Podcasts about MS3

In this episode of Medicine Grand Rounders, we're join by hematologist extrodinaire Dr. Dana Angelini, who goes over the do's and don'ts of anticoagulation for the Internal Medicine Physician. Moderated by: Seysha Mehta, MS3

Thinking about doing an away rotation? In this episode of Behind the Knife, we break down everything you need to know about away rotations and sub-internships. From how to apply and what to expect to making a great impression and building connections, we've got you covered. Plus, we discuss whether you should even do an away rotation at all and how to decide if it's the right move for your application. We're joined by a fantastic and diverse group of general surgery residents who share their insights, tips, and experiences. Episode Hosts: –Dr. Josh Roshal, University of Texas Medical Branch, @Joshua_Roshal, jaroshal@utmb.edu –Dr. Colleen McDermott, University of Utah, @ColleenMcDMD, Colleen.McDermott@hsc.utah.edu –Dr. Sophia Williams-Perez, Baylor College of Medicine, @SophWPerez, Sophia.Williams-Perez@bcm.edu –CoSEF: @surgedfellows, cosef.org Guests:  Dr. Steven Thornton, Duke University Medical Center, @swthorntonjr swt12@duke.edu Dr. Nicole Santucci, Washing University in St. Louis, @nicolemsantucci  snicole@wustl.edu Abbas Karim, MS3, University of Texas Medical Branch, @_AbbasKarim aakarim@utmb.edu Reagan Collins, MS4, Texas Tech University Health Sciences Center, @ReaganACollins, reagan.collins@ttuhsc.edu Dr. Annie Hierl, Indiana University, @annie_hierl ahierl@iu.edu  Dr. Jorge Zarate Rodriguez, Washington University in St Louis, @jzaraterod, j.zarate@wustl.edu  References: McDermott CE, Anand A, Brian R, Gan C, L'Huillier JC, Lund S, Sathe T, Silvestri C, Woodward JM. Should I Do a General Surgery Away Rotation?: Perspectives From the Collaboration of Surgical Education Research Fellows (CoSEF). Ann Surg Open. 2024 Dec 3;5(4):e509. doi: 10.1097/AS9.0000000000000509. PMID: 39711667; PMCID: PMC11661735. https://pubmed.ncbi.nlm.nih.gov/39711667/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

In this episode of Psychiatry & Psychotherapy, Dr. David Puder hosts a deep dive with experts Nicholas Fabiano, MD, Brandon Luu, MD, Joshua Mangunsong, MS3, and Liam Browning, MS4 into the exciting potential of creatine supplementation for mental health and cognitive enhancement. They explore cutting-edge research on how creatine can improve mood disorders, including depression and anxiety, enhance cognitive functions such as memory, attention, and reasoning, and support brain metabolism through its role in ATP regeneration. The episode also reviews clinical trials demonstrating creatine's effectiveness in psychiatric disorders, optimal dosing strategies, and its safety profile. Listen to learn how creatine may revolutionize treatment options in psychiatry. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Many medical students pursue passions and hobbies alongside their medical studies. Kerrigan Dougherty, MS3, was featured in The Baltimore Banner for their work with the Skylight Boutique in Baltimore. In today's episode, they share some of their life story, their nonstandard path to medicine, their joy in working with the Skylight Boutique, and some tips and tricks for superb time management when balancing med school with the rest of life.  Reference: Scharper, J. “One of the country's few gender-affirming thrift stores is in Baltimore.” The Baltimore Banner. November 4, 2024. Link.   

Luke Tomlinson, Category Manager at MS3, joins me for a captivating conversation on the transformative power of procurement.   We unravel the outdated notion of procurement as just a back-office function and spotlight its potential to be a driving force for business value.   With a focus on ESG, risk management, and supply diversification, we discuss how procurement, when collaborating with sales teams, can transcend simple cost management to become a cornerstone of business innovation and success.   Understanding the buying journey is no longer optional but essential for both sales and procurement professionals.   We look into the importance of early engagement in the sales process, emphasising how this alignment can lead to more effective decision-making and streamlined operations.   By balancing the art of being right with the necessity of being liked, procurement professionals can reshape their roles, gaining respect and influence within their organisations.   Through learning from salespeople, procurement can enhance its effectiveness, contributing to a more harmonious and productive business environment.   We also explore the nuanced relationship between transactional and strategic supplier partnerships and the vital role of personal connections and trust in developing strategic partnerships.   This episode offers a wealth of knowledge on modern sales techniques and how procurement can leverage these insights to create mutually beneficial relationships with sales teams.   -------- EPISODE CHAPTERS ---------   (0:00:00) - Collaboration in Procurement and Sales Procurement's evolving role involves collaboration with sales to create value beyond cost management.   (0:13:54) - Building Relationships Between Sales and Procurement Understanding the buying journey, aligning with procurement, changing perceptions, and collaborating effectively for smoother sales processes.   (0:22:25) - Strategic Partnerships in Procurement Transactional vs. strategic supplier relationships, importance of personal connections, and creating value beyond cost considerations in procurement.   (0:31:09) - Understanding RFPS in Procurement and Sales Nature's RFPs: Invitations, winning potential, buyer's stage, early involvement, due diligence, aligning with client's needs and procurement processes. websites, and fun and educational content.   Connect with Luke:   Follow me https://linktr.ee/fredcopestake   Take the  Collaborative Selling Scorecard https://collaborativeselling.scoreapp.com/   Watch this episode on YouTube https://youtu.be/wu4IH5aLkac

In this episode, which was first published in 2023 on the Sound of IR podcast as part of its VIR Legends series, hosts Eric Cyphers, MS3, and Subhash Gutti, MS4, interview Mr. John Abele, FSIR, about his experience as co-founder of Boston Scientific, challenges that arose after revolutionizing procedural medicine, and the early days of IR as a field.Related resources:"Learning to See Differently: An interview with John Abele, FSIR" (IR Quarterly, Summer 2021) READWe thank the Sound of IR producers for sharing this content with the Kinked Wire. You can listen to more Sound of IR episodes at thesoundofir.castos.com.Note: This episode was first published March 29, 2023. Support the show

For our Season 3 finale, MS3 students Darby Billing and Elise Kao host an episode on disorders of sexual development. They'll cover topics such as 5-alpha reductase deficiency, Mullerian agenesis, androgen insufficiency, and more in our usual question-and-answer style format. Never feel bad for not knowing the answers when you're listening to SoS! The point is to miss questions now so you'll never miss them again.

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/.

This week, we discuss the experiences of residents and medical students in surgery who identify as LGBTQIA+. We discuss the question of disclosure during interviews, how to identify programs that are welcoming to diverse identities, and how AOSA has grown the community of trainees and faculty mentors and hopes to continue to support them in the future. Hosts: Jason Bingham, MD Nina Clark, MD Guests: Andrew Schlussel, DO, Colorectal and General Surgeon, Charlie Norwood VA Medical Center Christina Georgeades, MD, R4 General Surgery at Medical College of Wisconsin cgeorgeades@mcw.edu, Twitter/X: @CGeorgeades Cameron Smith, MS3 at Kansas City University Cameron.smith@kansascity.edu, Instagram: @cameron_smith_1996, Twitter/X: @cafe_aficionad0 Jillian Wothe, MD, R1 General Surgery at Brigham & Women's Hospital jillian.wothe@gmail.com, Twitter/X: @JillianWothe Learn more and get involved with AOSA: https://www.outsurgeons.org Twitter/X: @OutSurgeons Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out episode one in this series: https://behindtheknife.org/podcast/association-of-out-surgeons-allies-aosa-episode-1/

In this episode of BackTable ENT, Dr. Tammara Watts, surgeon-scientist at Duke University, sits down with host Dr. Gopi Shah to discuss two exciting scholarship opportunities for medical students available through the American Head & Neck Society (AHNS). --- SHOW NOTES Fewer than 5% of practicing otolaryngologists identify as members of underrepresented minority groups (URM), and these scholarships directly address that disparity. Gopi and Tammara then transition to discussing the importance of diversity in otolaryngology more broadly. First, Tammara expounds on what is gained by having a workforce that includes individuals with diverse backgrounds and experiences. Through the Dr. Eddie Méndez Research Fellowship and the Myers' Family Summer Fellowship, AHNS provides unique opportunities for aspiring otolaryngologists who identify as URM to connect with future colleagues. The Research Fellowship provides $10,000 to a medical student interested in spending one year immersed in otolaryngology research. It is unique in that AHNS provides a list of mentors (with bio-sketches) that interested applicants can connect with to formulate a research plan before applying. The Myers' Family Summer Fellowship financially supports a rising MS2 or MS3 student to gain exposure in Head & Neck Surgery. Next, Tammara offers tips on cultivating successful mentor-mentee relationships, emphasizing that mentors enjoy supporting their future colleagues, and that it is easier to do so when the mentee takes initiative. Finally, Tammara shares her philosophy regarding DEI. Though otolaryngologic patients come from all walks of life, their surgeons can't always conceptualize how their experiences influence their care. By supporting URM students interested in ENT, she (along with her AHNS colleagues) are helping create a workforce that can better understand and heal. --- RESOURCES AHNS's Dr. Eddie Méndez Fellowship: https://www.ahns.info/dr-eddie-mendez-research-fellowship/ AHNS's Myers' Family Summer Fellowship in Otolaryngology: https://www.ahns.info/myers-summer-fellowship/ Dr. Tammara Watts MD, PhD's Duke University Profile: https://headnecksurgery.duke.edu/profile/tammara-lynn-watts

Episode 139: What is PCOS      Future Dr. Salimi explains the pathophysiology, signs, and symptoms of PCOS. Diagnostic criteria and the basics of treatment are also discussed. Dr. Arreaza adds some comments about the treatment of obesity.  Written by Elika Salimi, MS3, 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.Hello there! My name is Elika and I am a third-year medical student at Western University of Health Sciences. Today I will be talking to you about polycystic ovary syndrome AKA PCOS.Do you have a female patient in her reproductive years with irregular menstrual cycles, or no menstrual cycles at all? Is she unable to conceive a child? Did she have an unexpected diagnosis of diabetes? Does she have more acne than she would like, or has hair in unwanted or unexpected areas such as her chin?Does she have a hard time losing weight? If you answered YES to many of these questions, it is possible that your patient is suffering from polycystic ovary syndrome also known as PCOS, which is one of the most common endocrine disorders in women. Pathophysiology:The exact pathophysiology behind this syndrome is unknown; however, per the American College of Obstetricians and Gynecologists committee, some studies have shown a strong association between PCOS and obesity. In a woman with obesity disorder, the excess adipose tissue ends up increasing peripheral estrogen synthesis and as a result, there is a decrease in peripheral sensitivity to insulin which means many of these women tend to have hyperinsulinemia. To be more detailed, it is important to mention that during these anovulatory cycles, the increase in estrogen, which is also unopposed estrogen with a lack of progesterone, can lead to endometrial hyperplasia and consequently increase the risk of endometrial carcinoma.Clinical Features: Unless there is a clear history and physical or if perhaps there was an incidental ultrasound finding of polycystic ovaries, the diagnosis of PCOS is not exactly black-and-white. That is why it is important to increase awareness so that women can put the pieces of the puzzle together and come in to get evaluated. Multiple cysts in ovaries can present in patients without PCOS, and they are common in teenagers. To use the multiple cysts as part of the diagnosis, the patient has to be 2 years after menarche (AAFP). Some of these clinical symptoms typically start during adolescence displaying menstrual irregularities such as she could've had her period and then stopped getting it or she has a very delayed onset of her menstrual cycle. It is also possible to have spotty menstrual cycles also known as breakthrough bleeding or menorrhagia. And very important to many women, she could be infertile or have difficulties conceiving.She could also have diabetes because of insulin resistance that comes with the metabolic syndrome that develops with PCOS, which is also increased if she has obesity. This obesity disorder going hand in hand with the metabolic syndrome, can also increase the risk of having sleep apnea, which could affect the quality of her sleep, finding herself more fatigued than she should be after adequate hours of rest. Other symptoms include skin conditions such as hirsutism which is basically male pattern hair growth in women in areas such as the upper lip, chin, around the umbilicus, back, or even buttocks. She could also have male pattern hair loss on the head or too much acne or oily skin or acanthosis nigricans which are these brown/velvety hyperpigmented streaks on the neck or axilla, or groin. She could also find herself more depressed or anxious.Diagnosis:The diagnostic criteria and treatments are mainly addressed in the Journal of Clinical Endocrinology & Metabolism, an evidence-based guideline for the assessment and management of polycystic ovary syndrome, and the American Family Physician Journal:The diagnosis of PCOS requires the presence of at least two criteria that are not due to any other endocrine disorder such as thyroid disease or hyperprolactinemia, or other. 1) Periods of oligo-ovulation and or anovulation which means she's either having very low ovulatory cycles or she's not ovulating at all. 2) hyperandrogenism and this could be based on her clinical features or laboratory studies showing elevated testosterone levels or LH to FSH ratio and 3) Seeing enlarged and/or polycystic ovaries on a pelvic ultrasound. This means that the pelvic ultrasound shows an ovarian volume of equal to or greater than 10 mL and/or there's multiple cystic follicles that are about 2 to 9 mm in one or both of her ovaries which also usually tend to have a string of pearls appearance.So, if you have 2 out of the 3, you have PCOS. There are ways to confirm that there is in fact hyperandrogenism by doing lab studies and this could mean that her testosterone levels are elevated, or her androstenedione is elevated as well as elevated dehydro-epi-androsterone sulfate (DHEAS) and of course we need to rule out pregnancy and other endocrine disorders as I mentioned earlier. However, if the clinical picture of hyperandrogenism is there then that fulfills the diagnostic criteria for PCOS even if the serum antigen levels are normal. This also applies to an elevated LH:FSH ratio of typically greater than 2 to 1 which is also a characteristic finding of most patients with PCOS but this is not exactly necessary for diagnosis. We also don't need to find cystic follicles in order to diagnose PCOS. Treatment: In family medicine practices and even OB/GYN practice for PCOS the most common recommendation for all patients is to encourage them to increase their physical activity (exercise) and eat healthy and try to consider behavioral modifications to have a target BMI of ideally less than 25 kg/m² because this can reduce estrone production in adipose tissue.Then we are thinking about ways to treat patients who are not planning to conceive versus those that are. For those patients that are not planning to conceive the goal is to regulate their menstrual cycles and irregularities as well as their hyperandrogenism and to treat the comorbidities as well to overall improve their quality of life.The first line treatment for hyperandrogenism to try to regulate menstrual cycle abnormalities is combined oral contraceptives also known as birth control pills. This also reduces endometrial hyperplasia which in turn can decrease the risk of endometrial carcinoma as mentioned earlier and it can reduce menstrual bleeding and you can reduce acne and try to assist with the hirsutism as well. As mentioned earlier, PCOS can also go hand-in-hand with insulin resistance or hyperinsulinemia and therefore we can also use metformin that can improve menstrual irregularities but also address the metabolic side of this as well. Summary: Diet, exercise, combined oral contraceptives, and metformin.Some other more controversial medications to treat hyperandrogenism could be potassium-sparing diuretics such as spironolactone that also inhibits 17-a-hydroxylase or finasteride which is a 5-alpha-reductase inhibitor and flutamide which is an androgen receptor blocker. The mentioned examples are typically for those people that can't really tolerate combined oral contraceptives. Other things to consider for those that are suffering from obesity syndrome are to possibly consider bariatric surgery if of course the criteria are met, and this is on a case-by-case basis. Bariatric surgery may be an answer to many of our metabolic problems that's why it is now called metabolic surgery. For patients who are planning to conceive the goal is to manage their comorbidities such as weight loss but also to try to induce ovulation.Now the first-line therapy for inducing ovulation is a medication called letrozole which is an aromatase inhibitor that in turn reduces estrogen production stimulating FSH secretion and ultimately inducing ovulation, not to get too heavily into the weeds of how these medications work, but basically it improves pregnancy and live birth rate outcomes in patients who are infertile because of the fact that they have anovulatory cycles or a.k.a. they are not ovulating.Then we also have clomiphene which is just an alternative to letrozole and has a different mechanism of action but it also stimulates ovulation by more particularly causing a pulsatile secretion of GnRH and in turn increasing FSH and LH as well, and this medication might be actually preferred over metformin monotherapy in women that are suffering from obesity syndrome who also have anovulatory infertility. However, apparently, clomiphene can cause more chance of multiple gestations versus letrozole.Also, letrozole is preferred over clomiphene to induce ovulation because of a higher rate of live births, but we have the risk of multiple pregnancies with both these methods. Let's talk about the second-line therapies.As mentioned earlier we have this 2 to 1 ratio of FSH to LH in women with PCOS or at least a good amount of them. We said that that is not required to diagnose this disorder but we can also give women exogenous FSH plus human menopausal gonadotropin, but this is really a second-line treatment for ovulation induction and typically we go for second-line treatments if first-line therapies aren't successful. But I will mention that using this exogenous gonadotropin is very expensive and it requires you to have access to specialized healthcare facilities and constant ultrasound monitoring so this may just not be feasible for many people but if you have the resources and it's affordable for you then exogenous gonadotropins are actually preferred over clomiphene and metformin therapy.Metformin can also use as a second-line monotherapy for fertility treatments and this in combination with clomiphene can increase pregnancy rates, especially in women who are suffering from obesity disorder, and of course, this is first-line therapy for insulin resistance.Now if we're talking about an invasive type of procedure for infertility it would be laparoscopic ovarian drilling which basically, we use a laser beam or surgical needle to reduce ovarian tissue to decrease its volume and try to reduce androgen production. Doing this can cause a hormone shift that can induce FSH secretion and ultimately improve ovarian function as well. This is also a second-line treatment for ovulation induction, but it can be performed as a first line if other indications for laparoscopy are present. Third-line therapy would be in vitro fertilization which means that basically we take mature eggs from ovaries and then we fertilize them with sperm in a lab and then the fertilized egg or the embryo is transferred to a uterus to be implanted.For the management of hirsutism, the first-line therapy is usually non-pharmacological and that's electrolysis or light-based hair removal with laser or photo-epilation. For acne, we can consider benzoyl peroxide or topical antibiotics if necessary.Final thoughts: Now I know that was a ton of information but ultimately, we are trying to make women more aware of PCOS and let them know that they are not alone, also we are trying to reduce complications such as cardiovascular problems, diabetes, endometrial cancer, infertility or even pregnancy loss. The best we can do is try to educate more women because many are suffering from this condition and they have no idea. Again, my name is Elika Salimi, and I am a third-year medical student. If you have any questions, you can reach me at elika.salimi@westernu.edu.___________________________Conclusion: Now we conclude episode number 139, “What is PCOS.” Future Dr. Salimi explained that patients with Polycystic Ovary Syndrome present with: Hyperandrogenism, Oligo-ovulation or anovulation, and multiple cysts in ovaries. If your patient meets 2 out of the 3 criteria, then you can confidently give the diagnosis of PCOS. Dr. Arreaza reminded us that by treating obesity you are also treating PCOS. This week we thank Hector Arreaza and Elika Salimi. 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 College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology..ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome..Obstet Gynecol.2018; 131(6): p.e157-e171.doi:10.1097/AOG.0000000000002656Hoeger KM, Dokras A, Piltonen T.Update on PCOS: Consequences, Challenges, and Guiding Treatment.The Journal of Clinical Endocrinology & Metabolism.2020; 106(3): p.e1071-e1083.doi:10.1210/clinem/dgaa839Williams T, Mortada R, Porter S.Diagnosis and Treatment of Polycystic Ovary Syndrome..Am Fam Physician.2016; 94(2): p.106-13.pmid: 27419327.Legro RS, Arslanian SA, Ehrmann DA, et al.Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab.2013; 98(12): p.4565-4592.doi:10.1210/jc.2013-2350.International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018.https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf 

Episode 133: Neonatal JaundiceJennifer explained the pathophysiology of neonatal jaundice and how to treat it and described why screening for hyperbilirubinemia is important.    Written by Jennifer Lai, MS3, College of Osteopathic Medicine of the Pacific Western University of Health Sciences. 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 neonatal jaundice? Jenni: Infant jaundice, also known as hyperbilirubinemia, is when there is a high level of serum bilirubin causing yellow discoloration of the newborn's skin and eyes. Bilirubin is a red-orange byproduct of hemoglobin catabolism that gives yellow pigment to skin and mucosa membranes. Arreaza: When we see jaundice on the eyes, it is actually the conjunctiva color we are seeing. So, the term “scleral icterus” should be changed to “conjunctival icterus,” but you may get corrected by unaware clinicians. Bilirubin actually binds elastin.What's the pathophysiology/ big picture?Jenni: The key problem is the accumulation of high levels of bilirubin in serum and if left untreated, it can bind to tissues and cause toxicity. There are multiple reasons why there might be too much bilirubin in the serum. Excess bilirubin can be due to a benign normal condition, but it can also be due to a pathologic reason. It is important to differentiate between these two because the management and treatment can differ significantly. Arreaza: Highly bilirubin means that it is being either overproduced or under-eliminated. Physiologic jaundice Most of the time, hyperbilirubinemia is benign and physiologic, with yellowing typically occurring between 2-4 days. Normally, there is a period of transition caused by the turnover of the fetal red blood cells and the immaturity of the newborn's liver to efficiently metabolize bilirubin and increased enterohepatic circulation. The most common reason is that the liver isn't mature enough to get rid of the bilirubin in the bloodstream or because the baby's gut is sterile, so it does not have the bacteria to convert the bilirubin to get it out of the body. In general, newborns have a higher level of total serum or plasma bilirubin levels compared to adults for the following reasons: Newborns have more red blood cells (hematocrit between 50-60), and fetal red blood cells have a shorter life span (85 days vs. 120 days) than those of adults. After birth, there is an increased turnover of fetal red blood cells, so there is more bilirubin.Bilirubin clearance (conjugation and excretion) is decreased in newborns, mainly because of a deficiency of the hepatic enzyme UGT.Increase in the enterohepatic circulation of bilirubin as the amount of unconjugated bilirubin increases due to the limited bacterial conversion of conjugated bilirubin to urobilin.Pathologic JaundicePathologic jaundice includes severe neonatal hyperbilirubinemia, extreme neonatal hyperbilirubinemia, and bilirubin-induced neurologic disorders. We determine the severity of the jaundice using the total serum bilirubin (TSB). It is defined as a TSB >25 (severe) and TSB >30 (extreme). Other concerning signs include a TSB over the 95% percentile, a greater than 5mg/dL/day or 0.2mg/dL/hour, or jaundice that lasts for more than 2-3 weeks. Potential pathologic causes include but are not limited to: Increased bilirubin production from increased hemolysis which is when the red blood cells in the baby are being destroyed faster than normal, this can be due to blood group incompatibilities where the mom's immune system starts to attack the baby's red blood cells (such as Rh incompatibility) or from RBC membrane defects (spherocytosis).Birth Trauma when the head gets bruised after a vacuum or forceps is used to remove the baby from the vaginal canalInfection which prevents the bilirubin from being metabolized and excretedProblems with bilirubin clearance either from enzyme deficiencies such as Crigler-Najjar or Gilbert syndromeObstructed biliary systems causing bile to get stuck in the liverArreaza: Indirect bilirubin is the one elevated in newborns, but if you see direct hyperbilirubinemia, then you have to think of an obstruction.Jenni: Severe hyperbilirubinemia can cause brain damage. The amount of bilirubin and the duration of bilirubin ultimately determine the severity of the brain damage. This is because the bilirubin blocks some mitochondrial enzymes from being able to function properly, also it inhibits DNA synthesis/protein synthesis, and can cause DNA damage. This can ultimately lead to acute bilirubin encephalopathy which is described as 3 different phases: Phase 1 with poor feeding, lethargy, hypotonia, and seizures, Phase 2 with increased tone in extensor muscles causing neck contractions (retrocollis and opisthotonos), and Phase 3 with generalized increased tone. If the bilirubin encephalopathy persists it can also ultimately cause cerebral palsy, sensorineural hearing loss, and gaze abnormalities.  How and when do we treat? No phototherapy:The goal of treating jaundice is to safely decrease the amount of bilirubin in the body. Oftentimes babies with mild hyperbilirubinemia don't get any treatment and we just watch and wait. In premature babies, there is an increased risk for brain toxicity because a lower amount of bilirubin can result in brain toxicity. For these babies, it is important to ensure there is adequate breast milk to both prevent and treat jaundice because it helps the baby get rid of bilirubin through the stool and urine. Arreaza: Indirect sunlight exposure of the baby.Phototherapy:Other babies get phototherapy or more commonly known as light therapy. Phototherapy light treatment is when the baby's skin is exposed to a special blue light which will help break down bilirubin and help with the excretion in stool and urine. The phototherapy should be continuous and placed on as much skin as possible and the treatment should be administered until bilirubin levels drop to a safe level based on the baby's hour-specific thresholds. Arreaza: Home phototherapy is an option (UV blanket) available for rent or purchase.Phototherapy is very safe, however, with any treatment, there are risks and potential side effects. Some of these include skin rashes, loose stools, overheating, and dehydration. Occasionally, babies turn a dark gray-brown color in their skin and urine, but this is temporary and usually resolves on its own. While the baby is receiving phototherapy, it is important to continue breastfeeding to ensure appropriate fluid hydration, but in babies that cannot get enough breast milk, they may need to supplement with formula or even potentially start IV fluids. Benefits of screeningIt is therefore essential for universal bilirubin screening for all newborns prior to discharge to identify newborns who are at risk for developing severe hyperbilirubinemia. Hyperbilirubinemia is extremely common in newborns, with nearly all neonates having a higher total serum bilirubin than adults. The reason we screen is that this reduces the risk of developing severe hyperbilirubinemia and ultimately brain damage. This universal screening also then decreases hospital readmissions for neonatal hyperbilirubinemia. Arreaza: So, we check at 12-24 hours in a typical pediatric unit. We use a bilimeter (transcutaneous) and if we suspect it is not accurate, we do a serum bili. Be aware of the accuracy of bilimeters.How do we screen? We do this prior to newborn discharge through a transcutaneous bilirubin device (TcB) or lab total serum bilirubin (TSB). The bilirubin level is used with the assessment of risk for the development of severe hyperbilirubinemia. Newborn bilirubin screening guidelines include TSB or TcB within 24-48 hours after birth or before discharge. TcB is the noninvasive test, but TSB is the gold standard for assessing neonatal bilirubin. Newborns with visible jaundice in the first 24 hours should be concerned for severe hyperbilirubinemia. These babies should be screened earlier because of the risk of pathologic causes of jaundice. In addition to the bilirubin test, physicians will clinically assess by examining the skin under ambient or daylight to assess whether there is a yellow discoloration of the buccal, gingival, or conjunctival mucosa. Additionally, if a baby presents with scleral icterus, pallor, bruising, hepatosplenomegaly, or cephalohematoma (enclosed hemorrhage), these can be clinical presentations of neonatal jaundice. Follow up:After screening, we recommend that babies be closely monitored if jaundice does occur as it can be well managed with early treatment. A quick way to assess this at home is to press gently on the baby's forehead and if the skin looks yellow where you press, it's probably jaundice. If your baby doesn't have jaundice, then the place where you pressed it should look lighter than normal. _____________________Conclusion: Now we conclude episode number 133, “Neonatal Jaundice.” Jennifer explained the pathophysiology behind the increased levels of bilirubin in babies. She reminded us that it is a physiologic process, but when the level of bilirubin is too high, then we need to start treatment. Treatments include indirect sunlight exposure of the baby, breastfeeding, and in some cases phototherapy, IV fluids, and even antibiotics and exchange transfusion in some cases. Dr. Arreaza reminded us of the importance of screening and monitoring “bili babies” in the clinic. This week we thank Hector Arreaza and Jennifer Lai. 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:Episode 17: Why does bilirubin deposit in the eyes? – The Curious Clinicians, https://curiousclinicians.com/2021/01/20/episode-17-why-does-bilirubin-deposit-in-the-eyes/.Ansong-Assoku B, Shah SD, Adnan M, et al. Neonatal Jaundice. [Updated 2022 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532930/.Mayo Clinic. “Infant Jaundice – Symptoms and Causes.” Mayo Clinic, 2018, www.mayoclinic.org/disease-conditions/infant-jaundice/symptoms-causes/syc-20373865.“Newborn Jaundice.” Nhs.uk, 19 Oct. 2017, www.nhs.uk/conditions/jaundice-newborn/#:~:text=Jaundcie%20in%20newborn%20babies%20is.Preud'Homme D., “Neonatal Jaundice.” American College of Gastroenterology, Dec 2012, https://gi.org/topics/neonatal-jaundice/.Wong R., et al. “Risk factors, Clinical Manifestations, and Neurologic Complications of Neonatal Uncomplicated Hyperbilirubinemia.” Up to Date, Last Updated: Jan 5, 2023, https://www.uptodate.com/contents/risk-factors-clinical-manifestations-and-neurologic-complications-of-neonatal-unconjugated-hyperbilirubinemiaRoyalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

Pro tip from today's guest: Don't bring A-Rod into a Nashville dive bar. Also, always make sure your chickens are protected. Lastly, just because you like Diet Coke and binge-watching Netflix doesn't mean it's an "era".Intro (0:00)Celebrity baseball game (12:50)Football pressure (20:55)Tim Tebow (26:55)Fulfillment (40:15)Baseball guy vs football guy (1:10:30)A-Rod at Tin Roof (1:16:18)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC5/5 Jacksonville, FL5/6 Tampa, FL5/7 Fort Myers, FL5/19 Fort Collins, CO5/20 Grand Junction, CO5/21 Boise, ID6/3 Louisville, KY6/4 Washington, DC6/10 Salt Lake City, UT6/11 Colorado Springs, CO6/23 Sacramento, CA6/24 Fresno, CA6/25 Thousand Oaks, CA6/30 Las Vegas, NV7/1 San Diego, CA7/2 Anaheim, CA7/21 Goshen, IN-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSOR:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comBlinkist: Go to blinkist.com/netpositive  to start your 7-day free trial AND get 25% off of a Blinkist Premium membership. And now, for a limited time, you can use Blinkist Connect to share your premium account you will get 2 premium subscriptions for the price of one.Miracle Made: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

The infamous question: where is the line? Are you important enough to make demands at work? Should concerts be held in the morning instead of at night? Can you share an ice cream cone with someone?Topics Include: Intro (0:00)You overshot it (16:20)The Breaking Bad house (21:16)Country artists in the morning (30:23)Sharing germs (41:00)Ego's Anonymous (56:20)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC5/5 Jacksonville, FL5/6 Tampa, FL5/7 Fort Myers, FL5/19 Fort Collins, CO5/20 Grand Junction, CO5/21 Boise, ID-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSOR:Athletics Greens: Free 1-year supply of Vitamin D & 5 free travel packs. Go to athleticgreens.com/netpositiveMiracle Made: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

We might have found a common ground among everyone and it's Carrie Underwood. It's not Earl, the Dixie Chicks killed him.Intro (0:00)Carrie Underwood is our olive branch (7:12)Dixie Chicks Killed Earl (12:03)Funny facial hair guy (22:48)SNL, what are you doing? (38:04)FGL rules (57:40)Female Influencers (1:04:44)Confession time, fan mail (1:06:30)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC5/5 Jacksonville, FL5/6 Tampa, FL5/7 Fort Myers, FL5/19 Fort Collins, CO5/20 Grand Junction, CO5/21 Boise, ID-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSOR:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comBlinkist: Go to blinkist.com/netpositive  to start your 7-day free trial AND get 25% off of a Blinkist Premium membership. And now, for a limited time, you can use Blinkist Connect to share your premium account you will get 2 premium subscriptions for the price of one.PRODUCED BY:Alex Lagos / Lagos Creative

This episode consists of multiple mini-interviews of people with different backgrounds and paths to medicine exploring how they dealt with med-school/life balance. We asked everyone about hobbies, professions, sports, relationships, and pets during medical school (and beyond). Featuring Arianna Tovar, MD. Research Fellow at the Bascom Palmer Eye Institute, Sofia De Arrigunaga, MD. Research Fellow at the Bascom Palmer Eye Institute, Araliya Gunawardene, MS3 at NSU MD, and Piero Carletti, MS4 at NSU MD.

Jared Mullins is a triple threat, and that's a guarantee. We aren't quite sure what the third piece is, but he definitely has it. -----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSOR:Miracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

Episode 130: Epigenetics in childhood obesitySaakshi and Dr. Arreaza discuss some principles of epigenetics implicated in the development of obesity in children. Written by Saakshi Dulani, MS3, Western University College of Osteopathic Medicine of the Pacific. Edited 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.This topic is constantly expanding, and I'm excited to talk about it. It is a fact that epigenetic changes play a role in the development of certain diseases such as Prader-Willi syndrome, Fragile X syndrome, and various cancers. It has been demonstrated that certain foods can alter gene expression in animals, for example. What is epigenetics?Epigenetics is the regulation of gene expression without a change in the base sequence of DNA. Epigenetics means “on top of” the genes. Genes can be turned “on” or “off” as a response to external influences. Obesity and Epigenetics.The link between genetics and obesity is complex, but it is known that epigenetics plays a significant role in childhood obesity. Surprisingly, exposure to environmental factors starts in the uterus. Fetuses are exposed to intrauterine signals that increase their potential to develop obesity. Factors such as in-utero hyperglycemia, gestational diabetes mellitus, and early childhood diet and lifestyle practices can affect the development of the gut microbiome, modify gene expression through DNA methylation, and increase the risk of childhood obesity. These gene expression changes can be passed on to future generations. DNA methylation is the addition of a methyl group to part of the DNA molecule. That methyl group acts as a “chemical cap,” which prevents gene expression. Another example of epigenetics is histone modification. Histones are proteins that are used by DNA as spools to wrap around pieces of information that are “not needed”. The reason why a scalp cell and a neuron are different is that the expression of certain genes is suppressed while other genes are expressed.Factors that influence obesity.Some factors that increase the risk of childhood obesity through epigenetic changes include neonatal intestinal microbiome, C-section delivery, maternal insulin resistance, exposure to antibiotics and other environmental toxins, early introduction of complementary foods, parental diets high in carbohydrates and low in fruits and vegetables, and poor sleep. There are many other factors, but we will discuss only a few of them.Microbiome:The microbiome is a whole new world that is being explored by many investigators. The gut microbiome refers to the diverse community of organisms, including bacteria, fungi, and viruses, that reside in the human intestine. The neonatal intestinal microbiome is established during the first two years of life and may be influenced by factors such as the method of delivery, maternal obesity, and the maternal gut microbiome. Some bacteria worth mentioning are Bacteroides, Clostridium, and Staphylococcus. These gut bacteria are higher in pregnant women who have obesity, and they also have a low count of Bifidobacterium. Infants born to obese mothers have higher levels of bacteria associated with increased energy harvest compared to infants born to normal-weight mothers. The gut microbiome of infants delivered by C-section is different than infants delivered vaginally.Link to antibiotics:Early exposure to antibiotics is associated with the development of resistance in microorganisms. The intestinal microbiota exposed to antibiotics also shows reduced diversity. Antibiotics can decrease the number of mitochondria and impair their function, which is important in maintaining energy metabolism. Evidence suggests that some antibiotics can cause mutations in the mitochondrial genome, and they have a direct effect on the microbiome and influence metabolism. There is a strong association between early-life antibiotic exposure and childhood adiposity, with a strong dose-response relationship. A stronger association has been seen with exposure to broad-spectrum antibiotics and macrolides. Maternal insulin resistance (IR):Insulin resistance means that the mother needs levels of insulin that are higher than normal to stay normoglycemic. It means the insulin receptors are “exhausted” and do not respond to normal levels of insulin. Insulin does NOT cross the blood-placenta barrier, but glucose and other nutrients do. This causes the fetus to have an abundance of glucose that stimulates the secretion of high levels of insulin by the fetal pancreas to stay normoglycemic. The combination of insulin + glucose is the perfect combination for anabolism, adipocyte hyperplasia, and fetal growth. That explains why mothers with insulin resistance deliver larger babies (macrosomia). Maternal insulin resistance is a predictor of infant weight gain and body fat in the first year of life. This is not influenced by the mother's BMI before pregnancy. Maternal insulin resistance causes alterations in gene regulation for lipids, amino acids, and inflammation, leading to long-term health implications for both the mother and future pregnancies.C-section and obesity:C-section delivery is a saving procedure for many obstetrical emergencies. C-sections have improved the survival of larger infants and their mothers. C-sections are more frequent among populations with obesity and sedentary lifestyles. This method of delivery is also strongly associated with childhood obesity. Among many other reasons, whenever a vaginal delivery is feasible, a vaginal delivery is preferred over a c-section.   In summary, we discussed 4 factors that may influence childhood obesity: the newborn microbiome, exposure to antibiotics, maternal insulin resistance, and C-sections. There are many other factors that we did not talk about, but the more we know about genetics, epigenetics, and metabolism, the closer we get to a better understanding of obesity._____________________Conclusion: Now we conclude our episode number 130, “Epigenetics in childhood obesity.” Saakshi discussed with Dr. Arreaza that the in-utero environment can alter gene expression and increase the risk of obesity in children. Some factors, such as maternal insulin resistance and changes in gut microbiome, can be the cause of obesity in some children. This week we thank Hector Arreaza and Saakshi Dulani. 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! _____________________Sources:Burdge GC, Hoile SP, Uller T, Thomas NA, Gluckman PD, Hanson MA, Lillycrop KA. Progressive, transgenerational changes in offspring phenotype and epigenotype following nutritional transition. PLoS One. 2011;6(11):e28282. doi: 10.1371/journal.pone.0028282. Epub 2011 Nov 30. PMID: 22140567; PMCID: PMC3227644. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3227644/Rachael Rettner, Epigenetics: Definition & Examples, Live Science, published on June 24, 2013, available at: https://www.livescience.com/37703-epigenetics.htmlMulligan CM, Friedman JE. Maternal modifiers of the infant gut microbiota: metabolic consequences. J Endocrinol. 2017;235: R1-R12.Aghaali, M. and S. S. Hashemi-Nazari (2019). “Association between early antibiotic exposure and risk of childhood weight gain and obesity: a systematic review and meta-analysis.” J Pediatr Endocrinol Metab 32(5): 439-445.Yuan C, Gaskins AJ, Blaine AI, et al. Association between cesarean birth and risk of obesity in offspring in childhood, adolescence, and early adulthood. JAMA Pediatr. 2016;170(11):e162385. doi: 10.1001/jamapediatrics.2016.2385.Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

I think it's time you see a therapist. You can see if this couple who has been married for 58 years through 5 murder attempts will give you a recommendation. Now back to the real show...Topics Include:Intro (0:00)Time to see a therapist (7:25)Trapped in the airport by a fan (13:05)Asbury University revival (22:04)Just be honest (35:20)The News (52:00)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comAthletics Greens: Free 1-year supply of Vitamin D & 5 free travel packs. Go to athleticgreens.com/netpositive Stamps.Com: Get a 4-week trial, free postage, and a digital scale at https://www.stamps.com/netpositive. Thanks to Stamps.com for sponsoring the show!PRODUCED BY:Alex Lagos / Lagos Creative

By now, all IMGs who entered the 2022-2023 resident application cycle are toward the finish line. If you hear “rank order list” again, you might scream. Don't fret, this episode is dedicated to international medical students. Join host Tiffany as she interviews Match A Resident Ambassador and MS3 student Zein Khater about the ups and downs of medical school life.

Superbowl commercials were bad, and we can only blame ourselves. The solution? Join Aaron Rodgers on his darkness retreat.Intro (0:00)Cauliflower sandwich (7:45)Guys need something to do (11:50)Superbowl(20:28)Aaron Rodgers darkness retreat (36:11)The news (57:14)Fan emails (1:13:05)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/17 - Saginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Miracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

Judas definitely didn't execute that business deal correctly. Too bad he didn't have Mr. Beast or TD Jakes to help him out.Topics Include: Intro (0:00)Mr. Beast (23:33)The Lords Advocate (33:24)Judas' failed business deal (38:04)What's that country line mean? (50:10)The News (1:14:44)Fan emails (1:27:31)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/17 - Saginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comMiracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

We've got a guest on the show today, and it someone's voice we have literally all heard, and if you say otherwise you are a liar. He made a record deal with the Lord, and was almost in a band with Bert Kreischer kind of? Welcome to the show, Scott Stapp  from Creed.-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Saginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comMiracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

Episode 127: Obesity Update and Uterine CancerSaakshi presents some updates on the treatment of obesity in pediatric patients. Wendy explains a recent study connecting hair iron to uterine cancer. Updates on obesity management in pediatric patients.Written by Saakshi Dulani, MS3, Western University College of Osteopathic Medicine of the Pacific. Edited by Hector Arreaza, MD.Background information:The American Academy of Pediatrics has released new guidelines on obesity management in pediatric patients. This is the first update regarding childhood obesity in 15 years. According to the CDC, the rates of childhood obesity have tripled since the 1980s, and as of now, 1 in every 5 children suffers from obesity in the United States. It is important to recognize obesity is a chronic, multifaceted disease that comes with its own set of complications, such as type 2 diabetes mellitus, high blood pressure, asthma, sleep apnea, heart disease, and various mental and psychosocial health issues. The first-line treatment used to be comprised of behavioral health and lifestyle counseling, however, now, 1st line treatment for pediatric patients includes medications and surgery in addition to the previously suggested counseling. This is because research has shown that diet and level of physical activity are not the only factors that determine weight but also include genes, hormones, and metabolism. Similar to many other chronic diseases, the sooner the treatment is started, the better. There has been no benefit shown in waiting for adulthood to treat obesity. Who qualifies for which treatments?As a reminder, in the pediatric population, we use the BMI percentiles instead of the absolute number for BMI. Overweight is defined as BMI between 85-95th for patients of the same gender and age. Obesity is defined as being above the 95th percentile.Four drugs are now approved for obesity treatment in adolescents starting at age 12, which are Saxenda® (liraglutide), Qsymia® (phentermine-topiramate), Wegovy® (semaglutide), and Xenical® or Alli® (orlistat). Phentermine as monotherapy has been approved for teens aged 16 and older. Another drug called Imcivree® has been approved for children 6 and older affected by Bardet-Biedl syndrome. The problem with medications is that they are not available to everyone due to the cost, and there are many shortages occurring due to the high demand for these drugs. Surgical options:This is a MAJOR change in the recommendations for obesity treatment in children.  The new guidelines recommend discussing SURGERY with patients that are 13 years old and have severe obesity. It has been shown that bariatric surgery provides lasting results but also that it can reverse health issues such as type 2 diabetes mellitus and hypertension. It is exciting that more research is being done to provide us with more evidence regarding the treatment of obesity in children. Obesity treatment is challenging, even more so in children. So, we encourage all listeners to review the new guidelines about the use of medications and surgery to treat obesity in children and put them to practice if appropriate for your patients.____________________________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.____________________________Hair products and uterine cancer.Written by Wendy Collins, MS3, Ross University School of Medicine. Edited by Hector Arreaza, MD.What is the sister study? The Sister Study is a nationwide effort in the US conducted by the National Institute of Environmental Health Sciences, which includes over 50,000 sisters of women who have had breast cancer. This study aims to find environmental and genetic causes of breast cancer. The women in this study were breast cancer free and lived in the United States, including Puerto Rico. They were enrolled from 2003-2009 and were followed up until September 2019. If the sister study is made up of 50,000 women, why does this study only use about 30,000 of those women? Excluded women include those who withdrew from the study (n = 3), who self-reported a diagnosis of uterine cancer before enrollment (n = 380), had an uncertain uterine cancer history (n = 10), had an unclear timing of diagnosis relative to enrollment (n = 59), had a hysterectomy before enrollment (n = 15,585), who did not answer any hair product use questions (n = 736), and who did not contribute any follow-up time (n = 164), resulting in 33,947 eligible women. How was it done?The authors reviewed medical records and questionnaires about hair care within the past 12 months and compared women who developed uterine cancer with those who did not for about 10 years between 2003-2009. Of this sample, only 378 women developed uterine cancer. Further investigation needs to be done to make worthwhile associations between hair straighter use and the incidence of uterine cancer. This study drew 2 primary conclusions:Hair products are not associated with uterine cancer: No associations were found between hair product usage and the incidence of uterine cancer. This was investigated because it's thought that synthetic estrogenic compounds, such as endocrine-disrupting chemicals, could contribute to uterine cancer risk because of their ability to alter hormonal actions. This is something that has been linked to breast and ovarian cancers in the past, so it made sense to consider the same for uterine cancers.Using a straightening iron is positively associated with uterine cancer: Ever vs. never use of a straightening iron in the previous 12 months was associated with a hazard ratio of 1.80 with 95% confidence interval 1.12 to 2.88. The association was stronger when comparing frequent use (>4 times in the past 12 months) vs never use was associated with a hazard ratio of 2.55, 95% confidence interval 1.146 to 4.45.This was investigated because it is thought that heating processes such as flat ironing or blow drying could release or thermally decompose chemicals from the products. This can lead to potential higher exposures to hazardous chemicals through inhalation or percutaneous absorption of chemicals, which is higher in the scalp compared to other areas. While this hypothesis makes sense and supports the results, there are many confounding variables, including physical activity. Women with higher physical activity tend to have decreased sex steroid hormones and less chronic inflammation, reducing their risk of uterine cancer.Hair products are not associated with uterine cancer, and straightening iron is positively associated with uterine cancer, but further research is needed.The incidence of uterine cancer in the past 20 years has significantly increased. Investigating reasons for why this might be could lead to the discovery of potential targets for intervention. However, I am personally unconvinced by this study, and I fully intend to continue to use hair products, my blow dryer, my curling iron, my crimper, and yes even my straightener for the foreseeable future until further research is done.__________________________Conclusion: Now we conclude episode 127 “Obesity Update and Uterine Cancer.” We learned from Saakshi that the American Academy of Pediatrics now recommends discussion of pharmacologic and surgical treatments for pediatric obesity; then Wendy explained that some association between hair iron and uterine cancer was found but further research is needed. This week we thank Hector Arreaza, Saakshi Dulani, and Wendy Collins. Audio edition 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:Chang CJ, O'Brien KM, Keil AP, Gaston SA, Jackson CL, Sandler DP, White AJ. Use of Straighteners and Other Hair Products and Incident Uterine Cancer. J Natl Cancer Inst. 2022 Oct 17:djac165. doi: 10.1093/jnci/djac165. Epub ahead of print. PMID: 36245087. https://pubmed.ncbi.nlm.nih.gov/36245087/American Academy of Pediatrics Issues Its First Comprehensive Guideline on Evaluating, Treating Children and Adolescents With Obesity, American Academy of Pediatrics, AAP.org, published on January, 9, 2023, available at: https://www.aap.org/en/news-room/news-releases/aap/2022/american-academy-of-pediatrics-issues-its-first-comprehensive-guideline-on-evaluating-treating-children-and-adolescents-with-obesity/Gumbrecht, Jamie and Jacqueline Howard, Updated childhood obesity treatment guidelines include medications, surgery for some young people, January 11, 2023. CNN.com, available at: https://www.cnn.com/2023/01/09/health/childhood-obesity-treatment-guidelines-wellness/index.htmlSullivan, Kaitlin, New guidelines for treating childhood obesity include medications and surgery for first time, January 9, 2023. NBCnews.com, available at: https://www.nbcnews.com/health/kids-health/new-guidelines-treating-childhood-obesity-include-medications-surgery-rcna64651Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

There is one situational coffee that is superior to all, and we discover it. Along with a lion on Kylie Jenners dress.Intro (0:00)Broadway stack's (3:47)Situational coffee (12:40)Unmuting People (27:15)Fashion Week reactions (37:05)Kim K's scoreboard (54:15)Video mailbox submission (1:06:05)Fan emails (1:12:00)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Saginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comMiracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

Third-year OHSU medical students, Candace Chan and Devon Boorstein-Holler rehash the information from our first sleep medicine & psychiatry talk in a question-and-answer format. This episode is part of a project to help determine optimal podcast formats for student learning. Hosted by: Devon Boorstein-Holler, MS3 & Candace Chan, MS3 Questions? psychiatryexplored@gmail.com Studies Mentioned: Overview on the pharmacology of sleep: https://aasm.org/resources/pdf/pharmacologictreatmentofinsomnia.pdf Study on melatonin in OTC: https://jcsm.aasm.org/doi/full/10.5664/jcsm.6434 NEJM Bob Sack review melatonin for jet lag: https://www.nejm.org/doi/10.1056/NEJMcp0909838?url_ver=Z39.88-%202003&rft_id=ori:rid:crossref.org&rfr_dat-cr_pub%20%200pubmed Study on two groups with insomnia or not, odds to develop depression: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108260/ Resource for online CBTI: https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia CBTI for depression: https://academic.oup.com/sleep/article/31/4/489/2454177?login=true IRT vs. IRT+CBT vs. Prazosin: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265653/

In this episode, I get the opportunity to converse with Munachi, an MS3 at Dell Med. We spoke about growing up in Houston as a Nigerian/American, what drives her, and her journey to becoming a physician. Tune in!!!

Episode 126: Caffeine and AKI.  January 20, 2023. Olivia and Janelli explain that caffeine intake during pregnancy may cause short height in babies, and Anthony discusses the definition, evaluation, and management of AKI with Dr. Kooner. Introduction: Caffeine consumption during pregnancy. Written by Olivia Weller, MS3, American University of the Caribbean School of Medicine; and Janelli Mendoza, MS3, Ross University School of Medicine.Current Guidelines about caffeine during pregnancy: The American College of Obstetricians and Gynecologists (ACOG) current recommendations are to limit caffeine consumption during pregnancy to 200 mg of caffeine per day. Anything exceeding a moderate level of caffeine intake has been linked to an increased risk for preterm birth and miscarriage. [8 oz of brewed coffee has approximately 137mg of caffeine. Other drinks and foods contain caffeine: Brewed tea 48mg; Decaf coffee (12 oz), 9-15 mg; caffeinated soft drink (12 oz) 37mg, Dark chocolate (1.45 oz) 30mg] New Evidence: More recent data disclosed that moderate levels of caffeine consumed during pregnancy led to newborns being small for gestation age (SGA). This information was taken further, and scientists began to monitor these children as they aged. Researchers studied newborns born to mothers who consumed zero caffeine during pregnancy versus women who consumed moderate levels of caffeine. They tracked height, weight, BMI, and obesity risk but only found statistical differences in height. So far, they have only investigated children up to the age of 8 and found that the variance in height increased as the children got older. Therefore, even consuming a moderate level of caffeine during pregnancy can have lasting effects on a child's height, which likely persists into adulthood. Some professionals are now saying there may be no amount of caffeine that is safe to consume during pregnancy. American Family Physician Journal, 2009: “Caffeine intake is directly correlated with small but notable fetal growth restriction. Although a safe threshold cannot be determined, maternal caffeine intake of less than 100 mg per day minimizes the risk of fetal growth restriction.”Why does smaller birth size matter? Caffeine crosses the placenta and acts as a vasoconstrictor which reduces the blood supply to the fetus and thus hinders proper growth. It is a sympathomimetic agent that can affect fetal stress hormones and increase the risk for rapid weight gain after birth. Although height is not a pressing issue, children are potentially more susceptible to increased risk for certain conditions later in life, such as obesity, heart disease, and diabetes. More research is needed on this front to make the conclusion that these differences do in fact persist into adulthood and lead to adverse health outcomes. Conclusions and limitations. Pregnant women and children remain as a group with the least amount of research due to the potential adverse life outcomes. For this reason, the studies that have been done on caffeine consumption during pregnancy are comprised of self-reported data. Due to the association between high caffeine consumption and smoking, it is difficult to distinguish the two. Therefore, there is no clear cause-and-effect relationship between caffeine and intrauterine growth restriction (IUGR), leading to shorter stature later in life. However, the potential adverse health outcomes outweigh the psychological benefits of caffeine during the gestational period. If mothers can give up alcohol, drugs, smoking, raw fish, and so much more during pregnancy, why not caffeine too? With the emergence of this new information, perhaps it is time for a review of those guidelines. Welcome: 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.Acute Kidney Injury. January 20, 2023. Written by Anthony Floresca, MS4, American University of the Caribbean School of Medicine; edited by Hector Arreaza, MD; recording done with Gagan Kooner, MD.Definition of Acute Kidney Injury (AKI): Acute kidney injury is a clinically relevant disease process that often occurs during hospitalizations but can also occur as a result of pre-existing diseases such as diabetes mellitus, hypertension, and congestive heart failure, usually referred to as “AKI on CKD,” i.e., acute kidney injury can present as a worsening of renal function in a patient who already has decreased renal function at baseline. AKI is defined as a sudden onset decrease in renal function that can be diagnosed as early as 6 hours from disease onset. To diagnose AKI, specific parameters to consider are creatinine and urine output. Kidney Disease: Improving Global Outcomes or KDIGO established criteria in 2012 for diagnosing AKI:An increase in serum creatinine of ≥ 0.3 mg/dL within 48 hours, [for example, a serum creatinine increasing from 1.3 (baseline) to 1.6]An increase in serum creatinine ≥ 1.5 times baseline within the past week, [for example, an increase in serum creatinine from 1.3 (baseline) to 1.95]A decrease in urine output < 0.5 mL/kg/hr within 6 hours, [for example, a man who weighs 70 kg and is urinating less than 35mL of urine per hour]Classification:The severity of AKI is defined under the 2012 KDIGO guidelines: Stage ICreatinine 1.5-1.9 times greater than baseline or  ≥ 0.3 mg/dL increase in serum creatinine.Urine volume < 0.5 mL/kg/hr for ≥ 6-12 hoursStage IICreatinine 1.5-1.9 times greater than baseline or  ≥ 0.3 mg/dL increase in serum creatinine.Urine volume < 0.5 mL/kg/hr for ≥ 6-12 hoursStage IIICreatinine 3 times higher than baseline OR ≥ 4.0 mg/dL increase in serum creatinine(Kooner: For example, if a creatinine at baseline is 0.8 and it increases to 2.4, it is stage III)Anthony: Yes, it is stage III if the patient initiates renal replacement therapy (hemodialysis), OR a decrease in GFR to < 35 mL/min per 1.73 m^2 in patients

John buys a gun, and your horse will bring you home. Just make sure DJ Khaled isn't driving.Intro (0:00)John buys a gun (10:15)Biggest fear: Loitering (33:36)John's "too soon" video (41:08)The News (58:43)Fan Emails (1:12:14)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Saginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comMiracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

Episode 125: Non-opioid Chronic Pain Management Dr. Axelsson and Jesse explain how to treat chronic pain without opioids. Written by Anika Soleyn, MS4, Ross University School of Medicine. Edited by Jesse Lamb, MS3, American University of the Caribbean; Hector Arreaza, MD; and Fiona Axelsson, MD.This is the 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.Axelsson:Welcome to the first episode of 2023, Happy new year! Today is January 10, 2023.What is chronic pain?According to the International Association for the Study of Pain, chronic pain is nonstop or reoccurring pain that lasts more than 3 months or beyond the expected clinical course of illness. Chronic pain can adversely affect well-being and quality of life. We used to think of pain as a response to tissue damage, and as the tissue heals, the pain dissipates, but chronic pain is much more complex than that because there may be no evidence of tissue damage, yet the nociceptors keep sending signals to the brain that there is damage.There are 3 options for the management of chronic pain: non-pharmacologic, nonopioid pharmacological and opioid management. CDC recommends a combination of nonpharmacological and non-opioid management for chronic pain. The 7 most common chronic pain conditions are neuropathic pain, fibromyalgia or chronic pain syndrome, osteoarthritis, inflammatory arthritis, low back pain, chronic headache, and sickle cell anemia.Opioids in long-term care facilities.The use of opioids for the treatment of pain is common in the post-acute and long-term care setting. From the AFP Journal, the Choosing Wisely Recommendation states: “Don't provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.” The Society for Post-Acute and Long-Term Care Medicine published a statement in 2018 about the use of opioids. It states that the prescription of opioids should be based on an interprofessional assessment specifying why opioids are needed. When long-term opioids are not being used for cancer, palliative care, or end-of-life care in a long-term facility, a tapering plan must be “individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment with non-pharmacologic therapies and non-opioid medications”. Long-term opioid prescriptions should be reviewed regularly and take into consideration the potential harms of opioids. Clinicians are encouraged to offer alternatives such as behavioral therapy, non-opioid analgesics, and other non-pharmacologic treatments whenever available and appropriate.Initial assessment: Identify biopsychosocial factors and identify if the source is neuropathic, nociceptive, or central sensitization. This can be a challenging process and it may require several visits to determine the origin of pain. Neuropathic pain is due to nerve damage or irritation while nociceptive pain is due to tissue damage. Central sensitization is an abnormal response of the nociceptive system. There are changes in the nervous system that alter how it responds to sensory input that causes widespread pain with no apparent cause or in response to mild sensory input. Some examples include fibromyalgia, migraines in response to brushing hair, surgical scar pain, etc.Set goals and expectations: It is crucial to set up patient expectations if they have chronic pain. They should understand that pain can be improved to a manageable level but not always eliminated. Patients should have routine follow-up visits with education, and reassurance since they are shown to improve outcomes of pain management. Specific goals such as improved mobility and ability to do certain enjoyable tasks are more reasonable and specific goals than a goal of pain elimination. A good physician-patient relationship and clear communication are essential here. Patients could obviously become deeply upset at the prospect of pain that can't be eliminated, and those who have received opioids for their pain in the past could be even more distraught at the thought of not getting them now or needing to reduce their dose. The physician should be ready to have this discussion with their patients that have chronic pain and be ready to address their concerns appropriately. Reduce catastrophic thinking: Pain is an alarm system letting someone know there is some sort of damage. Because of this, it makes sense that a patient would respond to pain with anxious and catastrophic thinking. Patients who understand their own chronic diseases are more likely to be actively involved in their treatment, so understanding is crucial in the management of pain. Reducing fearful thoughts such as "there must be something wrong," and "hurt means harm'” is an important first step toward pain self-management and making sure the strategies attempted are effective.Rehabilitation: Focused pain clinics often include educational group classes for patients in distress. The programs include explanations for why pain might be present with no pathological factors. It also includes relaxation and mindfulness that help patients soothe themselves during attacks. The brain plays a big role in the experience of pain. Changing how your brain relates physical pain to stress and reducing those psychosocial barriers through self-care helps with pain management. Finding things that make you physically stronger like physical therapy or occupational therapy help, but also increasing mental strength by doing things that make you happy and having a quality social life is a strong determinant of how the brain perceives physical pain. Consistency is key in pain management even after the patient begins to feel better.Non-pharmacologic therapy – Most of what we will talk about today is non-pharmacological treatment. We will discuss the options and goals of different treatments. Chronic pain treatment should start with non-pharmacological approaches and then you can add medications if necessary. Again, these approaches aim to increase functionand reduce progression despite chronic pain. There should be a consistent non-pharmacological regimen, even if medications are added later. The three main approaches will be physical therapy, psychological therapy, and some integrative medicine methods.Physical therapy. The objective of physical therapy is to improve physical function. You should recommend programs that are specific for patients' limitations and the physical therapist should have trained specifically in chronic pain treatment. This ensures they do a proper initial evaluation and select appropriate therapeutic methods such as Therapeutic exercise: Sometimes patients can become so fearful of painful movement that they have deconditioned muscles. In the geriatric population, some patients are so afraid of falling, that they avoid any form of movement whatsoever, therefore almost certainly leading to falls due to deconditioning of those muscles. Adding small amounts of exercise as tolerated can begin to recondition patients and help them build strength. Patients with severe osteoarthritis are more likely to tolerate aquatic exercises. Therapeutic exercise programs may be available at the physical therapy facility or community centers. Patients can even find videos on the internet of tai chi, yoga classes, Pilates, and low-impact fitness programs. Exercise can certainly reduce pain and improve function, with few adverse effects but make sure patients tolerate the exercises and are not pushed beyond their limits. Stretching can also improve range of motion and strength, especially in chronic lower back pain patients. Psychological therapy:Cognitive-behavioral therapy. It is the most researched and recommended psychological treatment for chronic pain. It's normally recommended in conjunction with patient education, physical therapy, and exercise. CBT can be used after introducing meds and/or after surgery. There are 2 components to cognitive behavioral therapy: cognitions and behaviors. CBT addresses the way that patients' thoughts (cognitions) affect their actions and vice versa. This begins with helping patients identify situations and environments that trigger their pain and what they actually experience emotionally, behaviorally, and physically when they have pain.CBT addresses mental responses that may worsen pain, so patients learn to think about how they view their pain. To do this, they use a range of specific behavioral strategies such as relaxation and controlled-breathing exercises, activity pacing, pleasurable activities, improving their sleep, and cognitive reappraisal strategies, such as reframing negative situations to positive or practicing gratefulness.Complementary and integrative health therapies.-Mindfulness-based stress reduction. Mindfulness is the ability to be fully present where we are and what we're doing, and not be overly reactive or overwhelmed by what's going on around us.-Progressive muscle relaxation. For instance, tensing/relaxing muscles throughout the body along with positive imagery and meditation.-Biofeedback. During biofeedback, you're looking at biological signs, and feedback that is being correlated to physical sensations in your body to recognize the correlation between physical signs and symptoms of chronic pain. You're connected to monitors, such as electromyograms or electroencephalograms, to quantify muscle tension, brain waves, heart rate, and blood pressure to see how fluctuations and abnormal numbers physically feel in the body.-Massage therapy. It can relax painful muscles, tendons, and joints and relieve stress. The effect of pressure in certain areas that are tender causes relaxation and secretion of endorphins that can calm pains. That's why massage therapy can actually be addictive for some people, because of the endorphins. Another benefit of massage therapy is that it can help with improved absorption of medications due to improved circulation.There are many other integrative health therapies including Reiki, hypnosis, therapeutic touch, healing touch, and homeopathy. However, these are not well-researched and can't really be endorsed by evidence-based medicine.If patients are interested in trying complementary, integrative health therapy, you can guide them to practices that are at least safe. Some therapies can end up being harmful, such as herbal remedies or supplements with potential toxicities or known interactions with medications, so those should be taken cautiously. Make sure your med list while taking your history includes supplements and herbs patients might be trying. Shirodhara is an Ayurvedic approach to stress relief that involves having someone pour liquid — usually oil, milk, buttermilk, or water — onto your forehead.Herbal or plant-based treatments have also shown some efficacy in published studies. Ginger, turmeric, St John's Wort, and a handful of others seem like they could have some beneficial effects either on their own merit or as an adjunctive with other non-opioid therapies. Caution should be taken, though, as some of them, particularly St John's Wort, have been shown to have negative impacts on serum levels of opioids when used in combination with them due to their effects on the liver cytochrome system. Data is also rather mixed, with some studies showing reasonable efficacy and others showing almost none. If your patients want to take herbal supplements, it is essential to be diligent about checking their efficacy and interactions with other therapies to ensure safety. The physician should also be clear when discussing current medications to ask specifically if they take herbal supplements of any kind, as many patients don't consider these to be “medications” and will omit them during history. Of note, turmeric has to be taken with black pepper for better GI absorption.Weight reduction: A healthy diet and fitness are always recommended. Online guidelines are helpful on topics such as healthy fats, vegetables, avoiding refined sugar, and more. Obesity is a pro-inflammatory state, but it is important not to blame chronic pain problems solely on obesity since patients may still have pain after losing weight. Weight reduction can be a part of that plan, but we should not promise a cure for chronic pain after a patient reaches an ideal weight. Sleep disturbances: Ironically, sleep improves pain, but pain makes sleep more difficult. If patients complain of sleep disturbances, start with behavioral changes, including improved sleep hygiene (keep a regular sleep schedule, exercise regularly, don't use caffeine and caffeinated beverages, don't eat too late at night) and stimulus control (the bed should only be used for two things: sleep and sex, get out of bed if you can't sleep, wake up at the same time every day, and avoid bright screens before bedtime because they confuse your brain); cognitive behavioral therapy (deal with concerns or worries that may interfere with sleep). Treating sleep disturbance may have a positive effect on the treatment of chronic pain. Acupuncture: It involves the insertion of very thin needles through the skin at specific points on the body. Acupuncture is a key component of traditional Chinese medicine and can be considered in patients with chronic pain. There are significant difficulties in studying acupuncture, but randomized trials suggest that acupuncture and placebo may have similar efficacy, and both are superior to no treatment. Pharmacologic therapy – For patients with inadequate analgesia despite nonpharmacologic therapies, we add carefully selected multi-targeted pharmacological therapies based on the type of pain (i.e., nociceptive, neuropathic, central sensitization) For nociceptive pain, start with non-steroidal anti-inflammatory drugs (NSAIDs) while continuing non-pharmacologic treatments. If that doesn't work add a topical agent such as lidocaine, capsaicin, or topical NSAIDs. Consider opioid treatment if neither of those works. For neuropathic pain, start with antidepressants or antiepileptic drugs: tricyclic antidepressants, SNRIs, pregabalin, gabapentin, or carbamazepine in addition to non-pharmacologic therapy. If those medications do not provide relief of pain, then you can consider adding topical agents and then opioids after weighing the risk and benefits. Side effects can be viewed as harmful, but we can use them for our benefit.Opioids are reserved for people with moderate to severe pain who cannot function. Once you identify a treatment that works for the patient, follow-up visits should be continued to promote behavioral changes, monitor therapeutic response, and treat side effects. A pain contract should also be signed.Follow-up visits – Schedule follow-up visits to continue educating patients and their families and caregivers, to continue motivational interviewing, and to monitor improvement. Refer patients who are not making enough progress, such as not reaching goals of function and quality of life, to comprehensive pain programs that can use additional modalities such as injections.Bottom line: Non-pharmacologic options should be considered in the management of all patients with chronic pain. The main non-pharmacologic strategies include physical therapy, psychological therapy, and complementary and integrative therapy. Remember to treat sleep disturbances and obesity as part of your plan. Add pharmacologic agents such as NSAIDs, antidepressants, and anticonvulsants when non-pharmacologic therapies do not help the patient reach their goals. Consider opioids only in moderate to severe pain with loss of function. Opioid prescription is a complex topic that was addressed in episode 31 of this podcast, more than 2 years ago, it is time for an update. Stay tuned, we will talk about opioids soon.____________________________Conclusion: Now we conclude episode number 125, “Non-opioid Chronic Pain Management.” Non-pharmacologic therapy is proven to be effective in the treatment of chronic pain, especially physical therapy, psychological therapy, and some complementary therapy. Medications can be added to non-pharmacologic therapy, mainly NSAIDs, antidepressants, antiepileptic medications, and more. Opioids can be added in disabling chronic pain, but prescription needs to be done cautiously and watchfully. The treatment of chronic pain may be challenging and daunting at times, but fortunately, we have science to back us up with effective ways to help our patients. So, don't be discouraged and trust science! This week we thank Fiona Axelsson, Jesse Lamb, and Hector Arreaza. 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:Tauben, David, Brett R Stacey, Approach to the management of chronic non-cancer pain in adults, UpToDate. Last updated on May 06, 2022. Accessed January 10, 2023. https://www.uptodate.com/contents/approach-to-the-management-of-chronic-non-cancer-pain-in-adults.Choosing Wisely Recommendations: Don't provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life, American Family Physician, Collections 460, American Academy of Family Physician. Link: https://www.aafp.org/pubs/afp/collections/choosing-wisely/460.html.What is Mindfulness? Mindful.org. https://www.mindful.org/what-is-mindfulness/.Jahromi B, Pirvulescu I, Candido KD, Knezevic NN. Herbal Medicine for Pain Management: Efficacy and Drug Interactions. Pharmaceutics. 2021; 13(2):251. https://doi.org/10.3390/pharmaceutics13020251.Royalty-free music used for this episode: “Good Vibes - Fashionista." Downloaded on October 13, 2022, from https://www.videvo.net/

We weren't sure if this could be done, but it's a double-barrelled episode.Intro (0:00)Growing Up In Amish Communities (8:50)How To Work Hard (29:39)Working at Whiskey Row (48:02)Tipping Fatigue (1:00:26)Rating Bottle Opening Videos (1:26:56)Lizzo Comes To john's Rescue (1:34:35)-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Saginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comPRODUCED BY:Alex Lagos / Lagos Creative

We are back and psyched for 2023. In the new year, it is time to unmute everyone on Instagram, and also take a few notes from the Amish. They seem to have it figured out.-----BUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonU-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Saginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comPRODUCED BY:Alex Lagos / Lagos Creative

This NOT a "best of episode" like everyone else.  John and Alex have all the "rizz" heading into the new year.-----WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonUBUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Siginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, subscribe to our new clips channel, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comMiracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

Happy Holidays, enjoy your Costco hot dog!-----WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonUBUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Siginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, subscribe to our new clips channel, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comMiracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

It's time for your buzzcut.-----WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonUBUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Siginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, subscribe to our new clips channel, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + free shipping with promo code NETPOSITIVE at manscaped.comMiracle Brand: Save OVER 40% + 3 free towels with promo code NETPOSITIVE at trymiracle.com/NETPOSITIVEPRODUCED BY:Alex Lagos / Lagos Creative

In this episode, we get a close-up look at Hunter Biden's laptop, and he's quite funny.-----WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonUBUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Siginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, subscribe to our new clips channel, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + Free Shipping with promo code NETPOSITIVE at manscaped.comPRODUCED BY:Alex Lagos / Lagos Creative

Episode 121: Genital Herpes.     Wendy and Grace discuss the signs, symptoms, diagnosis, and management of genital herpes. Written by Jaspreet Johal, MS4, Ross University School of Medicine. Edits by Grace Yi, MS2, University of California Los Angeles; and Wendy Collins, MS3, Ross University School of Medicine. Comments by Hector Arreaza, MD.  December 1, 2022.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 & EpidemiologyGenital herpes is a common sexually transmitted infection caused by a virus called herpes simplex virus (HSV for short). There are two types of HSV. HSV type 1 commonly causes orolabial herpes (known as cold sores), and HSV type 2 typically causes genital herpes, which can present as painful blisters or ulcers in the genital regions. In recent years, an increasing number of genital herpes cases have been associated with HSV-1, especially in women. HSV infections are widespread among the global population and spread person to person through oral-to-oral contact or vaginal, anal, and oral sexual contact. Transmission can occur during periods of subclinical viral shedding, as in even when individuals are asymptomatic. In 2020, the seroprevalence of HSV-2 in the United States was approximately 13 percent among patients aged 15 to 49, with more women affected than men. Fifty to 80 percent of American adults have oral herpes (HSV-1), which causes cold sores or fever blisters in or around the mouth. HSV is a lifelong infection characterized by periodic reactivations that can be triggered by fatigue, stress, or illness, among other factors. Antiviral therapy can shorten symptom duration in primary infection and can also treat and prevent recurrences. Types of InfectionGenital HSV infection can be classified into three types: primary, nonprimary, and recurrent. Primary – Primary infection refers to an infection in a patient without preexisting antibodies to either HSV-1 or HSV-2.Nonprimary infection, a patient has a first occurrence of a genital HSV lesion but already has pre-existing HSV antibodies that are different from the HSV type related to the genital lesion.Recurrent – Recurrent infection refers to the reactivation of genital HSV (so the patient already has pre-existing antibodies in the serum)Clinical Features The incubation period for developing genital herpes after exposure ranges anywhere from 2 to 12 days.Most patients with primary HSV infection are asymptomatic or mildly symptomatic. However, in more severe cases, individuals can present with painful genital ulcers, dysuria, fever, tender local inguinal lymphadenopathy, and headache. HSV infection also presents with characteristic 2-4mm wide skin lesions that are vesicular or ulcerated. The vesicles are often clustered and can be fluid-filled with underlying erythema. Sometimes vesicles might have a depression in the center (called “umbilicated” vesicles.” It's important to note, though, that the clinical presentation can vary based on the type of infection (primary, nonprimary, or recurrent). As a general rule of thumb, the initial presentation of a non-primary genital infection tends to be milder (as in, fewer systemic symptoms and lesions) than that of a primary infection. Recurrent infections also tend to be less severe than primary or nonprimary infections. Also, around 50% of patients with symptomatic recurrent infections might experience prodromal symptoms in recurrent infections, like burning, pain, or pruritus, before lesions become visible.Symptoms in patients with primary infections typically resolve after an average of 19 days, whereas symptoms in nonprimary or recurrent infections resolve within 10 days. Also, there are no clear differences in a clinical presentation based on whether the virus is caused by HSV-1 or HSV-2. However, infections due to HSV-2 are associated with a higher recurrence rate than infections due to HSV-1. Extragenital complications Genital HSV infection can cause extragenital manifestations that typically occur during the primary episode of HSV infection but can reappear with subsequent episodes. Complications include aseptic meningitis, urinary bladder retention, proctitis, and lumbosacral radiculitis. Other areas that can be affected outside of the genital area are fingers, eyes, and other skin areas.Diagnosis.A clinical diagnosis of genital herpes is usually initiated by the finding of vesicular or ulcerated genital lesions. The diagnosis can be confirmed with lab testing like viral culture, polymerase chain reaction (PCR), direct fluorescence antibody, and type-specific serologic testing. The most appropriate test for a patient depends on their clinical presentation. We might opt for PCR-based testing and cell culture if a patient has active lesions. Viral culture has typically been the gold standard method to isolate HSV, but HSV PCR assays are becoming increasingly popular as they have the best overall sensitivity and specificity. Cell cultures are most accurate in the early stages of the disease and have greater diagnostic yield with primary as opposed to recurrent genital herpes. Another method, type-specific serologic testing, tells us if a patient has type-specific antibodies to HSV, which develop in the first few weeks after infection and persist indefinitely. We might opt for this method if a patient has a history of genital lesions without a diagnostic workup or if the patient has an atypical presentation, in which case we may get type-specific serologic testing in addition to PCR. Management. All individuals experiencing a first episode of genital HSV should be treated with antiviral therapy, ideally as soon as a lesion appears. Most cases of genital HSV can be treated with oral drug therapy for 7 to 10 days, and as of 2021, the CDC recommends 3 different options for treatment: acyclovir, famciclovir, and valacyclovir. These drugs have been shown to decrease the duration of lesion healing time, duration of pain, and duration of viral shedding. For example, if the disease is disseminated or ocular, we may use IV acyclovir in complicated infections. It is important to note that treating the initial episode does not eliminate the latent virus. Patients are still at risk for recurrence and may require additional antiviral therapy. For recurrent infections, treatment options include episodic therapy and chronic suppressive therapy. Episodic therapy – involves patients starting therapy at the very first sign of prodromal symptoms (tingling, paresthesia, pruritus). Patients with infrequent recurrences or mild symptoms might opt for episodic therapy. Wendy: Chronic suppressive therapy – involves daily antiviral therapy to decrease the risk of reactivation and recurrences. Suppressive therapy is helpful in patients with frequent recurrences or severe symptoms or at high risk for severe infections, such as those with HIV.ScreeningAccording to the US Preventive Services Task Force (USPSTF), routine screening for HSV-1 or HSV-2 is not recommended in asymptomatic adolescents and adults. The lack of specific treatment interventions for asymptomatic individuals, and the significant limitations of serologic testing, including low specificity and high false-positive rate, outweigh the potential benefits of screening. Prevention. Measures to prevent genital HSV infections include the use of barrier protection, patient education, and chronic suppressive therapy. Barrier protection – The use of condoms is one of the best ways to prevent the spread of genital HSV infection and other sexually transmitted diseases. It reduces the risk of transmission while patients are asymptomatic but are in the viral shedding stage. Patients with active lesions or prodromal symptoms should abstain from sexual activity completely while having an active episode. Patient Education – Counseling patients along with their sex partner(s) about safe sexual practices can decrease the incidence of HSV in our community and prevent the further spread of the disease. Chronic suppressive therapy – can reduce recurrences and viral transmission.Conclusion: Genital herpes is a sexually transmitted, worldwide infection that can be asymptomatic but often presents with painful vesicles that progress to ulcers in the genital area. Even though the course can be shortened, and the symptoms can be improved with medications, it is frequently recurrent. So, prevention is key to avoiding complications.________________________________Now we conclude episode number 121, “Genital herpes.” You listened to Grace and Wendy discuss the basics of genital herpes. They explained that episodic treatment of genital herpes with antivirals helps reduce the severity and duration of symptoms, while suppressive therapy prevents recurrences and transmission. Dr. Arreaza reminded us that screening asymptomatic adults and adolescents is not recommended by the USPSTF. HSV serology has a low sensitivity and specificity. PCR and viral culture are better diagnostic tools in most cases. And, as with all other STIs, promoting safe sex practices is key to the prevention of genital herpes.We thank Hector Arreaza, Grace Yi, Wendy Collins, and Jaspreet Johal this week. Audio edition by Adrianne Silva.Even without trying, you go to bed a little wiser every night. 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:Albrecht, Mary A. Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection, Up to Date, last updated: Dec 22, 2020. https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-genital-herpes-simplex-virus-infection.Albrecht, Mary A. Treatment of genital herpes simplex infection, Up to Date, last updated: Jun 28, 2021. https://www.uptodate.com/contents/treatment-of-genital-herpes-simplex-virus-infectionJames C, Harfouche M, Welton NJ, Turner KM, Abu-Raddad LJ, Gottlieb SL, Looker KJ. Herpes simplex virus: global infection prevalence and incidence estimates, 2016. Bull World Health Organ. 2020 May 1;98(5):315-329. doi: 10.2471/BLT.19.237149. Epub 2020 Mar 25. PMID: 32514197; PMCID: PMC7265941. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265941/Royalty-free music used for this episode: “Keeping Watch,” New Age Landscapes. Downloaded on October 13, 2022, from https://www.videvo.net/royalty-free-music-albums/new-age-landscapes/.

Comedian Shama is in the studio today. The primary takeaway is that your church needs flying drummer boys, and you need a reign-it-in guy. Get it done.-----WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonUBUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Siginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, subscribe to our new clips channel, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + Free Shipping with promo code NETPOSITIVE at manscaped.comPRODUCED BY:Alex Lagos / Lagos Creative

We get it you love Taylor Swift, but you have 3 kids and you're late for a staff meeting. Pull it together before we have to send the crew from Black Hawk Down to rescue you... -----WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonUBUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Siginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, subscribe to our new clips channel, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + Free Shipping with promo code NETPOSITIVE at manscaped.comPRODUCED BY:Alex Lagos / Lagos Creative

Want to know what medical school is actually like? These four medical students are in different phases of their medical school programs and will provide you with their perspective based on their experience. On our panel we have...Emamoke Stephen Odafe is an MS1 at the Uniformed Services University of the Health and Sciences. Sarah Bradley, an MS2 at the Medical University of South Carolina. Luke Hendrix, an MS3 at UT Health San Antonio, MD program. And Yunus Tekin, a 4th year DO medical student at Burrell College of Osteopathic MedicineMentioned in this episode:Ad 2022 11 21 MSHQ BFCM

Cory Asbury is in the studio with John today, and all we know for certain is that the chi is not effed, and God can still save you even if you do yoga or wear a Halloween mask.-----WATCH 'What Are We Doing' (Full Special): https://youtu.be/0a3nPKvhonUBUY John's First Book 'Delete That': https://johncristcomedy.com/deletethat/-----THE EMOTIONAL SUPPORT TOUR: https://johncristcomedy.com/tour/2/3 - Bowling Green, KY2/4 - Cincinnati, OH2/17 - Siginaw, MI2/18 - Indianapolis, IN2/23 - Shipshewana, IN2/24 - Shipshewana, IN2/25 - Grand Rapids, MI3/10 - Albuquerque, NM3/11 - El Paso, TX3/12 - Midland, TX3/17 - Shreveport, LA3/18 - Fort Worth, TX3/19 - Fayetteville, AR3/23 - Cleveland, MS3/24 - Memphis, TN3/25 - St. Louis, MO3/31 - Fayetteville, NC4/1 - Charlotte, NC4/2 - Charlotte, NC4/14 - Clear Lake, IA4/15 - Omaha, NE4/16 - Kansas City, MO4/21 - Athens, GA4/22 - Savannah, GA4/28 - Augusta, GA4/29 - Asheville, NC-----Catch the full video podcast on YouTube, subscribe to our new clips channel, and follow us on social media (@netpositivepodcast) for clips, bonus content, and updates throughout the week.Email us at netpositive@johncristcomedy.comFOLLOW JOHN ON:InstagramTwitterTikTokFacebookYouTubeSUPPORT OUR SPONSORS:Manscaped: Get 20% OFF + Free Shipping with promo code NETPOSITIVE at manscaped.comPRODUCED BY:Alex Lagos / Lagos Creative

Episode 117: Anxiety Screening. Adriana and Ikleel explain the new recommendation given by the USPSTF in October 2022 regarding screening for anxiety in children and adolescents 8-18 years old. Dr. Arreaza discusses the SCARED tool to screen for anxiety in pediatric patients. By Adriana Rodriguez, MS3, and Ikleel Moshref, MS3. Ross University School of Medicine. Moderated 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.Recommendation.The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years. Grade of recommendation: B (offer this service to your patients)The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in children 7 years or younger. Grade of recommendation: I (insufficient evidence, unknown benefits vs. harms)USPSTF concludes this new screening guideline for anxiety in this population has a moderate net benefit. For children 7 and younger, evidence is insufficient to determine screening tools accuracy and its effects, and benefit-to-risk balance. Anxiety. Anxiety disorder is characterized by excessive, persistent worry and or fear that is difficult to control, resulting in significant distress or impairment. Anxiety disorder manifests in psychological/emotional and physical/somatic symptoms. DSMV recognizes 7 types of anxiety disorders: GAD, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism. Comment: Anxiety is not your patient's fault. In some cultures, anxiety is seen as a weakness. America seems to be a highly stressful society.Epidemiology.Anxiety disorder is a common mental health condition in the United States. According to the National Survey of Children's Health in 2018-2019, 7.8% of people aged 3-17 yrs. old had an anxiety disorder that was current. In the adult population, past studies have shown ~3% past-year prevalence and ~5-12% lifetime prevalence of anxiety disorder in adults. Topic Importance.Anxiety disorders are the most common childhood-onset mental health condition. Childhood and adolescent anxiety disorder is associated with an increased likelihood of poor academic performance and co-occurring psychiatric conditions. It is also associated with future anxiety disorder, secondary depression, substance abuse, psychosocial functional impairment, chronic mental/somatic health conditions, and/or suicide. Screening anxiety disorder in youth may serve to improve potential prevent burdens in the future. Assessment of Risk. Although this new screening guideline is meant for children and adolescents aged 8-18 who have not been diagnosed with an anxiety disorder and without signs and symptoms, it is important to note what factors would increase their chances of developing any of the aforementioned anxiety disorders: Genetic, personality, and environmental factors: biopsychological vulnerability, attachment difficulties, child maltreatment, adverse childhood experience Demographic factors: poverty, low socioeconomic statusRacial and ethnic factors: racial discrimination, historic trauma, structural racismOther factors: LGBTQ youth, older adolescents 12-17Screening Tools.Although there are many screening tests for anxiety, two are widely utilized in clinical practice for screening purposes: (1) SCARED (Screen for Child Anxiety Related Disorders), and (2) Social Phobia Inventory. These screening instruments are insufficient for the actual diagnosis of any particular anxiety disorder listed earlier; if positive, however, a confirmatory assessment and follow-up is required to establish diagnosis using DSM V criteria for any of the recognized anxiety disorders (GAD, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism).SCARED (Screen for Children Anxiety Related Disorders): It is a 41-Item questionnaire, each question can be answered from 0-2 (0=not true or hardly true, 1=somewhat true or sometimes true, 2=very true or often true). A score greater than or equal to 25 is highly associated with anxiety disorder; panic disorder, significant somatic symptoms, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and significant school avoidance. SCARED is available online (here). There is a child version and a parent version. The only difference between the two is the different pronouns, for example, question 17 is “My child worries about going to school” vs “I worry about going to school”. Although the USPSTF could not find optimal screening intervals, these screenings may be best used in older adolescents aged 12-17 yrs. old with risk factors for anxiety disorder. Other anxiety screening tools have been assessed by the USPSTF but were insufficient for the purposes of this guideline because they were too specific to a specific anxiety disorder (for example, the Social Phobia and Anxiety Inventory for Children), were for a particular set of disorders, or were too long to use for screening in a primary care setting. In studies found by the USPSTF, social anxiety disorder and GAD were the most common detected anxiety disorder in children and adolescents. Fun fact: What is the most common phobia in the US? Public speaking, AKA glossophobia.Treatment. Anxiety disorders can be treated with medications, psychotherapy, a combination of both, or multidisciplinary care. Of the variety of psychotherapies available, cognitive behavioral therapy (CBT) is the most used. As for pharmacotherapy, US FDA has only approved duloxetine, an SNRI, for the treatment of GAD in children 7 yrs. and older. Off-label prescriptions of other drugs have been reported to treat anxiety in youth. Potential Harms.False-positive screening results may lead to an unnecessary burden on the patient and family from avoidable referrals, monetary costs, anxiety, the stigma of illness, and adverse effects of pharmacotherapy (weight loss, cholesterol, etc.)Bottom line: Anxiety is a treatable mental condition and detection in childhood is now recommended by the USPSTF. Screen if you have a way to treat (refer or treat yourself).____________________________Conclusion: Now we conclude episode number 117 “Anxiety Screening.” Adriana and Ikleel explained that screening for anxiety disorders in children between 8-18 is now a grade B recommendation by the United States Preventive Services Task Force. During this episode, you heard about “SCARED”, a useful screening tool to help in the diagnosis of anxiety disorders in children. Once diagnosed, anxiety is treated with psychotherapy, medications, or a combination of both. This week we thank Hector Arreaza, Adriana Rodriguez, and Ikleel Moshref. Audio edition 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:Final Recommendation Statement, Anxiety in Children and Adolescents: Screening, United States Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents#fullrecommendationstart, accessed on Oct 11, 2022. Screen for Child Anxiety Related Disorders (SCARED), available online, for example: Oregon Health & Science University: https://www.ohsu.edu/sites/default/files/2019-06/SCARED-form-Parent-and-Child-version.pdfBennett, Shannon, et al. Anxiety disorders in children and adolescents: assessment and diagnosis, UpToDate, last updated: Aug 19, 2022. https://www.uptodate.com/contents/anxiety-disorders-in-children-and-adolescents-assessment-and-diagnosis.Baldwin, David, et al. Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis, UpToDate, last updated: Apr 18, 2022. https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis.Craske, Michelle, et al. Generalized anxiety disorder in adults: Management, Up to Date, last updated Nov 12, 2021. https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-management.Royalty-free music used for this episode: Real Live by Gushito, downloaded on October 1, 2022, from https://www.videvo.net/. 

Episode 115: Erectile Dysfunction Diagnosis.  Discussion about the diagnosis of erectile dysfunction with Andrew, Adriana, and Dr. Arreaza. Causes, labs, and physical exam is briefly discussed. Written by Andrew Kim, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Adriana Rodriguez, MS3, Ross University School of Medicine; and Hector Arreaza, MD.September 22, 2022.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.In episode 39 o erectile dysfunction, Dr. Ihejirika gave us an overview, but today we will be more detailed about the diagnosis of ED. Definition.The American Urological Association (AUA) published an erectile dysfunction guideline in May 2018, which is available online at no cost. Based on that guideline, erectile dysfunction can be defined as “the consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction, including satisfactory sexual performance.” Comment: This guideline provides 25 principles for diagnosing and treating ED. Diagnosis.Getting a good history is important when diagnosing erectile dysfunction. The patient should be asked about the onset of symptoms, severity, how much it hinders his sexual performance, whether the patient can get and maintain an erection, psychological factors, social factors, and presence of morning erections. One can use different questionnaires: the five-question International Index of Erectile Function (IIEF-5) or a single-question self-assessment. Single-question self-assessment:Impotence means not being able to get and keep an erection that is rigid enough for satisfactory sexual activity. How would you describe yourself?Not impotent: always able to get and keep an erection good enough for sexual intercourse.Minimally impotent: usually able to get and keep an erection good enough for sexual intercourse.Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse.Completely impotent: never able to get and keep an erection good enough for sexual intercourse.Comment: Basically, the single-question self-assessment is a self-diagnosis of erectile dysfunction; the patient is giving you the severity of his condition. This questionnaire seems to be very subjective. International Index of Erectile Function (IIEF-5):IIEF-5 asks five questions, and the patient answers on a scale of 1 to 5 (1 is the worst, 5 is the best)How do you rate your confidence that you could get and keep an erection?When you had erections with sexual stimulation, how often were your erections hard enough for penetration?During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?When you attempted sexual intercourse, how often was it satisfactory for you?Diagnosis can be made based on the total score. 1 to 7: severe ED, 8 to 11: moderate ED, 12 to 16: mild-moderate ED, 17 to 21: mild ED, and 22 to 25: no ED.This is a self-reported questionnaire, and the score should be interpreted in a clinical context. Answers will likely be biased if, for example, the questionnaire is asked by a female medical assistant. Causes of ED:It is important to assess for medical conditions, psychological conditions, and medications because ED can be caused by vascular, neurological, psychological, and hormonal problems.  Cardiovascular: Some common conditions related to ED are cardiovascular disease (PAD, CAD) and HTN.Endocrine: DM, HLD, obesity, testosterone deficiency (hypogonadism), hyperprolactinemia, thyroid disorder, metabolic syndrome.Neurologic: Neurologic conditions (multiple sclerosis, stroke, spine injury), trauma, and venous leakage.Lifestyle causes: sedentary lifestyle, tobacco use.Psychological: Performance anxiety, relationship issues, anxiety, depression, and stress are common psychological causes.Medications and substances: Alcohol, illicit drugs, and nicotine are important causes of ED, but some medications also cause or worsen ED: opiates, diuretics (spironolactone), antifungals (azoles), anticonvulsants, antidepressants (SSRIs), antihistamines, H2 blocker (cimetidine) antihypertensives, nasal decongestants, and antipsychotics. Remember to ask about over-the-counter medications and supplements.Physical exam: Measure blood pressure, BMI, and a complete exam, especially a genital exam. A comprehensive genitourinary exam should include the inspection of the testicles (atrophy, varicocele, signs of hypogonadism). The penis should be inspected and palpated (look for scar tissue and Peyronie's plaques) and assessment of penile stretch/flaccid length (it is done by stretching the penis. An elastic penis is a healthy penis). Dr. Winter's expert opinion: consider a prostate exam in older patients presenting with ED.Labs: Following physical examination, some lab tests can be ordered to further evaluate possible causes of ED. -A1C and glucose levels can be ordered to look for diabetes. -Lipid panel for hyperlipidemia.-TSH should be checked for thyroid function and to rule out hypothyroidism. -Testosterone deficiency can be assessed by measuring morning serum total testosterone level, which is defined as total testosterone < 300 with signs and symptoms. -Prolactin (perform pituitary MRI in any degree of hyperprolactinemia. In patients taking medications that cause hyperprolactinemia, get MRI if prolactin is above 100) Why is it important to diagnose ED?ED can be linked to organic causes.- Glucose: ED is linked to increased fasting serum glucose levels (diabetes). People with PMH of DM are 3 times more likely to develop ED. The longer the patient had diabetes, the stronger association with ED. Fasting glucose levels are associated with the highest risk of ED. The probability of having undiagnosed DM is 1/50 in the age group 40 to 59 without ED but increases to 1/10 for those with ED.- Testosterone and obesity: Low serum testosterone levels can contribute to the link between metabolic syndrome and ED. In men with obesity, the adipose tissue enzyme aromatase is more prevalent and can convert testosterone into estradiol to cause hypogonadism. Furthermore, adipocytes can cause inflammation and recruit inflammatory cytokines, leading to impaired endothelial function and ED. - Cardiovascular disease: ED and CVD have some common risk factors: older age, HTN, dyslipidemia, smoking, obesity, and DM. ED is related to an increased risk of CVD, CAD, and stroke. Usually, it is thought that ED arises two to five years prior to CAD. If a patient develops signs and symptoms of ED before CAD, the patient can be counseled and educated to make lifestyle modifications to prevent CAD.Furthermore, men with ED are more likely to experience angina, MI, stroke, TIA, CHF, and cardiac arrhythmias when compared to their counterparts without ED. A study from 2003 suggested that patients with ED have a 75% increased risk of developing peripheral vascular disease. Studies suggest ED can predict silent CAD, and one study concluded that the incidence of CAD in men below 40 years of age with ED was seven times higher than that of the control population without ED. It is important to diagnose ED because it can be used as a marker for assessing cardiovascular risk.ED can be linked to many causes, and we as clinicians should be able to identify those causes to prescribe a more specific treatment. Not all ED will respond to “the blue pill”. We will talk about treatment in another episode. Conclusion: Now we conclude episode number 115, “Erectile Dysfunction Diagnosis.” Male sexual health sometimes can be taboo, and patients may not fully disclose personal issues like erectile dysfunction. Andrew and Adrianna explained that an open discussion about erectile dysfunction can help you diagnose underlying conditions, including cardiovascular disease. Dr. Arreaza reminded us that the diagnosis of erectile dysfunction should prompt a deeper investigation in most cases before you attribute it to psychological factors. This week we thank Hector Arreaza, Andrew Kim, Adriana Rodriguez, and Fiona Axelsson. Audio edition 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:Burnett AL, Nehra A, Breau RH, et al. Erectile Dysfunction: AUA Guideline. Journal of Urology. 2018;200(3):633-641. doi:10.1016/j.juro.2018.05.004. https://www.auajournals.org/doi/epdf/10.1016/j.juro.2018.05.004.Rew KT, Heidelbaugh JJ. Erectile Dysfunction. American Family Physician. 2016;94(10):820-827. Accessed September 19, 2022. https://www.aafp.org/pubs/afp/issues/2016/1115/p820.html.Khera M. Evaluation of male sexual dysfunction. UpToDate. www.uptodate.com. Last updated: April 28, 2020. Accessed September 19, 2022. https://www.uptodate.com/contents/evaluation-of-male-sexual-dysfunction.Abrams H, Winter A, Williams PN, Watto MF. “#317 Erectile Dysfunction”. The Curbsiders Internal Medicine Podcast. https://thecurbsiders.com/episode-list. January 24, 2022.Royalty-free music used for this episode: Gushito, Burn Flow. by Videvo, downloaded on May 06, 2022, from https://www.videvo.net/royalty-free-music-track/good-vibes-alt-mix/1017292/

If you ever wanted to know what it is like to be an emergency medicine physician, come listen to our very own Director of the Podcast, Assistant Professor of Medical Education here at CUSM, and an ABEM Certified EM physician, Dr. Vy Han. Sit back and enjoy one of the most popular professors here at the medical school. This episode is hosted by the wonderful Jon Oules, MS3.

This week on A Fist Full of Dirt podcast we visit with a family that just went for it. Sold everything and moved from California and bought a farm in Mississippi. That took a lot of grit and they share the whole journey with us. Why they did it and how they did it. Man I love happy endings. Listen and be inspired. #courage #land #family #goals

Episode 105: Renal Cell Carcinoma. Manpreet and Jon-Ade explain how to diagnose renal cell carcinoma. Introduction about age and kidney transplant by Dr. Arreaza and Dr. Yomi. Introduction: Too old for a new kidney?By Hector Arreaza, MD. Discussed with  Timiiye Yomi, MD.Today we will be talking about the kidneys, those precious bean-shaped organs that detoxify your blood 24/7. Amazingly, we can live normal lives with one kidney, but when the kidney function is not good enough to meet the body's demands, patients need to start kidney replacement therapy. Modern medicine has made a lot of advances with dialysis, but the perfection of a kidney has not been outperformed by any machine yet. That's why kidney transplant is the hope for many of our patients with end-stage kidney disease.The need for a kidney transplant is growing, likely due to increasing chronic diseases such as diabetes and hypertension, and also because of an increase in elderly population. About 22% of patients on the kidney transplant waiting list are over age 65. A cut-off age to receive kidney transplant has not been established across the globe. Different countries use different criteria for the maximum age for transplant. The American Society of Transplantation's guidelines states “There should be no absolute upper age limit for excluding patients whose overall health and life situation suggest that transplantation will be beneficial.” So, if your patient is older than 65 and needs a kidney, they may qualify for a transplant, and age should not be an absolute contraindication to receive it. Actually, older patients may have lower risk of rejection due to a theoretically weaker immune system. A live donor is likely to be a better option for elderly patients. A condition that would make your elderly patient a poor candidate for kidney transplant would be frailty. Common contraindications to kidney transplant include active infections or malignancy, uncontrolled mental illness, ongoing addiction to substances, reversible kidney failure, and documented active and ongoing treatment nonadherence.So, remember to take these factors into consideration when deciding if you need to refer your elderly patients for a kidney transplant, there is no such thing as being too old for a new kidney if your patient meets all the criteria for a transplant.This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. Renal Cell Carcinoma. By Manpreet Singh, MS3, Ross University School of Medicine, and Jon-Ade Holter, MS3 Ross University School of Medicine. Moderated by Hector Arreaza, MD. Definition:Renal cell carcinoma is a primary neoplasm arising form the renal cortex. 80-85 percent of renal tumors are renal cell carcinomas followed closely by transitional cell renal cancer and Wilms tumor.  Epidemiology: In 2022, 79,000 new cases of kidney cancer were diagnosed with almost 14,000 mortalities. There is a 2:1 male to female ratio and the average age is 64 and normally 65-74. African Americans and American Indians have a higher prevalence rate compared to other racial groups. The lifetime risk for developing kidney cancer in men is about 1 in 46 (2.02%) and 1 in 80 (1.03%) in women.  Risk Factors associated with RCC: Anything that causes assault to the kidneys and affects its function would cause increased demand, injury, and inflammation. This assault can lead to cell derangement and lead to cancer. The risk factors that have been associated with RCC are smoking, obesity, HTN, family history of kidney cancer, Trichloroethylene (a metal degreaser used in large manufacturing factories), acetaminophen, and patients with advanced kidney disease needing dialysis. Patients with syndromes that cause multiple types of tumors: VHL (von Hippel-Lindau) deficiency, a tumor suppressor, gives rise to clear cell renal cell carcinoma. Familial inheritance of VHL deficiency is mostly found in patients that have RCC at a very young age, before 40 y/o. Other tumors can be found in the eye, brain, spinal cord, pancreas, and pheochromocytomas.Hereditary leiomyoma-renal cell carcinoma due to FH gene mutations causing women who have leiomyomas to have a higher risk of developing papillary RCC.Birt-Hogg-Dube (BHD) syndrome mutation in FLCN gene who develop various skin and renal tumors.Cowden syndrome is a mutation in the PTEN gene giving rise to cancers associated with breast, thyroid , and kidney cancers.Tuberous sclerosis causes benign tumors of the skin, brain, lungs, eyes, kidneys, and heart. Although kidney tumors are most often benign, occasionally they can be clear cell RCC. Screening For RCC:Screening is unnecessary because of the low prevalence of this cancer in the general population, though certain groups require annual repeat imaging via US, CT, or MRI. Inherited conditions that are associated with RCC such as VHL syndrome or Tuberous SclerosisESRD patients who have been on dialysis for 3-5 yearsFamily history of RCCPrior kidney irradiation Clinical Picture: Most patients with RCC are asymptomatic until cancer grows large enough to cause disruption of local organs, such as the kidney, bladder, or renal vein, and dysregulates other organs via metastasis. Therefore, it's important to look at other signs and symptoms caused by RCC.  The patient most likely will be an older male who presents with the classic triad of: Flank pain: caused by rapid expansion and stretching of the renal capsule.Hematuria: occurs from the invasion of the neoplasm into the collecting duct.Palpable abdominal mass: mass tends to be homogenous and mobile with respirations. Though this presents only in 9% of patients during the presentation, having physical symptoms is a sign of advanced disease and 25% of patients with these signs tend to have distant metastasis.  Anemia: normally associated with anemia of chronic disease. It precedes the disease by at least 8 months to 1 year. Males can develop varicoceles because of decreased emptying due to neoplasm obstruction. Patients normally develop varicoceles on the left due to the spermatic vein emptying in the higher resistance left renal vein, which causes backup of the blood in the pemphigus plexus. Though a right-sided varicocele should raise a higher suspicion of obstruction due to the spermatic vein draining directly into the IVC which is lower in resistance. A right-sided varicocele is seen in approximately 11 percent of patients. The paraneoplastic syndrome can also arise from RCCEpo: Erythrocytosis with symptoms of weakness, fatigue, headache, and joint pain.PTHrP: PTH-related peptide acts like PTH which gives rise to hypercalcemia with the prevalent symptoms of arthritis, osteolytic lesions, confusions, tetany, ventricular tachycardia, shortened QTc, and nausea and vomiting.Renin: overproduction from the juxtaglomerular cells can cause disarrangement of the RAAS system causing hypertension.Others also like ACTH and beta-HCG. Other disorders present include hepatic dysfunction, cachexia, secondary amyloidosis, and thrombocytosis. Workup If a patient comes in with painless hematuria, then the first test should be abdominal CT or abdominal ultrasound. A CT is more sensitive than the US but it can quickly indicate if the abdominal mass felt can be a cyst or a solid tumor.  US of kidneys should show if it's a simple cyst:-The cyst is round and sharply demarcated with smooth walls- It's anechoic – appears solid black-There is a strong posterior wall echo-Use the Bosniak classification to classify mass  Bosniak I: benign simple cyst with thin wall less than equal to 2mm, no septa or calcifications. No future workup is needed. Bosniak II: benign cyst, 3 cm diameter, requires f/u with US/CT/MRI at 6 months, 12 months, and annually for the next 5 years. Chance of malignancy: 5%.  Bosniak III: indeterminate cystic mass with thick, irregular or smooth walls. This requires nephrectomy or radiofrequency ablation. Chance of malignancy: 55%  Bosniak IV: Clearly a malignancy its grade III with enhancing soft tissue components that its independent from the wall or septum. Requires total or partial nephrectomy. Chance of malignancy 100%.  CT of the kidneys for a neoplasm should show:-Thickened irregular walls or septa -Enhancement after contrast injection are suggestive of malignancy-CT can also help detect invasion in local tissue areas such as renal vein and perinephric organs  MRI is used if the patient cannot use contrast or kidney function is poor. MRI can also evaluate the growth of the cancer. Other imaging studies:Other imaging studies that may be useful for assessing for distant metastases include bone scan, CT of the chest, magnetic resonance imaging (MRI), and positron emission tomography (PET)/CT. Treatment and staging Nephrectomy, partial or total, will be used as the initial tissue collection for pathology. If the patient is not a surgical candidate, you can also obtain a percutaneous biopsy. The nephrectomy is preferred because first, it serves as a definitive treatment option, but also it allows for definitive staging of the cancer with tumor and nodal staging. Regardless of the size, any solid mass may indicate malignancy and point towards RCC, requiring resection.   TNM staging Stage I: Tumor is 7cm across or smaller and only in the kidney with no lymph nodes or distant mets. T1N0M0 Stage IIa: Tumor size is larger than 7cm but still in the kidney but no invasion of lymph node or mets. T2N0M0 Stage IIb: Tumor is growing into the renal vein or IVC, but not into neighboring organs such as adrenals or Gerota's fascia and still lacks lymph node invasion and mets. T3N0M0.  Stage III: Tumor can be any size but has not invaded outside structures such as adrenals, though nearby lymph node invasion is present but not distant. There is no distant mets. T3N1M0. Stage IV:  The main tumor is beyond the Gerota's fascia and may grow into the adrenal gland . It may or may not spread to the lymph nodes or may not have distant mets. Stage IV also consists of any cancer that has any number of distant mets. T4 Adjuvant therapy can be done with immune therapy. Conclusion: Now we conclude our episode number 105 “Renal cell carcinoma.” This type of cancer may be asymptomatic until it is large enough to cause symptoms. Keep it on your list of differentials on patients with hematuria, flank pain, weight loss, and abnormal imaging. Keep in mind the features of simple kidney cysts vs complex cysts when assessing kidney ultrasounds. Your patient will be grateful for an early diagnosis of RCC and a prompt treatment. Even without trying, every night you go to bed being a little wiser.This week we thank Hector Arreaza, Timiiye Yomi, Manpreet Singh, Jon-Ade Holter. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week!  Bibliography: Is There a Cut Off Age for Kidney Transplant?, Mayo Clinic Connect, Jul 18, 2017, https://connect.mayoclinic.org/blog/transplant/newsfeed-post/is-there-a-cut-off-age-for-kidney-transplant/ Atkins, Michael. “Clinical Manifestations, Evaluation, and Staging of Renal Cell Carcinoma.” UpToDate, January 21. https://www.uptodate.com/contents/clinical-manifestations-evaluation-and-staging-of-renal-cell-carcinoma American Cancer Society. “Key Statistics About Kidney Cancer”. Cancer.Org, 2022, https://www.cancer.org/cancer/kidney-cancer/about/key-statistics.html. Escudier B, Porta C, Schmidinger M, Rioux-Leclercq N, Bex A, Khoo V, Grünwald V, Gillessen S, Horwich A; ESMO Guidelines Committee. Electronic address: clinicalguidelines@esmo.org. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2019 May 1;30(5):706-720. doi: 10.1093/annonc/mdz056. PMID: 30788497. https://pubmed.ncbi.nlm.nih.gov/30788497/. Gaillard, F., Bell, D. Bosniak classification system of renal cystic masses. Reference article, Radiopaedia.org. (accessed on 20 May 2022) https://doi.org/10.53347/rID-1006. Kopel J, Sharma P, Warriach I, Swarup S. Polycythemia with Renal Cell Carcinoma and Normal Erythropoietin Level. Case Rep Urol. 2019 Dec 11;2019:3792514. doi: 10.1155/2019/3792514. PMID: 31934488; PMCID: PMC6942735. https://pubmed.ncbi.nlm.nih.gov/31934488/. Leslie SW, Sajjad H, Siref LE. Varicocele. [Updated 2022 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448113/. Maguire, Claire. “Understanding Endoscopic Ultrasound and Fine Needle Aspiration.” Educational Dimension, Educational Dimensions, 1 Jan. 2007, educationaldimensions.com/eLearn/aspirationandbiopsy/eusterm.php. Maller, V., Hagir, M. Renal cell carcinoma (TNM staging). Reference article, Radiopaedia.org. (accessed on 20 May 2022) https://doi.org/10.53347/rID-4699. Palapattu GS, Kristo B, Rajfer J. Paraneoplastic syndromes in urologic malignancy: the many faces of renal cell carcinoma. Rev Urol. 2002 Fall;4(4):163-70. PMID: 16985675; PMCID: PMC1475999. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1475999/.

Episode 104: What is Monkeypox. Monkeypox is a rare disease caused by the monkeypox virus that belongs to the orthopoxvirus (smallpox) family. Nabhan, Dr. Schlaerth, and Dr. Arreaza discuss the basics of what is known about this disease. Introduction: Monkeypox By Hector Arreaza, MD. As of June 29, 2022, there are 5,115 confirmed cases of monkeypox in the world. The country with the most cases is the United Kingdom with >1,000 cases. In the United States, there are 351 confirmed cases, distributed in 28 states, and the state with the highest number of cases is California with 80 cases. Today we will briefly discuss the history, epidemiology, transmission, and management of monkeypox. By the way, by the time you listen to this episode, this disease may have a different name, as the World Health Organization is planning to rename it to minimize stigma and racism. Monkeypox is still rare, but because of the current outbreak, we need to include it in our list of differentials when we see rashes. Symptoms of monkeypox can include fever, chills, headache, myalgias, lymphadenopathies, and general malaise. The rash resembles pimples or blisters that appear on the face, inside the mouth, and on other parts of the body, like the hands, feet, chest, genitals, or anus. The rash goes through different stages before healing completely. The illness typically lasts 2-4 weeks. Monkeypox spreads by direct or indirect contact with rash, respiratory secretions, and vertical transmission from mother to fetus. Sometimes, people get a rash first, followed by other symptoms. Others only experience a rash. Currently, there is not a formal treatment for the disease. The information will continue to evolve in the future. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's 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 monkeypox. By Nabhan Kamal, MS3, American University of the Caribbean School of Medicine. Comments by Katherine Schlaerth. Moderated by Hector Arreaza, MD. Background.Monkeypox is a viral zoonotic infection that results in a rash similar to smallpox. It is estimated that humans have been infected by the monkeypox virus for centuries in sub-Saharan Africa. Monkeypox is an orthopoxvirus that was first isolated in the decade of 1950s from a colony of sick monkeys. The variola virus and the vaccinia virus are in the same genus as the monkeypox virus. Variola is the smallpox virus, and vaccinia is the virus in the smallpox vaccine. The virion that has been seen in cells infected with the monkeypox virus looks exactly the same as the virions of variola or vaccinia viruses. It has a characteristic brick-like appearance.  The two strains of monkeypox identified in different regions of Africa are Central Africa and Western Africa. It seems like the strain of Western Africa is less virulent and lacks a number of genes present in the Central African strain. Transition to talking about Epidemiology Why is understanding the epidemiology of monkeypox important? I think it's important to touch on the epidemiology of the virus because it will help healthcare providers better understand the disease and have a more productive discussion with their patients about this illness if they, unfortunately, happen to fall victim to it.  Epidemiology In the 70s, the first time monkeypox was identified as a cause of disease in humans. It happened in the Democratic Republic of the Congo (formerly the Republic of Zaire). After that, only 59 cases of human monkeypox were identified in the decade between 1970 and 1980, with a mortality rate of 17%. All of these cases occurred in the rain forests of Western and Central Africa. These cases occurred in people exposed to rodents, squirrels, and monkeys. An important fact to note is that despite the virus being called “monkeypox”, monkeys and humans are incidental hosts; the reservoir remains unknown but is likely to be rodents. Despite the current common belief that this is the first outbreak of monkeypox in the US, the actual first outbreak of monkeypox in the Western Hemisphere occurred in the United States in 2003.  Transition to talking about Transmission Is the monkeypox virus extremely virulent and transmissible just like SARS COV-2? All people born after 1972 have not been vaccinated against smallpox. Routine vaccination of the American public against smallpox stopped in 1972 after smallpox was eradicated in the United States. The virus can spread between animals and humans, just like COVID-19 is believed to be. Transmission Animal-to-human transmission – A person gets infected by monkeypox by contact with body fluids coming from an infected animal or through a bite. Monkeypox infection has been found in many types of animals in Africa, including rope squirrels, tree squirrels, Gambian poached rats, dormice, and different species of monkeys. Human-to-human transmission – In general, humans get infected from other humans through large respiratory droplets, which are produced during cough or sneezing. Also, a person can get infected by close contact with infectious skin lesions and particles or from sexual contact with skin lesions. Currently, transmission from person-to-person is very low. An outbreak of monkeypox was reported in May 2022 in non-endemic countries with over 90 confirmed cases. Non-endemic countries are all countries outside of Central and Western Africa. However, in this new outbreak, it appears that close contact with infectious skin lesions during sexual contact may be the most likely mode of transmission based on the majority of initial cases in Europe being recorded amongst men who have sex with men.  As of this recording on June 8, 2022, there are a total of 1088 cases in 29 countries. The UK leads the world with 302 confirmed cases while the US only has 34 confirmed cases.  Incubation periodThe classic incubation period of monkeypox virus infection is usually from 6 to 13 days but can range from 5 to 21 days. Important to note, however, is that persons with a history of an animal bite or scratch may have a shorter incubation period than those with tactile exposures (9 versus 13 days, respectively). So, the infection shows up earlier in people who get an animal bite or scratch. Management Most patients with monkeypox will have mild disease and recover without medical intervention. For patients who are symptomatic, most of them will not require hospitalization. Unlike chickenpox, the vesicular rash caused by monkeypox occurs all at once rather than new lesions appearing as old ones start to crust over and heal. Antivirals: In some rare cases, antiviral medications can be used for patients that become severely ill as a result of being immunocompromised from HIV, various cancers, organ transplant recipients, etc. The antiviral drug of choice is Tecovirimat. It's a potent inhibitor of an orthopoxvirus protein required for dissemination within an infected host. This medication protects nonhuman primates from lethal monkeypox virus infections and is also likely to be efficacious against infection in humans. It's interesting that these medications have been approved for smallpox treatment.  In patients that have severe disease, dual therapy with Tecovirimat and Cidofovir is recommended. It has in vitro activity against monkeypox and has been shown to be effective against lethal monkeypox in animal models. However, there isn't any clinical data regarding Cidofovir's efficacy against monkeypox infection in humans specifically, and it also has significant side effects including nephrotoxicity. In June 2021, brincidofovir was approved for use in the US for the treatment of smallpox. Brincidofovir is an analog of cidofovir (meaning that it is almost the same with some small tweaks) that can be given orally. Given how new it is, however, its clinical availability is uncertain at this time. ____________________________Conclusion: Now we conclude our episode number 104 “What is Monkeypox.” Monkeypox is a developing story and we have presented information that may become obsolete in the future. For now, remember to rule out monkeypox in your patients who are highly suspicious to have it, for example, patients with STI-related rashes or with a viral illness followed by a papular rash. Even without trying, every night you go to bed being a little wiser.This week we thank Hector Arreaza, Katherine Schlaerth, Nabhan Kamal, and Lillian Petersen.Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! _____________________References:Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/poxvirus/monkeypox/, accessed on June 30, 2022.  Muller, Madison, WHO Will Rename Monkeypox Virus to Minimize Stigma and Racism, TIME, June 14, 2022. Isaacs, Stuart, MD, Monkeypox, UpToDate, https://www.uptodate.com/contents/monkeypox, accessed on Jun 06, 2022. 

Episode 102: Fluoride supplementation in kids.Steven and Dr. Cha explained the importance of fluoride recommendations to prevent dental decay in kids who live in areas where water fluoride is low.A: When I moved to Bakersfield, my children were 3 and a 5 years old, we took them to a pediatrician, and they got a prescription for fluoride supplements, that was something I had never seen before, so I was curious, and for many years I wanted to know the fluoride content of my water. Recently, I discovered the page nccd.cdc.gov thanks to the American Family Physician article about the fluorination of water, and I found the content of Bakersfield.  Because in Family Medicine we see patients from the cradle to the tomb and from head to toe, today we will talk about dental health. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's 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.___________________________Fluoride Supplementation in Kids. Written by Steve Beebe, MS3, Ross University School of Medicine. Editions by Hector Arreaza, MD; and Gina Cha, MD.G: Let's start with the definition of fluoride, What is fluoride?S: Fluoride is a mineral – a substance that occurs in nature in its well-defined crystalline form. Put another way, fluoride is the negatively charged form of the element fluorine -- one of the elements on the periodic table. Fluoride is considered one of the essential/beneficial trace elements that our body uses for a variety of purposes. Other common trace elements include copper, iodine, iron, and zinc.[1] Where can fluoride be found?G: Fluoride is commonly found in groundwater. It can also be found in tea, bones, shells, medical supplements, and fluoridated toothpaste. The fluoride takes the place of hydroxyl groups in the tooth matrix thereby making teeth more resistant to acidic substances which reduces dental caries.A: Why is fluoride a controversial topic?S: Although fluoride and dental caries/cavities are inversely correlated, it has yet to be shown that fluoride is strictly essential.[2]A: Also, fluoride is not innocuous, it can be detrimental if taken in excess. Why is the fluorination of water important?G: Dental caries is the most common chronic disease in children. The National Health & Nutrition Examination Survey showed that over 23% of children between ages 2-5 had dental cavities.[3] Unfortunately, having dental caries is associated with localized pain, tooth loss, impaired growth, impaired weight gain, and poor school performance, and it carries a risk for dental caries in the future as an adult.[4]A: Some parents think that having caries on your baby teeth does not matter because those teeth are going to fall anyways.G: The American Academy of Pediatric Dentistry explains that fluorination of the water supply helps balance the risk of getting dental caries with the risk of fluorosis or tooth mottling from excessive fluoride intake.[5] How much fluoride is enough for human consumption?S: The National Academic Press recommends a maximum of 2.5mg of fluoride each day to avoid fluorosis (mottling of teeth). The NAP recommends 0.1 to 1mg from birth to 1 year of age and 0.5 to 1.5mg from 1-3 years of age as safe and adequate.[6]The United States Preventive Services Task Force (USPSTF) recommends starting an oral fluoride supplement at 6 months of age in areas where the water supply is deficient in fluoride. S: Topical application of fluoride is seen as safe as early as the eruption of primary teeth.[7] (A: dental varnishing we do in well-child exams). Unfortunately, the USPSTF mentions that there have been no studies done to adequately address the dosage of oral fluoride supplementation in children with poor water fluoridation. Is there such a thing as too much fluoride?G: Yes. Symptoms are dose-dependent and range from generalized pain, nausea, vomiting, diarrhea, staining of the teeth (fluorosis), renal dysfunction, cardiac dysfunction, coma, and death. When do we start giving fluoride supplements to our patients if needed?S: The American Dental Association (ADA) recommends cleaning the teeth of children under the age of 2 years old with water and a brush as soon as teeth protrude into the mouth – a grain of rice-sized smear of fluoridated toothpaste can be used. At 3-6 years of age, the ADA recommends children use a pea-sized amount of fluoride toothpaste when brushing with a toothbrush.[8] (A: we have an obsession with comparing staff to food)G: The American Academy of Pediatric Dentistry (AAPD) recommends a community fluorination level of 0.7 ppm in the water supply. They recommend against supplementing children under 6 months of age. However, they recommend the following daily oral supplementation:Average:              6 m-3 years: 0.25 mg.3-6 years: 0.5.6-16 y: 0.5 – 1 mgThe dose changes based on how much fluoride you have in your water:0.25 mg of Fluoride in areas with

Holding Pressure AKA/BKA Shownotes   Name of Surgery: Above Knee Amputation/Below Knee Amputation   Authors: Dominique Dockery, MS3, Alpert Medical School of Brown University Robert Patterson, MD, FACS, Alpert Medical School of Brown University/Providence Surgical Care Group   Editor:  Yasong Yu   Reviewer: Ryan Meyer   Core Resources: Rutherford's Vascular and Endovascular Therapy 9th Edition Chapters 104, 105, 111, 112 Anson and McVeigh's Surgical Anatomy   Additional Resources: Article Explaining WIfI (https://www.jvascsurg.org/article/S0741-5214(13)01515-2/fulltext)  Links to Apps for CLTI Calculators (https://vascular.org/news-advocacy/society-vascular-surgery-launches-mobile-apps-staging-chronic-limb-threatening)  Callander Technique Original Article (https://jamanetwork.com/journals/jama/article-abstract/1155011) Logan, Meryl Simon & Bush, Ruth L. Vascular surgeons are health disparities doctors. JVS. Vol 74; Issue 5p1437. November 2021.    Underlying disease featured in episode: Peripheral arterial disease (PAD)/chronic limb threatening ischemia (CLTI) Pathophysiology/etiology Blockage of the arteries supplying blood to the lower limbs usually secondary to atherosclerosis Affects an estimated 8-12 million Americans Associated with smoking, diabetes, hypertension, obesity CLTI is more severe form of PAD (up to 20% of PAD patients)- associated with rest pain, ischemia ulceration, or gangrene Patient presentation Varies based on disease progression and prior intervention Ranges from asymptomatic to major tissue loss Often have patients with intermittent claudication, rest pain, or wounds/ulceration Patients can be classified using Rutherford scale or WIfI classification Diagnosis Ankle-brachial index is diagnostic (1.3) Often obtain CTA with run-off to visualize vessels prior to angiogram Angiogram to plan intervention Surgical treatment  Revascularization: either endovascular (angioplasty vs stenting) or open (bypass based on targets with either vein or graft) Amputation: after failed revascularization or irreversible/severe ischemia with no revascularization options Minor (toe/foot) vs major (below knee/through knee/above knee)   Indications for surgery:  acute ischemia: for irreversible ischemia, for severe ischemia with no revascularization options, or following unsuccessful attempts at revascularization chronic ischemia: failure of revascularization, lack of suitable conduit or target arteries, severe patient comorbidities, poor functional status, or extensive gangrene or infection such that foot salvage is not possible foot infection severe traumatic injury lower extremity skeletal or soft tissue malignancy   Preop Preparation: linking the patient with a prosthetist prior to surgery is ideal and helps with surgical planning, addressing patients' fears and concerns, determining level of amputation (pulses/blood flow, level of infection, etc.)   Surgical steps with relevant images:  Below the knee amputation (posterior flap technique): Create a hemi-circular incision anteriorly (generally about 1 handbreadth below the tibial tuberosity that goes from just anterior to the fibula to an equidistant portion of the other side) and a long posterior flap  Cut through the muscles of the anterior compartment (muscle bundle on the lateral side of the tibia) and expose the anterior tibial artery and vein- ligate and suture ligate Using a periosteal elevator, which is something like a chisel, strip the periosteum proximally from the tibia and divide the tibia with an oscillating saw. Then strip the periosteum and attachments of the fibula at this level and divide either with the saw or a bone shear.  Use an amputation knife to create the posterior flap along the skin and fascia incision lines (fashion it to make sure it will reach anteriorly without muscle bulk/tension). The remaining tibial vessels are then identified and individually suture ligated. Identify the tibial nerve, bluntly dissect it quite proximally and divide it with electrocautery.  After hemostasis has been established, remove a wedge of bone from the anterior portion of the tibia so that that doesn't provide a pressure point on the prosthesis and resect the fibula 1-2 centimeters above the line of tibial transection with a rib cutter to be sure that the fibula doesn't wear against the prosthesis laterally and create an ulceration or painful protrusion. Loosely approximate the posterior flap to the anterior fascia with several interrupted Vicryl sutures and then carefully re-approximate the skin with vertical mattress sutures of Prolene using a Keith needle to avoid traumatizing the skin with forceps.    Above knee amputations (Callander technique): Does not cut across any muscle bellies but is purely dividing all muscular attachments through the tendinous insertions. It is similar to a through the knee amputation, but it involves dividing the femur immediately above the flare of the condyle with curved anterior and posterior fish mouth type flaps that again allow division without the trauma of muscular transection.   Postoperative care: knee immobilizer post-operatively after BKA to reduce risk of contractures, non–weight bearing on the stump until the fitting of a prosthesis 4 to 6 weeks after surgery, close follow up with vascular surgeon   Complications: primary healing fails in 20% to 30% of patients and approximately 1 in 5 patients undergoing BKA need a higher-level amputation due to wound problems   Top Asked Questions:   What ankle-brachial index is diagnostic of peripheral arterial disease?   Less than 0.9, severe PAD is less than 0.4. An ABI greater than 1.3 or 1.4 is considered non-diagnostic and further workup is indicated.   What is the Rutherford classification for peripheral arterial disease?   0- asymptomatic, 1- mild claudication, 2- moderate claudication, 3- severe claudication, 4- ischemic rest pain, 5- minor tissue loss, 6- major tissue loss    Which amputation level requires more energy to ambulate with a prosthesis?    Above knee amputations require 50-70% more energy than below knee amputations What are the compartments of the lower leg, and which major vessels and nerves are in each compartment?   Anterior- anterior tibial artery and vein, deep peroneal nerve Lateral- superficial peroneal nerve Deep posterior- posterior tibial artery and vein, peroneal artery and vein, tibial nerve Superficial posterior- mostly musculature

Holding Pressure and Vascular Origin Stories: History of Hemodialysis Access   In this crossover episode of Holding Pressure and Vascular Origin Stories Gowri and Marlene explore the history of hemodialysis access, the creation of arteriovenous fistulas and prosthetic grafts. During this episode Gowri interviews Dr. Appell- the surgeon who created the first AV fistula for hemodialysis access and Marlene interviews Dr. Schanzer about his experience with early hemodialysis access and the development of the distal revascularization and interval ligation procedure.  Below you can find a picture of the first Teflon shunt used for hemodialysis, The Artificial Kidney Center Admission and Policy Committee (aka ‘God Squad'), evolution of early A-V shunts and Drs. James E Cimino, Kenneth Appell, Michael J. Brescia.    Links to other podcasts on bioethics and finance of hemodialysis and the God Squad: Beside Rounds: Episode 26 The God Squad   Freakonomics: Is dialysis a test case of medicare for all? References: [1] Klaus Konner. History of vascular access for haemodialysis. Nephrol Dial Transplant (2005) 20: 2629–2635.   [2]  B.H. Scribner, R. Buri, J.E.Z. Caner, R. Hegstrom, J.M. Burnell. Preliminary report on the treatment of chronic uremia by means of intermittent hemodialysis. Trans Am Soc Artif Intern Organs 1960; 6: 114–12.   [3]  Wayne Quinton, David Dillard, and Belding H. Scribner Authors. Cannulation of Blood Vessels for Prolonged Hemodialysis. Transactions of the ASA10, 1960, Vol. 6, pp. 104–107.   [4] Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966; 275: 1089–1092   [5] Cimino JE, Brescia MJ. The early development of the arteriovenous fistula needle technique for hemodialysis. ASAIO J 1994; 40: 923–927   [6] Scribner. Hemodialysis Using an Arteriovenous Fistula. N Engl J Med 1966;    [7] Baker, L. D., Jr, Johnson, J. M., & Goldfarb, D. (1976). Expanded polytetrafluoroethylene (PTFE) subcutaneous arteriovenous conduit: an improved vascular access for chronic hemodialysis. Transactions - American Society for Artificial Internal Organs, 22, 382–387.   [8] Blagg, CR. Development of ethical concepts in dialysis: Seattle in the 1960s. Nephrology  1998; 4, 235-238   [9] Blagg CR. The Early History of Dialysis for Chronic Renal Failure in the United States: A View From Seattle. World Kidney Forum.   [10] Rettig, RA. Origins of the Medicare Kidney Disease Entitlement: The Social Security Amendments of 1972. Biomedical Politics. Institute of Medicine (US) Committee to Study Decision Making; 1992   [11] Scribner, B. Treatment of Chronic Uremia.    [12] United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.   [13] Scribner, Belding. A Personalized History of Chronic Hemodialysis. American Journal of Kidney Diseases. Vol XVI No 6. December 1990. pp511-519 Hosts: Marlene Garcia-Neuer (@GarciaNeuer) is a MS4 at THE Ohio State University College of Medicine.   Gowri Gowda (@GowriGowda11)  is an MS3 at Tulane University School of Medicine.    Guests: Dr. Harry Schanzer, Vascular Surgeon Mount Sinai Hospital and Bronx VA (retired)   Dr. Kenneth Appel, General Surgeon, Bronx VA (retired) Calling all medical students! Submit your questions for the mailbag episode! Ask us any question related to vascular surgery, and have it answered on the podcast.  Include the following Your name, school, and year Who you want to address the question to (resident, fellow, attending, or someone specific) Send them in writing, or in voice recorded format.    Send them to HoldingPressure.AudibleBleeding@gmail.com. Also send us any ideas, suggestions, or comments.   Please share your feedback through our Listener Survey!   Follow us on Twitter @audiblebleeding   Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation. Please share your feedback through our Listener Survey!   Credits: Author: Marlene Garcia-Neuer, Gowri Gowda Editor: Yasong Yu Reviewers: Sharif Ellozy, Adam Johnson