Podcasts about ms4

In this 4th year medical student (MS4) series, we chat about the field of Pathology. Our guest, Dr. Anaisa Quintanilla-Arteaga, shares advice on how to set yourself up for success regarding matching into this unique specialty and shares tips to help you stand out both on paper and in person.Anaisa (Nisa) is an incoming PGY1 pathology resident at Northwestern University. She is originally from El Paso, Texas where she had her first exposure to pathology through forensic pathology. After attending Brown University for her undergraduate studies, she earned a master's degree at Georgetown University and worked at the National Institutes of Health before matriculating to Loyola University Chicago Stritch School of Medicine to pursue her medical degree. Nisa is a proud Hispanic/Latina woman in medicine of Mexican descent who is passionate about improving diversity and equity in medicine, healthcare, and pathology. When she isn't talking about how cool pathology is, Nisa can be found with her nose in a book or playing Dungeons & Dragons.To connect with Nisa, reach out to her on X @Anaisa_QATo further explore pathology, check out @Path_SIG and @MatchToPathEpisode produced by: Rasa ValiaugaEpisode recording date: 4/8/25www.medicuspodcast.com | medicuspodcast@gmail.com | Donate: http://bit.ly/MedicusDonate

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.

Program notes:0:33 TAVR outcomes improved1:33 Dapagliflozin 2:33 Looked at comorbidities3:00 Tolebrutinib for relapsing MS4:00 Annualized relapse rate5:00 Works in the CNS6:00 First endpoint wasn't proven6:20 Invasive group A strep7:20 Become more resistant to antibiotics8:01 Not a single type of group A strep8:25 Hearing loss and heart failure9:25 Psychological distress mediiates10:25 With hearing aids, you would think it would go down11:20 Everything looks associated12:03 End

Send us a textStorm Water Pollution Prevention Plans (SWPPPs) can be confusing - but they don't have to be. In this episode of Tank Talk, we're diving into the different types of SWPPPs, how they apply to various industries, and what you need to know to stay compliant. With the 2025 Multi-Sector General Permit (MSGP) expected for Alaska soon, it's the perfect time to brush up on the basics. Join us as we break down the differences between CGP, MSGP, and MS4 permits, the importance of SIC/NAICS codes, and why a "No Exposure Certification" might not be the easy way out you think it is. Whether you're managing compliance for a bulk fuel facility, a construction site, or an airport, this episode will help you navigate the stormwater regulations with confidence. 

In this podcast, Dr. Jonathan Kirschner from Hospital for Special Surgery (HSS) shares his perspective on the future direction of orthobiologics and discusses how advances in this field should shape not only clinical practice but also resident and fellow training. Credits/Acknowledgements: Jonathan Kirschner, MD, Luigi Gonzales, MS4, Kristen Santiago, MD

In this podcast, Dr. Hannah Hunter from the University of Washington discusses her path to finding Cancer Rehab, her current role as the Medical Director of a Cancer Rehab facility, and some insightful advice for trainees interested in the specialty. Credits/Acknowledgements: Luigi Gonzales, MS4 and Dr. Hannah Hunter

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

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

While the Israelites try to take their Promised Land, they suffer a set-back at the hands of the people of Ai… which makes the devil and Damon mistakenly think they've won a gigantic victory until… they find out that the Israelites are returning to Ai… This time, with God on their side! MS4 #kids, #biblestoriesforkids, #storiesforkids, #christiankids, #faith, #godisonourside, #bedtimestoriesforkids, #storiesforchristiankids, #godswordispowerful, #christiancharacterforkids, #bestronginthelord, #fishbytes4kids, #fishbites4kids, #ronandcarriewebb, #roncarriewebb

In this 4th year medical student (MS4) series, we chat about the field of Neurosurgery. Our guest, Dr. Deja Rush, shares advice on how to set yourself up for success regarding matching into this competitive specialty and shares tips to help you stand out both on paper and in person. Deja Rush, MD, was born and raised in Cleveland, Ohio. She is currently an incoming neurosurgery resident at Brown University. Deja attended The Ohio State University for college where she studied Biomedical Engineering and Spanish and graduated cum laude with honors research distinction. She went on to obtain her medical degree from Howard University where she finished first in her class and developed a passion for neurosurgery under the guidance of Dr. Damirez Fossett. Deja is extremely passionate about research that underscores disparities in healthcare, as well as mentorship, particularly for those underrepresented in neurosurgery. To connect with Deja, reach out to her on Instagram or Twitter at @djrush8 Episode produced by: Rasa Valiauga Episode recording date: 5/2/24 www.medicuspodcast.com | medicuspodcast@gmail.com | Donate: http://bit.ly/MedicusDonate

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

In this 4th year medical student (MS4) series, we chat about the field of Internal Medicine-Pediatrics. Our guest, Bran Garcia, shares advice on how to set yourself up for success regarding matching into this unique specialty and shares tips to help you stand out both on paper and in person. Brian Garcia, MD was born in Mexico City and immigrated to the United States at the age of 10. He grew up in a border town in south Texas, where he attended high school and completed his undergraduate education at Texas A&M International University. Growing up in a border town, he experienced the unique blend of Mexican American culture highlighted by its unique cuisine, traditions, and people. However, he also witnessed health disparities that exist within low-income communities.  Prior to medical school, Brian worked in construction where he learned valuable lessons about resilience and hard work, while noticing the detrimental effects on people's health due to lack of access to care as well as the language barrier that exists between Spanish-speaking immigrants and physicians. These experiences inspired Brian to pursue a career in medicine. During medical school, he focused on finding ways to extend access to care among low-income communities and minorities. Brian chose to pursue a specialty in Internal Medicine-Pediatrics because it allows him to treat patients of all ages while also working and learning from colleagues in other specialties. Brian is now an Internal Medicine-Pediatrics resident at the University of Rochester in Rochester, New York. If you would like to connect with Brian, reach out to him via email at bgarcia7@luc.edu  Episode produced by: Rasa Valiauga Episode edited by: Jackie Tarsitano Episode recording date: 5/4/34 www.medicuspodcast.com | medicuspodcast@gmail.com | Donate: http://bit.ly/MedicusDonate

In this 4th year medical student (MS4) series, we discuss the field of Psychiatry. Our guest, Julia Versel, shares advice on how to set yourself up for success regarding matching into this increasingly competitive specialty and shares tips to help you stand out both on paper and in person. Julia Versel, MD, MSc is a current resident at Brigham and Women's Hospital/Harvard Medical School Psychiatry Residency Program. She is passionate about medical education, with a particular interest in incorporating medical student mentorship into her career. Please reach out to the Medicus team if you would like to get in touch with her! To learn more about the field, check out these resources: Psychiatry Student Interest Group Network (PsychSIGN): https://www.psychsign.org/ AADPRT Psychiatry Training Resources: https://www.aadprt.org/trainees/psychiatry-training APA Roadmap to Applying for Psychiatry Residency: https://www.psychiatry.org/getmedia/b7007db1-b815-45fa-93bd-1f1eaf3dff99/APA-Roadmap-to-Psychiatric-Residency.pdf APA Resources for Medical Students: https://www.psychiatry.org/residents-medical-students/medical-students Episode produced by: Rasa Valiauga Episode recording date: 4/25/24 www.medicuspodcast.com | medicuspodcast@gmail.com | Donate: http://bit.ly/MedicusDonate

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

Send us a Text Message.In this episode, Rebecca Squared & Amanda the new kid continue the coversation with Stormwater Super Heros - Giants of municipal water protection activities; South Portland's Stormwater Coordinator Fred Dillon and Portland's Stormwater Coordinator Doug Roncarati and their state level partner Maine Department of Environmental Protection Stormwater Engineer Cody Obropta to tackle issues around development pressures. Does regulation make development harder or does regulation and planning make development cheaper on the community in the long run? Get the one the ground facts from the front lines and learn about the theory of low impact development versus use of green infrastructure and why those buzzwords are coming to an ordinance near you soon. Ever wondered about the intricate dance between stormwater law and water quality standards? Using the Long Creek Watershed as our case study, we delve into the stringent mandates of MS4 permits and the herculean efforts required to restore urban impaired stream habitats. Our discussion extends to the significance of maintaining viable aquatic ecosystems and a closer look at the progressively stricter requirements every five years. You'll gain insights into the benefits of educating service contractors, the impact of clearer statewide standards, and the promising potential of green infrastructure projects.Lastly, explore the innovative ways Portland's stormwater utility credit program incentivizes redevelopment while addressing pollutant-specific approaches for stormwater management. We highlight how these strategies benefit developers and the broader implications of climate change on future MS4 communities. Tune in to hear about Maine's unique phosphorus control strategies in lake watersheds and the persistent challenges posed by historical land use and climate change. Wrapping up, we stress the importance of expert consultation and community involvement, all while celebrating the camaraderie and shared humor of those dedicated to tackling these complex environmental issues."Urbanized and developed municipalities and other large public entities require Clean Water Act permits to send stormwater to nearby water bodies due to an increased likelihood of stormwater pollutants."  "Stormwater is precipitation that does not soak into the ground. Runoff accumulates in large quantities as it flows off of rooftops, driveways, roads and other impervious surfaces, picking up soil and polluting chemicals in its wake. It then flows into a storm drain, through an underground network of pipes, where it discharges into local rivers and streams, untreated."  Think Blue Maine https://thinkbluemaine.org/ Map of urban impaired streams: https://maine.maps.arcgis.com/apps/webappviewer/index.html?id=7f8f40a744ad49f3a6cccc7f1330872a Non-Point Source Training Center -

In this 4th year medical student (MS4) series, we chat about the field of Anesthesiology. Our guests, Steph Ryan and Will Chan, share advice on how to set yourself up for success to match into anesthesia and share tips to help you stand out both on paper and in person. Steph Ryan and Will Chan are both former students from Loyola Stritch School of Medicine, and will be transitioning to their first year of residency this summer. We chat about the things that separate anesthesiology from other specialties in the context of the residency application process.  Episode produced by: Griffin K Johnson Episode recording date: 04/08/2024 www.medicuspodcast.com | medicuspodcast@gmail.com | Donate: http://bit.ly/MedicusDonate --- Send in a voice message: https://podcasters.spotify.com/pod/show/medicus/message

In this 4th year medical student (MS4) series, we chat about the field of Radiation Oncology. Our guest, Dylan Ross, shares advice on how to set yourself up for success regarding matching into this competitive specialty and shares tips to help you stand out both on paper and in person. Dylan Ross, MD, attended the University of Minnesota for his undergraduate education where he met his now fiancée, Lindsey Greenlund, who is also a recent medical school graduate. While at Stritch, Dylan got involved with medical education and research with the radiation oncology department which were influential in his specialty decision. After a successful couple's match, Dylan is heading to Johns Hopkins for his radiation oncology residency following a transitional year at HCA Riverside Community Hospital. To connect with Dylan, email him at dross8@luc.edu  Resources mentioned in the podcast: NCCN Guidelines and Essentials of Clinical Radiation Oncology (The Red Book) Episode produced by: Rasa Valiauga Episode recording date: 3/27/24 www.medicuspodcast.com | medicuspodcast@gmail.com | Donate: http://bit.ly/MedicusDonate --- Send in a voice message: https://podcasters.spotify.com/pod/show/medicus/message

Elizabeth Killien, MD MPH is an Assistant Professor of Pediatrics at the University of Washington and an attending physician in the Pediatric ICU at Seattle Children's. She earned her MD from Dartmouth Medical School in 2011. She completed her residency in General Pediatrics and fellowship in Pediatric Critical Care Medicine at the University of Washington. She underwent additional training in pediatric trauma research at the Harborview Injury Prevention and Research Center in the Pediatric Injury Research Training Program from 2017-2019, and completed her Master of Public Health degree in Epidemiology at the University of Washington in 2019. She is a member of the Society of Critical Care Medicine, Pediatric Acute Lung Injury and Sepsis Investigators, and American Thoracic Society. Her scholarly work focuses on organ failure after traumatic injury and long-term outcomes after critical illness.Learning Objectives:By the end of this podcast, listeners should be able to:Define post-intensive care syndrome, recognize the clinical presentation and make the presumptive diagnosis.Recognize common risk factors of post-intensive care syndrome in children.Discuss practical ways to reduce the risk of post-intensive care syndrome in children admitted to the pediatric ICU.Discuss management strategies to optimize the care provided to children suffering from post-intensive care syndrome.Recall key next steps in post-intensive care syndrome research.How to support PedsCrit:Please rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.References:Manning, Joseph C. RN, PhD1,2,3; Pinto, Neethi P. MD, MS4; Rennick, Janet E. RN, PhD5,6; Colville, Gillian MPhil, CPsychol7; Curley, Martha A. Q. RN, PhD8,9,10. Conceptualizing Post Intensive Care Syndrome in Children—The PICS-p Framework*. Pediatric Critical Care Medicine 19(4):p 298-300, April 2018. | DOI: 10.1097/PCC.0000000000001476 https://www.palisi.org/ Killien EY, Zimmerman JJ, Di Gennaro JL, Watson RS. Association of Illness Severity With Family Outcomes Following Pediatric Septic Shock. Crit Care Explor. 2022 Jun 15;4(6):e0716. doi: 10.1097/CCE.0000000000000716. PMID: 35733611; PMCID: PMC9203075.Smith MB, Killien EY, Dervan LA, Rivara FP, Weiss NS, Watson RS. The association of severe pain experienced in the pediatric intensive care unit and postdischarge health-related quality of life: A retrospective cohort study. Paediatr Anaesth. 2022 Aug;32(8):899-906. doi: 10.1111/pan.14460. Epub 2022 Apr 22. PMID: 35426458; PMCID: PMC9990726.Support the show

Elizabeth Killien, MD MPH is an Assistant Professor of Pediatrics at the University of Washington and an attending physician in the Pediatric ICU at Seattle Children's. She earned her MD from Dartmouth Medical School in 2011. She completed her residency in General Pediatrics and fellowship in Pediatric Critical Care Medicine at the University of Washington. She underwent additional training in pediatric trauma research at the Harborview Injury Prevention and Research Center in the Pediatric Injury Research Training Program from 2017-2019, and completed her Master of Public Health degree in Epidemiology at the University of Washington in 2019. She is a member of the Society of Critical Care Medicine, Pediatric Acute Lung Injury and Sepsis Investigators, and American Thoracic Society. Her scholarly work focuses on organ failure after traumatic injury and long-term outcomes after critical illness.Learning Objectives:By the end of this podcast, listeners should be able to:Define post-intensive care syndrome, recognize the clinical presentation and make the presumptive diagnosis.Recognize common risk factors of post-intensive care syndrome in children.Discuss practical ways to reduce the risk of post-intensive care syndrome in children admitted to the pediatric ICU.Discuss management strategies to optimize the care provided to children suffering from post-intensive care syndrome.Recall key next steps in post-intensive care syndrome research.How to support PedsCrit:Please rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.References:Manning, Joseph C. RN, PhD1,2,3; Pinto, Neethi P. MD, MS4; Rennick, Janet E. RN, PhD5,6; Colville, Gillian MPhil, CPsychol7; Curley, Martha A. Q. RN, PhD8,9,10. Conceptualizing Post Intensive Care Syndrome in Children—The PICS-p Framework*. Pediatric Critical Care Medicine 19(4):p 298-300, April 2018. | DOI: 10.1097/PCC.0000000000001476 https://www.palisi.org/ Killien EY, Zimmerman JJ, Di Gennaro JL, Watson RS. Association of Illness Severity With Family Outcomes Following Pediatric Septic Shock. Crit Care Explor. 2022 Jun 15;4(6):e0716. doi: 10.1097/CCE.0000000000000716. PMID: 35733611; PMCID: PMC9203075.Smith MB, Killien EY, Dervan LA, Rivara FP, Weiss NS, Watson RS. The association of severe pain experienced in the pediatric intensive care unit and postdischarge health-related quality of life: A retrospective cohort study. Paediatr Anaesth. 2022 Aug;32(8):899-906. doi: 10.1111/pan.14460. Epub 2022 Apr 22. PMID: 35426458; PMCID: PMC9990726.Support the show

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

Why should you care about stormwater? What is a MS4 regulated community? Why do people pick up their dog poo and put it in a bag only to dump it on the trail or in the storm drain? What is a harbor trout? In this episode, Rebecca Squared & Amanda the new kid talk with Stormwater Super Heros - Giants of municipal water protection activities; South Portland's Stormwater Coordinator Fred Dillon and Portland's Stormwater Coordinator Doug Roncarati and their state level partner Maine Department of Environmental Protection Stormwater Engineer Cody Obropta to tackle these questions and a whole lot more! This episode is part 1 of a two part series. Fred, Doug and Cody share how they became stormwater rangers, what it's important and a small bit of the challenges communities in Maine face with old infrastructure and dense development. "Urbanized and developed municipalities and other large public entities require Clean Water Act permits to send stormwater to nearby water bodies due to an increased likelihood of stormwater pollutants.""Stormwater is precipitation that does not soak into the ground. Runoff accumulates in large quantities as it flows off of rooftops, driveways, roads and other impervious surfaces, picking up soil and polluting chemicals in its wake. It then flows into a storm drain, through an underground network of pipes, where it discharges into local rivers and streams, untreated." Think Blue Mainehttps://thinkbluemaine.org/Map of urban impaired streams: https://maine.maps.arcgis.com/apps/webappviewer/index.html?id=7f8f40a744ad49f3a6cccc7f1330872a Non-Point Source Training Center - https://www.maine.gov/dep/training/npstrc-schedule.html  Rutgers Green Infrastructure Champions Program - https://rutgers.zoom.us/webinar/register/WN_nuaE-xe4T8e080uhQ-l6vg    

Welcome back to Environmental Professionals Radio, Connecting the Environmental Professionals Community Through Conversation, with your hosts Laura Thorne and Nic Frederick! On today's episode, we talk with Nicole Beck, CEO and Founder of 2NDNATURE about Aquatic Chemistry, Ultimate Frisbee, and Translating Policy.   Read her full bio below.Help us continue to create great content! If you'd like to sponsor a future episode hit the support podcast button or visit www.environmentalprofessionalsradio.com/sponsor-form Showtimes: 2:58 Nic & Laura finish discussing their horror movie trilogy7:39  Interview with Nicole Beck starts10:11  Aquatic Chemistry20:10 Translating policy36:11  Field Notes41:05  Ultimate FrisbeePlease be sure to ✔️subscribe, ⭐rate and ✍review. This podcast is produced by the National Association of Environmental Professions (NAEP). Check out all the NAEP has to offer at NAEP.org.Connect with Nicole Beck at https://www.linkedin.com/in/nicole-beck2n/Guest Bio:Nicole Beck has a PhD in aquatic chemistry and a career long mission to bring science to decision makers.  She is motivated to apply her technical knowledge to develop practical science based tools to inform land management decisions that protect our water resources. Her journey has landed her as a CEO of a technology company that offers stormwater GIS software to empower local governments, corporations and other large urban land owners to manage runoff as a resource.Music CreditsIntro: Givin Me Eyes by Grace MesaOutro: Never Ending Soul Groove by Mattijs MullerSupport the showThanks for listening! A new episode drops every Friday. Like, share, subscribe, and/or sponsor to help support the continuation of the show. You can find us on Twitter, Facebook, YouTube, and all your favorite podcast players.

Join Psychiatrists, Dr. Brandon Cornejo & Dr. Justin Laporte, for a stimulating talk about all things Transcranial Magnetic Stimulation (TMS). Hosts: Candace Chan, MS4 & Devon Boorstein-Holler, MS4 Have Questions? Feel free to reach out to us at: psychiatryexplored@gmail.com References: rTMS for Craving in Methamphetamine Use Disorder, a clinical trial Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., ... & Zohar, J. (2019). Efficacy and safety of deep transcranial magnetic stimulation for obsessive-compulsive disorder: a prospective multicenter randomized double-blind placebo-controlled trial. American Journal of Psychiatry, 176(11), 931-938. Roth, Y., Tendler, A., Arikan, M. K., Vidrine, R., Kent, D., Muir, O., ... & Zangen, A. (2021). Real-world efficacy of deep TMS for obsessive-compulsive disorder: post-marketing data collected from twenty-two clinical sites. Journal of psychiatric research, 137, 667-672. Voigt, J. D., Leuchter, A. F., & Carpenter, L. L. (2021). Theta burst stimulation for the acute treatment of major depressive disorder: A systematic review and meta-analysis. Translational psychiatry, _11_(1), 330.

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

Story: A Good Day Author: PiecesofScully Rating: GA Site link: https://archiveofourown.org/works/39030903 Read by: Annie Summary: just a little diddy post MS4 written shortly after it had aired Used by the author's permission. The characters in these works are not the property of the Audio Fanfic Podcast or the author and are not being posted for profit.

We welcome Megan Aguilera to the “Let's Get Psyched” team by asking her to discuss one of her special interests. Terms such as “susto” and “ataque de nervios” are frequently used in Latin America to describe a variety of emotional reactions and behaviors that are often similar—but distinct from—mental health conditions commonly seen by clinicians. Megan, a fourth year medical student at the University of Colorado Denver, helps us sort through how and when these terms are used while also sharing her understanding of these terms amongst her family and community. Hosts: Eyrn, Toshia, Al Guest: Megan Aguilera, MS4

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

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

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

A major aspect of outpatient pediatric practice, and therefore also the shelf and board exams, is knowledge of childhood developmental milestones. This includes gross and fine motor skills, language, social and cognitive development, growth tracking, and sexual maturation. Review all of this material in this high-yield episode hosted by our newest MS4 team member Tania Mulherkar!

This episode is part of our specialty series, where we interview MS4 students about their experiences applying and matching into their chosen specialty. In this episode, we spoke with Dr. Elizabeth Belford, MD, who graduated from the Loyola University Chicago Stritch School of Medicine in May 2023. Elizabeth now is a first-year resident in Internal Medicine at the Medical University of South Carolina.  She reflects on her journey to Internal Medicine with us and shares valuable pieces of advice for medical students in various stages of training. Additionally, Elizabeth describes her decisions for choosing Internal Medicine and provides tips for how to wisely choose a specialty, crafting one's narrative, and putting one's best foot forward in the application process.  If you are interested in getting in touch with Elizabeth, you may reach her at @ElizabethMD15 or elizabeth.drews97@gmail.com.  Episode produced by: Emily Hagen, Nikki Ganeshan  Episode recording date: 3/31/23 www.medicuspodcast.com | medicuspodcast@gmail.com | Donate: http://bit.ly/MedicusDonate --- Send in a voice message: https://podcasters.spotify.com/pod/show/medicus/message

This month, the docs welcome Zenab Saeed, MS4 to the pod to talk about what it's like to come from a family of doctors, how she's dealing with pre-Match jitters, and nepotism in medicine. If you have a story you want to tell, contact us at impersonatingdoctors@gmail.com.If you want to support us, check out our patreon at https://www.patreon.com/user?u=53683451Music: What A Wonderful Day by Shane Ivers - https://www.silvermansound.comAny statements or views expressed by the "Impersonating Doctors" podcasters and their guests are made as an individual personal opinions and should not be interpreted as statements or official standpoints of their respective schools, places of work or employers.

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 Ashley Lopez, MS4 at Ponce Health Sciences University, Mona Amer, MS4 at the University of Louisville and Research Fellow at the Bascom Palmer Eye Institute, Becky Li, MD. Pediatrics PGY-1 at Nicklaus Children's Hospital and NSU MD graduate, and Piero Carletti MS4 at NSU MD.

Episode 131: Breastfeeding Part 2Lia and Aruna explain some updates given by the American Academy of Pediatrics regarding breastfeeding. Dr. Arreaza adds some comments about breastfeeding. Written by Aruna Sridharan, MS4, and Lia Khachikyan, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.The motivation for this episode was a recent publication by the American Academy of Pediatrics, on June 27, 2022, titled Policy Statement: Breastfeeding and the Use of Human Milk. During this episode, we included updated information along with other useful material.Duration of breastfeeding:The American Academy of Pediatrics (AAP), World Health Organization (WHO), and Center of Disease Control (CDC) recommend exclusive breastfeeding at least for the first 6 months, after which one can start to introduce complementary pureed foods. The US Department of Agriculture states that initiating complementary foods earlier than 6 months offers no benefit to the baby and can even be associated with a higher risk of overweight or obesity, especially if introduced before 4 months. Mothers are then encouraged to continue breastfeeding for at least one year and can further continue up to 2 years of age or longer - as long as mutually desired by mother and child. This is an update from previous recommendations regarding the duration of breastfeeding until 1 year of age.Composition of human breastmilk:As the sole source of nutrition for infants in the first 6 months of life, breast milk plays a critical role in development. Human milk has a unique composition of proteins, fats, and lactose, as well as vitamins, electrolytes, antimicrobial, anti-inflammatory immunoregulatory agents, and living leukocytes, all of which contribute to the developing immune system of the child. Breast milk is rich in Vitamins B1, B2, and B6, Vitamins C, A, E, Ca, Mg, phosphate, and folate. However, it is low in Vitamins K, D, B12, and iron, therefore supplementation of these nutrients is required. It is important for mothers to consume an adequate and healthy diet for their breastmilk to contain appropriate levels of these nutrients. Water-soluble and Fat-soluble vitamins can be low in breast milk if the mother has a deficiency. Selenium can be low if maternal serum levels are low. Dietary iodine deficiency may also be exacerbated by smoking; iron deficiency; and consumption of large amounts of foods that interfere with the production of thyroid hormones, known as goitrogens, including Brussels sprouts, kale, cabbage, cauliflower, and broccoli. Maternal diet:Mothers should consume iodine-rich foods, such as lean meat, eggs, dairy, beans, and lentils. It is important to choose a variety of whole grains, as well as fruits and vegetables, and continue taking multivitamins. Fun fact: Different foods will change the flavor of your breast milk. This will expose your baby to different tastes, which might help him or her more easily accept solid foods down the road! It is recommended that mothers consume 290 mcg of iodine and 550mg of choline a day. Is there anything that mothers should avoid in their diet?-Limit seafood: Although fish is a good source of protein and lean meat, it contains some mercury, which can be transferred to the baby's diet. High amounts of mercury can have an adverse effect on the baby's brain and nervous system.-Limit caffeine: Also, we know a lot of people love their morning dose of espresso! Low to moderate amounts, equivalent to 2-3 cups of coffee per day, do not adversely affect the infant. However, anything more than around 300 mg of caffeine can cause irritability, poor sleeping patterns, fussiness, and jitteriness. Remember! This also includes sodas, energy drinks, tea, and even chocolate! As a reminder, one cup of coffee can have 95mg of caffeine.Vegan mothers: Vegetarian/vegan mothers may have very limited amounts of vitamin B12 in their bodies, which can result in neurological damage to the baby. Iron levels may also be sparse since plant-based foods only contain non-heme iron, which is less absorbable than heme iron. The American Dietetic Association recommends supplementation of vitamin B12, iron, and other nutrients such as choline, zinc, iodine, or omega-3 fats. Benefits:For the baby: Studies show that exclusively breastfeeding for 6 months decreased rates of neonatal and infant mortality as well as pediatric disorders such as otitis media, diabetes mellitus, obesity, lower respiratory tract disorders, asthma, atopic dermatitis, sudden infant death syndrome (SIDS), severe diarrhea, and inflammatory bowel disease. The longer an infant is breastfed, the greater the protection from certain illnesses and long-term diseases. For the mother: The longer a mother breastfeeds, the greater the benefits to her health as well. Mothers who breastfeed experience a lower risk of hypertension, type 2 diabetes, and breast, ovarian, and endometrial cancers. Contraindications:-Alcohol: Having up to 1 drink per day is not harmful to the baby, especially if the mother waits at least 2 hours before feeding the infant. This allows time for the blood alcohol concentration in the breastmilk to decrease. Consuming more than 2 standard alcoholic drinks daily is highly discouraged.-Tobacco: Cigarette smoking, or the use of nicotine products, is associated with decreased production of milk, shorter lactation time, and an increased risk of SIDS, asthma, and other respiratory illnesses in infants. Therefore, mothers should be strongly encouraged to stop smoking and minimize secondhand exposure. We know it is very difficult for people to quit abruptly. While transitioning to cessation, mothers should be counseled to smoke right after breastfeeding to allow the greatest amount of time for nicotine to exit the body until the next feed. Other cessation alternatives such as the patch or gum can also be used during breastfeeding.Varenicline: No human data is available to assess the risk of infant harm, but it is likely excreted in the milk, no data on the assessment of milk production.-Other substances: Marijuana, opioids, amphetamine, cocaine, and other illicit drugs are contraindicated due to their effects on neurodevelopmental behaviors. If these substances have been used intrapartum or during breastfeeding, it is important to monitor the baby for Neonatal Abstinence Syndrome. Some symptoms include poor weight gain, tremors, high-pitched crying, stuffy nose, poor feeding/sucking, seizures, irritability, poor sleep, vomiting, and diarrhea.-Maternal infections: Breastfeeding is not contraindicated during most maternal infections. Some exceptions include HIV, Human T-cell lymphotropic virus type I or II, untreated brucellosis, Ebola virus, or active Herpetic lesions on the breast. Women with herpetic lesions may breastfeed from the unaffected breast. -Maternal medications: Medications are relatively safe for breastfed babies, but some contraindications include anticancer drugs, oral retinoids, lithium, iodine, and amiodarone. Mothers should go over their medication list with their primary physician.Pregnancy and Lactation Labeling Final Rule (PLLR): Classification of drugs according to their impact on pregnancy and breastfeeding (categories A, B, C, D, X) was started in 1979, but it was stopped in 2015 and replaced by the Pregnancy and Lactation Labeling Final Rule (PLLR). The former categories were replaced with narrative sections and subsections to include: Pregnancy (including labor and delivery), Lactation, and information for Females and Males of Reproductive Potential (pregnancy testing, contraception, infertility).Role of the physician and stigmas:It is well known that breastfeeding can strengthen the bond between the mother and her child. Therefore, when latching becomes a problem, mothers are quick to become discouraged. If this happens, pediatricians should educate the parents that many breastfeeding problems commonly arise between 4-7 days after birth. Sometimes, exclusive or any amount of breastfeeding is not always possible, despite the mother's best intentions. This can understandably cause them to feel a lot of guilt and disappointment as a new mother. Physicians should provide a safe, non-judgmental environment for the parents to openly discuss their difficulties while educating them on proper latching techniques and other alternatives for breastfeeding.Conclusion: Now we conclude our episode number 131 “Breastfeeding Part 2.” Aruna and Lia explained that the American Academy of Pediatrics now recommends continued breastfeeding until 2 years or as long as the mother and the baby desire it. It is important to remember some contraindications such as babies with galactosemia, mothers who are using illicit drugs, and some maternal infections such as HIV, untreated brucellosis, and Ebola virus. This week we thank Hector Arreaza, Aruna Sridharan, and Lia Khachikyan. 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! _____________________Dror, D. K., & Allen, L. H. (2018, May 29). Overview of Nutrients in Human Milk. PubMed Central (PMC). https://doi.org/10.1093/advances/nmy022.Meek, J. Y., Noble, L., & Breastfeeding, S. O. (2022, July 1). Policy Statement: Breastfeeding and the Use of Human Milk. American Academy of Pediatrics. https://doi.org/10.1542/peds.2022-057988.“Maternal Diet.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 17 May 2022, https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet-and-micronutrients/maternal-diet.html.Breastfeeding FAQs. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/faq/index.htm. Accessed February 21, 2023. Butte, Nancy F., and Alison Stuebe. Maternal nutrition during lactation. UpToDate, July 13, 2022. https://www.uptodate.com/contents/maternal-nutrition-during-lactation. Accessed March 6, 2023. Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

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.

In this episode, we will go over how we discovered ophthalmology, and how we sought opportunities to be exposed to this field whether you do or don't have an affiliated residency program. Additionally, we will go over the decision behind taking a research gap year, how we found it, what kinds of research years are available out there, and how we are making the most out of ours. Featuring Mona Amer, MS4 at the University of Louisville and Research Fellow at the Bascom Palmer Eye Institute and Piero Carletti, MS4 at NSU MD and Research Fellow at the Bascom Palmer Eye Institute.

In this episode, we will give you a detailed overview of the ophthalmology application process. We will talk about what you should be aware of before heading into the application season, and how to navigate the application portal, which can be drastically different from ERAS. In this episode, you will get the perspectives of two ophthalmology applicants on how the interpreted and filled out each section of their application. Featuring Mona Amer, MS4 at the University of Louisville and Research Fellow at the Bascom Palmer Eye Institute & Piero Carletti, MS4 at NSU MD and Research Fellow at the Bascom Palmer Eye Institute.

Episode 129: Emergency ContraceptionBailey describes the available methods of emergency contraception in the United States. Written by Bailey Corona, MS4, American University of the Caribbean. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Emergency contraception refers to therapy used after intercourse to prevent pregnancy. The need for emergency contraception can happen for many reasons, such as a condom breaking or failure to use contraception. More than 11% of sexually active women in the United States between ages 15 and 44 reports using emergency contraception at least once. With such high demand, a multitude of options has become available to meet these needs. With so many options on the market, it may be difficult to decide which option best fits the needs of each individual, which makes it important for providers to have a clear understanding of the risks and benefits associated with each method. Emergency contraception may be commonly used by young patients as their main contraception method. Let's talk about the types of emergency contraception.Levonorgestrel-only (Plan B®).Levonorge'strel-only emergency contraception is the most popular option on the market today. More commonly known as “Plan-B”, this therapy works because of levonorgestrel's similar make-up to progesterone. Mechanism of action.High levels of progesterone delay follicular development so long as it is administered before the level of luteinizing hormone begin to rise. This gives contraceptive therapy of this class a therapeutic window of 72 hours which is the most limited window of all the methods discussed. Despite this shortcoming, Levonorgestrel contraception remains the most popular option because it can be purchased over the counter without the need of a physician and is available to women of all ages. Additionally, therapy includes only a single 1.5mg dose making noncompliance virtually non-existent. Side effects. Side effects include nausea in 12% of patients and headache in 19% of patients. According to one study, 16% of women reported self-resolving uterine bleeding within the first week after use.Selective progesterone modulators (Ella®).The second most commonly used form of emergency contraception are the selective progesterone receptor modulators or more widely known as Ella®. Mechanism of action.Treatment includes a single 30mg dose of ulipristal acetate, which inhibits follicular rupture even after the luteinizing hormone has begun to rise. Due to this mechanism of action, selective progesterone receptor modulators have a wider therapeutic window of 5 days.Side effects.Side effects resemble that of progesterone-only therapy, significant for nausea and headache. Treatment has 2 major barriers preventing it from being the most widely used. Firstly, efficacy is decreased in women with a BMI greater than 35, and secondly, treatment requires a prescription from a medical professional. Estrogen-progesterone combination.Estrogen-progesterone combination therapy is also a viable option for emergency contraception; however, it is no longer available as a dedicated product but can be made from a variety of oral contraceptives. Its decreased popularity is likely due to its increased incidence of nausea when compared to the other options available.Copper IUD.Lastly, Copper IUDs like Paragard can be used for emergency contraception despite not being FDA-approved for this purpose. Copper IUDs are highly effective if placed within 5 days of intercourse, but studies have shown therapy to be effective up to 10 days after. Mechanism of action.Copper IUDs prevent fertilization by altering sperm viability and oocyte-endometrium interaction. This method is the most invasive as it requires placement by a physician and carries the rare risk of uterine perforation, occurring in around 1/1000 IUD placements. That said, copper IUD placement carries with it the added benefit of continued contraception for 10 years. It is contraindicated, however, in patients with a history of heavy menstrual bleeding. FAQs about emergency contraception:Does increasing the availability of emergency contraception encourage risky sexual behavior?No, according to a systematic review by Maria Rodrigues, there was no significant increase in sexually risky behavior correlated with increased availability of emergency contraception.Rodriguez MI, et al.What is the greatest barrier to emergency contraception use in the United States?Education. A study by Abbott J, et al, interviewed adolescents receiving care in urban emergency rooms. The study showed that only 64% of patients had ever heard of emergency contraception. By educating patients of reproductive age on what options may be available to them it is expected that there would be a decrease in unplanned pregnancies. Additionally, studies like “knowledge of emergency contraception among women aged 18-44 in California” by Foster DG have gone further to establish that women of lower socioeconomic status, foreign birth, or who have not graduated high school also have suboptimal education in emergency contraception.When should someone use emergency contraception?Treatment should begin as soon as possible after unprotected intercourse in order to ensure maximum efficacy. 3 days for Plan B, 5 days for Ella, and 10 days for IUD.How effective is emergency contraception?The answer to this question differs based upon what method a patient decides to useIUDsA systematic review of 42 studies over a 35-year time period reports that pregnancy rates were between 0 and 2%.The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience by Cleland K. et al. Oral regimens have been studied extensively and have shown that ulipristal acetate like Ella® are slightly more effective, showing a pregnancy rate of 1.4% and a rate of 2.2% in levonorgestrel-only pills like Plan B. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomized non-inferiority trial and meta-analysis by Glacier AF.Do patients require follow up after use of emergency contraception?No. Only if there is a delay in the start of normal menses by greater than 1 week or if lower abdominal pain or persistent irregular bleeding develops.___________________Conclusion: Now we conclude episode number 129 “Emergency Contraception.” Bailey explained that a pelvic exam is not needed in most cases before or after emergency contraception. Plan B® is available over the counter, while Ella® is available with a prescription. Copper IUD is not FDA-approved for emergency contraception, but evidence has shown it is an effective method. Dr. Arreaza suggested that, after learning more about emergency contraception, listeners can draw their own conclusions about the ethical dilemma of prescribing it to their patients. This week we thank Hector Arreaza and Bailey Corona. 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:Abbott J, Feldhaus KM, Houry D, Lowenstein SR. Emergency contraception: what do our patients know? Ann Emerg Med. 2004 Mar;43(3):376-81. doi: 10.1016/S019606440301120X. PMID: 14985666. https://pubmed.ncbi.nlm.nih.gov/14985666/.Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod. 2012 Jul;27(7):1994-2000. doi: 10.1093/humrep/des140. Epub 2012 May 8. PMID: 22570193; PMCID: PMC3619968. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3619968/.“Emergency Contraception.” ACOG, https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2015/09/emergency-contraception.Foster DG, Harper CC, Bley JJ, Mikanda JJ, Induni M, Saviano EC, Stewart FH. Knowledge of emergency contraception among women aged 18 to 44 in California. Am J Obstet Gynecol. 2004 Jul;191(1):150-6. doi: 10.1016/j.ajog.2004.01.004. PMID: 15295356. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3619968/Glasier AF, Cameron ST, Fine PM, Logan SJ, Casale W, Van Horn J, Sogor L, Blithe DL, Scherrer B, Mathe H, Jaspart A, Ulmann A, Gainer E. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010 Feb 13;375(9714):555-62. doi: 10.1016/S0140-6736(10)60101-8. Epub 2010 Jan 29. Erratum in: Lancet. 2014 Oct 25;384(9953):1504. PMID: 20116841.https://pubmed.ncbi.nlm.nih.gov/20116841/Jayson, Sharon. “5.8M Women Have Used 'Morning after' Pill.” USA Today, Gannett Satellite Information Network, 14 Feb. 2013, https://www.usatoday.com/story/news/nation/2013/02/13/cdc-contraception-emergency-methods/1914673/. Rodriguez MI, Curtis KM, Gaffield ML, Jackson E, Kapp N. Advance supply of emergency contraception: a systematic review. Contraception. 2013 May;87(5):590-601. doi: 10.1016/j.contraception.2012.09.011. Epub 2012 Oct 4. PMID: 23040139. https://pubmed.ncbi.nlm.nih.gov/23040139/.von Hertzen H, Piaggio G, Ding J, Chen J, Song S, Bártfai G, Ng E, Gemzell-Danielsson K, Oyunbileg A, Wu S, Cheng W, Lüdicke F, Pretnar-Darovec A, Kirkman R, Mittal S, Khomassuridze A, Apter D, Peregoudov A; WHO Research Group on Post-ovulatory Methods of Fertility Regulation. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet. 2002 Dec 7;360(9348):1803-10. doi: 10.1016/S0140-6736(02)11767-3. PMID: 12480356. https://pubmed.ncbi.nlm.nih.gov/12480356/.Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

Advocacy work can sometimes be conflated with identity. When you have placed so much time and energy into something, it can be easy for it to consume all of who you are. But you are more than your advocacy work, and your continued drive to create change does not have to be all that you are. In S6E5, Hạ talks to Karishma Shah, MD/PhD candidate at University of Utah School of Medicine, and Victoria Ngo, MS4 at Virginia Commonwealth University, about how their advocacy work within the confines of medical education has both been defined by and impacted their identities.

Advocacy work can sometimes be conflated with identity. When you have placed so much time and energy into something, it can be easy for it to consume all of who you are. But you are more than your advocacy work, and your continued drive to create change does not have to be all that you are. In S6E5, Hạ talks to Karishma Shah, MD/PhD candidate at University of Utah School of Medicine, and Victoria Ngo, MS4 at Virginia Commonwealth University, about how their advocacy work within the confines of medical education has both been defined by and impacted their identities.

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

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/

Be on the lookout for outcome manipulation! Pharmaceutical companies are important innovators, but they are businesses first. In this episode, renowned pharmaceutical critic, Dr. Daniel Carlat, gives us tips on spotting common research methods used to bias findings. Hosts: Al, Toshia Guests: Daniel Carlat, MD, Yasmine Dakhama, MS4

Renowned psychiatry professor Dr. Daniel Carlat details his journey from pharmaceutical spokesperson to receiving legal threats from pharmaceutical companies. Dr. Carlat gets candid about his transformation and his doubts along the way. Hosts: Al, Toshia Guests: Daniel Carlat, MD, Yasmine Dakhama, MS4

This family doc paid of $184K+ in 3.5 years. Starting her financial education as an MS4 and continuing into residency, she had the confidence she was doing the right thing and just needed to keep chugging along. Patience is hard but is required for success. Just like medical training, it is not simply about intelligence but also about perseverance. Stay the course! https://www.whitecoatinvestor.com/why-staying-the-course-is-hard/  Shopping for disability insurance is complicated. Wondering if you are getting the right coverage, unbiased advice, along with the best prices and discounts can make the process even more overwhelming. Pattern knows doctors have more important things to do than spend hours sorting through numerous insurance options. This is why thousands of White Coat Investor's followers have trusted Pattern to help them compare and understand the disability insurance they are buying. Their online process is simple: First, request your quotes online. Second, compare your options and ask questions. And third, secure your policy. Be confident you have the right policy at the best price. Request your disability insurance quotes with Pattern at https://patternlife.com/wcipodcast  The White Coat Investor has been helping doctors with their money since 2011. Our free financial planning resource covers a variety of topics from doctor mortgage loans and refinancing medical school loans to physician disability insurance and malpractice insurance. Learn about loan refinancing or consolidation, explore new investment strategies, and discover loan programs for specifically aimed at helping doctors. If you're a high-income professional and ready to get a "fair shake" on Wall Street, The White Coat Investor channel is for you! Be a Guest on The Milestones to Millionaire Podcast: https://www.whitecoatinvestor.com/milestones  Main Website: https://www.whitecoatinvestor.com  Student Loan Advice: https://studentloanadvice.com  YouTube: https://www.whitecoatinvestor.com/youtube  Facebook: https://www.facebook.com/thewhitecoatinvestor  Twitter: https://twitter.com/WCInvestor  Instagram: https://www.instagram.com/thewhitecoatinvestor  Subreddit: https://www.reddit.com/r/whitecoatinvestor  Online Courses: https://whitecoatinvestor.teachable.com  Newsletter: https://www.whitecoatinvestor.com/free-monthly-newsletter 

We can't believe we haven't done this episode already! Regardless, Fei and Nick highlight some of the issues with postpartum care in the United States and outline, based on ACOG, what the ideal postpartum care could look like.  If you're an MS4 who has matched into an Ob/Gyn residency in the United States, you are eligible to sign up for our annual #OBGynInternChallenge! Go to www.obgyninternchallenge.com to sign up starting on April 18th. The curriculum starts on May 2nd, so don't forget to sign up for free!  Interested in Rosh Review? Not only do we have the Rosh Review question of the week, but if you and 7 of your friends get together, you may qualify for a group discount and a free ABOG practice test. Go on our website to find out how.  Twitter: @creogsovercoff1 Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com Patreon: www.patreon.com/creogsovercoffee You can find the OBG Project at: www.obgproject.com

Today, we discuss what to do if your cytology comes back as a high grade lesion or something else -- What exactly is AIS, AGC, or AEC? And, the most frustrating thing: what do you do if you have an insufficient pap?  If you're an MS4 who has matched into an Ob/Gyn residency in the United States, you are eligible to sign up for our annual #OBGynInternChallenge! Go to www.obgyninternchallenge.com to sign up starting on April 18th. The curriculum starts on May 2nd, so don't forget to sign up for free!  Interested in Rosh Review? Not only do we have the Rosh Review question of the week, but if you and 7 of your friends get together, you may qualify for a group discount and a free ABOG practice test. Go on our website to find out how.  Twitter: @creogsovercoff1 Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com Patreon: www.patreon.com/creogsovercoffee You can find the OBG Project at: www.obgproject.com

What? There are more Pap Smear guidelines already? Yup! Nick and Fei explore some recent updates to Paps.  If you're an MS4 who has matched into an Ob/Gyn residency in the United States, you are eligible to sign up for our annual #OBGynInternChallenge! Go to www.obgyninternchallenge.com to sign up starting on April 18th. The curriculum starts on May 2nd, so don't forget to sign up for free!  Interested in Rosh Review? Not only do we have the Rosh Review question of the week, but if you and 7 of your friends get together, you may qualify for a group discount and a free ABOG practice test. Go on our website to find out how.  Twitter: @creogsovercoff1 Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com Patreon: www.patreon.com/creogsovercoffee You can find the OBG Project at: www.obgproject.com

We are back with more journal club on the ALPS Study - why do we give late preterm steroids? Fei and Nick discuss this practice changing study that came out in 2016.  If you're an MS4 who has matched into an Ob/Gyn residency in the United States, you are eligible to sign up for our annual #OBGynInternChallenge! Go to www.obgyninternchallenge.com to sign up starting on April 18th. The curriculum starts on May 2nd, so don't forget to sign up for free!  Interested in Rosh Review? Not only do we have the Rosh Review question of the week, but if you and 7 of your friends get together, you may qualify for a group discount and a free ABOG practice test. Go on our website to find out how.  Twitter: @creogsovercoff1 Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com Patreon: www.patreon.com/creogsovercoffee You can find the OBG Project at: www.obgproject.com