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

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

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

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

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

This podcast is produced by ⁠⁠Bloody Vegans Productions⁠⁠ Get in touch if you would have a podcast and need help or are thinking of starting one.Professor Andrew Knight is a distinguished veterinary expert specializing in animal welfare and ethics. Originally from Australia, he has been a prominent animal advocate since the early 1990s, notably initiating Australia's campaign against live sheep exports to the Middle East. He has practiced veterinary medicine in London and held academic positions globally, including directing the Clinical Skills Laboratory at Ross University School of Veterinary Medicine in the Caribbean. Professor Knight founded and led the Centre for Animal Welfare at the University of Winchester from 2015 to 2023, establishing it as a leading research hub. He holds multiple specialist qualifications in animal welfare science, ethics, and law across Europe, the USA, and New Zealand. His extensive publications and presentations often focus on vegan companion animal diets, climate change, and humane education. In this episode of The Bloody Vegans Podcast, Professor Knight shares his insights on pet food, animal agriculture and the environmental impact of pet food.https://www.andrewknight.infoFind out more about Sue's amazing work at https://www.littlegreenpigeon.co.uk

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

Looking to connect with a community of physician podcasters? We provide the tools, connections, and resources you need to amplify your voice and grow your audience. Be part of something exciting as we prepare to launch. Join the Doctor Podcast Network today!—--------What are the biggest misconceptions about addiction, and how can we better support patients struggling with it? In this episode, Dr. Bradley Block speaks with Dr. Paula Donnelly Cook and Dr. Darlene Peterson, both board-certified specialists in addiction and family medicine, who co-host The Addiction Files podcast. They address the stigma associated with substance use disorders, highlighting the significance of person-first language to lessen bias and promote compassionate care.The discussion sheds light on prevalent misconceptions, such as equating dependence with addiction or viewing it as an acute issue rather than a chronic condition requiring long-term management. Drs. Cook and Peterson advocate for harm reduction approaches, motivational interviewing, and addressing patients' individual goals to support recovery. They also stress the critical role of trauma-informed care, recognizing the deep connections between trauma and addiction. They caution against iatrogenic addiction, urging careful pain management practices and collaboration with specialists for patients in recovery. Bio.Dr. Paula Donnelly Cook is a board-certified physician in both addiction medicine and family medicine. She serves as an Assistant Professor of Clinical Medicine at the University of Utah, where she is involved in teaching and mentoring medical students and residents. Dr. Cook is also the Medical Director at Moab Regional Hospital in Moab, Utah. She co-hosts The Addiction Files podcast, aiming to provide evidence-based education on addiction medicine.Dr. Darlene Petersen is a board-certified physician in both addiction medicine and family medicine. She practices with Revere Health in Roy, Utah, where she offers comprehensive family and addiction medicine services. Dr. Petersen completed her residency at St. Mark's Family Medicine Residency Program in 2009 and earned her medical degree from Ross University School of Medicine in 2006. She co-hosts The Addiction Files podcast with Dr. Cook, focusing on destigmatizing addiction treatment and providing evidence-based education. Outside of her medical practice.Website and socials for Dr Cook:https://www.doximity.com/pub/paula-cook-mdhttps://x.com/PjaneCookhttps://www.theaddictionfiles.com/Website and socials for Dr Petersen:https://doctors.intermountainhealth.org/provider/darlene-l-petersen/2618429https://www.theaddictionfiles.com/_______________________Did you know…You can also be a guest on our show? Please email me at brad@physiciansguidetodoctoring.com to connect or visit www.physiciansguidetodoctoring.com to learn more about the show!Socials:@physiciansguidetodoctoring on FB@physicianguidetodoctoring on YouTube@physiciansguide on Instagram and Twitter Visit www.physiciansguidetodoctoring.com to connect, dive deeper, and keep the conversation going. Let's grow! Disclaimer:This podcast is for informational purposes only and is not a substitute for professional medical, financial, or legal advice. Always consult a qualified professional for personalized guidance.

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/.

Dr. Stephanie Saucier is a cardiologist specializing in Preventative Cardiology and women's heart health.  Dr. Saucier's medical journey spanned across Ross University School of Medicine, University of Connecticut School of Medicine, and currently at Hartford Hospital Healthcare's Heart and Vascular Institute, where she is the director of women's heart wellness program and the medical director of cardiac rehabilitation Hartford region. Dr. Saucier's expertise is on how people can prevent cardiovascular diseases, which is the #1 cause of death across the world. She has a passion for physical endurance activities such as scuba diving, traveling, promoting healthy lifestyle, global health, tea, and more. To learn about the field of cardiology, women's health, and tools to manage a healthier lifestyle, you can follow Dr. Saucier on Instagram @heartdrsaucier or tune into any of her other podcast appearances. 

Letosky's watch. Tune in for a deep dive into the world of K9 rehabilitation and discover how we can better support our beloved pets! Dr. Letosky is a general practitioner at the Avon Lake Animal Clinic, and has been a part of the team since 1996. She has special interests in ultrasonography, and obtained her certification in this field through the University of Illinois Executive Veterinary Program. Dr. Letosky is also a Certified Canine Rehabilitation Practitioner. She received this certification through the University of Tennessee. She earned her Bachelors of Science from Wayne State University and her Doctorate of Veterinary Medicine from Ross University School of Veterinary Medicine. In addition to practicing veterinary medicine, Dr. Letosky also enjoys golfing and birding. Her love for animals extends to her home life, where she has three pets: two cats named Radar and Shade, and a Boston Terrier named Tug. In 2022 Dr. Letosky was awarded a certificate in Veterinary acupuncture (CVAT) through the Canine Rehab Institute. --- As a veterinary dermatologist, Dr. Alice Jeromin can tell you that the chronically affected allergic pet condition Atopic Dermatitis is rarely ever 'cured', but can be effectively managed. Command™ Deep Cleansing Shampoo from VetriMax is a top veterinarian-prescribed treatment for skin problems resulting from chronic itch, pyoderma, infection, and allergic dermatitis. VetriMax makes practicing veterinary medicine better by giving doctors high-performing, high-value, evidence-based products. Now with Command Shampoo you can bring that same quality into your regular home routine. Go to Chewy.com and enter promo code COMMAND15 to save 15% off on Command™ Deep Cleansing Shampoo. VetriMax Makes it Better. --- Support our sponsor for this episode Blue Buffalo by visiting bluebuffalo.com. BLUE Natural Veterinary Diet formulas offer the natural alternative in nutritional therapy. At Blue Buffalo, we have an in-house Research & Development (R&D) team with over 300 years' experience in well-pet and veterinary therapeutic diets, over 600 scientific publications, and over 50 U.S. patents. At Blue Buffalo, we have an in-house Research & Development (R&D) team with over 300 years' experience in well-pet and veterinary therapeutic diets, over 600 scientific publications, and over 50 U.S. patents. --- All footage is owned by SLA Video Productions.

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

Backpain is one of the most common ailments worldwide, and the majority if people will suffer from it at one point. In this episode of the Get Healthy 360 podcast, Kris Ferguson, MD welcomes Nomeen Azeem, MD to talk about the various back pain treatments available today. Don't miss this episode of the Get Healthy 360 Podcast! Dr. Azeem completed his undergraduate education at James Madison University in Harrisonburg, Virginia, and graduated from medical school, earning his Doctor of Medicine from Ross University School of Medicine. After that, he completed an internship at Medstar Harbor Hospital Center in Baltimore and a residency at Medstar Georgetown University Hospital Physical Medicine and Rehabilitation in Washington, DC, where he was the chief resident. After filling a faculty position at Medstar Georgetown University as a musculoskeletal medicine specialist, he went on to complete an ACGME interventional pain fellowship at Temple University Hospital in Philadelphia, under the guidance of internationally renowned pain physician Dr. Frank J.E. Falco. His most recent book: How to Treat Low Back Pain, is available now! https://shop.elsevier.com/books/how-to-treat-low-back-pain/deer/978-0-443-15962-6

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

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

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

We're joined by Dr. Afifah Rahim-Leong, the co-founder of The Mobile Pawlyclinic – veterinary care in the comfort of your home. Originally from Singapore, Dr. Rahim moved to the US to pursue an Animal Science degree from Iowa State University and subsequently received her doctorate from Ross University School of Veterinary Medicine. Dr. Afifah's passion for veterinary care is deeply rooted in her commitment to improving the lives of pets and their owners. Driven by a purpose to leave a lasting impact in her community, Dr. Afifah's work goes beyond treating ailments. She is dedicated to empowering pet parents with the knowledge and tools to prevent common health issues, ensuring our furry friends live longer, healthier lives. Her innovative approach with The Mobile Pawlyclinic brings veterinary care directly to the homes of pet owners, breaking down barriers and making essential services more accessible. Join us as we explore Dr. Afifah's journey, her dedication to animal health, and the transformative work she is doing to support and educate pet owners everywhere. Dr Rahim's Instagram: @dr.fifarahimleong www.thepawlyclinic.com Ryan's Instagram: @ryanejezie | @eazy.community Ryan's website: eazyliving.net

Curious about how your reproductive health and fertility options work?On today's episode, we dive into these important issues with the amazing Dr. Roohi Jeelani, a double-board-certified obstetrician-gynecologist who specializes in reproductive endocrinology and infertility.Dr. Jeelani is passionate about starting more open conversations about fertility and reproductive health, especially in the South Asian community. She not only shares medical advice but also talks about the social, cultural, and political factors that affect reproductive rights. Together, we explore the complexities of fertility care, the impact of legislation on treatments, and the importance of supporting policies and candidates that protect reproductive rights.Highlights:Navigating Legal Challenges: Dr. Jeelani explains how laws impact fertility treatments and abortion rights and why it's crucial to support policies that protect these healthcare services.The Journey of Fertility: Learn about the transition from general gynecology to specializing in fertility, and when you should consider seeking fertility treatment based on age and fertility status.Fertility Myths Debunked: Find out why home fertility tests might not be as reliable as they seem, and the importance of clinical tests for effective treatment plans.Managing PCOS: Dr. Jeelani shares tips on lifestyle changes, diet, and supplements to boost fertility in PCOS patients. She also discusses medication options like Metformin and GLP-1 agonists.The Real Deal on Egg Freezing: Understand the egg freezing process, what to expect, and why it's like an insurance plan for future fertility. Dr. Jeelani provides statistics on success rates based on age and the number of eggs retrieved.Personal Advocacy in Healthcare: Dr. Jeelani emphasizes the importance of knowing your body, asking the right questions, and seeking second opinions. She highlights the need for a supportive and comfortable healthcare setting for effective treatment.Remember, you don't have to walk this journey alone. Being informed, asking questions, and standing up for your reproductive health are key steps.Who do you want to hear from next? Our podcast is here to educate so you can and advocate for yourself. If you enjoyed this episode, please give us a 5-star review on Apple Podcasts, subscribe, and share with your friends!Guest Bio:Roohi Jeelani, MD, FACOG, is a double board certified Reproductive Endocrinologist and Infertility Specialist (REI). A graduate of Ross University School of Medicine, she completed both her residency in Obstetrics and Gynecology and her fellowship in Reproductive Endocrinology and Infertility at Wayne State University – Detroit Medical Center. During her medical training, Dr. Jeelani received numerous awards in the areas of fetal medicine and reproductive medicine. In addition, she has authored a variety of publications and book chapters in well known journals highlighting cutting-edge REI advancement and has presented at national/international conferences and symposiums focused on advancements in women's health. Dr. Jeelani is an active member of many medical associations. A highly-skilled reproductive endocrinologist and infertility specialist focusing on all areas of reproductive health, Dr. Jeelani has a special interest in oncofertility, toxins' impact on reproductive function, chemotherapy, and oocyte cryopreservation.Dr. Jeelani serves patients from our Chicago, IL and our Detroit, MI clinicsConnect with Dr. Roohi Jeelani: WebsiteInstagramGet in Touch with Dr. Rahman:

In this episode of the Brawn Body Health and Fitness Podcast, Dan is joined by Dr. Gabriel Petruccelli to discuss biceps injury examination, assessment, imaging, surgical and rehab considerations. Gabriel L. Petruccelli is an accomplished board-certified orthopaedic surgeon specializing in arthroscopy, sports medicine, shoulder replacements and general orthopaedics. Dr. Petruccelli joined Greater Washington Orthopaedic Group, PA in 2012, with three locations: Rockville, Silver Spring and  GermanTown, Maryland. Dr. Petruccelli is a Maryland native, who graduated from The Heights School in Potomac, where he played basketball and soccer. Dr. Petruccelli graduated from the George Washington University with a Bachelor of Science degree in Exercise Science before receiving a certificate in Physiology at the Virginia Commonwealth University. He completed his medical degree from Ross University School of Medicine in Barbados in 2006 before relocating to New York City to complete his Internship and Orthopaedic residency at New York Medical College-St. Vincent's Catholic Medical Center/ Kingsbrook Jewish Medical Center in 2011. In 2012, Dr. Petruccelli relocated to the west coast to complete his fellowship with the San Diego Arthroscopy and Sports Medicine Fellowship. There he honed and specialized his skills within the field of sports medicine and open shoulder surgery.  Also, during his time there, he worked closely with Major League Baseball's San Diego Padres. He also assisted the team physician for the San Diego State Aztecs. Given the opportunity to research, he published surgical technique videos for national orthopaedic society meetings that year. Dr. Petruccelli has received the Top Doctors Washingtonian Magazine Award in 2017, 2018 & 2019. Since 2016, he has been the Section Chief of the Department of Orthopaedics at Adventist Healthcare Shady Grove Medical Center. Dr. Petruccelli supports the athletic programs as the team physician at Georgetown Preparatory School and supporting his high school alma mater, The Heights School. He also gives valuable educational talks throughout the community. Dr. Petruccelli's main focus is to help each individual get back to their normal daily life and activities as soon as possible with top quality and very personalized orthopaedic care. He takes great pride in listening to his patients and understanding their needs. He works closely with his carefully selected physical therapists to ensure a safe and quick rehabilitation protocol and recovery. Outside of the medical office, Dr. Petruccelli values spending time with his wife and children. He also enjoys, exercise, music, travel and cutting hair. For more on Dr. Petruccelli, be sure to check out @dr.petruccelli on Instagram or click here: https://www.gwog.com/provider/gabriel-l-petruccelli-md-faaos *SEASON 5 of the Brawn Body Podcast is brought to you by Isophit. For more on Isophit, please check out isophit.com and @isophit - BE SURE to use coupon code brawnbody10 at checkout to save 10% on your Isophit order! Episode Sponsors: MoboBoard: BRAWNBODY10 saves 10% at checkout! AliRx: DBraunRx = 20% off at checkout! https://alirx.health/ MedBridge: https://www.medbridgeeducation.com/brawn-body-training or Coupon Code "BRAWN" for 40% off your annual subscription! CTM Band: https://ctm.band/collections/ctm-band coupon code "BRAWN10" = 10% off! GOT ROM: https://www.gotrom.com/a/3083/5X9xTi8k Red Light Therapy through Hooga Health: hoogahealth.com coupon code "brawn" = 12% off Ice shaker affiliate link: https://www.iceshaker.com?sca_ref=1520881.zOJLysQzKe Make sure you SHARE this episode with a friend who could benefit from the information we shared! Check out everything Dan is up to, including blog posts, fitness programs, and more by clicking here: https://linktr.ee/brawnbodytraining Liked this episode? Leave a 5-star review on your favorite podcast platform! --- Send in a voice message: https://podcasters.spotify.com/pod/show/daniel-braun/message Support this podcast: https://podcasters.spotify.com/pod/show/daniel-braun/support

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

Cheng Ruan, M.D. is a board certified internal medicine physician. He is the founder and serves as the Chief Executive Officer at Texas Center for Lifestyle Medicine, a novel approach to primary care focused on coaching, collaboration, and integrative health. He completed his bachelor's degree in Microbiology at Texas A&M University, his medical degree at Ross University School of Medicine, residency and chief residency in Internal Medicine at Columbia Presbyterian Queens, Weill-Cornell Medical College. He completed his Functional Medicine training at the Institute for Functional Medicine. Dr. Ruan's passion is to create medical systems that work within the current and upcoming medical insurance model to optimize integrative medicine for population health. His holistic approach comes from a long line of physicians in his family. His mother is a traditional chinese medicine doctor and father a world renowned doctor in the field of immunology, cardiology, oncology, and pharmacology.

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

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

Dr. Katie Kling joins Dr. Andy Roark on the Cone of Shame Podcast to discuss the importance of working with pet owners on dental disease prevention without risking their human animal bond in the process. Together they go over what to do when pet owners bring in their favorite dental products and how we as veterinary professionals can guide them to the right resources. This episode is brought to you by Hill's Pet Nutrition! LINKS: https://vohc.org/ https://www.veterinarydentalforum.org/ The Hill's Veterinary Academy is a one site solution for educating the entire veterinary team. On the HVA, you can find FREE RACE CE from leading specialists and experts, patient-centric education beyond nutrition and flexible, on-demand content that fits your schedule. Hill's Veterinary Academy: https://na.hillsvna.com/ For more information on Hill's Prescription Diet t/d: https://www.hillspet.com/dog-food/pd-td-canine-dry?cq_src=google_ads&cq_cmp=12261618933&cq_con=112560662610&cq_term=hills%20t%20d&cq_med=&cq_plac=&cq_net=g&cq_plt=gp&gad_source=1&gclid=Cj0KCQiAhc-sBhCEARIsAOVwHuTKmxq_KgsHKYAg1fcTDouLT7WZcFHbjYgrODPqvxZn7xMiB7zDP08aAgrkEALw_wcB&gclsrc=aw.ds Continuing education on gaining dental home care compliance: https://na.hillsvna.com/en_US/videos-on-demand/gaining-dental-home-care-compliance-what-works/ Veterinary Oral Health Council Seal of Acceptance products: https://vohc.org/accepted-products/ ABOUT OUR GUEST: Dr. Katie Kling graduated from Ross University School of Veterinary Medicine in 2008 and spent the first 7 years of her career in general practice in Cincinnati, Ohio and College Station, Texas prior to completing her dental residency at the University of Illinois in 2019. She stayed on at the University as an Assistant Professor until 2021 at which time she joined the Veterinary Dental Center in Aurora, IL where she now practices as a part of a dedicated dentistry team. She is happy to serve on the AVDC Diversity, Equity, and Inclusion Committee and the AVDC Exam Committee.

This Living to 100 Club podcast introduces our listeners to an innovative home-based medical care program, WellBe Senior Medical. Our guest is Dr. Iyad Houshan. We discuss the benefits of at-home medical care with older adults who are faced with multiple and complex health challenges. Our listeners will learn about the “full risk” model of reimbursement, vs. the traditional fee-for-service model. We understand how this incentivizes WellBe to provide a comprehensive, holistic services program. We also learn how this comprehensive care model reduces the need for frequent acute hospital or skilled nursing re-admissions. It also avoids the problems with home health services that too often become fragmented and ineffective at avoiding re-admissions. This is another highly educational conversation for our listeners as we explore a breakthrough care model for the most-frail seniors in our communities.  Mini Bio Dr. Iyad Houshan is the Chief Medical Officer at WellBe Senior Medical. Prior to joining WellBe, he served as the Senior Medical Officer at Alignment Healthcare from January 2017 to June 2019. In this role, he was responsible for managing the clinical program at an innovative Medicare Advantage provider. This provider offers an integrated clinical model, proactive healthcare, advanced technologies, and alliances with major health care partners. Iyad also structured the home-based program designed for optimal revenue and clinical / hospice outcomes. Dr. Houshan has been recognized for his strong patient and family satisfaction skills, which he has used to set the stage for improvements in hospice metrics and drop in unnecessary resource utilization. Iyad Houshan began his educational career by obtaining a B.S. in Chemistry from UC San Diego. Iyad then went on to obtain an M.D. from Ross University School of Medicine. After completing his medical degree, he pursued a career in general education and obtained a position at San Diego Miramar College. Iyad later went on to complete an Internal Medicine Residency at the University of Nevada, Reno. For Our Listeners Website for WellBe Senior Medical: WellBe.com See omnystudio.com/listener for privacy information.

This Living to 100 Club podcast introduces our listeners to an innovative home-based medical care program, WellBe Senior Medical. Our guest is Dr. Iyad Houshan. We discuss the benefits of at-home medical care with older adults who are faced with multiple and complex health challenges. Our listeners will learn about the “full risk” model of reimbursement, vs. the traditional fee-for-service model. We understand how this incentivizes WellBe to provide a comprehensive, holistic services program. We also learn how this comprehensive care model reduces the need for frequent acute hospital or skilled nursing re-admissions. It also avoids the problems with home health services that too often become fragmented and ineffective at avoiding re-admissions. This is another highly educational conversation for our listeners as we explore a breakthrough care model for the most-frail seniors in our communities.  Mini Bio Dr. Iyad Houshan is the Chief Medical Officer at WellBe Senior Medical. Prior to joining WellBe, he served as the Senior Medical Officer at Alignment Healthcare from January 2017 to June 2019. In this role, he was responsible for managing the clinical program at an innovative Medicare Advantage provider. This provider offers an integrated clinical model, proactive healthcare, advanced technologies, and alliances with major health care partners. Iyad also structured the home-based program designed for optimal revenue and clinical / hospice outcomes. Dr. Houshan has been recognized for his strong patient and family satisfaction skills, which he has used to set the stage for improvements in hospice metrics and drop in unnecessary resource utilization. Iyad Houshan began his educational career by obtaining a B.S. in Chemistry from UC San Diego. Iyad then went on to obtain an M.D. from Ross University School of Medicine. After completing his medical degree, he pursued a career in general education and obtained a position at San Diego Miramar College. Iyad later went on to complete an Internal Medicine Residency at the University of Nevada, Reno. For Our Listeners Website for WellBe Senior Medical: WellBe.com

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

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

This week on the show, Petrendologist Charlotte Reed and Michael Fleck, DVM talk with Dr. Ibrahim Shokry, retired professor of pharmacology and toxicology at Ross University School of Veterinary Medicine in St. Kitts, about holiday plant safety, and with Kim Scribner of Christmas Designs about pet-themed holiday decorating.

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

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

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

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

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

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

In this episode of the Brawn Body Podcast, Dan is joined by Dr. Gabriel Petruccelli from Greater Washington Orthopaedic Group to discuss rotator cuff injuries, surgical considerations, reverse total shoulder, & more! Gabriel L. Petruccelli is an accomplished board-certified orthopaedic surgeon specializing in arthroscopy, sports medicine, shoulder replacements and general orthopaedics. Dr. Petruccelli joined Greater Washington Orthopaedic Group, PA in 2012, with three locations: Rockville, Silver Spring and  GermanTown, Maryland. Dr. Petruccelli is a Maryland native, who graduated from The Heights School in Potomac, where he played basketball and soccer. Dr. Petruccelli graduated from the George Washington University with a Bachelor of Science degree in Exercise Science before receiving a certificate in Physiology at the Virginia Commonwealth University. He completed his medical degree from Ross University School of Medicine in Barbados in 2006 before relocating to New York City to complete his Internship and Orthopaedic residency at New York Medical College-St. Vincent's Catholic Medical Center/ Kingsbrook Jewish Medical Center in 2011. In 2012, Dr. Petruccelli relocated to the west coast to complete his fellowship with the San Diego Arthroscopy and Sports Medicine Fellowship. There he honed and specialized his skills within the field of sports medicine and open shoulder surgery.  Also, during his time there, he worked closely with Major League Baseball's San Diego Padres. He also assisted the team physician for the San Diego State Aztecs. Given the opportunity to research, he published surgical technique videos for national orthopaedic society meetings that year. Dr. Petruccelli has received the Top Doctors Washingtonian Magazine Award in 2017, 2018 & 2019. Since 2016, he has been the Section Chief of the Department of Orthopaedics at Adventist Healthcare Shady Grove Medical Center. Dr. Petruccelli supports the athletic programs as the team physician at Georgetown Preparatory School and supporting his high school alma mater, The Heights School. He also gives valuable educational talks throughout the community. Dr. Petruccelli's main focus is to help each individual get back to their normal daily life and activities as soon as possible with top quality and very personalized orthopaedic care. He takes great pride in listening to his patients and understanding their needs. He works closely with his carefully selected physical therapists to ensure a safe and quick rehabilitation protocol and recovery. Outside of the medical office, Dr. Petruccelli values spending time with his wife and children. He also enjoys, exercise, music, travel and cutting hair. For more on Dr. Petruccelli, be sure to check out @dr.petruccelli on Instagram or click here: https://www.gwog.com/provider/gabriel-l-petruccelli-md-faaos Episode Sponsors: MoboBoard: BRAWNBODY10 saves 10% at checkout! AliRx: DBraunRx = 20% off at checkout! https://alirx.health/ MedBridge: https://www.medbridgeeducation.com/brawn-body-training or Coupon Code "BRAWN" for 40% off your annual subscription! CTM Band: https://ctm.band/collections/ctm-band coupon code "BRAWN10" = 10% off! PurMotion: "brawn" = 10% off!! TRX: trxtraining.com coupon code "TRX20BRAWN" = 20% off GOT ROM: https://www.gotrom.com/a/3083/5X9xTi8k Red Light Therapy through Hooga Health: hoogahealth.com coupon code "brawn" = 12% off Ice shaker affiliate link: https://www.iceshaker.com?sca_ref=1520881.zOJLysQzKe Training Mask: "BRAWN" = 20% off at checkout https://www.trainingmask.com?sca_ref=2486863.iestbx9x1n Make sure you SHARE this episode with a friend who could benefit from the information we shared! Check out everything Dan is up to, including blog posts, fitness programs, and more by clicking here: https://linktr.ee/brawnbodytraining Liked this episode? Leave a 5-star review on your favorite podcast platform --- Send in a voice message: https://podcasters.spotify.com/pod/show/daniel-braun/message Support this podcast: https://podcasters.spotify.com/pod/show/daniel-braun/support

Have you thought of medicine as a ministry? Dr. Sandra E. Luyindula does, and she shares her approach to healing. I'm excited about this conversation. Dr. Luyindula earned her Bachelor's in Biology Pre Med with minors in Chemistry and French from Xavier University of Louisiana. She then attended Ross University School of Medicine and completed her family residency at Greenville Health System, where she received the Greenville Health System Gold Award. Dr. Luyindula is double board-certified, in Family Medicine and Lifestyle Medicine. She enjoys providing primary care for patients of all ages and making house calls for her patients. She has a special interest in women's health and lifestyle medicine.  Dr. Luyindula speaks 4 different languages fluently (English, French, Lingala, and Tetela). She also has been exposed to and can communicate in Spanish, Creole, and Swahili. She has ventured into Luba, Kongo, Twi, Igbo, and Yoruba. Website: Thewell-md.com FB: sandra El and The Well-MD IG: @thewell.md LinkedIn: Sandra E. Luyindula, MD DipABLM --- Send in a voice message: https://podcasters.spotify.com/pod/show/urcaringdocs/message

“Turmeric saved my dog” you'll hear online. And it's true that this dark yellow spice, used for thousands of years, has a host of benefits. But it's really hard to get into the bloodstream, which means it has low bioavailability. Just how useful is it, really? Dr. Jessica Tartof, an integrative veterinarian, joins us to explain why so many of the blends she recommends to her own clients include curcumin … and why feeding your dog spice off the shelf might not be as effective as you hope. Visit us at DogCancer.com to see more articles about supplements along with hundreds of other helpful resources for your dog. Links Mentioned in Today's Show: Curcumin for Dogs article Related Links: Doxorubicin article Apoptosis article Where Do I Start with Supplements for Dog Cancer? podcast episode Inflammation and Cancer article Chapters: 00:00 Start 02:59 Benefits of Curcumin                05:07 Is Curcumin a Miracle Cure?                05:50 Absorption and Bioavailability             09:12 Golden Paste                              10:48 Why So Little Research on Supplements                     14:03 Curcumin Dose                          16:02 Warming in Traditional Chinese Medicine       17:03 Side Effects                     18:28 Giving More Isn't Helpful         20:15 Making the Most of Curcumin             21:23 Curcumin Stains About Today's Guest, Dr. Jessica Tartof:   Dr. Jessica Tartof is an Integrative Veterinarian who received her Doctor of Veterinary Medicine in 2002 from Ross University School of Veterinary Medicine. She has practiced in both equine and small animal Western and Eastern medicine. She became certified in Veterinary Acupuncture (CVA) through the International Veterinary Acupuncture Society.  She earned her certification in Veterinary Spinal Manipulation Therapy (CVSMT) through the College of Animal Chiropractors and the Healing Oasis Center.  A post graduate diploma in Veterinary Chinese Herbal Medicine (CVCHM) was obtained through the College of Integrative Veterinary Therapies.  Dr. Tartof pursued training in alternative therapies to get to the root of a problem instead of simply treating the symptoms, which are the warning signs of larger deeper issues. Treating the symptoms is like cutting the top of weeds instead of digging them up at their root. The symptoms will keep coming back. Alternative therapies allow patients to have more treatment options as “one size fits all” doesn't work for every patient. She also has a soft spot for working with geriatric and blind patients, improving their quality of life and helping to soothe their aches and pains to keep them moving.  Dr. Tartof has joined many people and their dogs on the cancer journey, and has seen firsthand how integrative therapies can offer high life quality. She is glad to join her DogCancer.com colleagues to help dog lovers find safe alternative veterinary information.  LinkedIn  Other Links: If you would like to ask a dog cancer related question for one of our expert veterinarians to answer on a future Q&A episode, call our Listener Line at 808-868-3200.  Dog Cancer News is a free weekly newsletter that contains useful information designed to help your dog with cancer. To sign up, please visit DogCancerNews.com  Learn more about your ad choices. Visit megaphone.fm/adchoices

Episode 146: RA vs OA    Future Dr. Magurany explains how to differentiate rheumatoid arthritis from osteoarthritis.  Written by Thomas Magurany, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.1. Etiology: Rheumatoid Arthritis (RA): RA is an autoimmune disease wherein the immune system mistakenly attacks healthy tissues, particularly the synovial joints, usually between the ages of 30-50. Genetic predisposition, environmental factors such as smoking or infections, hormonal imbalances, and lower socioeconomic status have been associated with an increased risk of developing RA(1).Osteoarthritis (OA): OA primarily arises due to mechanical stress on the joints over time. Factors contributing to OA include age, obesity, joint injury or trauma, repetitive joint use or overuse, genetic abnormalities in collagen structure, and metabolic disorders affecting cartilage metabolism (2).The greatest risk factor for the development of OA is age with most patients presenting after 45 years of age. The greatest modifiable risk factor for OA is weight. People with a BMI >30 were found to have a 6.8 times greater risk of developing OA. (3) Primary OA is the most common and is diagnosed in the presence of associated risk factors such as: older age, female gender, obesity, anatomical factors, muscle weakness, and joint injury (occupation/sports activities) in the absence of trauma or disease. Secondary OA occurs alongside a pre-existing joint deformity including trauma or injury, congenital joint disorders, inflammatory arthritis, avascular necrosis, infectious arthritis, Paget disease, osteopetrosis, osteochondritis dissecans, metabolic disorders (hemochromatosis, Wilson's disease), Ehlers-Danlos syndrome, or Marfan syndrome.2. Pathogenesis:Rheumatoid Arthritis (RA):In some patients, RA is triggered by some sort of environmental factor in a genetically predisposed person. The best example is tobacco use in a patient with HLA-DRB1. The immune response in RA starts at sites distant from the synovial joints, such as the lung, gums, and GI tract. In these tissues, modified proteins are produced by biochemical reactions such as citrullination. (4)In RA, an abnormal immune response leads to chronic inflammation within the synovium lining the joints. The inflammatory cytokines released cause synovitis and lead to the destruction of articular cartilage and bone erosion through pannus formation. Immune cells infiltrate the synovium causing further damage. (4) In summary: formation of antibodies to citrullinated proteins, these antibodies begin attacking wrong tissues.Osteoarthritis (OA):The primary pathological feature of OA is the degeneration of articular cartilage that cushions the joints causing surface irregularity, and focal erosions. These changes progress down the bone and eventually involve the entire joint surface. Mechanical stress triggers chondrocyte dysfunction, leading to an imbalance between cartilage synthesis and degradation that cause cartilage outgrowths that ossify and form osteophytes. This results in the release of enzymes that degrade the extracellular matrix, leading to progressive cartilage loss. As more of the collagen matrix is damaged, chondrocytes undergo apoptosis. Improperly mineralized collagen causes subchondral bone thickening; in advanced disease, bone cysts infrequently occur (5). In summary: Osteophytes formation and cartilage loss.3. Clinical Presentation:Rheumatoid Arthritis (RA):The most common and predominant symptoms include joint pain and swelling, usually starting insidiously over a period of weeks to months. RA typically affects multiple joints symmetrically, commonly involving small joints of the hands, wrists, feet and progresses to involve proximal joints if left untreated. Morning stiffness lasting more than an hour is a characteristic feature. The affected joint will be painful if pressure is applied to the joint or on movement with or without joint swelling. Synovial thickening with a "boggy" feel on palpation will be noted. The classical physical findings of ulnar deviation, metacarpophalangeal joint subluxation, swan neck deformity, Boutonniere deformity, and the "bowstring" sign (prominent and tight tendons on the dorsum of the hand) are seen in advanced chronic disease. (4) Around ¼ of patients with RA may present with rheumatoid noduleswhich are well demarcated, flesh-colored subcutaneous lumps. They are usually described as being doughy or firm and are not typically tender unless they are inflamed. They are usually found on areas susceptible to repeated trauma or pressure and include the elbows, fingers and forearms. Osteoarthritis (OA):OA primarily affects weight-bearing joints such as knees, hips, spine, and hands. Symptoms include joint pain aggravated by activity and relieved with rest, morning stiffness lasting less than 30 minutes, joint swelling due to secondary inflammation, and occasionally the formation of bony outgrowths called osteophytes (6). Tenderness may be present at joint lines, and there may be pain upon passive motion. Classic physical exam findings in hand OA include Heberden's nodes (posterolateral swellings of DIP joints), Bouchard's nodes (posterolateral swellings of PIP joints), and “squaring” at the base of the thumb (first Carpal-Metarcapal or CMC joints), bony enlargement, crepitus, effusions (non-inflammatory), and a limited range of motion. Patients may also experience bony swelling, joint deformity, and instability (patients complain that the joint is “giving way” or “buckling,” a sign of muscle weakness). (5)4. Lab findings:Rheumatoid Arthritis: Laboratory testing often reveals anemia of chronic disease (increased ferritin, decreased iron and TIBC) and thrombocytosis. Neutropenia may be present if Felty syndrome is present. RF is present in 80-90% of patients with a sensitivity of 69%. In patients who are asymptomatic or those that have arthralgias, a positive RF and especially CCP predicts the onset of clinical RA. Patients with RA with RF, ACPA, or both are designated as having seropositive RA. About 10% of RA patients are seronegative. ESR and levels of CRP are usually elevated in patients with active disease and can be used to assess disease activity. The synovial fluid in RA will also reveal low C3 and C4 levels despite elevated serum levels.(4) Some non-specific inflammatory markers such as ESR, CRP can help you guide your diagnosis of RA.Osteoarthritis:Lab findings are not significant. Clinical diagnosis if the following are present: 1) pain worse with activity and better with rest, 2) age more than 45 years, 3) morning stiffness lasting less than 30 minutes, 4) bony joint enlargement, and 5) limitation in range of motion. Blood tests such as CBC, ESR, rheumatoid factor, ANA are usually normal but usually ordered to rule out an inflammatory process. Synovial fluid should show a white blood cell count less than 2,000/microL, predominantly mononuclear cells (non-inflammatory). X-rays of the affected joint can show findings consistent with OA, such as marginal osteophytes, joint space narrowing, subchondral sclerosis, and cysts; however, radiographic findings do not correlate to the severity of the disease and may not be present early in the disease. (5)5. Treatment Approaches:Rheumatoid Arthritis (RA):There is no cure for RA.The goal of treatment in RA is inducing remission and optimizing quality of life. This is initially done by beginning DMARDs, include methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide. Methotrexate is the initial DMARD of choice. Anti-TNF-alpha inhibitors include etanercept, infliximab, adalimumab, golimumab, and certolizumab may be used if DMARDs fail. NSAIDs are used to control joint pain and inflammation. Corticosteroids may be used as a bridge therapy to DMARDs in a newly diagnosed patient with a very active disease. (7) Coronary artery disease has a strong association with RA. RA is an independent risk factor for the development of coronary artery disease (CAD) and accelerates the development of CAD in these patients. Accelerated atherosclerosis is the primary cause of morbidity and mortality. There is increased insulin resistance and diabetes mellitus associated with RA and is thought to be due to chronic inflammation. When treated with specific DMARDs such as hydroxychloroquine, methotrexate, and TNF antagonists, there was a marked improvement in glucose control in these patients. (8) RA is not just a disease of the joints, it is able to affect multiple organ systems.Osteoarthritis (OA):OA treatment aims at reducing pain and improving joint function through a combination of non-pharmacological interventions like exercise programs tailored to strengthen muscles around affected joints, weight management strategies, and assistive devices like braces or walking aids if required (9). Medications including analgesics or nonsteroidal anti-inflammatory drugs may be prescribed for pain relief when necessary. Duloxetine has modest activity in relieving pain associated with OA. Intraarticular glucocorticoid joint injections have a variable response but are an option for those wanting to postpone surgical intervention. In severe cases where conservative measures fail, surgical options like joint replacement may be considered (9). Weight loss is a critical intervention in those who have overweight and obesity; each pound of weight loss can decrease the load across the knee 3 to 6-fold. (5) Summary: Medications (NSAIDs, topical, duloxetine), weight loss, PT, intraarticular injections of corticosteroids, and joint replacement.________________________________Conclusion: Now we conclude episode number 146, “RA vs. OA.” Future Dr. Magurany explained that rheumatoid arthritis is an autoimmune disease that presents with joint pain and inflammation, mostly on hands and small joints, accompanied by morning stiffness longer than 1 hour. The rheumatoid factor and ACPA may be positive in a percentage of patients but not always. The base of treatment is early treatment with disease-modifying antirheumatic drugs to induce remission of the disease. OA affects weight-bearing joints with little to no inflammation, treatment is mainly lifestyle modifications, analgesics, intraarticular injections, and joint replacement.This week we thank Hector Arreaza and Thomas Magurany. 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:Myasoedova E, Crowson CS & Gabriel SE et al. (2010). Is the incidence of rheumatoid arthritis rising?: Results from Olmsted County, Minnesota, 1955-2007. Arthritis and Rheumatism, 62(6), 1576-1582.Goldring MB & Goldring SR. (2007). Osteoarthritis. Journal of Cellular Physiology, 213(3), 626-634.King LK, March L, Anandacoomarasamy A. Obesity & osteoarthritis. Indian J Med Res. 2013;138(2):185-93. PMID: 24056594; PMCID: PMC3788203.Chauhan K, Jandu JS, Brent LH, et al. Rheumatoid Arthritis. [Updated 2023 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.Sen R, Hurley JA. Osteoarthritis. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.Hunter DJ, Bierma-Zeinstra S. & Eckstein F. (2014). OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for primary hip and knee osteoarthritis: An expert consensus initiative of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) Task Force in collaboration with the Osteoarthritis Research Society International (OARSI). Osteoarthritis Cartilage, 22(7), 363-381.van Everdingen AA, Jacobs JW, Siewertsz Van Reesema DR, Bijlsma JW. Low-dose prednisone therapy for patients with early active rheumatoid arthritis: clinical efficacy, disease-modifying properties, and side effects: a randomized, double-blind, placebo-controlled clinical trial. Ann Intern Med. 2002 Jan 1;136(1):1-12. doi: 10.7326/0003-4819-136-1-200201010-00006. PMID: 11777359.Nicolau J, Lequerré T, Bacquet H, Vittecoq O. Rheumatoid arthritis, insulin resistance, and diabetes. Joint Bone Spine. 2017 Jul;84(4):411-416.Fernandes L, Hagen KB, Bijlsma JWJ et al. (2019). EULAR recommendations for non-pharmacological core management of hip and knee osteoarthritis. Annals of Rheumatic Diseases, 79(6), 715-722.Royalty-free music used for this episode: "Driving the Point." 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/ 

Episode 142: Tirzepatide IIFuture Dr. Beuca explains that tirzepatide has shown benefits in patients with obesity that go beyond its weight-reducing effects and includes reduction of blood pressure, among others. Dr. Arreaza explains that Wegovy (semaglutide approved for weight loss) is also very beneficial for weight loss and explains.  Written by Maria Beuca, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Maria: Hello everyone, today is June 2, 2023, and we want to re-visit our discussion about the drug Tirzepatide from our May 19th, 2022. A little re-cap for those of you who don't know, tirzepatide, also known by the brand name Mounjaro, is a drug that was approved by the FDA a year ago for the treatment of type 2 Diabetes. It is similar to the drug Semaglutide, also known by the brand name Ozempic which many of you may be more familiar with, thanks to the Kardashians and other celebrities making it popular as a “weight loss” drug. Arreaza: The brand name for weight semaglutide is Wegovy.Maria: Both of these drugs are injected once a week and mimic the effect of the incretin hormone GLP-1 by binding to its receptor. Incretin hormones are a group of hormones that cause insulin to be released from the pancreas after eating to help lower blood sugar levels.  These incretin hormones also help suppress the appetite, causing you to eat less and lose weight. Tirzepatide is different because it is the first drug to mimic the action of two hormones, both GLP-1 and GIP. In our last episode, we also discussed the SURPASS-2 study that showed tirzepatide to be superior to semaglutide because of this dual incretin action, with greater weight loss, lower HA1c levels, and lower triglyceride and VLDL levels. At that time, we also mentioned the SURMOUNT-1 Phase 3 clinical trial that was ongoing at the time. Well, it is now complete, and the results are in. There were 2,539 obese or overweight participants without diabetes in the study who lost between 16-22.5% of their starting weight on Tirzepatide. On 15 mg dose, participants lost about 52 lbs (24 kg), on 10 mg 49 lbs (22 kg) and on 5 mg about 35 lbs (16 kg), but those on the placebo lost only 2.4% or about 5 lbs (2 kg). As you can see there is very little difference in weight loss between the 10 mg dose and the 15 mg dose, although a big difference is seen compared to the 5 mg dose. It's important to note that they took Tirzepatide for 72 weeks or a year and a half. Arreaza: That's very significant weight loss. It is important to emphasize that these patients did NOT have diabetes. Maria: These weight loss results have proven to be comparable to bariatric surgery. The study also showed improvement in cardiovascular and metabolic risk factors such as lower blood pressure, fasting insulin, lipid levels and even aspartate aminotransferase levels in comparison to the placebo. By the end of the study, more than 95% of the participants who had pre-diabetes had converted to normal glucose levels. This study was so impressive that it was presented at the 82nd Scientific Sessions of the American Diabetes Association and was also published in The New England Journal of Medicine. Arreaza: It seems like tirzepatide is ahead of the game for weight loss.Maria: Although it is approved as a drug for diabetes, the next step is to approve it for weight loss and to begin treating obesity as a chronic disease that needs to be treated. Maria: And this makes sense. Currently, more than 4 in 10 American adults have obesity, and obesity is the cause of many other conditions. Just yesterday, I was seeing patients in the orthopedic clinic and I had several patients being seen for knee pain due to obesity, and they are postponing surgery because they have been losing weight on tirzepatide and are already feeling better. I think avoiding knee surgery alone is a pretty good reason to approve these drugs for weight loss, but there are many other conditions that are improved by weight loss. Arreaza: My anecdotes are related to semaglutide, but I can imagine that this may also apply to tirzepatide. I had a patient who was able to stop all antihypertensive medications because of 40-lb weight loss. Maria: Dr. Caroline Apovian, director of the Center for Weight Management and Wellness at Brigham Women's Hospital, states that “If everybody who had obesity in this country lost 20% of their body weight, we would be taking patients off all these medications for reflux, for diabetes, for hypertension. We would not be sending patients for stent replacement.”Maria: Last month, officials from Eli Lilly, the company that makes tirzepatide, stated that they are hoping to have a fast-track approval to sell it for chronic weight management by sometime this year. The problem is that many of these patients who were prescribed Tirzepatide have not been able to get it because it has been out of stock for the last few months in all the local pharmacies. They get the prescription, start taking Tirzepatide and begin to lose weight or improve their blood sugar levels and then it is out of stock and now you have people with Diabetes who have gotten off insulin because Tirzepatide worked so well and suddenly they can't get it and are at risk for getting pretty sick without it. Arreaza: The manufacturer of Wegovy announced this, “we will only be able to supply limited quantities of 0.25 mg, 0.5 mg, and 1 mg dose strengths to wholesalers for distribution to retail pharmacies which will not meet anticipated patient demand. We anticipate that many patients will have difficulty filling Wegovy® prescriptions at these doses through September 2023. We do not currently anticipate supply interruptions of the 1.7 mg and 2.4 mg dose strengths of Wegovy®”. Why is this happening? Maria: The problem is that this drug was not meant for the masses, for all these young girls wanting to lose a few pounds for aesthetic reasons. It was meant for people with a BMI 30 or with a BMI 27 plus another comorbidity such as hypertension. Celebrities have brought attention to these drugs for weight loss, for example Ozempic has over 433 million views on TikTok. It has gotten so bad that people are turning to questionable sources online to purchase these drugs, where it is given cute names like “skinny shots.” And if your insurance does not cover Tirzepatide, it is still expensive, starting at around $1000 per month. Some of the insurers who used to cover the cost stopped covering it or placed new restrictions on who qualifies. Another downside is that tirzepatide and other drugs of this class have not been on the market that long, so the long-term effects are still not known. So far, early evidence shows that most people gain the weight back as soon as they stop taking it, so are the weight loss benefits sustainable at this high cost? Maria: We talked about the adverse effects in the last episode, but it's important to go over them again. Patients can have diarrhea, nausea, vomiting, constipation, and abdominal pain that can often bring these patients into the clinic or even the Emergency room thinking they are ill, when in fact it is an adverse effect of their medication, especially the first few days of starting or increasing the dose. So, educating patients is very important before they start this new drug. There is also a small risk of pancreatitis or gallbladder problems, so it is important to have blood work done to check the pancreas and gallbladder prior to starting tirzepatide. There is also a warning to avoid using it if you have a family or personal history of thyroid cancer. Arreaza: Reminder, MEN type 1. I would like to mention the so-called “Ozempic face”. It is the face you get with rapid weight loss, making you look a little older due to fat loss on the face. As a summary, tirzepatide is a very effective medication for weight loss, pending FDA approval. It is not free of side effects, so we still need to follow the recommendations from FDA and other reputable sources to prescribe it responsibly. There is room for further research on these medications. Currently, there are no clear guidelines regarding labs before starting treatment (lipase?) or labs for monitoring after treatment. The evidence regarding these medications continues to evolve and we should stay up to date with the changes. _______________________Conclusion: Now we conclude episode number 142 “Tirzepatide II.” Future Dr. Beuca came back almost one year later to shed more light on the use of tirzepatide in the treatment of obesity. Dr. Arreaza provided some insight into the management of side effects and the potential harm of this novel medication. Overall, tirzepatide is effective and safe and may be the answer to many of our patients with diabetes and obesity. This week we thank Hector Arreaza and Maria Beuca. 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:Brownie, Grace. “The Problematic Arrival of Anti-Obesity Drugs.” Wired, 25 January 2023. https://www.wired.com/story/anti-obesity-drugs/Dockrill, Peter. “Experimental Drug Breaks Record for Weight Loss in Latest Clinical Trial Results.”ScienceAlert, 9 May 2022, https://www.sciencealert.com/experimental-drug-breaks-record-for-weight-loss-in-latest-clinical-trial-results.Frías, Juan P., et al. “Tirzepatide versus Semaglutide Once Weekly in Patients with Type 2 Diabetes.”New England Journal of Medicine, 5 August 2021, https://www.nejm.org/doi/full/10.1056/NEJMoa2107519.Jastreboff, Ania  M., et al. “Tirzepatide Once Weekly for the Treatment of Obesity.” New England Journal of Medicine, 21 July 2022, www.nejm.org/doi/full/10.1056/NEJMoa2206038.“Label as Approved by FDA. - Pi.lilly.com.”Mounjaro Prescribing Information, Lilly USA, LLC, May 2022, https://pi.lilly.com/us/mounjaro-uspi.pdf.Mounjaro. Prescribing Information. Lilly USA, LLC.  May 2022. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi“Surmount-1 Study Finds Individuals with Obesity Lost up to 22.5% of their Body Weight when Taking Tirzepatide.” 4 June 2022. https://diabetes.org/newsroom/press-releases/2022/surmount-1-study-finds-individuals-%20with-obesity-lost-up-to-22.5-percent-body-weight-taking-tirzepatide.Royalty-free music used for this episode: "Happy-Go-Lucky." Downloaded on October 13, 2022, from https://www.videvo.net/ 

Billy called in to our Listener Line with a question about supplements for dog cancer. Integrative veterinarian Jessica Tartof explains that each dog will likely benefit from different supplements, but there are some ones that she uses frequently for her cancer patients. Some good starting points to consider are Chinese herbal blends, vitamins, and medicinal mushrooms. Talk to your vet to see if these might be right for your dog, and listen in for more advice and resources! Links Mentioned in Today's Show: How to Choose the Best Dog Supplements article https://www.dogcancer.com/articles/supplements/best-dog-supplements/ Dog Cancer Dot Com https://www.dogcancer.com/ Related Links: Supplements for Dogs with Cancer podcast episode Medicinal Mushrooms for Dog Cancer Part 1 podcast episode Traditional and Classic Chinese Medicine for Dog Cancer podcast episode Chapters: 0:00 Start 3:03 Medicinal Mushrooms About Today's Guest, Dr. Jessica Tartof: Dr. Jessica Tartof is an Integrative Veterinarian who received her Doctor of Veterinary Medicine in 2002 from Ross University School of Veterinary Medicine. She has practiced in both equine and small animal Western and Eastern medicine. She became certified in Veterinary Acupuncture (CVA) through the International Veterinary Acupuncture Society. She earned her certification in Veterinary Spinal Manipulation Therapy (CVSMT) through the College of Animal Chiropractors and the Healing Oasis Center. A post graduate diploma in Veterinary Chinese Herbal Medicine (CVCHM) was obtained through the College of Integrative Veterinary Therapies. Dr. Tartof pursued training in alternative therapies to get to the root of a problem instead of simply treating the symptoms, which are the warning signs of larger deeper issues. Treating the symptoms is like cutting the top of weeds instead of digging them up at their root. The symptoms will keep coming back. Alternative therapies allow patients to have more treatment options as “one size fits all” doesn't work for every patient. She also has a soft spot for working with geriatric and blind patients, improving their quality of life and helping to soothe their aches and pains to keep them moving. Dr. Tartof has joined many people and their dogs on the cancer journey, and has seen firsthand how integrative therapies can offer high life quality. She is glad to join her DogCancer.com colleagues to help dog lovers find safe alternative veterinary information. LinkedIn Other Links: If you would like to ask a dog cancer related question for one of our expert veterinarians to answer on a future Q&A episode, call our Listener Line at 808-868-3200.  Dog Cancer News is a free weekly newsletter that contains useful information designed to help your dog with cancer. To sign up, please visit DogCancerNews.com  Learn more about your ad choices. Visit megaphone.fm/adchoices

Episode 140: Bullous pemphigoid basicsFuture Dr. Stetkevych explains the diagnosis and treatment of bullous pemphigoid. She explains how to differentiate BP from pemphigus vulgaris. Dr. Arreaza added some comments and summaries.  Written by Katherine Stetkévych, MSIV, Ross University School of Medicine.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Bullous pemphigoid is an autoimmune condition in which the body produces antibodies against hemidesmosomes at the basement membrane of the skin. (Hemidesmosomes anchor the epidermis to the dermis.) As a result of this autoimmune reaction, inflammatory cells, and fluid fill under the epidermis, creating a blister.As a reminder, a vesicle is a collection of free fluid

May 12, 2023 https://linkr.bio/Nefertiti.Ra.Seti.?fbclid=PAAaagpeqTwvTnz9GrwGheujwgwKVxkr23kKEpVifnc2lz4JF8sz1D_AMBZkc https://www.theguardian.com/science/2023/may/09/first-uk-baby-with-dna-from-three-people-born-after-new-ivf-procedure https://www.youtube.com/live/c64VqB9MYZ0?feature=share Company Owner at Steele & Associates Consulting, LLC She is a Spiritualist.have an MD from Ross University School of Medicine (2017) and a BS in Molecular Biology with a Chemistry Minor (WSSU 2006). I have worked as a consultant in various roles in research and development,  clinical trials, and quality and regulatory assurance for the last 21 years. She has an online spiritual shop  offering professional services, handmade jewelry, metaphysical supplies and organic items for personal care.  Experienced Quality and Regulatory Consultant with a demonstrated history of working in the Pharmaceutical, Nutraceutical, Biotechnology and Medical Device industries. Thorough knowledge of Domestic and International Regulatory requirements for Compliance and Safety. Highly skilled Technical Writer with experience (including but not limited to) authoring Quality Investigations, Standard Operating Procedures (SOPs), Work Instructions (WI), and Formal Responses to Regulatory Authorities. Strong consulting professional with emphasis on timelines and deliverables with a Doctor of Medicine (M.D.) from Ross University School of Medicine and Pfizer Yellow Belt Certification.

Episode 138: SGLT-2 Inhibitors in heart failureFuture doctor Enuka explains the use of sodium-glucose-linked cotransporter-2 inhibitors (SGLT-2 inhibitors) in heart failure. Dr. Arreaza adds his experience with these medications and emphasizes their role as an effective treatment for type 2 diabetes.  Written by  Princess Enuka, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Intro:Heart failure is a major medical condition that affects millions of people worldwide. It is one of the leading causes of hospitalization and death in developed countries. Recently, SGLT2 inhibitors have emerged as a promising treatment option for heart failure. Today, we will discuss their benefits, their effectiveness, and their adverse effects.SGLT2 inhibitors, also known as sodium-glucose-linked cotransporter-2 inhibitors, are a relatively novel class of drugs that have shown promise in heart failure treatment. This transporter reabsorbs glucose from the glomerular filtrate back into the bloodstream. Under normal circumstances, SGLT-2 reabsorbs 100% of the filtered glucose unless it is saturated (as in hyperglycemia) or blocked by medications. SGLT2 inhibitors increase the amount of glucose excreted in the urine, which leads to blood glucose reduction. Examples include empagliflozin, dapagliflozin, and canagliflozin.SGLT-2 inhibitors have become a first-line therapy for diabetes mellitus. I heard before that it was used in Europe for T1DM, but it seems like they are no longer used, according to my most recent review of articles. SGLT2 inhibitors are not approved by the FDA for use in type 1 diabetes due to the risk of DKA. Princess, besides the benefits in diabetes, what else did you find in your review?Benefits/Efficacy:SGLT2 inhibitors have additional benefits beyond their glucose-lowering effects. One of the benefits of SGLT2 inhibitors is their ability to increase myocardial energy production, alleviate systemic microvascular dysfunction, and improve systemic endothelial function. Natriuresis and glucosuria mediated by SGLT2 inhibitors have been shown to lower cardiac pre-load and reduce pulmonary congestion and systemic edema, which is beneficial for heart failure management.Studies have shown that these drugs can also improve cardiovascular outcomes in patients with heart failure with a reduced ejection fraction. Some studies:The EMPEROR-Reduced trial demonstrated that empagliflozin, brand name Jardiance®, reduced the risk of cardiovascular death and hospitalization for heart failure in patients with reduced ejection fraction by 25% compared to placebo. Several clinical trials have also shown that this result is significant whether patients have type 2 diabetes or not. Also, in a multicenter, double-blind, randomized, placebo-controlled trial in patients with heart failure, treatment with dapagliflozin, brand name Farxiga®, improved heart failure-related symptoms and physical limitations after only 12 weeks of treatment. Patients treated with dapagliflozin had a significant, clinically meaningful improvement in the 6-minute walking test distance. The magnitude of these benefits was statistically and clinically significant, spanning all subgroups categorized. This included patients with and without type 2 diabetes and those with an ejection fraction above or below 60%.Anecdote:During a previous clinical rotation, I had a patient taking Jardiance for heart failure. He also had a history of chronic kidney disease and managed his condition well with medications and regular follow-ups. Interestingly, he was prescribed Jardiance®, which I initially believed was solely for diabetes management. When I asked him about it, he explained that his cardiologist prescribed Jardiance specifically for his heart. At the time, I did not understand the rationale behind prescribing Jardiance®, especially since the patient did not have type 2 diabetes. But after researching the medication, I figured that his cardiologist had chosen Jardiance® due to its demonstrated benefits in reducing the risk of cardiovascular death and hospitalization for heart failure. Although initially considered to be only glucose-lowering agents, the effects of SGLT2 inhibitors have expanded far beyond that. Their use has expanded to include heart failure and chronic kidney disease, even in patients without diabetes. It is, therefore, essential that cardiologists, diabetologists, nephrologists, and primary care physicians are familiar with this drug class.Adverse effects:It is worthwhile to note that SGLT2 inhibitors are not typically used as first-line treatment for heart failure, and not all patients with heart failure are appropriate candidates for these medications. SGLT2 inhibitors are generally well-tolerated, but they can cause adverse effects. Genital and urinary tract infections and euglycemic diabetic ketoacidosis are the most common side effects experienced by patients. The incidence of these adverse effects is generally low and can be managed with appropriate monitoring and treatment. In addition, SGLT2 inhibitors can also cause dehydration, electrolyte imbalances, hypotension, and acute kidney injury (AKI). These imbalances are more common in elderly patients or those with renal impairment, like the patient I discussed earlier. Genital yeast infections: Diabetes is also a risk factor for genital yeast infections because glucose in the urine is used as a substrate by microorganisms to grow in the GU tract. UTI and genital yeast infections are prevented by staying well hydrated while taking these meds. Increased intake of water will dilute the urine and decrease the concentration of glucose in urine. UTI/genital yeast infections are treated as usual, and the SGLT-2 can be resumed after infections are treated. In case of recurrence, the clinician may consider discontinuation of medication based on a case-by-case assessment. Patients using SGLT2 inhibitors for treatment should have regular follow-ups with their physicians for the early detection of adverse effects. Bladder cancer: It is not clear if chronic glucosuria is tumorigenic since there are no long-term data. In clinical trials, 10 cases of bladder cancer were diagnosed among dapagliflozin users, five of which occurred only in the first six months of treatment. The FDA has recommended postmarketing surveillance studies. Dapagliflozin is not recommended in patients with active bladder cancer. Bone fractures and limb amputation: One trial (CANVAS) demonstrated an increased incidence of bone fractures and limb amputations among users of canagliflozin, but another trial (CREDENCE) did not demonstrate such an increased incidence of bone fractures or limb amputations. This increased risk has not been proven with empagliflozin. Summary: SGLT2 inhibitors have shown promise in heart failure treatment, particularly in patients with a reduced ejection fraction. Even though the specific mechanism of action through which they work on the cardiovascular system is currently unknown, they have been shown to reduce the risk of hospitalization for heart failure and cardiovascular death in several clinical trials. These medications lower blood glucose levels and have other beneficial effects on the cardiovascular system that make them good options for the management of heart failure.____________________Conclusion: Now we conclude episode number 138, “SGLT-2 inhibitors in heart failure.” Princess explained that SGLT-2 inhibitors have many benefits that go beyond their glucose-lowering properties. Recently, the use of SGLT-2 inhibitors has been extended to include heart failure with reduced ejection fraction and chronic kidney disease, even in patients without diabetes. Dr. Arreaza also explained that FDA has not approved the use of SGLT-2 inhibitors for the treatment of type 1 diabetes because of the reported increased risk of diabetic ketoacidosis or DKA. There is ongoing research about additional uses of SGLT-2 inhibitors, and we are looking forward to hearing more about these medications in the future.This week we thank Hector Arreaza and Princess Enuka. 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:Packer M, Anker SD, Butler J, et al. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med. 2020;383(15):1413-1424. https://pubmed.ncbi.nlm.nih.gov/32865377/Cosentino F, Grant PJ, Aboyans V, et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020;41(2):255-323. https://pubmed.ncbi.nlm.nih.gov/31497854/Heerspink HJL, Perkins BA, Fitchett DH, et al. Sodium glucose cotransporter 2 inhibitors in the treatment of diabetes mellitus: cardiovascular and kidney effects, potential mechanisms, and clinical applications. Circulation. 2016;134(10):752-772. https://pubmed.ncbi.nlm.nih.gov/27470878/Zelniker TA, Braunwald E. Mechanisms of cardiorenal effects of sodium-glucose cotransporter 2 inhibitors: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(4):422-434. https://pubmed.ncbi.nlm.nih.gov/32000955/Nassif, M. E., et al. (2020). The SGLT2 inhibitor dapagliflozin in heart failure with preserved ejection fraction: A multicenter randomized trial. Nature Medicine, 27(11), 1954-1960. https://doi.org/10.1038/s41591-021-01536-xRoyalty-free music used for this episode: "Tempting Tango." Downloaded on October 13, 2022, from https://www.videvo.net/

Today we're talking with Dr. Isaac Motamarry about the safest methods for treating obesity, including the trendy prescription drug, Ozempic. Dr. Motamarry walks us through the benefits and potential side effects of Ozempic for those needing to lose a significant amount of weight. He also explains when someone might need a medical procedure to lose weight because of the dangers excess weight can have on their overall health. Learn more about Dr. Isaac Motamarry at nflsurgeons .com Dr. Isaac Motamarry completed his surgical training at Cleveland Clinic before completing an advanced fellowship in Bariatrics and Foregut surgery at University of Florida. He is a Board Certified General Surgeon, and has been practicing with North Florida Surgeons since 2014. Dr. Motamarry's practice includes General Surgery with a special interest in Bariatrics, Gastroesophageal reflux disease, and Endocrine surgery. He completed his undergraduate degree at the University of Mary Washington while enlisted as active duty in the US Navy, and  received his medical degree from Ross University School of Medicine. Thank you to our sponsors!Enviromedica – The BEST probiotics on the planetChildren's Health Defense - Listen every Monday as we recap the top stories of the week from the “Defender” newsletter.Sunwarrior - Use the code OLR for 20% off your purchase!Well Being JournalThorne - Get 20% off your order and free shipping!

Dr Shawanda Steele aka Nefertiti Ra SETI, High Priestess https://linkr.bio/Nefertiti.Ra.Seti.?fbclid=PAAaagpeqTwvTnz9GrwGheujwgwKVxkr23kKEpVifnc2lz4JF8sz1D_AMBZkc The chemical Watergate on our food and water supplies and they are putting the vaccine into meat and vegetables Company Owner at Steele & Associates Consulting, LLC She is a Spiritualist.have an MD from Ross University School of Medicine (2017) and a BS in Molecular Biology with a Chemistry Minor (WSSU 2006). I have worked as a consultant in various roles in research and development,  clinical trials, and quality and regulatory assurance for the last 21 years. She is a mother of 4, spiritual mentor to many,host two telegram groups The Moksha Discussions and The Moksha Discussions Current Events. She has an online spiritual shop  offering professional services, handmade jewelry, metaphysical supplies and organic items for personal care. In my free time, I enjoy meditation, traveling, and spending time with my children. I currently reside outside of Atlanta with my youngest daughter. Experienced Quality and Regulatory Consultant with a demonstrated history of working in the Pharmaceutical, Nutraceutical, Biotechnology and Medical Device industries. Thorough knowledge of Domestic and International Regulatory requirements for Compliance and Safety. Highly skilled Technical Writer with experience (including but not limited to) authoring Quality Investigations, Standard Operating Procedures (SOPs), Work Instructions (WI), and Formal Responses to Regulatory Authorities. Strong consulting professional with emphasis on timelines and deliverables with a Doctor of Medicine (M.D.) from Ross University School of Medicine and Pfizer Yellow Belt Certification.

In this episode, we're joined by Heidi Chumley, dean at the Ross University School of Medicine, to discuss the barriers facing aspiring physicians in their journey to residency. Heidi will delve into the challenges of the residency matching process, including the cost of applications and travel expenses, as well as bias based on USMLE scores and discrimination in residency programs. She will also discuss the steps her medical school is taking to increase diversity and support its students in their journey to become successful resident physicians. With a 96 percent first-time residency attainment rate, Heidi provides valuable insight into the challenges and solutions in this important aspect of the health care industry. Heidi Chumley is dean, Ross University School of Medicine. She shares her story and discusses her KevinMD article, "Proposing solutions to end bias in the medical residency selection process." The Podcast by KevinMD is brought to you by the Nuance Dragon Ambient eXperience. With so many demands on their time, physicians today report record levels of burnout. Burnout is caused by many factors, one of which is clinical documentation. Studies indicate physicians spend two hours documenting care for every hour spent with patients. At Nuance, we are committed to helping physicians do what you love – care for patients – and spend less time on clinical documentation. The Nuance Dragon Ambient eXperience, or DAX for short, is an AI-powered, ambient clinical intelligence solution that automatically captures patient encounters securely and accurately at the point of care. Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 83 percent of patients say their physician is more personable and conversational. Rediscover the joy of medicine with clinical documentation that writes itself, all within the EHR. VISIT SPONSOR → https://nuance.com/daxinaction SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended GET CME FOR THIS EPISODE → https://earnc.me/opt1K1 Powered by CMEfy.

This episode features Dr. Heidi Chumley, Dean of Ross University School of Medicine and head of Adtalem Global Education's Academic Council. Here, she discusses match week, what that looks like for international schools this year, advice for medical students applying for residency, and more.

"My hope for the future is to see a health care workforce that matches the diversity of the communities it serves. As we continue to push for health equity, we also continue to evaluate and reassess our student programs to provide tailored support and help them reach their full potential. I also hope that other medical institutions begin to use social determinants of learning to individualize their education methods so that more Black, Hispanic, and other students of color can achieve their dreams of becoming doctors." Heidi Chumley is dean, Ross University School of Medicine. She shares her story and discusses her KevinMD article, "Who gets to graduate from medical school?" The Podcast by KevinMD is brought to you by the Nuance Dragon Ambient eXperience. With so many demands on their time, physicians today report record levels of burnout. Burnout is caused by many factors, one of which is clinical documentation. Studies indicate physicians spend two hours documenting care for every hour spent with patients. At Nuance, we are committed to helping physicians do what you love – care for patients – and spend less time on clinical documentation. The Nuance Dragon Ambient eXperience, or DAX for short, is an AI-powered, ambient clinical intelligence solution that automatically captures patient encounters securely and accurately at the point of care. Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 83 percent of patients say their physician is more personable and conversational. Rediscover the joy of medicine with clinical documentation that writes itself, all within the EHR. VISIT SPONSOR → https://nuance.com/daxinaction SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast RATE AND REVIEW → https://www.kevinmd.com/rate FOLLOW ON INSTAGRAM → https://www.instagram.com/kevinphomd FOLLOW ON TIKTOK → https://www.tiktok.com/@kevinphomd GET CME FOR THIS EPISODE → https://earnc.me/qcMP7x Powered by CMEfy.