscle fibers are shortened maximally. This causes uninhibited nerve stimulation with high-frequency involuntary discharge from lower motor neurons, which causes cramping. Another possible etiology is nerve damage because neurologic conditions such as Parkinson's disease are associated with a higher-than-normal incidence of cramps. Peripheral neuropathy, or damage to the connection between motor nerves and the brain can lead to hyperactive nerves when they are not being properly regulated. Thus, diabetes mellitus is a major risk factor for nocturnal cramps due to the high blood sugar levels damaging the small blood vessels which supply the muscles. Decreased blood flow has also been attributed as a cause of leg cramps. People with diseases that affect their vasculature, such as varicose veins or peripheral arterial disease also have a higher incidence of leg cramps. Decreased blood flow to the muscles means less delivery of oxygen and nutrients to the muscles which makes them more susceptible to fatigue. Muscle overuse is one of the dominant explanations for cramping. This can be related to doing too much high-intensity exercise without adequate stretching before and after. Pregnant women have added weight which puts extra strain on the muscles, along with sitting or standing for long periods of time, poor posture and flat feet. Notably, when we age, our tendons naturally shorten and they cannot work as hard, or as quickly which makes them more susceptible to overuse. Additionally, there are mineral deficiencies such as magnesium and potassium or decreased levels of B and D vitamins. With this in mind, people with renal failure that are on hemodialysis have an increased risk of nocturnal leg cramps. And finally, we have medications, some of which are related to mineral deficiencies. The main contributors are statins, diuretics, conjugated estrogens, gabapentin or pregabalin, Zolpidem, clonazepam, albuterol, fluoxetine, sertraline, raloxifene, and teriparatide (analog for parathyroid hormone). Management and preventionThere is no magic treatment to make them go away immediately, however, there are different remedies you can try to help facilitate. My Grandma told me about an old wives' tale, that if you put a bar of soap in your bed at your feet while you sleep, you won't get cramps at night. Maybe it works by the placebo effect, maybe there's a mechanism going on there I don't understand who knows, I'll have to do a study on it. If you get them very often, you can keep a foam roller or a heating pad next to your bed in preparation for when they come. Stretching the muscle is known to be very effective, as well as applying heat or ice to the affected area. You can also try massaging the muscle with your hands or getting out of bed to stand or walk around. Elevating the leg while laying down in bed can also be beneficial. In terms of prevention, you can try out different sleeping positions to see if one works better for you. If you usually sleep on your back, you can stick a pillow under your feet to help keep your toes pointed upward. Or, if you sleep on your stomach you can try to keep your feet hanging off the bed. Another tip is loosening the sheets or blankets around your feet. Daily stretching, especially before and after exercise as well as before bed is useful. Make sure to exercise, stay hydrated, and limit your alcohol and caffeine consumption. You also want to wear supportive shoes or use orthotic inserts in your shoes, especially if you spend lots of time on your feet during the day. Medications/supplements: Since various deficiencies can cause cramps, one way to prevent them is to take supplements such as magnesium, vitamin D, and B12 complex. And as a last resort, you can try medications. Calcium channel blockers such as diltiazem or verapamil have been used, and muscle relaxants including Orphenadrine (Norflex®) and Carisoprodol (Soma®). Gabapentin is an anticonvulsant commonly used as a neuropathic pain medication; this used to be used to treat leg cramps but later it was found that they can actually increase the frequency of muscle cramps so they are no longer used. Quinine was also used for many years to treat leg cramps; however, it is no longer recommended because of drug interactions and serious hematologic effects such as immune thrombocytopenic purpura (ITP) and hemolytic uremic syndrome (HUS). Summary: Leg cramps are common, the pathophysiology is unclear, but may be related to problems with blood flow, the nervous system, sleeping position, and muscle overuse. Treatment includes nonpharmacologic therapies such as changes in sleeping position, heat, and massaging; and medications/supplements that may be useful include Carisoprodol (Soma®), diltiazem, gabapentin (Neurontin), magnesium, orphenadrine (Norflex®), verapamil, and vitamin B12 complex.____________________________Conclusion: Now we conclude episode number 148, “Leg Cramps.” Future Dr. Weller explained that the etiology of leg cramps is multifactorial. Some theories about why leg cramps happen include poor circulation, muscle overuse, dysfunctions in the nervous and musculoskeletal systems, electrolyte imbalances, mineral deficiencies, and more. Some therapies were discussed, including changes in position while sleeping, massage, heat pads, and medications such as calcium channel blockers, muscle relaxants, and supplements of magnesium and Vitamin B12. Gabapentin is a medication that can cause leg cramps, but some sources recommend it as a treatment as well. This week we thank Hector Arreaza and Olivia Weller. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Leg Cramps. Cleveland Clinic. (2023, May 6). https://my.clevelandclinic.org/health/diseases/14170-leg-crampsAllen, R. E., & Kirby, K. A. (2012, August 15). Nocturnal leg cramps. American Family Physician. https://www.aafp.org/pubs/afp/issues/2012/0815/p350.htmlMayo Foundation for Medical Education and Research. (2023, March 2). Night leg cramps. Mayo Clinic. https://www.mayoclinic.org/symptoms/night-leg-cramps/basics/definition/sym-20050813Royalty-free music used for this episode: Simon Pettersson - Good Vibes_Sky's The Limit_Main. Downloaded on July 29, 2023, from https://www.videvo.net/ 

Episode 147: Routine Prenatal CareWritten by Elika Salimi, MSIV. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice._____________________Elika: So, we're going to talk about some general principles of prenatal care and some of the most important diagnostic methods that we mainly use for taking care of pregnant women. I will forewarn you that there will be a ton of details in this talk, and I do recommend possibly taking notes as things can get easily confusing. This way you can have something to refer back to whenever you have a pregnant patient of your own.Arreaza: You can also download the episode notes from our website.Elika - So your patient is pregnant and she comes to you for care. How do we go about it? Well, this is assuming she had it at home urine pregnancy positive test and we got a blood hCG on her and everything's good and we know she's pregnant. Ok so now what happens next?Arreaza – We need to confirm the patient wants to keep the pregnancy.Elika - First, we're going to talk about the frequency of the check-ups. In this case, we are talking about a situation where the mother is coming to her appointments as she was supposed to but we all know that sometimes that doesn't happen if everything is going as it is supposed to then typically we get the initial examination at about 10 weeks of gestation and then until the 28th week there should be monthly visits, then from the 28th through the 36th there should be biweekly visits, and from the 36th week until birth, the visits are every week.Areaza – What´s next?Elika - Now I'd like to note that during the prenatal period, informed consent is very important and it should be obtained during this time because you want to prevent and manage any ethical conflicts that might exist between the mother and possibly the healthcare providers because we all know that any pregnancy can become high-risk at some point and pregnant individuals should be informed about the potential need for a c-section for example and be encouraged to discuss any concerns ahead of time. Elika - Now while we're talking about ethics, if the doctor finds him/ or herself in a situation where the patient is asking for something that the Dr does not feel comfortable with such as a certain type of treatment or a certain method of delivery or if they're, let's say, desiring an abortion and the doctor doesn't do abortions, then in this case you would refer the patient to a physician that is comfortable with the patient's desired outcome or treatment. And this is perfectly legal and fine just as long as you help the patient find somebody else. Arreaza – Abortion is legal in most states, but check your local regulations.Elika - So as mentioned earlier, the initial visit occurs at about 10 weeks of gestation. We start with checking their personal and family history and finding out about any previous pregnancies including at what GA baby born and weight if they know, any complications, gestational diabetes or preeclampsia, any history of postpartum hemorrhage requiring blood transfusion, any abortions (if present at what GA), and the method of deliveries, whether it was vaginal or a cesarean and what kind of C-section they had done. These are very important for you to obtain from your patient. You will also assess for depression and domestic partner violence.Arreaza – In California, we have a wonderful service called CPSP: Comprehensive Perinatal Services Program. What comes next? Elika - Upon receiving the history, we will do the gynecological examination and send in some samples. We will also send her to do some lab work. Now what do those labs entail? Well, we are going to get a CBC such as screening for anemia, we will also do TSH but only in people who have possible signs of thyroid disorder so not everybody needs to get this. And, we are going to send for a blood typing to find out about their ABO group and the Rhesus status. We will also obtain a urine analysis to screen for proteinuria and asymptomatic bacteriuria because in pregnancy, unlike outside of pregnancy, you do need to treat asymptomatic bacteriuria. We will also ensure that the mother is on prenatal vitamins, so folic acid, if not already, and iron, if indicated, and vitamin B6 if the patient has signs of nausea or hyperemesis gravidarum and this can be combined with doxylamine. Usually, pregnant women don't get a glucose screening test at the first visit unless let's say they have high risk of diabetes or they there was glucose in the urine. Arreaza – I like the topic of diabetes in pregnancy. So, in a high-risk population, we want to make sure a pregnant patient does not have diabetes, or pregestational diabetes.Elika - We will also screen for STI's including HIV, syphilis, hepatitis B, Hep C, and we also check for gonorrhea and chlamydia (pap) screening particularly in those under 25, or over 25 with high risk of infection. We will also test for rubella and varicella. Some places also order a QuantiFERON gold for tuberculosis. There are certain women that have indications for third-trimester screening for STI's on top of the ones that they already got in their first trimester. Those include chlamydia, gonorrhea, HIV, syphilis, and Hep B, and C but each of those have its own indications so for the purposes of time I will let you look that up on your own.Arreaza – Summary: Physical exam and labs to rule out preexisting conditions that may interfere with pregnancy, either infectious or metabolic, to mention some diseases. Elika - And finally, we will do an ultrasound assessment to get a more accurate reading of the fetus's gestational age.Arreaza – What comes after the first trimester?Elika- So like I mentioned they're going to need to be following up and some particular things need to be done at specific weeks. So we are going to discuss those. At every follow visit you need to obtain: the patient's weight, BP and other vitals, fetal heart sounds, the baby's measurement from the mother's pubic symphysis up until the fundus of the uterus, as well as a urine analysis to check for any glucose or protein in the urine because we are always concerned of possible preeclampsia or gestational diabetes. Another examination that I should mention is a Doppler ultrasound and this is usually indicated if there is suspected fetal growth restriction or if there's pregnancy-induced hypertension or if there's suspected fetal deformities or there is growth discordance in multiple pregnancies.Now we are going to discuss assessing for any abnormalities in the fetus. All pregnant women regardless of age should be offered noninvasive and aneuploidy screening test before 20 weeks of gestation. The 1st trimester combined screening occurs at about 10 to 13 weeks gestation, where we can order some blood tests for the mom such as the amount of hCG in maternal serum, as well as PAPP-A, on top of nuchal translucency that will see on the ultrasound. There is also the triple screen at 15-20 weeks which consists of ordering hCG, alpha-fetoprotein aka AFP, and estriol then there's also the quad screen test at 15-22 weeks gestation that consists of hCG, AFP, Estriol and Inhibin A. We also have the cell free fetal DNA testing that can occur after 10 weeks gestation at which the fetal DNA is isolated from the maternal blood specimen for genetic testing and this one actually happens to be the most sensitive and specific screening test for common fetal aneuploidies, and it is used for secondary screening after the ultrasound.Arreaza – Actually that test is done in all our patients on Medi-Call (cfDNA).Elika - If any of the screening tests are abnormal then we can provide counseling to mothers for more invasive diagnostic tests such as chorionic villus sampling, amniocentesis, and cordocentesis. At that point, you want to refer the patient to perinatology. Finally, in general an anatomical scan occurs ~18-22 weeks. Arreaza – Excellent, we have done the non-invasive genetic screening. What's next? Elika - Now we are going to talk about what happens in the third trimester specifically and what test you need to order. In the third trimester, you will order a CBC again, particularly at 24 weeks you want to do a repeat hemoglobin. We will also do the indicated repeat STI checks. We are also going to do gestational diabetes screening with the oral glucose test that I briefly mentioned earlier at around 24-28 weeks. This is usually done with a 50g 1 hr glucose tolerance test and if abnormal then a 100g 3 hour glucose test. You will also be repeating the Rh antibody just to make sure that the mother is still Rh negative because at 28 weeks, Rh negative mother should be administered RhoGAM 300 mcg intramuscularly and they need to get it again within 72 hours of delivery. Don't forget to give a TDAP vaccine at 27 weeks. And at 36 weeks you need to be obtaining a GBS culture (vaginal and rectal) for the patient just to make sure that there is no colonization because if there is then the patient is going to need GBS prophylaxis at admission because colonization by these bacteria can cause chorioamnionitis and neonatal infection such a sepsis. Overall when third trimester approaches you're going to make sure the plans for delivery have been properly scheduled or discussed with the patient and typically around 34 weeks you also want to check with your patient to see if they desire sterilization and obtain a consent if they will be having a C-section and they want to be sterilized after that. In those not requesting sterilization, it is a good idea to discuss what they want to do after this pregnancy for birth control since it is not safe to get pregnant again for another year. From 36 weeks' gestation, use Leopold maneuvers for assessment of fetal presentation but I'll let you look that up on your own. At this time, you may also use ultrasound as needed to confirm fetal lie and placental position.Patients with maternal conditions such as gestational diabetes or gestational hypertension/pre-eclampsia, or fetal condition such as heart defects or fetal growth restriction need to get biweekly NST/BPP tests at clinic in the third trimester because there is an increased risk of fetal hypoxic injury or death. An NST is basically a non-stress test that measures fetal heart rate reactivity to fetal movements. BPP /biophysical profile is a noninvasive test that evaluates the risk of antenatal fetal death usually after the 28th gestational week and what it consists of is the ultrasound assessment of fetal movement, fetal tone, fetal breathing, and amniotic fluid volume or we can also perform a contractions stress test that basically measures fetal heart rate reactivity in response to uterine contractions. Arreaza – I like talking about obesity. Weight gain is expected during pregnancy. Patients with normal weight are expected to gain 25-35 pounds. Patients with obesity are recommended to gain 11-20 only.Summary: Now I know that this was very extensive talk with a ton of details but if you took notes and refer back to it then I think things will somewhat make more sense and come together that way. The best thing we can do is try to adhere to guidelines to make sure that we don't miss anything. Sometimes it could be particularly difficult to manage patients that don't or can't come to their appointments regularly and you may sometimes have to give them bad news and what not so overall it is not always happy moments we face but the best we can do is try to give them the best care possible to avoid complications and have the patient deliver a healthy baby. Thank you for listening to me once again and hopefully I'll be back again soon on another talk on an OB/GYN related topic soon. Thank you very much. _____________________Conclusion: Now we conclude episode number 147, “Routine Prenatal Care.” Future Dr. Salimi gave an excellent summary of the care provided during the different trimesters of pregnancy. Remember to collect a detailed history, perform a comprehensive physical exam, and order the labs to rule out pre-existing conditions that could interfere with pregnancy or detect complications early to start timely interventions or refer to a higher level of care. This week we thank Hector Arreaza, Elika Salimi, and Verna Marquez. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:AAP, ACOG. Guidelines for Perinatal Care. American College of Obstetricians and Gynecologists Women's Health Care Physicians; 2017Zolotor AJ, Carlough MC. Update on prenatal care. Am Fam Physician. 2014; 89(3): p.199-208. pmid: 24506122.World Health Organization. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization; 2016Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR. Recommendations and Reports. 2021; 70(4): p.1-187. doi: 10.15585/mmwr.rr7004a1Murray ML, Huelsmann G, Koperski N. Essentials of Fetal and Uterine Monitoring. Springer Publishing Company; 2018Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/.