Podcasts about American Family Physician

A client has hereditary hemochromatosis, which has affected their hip and toes. It is bad enough that they are considering joint replacement. In the meantime, they would like to receive massage for hip pain. Oh, and there's this tiny little issue about having recent strokes. What is going on? How can iron overload cause joint damage, and is it involved in strokes too? Is bodywork even possible in this situation?   Resources:   IHACW Episode 317, available here   Agarwal, A.R. et al. (2022) ‘Postoperative Complications in Patients With Hereditary Hemochromatosis Undergoing Total Joint Arthroplasty: A Matched Cohort Analysis', The Journal of the American Academy of Orthopaedic Surgeons, 30(1), pp. e99–e107. Available at: https://doi.org/10.5435/JAAOS-D-21-00105.   Arteriovenous Malformations (AVMs) | National Institute of Neurological Disorders and Stroke (no date). Available at: https://www.ninds.nih.gov/health-information/disorders/arteriovenous-malformations-avms (Accessed: 28 August 2024).   Arthropathy and joint pain (2020) Haemochromatosis UK. Available at: https://www.haemochromatosis.org.uk/arthropathy (Accessed: 29 August 2024).   Brain AVM (arteriovenous malformation) - Symptoms and causes (no date) Mayo Clinic. Available at: https://www.mayoclinic.org/diseases-conditions/brain-avm/symptoms-causes/syc-20350260 (Accessed: 30 August 2024).   Carroll, G.J., Breidahl, W.H. and Olynyk, J.K. (2012) ‘Characteristics of the arthropathy described in hereditary hemochromatosis', Arthritis Care & Research, 64(1), pp. 9–14. Available at: https://doi.org/10.1002/acr.20501.   Hemochromatosis | Arthritis Foundation (no date). Available at: https://www.arthritis.org/diseases/hemochromatosis (Accessed: 28 August 2024).   Hemochromatosis (Iron Overload): Causes, Symptoms, Treatment, Diet & More (no date). Available at: https://my.clevelandclinic.org/health/diseases/14971-hemochromatosis-iron-overload (Accessed: 28 August 2024). McCurdie, I. and Perry, J.D. (1999) ‘Haemochromatosis and exercise related joint pains', BMJ : British Medical Journal, 318(7181), pp. 449–451.   Porter, J.L. and Rawla, P. (2024) ‘Hemochromatosis', in StatPearls. Treasure Island (FL): StatPearls Publishing. Available at: http://www.ncbi.nlm.nih.gov/books/NBK430862/ (Accessed: 30 August 2024).   Sahinbegovic, E. et al. (2010) ‘Hereditary hemochromatosis as a risk factor for joint replacement surgery', The American Journal of Medicine, 123(7), pp. 659–662. Available at: https://doi.org/10.1016/j.amjmed.2010.01.024.   Walling, A.D. (1999) ‘The Differential Diagnosis of Joint Pain: Hemochromatosis', American Family Physician, 59(9), pp. 2587–2588.   Host:            Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP's partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner's books are available at www.booksofdiscovery.com. And more information about her is available at www.ruthwerner.com.      This podcast sponsored by:     Books of Discovery: www.booksofdiscovery.com   Anatomy Trains: www.anatomytrains.com    Elements Massage: www.elementsmassage.com/abmp   MassageBook: www.massagebook.com

Management of obesity (1:45), diagnosing dementia (6:10), mastitis (9:10), the G2211 code (13:30), alcohol use in adolescents (16:10), and imaging guidelines for mild traumatic brain injury (18:20).

Conjunctivitis (1:40), measles (6:10), perioperative glycemic control (8:20), chronic cough (11:20), HPV vaccine preventing cervical cancer (15:10), and tirzepatide for treatment of obesity (18:10).

Cognitive enhancers and Mini-Mental State Examination (1:40), primary care of adult cancer survivors (4:00), bupropion for depression in adolescents (8:50), acute and chronic prostatitis (10:50), antibiotics in uncomplicated but febrile urinary tract infections (14:10), and top 20 research studies of 2023 (15:30).

Obstructive sleep apnea in adults (1:40), e-cigarettes (5:30), breastfeeding support for healthy mothers and infants (7:40), hematologic emergencies (10:20), midodrine for recurrent vasovagal syncope (15:30), and cranberry products for preventing urinary tract infections (17:20).

Testosterone therapy for male hypogonadism (1:40), avoiding judgmental clinical documentation (5:50), bipolar disorder (8:10), gallstone disease (11:40), bempedoic acid (15:50), and stable chronic obstructive pulmonary disease (18:40).

Lifelong care for patients after gender-affirming surgery (1:30), lipid management (6:10), carpal tunnel syndrome (11:10), spontaneous vaginal delivery (14:00), oseltamivir (17:20), and new medicines for RSV prevention (19:40).

Atrial fibrillation (1:30), sFlt-1/PlGF ratio in preeclampsia (4:50), hyaluronic acid for wounds (6:40), substance misuse (9:00), nirsevimab (12:50), and AFP Clinical Answers (14:10).

Acute pericarditis (1:30), saw palmetto for benign prostatic hyperplasia (5:30), baclofen for alcohol use disorder (8:00), nausea and vomiting (10:30), fecal microbiota spores for Clostridioides difficile (15:20), and monoclonal antibody therapy for Alzheimer disease (18:20).

Noninsulin therapy for type 2 diabetes mellitus (1:50), high-dose flu vaccine (4:40), remote psychotherapy for chronic pain (6:20), lumbar spinal stenosis (8:30), primary care access in areas with aging populations (12:40), and herbal medicines for functional dyspepsia (14:10).

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/

Preventive care for men who have sex with men (1:30), inactivated polio vaccine (5:30), Beers criteria (7:20), streptococcal pharyngitis (12:20), peanut ball in labor (17:00), and watching and waiting for symptomatic gallstones (18:30).

Ten concepts of information mastery that every family physician should know.

Diabetic peripheral neuropathy (1:30), melatonin for delirium (5:00), fezolinetant (6:30), remote psychological therapies for chronic pain (9:30), hypertensive disorders in pregnancy (12:30), and cognitive behavior therapy for long COVID (18:50).

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/

Thiazide diuretics (2:20), pancreatic cancer (4:40), DermTech pigmented lesion assay (8:30), chronic low back pain (17:00), hearing aids (23:40), and blood pressure cuff size (27:50).

Urinary tract infections in adults (2:00), brexpiprazole as adjunctive therapy for depression (5:30), chronic conditions in hospitalized patients (8:30), postpartum hypertension (13:40), inequities in kidney transplant (15:50), and exercise for depression in older adults (17:40).

Abnormal uterine bleeding (2:00), eating disorders (7:00), osteopathic schools and family medicine residencies (9:10), chronic insomnia (11:10), an insomnia editorial (15:10), and plaque psoriasis (16:40).

Injections of the hip and knee (1:30), carpal tunnel syndrome (6:20), Opill for contraception (8:10), acute coronary syndrome (12:20), oral isotretinoin (16:50), and screening for syphilis (19:20).

Do you feel like "hibernating" in the winter months? Does the loss of daylight affect your mood? Regardless of whether you tough it out in the northern US in cold winter conditions, or you escape to warmer temperatures down south, none of us are immune to seasonal changes in the amount of daylight hours. The winter solstice comes for us all, whether you're in Fargo or Fort Lauderdale. Have you ever wondered if you had “seasonal affective disorder”? (As an aside, it's either genius, or a giant bummer that the acronym for this condition is “SAD”).  Today's episode talks all about seasonal affective disorder! Who gets it? Why? How can we treat and/or prevent it? Does staring into a light box actually work? Are medications helpful for SAD? What about behavioral therapy? What does the research show? Bonus topic at the end, Jeremy dives into the recent rise in measles cases in the US, and gives some context as to why that trend may be occurring. We give a brief overview of measles, and clarify the "controversy" over the MMR vaccine (Andrew Wakefield, cough, cough...) Resources for this episode include: The National Institute of Health website for Seasonal Affective Disorder. A 2007 article from Dialogues in Clinical Neuroscience titled "The phase shift hypothesis for the circadian component of winter depression". The American Family Physician article from 2012 titled "Seasonal Affective Disorder". The Mayo Clinic website re: choosing a lightbox for SAD. A link to the Rohan et al study published in the American Journal of Psychiatry comparing light therapy to cognitive behavioral therapy for treatment of SAD. AND YOU CAN'T MISS this clip of the wonderful Meteorologist (Chicago's Very Own) Tom Skilling feeling overcome with emotion watching a total solar eclipse in 2017 :) Tom Skilling is so pure, we do not deserve him! Thanks for tuning in, folks! and please sign up for our "PULSE CHECK" monthly newsletter! Signup is easy, right on our website page, and we PROMISE we will not spam you! We just want to send you cool articles and thoughts :) For more episodes, limited edition merch, or to become a Friend of Your Doctor Friends (and more), follow this link! This includes the famous "Advice from the last generation of doctors that inhaled lead" shirt :) Also, CHECK OUT AMAZING HEALTH PODCASTS on The Health Podcast Network   Find us at: Website: yourdoctorfriendspodcast.com  Email: yourdoctorfriendspodcast@gmail.com  Connect with us: @your_doctor_friends (IG) Send/DM us a voice memo/question and we might play it on the show! @yourdoctorfriendspodcast1013 (YouTube) @JeremyAllandMD (IG, FB, Twitter) @JuliaBrueneMD (IG) @HealthPodNet (IG)

Sarcoidosis (1:30), compression therapy in venous ulcers (4:30), FilmArray GI panel (6:30), medications for alcohol use disorder (10:00), removing erroneous penicillin allergy labels (14:50), and tadalafil for benign prostatic hyperplasia (16:50).

Preventing cardiovascular disease in women (1:40), initial evaluation of dementia (4:50), adjunctive corticosteroids for community-acquired pneumonia (8:10), magnesium for leg cramps (10:40), childhood sports-related overuse injuries (12:00), and terbinafine for onychomycosis (16:50).

Preconception counseling (1:30), research in family medicine (5:30), pre-exposure prophylaxis to prevent acquisition of HIV (6:40), psoriasis (9:50), transgender care (12:20), and overuse of antireflux medicines in infants (17:20).

Syncope (1:40), testosterone therapy and adverse effects (7:40), baricitinib for alopecia areata (9:30), intestinal parasites (13:10), antiarrhythmics in atrial fibrillation (19:20), and AFP Clinical Answers (21:40).

Dog and cat bites (1:40), inappropriate medication use in older adults (5:50), pleural effusions (8:10), poststroke depression (12:20), and pro/con editorials about bone turnover markers in osteoporosis therapy (15:00).

The ill returning traveler (1:30), the Community Preventive Services Task Force (5:30), thiazide diuretics (7:50), over-the-counter medications in pregnancy (10:00), RSV vaccination (13:40), mild chronic hypertension in pregnancy (15:10), childhood obesity (17:30), and Halloween ICD-10 codes (19:50).

Hypertension in adults (1:30), magnesium in COPD (5:50), medications to promote weight loss (7:50), cryptorchidism (11:00), early return to activity in concussion (13:30), and RSV vaccination (15:00).

Nicotine receptor partial agonists for smoking cessation (1:30), primary aldosteronism (2:50), dual- vs. triple-combination inhalers for asthma (5:30), smell and taste disorders (9:40), finerenone (14:30), and diagnostic overshadowing (17:30).

Andrew Foy rejoins the Sensible Medicine podcast. We talk first about coronary artery calcium. Andrew is an expert in this area. We have co-written our case against CAC scoring for any cause in the American Family Physician. It's had little effect as CAC scoring is running rampant. Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The second part of our conversation centers on a big med-ed project Andrew is co-leading at Penn State. He calls it Argue-to-Learn. The idea is to expose pre-clinical students to the value of civil debate. Here is their paper: Student Perceptions of a New Course Using Argumentation in Medical EducationHere is a quote: The absence of argumentation (i.e., a productive exchange of opposing views aimed at improved understanding of a given issue) in medical education may leave physicians susceptible to medical marketing, and incapable of both resolving industry claims and adapting to changing paradigms.Gosh. Gosh. Double Gosh, this is an exciting effort. Listen to Andrew explain. JMM This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Gestational diabetes mellitus (1:40), steroid injections and blood glucose (5:40), heart failure management (8:10), BD Max vaginal panel (13:20), benzodiazepine use disorder (15:20), chlorthalidone vs. hydrochlorothiazide (19:10).

Pressure injuries (1:40), perioperative management of antithrombotic medications (5:00), irritable bowel syndrome (6:20), speech and language delay in children (9:30), family medicine residency applications and abortion (13:00), ischemic heart disease (14:20), and the number needed to treat game (16:30).

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/ 

Prenatal care (1:40), treatment of mild hypertension (4:30), food allergies (7:30), discharge against medical advice (12:50), inspiratory muscle training for COPD (14:40), and oral anticholinergics for overactive bladder (17:00).

Mpox (1:40), trigger point injections for low back pain (8:00), conservative interventions for urinary incontinence (9:30), torsemide versus furosemide (12:10), childhood eye exam (14:20), and headache during pregnancy and breastfeeding (18:50).

Episode 145: Family Planning for the LGBTQIA+Future Dr. Hoque explains how to assist with family planning for the LGBTQIA+ community. Some principles such as avoiding unintended pregnancies and reducing and early treatment of STIs are discussed.  Written by Ashfi Hoque, MBA, MS4, 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: Welcome to episode 145 of the Rio Bravo qWeek podcast. My name is Hector Arreaza, a faculty member of the Rio Bravo Family Medicine Residency Program.Ashfi: Hello everyone, I am Ashfi Hoque a 4th-year medical student at Ross University School of Medicine. I am from Long Beach, California. Patient advocacy and patient-centered care have always been a priority of mine. I've volunteered for years at the LGBT+ center in Weho and Long Beach. Today we will be discussing Family Planning for everyone while learning ways to become LGBTQIA+ inclusive. Arreaza: Yes, family planning is important, and I'm glad you included all types of families. I believe medical care must be offered to everyone, and I also believe in freedom of conscience, that's why I can freely express that I support traditional family for me. Why did you choose this topic?Ashfi: I chose this topic because my partner recently went to get her physical. Her provider had an extensive conversation about family planning and even discussed the anticipated cost of freezing her oocytes. I really loved the way this provider went about the conversation so I started researching ways I can support my community and also teach others to provide Queer inclusive medical care. What is LGBTQIA+?LGBTQIA+ stands for Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual, etc. The community will be referenced as the Queer community, an umbrella term for people who are not heterosexual or not cisgender. There are many inequalities that the community faces and we can do our due diligence to educate ourselves continuously and be aware that terminology and health needs may change. We have another Rio Bravo episode, Caring for LGBTQ+ Patients on Episode 103, that discusses healthcare disparities, but during this episode, we will be diving into an introduction to bridging health gaps, creating health equity, and building trust with the community. A 2023 Global Survey found that the self-identified Queer community represents 9% of the population, while the true estimate may be higher due to safety concerns. While diabetics are 10-13% of the population. These statistics show that as a medical provider, you'll encounter Queer patients more often than you think. One of the healthcare issues that Queer folks face is a lack of family planning.What is Family Planning?The World Health Organization (WHO) defines family planning as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through the use of contraceptive methods and the treatment of involuntary infertility.”Family planning serves three critical needs: Avoiding unintended pregnanciesReducing sexually transmitted diseases (STDs)Early treatment of STDs to reduce rates of infertilityWhen discussing family planning for patients, here are some examples of questions you can ask. What name may I use to address you?What are your pronouns?What is your gender? (Only if necessary for care, what is your assigned sex at birth?)Are you sexually active?What is the gender(s) of your partner(s)?Are you concerned about unintended pregnancy?Are you currently using any contraceptive measures?Are you taking any precautions to reduce STI/STD such as physical barriers like condoms, dental dams, or any harm reduction such as PrEP?What kind of STI/STD screening are you requesting?Do you need me to request additional labs such as oral or anal swabs?Those questions must be asked in a natural, non-judgmental way. While STD/STI screening and treatment is part of family planning, the part that we tend to neglect is the desire for Queer folks to build a family. Why is Family Planning Important for the LGBTQIA+ community?The Queer community gained the legal right to marry eight years ago, in 2015. They did not have the nationwide right to adopt until the last state, Mississippi, overturned the unconstitutional restrictions for the Queer community to adopt in 2016. A UCLA study in 2018 titled, “How many same-sex couples in the US are raising children?” reported cis-heterosexual couples: 3% are raising at least one adopted child and 95% are raising biological children while same-sex couples: 21.4% are raising at least one adopted child and 68% have a biological child. When it comes to family planning, there is more than adoption for Queer people. Queer folks are not offered the same pregnancy planning options, such as cis hetero-couples who are experiencing infertility or cis-women planning for advanced maternal age pregnancy. However, the options are quite similar. These options require specific types of planning, and that information can be provided to patients by their primary care doctor. A couple needs to know their options and consider the long-term financial planning necessary for surrogacy, in vitro fertilization (IVF), or donor insemination. The main difference for many Queer couples is the method of conception needed. Depending on sexual orientation and gender identity, patients may have varying reproductive needs as part of their family planning. We cannot make assumptions about how family planning should look and need to remember this journey looks different from person to person and couple to couple.How to approach family planning with the LGBTQIA+ community? Basic tenants of providing medical care for queer patients: Clinics specializing in Queer family planning found patient-centered care leads to better outcomes. The best approach is to be mindful, conscious, and to communicate without assumptions. We have to start with providers building trust, being honest, showing sensitivity assisting with reproductive services, and working towards being more knowledgeable about Queer parenthood. A provider could ask questions such as: Would you like information about family planning?What do you imagine your future family to look like?Would you like to see options and potential costs?Would you need a referral for a specialist?Or it can be as simple as being honest about your scope of knowledge by stating, “I am not well versed in LGBTQIA+ community issues but what ways can I support you?” It is ethically appropriate to transition care to a physician with better knowledge if you feel unable to assist a person from the LGBTQ+ community. Make sure to do it in a polite and respectful way.Gender inclusive: With more people openly identifying as non-binary and trans, there is a need for a gender-neutral approach to discussing a patient's biological and reproductive needs. First, we will avoid assuming gender identity based on the biological sex of a patient. Episode 14 of Rio Bravo does a great job of breaking down gender diversity and the difference between gender identity and biological sex. For transgender and nonbinary patients, providing care for medical transitioning often includes conversations about family planning before starting HRT. It is common to ask patients about to begin HRT if they would like to freeze their sperm or eggs. Second, we want to avoid assuming anything based on what reproductive organs a patient has. We can ask a patient about their intention to start a family. Avoid asking if a trans patient has received transitional surgery (bottom surgery) unless it is completely necessary for the care we are providing. Instead, it is appropriate to ask the patient if birthing is an option? Have you given birth before? Were there any complications? Is there any current hormonal treatment? This mindful strategy is also useful for patients who may have limitations in: producing oocytes or sperm, the ability to house a fetus in utero, or implantation and fertility. Third, we are going to address our underlying beliefs and assumptions about gendered parenthood. Parenthood is almost always thought of as motherhood and fatherhood, but this can be alienating for transgender patients. There are many possible ways of being a parent, and to be inclusive let's consider the possibility of a masculine woman or transmasculine man being a birthing parent or of a transgender woman being the mother of a child without giving birth to the child. There are many more scenarios we can discuss at another point. In the interest of time, we are going to shift into discussing family planning for lesbian and gay people and couples. Sexuality inclusive:For homosexual cis-gendered people who are single or in relationships, family planning can look similar to couples facing infertility issues. When having family planning conversations with these patients, a provider should ask broad, unassuming questions. If you have established that a queer person or couple wants a child, then you can ask if they have a family plan. If the patient or couple has a plan, follow the couple's lead. If the patient(s) do not have a plan, then you can begin to ask questions like: Do you have someone in mind to be a birth giver? Do you have a sperm donor? Do you have an egg donor? These questions are a great transition into discussing the following options for family planning.What are the options for having a newborn and the financial and ethical cost?Having a child can cost up to $100k, and this does not even include the cost of childcare. Infertility treatment is not covered by regular insurance, so patients need either infertility insurance or private financing to cover the cost of treatment. However, fertility insurance does not cover same-sex couples. There is a large emotional, physical, and ethical cost to deciding which route to choose. Let's discuss options and obstacles.1. Donor Insemination: The most affordable route is having a birth-giving parent who is fertile with a known sperm donor. This method can be as simple as using a syringe to inseminate the uterus-carrying person, but we need to consider necessary attorney fees to terminate the parental rights of the sperm donor. Sperm from a sperm bank requires an extensive workup including STD panel, HIV, and genetic disorder screening. The sperm donor gives up all parental rights during the process. The price of these procedures is constantly changing and depends on location.California Cryobank costs start at $1200 for anonymous donors and $1900 for identification disclosure donor which the child will receive information about the donor at age 18. Selecting a donor can include specifics such as race, talents, education, hobbies, physical attributes, and showing donor baby photos. There are two common insemination processes:Intracervical insemination: semen inside the cervical opening and covers the cervixIntrauterine insemination: semen is inserted through the cervix and placed directly into the cavityThe next option jumps up in cost significantly.2. Freezing Eggs (Oocyte Cryopreservation):Pacific Fertility Center Los Angeles, reports a single cycle of egg freezing can cost $6-10k per freezing cycle and may need multiple cycles without medication. The medications are typically around $3-6k depending on how much your body needs. Storage is an additional cost of $700-$1,000 a year. This is an option for parents planning pregnancy during advanced ages.3. In Vitro Fertilization (IVF): It is a process where an oocyte is collected similarly to freezing eggs but fertilized with a partner's or donor's sperm.Pacific Fertility Center Los Angeles reports it costs $8-13k per cycle of fertilization. It is an option for those who have issues with infertility, previous pelvic inflammatory diseases, surgeries, and issues with implantations.4. Surrogacy: This is the process of hiring a professional birthing surrogate to carry an embryo. This is an alternative option for couples who decline or cannot carry a pregnancy. The surrogate has no legal rights or biological relation to the fetus. Family Tree Surrogacy reports it costs about $45-65k.5. Adoption: Foster care adoption in California can be $1-5k. American Cost of Adoption, reports the cost of adoption for infants in California $40-70k including the medical expenses for the birth-giving person and legal expenses for the process. Versus adopting an infant from another country due lack of resources and poverty may better their lives or cause a higher demand for infants which may be an ethical issue. Also, transcultural adoption where the race of the parents and the children are different, and navigating culture and race with the children. Adoptees have reported having racial identity crises.With all these studies, it is well documented that providers will not be perfect at giving care to the Queer community. These studies do not represent every queer person and do not take the intersectionality of race, class, or gender identity into consideration. It is our job as providers to be supportive of all types of patients in order to increase their access to proper medical care. _______________Conclusion: Now we conclude episode number 145, “Family Planning for the LGBTQIA+.” Future Dr. Hoque explained how queer people can be included in family planning conversations, even before heterosexual couples. She described some options such as donor insemination, freezing eggs, IVF, and adoption. Dr. Arreaza explained that it is important to ask reproductive questions in a natural, non-judgmental way to all your patients, and refer to another professional when needed. This week we thank Hector Arreaza and Ashfi Hoque. 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:American Adoptions—How Much Does a Private Adoption Cost in California? [And Why?]. (n.d.). Retrieved July 14, 2023, fromhttps://www.americanadoptionsofcalifornia.com/adopt/cost-of-adoption-in-californiaAmerican Adoptions—LGBTQ Adoption: Can Same-Sex Couples Adopt? (n.d.). Retrieved July 14, 2023, fromhttps://www.americanadoptions.com/adopt/LGBT_adoptionCarpenter, E. (2021). “The Health System Just Wasn't Built for Us”: Queer Cisgender Women and Gender Expansive Individuals' Strategies for Navigating Reproductive Health Care. Women's Health Issues, 31(5), 478–484.https://doi.org/10.1016/j.whi.2021.06.004Choosing the Right Sperm Donor | California Cryobank. (n.d.-a). Retrieved July 14, 2023, from HTTPS://www.cryobank.com/how-it-works/choosing-your-donor/Choosing the Right Sperm Donor | California Cryobank. (n.d.-b). Retrieved July 14, 2023, from HTTPS://www.cryobank.com/how-it-works/choosing-your-donor/Cost of Egg & Embryo Freezing in the U.S. | PFCLA. (n.d.). Retrieved July 14, 2023, fromhttps://www.pfcla.com/blog/egg-freezing-costs. (2012, April 25).Donor Insemination. American Pregnancy Association.https://americanpregnancy.org/getting-pregnant/donor-insemination/Hollingsworth, L. D. (2003). International adoption among families in the United States: Considerations of social justice. Social Work, 48(2), 209–217.https://doi.org/10.1093/sw/48.2.209In vitro fertilization (IVF): MedlinePlus Medical Encyclopedia. (n.d.). Retrieved July 14, 2023, fromhttps://medlineplus.gov/ency/article/007279.htmIngraham, N., Fox, L., Gonzalez, A. L., & Riegelsberger, A. (2022a). “I just felt supported”: Transgender and non-binary patient perspectives on receiving transition-related healthcare in family planning clinics. PLOS ONE, 17(7), e0271691.https://doi.org/10.1371/journal.pone.0271691Ingraham, N., Fox, L., Gonzalez, A. L., & Riegelsberger, A. (2022b). “I just felt supported”: Transgender and non-binary patient perspectives on receiving transition-related healthcare in family planning clinics. PLOS ONE, 17(7), e0271691.https://doi.org/10.1371/journal.pone.0271691Ingraham, N., & Rodriguez, I. (2022a). Clinic Staff Perspectives on Barriers and Facilitators to Integrating Transgender Healthcare into Family Planning Clinics. Transgender Health, 7(1), 36–42.https://doi.org/10.1089/trgh.2020.0110Ingraham, N., & Rodriguez, I. (2022b). Clinic Staff Perspectives on Barriers and Facilitators to Integrating Transgender Healthcare into Family Planning Clinics. Transgender Health, 7(1), 36–42.https://doi.org/10.1089/trgh.2020.0110Klein, D. A., Malcolm, N. M., Berry-Bibee, E. N., Paradise, S. L., Coulter, J. S., Keglovitz Baker, K., Schvey, N. A., Rollison, J. M., & Frederiksen, B. N. (2018). Quality Primary Care and Family Planning Services for LGBT Clients: A Comprehensive Review of Clinical Guidelines. LGBT Health, 5(3), 153–170.https://doi.org/10.1089/lgbt.2017.0213PFCLA. (n.d.). The Cost of IVF in California. Retrieved July 14, 2023, fromhttps://www.pfcla.com/blog/ivf-costs-californiaPODCAST. (n.d.). Rio Bravo Residency. Retrieved July 14, 2023, fromhttps://www.riobravofmrp.org/qweek/episode/fcb76527/episode-103-caring-for-lgbtq-patientsRotabi, K. S. (n.d.). From Guatemala to Ethiopia: Shifts in Intercountry Adoption Leaves Ethiopia Vulnerable for Child Sales and Other Unethical Practices.Smoley, B. A., & Robinson, C. M. (2012). Natural Family Planning. American Family Physician, 86(10), 924–928.Surrogate Compensation | How Much Do Surrogater Paid in CA? (n.d.). Https://Familytreesurrogacy.Com/. Retrieved July 14, 2023, fromhttps://familytreesurrogacy.com/blog/surrogate-pay-california/The National Academies Press. (n.d.). Retrieved July 14, 2023, fromhttps://nap.nationalacademies.org/thisisloyal.com, L. |. (n.d.). How Many Same-Sex Couples in the US are Raising Children? Williams Institute. Retrieved July 14, 2023, fromhttps://williamsinstitute.law.ucla.edu/publications/same-sex-parents-us/Royalty-free music used for this episode: "Rain in Spain." Downloaded on October 13, 2022, from https://www.videvo.net/ 

The Society of Teachers of Family Medicine President's Address from Dr. Renée Crichlow is featured. Dr. Crichlow is Vice Chair of Health Equity, Boston University Medical School Department of Family Medicine, and Chief Medical Officer of Codman Square Health Center. She also serves as Medical Editor for Diversity, Equity, and Inclusion for the American Family Physician journal.

Menopausal symptoms (1:40), inflammatory markers in acute respiratory illnesses (5:50), nebulized hypertonic saline (8:30), fatigue (11:30), behavior therapy for insomnia (14:40), and phosphatidylethanol testing (16:30).

Benign prostatic hyperplasia (1:30), antidepressants in osteoarthritis (6:10), overdiagnosis of chronic kidney disease (8:00), infertility (10:20), Guardant Health Shield (14:50), and morning vs. bedtime medications for hypertension (17:50).

Growth faltering and failure to thrive in children (1:30), integrated behavioral health (6:30), colon cancer screening (8:20), COVID risk stratification (11:10), COPD (14:00), and a hyperbilirubinemia guideline (19:50).

Disability evaluations (1:40), screening for genital herpes infection (5:30), management of type 2 diabetes (7:00), music for insomnia therapy (9:10), evaluating the child with a limp (10:40), and nonalcoholic fatty liver disease (15:00).

Neonatal hyperbilirubinemia (2:50), Lumipulse G β-Amyloid Ratio test for Alzheimer disease (7:50), cabotegravir for pre-exposure prophylaxis (10:10), dizziness (14:20), baclofen for alcohol use disorder (19:40), and AFP clinical answers (22:20).

Systemic lupus erythematosus (1:40), Bell palsy (6:30), outpatient management of COVID-19 (10:20), metformin or lifestyle changes to prevent diabetes (13:50), acetazolamide for acute heart failure (18:00), low back pain (20:20), and a brand new game (22:20).

Chronic asthma management (1:40), conflict of interest in asthma guidelines (6:50), top 20 research studies of 2022 (9:40), legal challenges for family physicians and abortion care (16:30), management of postpartum hemorrhage (20:10), and liraglutide for Type 2 diabetes (22:30).

Corticosteroids for low back pain (1:40), glaucoma (4:20), screening for obstructive sleep apnea (10:10), polycystic ovary syndrome (13:20), diabetic peripheral neuropathy (17:50), and antiplatelet agents for deep venous thrombosis (20:10).

Posttraumatic stress disorder (1:30), risk for ovarian cancer (5:40), viloxazine for attention-deficit/hyperactivity disorder (9:30), foot orthoses for flat feet (12:50), diagnosing appendicitis (14:40), and pulmonary nodules (17:50).

Acute otitis externa (1:30), trazodone for insomnia (4:40), long COVID (7:10), common skin conditions during pregnancy (9:20), chronic disease management during Ramadan (14:50), statins for primary prevention (16:50), and an evidence-based medicine minute (19:30).

Introduction of the newly available Spanish-language AFP podcast (0.30), fibromyalgia (7:00), bee stinger removal (11:30), eczema (13:20), televisits for prenatal care (15:10), peptic ulcer disease and Helicobacter pylori infection (17:30), and AFP clinical answers (21:20).

Pharmacogenomic testing for antidepressant selection (2:40), lung cancer screening (4:00), temporomandibular disorders (8:50), SGLT-2 inhibitors for heart failure (13:00), analgesics in soft tissue injury (15:00), and tonsillitis (17:30).

Infectious mononucleosis (1:10), polyarticular joint pain (5:10), first-trimester abortion (9:20), corticosteroids for Kawasaki disease (12:00), scaphoid wrist fractures (14:40), and semaglutide for obesity (16:40).