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Did you know that congenital cytomegalovirus (cCMV) is the most common congenital viral infection in newborns and a leading cause of non-genetic hearing loss? Despite its prevalence, awareness and screening for cCMV remain inconsistent across healthcare systems. In this episode, we dive into the critical importance of cCMV screening, early diagnosis, and intervention. Join our expert guests Dr. Ingrid Camelo and Dr. John Noel as they discuss: The impact of cCMV on neonatal and long-term health outcomes Best practices for screening and diagnostic methods The role of early intervention, including antiviral therapy How advocacy efforts are shaping the future of universal screening policies Tune in to stay informed on how pediatricians and healthcare providers can play a vital role in improving outcomes for infants affected by cCMV. Special thanks to Dr. James Grubbs for peer reviewing this episode. CME Credit (requires free sign up): Link Coming Soon! References:  American Academy of Pediatrics. A targeted approach for congenital cytomegalovirus. Available at: https://publications.aap.org/pediatrics/article/139/2/e20162128/60211/A-Targeted-Approach-for-Congenital-Cytomegalovirus. Accessed August 13, 2024. Chiopris G, Veronese P, Cusenza F, Procaccianti M, Perrone S, Daccò V, Colombo C, Esposito S. Congenital cytomegalovirus infection: update on diagnosis and treatment. Microorganisms. 2020 Oct 1;8(10):1516. doi: 10.3390/microorganisms8101516. PMID: 33019752; PMCID: PMC7599523. Gantt S. Newborn cytomegalovirus screening: is this the new standard? Curr Opin Otolaryngol Head Neck Surg. 2023 Dec 1;31(6):382-387. doi: 10.1097/MOO.0000000000000925. Epub 2023 Oct 11. PMID: 37820202. Minnesota Department of Health. Minnesota implements universal newborn screening for cytomegalovirus. Available at: https://www.health.state.mn.us/news/pressrel/2023/ccmv020823.html. Accessed August 13, 2024. National CMV Foundation. Advocacy: universal newborn CMV screening. Available at: https://www.nationalcmv.org/about-us/advocacy#:~:text=Minnesota%20was%20the%20first%20state%20to%20enact%20universal%20newborn%20CMV%20screening. Accessed August 13, 2024. New York State Department of Health. Newborn screening for cytomegalovirus. Available at: https://www.health.ny.gov/press/releases/2023/2023-09-29_newborn_screening.htm#:~:text=ALBANY%2C%20N.Y.,all%20babies%20for%20the%20virus. Accessed August 13, 2024. UpToDate. Congenital cytomegalovirus (CMV) infection: clinical features and diagnosis. Available at: https://www.uptodate.com/contents/congenital-cytomegalovirus-ccmv-infection-clinical-features-and-diagnosis?search=cmv%20screening&source=search_result&selectedTitle=1%7E28&usage_type=default&display_rank=1#H92269684. Accessed August 13, 2024. UpToDate. Congenital cytomegalovirus (CMV) infection: management and outcome. Available at: https://www.uptodate.com/contents/congenital-cytomegalovirus-ccmv-infection-management-and-outcome?search=congenital%20cmv&source=search_result&selectedTitle=2%7E66&usage_type=default&display_rank=2. Accessed August 13, 2024. UpToDate. Ganciclovir and valganciclovir: an overview. Available at: https://www.uptodate.com/contents/ganciclovir-and-valganciclovir-an-overview?search=ganciclovir&source=search_result&selectedTitle=2%7E80&usage_type=default&display_rank=1#H6. Accessed August 13, 2024. University of Texas Medical Branch. Neonatology manual: infectious diseases. Available at: https://www.utmb.edu/pedi_ed/NeonatologyManual/InfectiousDiseases/InfectiousDiseases3.html#:~:text=may%20be%20required.-,Cytomegalovirus,Clinical%20findings. Accessed August 13, 2024. National Center for Biotechnology Information. Cytomegalovirus (CMV) infection. Available at: https://www.ncbi.nlm.nih.gov/books/NBK541003/. Accessed August 13, 2024.                                                                                                             

Ever wonder what might be happening when someone passes out in a restaurant? Join hosts Anna Zarov and Olivia Horrigan as they unpack another eventful episode in this week's Myth vs Medicine: Debunking Grey's Anatomy podcast show. In this episode, we will cover:Marfan Syndrome and its complicationsPorcelain Gallbladder and Gallbladder cancerThe reasoning behind prophylactic surgery How personal and professional lives influence one anotherGrab your favorite snack, beverage, or listening buddy and press play! It's a beautiful day to learn what is myth… and what is medicine.Sources: https://greysanatomy.fandom.com/wiki/Let_It_Behttps://www.uptodate.com/contents/porcelain-gallbladder#:~:text=Patients with a porcelain gallbladder,risk appears to be smallhttps://www.uptodate.com/contents/management-of-marfan-syndrome-and-related-disorders#H29https://www.uptodate.com/contents/genetics-clinical-features-and-diagnosis-of-marfan-syndrome-and-related-disorders?search=marfansyndrome&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1https://www.ncbi.nlm.nih.gov/books/NBK441963/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464744/#:~:text=The cardiovascular manifestation with aortic,premature death of these patients.https://pubmed.ncbi.nlm.nih.gov/22133496/#:~:text=Event rate (death%2Faortic dissection) was 0.17%25%2Fy.https://www.ncbi.nlm.nih.gov/books/NBK518979/#:~:text=Introduction-,Porcelain gallbladder refers to the condition in which the inner,cholecystitis%2C and cholecystopathia chronica calcarea.https://screenrant.com/how-greys-anatomy-was-originally-different/Mentioned in this episode:Join our email list: mythvsmedpod.comJoin our email list!Join our email list: mythvsmedpod.comJoin our email list!We hope you enjoyed the show! Don't forget to leave us a review on your favorite streaming platform and check out the rest of our links at: linktr.ee/mythvsmedpodOur Link Tree!We hope you enjoyed the show! Don't forget to leave us a review on your favorite streaming platform and check out the rest of our links at: linktr.ee/mythvsmedpodOur Link Tree!Ask us anything about the medicine in Grey's Anatomy here: https://mythvsmedpod.com/ask-questionsAsk us a question!This podcast uses the following third-party

This is Part 2. Derek, an experienced clinician in burn care, joins us to delve into the intricacies and challenges of treating burn patients. This discussion provides valuable insights into the unique aspects of burn injuries, the importance of a comprehensive assessment, and the latest trends in burn treatment. Blog post- The Critically Burned Patient Key Topics Covered Complexity of Burn Injuries: Derek begins by explaining why burn patients require a unique approach compared to other trauma patients. He highlights the potential for burns to mask other critical injuries, underscoring the necessity of a thorough and trauma-informed initial assessment. The 'Big Three' Considerations: The conversation shifts to what Derek refers to as the "big three" — polytrauma, airway loss, and inhalation injuries — which are crucial early considerations in burn care. He stresses the importance of recognizing these potentially life-threatening conditions alongside the burn injury itself. Fluid Resuscitation: A significant portion of the discussion is dedicated to fluid resuscitation, a critical aspect of burn care. Derek talks about the Parkland formula for calculating fluid needs based on the total body surface area affected by burns but a better simpler method is- 500 ml/hr for an adult (

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

We're baaaack with episode 2 of Turn-Based Besties, and today we are diving right into our top three games of 2023. Note, these will be our personal favorite games we played in 2023, not necessarily games that were released in 2023 (because we know DJ likes his retro and indie games). We will also be trying out a new segment called "Medical Moment" with Sam, as he discusses video games and certain illness or conditions that occur with a character. Disclaimer: we do not provide medical diagnoses, recommendations, treatment, etc. Here's a brief reference list for you nerds out there ;) References:  Loewenstein, Richard. (2023). Dissociative amnesia: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis. Retrieved 1/14/2024, from https://www.uptodate.com/contents/dissociative-amnesia-epidemiology-pathogenesis-clinical-manifestations-course-and-diagnosis?search=amnesia&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2# Lucas Alessandro, Mario Ricciardi, Hernán Chaves, Ricardo F. Allegri. Acute amnestic syndromes. Journal of the Neurological Sciences. Volume 413. 2020. https://doi.org/10.1016/j.jns.2020.116781. Angelica Staniloiu, Hans J Markowitsch. Dissociative amnesia. The Lancet Psychiatry. Volume 1, Issue 3. 2014. Pages 226-241. ISSN 2215-0366. https://doi.org/10.1016/S2215-0366(14)70279-2.

Coughs are one of the most common symptoms of childhood illness. But when should we start to get worried? What is a child's cough trying to tell you? Dr. Sunil Kapoor, a Pediatric Pulmonology Physician, joins Dr. Rebecca Yang and medical student Aparna Prasad to discuss the evaluation and management of chronic cough in children.  Specifically, they will:  Review the history and physical examination for a child presenting with a chronic cough Discuss the treatment for the most common causes of cough in children Evaluate the symptoms that suggest an underlying immunodeficiency Review the criteria for a referral to pulmonology Special thanks to Dr. Dionne Adair, Dr.Sunil Kapoor, and Dr. Rebecca Yang for peer reviewing this episode. CME Credit (requires free sign up): Link Coming Soon! References: Marchant, J. (2021, September 30). Causes of chronic cough in children. UpToDate. Retrieved June 2, 2022, from https://www.uptodate.com/contents/causes-of-chronic-cough-in-children?search=common+causes+of+chronic+cough+in+young+kids&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1    Chang, A. (2020, November 18). Approach to chronic cough in children. UpToDate. Retrieved June 2, 2022, from https://www.uptodate.com/contents/approach-to-chronic-cough-in-children?search=common+causes+of+chronic+cough+in+young+kids&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2    Gregory, S. (2021, May 4). Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control. UpToDate. Retrieved June 2, 2022, from https://www.uptodate.com/contents/asthma-in-children-younger-than-12-years-overview-of-initiating-therapy-and-monitoring-control?search=chronic+cough+in+children&topicRef=91328&source=related_link    Pratter M. Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 suppl):63S-71S.

Cancer inherently increases the risk of Deep Vein Thrombosis and Pumlmonary Embolism. This is merely a nuisance for some, while others experience significant morbidity, leading to hemodynamic instability and potential death. Historically known as "the great masquerader" with pulmonary embolisms, we explore signs, symptoms, and different approaches to treatment. Warfarin remains the original and is still an option for patients, but have better therapies emerged like direct oral anticoagulants (DOACs)? The short answer is yes, but tune in as we dive again into systematic reviews and give you a summarised version of everything you should know.Useful Links:Statpearls DVT: https://www.ncbi.nlm.nih.gov/books/NBK507708/Anticoagulation for thrombus in malignancy: https://www.uptodate.com/contents/anticoagulation-therapy-for-venous-thromboembolism-lower-extremity-venous-thrombosis-and-pulmonary-embolism-in-adult-patients-with-malignancy?search=cancer%20induced%20DVT&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4For more episodes, resources and blog posts, visit www.inquisitiveonc.comFind us on Twitter @InquisitiveOnc!If you want us to look at a specific trial or subject, email us at inquisitiveonc@gmail.comArt courtesy of Taryn SilverMusic courtesy of Music Unlimited: https://pixabay.com/users/music_unlimited-27600023/Disclaimer: This podcast is for educational purposes only. If you are unwell, seek medical advice. Hosted on Acast. See acast.com/privacy for more information.

When you hear the story of how syphilis research was carried out in the United States in the 20th century, you'll probably start to understand why there is a history of mistrust of the medical establishment, especially among the African American community.  This episode details one of the bleakest and most shameful chapters in U.S. medical history, a time when ethics were cast aside at the expense of minority communities.  We'll talk about the Tuskegee Syphilis Study (aka Tuskegee Experiment) as well as the Guatemala syphilis experiments that preceded them.  Sources:For symptom confirmation: https://www.uptodate.com/contents/syphilis-epidemiology-pathophysiology-and-clinical-manifestations-in-patients-without-hiv?search=syphilis&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H10 UpToDate (paywall)Emily Blunt gets Syphilis: https://en.wikipedia.org/wiki/The_English_(TV_series)Medical Microbiology, Chapter 36: https://www.ncbi.nlm.nih.gov/books/NBK7716/ Wikipedia Syphilis: https://en.wikipedia.org/wiki/SyphilisLong Article on Syphilis Origin: https://asm.org/Articles/2019/June/Revisiting-the-Great-Imitator,-Part-I-The-Origin-aRepublication of the AP study about Tuskeegee: https://apnews.com/article/business-science-health-race-and-ethnicity-syphilis-e9dd07eaa4e74052878a68132cd3803aBioethics statement on Guatamala Studies: https://bioethicsarchive.georgetown.edu/pcsbi/sites/default/files/Ethically%20Impossible%20(with%20linked%20historical%20documents)%202.7.13.pdfWikipedia on Guatemala Studies: Sponsor: Artery InkUse promo code LISTENTOPHP at Artery Ink's website to save 10%* on your order of $35 or more and show support for our show as well as for a homegrown, wonderful local company. Artery Ink specializes in apparel and decor inspired by anatomy and the human body. Whether you're in the field of healthcare or not, Artery Ink has something that will definitely appeal to you so go and check them out! (*Discount code does not apply to subscription boxes)Submissions for Mike's Trivia Challenge Segment:-We invite our audience to submit medical history trivia questions (with or without a supporting article) to see if Mike happens to know the answer off the top of his head.-If Mike is wrong we'll award you your very own medical eponym so that you can join us in becoming a part of medical history.-Submit through our website, social media DMs, or via e-mail: poorhistorianspod@gmail.comPodcast Links:-Linktree (reviews/ratings/social media links): linktr.ee/poorhistorianspod-Merch Site: https://www.teepublic.com/user/poor-historians-pod...

In this special three-part series, we discuss Rett Syndrome, a genetic disease that has resulted in the permanently arrested development of untold children till the modern era. Affecting girls predominantly, families have learned to live life with their loved ones suffering under it… but will it always have to be this way? This episode takes a deeper dive into the known pathophysiology of Rett Syndrome, as well as the efforts underway to devise a cure.Episode Team:Guest - G. Vicky Casillas, Pharm.DHosts - Cameron Casillas (MS4)Script Writers - Cameron Casillas (MS4), Skye Lander (MS3)Audio - Dharshan Chandramohan (MS4), Vedhika Reddy (MS3)Producer - Cameron Casillas (MS4), Cheyenne Canizares (MS3), Jude Banihani (MS4), Sydney Cummings (MS4)Director - Vy Han, MDResources:https://reverserett.org/ Rett Syndrome Research Trusthttps://www.rettsyndrome.org/ International Rett Syndrome Foundationhttps://rettsyndromenews.com/experimental-treatments-for-rett-syndrome/ Rett Syndrome Newshttps://www.uptodate.com/contents/rett-syndrome-genetics-clinical-features-and-diagnosis?search=rett%20syndrome&source=search_result&selectedTitle=1~35&usage_type=default&display_rank=1 UpToDatehttps://www.sciencedirect.com/science/article/pii/S0166223615002829 Rett Syndrome: Crossing the Threshold to Clinical Translation

Brittany and Jordan continue their discussion with Dr. Mahela Ashraf on perinatal mood disorders. 00:46 Case 1: A 31 year old G2P2 comes in to clinic for her 6 week postpartum visit. 08:50 Case 2: The patient in the previous vignette is interested in starting an SSRI to treat her anxiety. Transcript: https://tinyurl.com/UltrasoundsPerinatalMH2 Berens, Pamela. “Overview of the Postpartum Period: Disorders and Complications.” Edited by Charles Lockwood and Vanessa Barss, UpToDate, 6 Sept. 2022, https://www.uptodate.com/contents/overview-of-the-postpartum-period-disorders-and-complications?search=postpartum+anxiety&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H352546182. Lanza di Scalea T, Wisner KL. Antidepressant medication use during breastfeeding. Clin Obstet Gynecol. 2009 Sep;52(3):483-97. doi: 10.1097/GRF.0b013e3181b52bd6. PMID: 19661763; PMCID: PMC2902256. Use of psychiatric medications during pregnancy and lactation. ACOG Practice Bulletin No. 92. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:1001–20.

Survey: https://bit.ly/feedback_UltraSounds Brittany and Jordan discuss perinatal mood disorders with Dr. Mahela Ashraf. 00:43 Dr. Ashraf Biography 02:16 Case: 23 year old G1P1 comes into clinic for her 6 week postpartum visit Transcript: https://tinyurl.com/UltrasoundsPerinatalMH Berens, Pamela. “Overview of the Postpartum Period: Disorders and Complications.” Edited by Charles Lockwood and Vanessa Barss, UpToDate, 6 Sept. 2022, https://www.uptodate.com/contents/overview-of-the-postpartum-period-disorders-and-complications?search=postpartum+anxiety&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H352546182. Lanza di Scalea T, Wisner KL. Antidepressant medication use during breastfeeding. Clin Obstet Gynecol. 2009 Sep;52(3):483-97. doi: 10.1097/GRF.0b013e3181b52bd6. PMID: 19661763; PMCID: PMC2902256. Use of psychiatric medications during pregnancy and lactation. ACOG Practice Bulletin No. 92. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:1001–20.

In this episode, we discuss the fundamentals and approaches to chronic management and treatment for patients with known inherited hemophilia. What is hemophilia?* As name suggests, tendency to bleed* Two types: genetic and acquiredInherited hemophilia: * Genetic: sex-linked, meaning males will express it, females will, by and large be carriers * Main ones to be worried about: Hemophilia A and Hemophilia B** Hemophilia A: deficiency in factor VIII (1:5000 men)** Hemophilia B: deficiency in factor IX (1:30,000 men)** Thousands of underlying mutations * We grade the severity of hemophilia using the factor activity levels: ** Severe: 1 bleed into the joints for patients with severe hemophilia (goal is to keep levels >1%)** In patients with moderate or mild can do intermittent dosing *Hemophilia A/Factor VIII replacement (many options; here is what we use at Rouleaux): **Recombinant factor concentrates: Advate**Plasma-derived concentrates: Humate-P* Factor IX replacement: ** Recombinant factor concentrates: BenefIX*Bypassing agents: For patients with inhibitors (to be discussed in a future episode) or can be used for Hemophilia A or B*Options:** Novoseven (activated recombinant factor VII): Activates the extrinsic pathway to bypass the need for factors VIII or IX** FEIBA (factor eight inhibitor bypassing agent): Activated prothrombin complex concentrate (FIIa, VIIa, Xa)* Emicizumab (Hemlibra): bispecific monoclonal antibody that binds factor activated IX and X → essentially doing the job of factor VIII and leads to activation of the downstream common pathway** Note that it binds activated factor IX not inactivated factor IX and this is why you won't just constantly form clots by forcing down the common pathway like you would by giving a bypassing agent***cannot be used in Hemophilia B because it relies on the presence of factor IX**** Several new therapies have been introduced in recent yearsReferences:https://www.uptodate.com/contents/hemophilia-a-and-b-routine-management-including-prophylaxis?search=hemophilia%20treatment&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2: UpToDate article on current management of Hemophilia DOI: 10.1055/s-0042-1756188: “The More Recent History of Hemophilia Treatment.” Semin Thromb Hemost. 2022. Love what you hear? Tell a friend and leave a review on our podcast streaming platforms!Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Adolescents represent a portion of the fastest growing demographic for development of sexually transmitted infection. Studies have found that STIs have some of the highest rates in individuals aged 15-24, and 20% of new HIV diagnoses occur in people aged 13-24. Pre-exposure prophylaxis (PrEP) is medicine people at risk for HIV take to prevent getting HIV from sex or injection drug use and is an effective tool to dramatically decrease the risk of HIV acquisition in at-risk youth. Dr. Cheryl Newman, a board certified infectious disease specialist joins medical students Patrice Collins and Elise Liu to discuss PrEP for HIV prevention in the adolescent population.  After listening to this podcast, learners should be able to: Learn the approach to sexual health screening in adolescents. Understand the risks of HIV exposure in adolescents. Define PrEP and how it works. Understand the requirements for starting PrEP, including demographics and preliminary testing. Explain the federal and/or state laws that govern the prescription of HIV prevention medicine for adolescents. FREE CME Credit (requires free sign-up):  https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=11407    References:  Agwu A. Sexuality, Sexual Health, and Sexually Transmitted Infections in Adolescents and Young Adults. Top Antivir Med. 2020;28(2):459-462. Centers for Disease Control and Prevention. Prep for HIV Prevention in the U.S. Accessed Apr 15, 2022. https://www.cdc.gov/nchhstp/newsroom/fact-sheets/hiv/PrEP-for-hiv-prevention-in-the-US-factsheet.html Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. National Institute of Health. Updated Jun 03, 2021. Accessed Apr 15, 2022. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/adolescents-and-young-adults-hiv#:~:text=Preventive%20Measures%20and%20Supporting%20Long,%2C%20osteoporosis%2C%20and%20neurocognitive%20impairment. Hsu K, Rakhmanina N. Adolescents and Young Adults: The Pediatrician's Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis. Pediatrics. 2022; 149(1):e2021055207 Hosek S, Henry-Reid L. PrEP and Adolescents: The Role of Providers in Ending the AIDS Epidemic. January 2020; 145 (1): e20191743. 10.1542/peds.2019-1743 Truvada Website. https://www.truvada.com/truvada-safety/clinical-studies. Accessed Apr 15, 2022. Descovy Website. https://www.descovy.com/#isi. Accessed Apr 15, 2022. FDA Approves First Injectable Treatment for HIV Pre-Exposure Prevention. Dec 20, 2021. Accessed Apr 15, 2022. https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention Landovitz RJ, Donnell D, Clement ME, et al. Cabotegravir for HIV Preention in Cisgender Men and Transgender Women. N Engl J Med. August 2021; 385:595-608. https://www.nejm.org/doi/full/10.1056/NEJMoa2101016 Highleyman L. US approves injectable cabotegravir for PrEP. Accessed Apr 15, 2022. https://www.aidsmap.com/news/dec-2021/us-approves-injectable-cabotegravir-prep Trial results reveal that long-acting injectable cabotegravir as PrEP is highly effective in preventing HIV acquisition in women. Nov 9, 2020. Accessed Apr 15, 2022. https://www.who.int/news/item/09-11-2020-trial-results-reveal-that-long-acting-injectable-cabotegravir-as-prep-is-highly-effective-in-preventing-hiv-acquisition-in-women FDA approves second drug to prevent HIV infection as part of ongoing efforts to end the HIV epidemic. Oct 3, 2019. Accessed Apr 15, 2022. https://www.fda.gov/news-events/press-announcements/fda-approves-second-drug-prevent-hiv-infection-part-ongoing-efforts-end-hiv-epidemic#:~:text=The%20U.S.%20Food%20and%20Drug,who%20have%20receptive%20vaginal%20sex Centers for Disease Control and Prevention. Pre-exposure Prophylaxis (PrEP). Accessed Apr 15, 2022. https://www.cdc.gov/hiv/clinicians/prevention/prep.html#:~:text=For%20oral%20PrEP&text=Assess%20creatinine%20clearance%20once%20every,creatinine%20clearance%20every%206%20months Tanner M, Miele P, et al. Preexposure Prophylaxis for Prevention of HIV Acquisition Among Adolescents: Clinical Considerations, 2020. CDC Recommendations and Reports. 2020; 69(3):1-12 Cowan EA, McGowan JP, Fine SM, et al. Diagnosis and Management of Acute HIV [Internet]. Baltimore (MD): Johns Hopkins University; 2021 Jul. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563020/ Sax PE. Screening and diagnostic testing for HIV infection. In: Post TW, ed. UpToDate; 2022. Accessed May 15, 2022. https://www.uptodate.com/contents/screening-and-diagnostic-testing-for-hiv-infection?search=hiv%20screening&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Jaspard M, Le Moal G, Saberan-Roncato M, Plainchamp D, Langlois A, Camps P, Guigon A, Hocqueloux L, Prazuck T. Finger-stick whole blood HIV-1/-2 home-use tests are more sensitive than oral fluid-based in-home HIV tests. PLoS One. 2014 Jun 27;9(6):e101148. doi: 10.1371/journal.pone.0101148. PMID: 24971842; PMCID: PMC4074152. NBC News. 2022. PrEP, the HIV prevention pill, must now be totally free under almost all insurance plans. [online] Available at: [Accessed 19 May 2022].

Episode 106: Weight Loss Meds. Anti-obesity medications are FDA-approved drugs to support your patient's efforts to lose weight. It is important for primary care providers to learn about these medications to continue fighting against obesity in our communities.Introduction: Obesity is a chronic disease.By Hector Arreaza, MD. Obesity has all the characteristics of a chronic disease. Let's use our imagination and think about a patient with hypertension, for example. Let's imagine you are the doctor or Mr. Lee. He is 45 years old and his blood pressure has been persistently high, around 150/100, even after lifestyle modifications. You decide to start chlorthalidone 25 mg and Mr. Lee takes chlorthalidone every day. Four weeks later you see Mr. Lee again and you review his labs with him. He has normal renal function and normal electrolytes. His blood pressure is now 119/75. He is feeling great and reports no side effects to chlorthalidone. Would you stop the medication at this time? Think about it. The most obvious answer is NO, you will not stop chlorthalidone. Today you will listen to a discussion about anti-obesity medications, common indications, contraindications, cautions, and more. We will learn that obesity requires chronic treatment with medications just like any other chronic disease. I hope you enjoy it.This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________Weight Loss Meds. By Sapna Patel, MS4; and Danish Khalid, MS$. Ross University School of Medicine. Moderated by Hector Arreaza, MD. S: Hello and welcome back to our nutrition series! If you haven't already listened to our previous episodes, pause this and make sure to give them a listen. We have talked about physical activity, meal plans, and intermittent fasting. Today we are going to talk about the clinical management of obesity, specifically the pharmacotherapy that is used. We will divide these drugs into drugs that reduce food intake primarily acting on the CNS, drugs that reduce fat absorption and medications that are associated with weight gain. D: Can anyone who is considered obese take medications to help them lose weight? Pharmacotherapy should be considered if the patient will be taking the medication in conjunction with the overall weight management program, including changes in eating habits, increased physical activity, and realistic expectations of the medication therapy. Adjuvant pharmacologic treatments should be considered for patients with a BMI >30 kg/m2 or with BMI >27 kg/m2 who have concomitant obesity related diseases. A: You are going to find doctors who are pretty much against anti-obesity drugs, but that's not my case.  S: Drugs that reduce food intake primarily acting on the CNS: Let's start with Phentermine and other sympathomimetic drugs A: Phentermine has been in the market over 60 years and it is well tolerated by most patients. It is effective, expect 5-8 lbs weight loss a month when taken with dietary changes and increased physical activity. The weight loss happens mostly the first 3-6 months when you take anti-obesity medications. S: One of the longest clinical trials of the drugs in this group lasted 36 weeks and compared placebo treatment to treatment with continuous phentermine and intermittent phentermine. Both the continuous and intermittent phentermine therapy produced more weight loss than placebo. D: Other options are Phentermine and topiramate ER which is known as  “Qsymia”. These drugs combine a catecholamine releaser and anticonvulsant respectively.  Topiramate is currently approved by the USFDA as an anticonvulsant for treatment of epilepsy and for prophylaxis of migraine headaches. Weight loss was seen as an unintentional side effect during clinical trials for epilepsy.The mechanism responsible for this is thought to be mediated through the modulation of GABA receptors, inhibition of carbonic anhydrase and antagonism of glutamate to reduce food intake The common adverse effects include cognitive impairment, paresthesia, and increased risk for kidney stones. Topiramate is also a teratogenic drug, so patients need to be in a good birth control to take it. It causes cleft palate in the fetus.The 2 phase-III trials called EQUIP and CONQUER, both 1 year randomized  placebo-controlled double-blinded clinical trials, 3 different strengths of a once-a day formulation were tested: full strength dose (15 mg of phentermine and 92 mg of topiramate ER), mid-dose (7.5mg of phentermine and 92 mg topiramate ER) and low dose (3.75mg of phentermine and 23 mg of topiramate ER). Subjects  randomized to the full strength dose in EQUIP and CONQUER trials lost an average of 10.9% and 9.8% body weight in 1 year compared to 1.6% and 1.2% loss for placebo subjects respectively. Significant improvement in fasting glucose, insulin, Hemoglobin A1C and lipid profile were seen.Due to the dose dependent side effects of the medications an initial dose of 3.75/23 mg is prescribed daily for the first 14 days then increased to 7.5/23mg daily. These patients should be re-evaluated after 3 months. If 3% weight loss is not achieved by that time, either discontinue or escalate the dose to 15/92mg for 12 weeks. S: Drugs that reduce fat absorption:Orlistat. What is orlistat? Well it's a selective inhibitor of pancreatic lipase that reduces the intestinal digestion of fat. The mean weight loss when compared to a placebo was 2.51kg at 6 months and 2.75kg at 12 months. A: It is one of the few anti-obesity medications approved to be used in children 12 years and older. D: GLP-1 Receptor Agonist (-glutide): Semaglutide and Liraglutide - Only two that have been approved for treatment of obesity. A 20-week randomized trial, comparing Liraglutide, placebo, and orlistat, showed that patients assigned to liraglutide lost significantly more weight than those assigned to both. When compared to placebo, those on liraglutide lost a mean weight loss of 2.8 kg. Whereas compared to orlistat lost an average of 5.8kg, however this was on the higher doses of liraglutide. A 56-weeks trial, comparing liraglutide with placebo, showed a mean weight loss was significantly greater in the liraglutide group (8.0 kg vs 2.6 kg). Furthermore, those who initially lost weight with diet and exercise, a greater proportion of those taking liraglutide maintained the weight loss.  Similarly, clinical trials favored semaglutide, with a weight loss greater in the semaglutide group versus placebo. For both, weight loss occurred in patients with and without diabetes. Note: Semaglutide: once a week. Helps induce weight loss. Liraglutide: daily.  A: We dedicated a whole episode on Semaglutide and another whole episode on Tirzepatide. Tirzepatide (dual agonist: GLP-1 and GIP) seems promising for weight loss and it is likely to be approved soon for obesity treatment. So, when do we discontinue anti-obesity medications? We can ask the same question for other chronic diseases: When do we stop medication for hypertension or diabetes? When we have a patient is unable to keep their weight off, we can't see him/her as someone who has lost their motivation to keep their weight off. Really what's happened is that their hormones have changed in a way that is promoting weight gain and it's very hard to lose weight. We should be at the patient's side to fight it off. Conclusion: Now we conclude our episode number 106 “Weight Loss Meds.” Phentermine is the most widely used anti-obesity medication. It is a stimulant, and it is a safe and effective medication for most patients who are fighting obesity. Make sure you learn the contraindication, side effects, and precautions when you prescribe it. Also, learn about other meds that are very effective, including GLP-1 receptor agonists, and your patients will thank you. This week we thank Hector Arreaza, Danish Khalid, and Sapna Patel. Audio by Sheila Toro.Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References: Perreault, L., Apovian, C. (2021). Obesity in adults: Overview of management. Pi-Sunyer,  F.X., Seres, D., & Kunins, L. (Eds.) Uptodate. Available from: https://www-uptodate-com.rossuniversity.idm.oclc.org/contents/obesity-in-adults-overview-of-management?search=weight%20loss%20medications&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 Perreault, L. (2022). Obesity in adults: Drug therapy. Pi-Sunyer,  F.X., & Kunins, L. (Eds.) Uptodate. Available from: https://www-uptodate-com.rossuniversity.idm.oclc.org/contents/obesity-in-adults-drug-therapy?search=weight%20loss%20medications&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Dungan, K., DeSantis, A. (2022) Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus. Nathan, D.M., & Mulder, J.E. (Eds.) Uptodate. Available from: https://www-uptodate-com.rossuniversity.idm.oclc.org/contents/glucagon-like-peptide-1-based-therapies-for-the-treatment-of-type-2-diabetes-mellitus?search=glp%201%20receptor%20agonists&source=search_result&selectedTitle=2~97&usage_type=default&display_rank=1 Perreault, L., Bessesen, D. (2022). Obesity in adults: Etiologies and risk factors. Pi-Sunyer,  F.X., & Kunins, L. (Eds.) Uptodate. Available from: https://www-uptodate-com.rossuniversity.idm.oclc.org/contents/obesity-in-adults-etiologies-and-risk-factors?search=medication%20associated%20with%20weight%20gain§ionRank=1&usage_type=default&anchor=H1612312650&source=machineLearning&selectedTitle=1~150&display_rank=1#H1612312650. Royalty-free music used for this episode: Salsa Trap by Caslo, downloaded on July, 20, 2022 from https://freemusicarchive.org/music/caslo/caslo-vol-1/salsa-trap/. Space Orbit by Scott Holmes, downloaded on July, 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/.  

Episode 82: Eczema Basics. By Lam Chau, MS3, Ross University School of Medicine; and Brandy Truong, MS4, Ross University School of Medicine. Edited and moderated by Hector Arreaza, MD. Brandy and Lam discuss the basics of pathophysiology, presentation, and general treatment of eczema.   This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Atopic dermatitis (eczema). A common skin disorder among children is atopic dermatitis, commonly known as eczema. At least 1 in 10 children have eczema; however, it affects many adults as well. About 31.6 million people, which is 10% in the U.S., have some form of eczema. Some other statistics worth noting are that children born outside of the U.S. have a 50% lower risk of developing eczema. The risk increases after living in the U.S. for 10 years. Also, 80% of individuals with eczema experience the onset at younger than 6 years old, and at least 80% will outgrow it by adolescence or adulthood.  Pathophysiology.  Eczema is caused by a disruption of the skin barrier. The outer layer of the skin contains a protein called “filaggrin” which helps form a barrier between the skin and environment. If a person has less of this protein, it's harder for the skin to retain water and lock in that moisture. Genetics and environment play a role and it often runs in families. People with eczema often have other allergic conditions such as asthma, seasonal allergies, and/or food allergies. Presentation. Eczema rashes can present differently for each person. It can be all over the body or just a few spots and people go through exacerbations or flare ups where the rash worsens and then gets better, which we call remission.  In babies, eczema tends to start on the scalp and face. You'll sometimes see red, dry rashes on the cheeks, forehead, and around the mouth.  For young children, rashes can occur in the elbow creases, on the back of the knees, the neck, and around the eyes. Sometimes the rash will ooze and crust.  There's different severities in eczema which helps guide treatment. Mild: some mild areas of dry skin, mild itching (with or without small areas of redness), little or no impact on everyday activities, sleep, and psychosocial well-being.Moderate: moderate areas of dry skin, pruritus becomes more frequent, redness is moderate, moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.Severe: widespread areas of dry skin, continuous itching, redness, bleeding, oozing, cracking, severe limitation of everyday activities and psychosocial functioning, and loss of sleep each night. Exacerbating factors. Factors that exacerbate eczema include excessive bathing without moisturizing, low humidity environments, stress, overheating, and exposure to solvents and detergents. Management. Explaining in detail the management of eczema would take a long time, but we will give you some of the basic principles of treatment. Patient follow up is key to succeed in the management of eczema. You may need to see these patients every 2-4 weeks in some cases and escalate treatment depending on severity. Eczema can be very frustrating for parents and patients. The management requires a multi approach including - eliminating factors that exacerbate eczema, restoring the skin barrier, treating infection, hydrating the skin, patient education, and oral medications. In terms of patient education, a study was done where it showed a 6-week education program that had 2-hour weekly sessions that talked about medical, nutritional, and psychological issues associated with eczema. It resulted in an overall decrease in severity after one year. Moisturizing cannot be overstressed. It is the mainstay of the treatment. Use as much creams as you can. The best moisturizers have a high content of oil, and they are recommended instead of lotions, which contain a percentage of alcohol. So, use emollients or thick creams liberally. Emollients should be applied two times daily and after bathing or handwashing. Some common moisturizers that can be found at common drug stores include Lubriderm, Aveeno, Aquaphor, Cetaphil, and CeraVe.  Keeping the skin hydrated and moisturized will also help with the itching. Itching can be very disrupting in the patients' lives and it can worsen symptoms if left untreated. Itching can result in lichenification, infection, bleeding, crusting, oozing, and cause permanent scars.   Topical steroids is another basic treatment for mild to moderate cases of eczema. Steroids can be used intermittently to prevent and treat exacerbations. For prevention, for example, topical steroids can be used two days a week (weekends) for 16 weeks. To treat exacerbations, prescribe twice a day topical steroid for 2-4 weeks.  When using topical corticosteroids, there should be caution using a high potency on areas like the face and skin folds since those are areas at risk for atrophy. However, a brief use of a higher potency can provide a quick response then patients can be switched to a lower potency. In the US, topical steroids are classified in 7 groups, going from group 1 “super-high potency” to group 7 “least potent”. As a primary care provider, you can memorize at least one formulation from each category and prescribe it as needed.  An example of low potency topical steroid would be hydrocortisone 2.5% (least potent, group 7) and triamcinolone 0.1% (Kenalog®), low potency, group 6.  A high potency topical corticosteroid would be Betamethasone dipropionate 0.05% cream (Diproline®) or mometasone furoate 0.1% cream (Elocon®). Those two creams are in the group 2 or high potency. There are other treatments we did not talk about, including calcineurin inhibitors, crisaborole, a phosphodiesterase 4 inhibitor (Eucrisa®), antibiotics, and oral medications. We invite you to keep learning about eczema. As we conclude this episode, we'd like to recommend you take a look at the National Eczema Association website. It contains a lot of helpful information material for patients. Invite your patients to consult that website as well.  Conclusion: Now we conclude our episode number 82 “Eczema Basics.” Our medical students have become excellent teachers. Today they explained very well the basics of eczema. Remind your patients to moisturize, moisturize and moisturize their skin with emollients. Topical steroids can be used for the treatment and prevention of exacerbations. Other treatments such as antibiotics, medications and even biologicals are not always needed but they may be used depending on severity. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Brandy Truong, and Lam Chau. Audio edition: Suraj Amrutia. See you next week! _____________________References:“Eczema Prevalence, Quality of Life and Economic Impact.” National Eczema Association, 8 Sept. 2021, https://nationaleczema.org/research/eczema-facts/.  Howe, William. Treatment of atopic dermatitis (eczema). Up to Date, last updated: December 08, 2021. https://www.uptodate.com/contents/treatment-of-atopic-dermatitis-eczema?search=eczema&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1 . Sarah, Stein. “Eczema in Babies and Children.” HealthyChildren.org, American Academy of Pediatrics, 13 Mar. 2020, www.healthychildren.org/English/health-issues/conditions/skin/Pages/Eczema.aspx#:~:text=At%20least%20one%20in%2010,sensitive%20skin%20than%20other%20people.   Watson, Stephanie. “Eczema Support Group: Local, How to Find, and More.” Healthline, Healthline Media, 27 May 2021, www.healthline.com/health/eczema/eczema-support-group#takeaway. 

Episode 76: Eating Disorders. The malaria vaccine is announced by Dr Parker, eating disorders such as anorexia and bulimia are briefly discussed by Sophia, Jeffrey and Dr Arreaza. Introduction: Introducing the malaria vaccine (RTS,S)Written by Hector Arreaza, MD; read by Tana Parker, MD.  Today is November 26, 2021.Malaria is a devastating disease that continues to kill thousands of people every year around the world. Since the year 2000, there have been 1.5 billion cases of malaria and 7.6 million deaths. In 2019, there were 229 million new cases, and 409,000 deaths, mostly children under 5 years of age.Effective vaccines for many protozoal diseases are available for animals (for example, the vaccine against toxoplasmosis in sheep, babesiosis in cows, and more.) However, vaccines for protozoal disease in humans had not been widely available … until now. The RTS,S is a vaccine against malaria approved by the European Medicines Agency in July 2015 for babies at risk, and it was rolled out in pilot projects in Malawi, Ghana and Kenya in 2019.  In October 2021, the World Health Organization announced the recommendation of this anti-malaria vaccine. The trade name of this vaccine is Mosquirix®. The vaccination is recommended for children in sub-Saharan Africa and other regions with moderate to high transmission of Plasmodium falciparum, which is considered the deadliest parasite in humans.  The approved vaccine has shown low to moderate efficacy, preventing about 30% of severe malaria after 4 doses in children younger than five years old. Implementation of vaccination is not free from challenges, and it should be executed not as the solution for the disease, but as part of the solution, along with other efforts such as mosquito control, effective health care, and more.RTS,S is an add-on to continue the fight against malaria worldwide. Hopefully we can lighten the heavy burden of malaria for more than 87 countries that suffer the severe consequences of poor control of this devastating disease. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Eating Disorders. Written by Sophia Dhillon, MS3, Jeffrey Nguyen, MS3. Discussion with Hector Arreaza, MD.  This is not intended to be a comprehensive lecture on eating disorders. This episode is intended to give you basic information, hoping to motivate you keep learning about it. Let's start talking about eating disorders today, specifically anorexia nervosa and bulimia nervosa. What is an eating disorder? An eating disorder is a disturbance of eating that interferes with health. As a reminder, health is “a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity.” So, an eating disorder, in a wide context, is any eating pattern that is out of what is considered “normal”, and that variation in feeding causes health problems. But in general, when we talk about eating disorders in medicine, we refer to anorexia nervosa and bulimia nervosa, but it includes also avoidant/restrictive food intake disorder, binge eating disorder, night eating disorder, pica, and rumination disorder.  ANOREXIAIn general, anorexia is characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure or an irrational fear of weight gain as well as distorted body self-perception. There are 2 main subtypes of anorexia: restricting type vs binge-eating/purging type. Tell us the difference between anorexia restrictive type and binge eating-purging type.Anorexia, restrictive type is when weight loss is achieved by diet, fasting and/or excessive exercise, meanwhile the binge-eating/purging type entails eating binges followed by self-induced vomiting and/or using laxatives, enemas or diuretics. These patients will have intense fear of gaining weight or becoming fat. They will have a distorted perception of body weight and shape or denial of the medical seriousness of one's low body weight.Anorexia nervosa is different than avoidant/restrictive food intake disorder. In anorexia, you have an altered perception of your body (“I'm fat”), but in avoidant/restrictive food intake disorder, your perception of your body weight and shape is not abnormal. “I'm skinny, and I'm OK with that.” This is new information for me. I thought anorexia was present always when a patient refused to eat, whether you liked your body or not.Why do people develop eating disorders? There are so many reasons why people develop eating disorders. First, it can be psychological due to low self-esteem, feelings of inadequacy or failure, feeling of being out of control, response to change (i. e. puberty) or response to stress. Second, it can be due to interpersonal issues like having trouble with family and personal relationships, difficult expressing emotions or feelings, or even history of being teased based on size or weight. Lastly, it is the social and cultural norms that we grow up in. There are cultural pressures that glorify thinness and place value on obtaining the perfect body, narrow definitions of beauty that include women and men of specific body weights and shapes. Sometimes there is no reason. Some people just get obsessed with their weight and perceive themselves as “fat”. Effect of anorexia on different parts of the bodySince these patients are scared of gaining weight, how does it affect the entire body?Anorexia can affect multiple systems in our body. Just to name a few symptoms that it can manifest as: amenorrhea, infertility, constipation, dizziness, hypothermia, bradycardia, hypotension, dry skin and even hair loss. Starvation induces protein and fat catabolism that leads to loss of cellular volume and atrophy of the heart, brain, liver, intestines, kidneys, and muscles. Cardiac: It can decrease cardiac mass, decrease cardiac chamber volumes, cause myocardial fibrosis and pericardial effusion. These manifestations are reversible if the patient gains weight. Functionally, it can cause bradycardia due to increased parasympathetic activity, hypotension, decreased heart rate variability and QT prolongation on ECG. Lungs: shortness of breath due to weakened and wasting of the respiratory muscles, pneumothorax and aspiration pneumonia. GI system: it leads to gastroparesis with bloating, constipation, severe pancreatitis and mild transaminitis. Hematologic: anemia, leukopenia and thrombocytopenia. Skin manifestations include dry/scaly skin, hair loss, acne, hyperpigmentation and acrocyanosis. You can also find lanugo, which is a very thin, light colored hair on the face and body. It is thought that the lanugo is an adaptation from the body to keep it warm. Lanugo is common in patients with anorexia nervosa or other causes of malnourishment. That's why wearing coats in warm weather can be a silent sign of anorexia. Other subtle signs include social withdrawal, fidgeting (to burn calories), and always “eating” in private.  It is important to remember that all these manifestation that Jeffrey mentioned are not present with intermittent fasting because intermittent fasting is an intermittent restriction of food, the nutritional needs are met during the “feasting” periods after “fasting”. Some may argue that intermittent fasting may promote eating disorders, but I believe intermittent fasting is just an effective treatment for obesity.Treatment plan for anorexiaThere are several treatment options for these patients. We can refer them to nutritional rehabilitation where they can supervise meals. We can refer them to psychotherapy, such as cognitive behavioral therapy or motivational interviewing. There is also a drug called Olanzapine for this condition. Sometimes, patients may need admission to the hospital. I learned recently that UCLA has an Eating Disorder Program which includes inpatient services. Some centers are very specialized and include family therapy and group therapy. Listeners, you can continue to research about anorexia, it's is fascinating. The prevalence of anorexia in the US is estimated to be 0.6%[3]. BULIMIABy definition, bulimia nervosa is when a person binge eats and then uses certain behaviors to prevent weight gain. These behaviors may include self-induced vomiting, using laxatives or diuretics, exercising excessively, or fasting and having a restrictive diet. Signs and symptoms to look forA physical examination is key. On physical presentation, these people usually can have overweight or obesity. That's the main difference with anorexia. Anorexia: skinny people, bulimia: normal weight, overweight or obesity. Regardless of their weight, these patients are malnourished. They may lack some essential nutrients causing serious health consequences. That's why nutrition cannot be assessed by BMI only. Common signs they will present with will include tachycardia, hypotension (systolic blood pressure below 90), dry skin, and hair loss. If the person uses self-induced vomiting to prevent weight gain, they may have erosion of the dental enamel from all the acid that comes up when they vomit. There may also be scarring or calluses on the dorsum side of the hand from all the acid too. Their parotid glands, that are located on the side of the jaws will also be swollen, causing a sign known as chipmunk face of bulimia.From talking to this person and getting a detailed history, we will learn of the symptoms bulimia nervosa can cause. This will include lethargy and fatigue, irregular menstrual periods in a female, abdominal pain and bloating, and constipationThis disorder really does take a toll on the body. There's plenty of complications that come with it as well. Let's try to break it down by system. GI system has the most complications: esophageal tears from the vomiting called Mallory-Weiss syndrome, which will present with bloody vomits, a loss of gag reflex, esophageal dysmotility, abdominal pain and bloating, GERD, diarrhea and malabsorption of nutrients, fatty stools known as steatorrhea, colonic dysmotility leading to constipation, irritable bowel syndrome, rectal prolapse, and pancreatitis. Cardiac: serious complication is ipeac-induced myopathy, let's spend a little time on this. Ipecac is a syrup that someone with bulimia nervosa may use to make themselves vomit. If a person uses this syrup frequently or for a long amount of time, there is a component called emetine will accumulate in muscle, including cardiac muscle. If a person uses ipecac chronically, it can be detected in the urine for up to 60 days. This will damage the heart muscles or myocardium and lead to cardiomyopathy. It will present with symptoms such as chest pain, shortness of breath, hypotension, tachycardia or bradycardia, T wave abnormalities on ECG, conduction delays, arrythmias, pericardial effusions, and even congestive heart failure. Cardiomyopathy may be irreversible. Renal system: dehydration, hypokalemia, hypochloremia, hyponatremia, and metabolic alkalosis. This could happen in patient who use diuretics as a purging mechanism. Endocrine system: Electrolytes and hormones imbalance. The endocrine system primarily impacts the reproductive and skeletal systems. Among 82 women treated for bulimia nervosa, menstrual irregularities were present in 45 percent at pretreatment and in 31 percent at 12-month follow-up. These irregularities may look like spotty or very light menstrual cycles. Cycles may be very erratic or completely absent. Skeletal system: osteopenia and osteoporosis are common with bulimia nervosa. Osteopenia means weaker and more brittle bones. Osteoporosis is more serious than osteopenia and can more easily result in fractures.The diagnosis of bulimia nervosa can usually be made clinically. And after the diagnosis with bulimia nervosa, the first step in helping them is always getting a full lab work up to see what systems to the body have been impacted. Treatment options include nutritional counseling, behavioral therapy, and even medications. If a person needs help connecting with someone that can help with this disorder, there are organizations that they can contact which will connect them with proper resources in their area. Organizations include the Academy for Eating Disorders and the National Eating Disorders Association. Bulimia nervosa is more prevalent in females than males in all age groups. In the US, adult prevalence is 1.0% and adolescent prevalence is 0.9%, with the median age of onset of 18 years. After comparing different age groups, we have seen the prevalence of bulimia nervosa has increased over time. Conclusion: Anorexia nervosa and bulimia nervosa are eating disorders that can have consequences on the health of our patients. We should know the difference between these two diseases and know the resources available in our community to assist these patients. The diagnosis may be done clinically, but you will need to order labs or imaging for a full assessment. Eating disorders are an example of the direct effect a mental illness can have in the body. In the specific case, anorexia and bulimia cause malnutrition. The treatment of these diseases requires a multidisciplinary team to treat the patient and the family as well.____________________________Conclusion: Now we conclude our episode number 76 “Eating Disorders.” We started this episode with exciting news about the new malaria vaccine, a step forward on our fight against malaria. Sophia, Jeffrey, and Dr Arreaza presented an interesting overview about anorexia and bulimia. They taught us that if a patient perceives him or herself as “fat”, but they are actually underweight, they may have anorexia. Patients with bulimia tend to have normal or above normal BMI but have periods of binging and purging. Be aware of these conditions while assessing your patients' nutritional status and treat appropriately or refer as needed. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Tana Parker, Sophia Dhillon, and Jeffrey Nguyen. Audio edition: Suraj Amrutia. See you next week! _____________________References: Malaria's Impact Worldwide, Centers for Disease Control and Prevention, https://www.cdc.gov/malaria/malaria_worldwide/impact.html, accessed on November 15, 2021.  Constitution of the World Health Organization, Basic Documents, Forty-fifth edition, Supplement, October 2006, accessed on Aug 26, 2021. Accessed on November 15, 2021.  https://www.who.int/governance/eb/who_constitution_en.pdf. 12 Secret Signs of Anorexia, CBS News, August 12, 2010, https://www.cbsnews.com/pictures/12-secret-signs-of-anorexia/3/.  Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58. doi: 10.1016/j.biopsych.2006.03.040. Epub 2006 Jul 3. Erratum in: Biol Psychiatry. 2012 Jul 15;72(2):164. PMID: 16815322; PMCID: PMC1892232. https://pubmed.ncbi.nlm.nih.gov/16815322/.  Mitchell, James E, MD; and Christie Zunker, PhD, CPH, CHES, Bulimia nervosa and binge eating disorder in adults: Medical complications and their management, UpToDate, October 2021. https://www.uptodate.com/contents/bulimia-nervosa-and-binge-eating-disorder-in-adults-medical-complications-and-their-management?search=Bulimia%20nervosa%20and%20binge%20eating%20disorder%20in%20adults:%20Medical%20complications%20and%20their%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Yager, Joel, MD, Eating disorders: Overview of epidemiology, clinical features, and diagnosis, UpToDate, October 2021. https://www.uptodate.com/contents/eating-disorders-overview-of-epidemiology-clinical-features-and-diagnosis?search=Eating%20disorders:%20Overview%20of%20epidemiology,%20clinical%20features,%20and%20diagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Yager, Joel, MD, Eating disorders: Overview of prevention and treatment, UpToDate, October 2021. https://www.uptodate.com/contents/eating-disorders-overview-of-prevention-and-treatment?search=Eating%20disorders:%20Overview%20of%20prevention%20and%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Episode 75: Multisystem Inflammatory Syndrome in Children (MIS-C).  Dr Schlaerth explains the signs, symptoms, and basic management of MIS-C. Lam explain the role of anti-obesity medications in weight management. Introduction: The Role of Drugs in Weight Loss Management    By Lam Chau, MS3, Ross University School of Medicine     Today about 70% of adult Americans are overweight or obese. Obesity is associated with increased risk of heart disease, stroke, and diabetes, among many other diseases. Studies have shown losing 5-10% of your body weight can substantially reduce your risk of cardiovascular disease.  Traditional belief is that weight loss can only be attributed to diet and exercise. While there are certainly elements of truth to that statement, medication is a safe and proven method for weight management that is often overlooked. The fact of the matter is that weight loss is an ongoing field of study with constant new research and innovations.  In June of this year, a medication named Wegovy was approved for weight loss management by the FDA. This drug is indicated for chronic weight management in patients with a BMI of 27 or greater with an accompanying weight-related ailment or in a patient with a BMI of 30 or greater. Rachel Batterham, PhD, of the Centre for Obesity Research at University College London, shared: "The findings of this study represent a major breakthrough for improving the health of people with obesity. No other drug has come close to producing this level of weight loss — this really is a game changer.” Despite breakthroughs like these, the use of medication for weight loss is still relatively low. Dr. Erin Bohula, a cardiologist and assistant professor at Harvard Medical School, believes “there are probably a few reasons for this, including cost, if not covered by insurance, and a perception these agents are not safe in light of the history with weight loss agents.” A study from 2019 examined the medical records from eight geographically dispersed healthcare organizations. They found that out of 2.2 million patients who were eligible for weight loss medication, only 1.3% filled at least 1 prescription. Weight loss is a dynamic process with many different variables. While it may not necessarily be for everyone, medication can help tremendously and is an option you should consider if you are interested in weight loss[1,2]. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.  ___________________________Multisystem Inflammatory Syndrome in Children (MIS-C).   By Katherine Schlaerth, MD, and Hector Arreaza, MD. History and epidemiologyMost children who get COVID-19 have either no symptoms or very mild symptoms. However, about 18 months ago, a new pediatric complication of COVID-19, possibly postinfectious, was described.  The eight children who were initially described had a clinical presentation which was similar to either Kawasaki Disease or perhaps toxic shock syndrome, and since these children had signs of a hyperinflammatory state coupled with shock, the new syndrome was named Multisystem Inflammatory Syndrome in Children, or MIS-C for short. By midsummer of 2021, the United States had about two thousand cases and 30 deaths in children under 21.  Other name for this condition is Pediatric Hyperinflammatory Shock. DiagnosisWhat are the criteria for a diagnosis of Multisystem Inflammatory Syndrome? They include:Age below 21Fever above 100.4 degrees Fahrenheit or 38 degrees centigrade for 24 hours (a subjective fever for more than 24 hours counts too). Laboratory evidence of inflammation which should include at least two of the following tests: elevated CRP, elevated ESR, elevated fibrinogen level, procalcitonin, D-dimer, ferritin, lactic acid dehydrogenase (LDH), interleukin-6, and neutrophil counts, low lymphocyte count and low albumin.Severe disease necessitating hospitalization with multisystem organs affected. The systems affected include cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, and neurologic (at least three systems need to be involved). No creditable other diagnosis. Other symptoms include:GI complaints (diarrhea, vomiting, abdominal pain)Skin rashConjunctivitisHeadacheLethargyConfusionRespiratory distressSore throatMyalgiasSwollen hands/feetLymphadenopathyCardiac signs and symptoms include troponin/BNP elevation and arrhythmia. Findings on ECHO may include depressed LVEF, coronary artery abnormalities, including dilation or aneurysm, mitral regurgitation, and pericardial effusion. There also must be a positive test for SARS-CoV-2 and this test can be either a reverse transcriptase polymerase chain reaction (RT-PCR), serologic, or antigen testing. Exposure to someone who has had or is suspected of having had COVID-19 within the last 4 weeks also counts.  Patients with MIS-C may have predominately gastrointestinal symptoms, mucocutaneous findings, and may be hypotensive or “shocky” on presentation. Up to 80% require ICU admission. Thrombocytopenia and /or elevated transaminase levels can also be seen.  MIS-C vs Kawasaki DiseaseThe big issue in diagnosing MIS-C is the overlap with Kawasaki's disease and with toxic shock syndrome. Patients with Kawasaki Disease in their second week of illness often will have thrombosis, not thrombocytopenia. Whereas MIS-C usually affects school age children or adolescents, Kawasaki Disease is more commonly a problem in younger children, who have an average age of 2 years.  Kawasaki Disease is also more common in Asian children and MIS-C disproportionately seems to affect Black and Hispanic children.  Obesity seems to be another risk factor for MIS-C.  Kawasaki's Disease also has different cardiac manifestations from MIS-C. Coronary artery dilatation is common in Kawasaki's disease and left ventricular dysfunction in MIS-C, although sometimes coronary artery dilatation and rarely aneurisms can be noted on echocardiogram in putative MIS-C, which is why differentiation from Kawasaki's Disease is an issue.  PathophysiologyThe cause of MIS-C is probably postinfectious immune dysregulation. Only a minority of MIS-C patients are identified as having COVID-19 by RT-PCR, but most have positive tests for immunoglobulin G.  Statistically, there is a lag of 4-6 weeks between peak community cases of COVID-19 and the time at which children present with MIS-C.   Although research is being done on MIS-C, and theories abound about etiology, there is no clear-cut answer to why some children get MIS-C and the vast majority do not. In a review of the literature on MIS-C using literature from December 2019 through May 2020, gastrointestinal symptoms such as diarrhea, and abdominal pain were 4-5 times more common than cough and respiratory distress.  There was a slight preponderance of male patients and mean age was 8 ½ years. ICU admission was common and 2/3 required inotropic support, over ¼ needed respiratory help with extracorporeal membrane oxygenation warranted in 31 children. The death rate was 1.5 % of these very sick children treated in hospital.  In another smaller study, 80% had mild, but 44% had moderate to severe EKG abnormalities including coronary involvement. The good news was that coronary arteries were normal in all children after a month, and at 4-9 months, only 2-4% had mild heart abnormalities. Unfortunately, mechanisms of MIS-C as well as universal treatment is still being worked out. Published articles may be delayed due to time constraints in publishing. Other immunologic interventions do not have sufficient data. TreatmentWhat about the treatment of children diagnosed with MIS-C?Usually, a variety of specialists become involved initially. These can include pediatric rheumatology, infectious disease, cardiology, and hematology. If children with MIS-C meet criteria for complete or incomplete Kawasaki disease as well, regardless of COVID-19 testing results, IVIG and aspirin are reasonable.  Corticosteroid use must be individualized, and if used it may require a taper.  An echocardiogram can be done initially looking for coronary aneurisms and repeated in a week.  In severe cases, shock may be a presenting factor needing urgent attention. Generally, the treatments used are decided by the aforementioned consults and may consist of immunomodulating therapy, including possibly IVIG (2g/kg), and/or corticosteroids methylprednisolone (30mg/kg).  AntiviralsThe role of antiviral therapy is unclear and remdesivir should be reserved for children with acute COVID-19.  COVID-19 vaccination-associated myocarditisAnother entity which needs further evaluation is COVID-19 vaccination-associated myocarditis in adolescents. This problem is more common in young males and may occur after the administration of mRNA based COVID-19 vaccines. The presentation occurs within 2 weeks of COVID-19 vaccination, and clinical presentation can include chest pressure, abnormal biomarkers (elevated troponins), and cardiac imaging findings. It is unknown if subclinical cases occur.  COVID-19 infection in children, while usually benign, has the potential to become serious, and the association between some mRNA vaccines and the occurrence of myocarditis has yet to be thoroughly studied. We look forward to more and better data to guide the care of children and young adults in these spheres. The risk of having myocarditis is still higher with the actual COVID-19 than the COVID-19 vaccine. The incidence of myocarditis after BioNtech/Pfizer vaccine was 2.13 cases per 100,000 persons in a large study done in a large health care organization in Israel where more than 2 million people were vaccinated (that represents 0.00213%). Another US study showed that there were 77 cases per million doses of vaccines in young male, in contrast, there were 450 cases of myocarditis per million COVID-19 cases in the same age group.____________________________Conclusion: Now we conclude our episode number 74 “Multisystem Inflammatory Syndrome in Children.” Dr. Schlaerth explained that MIS-C is a work in progress in terms of pathophysiology, diagnosis, treatment, and prognosis. MIS-C and Kawasaki Disease are very similar, but, for example, GI symptoms, cardiac dysfunction, shock and multisystem dysfunction are more prominent in MIS-C than Kawasaki Disease. Whereas coronary artery aneurysms are more common in Kawasaki disease than MIS-C. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Katherine Schlaerth, and Lam Chau. Audio edition: Suraj Amrutia. See you next week! _____________________References:FDA Approves New Drug Treatment for Chronic Weight Management, First Since 2014, June 04, 2021, U.S. Food and Drug Administration (FDA), https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014. Saxon DR, Iwamoto SJ, Mettenbrink CJ, et al. Antiobesity Medication Use in 2.2 Million Adults Across Eight Large Health Care Organizations: 2009-2015. Obesity (Silver Spring). 2019;27(12):1975-1981. doi:10.1002/oby.22581. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868321/.  Carroll, Linda, Weight-loss pills can help. So why don't more people use them? NBC News Health Care, September 2, 2018.  https://www.nbcnews.com/health/health-care/weight-loss-pills-can-help-so-why-don-t-more-n905211 World Health Organization, WHO recommends groundbreaking malaria vaccine for children at risk, October 6, 2021. https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk Lee, Min-Sheng et. al, Similarities and Differences Between COVID-19-Related Multisystem Inflammatory Syndrome in Children and Kawasaki Disease, Front. Pediatr., 18 June 2021, https://doi.org/10.3389/fped.2021.640118.  Gail F. Shust, Vijaya L. Soma, Philip Kahn and Adam J. Ratner, Pediatrics in Review July 2021, 42 (7) 399-401; DOI: https://doi.org/10.1542/pir.2020-004770. Jain SS, Steele JM, Fonseca B, et al. COVID-19 vaccination-associated myocarditis in adolescents. Pediatrics. 2021; doi:10.1542/peds.2021-053427.  https://pediatrics.aappublications.org/content/pediatrics/early/2021/08/12/peds.2021-053427.full.pdf.  Wilson, Clare, Myocarditis is more common after covid-19 infection than vaccination,  New Scientist, 4 August 2021, https://www.newscientist.com/article/mg25133462-800-myocarditis-is-more-common-after-covid-19-infection-than-vaccination/#ixzz79JPn2E47. Son, Mary Beth F, MD, and Kevin Friedman, MD, COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis, Up to Date, September 2021, https://www.uptodate.com/contents/covid-19-multisystem-inflammatory-syndrome-in-children-mis-c-clinical-features-evaluation-and-diagnosis?search=kawasaki%20vs%20misc&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1  

Episode 70: HIV Prevention. Prevention is key in controlling HIV-AIDS. Listen to ways to prevent HIV, mainly by using condoms, PrEP and PEP.Introduction: HIV and AIDSBy Robert Dunn, MS3.Introduction: The Human Immunodeficiency Virus (HIV) is a retrovirus that is primarily transmitted via sex, needles or from mother to fetus. Once infected, the virus increases in its copies and decreases the individual's CD4+ cell count, thus leading to an immunocompromised state known as Acquired Immune Deficiency Syndrome (AIDS). Once with AIDS, the patient is susceptible to opportunistic infections. Prevention from AIDS includes several options. Condoms for safe sex practices are the least invasive and most readily accessible option for all patients. Pre-exposure prophylaxis (PrEP) is also an option for men who have sex with men (MSM) and transgender women. If the patient is also exposed to HIV, post-exposure prophylaxis (PEP) may also be an option to prevent infection but must be administer ideally 1-2 hours after exposure but no later than 72 hours after. Today we will briefly discuss how to prevent HIV infection.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.___________________________HIV Series IV: HIV Prevention. By Robert Dunn, MS3.Participation by Huda Quanungo, MS3; Bahar Hamidi, MS3; and Hector Arreaza, MD.  HIV PreventionIntroductionThe Human Immunodeficiency Virus (HIV) is a retrovirus that is primarily transmitted via sex, needles or from mother to fetus. Once infected, the virus increases in its copies and decreases the individual's CD4+ cell count, thus leading to an immunocompromised state known as Acquired Immune Deficiency Syndrome (AIDS). Once with AIDS, the patient is susceptible to opportunistic infections. Prevention from AIDS includes several options. Condoms for safe sex practices are the least invasive and most readily accessible option for all patients. Pre-exposure prophylaxis (PrEP) is also an option for men who have sex with men (MSM) and transgender women. If the patient is also exposed to HIV, post-exposure prophylaxis (PEP) may also be an option to prevent infection, but it must be administered ideally 1-2 hours after exposure but no later than 72 hours after. We will concentrate in prevention during this episode.   What is HIV?The Human Immunodeficiency Virus (HIV) is a retrovirus. When the virus gains access to our body via cuts on the skin or mucosa:The virus injects its 10kb sized RNA genome into our cells. The RNA is transcribed to DNA via viral reverse transcriptase and is incorporated into our cellular DNA genome. This causes our cells to become a virus producer. Viral proteins translated in the cell are transported to the edge of the cell and can bud off into new viruses without lysing the cell.  Acute HIV symptoms. Some potential early symptoms of HIV can include fever, chills, rash, night sweats, muscle aches, sore throat, fatigue, lymphadenopathy, and mouth ulcers. The most common acute symptom is NO SYMPTOM. Many people do not feel sick with the acute infection of HIV. Some people can live years with HIV in “clinical latency” without knowing they are infected, but they can still be contagious during this time. As viral load (the amount of virus copies you have in your blood stream) increases, the CD4+ cells that contribute to our adaptive immunity continues to fall. That's why the best test during this period is not going to be HIV antibody but you should test for antigens. Specifically, the 4th Generation HIV test, which tests for both antibody and p24 antigens.Chronic symptoms. Once patients begin to present with opportunistic infections (i.e. Pneumocystis pneumonia – PCP), or have a CD4 count below 200, the patient is considered to have Acquired Immune Deficiency Syndrome (AIDS) and makes them susceptible to more serious infections. Without treatment, patients with AIDS typically survive about 3 years. Epidemiology of HIVHIV incidence: In 2019, there were 34,800 new HIV infections in the United States. This is an 8% decline from 2015. Amongst age groups: Age 25-34 had the highest rate of incidence (30.1 per 100,000)Age 35-44 had the second highest rate (16.5 per 100,000)Age 45-54 remained stableAge 13-24 had decreasing rates of incidence Amongst ethnic groups: Black/African-American groups has the highest rate of incidence (42.1 per 100,000)Hispanic/Latino had the second highest rate (21.7 per 100,000)Person of multiple races had the third highest (18.4 per 100,000) Amongst sex: Males had the highest rate of incidence (21 per 100,000)Females had the lowest rate of incidence (4.5 per 100,000) HIV Prevalence:In 2019, 1.2 million people (Ages 13 and older) in the US have HIV and 13% of them do not even know it. In 2020, there were an estimated 1.5 million people worldwide that acquired a new HIV infection. This is a 30% decline since 2020. An estimated 66% are receiving some HIV care and 57% were virally suppressed. Mortality: In 2019, there were 15,815 deaths among adults and adolescents diagnosed with HIV in the US. Preventative ScreeningThe USPSTF gives a Grade A recommendation for HIV screening for: Pregnant people and everyone between 15-65 years of age. All pregnant people at any point of their pregnancy, including those who present in labor or delivery and have an unknown status of HIV.The USPSTF only recommends a one-time screening and shows no benefit of repeat screening thereafter. Women may also be screened for subsequent pregnanciesAlso screen all Adolescents and adults ages 15-65.  An effective approach is routine opt-out HIV screening. This approach includes HIV screening as part of the standard preventive tests. This approach removes the stigma associated with HIV testing, it promotes earlier diagnosis and treatment, reduces risk of transmission, and it is cost-effective. The determination for repeated screening of individuals should take into account the following risk factors: -Men who have sex with men (MSM)-Individuals who live in areas with high prevalence of HIVIncluding attending to tuberculosis clinics, stay in a correctional facility, or homelessness-Injection drug use-Transactional/commercial sex work-1 or more new sexual partners -History of previous STIs Annual screening for HIV is reasonable, however, clinicians may want to screen patients every 3-6 months if they have an increased risk of HIV.  CondomsA simple and very effective method in HIV prevention is the use of condoms for safe sex practices. In 2009, the American College of Physicians (ACP) and the HIV medicine Association called for the wider availability of condoms and education to minimize HIV transmission. A meta-analysis of 12 HIV studies amongst heterosexual couples demonstrated the use of condoms in all penetrative sex acts reduced the risk of HIV transmission 7.4 times in comparison to those who never used condoms. Other studies show a 90-95% effectiveness in HIV prevention when “consistently” using condoms. A Cochrane review shoed that the use of a male latex condom in all acts of penetrative vaginal sex reduced HIV incidence by 80%. Overall, condoms are effective in HIV prevention.Pre-Exposure Prophylaxis (PrEP)Truvada and Descovy:Another option for prevention amongst HIV negative individuals is the use of Pre-Exposure Prophylaxis (PrEP). It is an anti-retroviral pill that is taken daily to maintain a steady-state level of the medication in the blood stream. The medication specifically a combination of 2 antiretroviral medications – Tenofovir and Emtricitabine. Both medications are nucleoside reverse transcriptase inhibitors (NRTIs) that work by blocking the viral reverse transcriptase from HIV and prevent the enzyme from copying the RNA genome into DNA. Therefore, it stops viral replications. There are 2 formulations of PrEP: Truvada and Descovy. Truvada's primary side effects are renal and bone toxicity with long-term use. Descovy's primary side effects are mild weight gain and dyslipidemia. Truvada is the most commonly prescribed PrEP because it has the most data since it has been around the longest. However, extra consideration should be taken for: Adolescents should weigh at least 35 kg before being prescribed PrEPDescovy may be preferred for adolescents by the prescribing physician as it is not associated with reduction in bone density, as Truvada is. Estimated GFR between 30 – 60Truvada is associated with acute and chronic kidney disease whereas Descovy is safe for patients with a GFR greater than 30Patients with osteoporosisTruvada is associated with bone toxicity, whereas Descovy is not. It is important to note that PrEP has only been studied in men or people who were assigned men at birth. So, its efficacy in vaginal sex and with vaginal fluids cannot be generalized at this time. Future of PrEP: In May 2020, the HIV Prevention Trials Network (HPTN) 083 randomized trial demonstrated the potential of an injectable PrEP. Carbotegravir, is an integrase inhibitor, which prevents the HIV integrase from incorporating the HIV genome into the cellular genome. This study demonstrated its efficacy as PrEP in comparison to Truvada with few new infections (13 versus 39, respectively). Carbotegravir would be given via injection once every 8 weeks. In September 2021, the pharmaceutical company Moderna will begin 2 human clinical trials for an HIV vaccine that use mRNA technology. Previous studies conducted with non-mRNA vaccines demonstrated that B cells can be stimulated to create antibodies against HIV. Since HIV becomes integrated in the cellular genome within 72 hours of transmission, a high level of antibodies must be produced and present in the body to offer an adequate level of immunity. Post-Exposure Prophylaxis (PEP)If an individual is exposed to blood or bodily fluids with high risk of HIV via percutaneous, mucus membrane or nonintact skin route, post-exposure prophylaxis (PEP) may be an option. PEP is indicated when the HIV status of the exposure source is unknown and are awaiting test results, or if the exposure source is HIV positive. Therapy should be started within 1 or 2 hours of exposure and it is not effective after 72 hours of initial exposure. The recommended duration of therapy is 4 weeks but no evidence has been shown for an optimal duration. Occupational exposure. There are 2 regimens for PEP: Truvada with Dolutegravir Truvada  with Raltegravir Both Doltegravir and Raltegravir are integrase inhibitors which block the integration of the viral genome into the cellular DNA. The regiments are chosen based on efficacy, side effects, patient convenience, and completion rates. Dolutegravir is chosen because it is given once daily. While Raltegravir is taken twice daily, most experience with PEP has been with Raltegravir. Other risk with Raltegravir are potential skeletal muscle toxicity and systemic-cutaneous reactions resembling Steven-Johnson syndrome. One final word about prevention of vertical transmission is making sure pregnant women are treated during pregnancy and if the baby is delivered from a patient whose viral load is “detectable”, the baby needs to be treated, but we'll let that topic for another time to discuss. Joke: What do you call the patient zero of HIV? First Aids.HIV incidence is decreasing thanks to many prevention measures taken globally, and we discussed screening, condoms, PrEP and PEP as part of this prevention efforts. Stay tuned for more relevant medical information in our next episode. ____ Now we conclude our episode number 70 “HIV Prevention.” Robert, Huda and Bahar explained some ways to prevent HIV, mainly by screening those at risk, using condoms, PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis). Let's also remember that having a monogamous relationship and avoiding high risk sexual behaviors confer significant protection against HIV. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Robert Dunn, Huda Quanungo, and Bahar Hamidi. Audio edition: Suraj Amrutia. See you next week!   References:About HIV. Center for Disease Control and Prevention, CDC.gov, June 1, 2021. https://www.cdc.gov/hiv/basics/whatishiv.html . Accessed September 21, 2021. Simon V, Ho DD, Abdool Karim Q. HIV/AIDS epidemiology, pathogenesis, prevention, and treatment. Lancet. 2006 Aug 5;368(9534):489-504. doi: 10.1016/S0140-6736(06)69157-5. PMID: 16890836; PMCID: PMC2913538. [https://pubmed.ncbi.nlm.nih.gov/16890836/]   US Statistics. HIV.gov, June 2, 2021. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics . Accessed September 21, 2021.  The global HIV/AIDS Epidemic. HIV.gov, June 25, 2021. https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics. Accessed September 21, 2021.  Human Immunodeficiency Virus (HIV) Infection: Screening. U.S. Preventative Services Task Force, June 11, 2019. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/human-immunodeficiency-virus-hiv-infection-screening. Accessed September 21, 2021.  Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bull World Health Organ. 2004 Jun;82(6):454-61. PMID: 15356939; PMCID: PMC2622864. [https://pubmed.ncbi.nlm.nih.gov/15356939/] Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002;(1):CD003255. doi: 10.1002/14651858.CD003255. PMID: 11869658. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003255/full] Mayer, Kenneth H, MD, and Douglas Krakower, MD. Administration of pre-exposure prophylaxis against HIV infection. UpToDate, June 24, 2020. Accessed September 21, 2021. [https://www.uptodate.com/contents/administration-of-pre-exposure-prophylaxis-against-hiv-infection?search=8)%09Administration%20of%20pre-exposure%20prophylaxis%20against%20HIV%20infection&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1] Zachary, Kimon C, MD. Management of health care personnel exposed to HIV. UpToDate, June 07, 2019. Accessed September 21, 2021. [https://www.uptodate.com/contents/management-of-health-care-personnel-exposed-to-hiv?search=9)%09Management%20of%20health%20care%20personnel%20exposed%20to%20HIV&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1]

Episode 66: Meth Abuse. By Ikenna Nwosu, MD, and Hector Arreaza, MD.  Discussion about screening, epidemiology, clinical presentation, diagnosis, and treatment of meth abuse. Association between intranasal corticosteroids and lower risk of COVID-19 complications is mentioned.Introduction: Intranasal corticosteroids associated with better outcomes in COVID-19By Bahar Hamidi, MS3, American University of the Caribbean When I first heard of the news of a pandemic occurring, I never thought it would last more than a couple weeks. Of course, as a medical student the first thing I wanted to know was what bug is causing all this commotion in the news. When I discovered “Coronavirus” my first reaction was a chuckle and blurting out “no way.” Why did I respond this way you may ask? As a student when we studied that coronavirus would cause nothing more than a regular cold, thus a mere pesky virus causing a whole pandemic seemed odd to me at the time. Little did I know almost two years later we are still talking about it! “Don't touch your face before washing your hands.” These are the words that run through my mind anywhere I am nowadays. Why? Well, SARS-CoV-2 spike (S) protein is why. This protein engages ACE2 (angiotensin-converting enzyme 2) as the entry receptor. This virus's receptor is found to be highly expressed in our nasal mucosa. How much of this ACE2 we have interestingly can correlate with your age; lower in children compared with adults. Other things that can affect a person's susceptibility is the level of eosinophils in your body. High absolute eosinophil count showed to have a lower hospitalization risk in a group of individuals with asthma and COVID, but we must keep in mind that the study can be confounded by the use of inhaled corticosteroids (iCS). This was taken into account during a study.The study was done by Ronald Strauss and collaborators, it's titled, Intranasal Corticosteroids Are Associated with Better Outcomes in Coronavirus Disease 2019, and it was published on The Journal of Allergy and Clinical Immunology: In Practice, September 2021.So how may inhaled corticosteroids prevent significant illness from COVID? The answer is lower expression of ACE2 and its cellular serine protease TMPRSS2. Theoretically, it makes sense because the less entry gates the virus has the less sick someone may possibly get. Therefore, the study hypothesizes that by suppressing receptor expression, intranasal corticosteroid use is protective against complicated outcomes like hospitalizations, admission to ICU and mortality.Interestingly in addition, two types of corticosteroids [ciclesonide (Alvesco®) and mometasone (Asmanex® for asthma and Nasonex for allergic rhinitis)] were discovered to suppress replication of coronavirus. This overall study has pertinent findings for the treatment of this everlasting pandemic and proves there is yet much left to discover and continue to research.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Meth Abuse. By Ikenna Nwosu, MD, and Hector Arreaza, MD IntroductionDrug use is a growing problem with serious consequences to individuals, families, and whole nations. Today we will discuss one of the most common drugs abused by our patients: Methamphetamine. Definition   Methamphetamine (street name chalk, crank, crystal, glass, ice, meth) is a stimulant commonly abused in many parts of the United States. It is a psychostimulant that causes the release and blocks the reuptake of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin. Methamphetamine is most often smoked or snorted and is less commonly injected or ingested orally.  Arreaza: Phentermine (appetite suppressant) is not meth. Phentermine is less potent because it acts mostly on norepinephrine, very little on dopamine, and minimally on serotonin.  Epidemiology  Amphetamine-type stimulants, which include methamphetamine, are the fastest rising drug of abuse worldwide. An estimated 2.1% of the United States population have been reported to have tried methamphetamine at some time in their lives with its rate of use found to be similar among men and women. Data indicates that methamphetamine is a significant public health problem. Mortality has increased by about 40 percent from 2015 to 2016 and drug overdose deaths involving methamphetamine have tripled since 2011. Arreaza: The mortality is high but also the morbidity. I can imagine how costly it is for health systems to take care of the complications of meth use, from dental work to cardiovascular disease, i.e., heart failure. It is a serious problem in Bakersfield, California. As an interesting fact, meth is the most common drug identified in urine drug screenings, then follows marijuana, cocaine, heroin, and fentanyl. Clinical manifestations  When someone uses meth, they have increased energy and alertness, pupillary dilation, tachycardia, euphoria, decreased need for sleep, grinding teeth, dry mouth, loss of appetite, and other symptoms of sympathetic nervous system activation.  Repeated use causes weight loss, dental decay, chronic adverse mood, and cognitive changes, including irritability, aggression, panic, suspiciousness, and/or paranoia, hallucinations, and memory impairment.  Chronic use also can exacerbate depression and anxiety, and those changes can interfere tremendously in patient care. The risk of suicide is also higher. It can also cause complications in other systems:-Cardiovascular (cardiomyopathy, myocardial infarction, and stroke)-Skin (abscesses, aged appearance, and skin lesions)-Neurologic (confusion, memory loss, slowed learning)-Oral (dental decay or “meth mouth”) Acute intoxicationComplications of severe acute intoxication: hypovolemia, metabolic acidosis, hyperthermia, disseminated intravascular coagulation (DIC), rhabdomyolysis, tachydysrhythmia, hypertension, and seizures.  Methamphetamine as a psychostimulant, has a half-life of 12 hours, so its effects last longer than those of cocaine. It is metabolized by the liver through the cytochrome P2D6 system. After the acute intoxication you can see the opposite: sedation, slurred speech, hypersomnia.  Screening  No specific guidelines regarding screening for methamphetamine use are available.  In 2008, The U.S. Preventive Services Task Force concluded that evidence available at that time was insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.  This guideline was updated in June 2020. The USPSTF now gives a grade of recommendation “B” to screening for unhealthy drug use. How do you screen? By asking questions about unhealthy drug use in all adults older than 18 years old. This recommendation does not include testing biological specimens. Screening should be implemented when diagnosis, effective treatment and care can be offered at your clinic or you can refer to other providers for treatment. The American Academy of Pediatrics, the American Medical Association's Guidelines for Adolescent Preventive Services, and the Bright Futures initiative endorse screening adolescents for illicit substance use. On the other hand, the USPSTF concluded in June 2020 that the current evidence is insufficient to recommend screening for unhealthy drug use in adolescents. So, it gives a grade of recommendation “I”. Remember, “I” does not mean “Do not screen”, “I” means “Insufficient or I don't know”. The American College of Obstetricians and Gynecologists recommends direct questioning of all patients about their use of drugs as part of periodic assessments. Screening for methamphetamine use by history should be considered for pregnant women, teenagers and young adults, persons with criminal histories, men who have sex with men, and persons in high-risk ethnic groups. Diagnostic testing with informed consent can be useful in patients with stimulant-associated symptoms and signs, but this is not screening, this is a diagnostic test. Diagnosis  DSM-5 criteria — A problematic pattern of methamphetamine use leading to clinically significant impairment or distress, as manifested by two or more of the following within a 12-month period:• Methamphetamine is often taken in larger amounts or over a longer period than was intended (patient wants more and more meth)• There is a persistent desire or unsuccessful efforts to cut down or control methamphetamine use (patients want to quit but they can't)• A great deal of time is spent in activities necessary to obtain methamphetamine, use methamphetamine, or recover from its effects (patient spends a long time using meth and recovering)• Craving, or a strong desire or urge to use methamphetamine (patient crave)• Recurrent methamphetamine use resulting in a failure to fulfill major role obligations at work, school, or home• Continued methamphetamine use despite having persistent or recurrent social problems caused or exacerbated by the effects of methamphetamine• Important social, occupational, or recreational activities are given up or reduced because of methamphetamine use• Recurrent methamphetamine use in situations in which it is physically hazardous• Continued methamphetamine use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by methamphetamine Subtypes of severity of methamphetamine use disorder ●Mild: Two to three symptoms●Moderate: Four to five symptoms●Severe: Six or more symptoms Urine drug testMethamphetamine can be detected in urine for approximately 48 hours after use. It can be detected in meconium in newborns,indicating maternal use in the second half of pregnancy. Pseudoephedrine can cause a false positive test result for amphetamines.The amphetamine portion of the "tox screen" is susceptible to both false positive and false negative results and must be interpreted in clinical context.  Drugs of abuse, such as benzphetamine and bupropion (a synthetic cathinone), may give positive results. Medications such as selegiline and nonprescription nasal inhalers (decongestants) containing the active ingredient l-methamphetamine (l-desoxyephedrine) may yield positive results for amphetamine. Phentermine can give a false positive result in Utox for meth or MDMA (ecstasy). If a patient states he/she is taking phentermine, you can order a confirmatory test, which will then show that it was phentermine and not amphetamine or methamphetamine. If you are taking phentermine for weight loss, you should stop taking it a week before the drug test. Treatment of acute intoxicationThe treatment of acute methamphetamine intoxication is largely supportive. -Activated charcoal (after oral ingestion) when there are severe symptoms of intoxication and absorption needs to be reduced-Benzodiazepines may be indicated for seizures or agitation-Antipsychotics may be needed for paranoia or psychosis. -Cooling measures may be required if there is hyperthermia. -If elevated blood pressure is dangerously high, it should be lowered, but there are no data regarding blood pressure goals or which medications to use. -Abuse of multiple substances is possible. Patients may have used a combination of marijuana, alcohol, and cocaine, for example. You should also consider testing for several STIs in meth users since high risk sexual behaviors are possible. Treatment of abuseOutpatient behavioral therapies are the standard treatment for methamphetamine abuse and dependence. Inpatient treatment may be needed in some cases. -Cognitive behavior therapy and contingency management programs are successful in treating cocaine addiction and may be effective in treating methamphetamine addiction as well. -Contingency programs consists of rewarding patients who provide a drug-free urine sample.-The Matrix Model is an individualized outpatient regimen that has been used successfully to treat patients who abuse stimulants. It is based on cognitive principles, incorporating individual, group, and family therapies, as well as drug testing and a 12-step program.  Medications to treat meth abuseThere are no medications approved by the U.S. Food and Drug Administration to treat methamphetamine dependence. Some studies on this topic include:-A Cochrane review showed that fluoxetine (Prozac, 40 mg per day) may have modest benefit in reducing cravings for a short time but does not reduce use of meth, and that imipramine (Tofranil) may improve adherence to therapy in methamphetamine users. -One small RCT showing that bupropion (Wellbutrin) decreased subjective methamphetamine-induced effects and craving in a laboratory setting. -A randomized controlled trial enrolled 60 men who have sex with men; participants had methamphetamine use disorder and were actively using the drug. All the men received weekly counseling plus mirtazapine (Remeron), 30 mg per day, or placebo. Men in the mirtazapine group had decreased methamphetamine use and sexual risk, despite low adherence.In Episode 47, Kafiya Arte mentioned the Accelerated Development of Additive Treatment for Methamphetamine Disorder (ADAPT-2), which assessed the efficacy of combined bupropion and naltrexone for the treatment of meth use disorder. 403 participants were enrolled. The efficacy of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg) was evaluated, as compared to placebo.  Results: 13.6% response rate in the naltrexone-bupropion group and only 2.5% response with placebo. The response rate among participants that received naltrexone and bupropion was low, but it was higher than those who received placebo. Withdrawal-Stimulant withdrawal is less dangerous than withdrawal from alcohol, opioids, or sedatives, but seizures are possible.-Stimulant withdrawal symptoms include depression, somnolence, anxiety, irritability, inability to concentrate, psychomotor slowing, increased appetite, and paranoia. -There are no known effective treatments. -Methamphetamine withdrawal is associated with more severe and prolonged depression than is cocaine withdrawal, so patients with withdrawal should be monitored closely for suicidal ideation. How is methamphetamine made?Most methamphetamine used in the United States comes from small illegal laboratories in Mexico and within the US. It is unexpensive, potent, and highly pure. Pseudoephedrine is a common component used in the production of meth, along with many other dangerous ingredients. These chemicals can cause deadly lab explosions and house fires and they may remain in the air of the houses used as laboratories.   Can you get high if you breath second-hand methamphetamine smoke?Researchers have not proven that people who inhale secondhand methamphetamine smoke get high or have other health consequences but breathing these fumes can cause a positive urine test for methamphetamine. More research is needed in this field. Methamphetamine use is a big problem. Prevention of use is key in fighting this devastating addiction. In patients who are addicted, treatment includes behavioral health strategies. No medications have been approved for treatment of dependence, but we hope new research finds an effective medication to treat it.  Conclusion: Now we conclude our episode number 66 “Meth Abuse.” This topic is very extensive, but Dr Nwosu presented a good summary. Meth will continue to be a significant problem as long as we do not find a cure for this devastating addiction. Remember to screen your patients for drug use by asking direct and simple questions, then offer the addiction services available in your area. Even without trying, every night you go to bed being a little wiser. Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ikenna Nwosu, and Bahar Hamidi. Audio edition: Suraj Amrutia. See you next week! ___________________________  References: Ronald Strauss, Nesreen Jawhari, Amy H. Attaway, Bo Hu, Lara Jehi, Alex Milinovich, Victor E. Ortega, Joe G. Zein, Intranasal Corticosteroids Are Associated with Better Outcomes in Coronavirus Disease 2019, The Journal of Allergy and Clinical Immunology: In Practice, September 2021, ISSN 2213-2198, https://doi.org/10.1016/j.jaip.2021.08.007. Winslow BT, Voorhees KI, Pehl KA. Methamphetamine abuse. Am Fam Physician. 2007 Oct 15;76(8):1169-74. PMID: 17990840. https://www.aafp.org/afp/2007/1015/p1169.html Klega AE, Keehbauch JT. Stimulant and Designer Drug Use: Primary Care Management. Am Fam Physician. 2018 Jul 15;98(2):85-92. PMID: 30215997. https://www.aafp.org/afp/2018/0715/p85.html Paulus, Martin, Methamphetamine use disorder: Epidemiology, clinical manifestations, course, assessment, and diagnosis, Up ToDate, last updated: July 20, 2021. https://www.uptodate.com/contents/methamphetamine-use-disorder-epidemiology-clinical-manifestations-course-assessment-and-diagnosis?search=methamphetamine%20use%20disorder&source=search_result&selectedTitle=2~128&usage_type=default&display_rank=2 Boyer, Edward W and Steven A Seifert, et. al, Methamphetamine: Acute intoxication, Up To Date, last updated: December 24, 2019. https://www.uptodate.com/contents/methamphetamine-acute-intoxication?search=Methamphetamine:%20Acute%20intoxication&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Methamphetamine, Drug Facts, National Institute on Drug Abuse (NIDA), accessed on July 28. 2021. https://www.drugabuse.gov/publications/drugfacts/methamphetamine.  

Episode 64: H. pylori. Dr Lorenzo explains testing, diagnosis, and treatments for H. pylori, a bacterium that can cause peptic ulcer disease and other complications.By Anabell Lorenzo, MD, and Hector Arreaza, MD.   This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Today we are going to discuss a topic that may be very basic for many of our listeners, but it is important to check our knowledge foundation to keep building on it. Helicobacter pylori was discovered in 1982 by Barry Marshall and Robin Warren from Australia. They received the Nobel prize in 2005 for their discovery of “the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease”. 1. What is H. pylori?It's a gram-negative bacteria found in the stomach causing infection and GI symptoms such as dyspepsia. It is a chronic infection and it's usually acquired in childhood. Incidence and prevalence of H. pylori infection are generally higher in people born outside of North America than among people born here. About 50% of humans are infected by H. pylori in the world. The infection can be life-long and cause no symptoms. The infection can cause peptic ulcers too. 2. When do you test for H. pylori and treat it?Test these patients for H. pylori: -All patients with active peptic ulcer disease (PUD).-Patients with history of PUD (unless previous cure of H. pylori infection has been documented).-Patients diagnosed with low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma.-Patients with a history of endoscopic resection of early gastric cancer (EGC).In a few words, test patients with PUD and stomach malignancies.  Controversial indications include:- Consider non-endoscopic test (stool or breath) in patients with unexplained dyspepsia who are younger than 60 years old without red flags.- Patients with typical symptoms of gastroesophageal reflux disease (GERD) who do not have a history of PUD do not need to be tested for H. pylori infection. However, for those who are tested and found to be infected, treatment should be offered, but to the patient that the effects of treatment of H. pylori on GERD symptoms are unpredictable. This means that eradication of H. pylori may or may not affect GERD symptoms. -Patients taking long-term, low-dose aspirin (to reduce the risk of ulcer bleeding)-Prior to initiation of chronic treatment with NSAIDs-Patients with unexplained iron deficiency anemia despite an appropriate evaluation  3. What are the testing options for H. pylori?-In patients is having an EGD, they can be tested with gastric biopsy histology and biopsy urease (best options). Endoscopy biopsy is the best diagnostic test for H. pylori. -In patients who do not require EGD, NONINVASIVE TESTING like STOOL ANTIGEN ASSAY and UREA BREATH TEST are a great option-Before performing the test, it is important to stop PPIs (proton pump inhibitors) for 2-4 weeks and Bismuth/antibiotics use within 4 weeks to avoid false negative results.  4. What ar ethe recommended first-line treatments for H. pylori?Triple therapy: Clarithromycin triple therapy is the recommended option. This treatment includes PPI, clarithromycin, and amoxicillin OR metronidazole for 14 days. This is the recommended in areas where clarithromycin resistance is less than 15%, and in patients with no exposure to macrolides. The two antibiotics and PPI twice a day are given for 2 weeks, and the PPI is continued once daily for one month. PPI may be omeprazole, pantoprazole, or others. Quadruple therapy: Bismuth quadruple therapy consisting of a PPI, bismuth, tetracycline, and a nitro imidazole for 10–14 days is another treatment option. Bismuth quadruple therapy is particularly attractive in patients with any previous macrolide exposure or who are allergic to penicillin. 5. Should we test for H. pylori eradication?Confirmation of eradication should be performed in all patients treated for H. pylori because of increasing antibiotic resistance. There is not a lot of information about antibiotic resistance in the US. The test should be done 4 weeks after completing treatment. 6. What is refractory H. pylori infection? Refractory H. pylori infection is defined by a persistent positive H. pylori test (no serologic), at least 4 weeks after 1 or more full course(s) of a recommended first-line therapy, and when the patient has been off any medications, such as proton-pump inhibitors (PPIs), that may impact the test sensitivity. Refractory H. pylori infection should be differentiated from recurrent infection. A recurrent infection happens when a no serologic test was negative after treatment, then becomes positive again. 7. What tests can be done to evaluate H. pylori antibiotic resistance?We can test for resistance with culture or molecular testing, but these tests are currently not widely available in US. 8. What are the option for salvage therapy after failure of treatment? In patients with persistent H. pylori infection, try to avoid antibiotics that have been previously taken by the patient. Bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options if a patient received a first-line treatment containing clarithromycin.  Regimens that contain clarithromycin or levofloxacin are the preferred treatment options if a patient received bismuth quadruple therapy.  Rifabutin triple regimen consisting of a PPI, amoxicillin, and rifabutin for 10 days is a suggested salvage regimen. Conclusion:H. pylori is an infection that can be asymptomatic, but it needs to be eradicated if symptoms are present. Detection of H. pylori is fairly easy, but we may need to perform an EGD if patient has red flags. Antibiotics and PPIs are the first line of treatment. Test of cure is recommended for all patients. ____________________________Now we conclude our episode number 64 “H. pylori.” Dr Lorenzo explained when and how to test patients for H. pylori. She explained that patients with GERD symptoms to not need to be tested for H. pylori, but if they are tested and have positive results, then we should eradicate H. pylori. Remember to stop PPIs 2-4 weeks before non-endoscopic tests for H. pylori. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza and Anabell Lorenzo. Audio edition: Suraj Amrutia. See you next week! _____________________References:William D. Chey, Grigorios I. Leontiadis, Colin W. Howden, and Steven F. Moss. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212–238. https://pubmed.ncbi.nlm.nih.gov/28071659/ Shailja C. Shah, Prasad G. Iyer, and Steven F. Moss. AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review. Gastroenterology 2021;160:1831–1841. https://pubmed.ncbi.nlm.nih.gov/33524402/ J. Thomas Lamont. Treatment regimens for Helicobacter pylori in adults. Up to date, last updated on May, 20, 2021. https://www.uptodate.com/contents/treatment-regimens-for-helicobacter-pylori-in-adults?search=h%20pylori%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. 

Episode 62: Onychomycosis (nail fungus). Future doctors Gabrielle and Jeanette discuss with Dr Arreaza the diagnosis and treatment of onychomycosis, AKA nail fungus.By Gabrielle Robinson, MS3, and Jeanette Adereti, MS3Ross University School of MedicineFacilitated by Hector Arreaza, MDThis is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.What is onychomycosis?-Onychomycosis is a fungal infection that resides in the finger and toenails. The nails become discolored, have onycholysis (painless separation of nail bed), splitting of nail bed, thickened. There are various causes of onychomycosis and examples include the following: dermatophytes, yeast, non-dermatophyte molds.-Onychomycosis occurs in 10% of the general population. Microbiology:Dermatophytes such as Tinea rubrum, account for most onychomycosis infections (~60-70%) while candida account for most of yeast causes of onychomycosis. Non-dermatophyte molds include fusarium, aspergillus, acremonium, scytalidium, Scopulariopsis brevicaulis. The type of organism involved has an association for the type of infection it causes. Yeast infects fingernails preferentially while the dermatophytes prefer to infect toenails. Diagnostic testing including culture, KOH preparation and PAS staining can help with confirming fungal infection, but culture not required for empiric treatment with oral terbinafine. Severity of onychomycosis:-Mild-moderate: ≤50 percent involvement of the nail and sparing the matrix/lunula-Moderate-severe: involving >50 percent of the nail or involving the matrix or lunula, including further spread throughout nail.-It's common to have multiple nails affected at the same time. Toenails and fingernails can both be affected. Remember to check all nails in your patients. Nails can show signs of local but also systemic diseases. Risk factors:-Health conditions: Diabetes, immune suppression, venous insufficiency, peripheral artery disease, or even just having slow growth of the nails. This makes sense because there is decreased blood flow to those areas resulting in decreased immune surveillance of that area. Patient s with PAD are at risk for onychomycosis. Nails normally grow slower in male. Hormones play a role in that growth.-Exposure: smoking, trauma to the nail, sports, wearing sweaty shoes, being barefoot in communal areas such as swimming pools, college showers, jail house showers, and gyms.-Dermatological diseases: tinea pedis (athletes' foot), excessively sweaty hands (hyperhidrosis), psoriasis-Other factors: old age, having family members whom the patient shares a living space with, bunion (hallux valgus). Effects on mental healthUnfortunately, the infection takes a toll on the patient because the infection is unsightly it results in psychosocial disturbances. The patients may not want to wear sandals, get pedicures, or shower during gym class if they are school age. These types of feelings can cause patients to not want to go to work or do things they enjoy due to feelings of embarrassment. ManagementTreatment of dermatophyte onychomycosis is guided by causative organism, severity, treatment availability, and cost.Oral agents-Oral treatment is generally the gold-standard for onychomycosis due to shorter course and greater efficacy compared to topical. -Oral terbinafine is the preferred oral agent. Itraconazole can be used in patients not able to tolerate/respond to terbinafine.-Terbinafine and itraconazole both work by blocking important enzymes in fungal synthesis.-A randomized double-blind trial showed that terbinafine is more effective outcomes and better long-term cure rates than itraconazole.-Adult dosing of terbinafine: fingernail onychomycosis =250 mg per day for 6 weeks. Toenail onychomycosis= 250 mg per day for 12 weeks.-Some side effects of oral terbinafine include headache, dermatitis, GI distress, taste disturbances, and liver enzyme abnormalities. Adverse effects of Itraconazole include headache, GI disturbances, liver enzyme abnormalities.-In patients receiving continuous therapy, monitoring of transaminase levels is typically performed at baseline and repeated at six weeks if therapy will continue beyond six weeks. A medication interaction check is recommended before starting treatment with oral agents. -Mycotic cure rates of 76% for terbinafine, 63% for itraconazole with pulse dosing, 59% for itraconazole with continuous dosing, and 48% for fluconazole, topical cure rate is about 40%.-Recurrence of infection ranges 10-50% (reinfection or persistent infection). Patients need to wait for up to 1 year to see full effect of treatment. Treatment is highly recommended in patients with diabetes, treatment in other patients is cosmetic.CompliancePatient compliance is difficult because while taking oral medications, you cannot drink alcohol, and this becomes a problem due to the length of the treatment.Topical agents-Efinaconazole, Amorolfine, Tavaborole, Ciclopirox-Patients who have contraindications to systemic antifungal therapy, who are at risk for drug-drug interactions with systemic antifungal drugs, or who prefer to avoid systemic treatment can be treated with topical therapy. Similarly, to oral agents, these medications work by blocking important processes in fungal synthesis. These agents come in solutions or nail lacquer. Possible side effects include local skin irritation or ingrown nails.Alternatives-Less common therapeutic interventions for onychomycosis include oral antifungal agents other than terbinafine and itraconazole, laser therapy, photodynamic therapy, and surgical nail removal.-Patients with pain or discomfort from infected nails may benefit from removal of hyperkeratotic nail debris. Application of topical urea under occlusion can help with debridement of the nail and symptom improvement.-Recurrence after treatment of onychomycosis is common.Prevention:Now that we have gone over a lot of material about onychomycosis, we should discuss how we can prevent these types of infections from occurring.  Having good “foot hygiene” can help reduce the of infection and re-infection.Wash your hands and feet frequently, especially after encountering someone who is infected.  Clip nails straight across and file afterward making sure to sterilize clippers before and after each use.  Do not share nail clippers with others.If you have a history of sweaty feet, consider using sweat absorbing socks or wearing “breathable shoes” to prevent sweat from accumulating.Throw out old shoes or disinfect them using antifungal powders.Wear sandals in communal shower areas and at the pool.Pay attention to the cleanliness of your nail salon.Joke: Do you want to know how a person with toenail fungus feels? Just step into their shoes.Conclusion: Now we conclude our episode number 62 “Onychomycosis (nail fungus).” Future doctors Robinson and Adereti gave a very good summary about symptoms, diagnosis, and treatment of this common infection. Remember, not all patients need to be treated, but patients with diabetes or other risks are highly encouraged to receive treatment to prevent future complications. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Gabrielle Robinson, and Jeanette Adereti. Audio edition: Suraj Amrutia. See you next week!__________________________References: Goldstein, Adam O et al, Onychomycosis: Epidemiology, clinical features, and diagnosis, Up to Date, last updated: Apr 30, 2019. https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis?search=onychomycosis&source=search_result&selectedTitle=2~92&usage_type=default&display_rank=2. Bai, Jennifer, MD, Consult Corner: Laceration through the nail bed, American Society of Plastic Surgeons, January 1, 2020. https://www.plasticsurgery.org/for-medical-professionals/publications/plastic-surgery-resident/news/consult-corner-laceration-through-the-nail-bed. Goldstein, Adam O et al, Onychomycosis: Management, Up to Date, last updated: Nov 20, 2020. https://www.uptodate.com/contents/onychomycosis-management?search=onychomycosis&source=search_result&selectedTitle=1~92&usage_type=default&display_rank=1. Rodgers P, Bassler M. Treating onychomycosis. Am Fam Physician. 2001 Feb 15;63(4):663-72, 677-8. Erratum in: Am Fam Physician 2001 Jun 1;63(11):2129. PMID: 11237081. https://www.aafp.org/afp/2001/0215/p663.html. Mayo Clinic, Patient and Health Information, Nail Fungus, https://www.mayoclinic.org/diseases-conditions/nail-fungus/symptoms-causes/syc-20353294

What is creatine? What is it used for? Is it safe? Has it really been shown to be effective - especially in kids? What are the concerns about using it? Bottom line: Which molecule to use, how much to take, what age is it recommended, will it really help? Should it be taken Concerns - Dehydration / additives / possible liver and kidney damage https://i1.wp.com/offseasonathlete.com/wp-content/uploads/2020/09/Creatine-for-teens-infographic.png?resize=468%2C1170&ssl=1 (Infographic) https://offseasonathlete.com/benefits-of-creatine-for-teen-athletes/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279854/ https://www.uptodate.com/contents/nutritional-and-non-medication-supplements-permitted-for-performance-enhancement?search=creatine%20supplements&source=search_result&selectedTitle=1~28&usage_type=default&display_rank=1 https://medlineplus.gov/druginfo/natural/873.html https://www.arnoldpalmerhospital.com/content-hub/should-i-let-my-teen-use-creatine https://www.cbsnews.com/news/creatine-bodybuilding-dietary-supplement-easy-for-teens-to-buy/ --- Send in a voice message: https://anchor.fm/gaurav-gupta6/message

Welcome to Episode 007 (cue the James Bond music please) of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 7 of “The 2 View” A Wolf in Sheep's Clothing Birnbaumer, Diane MD. A Wolf in Sheep's Clothing: Serious Causes of Common Complaints. Advanced Emergency Medicine Boot Camp. September 2019. Las Vegas. Accessed June 29, 2021. Subarachnoid Hemorrhage Carpenter CR, Hussain AM, Ward MJ, et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture with an Exploration of Test Thresholds. Acad Emerg Med. PubMed.gov. Published September 6, 2016. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/27306497/ Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. Published 2012. Accessed June 29, 2021. https://www.ahajournals.org/doi/full/10.1161/str.0b013e3182587839 Headache. Acep.org. Published June 2019. Accessed June 29, 2021. https://www.acep.org/patient-care/clinical-policies/headache/ Hine, J MD, Marcolini, E MD. Aneurysmal Subarachnoid Hemorrhage. EM:RAP CorePendium. Emrap.org. Published September 17, 2020. Accessed June 29, 2021. https://www.emrap.org/corependium/chapter/recTI59VW0TPBpesx/Aneurysmal-Subarachnoid-Hemorrhage Kim YW, Neal D, Hoh BL. Cerebral aneurysms in pregnancy and delivery: pregnancy and delivery do not increase the risk of aneurysm rupture. Neurosurgery. PubMed.gov. Published February 2013. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/23147786/ Marcolini E, Hine J. Approach to the Diagnosis and Management of Subarachnoid Hemorrhage. West J Emerg Med. NCBI. Published February 28, 2019. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404699/ Ogilvy, C MD, Rordorf, G MD, Singer, R MD. Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis. UpToDate. Uptodate.com. Updated February 25, 2020. Accessed June 29, 2021. https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-clinical-manifestations-and-diagnosis?search=subarachnoid%20hemorrhage&source=searchresult&selectedTitle=1~150&usagetype=default&display_rank=1 Ottawa Subarachnoid Hemorrhage (SAH) Rule for Headache Evaluation. Mdcalc.com. Accessed June 29, 2021. https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation Subarachnoid Hemorrhage, no LP. EM:RAP. Emrap.org. Published May 2020. Accessed June 29, 2021. https://www.emrap.org/episode/emrap2020may/subarachnoid Gonococcal Arthritis Klausner, J MD, MPH. Disseminated gonococcal infection. UpToDate. Uptodate.com. Updated January 7, 2021. Accessed June 29, 2021. https://www.uptodate.com/contents/disseminated-gonococcal-infection Li R, Hatcher JD. Gonococcal Arthritis. In: StatPearls. StatPearls Publishing. Published July 26, 2020. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK470439/ Milne, Wm. MD. SGEM#335: Sisters Are Doin' It for Themselves…Self-Obtained Vaginal Swabs for STIs. Thesgem.com. Published June 26, 2021. Accessed June 29, 2021. https://www.thesgem.com/2021/06/sgem335-all-by-myselfself-obtained-vaginal-swabs-for-stis/ Ventura, Y MD, Waseem, M MD, MS. Disseminated Gonococcal Infection: Emergency Department Evaluation and Treatment. Emdocs.net. Published May 17, 2021. Accessed June 29, 2021. http://www.emdocs.net/disseminated-gonococcal-infection-emergency-department-evaluation-and-treatment/ Epiglottitis Abdallah C. Acute epiglottitis: Trends, diagnosis and management. Saudi J Anaesth. Published July-September 2012. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498669/ Ames WA, Ward VM, Tranter RM, Street M. Adult epiglottitis: an under-recognized, life-threatening condition. Br J Anaesth. Oxford Academic. Published November 1, 2000. Accessed June 29, 2021. https://academic.oup.com/bja/article/85/5/795/273886 Dowdy RAE, Cornelius BW. Medical Management of Epiglottitis. Anesth Prog. Published July 6, 2020. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342809/ Farkas, J. Epiglottitis. Emcrit.org. Published December 18, 2016. Accessed June 29, 2021. https://emcrit.org/ibcc/epiglottitis/ Mayo-Smith M. Fatal respiratory arrest in adult epiglottitis in the intensive care unit. Implications for airway management. Chest. PubMed.gov. Published September 1993. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/8365325/ Roberts, J MD, Roberts, M ACNP, PNP. Nasal Endoscopy for Urgent and Complex ED Cases. Lww.com. Published October 28, 2020. Accessed June 29, 2021. https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=110 Wolf M, Strauss B, Kronenberg J, Leventon G. Conservative management of adult epiglottitis. Laryngoscope. PubMed.gov. Published February 1990. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/2299960/ Wellens Syndrome Wellens Syndrom EKG Sign: See full show notes here: https://bit.ly/3eSyzp0 Cadogan M, Buttner R. Wellens Syndrome. Life in the Fastlane. Litfl.com. Published June 4, 2021. Accessed June 29, 2021. https://litfl.com/wellens-syndrome-ecg-library/ Smith S. Wellens' missed. Then returns with Wellens' with dynamic T-wave inversion. Dr. Smith's ECG Blog. Blogspot.com. Published May 4, 2011. Accessed June 29, 2021. http://hqmeded-ecg.blogspot.com/2011/05/wellens-missed-then-returns-with.html?m=1 Wellens Syndrome ECG Recommended Book Resources for the Month Merck. The Merck Manual of Patient Symptoms. (Porter RS, ed.). Merck; 2008. Schaider JJ, Barkin RM, Hayden SR, et al., eds. Rosen and Barkin's 5-Minute Emergency Medicine Consult. 4th ed. Lippincott Williams and Wilkins; 2010. Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Last month we asked you a trivia question regarding the very first NP program – who was the duo that began the program and what was the first NP specialty program? The correct answer was Dr. Loretta Ford and Dr. Henry Silver. The first NP specialty program was pediatrics. We'll be sending Lindsey Harvey, MSN, FNP-BC to the November Original EM Boot Camp Gratis for providing that answer! We can't wait to see you and all of the other registrants in November in Las Vegas! Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to.

Joanne, Fred e Letícia comentam sobre os aspectos de diagnóstico clínico e laboratorial da meningite bacteriana assim como o tratamento e a profilaxia. Esse episódio foi em parceria com o Whitebook! Acesse o aplicativo que te ajuda de forma rápida com informação de confiança na hora que você mais precisa! Dose da ceftriaxone na meningite? Principais patógenos? Tem tudo isso lá! Clique no link para descobrir mais https://tinyurl.com/TdC-Whitebook Minutagem (0:50) Apresentação da convidada e colaboradora Letícia (2:00) Parceria com Whitebook (4:08) Definição ( 7:07) Sintomas e sinais clínicos (10:08) Etiologia (15:30) Exames complementares (20:25) liquor (25:16) Gram no liquor (26:18) Cultura no liquor (26:36) Outros modos de pesquisa no liquor (28:45)Abordagem inicial e antibioticoterapia (38:22) Dexametasona (42:10) Profilaxia (45:30) Resposta do desafio da semana anterior (46:20) Desafio da semana (47:27) Salves Referências: Visão geral da meningite - Sumário das afecções relevantes | BMJ Best Practice. https://bestpractice.bmj.com/topics/pt-br/111. Acessado 9 de junho de 2021. Meningite viral - Sintomas, diagnóstico e tratamento | BMJ Best Practice. https://bestpractice.bmj.com/topics/pt-br/540?q=Meningite%20viral&c=suggested. Acessado 9 de junho de 2021. Meningite bacteriana - Sintomas, diagnóstico e tratamento | BMJ Best Practice. https://bestpractice.bmj.com/topics/pt-br/539?q=Meningite%20bacteriana&c=suggested. Acessado 9 de junho de 2021. F. McGill, et al. "The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults." Journal of Infection,72 (2016): 405-438 Initial therapy and prognosis of bacterial meningitis in adults | UpToDate. https://www.uptodate.com/contents/initial-therapy-and-prognosis-of-bacterial-meningitis-in-adults?search=Initial%20therapy%20and%20prognosis%20of%20bacterial%20meningitis%20inadults&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Acesso em 08 de junho de 2021. Treatment and prevention of meningococcal infection | UpToDate. https://www.uptodate.com/contents/treatment-and-prevention-of-meningococcal-infection?search=Treatment%20and%20prevention%20of%20meningococcal%20infection&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Acesso em 08 de junho de 2021. Tunkel,A.R. et al. “Practice Guidelines for the Management of Bacterial Meningitis”. Clinical Infectious Diseases 2004.39; 1267-84. Informação da Vigilância das pneumonias e meningites bacterianas. Secretaria de Estado de Saúde: Coordenadoria de Controle de Doenças. Instituto Adolfo Lutz. 2017.

Welcome to Episode 6 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 6 of “The 2 View” Lyme Disease Arumugam S, Nayak S, Williams T, et al. A Multiplexed Serologic Test for Diagnosis of Lyme Disease for Point-of-Care Use. J Clin Microbiol. Published November 22, 2019. Accessed June 1, 2021. https://journals.asm.org/doi/full/10.1128/JCM.01142-19 Gastroparesis Camilleri, M. MD. Gastroparesis: Etiology, Clinical Manifestations, and Diagnosis. Uptodate.com. Updated September 30, 2020. Accessed June 1, 2021. https://www.uptodate.com/contents/gastroparesis-etiology-clinical-manifestations-and-diagnosis?search=gastroparesis§ionRank=1&usagetype=default&anchor=H859989&source=machineLearning&selectedTitle=2~150&displayrank=2 Center for Drug Evaluation, Research. How to Request Domperidone for Expanded Access Use. Fda.gov. Published February 2, 2021. Accessed June 1, 2021. https://www.fda.gov/drugs/investigational-new-drug-ind-application/how-request-domperidone-expanded-access-use Gastroparesis. American College of Gastroenterology. Updated December 2012. Accessed June 1, 2021. https://gi.org/topics/gastroparesis/ Gastroparesis - NORD (national organization for rare disorders). Rarediseases.org. Published February 11, 2015. Accessed June 1, 2021. https://rarediseases.org/rare-diseases/gastroparesis/ Spiked Helmet EKG Sign: See full show notes here: https://bit.ly/3xaCoga Career Advancements: Side Gigs & Moving Up in the Workforce Passive Income. The List of Physician Side Hustles. Passiveincomemd.com. Published February 4, 2020. Accessed June 1, 2021. https://passiveincomemd.com/list-physician-side-hustles/ Shemmassian. 14 Physician Side Gigs to Accelerate Your Income — Shemmassian Academic Consulting. Shemmassianconsulting.com. Published March 26, 2020. Accessed June 1, 2021. https://www.shemmassianconsulting.com/blog/physician-side-gigs Sitar, D. 11 Side Gigs You Can Do Entirely from Home. Thepennyhoarder.com. Published July 7, 2020. Accessed June 1, 2021. https://www.thepennyhoarder.com/make-money/side-gigs/work-from-home-coronavirus/ Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Last month we asked you a trivia question regarding needlestick safety and prevention – who was the President of the United States that signed the Needlestick Safety and Prevention Act into law and who was the Massachusetts nurse whose advocacy for sharps injury safety helped the act pass and who later became president of the American Nurses Association? The correct answer was President Bill Clinton and Karen Daley, PhD, MPH, RN, FAAN. Please note that for this month, if you get the trivia question correct, you will win your course registration to one of our LIVE EM Boot Camp Courses, available in July and November of this year! It's a great course so be sure to download and listen to the episode for the question! Please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to.

Nella puntata di oggi andremo ad affrontare il Papilloma Virus Umano (HPV).  Che cos'è? Cosa può provocare? Come viene diagnosticato? Ma sopratutto, come si può fare prevenzione a riguardo?  Ve lo racconto in 7 minuti.  Link utili ed evidenze: - https://www.evidence.it/articolodettaglio/209/it/535/vaccino-antihpv-prove-di-efficacia-profilo-di-sicurezza-e-cop/articolo - https://www.uptodate.com/contents/virology-of-human-papillomavirus-infections-and-the-link-to-cancer - https://www.uptodate.com/contents/human-papillomavirus-infections-epidemiology-and-disease-associations?search=human-papillomavirus-hpv&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

For paramedics, click here for CE credits! We all know the standard phrase in EMS But did you know that, in this episode, the But Why team added, "squirt mustard on the chest" to the EMS mantra?   Find out how the mustard phrase arose in this hilarious episode that covers cardiac arrest treatment history and myths with Dr. Adam Heilman Click here to check it out today! Thank you for listening! Hawnwan Philip Moy MD  Gina Pellerito EMT-P John Reagan EMT-P   Works Cited 1. American Heart Association. (n.d.). History of CPR. cpr.heart.org. https://cpr.heart.org/en/resources/history-of-cpr. 2. Bonnes JL, Brouwer MA, Navarese EP, Verhaert DV, Verheugt FW, Smeets JL, de Boer MJ. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med. 2016 Mar;67(3):349-360.e3. doi: 10.1016/j.annemergmed.2015.09.023. Epub 2015 Nov 19. PMID: 26607332. 3. Cheskes S, Dorian P, Feldman M, McLeod S, Scales DC, Pinto R, Turner L, Morrison LJ, Drennan IR, Verbeek PR. Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial. Resuscitation. 2020 May;150:178-184. doi: 10.1016/j.resuscitation.2020.02.010. Epub 2020 Feb 19. PMID: 32084567.https://pubmed.ncbi.nlm.nih.gov/32084567/ 4. Delorenzo A, Nehme Z, Yates J, Bernard S, Smith K. Double sequential external defibrillation for refractory ventricular fibrillation out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2019 Feb;135:124-129. doi: 10.1016/j.resuscitation.2018.10.025. Epub 2018 Oct 26. PMID: 30612966. 5. Fig Leaf Times Two by Kevin MacLeod is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ Source: http://incompetech.com/music/royalty-free/index.html?isrc=USUAN1200096 Artist: http://incompetech.com/ 6.  Kette F, Ghuman J, Parr M. Calcium administration during cardiac arrest: a systematic review. Eur J Emerg Med. 2013 Apr;20(2):72-8. doi: 10.1097/MEJ.0b013e328358e336. PMID: 22990036. 7.  Landry A, Foran M, Koyfman A. Does calcium administration during cardiopulmonary resuscitation improve survival for patients in cardiac arrest? Ann Emerg Med. 2014 Aug;64(2):187-9. doi: 10.1016/j.annemergmed.2013.07.510. Epub 2013 Aug 30. PMID: 23992943. 8. Mapp JG, Hans AJ, Darrington AM, Ross EM, Ho CC, Miramontes DA, Harper SA, Wampler DA; Prehospital Research and Innovation in Military and Expeditionary Environments (PRIME) Research Group. Prehospital Double Sequential Defibrillation: A Matched Case-Control Study. Acad Emerg Med. 2019 Sep;26(9):994-1001. doi: 10.1111/acem.13672. Epub 2019 Jan 6. PMID: 30537337. 9.  Mount DB (2020).  Treatment and Prevention of Hyperkalemia in Adults. In T.W. Post Sterns RH, Forman JP (Eds.). UpToDate. Available from:  https://www-uptodate-com.beckerproxy.wustl.edu/contents/treatment-and-prevention-of-hyperkalemia-in-adults?search=hyperkalemia%20treatment§ionRank=1&usage_type=default&anchor=H462542914&source=machineLearning&selectedTitle=1~150&display_rank=1#H462542914 10. Poole K, Couper K, Smyth MA, Yeung J, Perkins GD. Mechanical CPR: Who? When? How? Crit Care. 2018 May 29;22(1):140. doi: 10.1186/s13054-018-2059-0. PMID: 29843753; PMCID: PMC5975402. 11.  Pozner CN, Link MS (2020). Supportive data for advanced cardiac life support in adults with sudden cardiac arrest. In T.W. Page RL, Walls RM, Dardas TF (Eds.).  UpToDate.  Available from:  https://www-uptodate-com.beckerproxy.wustl.edu/contents/supportive-data-for-advanced-cardiac-life-support-in-adults-with-sudden-cardiac-arrest?search=calcium%20cardiac%20arrest&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 12. Vallentin MF, Granfeldt A, Holmberg MJ, Andersen LW. Drugs during cardiopulmonary resuscitation. Curr Opin Crit Care. 2020 Jun;26(3):242-250. doi: 10.1097/MCC.0000000000000718. PMID: 32348092. 13. Velissaris D, Karamouzos V, Pierrakos C, Koniari I, Apostolopoulou C, Karanikolas M. Use of Sodium Bicarbonate in Cardiac Arrest: Current Guidelines and Literature Review. J Clin Med Res. 2016 Apr;8(4):277-83. doi: 10.14740/jocmr2456w. Epub 2016 Feb 27. PMID: 26985247; PMCID: PMC4780490.    

Colorectal cancer screening update, COVID-19 vaccine update, and abnormal uterine bleeding basics.Today is May 24, 2021.Colorectal cancer screening update Written by Hector Arreaza, MD. Participation: Ikenna Nwosu, MD, and Daniela Viamontes, MD.Today is May 24, 2021.On august 29, 2020, we were in the midst of a pandemic and we woke up with the sad news about the death of Chadwick Aaron Boseman (also known as Black Panther). An interesting fact: The tweet in which his family announced his death on Twitter became the most-liked tweet in history. But why are we talking about Chadwick’s death? Because he died of colon cancer. I do not know if this recommendation came because of Chadwick, but it’s a good way to open this episode: remembering Black Panther.We heard the rumors, but now it’s official. On May 18, 2021, the USPSTF released their final recommendation statement about colorectal cancer screening. The age to start screening has been changed from 50 to 45 years old. This is a grade B recommendation. Grade B means that this recommendation has moderate to substantial net benefit, so offer this service to your patients. Screening adults between 76 and 85 years old who have been previously screened has a small net benefit (grade C recommendation). So, select patients may be screened for colorectal cancer in this age group (76-85), especially those who have never been screened.Do you remember this recommendation from medical school for high risk patients? Start screening at age 40 or 10 years before a patient’s direct-relative was diagnosed with colon cancer. This was a recommendation given by the US Multi-Society Task Force (which includes the American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy). This same organization already recommended in 2017 to start screening at age 45 in African American patients, and the American Cancer Society recommended screening all patients at age 45 in 2018. The ACS does not have a guideline to screen high risk patients for colon cancer. Most organizations agreed on not screening after age 85.Strategies for screening:High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every yearDani: Stool DNA-FIT every 1 to 3 years (Cologuard®)  CT colonography every 5 years Flexible sigmoidoscopy every 5 years OR Flexible sigmoidoscopy every 10 years + annual FIT Colonoscopy screening every 10 yearsDiscuss different options with your patients, choose your favorite and do it!  Introduction: Update on COVID 19 vaccines  By Hector Arreaza, MD, and Lillian Petersen, RN. COVID-19 vaccines now can be co-administered with other vaccines according to the ACIP. COVID-19 vaccines and other vaccines may now be administered without regard to timing. They can be given on the same day or within the 14 days previously recommended between vaccines.  It is not known if reactogenicity of COVID-19 vaccine is increased with co-administration with other reactogenic vaccines (such as vaccines with live attenuated viruses).  How do you decide if you want to co-administer a vaccine? 1. Consider whether the patient is behind or at risk of becoming behind on recommended vaccines.2. Consider their risk of vaccine-preventable disease.3. Consider the reactogenicity profile of the vaccines. If multiple vaccines are administered at a single visit, administer each injection in a different injection site, at least one inch apart or in different limbs. Current or previous SARS-CoV-2 infection: Everyone should be offered COVID-19 vaccination regardless of their history of COVID-19 infection. Viral testing or serologic test is not recommended for the purposes of vaccine decision-making. People with current SARS-CoV-2 infection should be deferred until the person has recovered from the acute illness (if the person had symptoms) and they have met criteria to discontinue isolation. This applies to patients who got the disease before receiving any vaccine or after receiving the first dose.  A minimum interval between infection and vaccination has not been established, but evidence suggests that the risk of reinfection is low in the months after initial infection but may increase with time due to waning immunity. People with a history of multisystem inflammatory syndrome in children (MIS-C) or adults (MIS-A):It is unclear if people with a history of MIS-C or MIS-A are at risk of recurrence of the same dysregulated immune response following reinfection with SARS-CoV-2 or in response to vaccination. People with a history of MIS-C or MIS-A may choose to be vaccinated but they should consider delaying vaccination until they have recovered from their illness and for 90 days after the date of diagnosis. Find more information at the CDC.gov website. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Abnormal Uterine Bleeding. By Sherika Adams, MS3, P. Eresha Perera, MS3, and Hector Arreaza, MD.  Definition. AUB is a symptom, not a diagnosis. It is equivalent to say: “This patient’s periods are abnormal.” Anything that falls out of what is considered “normal periods” is classified as abnormal uterine bleeding.These 4 elements are assessed when determining if a patient has AUB: Regularity, frequency, duration, and volume.  What is considered normal? Frequency = Every 24-38 days, regularity +/- 2-20 days over 12 months, duration = 4.5 to 8 days, volume = 5-80 mL. 10-30% of women of reproductive age may have AUB. According to the American College of Obstetricians and Gynecologists (ACOG), abnormal uterine bleeding is characterized by bleeding or spotting following sexual intercourse or menopause, between menstrual cycles, menstrual cycles lasting more than 38 days or shorter than 24 days, heavy bleeding during menstruation, and “irregular” menstrual cycles that have 7-9 days of variation.Terms no longer used: menorrhagia, metrorrhagia, and dysfunctional uterine bleeding (DUB). Not all symptoms reported as “vaginal bleeding” are coming from the vagina. For example, bleeding from anus, urethra, bladder, and perineum should be ruled out before establishing the diagnosis of AUB. Classification of Abnormal Uterine Bleeding (AUB). Abnormal uterine bleeding (AUB) in nonpregnant premenopausal women can be classified by the acronym PALM-COEIN, which was established by the International Federation of Gynecology and Obstetrics (FIGO) in 2011.  PALM-COEIN: Palm: Structural etiologies, Coein: Non-structural etiologies P is for polyps: Polyps are epithelial tumors in the endometrium or cervix and can be identified by hysterosonography or hysteroscopic imaging. A is for adenomyosis: Adenomyosis is endometrial stroma and glands in the myometrium and can be identified by histopathology, and now MRI and transvaginal ultrasound. L is for leiomyomas: Leiomyomas also known as uterine fibroids are benign smooth muscle tumors that are diagnosed by pelvic examination and pelvic imaging such as ultrasound with contrast or MRI. M is for malignancy and hyperplasia: Malignancy and hyperplasia are often abnormal epithelial tissue that is benign or cancerous that can be seen with transcervical endometrial sampling. C is for coagulopathy: Coagulopathy is bleeding disorders such as Von Willebrand disease is identified by laboratory testing. O is ovulatory dysfunctions: Ovulatory dysfunction occurs when there is a variation of more than seven days of the menstrual cycle in the past 12 months and ovulation is dysfunctional. In a woman without ovulation, there is no corpus luteum, and there is no progesterone, so estrogen goes unopposed, causing a buildup of endometrium and irregular bleeding.   E is endometrial causes: Endometrial causes can occur when there is normal ovulation, no other identifiable cause of AUB, and there is heavy menstrual bleeding, which includes intermenstrual bleeding. Primary disorders of endometrial hemostasis are likely due to vasoconstriction disorders, inflammation, or infection. Endometrial dysfunction is poorly understood; there are no reliable diagnostic methods, and it should be considered only after other causes are excluded. I is for iatrogenic cause: Iatrogenic causes include gonadal steroids (estrogen, androgens), anticoagulants, intrauterine devices, antipsychotics, antidepressants, and anti-hypertensives. N is for not otherwise classified: Example of an etiology under not otherwise classified might be AV malformations. This classification does not include pregnancy. Postmenopausal bleeding: Abnormal uterine bleeding can also occur in post-menopausal women and is an indication of potentially lethal endometrial cancer. Post-menopausal women should be worked up for cancer when they present with bleeding. However, most common cause of bleeding in this population is atrophy of the vaginal mucosa or endometrium. If younger than 45 patients but history of unopposed estrogen exposure (PCOS, obesity, estrogen therapy) should also undergo endometrial biopsy to rule out possibility of endometrial cancer.  Management of AUB. Management of the AUB can be initiated only after the etiology of the bleeding has been established. Firs of all, rule out pregnancy related bleeding by performing a pregnancy test. Also, rule out other sources of bleeding. The first question to answer would be: Does this patient need an emergent treatment for her AUB or can she be treated as outpatient? Determine that by checking the history, vitals, orthostatic vitals, physical exam, and labs.  If patient requires admission, the options for treatment include: uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization. In case of severe bleeding without hemodynamic instability, patients can be treated initially with oral estrogen, high-dose estrogen-progestin oral contraceptives, oral progestins, or intravenous tranexamic acid.For chronic AUB, once etiology has been established, the goal is to treat the underlying condition. The goal of treatment is to control the bleeding since AUB can persists until menopause.  Initial outpatient treatment is usually pharmacological. For those not wanting to conceive soon, consider IUD placement. “Among medical therapies, the 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena) is most effective for decreasing heavy menstrual bleeding (71% to 95% reduction in blood loss) and performs similarly to hysterectomy when quality-adjusted life years are considered.”[8] Other long-term medical treatment options include estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, NSAIDs (nonsteroidal anti-inflammatory drugs), and depot medroxyprogesterone. Surgical treatment is often considered for patients on long term medical therapy with no response, or for severe cases of bleeding with recurrent need for emergent treatment. Some surgical options are endometrial ablation, which performs as well as the levonorgestrel-releasing intrauterine system. Some structural lesions can be resected via hysteroscopy (polyps). Myomectomy and uterine artery embolization are options for patients with severe AUB who want to preserve fertility. Uterine leiomyomas or adenomyosis can be medically managed with OCPs but can also be treated with surgery as well, depending on the physician-patient discussion of options. Hysterectomy is the definitive treatment of severe AUB. Remember, PALM COEIN stands for: Polyps, Adenomyosis, Leiomyomas, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial causes, Iatrogenic cause, Not otherwise classified. ____________________________Conclusion. Written by Hector Arreaza, MDNow we conclude our episode number 53 “Abnormal Uterine Bleeding”. Eresha and Sherika did a great job explaining the Palm-Coein classification, and gave us a good overview of the management of AUB. Remember to start screening for colorectal cancer at age 45 now, what strategy for screening will you use? And for those patients who were hesitant about getting the COVID-19 vaccine with other vaccines, well, the ACIP said we can co-administer it with other vaccines. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Daniela Viamontes, Ikenna Nwosu, Lillian Petersen, Sherika Adams, and P. Eresha Perera. Audio edition: Suraj Amrutia. See you next week! _____________________References:U.S. National Library of Medicine, Clinical Trials.Gov, https://clinicaltrials.gov/ct2/show/study/NCT02026869. Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States, Centers for Disease Control and Prevention, https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html#Coadministration, accessed on May 20, 2021.  Colorectal Cancer: Screening, Final Recommendation Statement, U.S. Preventive Services Task Force, May 18, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening. Abnormal Uterine Bleeding FAQ, The American College of Obstetricians and Gynecologists (ACOG), https://www.acog.org/womens-health/faqs/abnormal-uterine-bleeding, accessed on May 17, 2021.  Fraser, Ian, et al. Abnormal uterine bleeding in reproductive-age women: Terminology and PALM-COEIN etiology classification, Up to Date, last updated: Dec 16, 2019. https://www.uptodate.com/contents/abnormal-uterine-bleeding-in-reproductive-age-women-terminology-and-palm-coein-etiology-classification?search=palm%20coein&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Goodman Annekathryn, et al, Postmenopausal uterine bleeding, Up to Date, last updated: Feb 02, 2021. https://www.uptodate.com/contents/postmenopausal-uterine-bleeding?search=abnormal%20uterine%20bleeding%20postmenopausal&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Kaunitz, Andre M, Abnormal uterine bleeding: Management in premenopausal patients, Up to Date, last updated: Aug 25, 2020. https://www.uptodate.com/contents/abnormal-uterine-bleeding-management-in-premenopausal-patients?search=abnormal%20uterine%20bleeding%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Wouk N, Helton M. Abnormal Uterine Bleeding in Premenopausal Women. Am Fam Physician. 2019 Apr 1;99(7):435-443. PMID: 30932448. https://pubmed.ncbi.nlm.nih.gov/30932448/ 

Thanks for tuning in! Here are the sources from this episode of MedBits: https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-questions-and-answers?search=covid%20questions%20and%20answers&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

This week, we're discussing breast cancer screening guidelines. When should women start receiving mammograms? What are the signs we want to look out for as patients and as providers? When are other tests indicated? Find out in this week's episode! If you have any requests, questions, or are interested in speaking on our podcast, please email obwannabes@gmail.com. You can find us on Instagram at @obwannabes. See you next week when we interview Tayyaba Ahmed, DO, about her career as a pelvic pain specialist! UpToDate: Clinical Features, Diagnosis, and Staging of Newly Diagnosed Breast Cancer - https://www.uptodate.com/contents/clinical-features-diagnosis-and-staging-of-newly-diagnosed-breast-cancer?search=breast%20cancer&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H1583246092 UpToDate: Breast Biopsy - https://www.uptodate.com/contents/breast-biopsy?search=mammogram&topicRef=808&source=see_link

This week, we're discussing cervical cancer, screening guidelines, and what the next steps are when a Pap smear is abnormal. If you have any requests, questions, or are interested in speaking on our podcast, please email obwannabes@gmail.com. You can find us on Instagram at @obwannabes. See you next week when we discuss mammograms and breast cancer screenings! UpToDate Cervical Cancer Screening: https://www.uptodate.com/contents/screening-for-cervical-cancer-in-resource-rich-settings?search=cervical%20cancer%20screening&source=search_result&selectedTitle=1~124&usage_type=default&display_rank=1 ACOG Practice Bulletin: Management of Cervical Cancer Screening Abnormalities: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/10/updated-guidelines-for-management-of-cervical-cancer-screening-abnormalities UpToDate: Invasive Cervical Cancer https://www.uptodate.com/contents/invasive-cervical-cancer-epidemiology-risk-factors-clinical-manifestations-and-diagnosis?search=cervical%20cancer&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

This week Katee, Dave, and Corbin talk pop culture's favorite (according to Corbin) syndrome with cystic ovaries, PCOS (polycystic avarian syndrome.) We talk the difference between a syndrom and a disease, symptoms, and treatments. Stay tuned! E-mail: thevagibondspodcast@gmail.com Twitter: @thevagibonds Instagram: @thevagibondspod Facebook: The Vagibonds Podcast References: https://www.uptodate.com/contents/diagnosis-of-polycystic-ovary-syndrome-in-adults?source=search_result&search=PCOS&selectedTitle=3~150

This week Katee and Corbin dive deep into the depths of yahoo to discover the internet's most burning issues about women's health. Grab your hiking shorts and speluncking equitment it's going to be a fun adventure! E-mail: thevagibonds@gmail.com Twitter: @thevagibonds Instagram: @thevagibondspod Facebook: The Vagibonds Podcast References: https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-early-pregnancy?source=search_result&search=pregnancy&selectedTitle=2~150