Episode 110: Pulse Ox in Dark-skinned People.  

Learn about the most recent findings in pulse oximeters in dark-skinned people. Bahar and Arianna explain the new recommendations by FDA regarding this topic.  

Written by Bahar Hamidi, MS4; and Arianna Crediford, MS4. American University of the Caribbean (AUC). Comments by Hector Arreaza, MD.    

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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.

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Bahar: When I first saw this news breakout on CNN I was stunned! A cohort study just published (7/11/22) in JAMA called “Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit” revealed that Asian, Black, and Hispanic patients received less supplemental oxygen than White patients, because of the differences in pulse oximeter performance, which may contribute to known race and ethnicity–based disparities in care. I cannot believe this discovery has not been given the attention it deserves earlier. I believe maybe COVID had a lot to do with it; as checking the pulse ox deciphered the patients’ treatment plan. Let’s think about it for a moment, how important is the pulse ox accuracy?

Arianna: Well, we know that insufficient administration of supplemental oxygen can make changes in the initiation and management of noninvasive verse invasive mechanical ventilation. The study mentions some other important points like pulse oximeter performance disparities playing a role in decision-making regarding fluid management, specialty service consultation, and even intensive care unit (ICU) admission.  

Bahar: It states, “artificially high SpO2 readings in the emergency department could also affect the perceived need for cardiology service admission for heart failure management, possibly explaining the finding that Black and Hispanic patients were less likely than White patients to be admitted to a cardiology service.”

Arianna: So how you may ask the study really put this to the test? The large cohort study had 3,069 patients in the intensive care unit, so what they did was they took the average hemoglobin oxygen saturation for each patient and tracked how much supplemental oxygen was given to the patients and lo and behold, the data revealed that Asian, Black, and Hispanic patients had a higher adjusted time-weighted average pulse oximetry reading and were administered significantly less supplemental oxygen compared with White patients even with adjusting for potential confounders.

Bahar: And what is the solution you may ask? Well, the FDA issued a new draft guidance that recommends companies making medical products submit a “race and ethnicity diversity plan” to the agency early in their development of products, and that a plan should include enrolling diverse groups of people into their clinical trials as of April 2022. As a reminder, it's been a year since CDC declared racism a public health threat.  

Arianna: Rutendo Jakachira is a Ph.D. student in Brown University's Department of Physics. She is studying racial disparities in pulse oximetry. She stated that COVID-19 likely helped uncover the suspected pulse oximeter limitations in dark-skinned people. Kimani Toussaint is a professor and senior associate dean in the School of Engineering at Brown University. Jakachira, Toussaint, and their colleagues from Engineering at Brown University are developing non-invasive methods to make pulse oximeters more accurate in blood oxygen readings for people with dark skin tones.

Bahar: Toussaint stated that they are “trying to mitigate the skin tone issues by doing something interesting with the light, but it’s a significant challenge and this really highlights the need to have diversity and inclusion.”  

Pulse oximeters work by sending beams of light through the fingertips to measure blood oxygen levels, they are actually measuring how much oxygen has been absorbed by hemoglobin. Melanin is the brown pigment that gives color to our skin, hair, and eyes. It turns out that both hemoglobin and melanin absorb light at similar wavelengths and it can be challenging to separate their contributions to the detected level of oxygen.  

Arianna: Toussaint explains that melanin will overlap with the absorption properties of the hemoglobin in your blood, which can lead to inaccurate pulse oximeter readings because people have different amounts of melanin.

Bahar: Jakachira and Toussaint are trying to cancel out the effect of melanin on how pulse oximeters measure blood oxygen levels. The result of this work would be a contribution that can be applied to other similar-based technologies that measure levels of substances through the skin, but they could not share additional details of their proceedings as the research team is currently completing a patent application. Now what is also shocking is that there have actually been prior studies that have shown differences of several percentage points in SpO2 for a given hemoglobin oxygen saturation between Black and White patients, but in the past, the clinical significance of these findings was discounted and downplayed.  

Arianna: I think this study and discovery urges further studies in different regions and not just at one institution or geographic location. The article encourages further exploration of specific factors within a racial and ethnic group that could put some patients at particularly high risk of oxygenation disparities, including skin tone, degree of desaturation, exposure to specific oxygen delivery devices, comorbidities, and other sociodemographic factors.  

Bahar: Some other studies they hope will be performed are:

-Differences in oxygen supplementation in patients receiving invasive or noninvasive positive pressure ventilation and a potential association of vasopressors and inotropes AND Clinical decisions other than oxygen delivery that may be affected by pulse oximeter performance discrepancies.

Arianna: So we can definitely say that some groundwork has been done but further research is needed to confirm these findings and explore other clinical factors associated with treatment disparities.

Bahar: It is great to stay in the loop and know what health care providers should look out for, I hope this podcast will raise awareness of the matter and hopefully we come up with a more accurate Pulse Ox prototype that will be fit for all ethnicities and skin tones.

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Conclusion: Now we conclude episode number 110 “Pulse Ox in Dark-skinned People.” Today we learned that pulse oximeters are being adjusted to become more accurate in different shades of skin. We are working together to make medicine a better science for all. “Not everything that is faced can be changed, but nothing can be changed until it is faced,” said James Baldwin. This week we thank Hector Arreaza, Bahar Hamidi, Arianna Crediford, Valeri Civelli, and Ariana Lundquist. Audio by Adrianne Silva.

Even without trying, every night, you go to bed being a little wiser. 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!  

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References:

Gottlieb ER, Ziegler J, Morley K, Rush B, Celi LA. Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit. JAMA Intern Med. Published online July 11, 2022. doi:10.1001/jamainternmed.2022.2587. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2794196Howard, Jacqueline, Scientists are searching for solutions after studies show pulse oximeters don't work as well for people of color, CNN Health, Published on July 11, 2022. https://www.cnn.com/2022/07/11/health/pulse-oximeters-dark-skin-study/index.htmlRoyalty-free music used for this episode: Good Vibes Alt Mix by Videvo, downloaded on May 06, 2022 from https://www.videvo.net/royalty-free-music-track/good-vibes-alt-mix/1017292/

Episode 109: Shingles vaccine before 50

Prabhjot and Dr. Arreaza discuss the indications and contraindications of the zoster recombinant vaccine (Shingrix®). Shingrix is now FDA-approved to be used in people younger than 50 years old. Magic mushroom as a therapy for alcohol use disorder.

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Introduction: “Magic mushroom” as a potential treatment for alcohol addiction

By Hector Arreaza, MD.  

Addiction is one of the biggest challenges in medicine. Patients with addictions are at risk of adverse events or even death from overdose but also are at risk of withdrawal when trying to quit. As medical providers, our goal is to assist our patients to stop using substances that may be toxic and cause detrimental effects on their health in the short and long term. It is not easy to help patients overcome the discomfort, cravings, and even life-threatening symptoms that result from withdrawal.  

Out of the many addictions, alcohol use disorder is one of the most destructive addictions, and the harms from it go beyond the personal effects, as it affects families, communities, and the whole nation. It is a serious public health issue. It is estimated that 15 million people (12 and older) in the US have alcohol use disorder, and about 140,000 people die every year from alcohol-related causes.  

Many patients would like to stop drinking, but the withdrawal symptoms may be more than just discomfort and may become unbearable and even fatal. Today I want to share the news published on August 24, 2022, on JAMA and many news outlets regarding the potential use of Psylocibin as an adjunct therapy to quit drinking alcohol.  

This was a double-blind randomized clinical trial that compared Psilocybin with diphenhydramine. Psilocybin is also known as “magic mushroom”. Participants were offered 12 weeks of psychotherapy and were randomly assigned to receive psilocybin vs. diphenhydramine during 2-day-long medication sessions at weeks 4 and 8. There were 93 participants. The percentage of heavy drinking days during a 32-week period after the first dose of medication was 9.7% for the psilocybin group and 23.6% for the diphenhydramine group. So, patients in the Psylocibin group had decreased heavy drinking, and the mean alcohol consumption was also lower. Blinding was an issue during the study because many participants could guess which medication they were receiving. Some participants described “flying over landscapes, seeing [their] late father and merging telepathically with historical figures.”  

The bottom line of the study is that administration of Psilocybin in combination with psychotherapy produced a significant reduction in the percentage of heavy drinking days over and above those produced by active placebo and psychotherapy. These are exciting news for those who are trying to quit alcohol, and it provides a foundation for additional research on psilocybin-assisted treatment for AUD.

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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.

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Shingrix before 50. 

By Prabhjot Kaur, MS4, Ross University School of Medicine.    

1. What is Shingrix?

It’s a recombinant zoster vaccine to protect against Herpes Zoster (Shingles) in adults over 50 years old.  

2. What is Herpes Zoster?

Prabhjot: It’s a viral infection that is caused by the Varicella-Zoster virus, which also causes chickenpox. Chickenpox, also called varicella, can happen in children and adults. After a person is infected with chickenpox, the virus remains dormant in the dorsal root ganglia, which are the clusters of neurons along the spinal column. As the person grows older, or his or her immunity decreases due to conditions such as an infection, malignancy, or pregnancy, the dormant virus becomes reactivated.  

Prabhjot: When the virus reactivates in adults, it presents with a painful, blistering, itchy rash over the specific dermatomes. The rash mostly occurs on the torso, face, or upper extremities, and it is usually only on one side of the body.  

Arreaza: A common belief in the Latino culture (since our audience sees a lot of patients of Latino descent) is that if the rash crosses the midline of your body and it makes a circle around your chest, you will die. If you, as a doctor, get that question from a patient, the answer is: herpes zoster normally affects the root ganglia on one side of the body. If your patient has bilateral herpes zoster, you must rule out immunodeficiency.  

The rash may be preceded or followed by pain, burning, numbing, or tingling of the skin. Some patients might even have fevers, chills, fatigue, and photosensitivity. One of the most common complications of shingles is postherpetic neuralgia, which is a long-lasting pain after the blisters and rash have resolved.  

3. What is the role of the vaccine?

Prabhjot: Shingrix® can reduce the risk of shingles and its complications, such as postherpetic neuralgia. Shingrix is recommended for everyone over 50, even if they have already had shingles, received Zostavax® (discontinued in 2019), or received the varicella vaccine.  

Arreaza: Good point. Let´s talk a little bit about varicella in adults. Patients who have received the varicella vaccine as a child can still receive Shingrix. Let’s remember the chickenpox vaccine (varicella vaccine) became available in the United States in 1995. Normally, a serology test for varicella is not required for people to receive the varicella vaccine as adults, except in certain patients who are planning immunosuppression in the near future. In such cases, if varicella immunity is not reactive, they should be vaccinated against varicella (live attenuated virus) if the immunosuppression can be delayed.  

Prabhjot:What if the patient is already immunosuppressed?

Arreaza: If the patient is already immunosuppressed, the decision is not simple. The varicella vaccine is contraindicated, but some clinicians may recommend Shingrix for the potential protection against primary varicella. Post-exposure prophylaxis with antiviral therapy or immunoglobulin in case of exposure is possible.    

4. How is Shingrix given?

Prabhjot: Shingrix is given in 2 doses, and each dose is given 2-6 months apart. Its immunity stays strong for at least 7 years. Like most vaccines, the most common side effects of the Shingrix vaccine are redness, tenderness, swelling, and discomfort at the vaccine site. Shingrix is deemed to be safe for most people over 50 but not given to pregnant women, people with active shingles, and or with a severe allergy to the vaccine.  

Arreaza: Shingrix is generally avoided in patients with a known history of Guillain-Barré syndrome (GBS) due to a probable association between Shingrix and GBS. This association was not seen with Zostavax, so in case of history of GBS, Zostavax is an option.

5. Effectiveness

Prabhjot: As for its effectiveness, according to the CDC, Shingrix is 97% effective in preventing shingles in adults 50 to 69 and 91% in adults older than 70. If one is immunosuppressed and has a weakened immune system, the vaccine was effective, ranging between 69%-91% in preventing shingles.

6. New update:

Prabhjot: New updates have been made to expand the vaccination of the population under 50 as well. On July 23, 2021, the FDA approved the vaccination for adults over the age of 18 who are at an increased risk or will be in the future due to immunodeficiency or immunosuppression. Such immunodeficiency could be secondary to a disease, malignancy, or therapy such as chemotherapy. Just like the prior recommendation, it is recommended for these individuals to receive two doses of Shingrix for the prevention of shingles and its complications. However, the interval between the two doses can be shortened from the recommended 2-6 months to 1-2 months if the person will be going through intense immunosuppression in the upcoming months. This shortened interval will prevent vaccination during an intense immunosuppressed state. The second dose must not be given before one month.  

7. When to get vaccinated?

Prabhjot: Ideally, one should get vaccinated before starting immunosuppressing therapy; if this cannot be possible, then one should aim for vaccination when their immune response is likely to be the strongest. For example, if it’s an immunity-changing disease such as malignancy, the vaccine would be ideal in the beginning stages, and if a person will receive chemotherapy, it would be ideal to vaccinate before starting chemo.  

8. Few recommendations from CDC:

For Hematopoietic cell transplant:  

Administer Shingrix at least 3-12 months after transplantation. It is important to consider the vaccine is recommended 2 months before the prophylactic antiviral therapy is discontinued. Since the prophylactic antiviral therapy is also protecting against shingles, the vaccine is preferred to be injected while the antiviral therapy is going on.  

Arreaza:For allogeneic HCT (when donor is another person), Shingrix should be given a little bit later, 6-12 months after transplant, prior to discontinuation of antiviral therapy. Acyclovir, famciclovir, and valacyclovir will not neutralize the effectiveness of Shingrix because the vaccine is not a live virus vaccine.

For cancers:

It is ideal to administer Shingrix before chemo, immunosuppressive medications, radiation, or splenectomy. If that is not possible for some reason, administer the vaccine when the patient is stable and not acutely suppressed. For patients on long-term immunosuppressive therapies, administer the vaccine when the immune response is most likely the strongest or right before starting the next cycle of therapy.  

For patients with HIV:

Prabhjot:Shingrix is recommended for patients with HIV due to the high risk of shingles. Immune response to the vaccine may be improved while the patient is on antiretroviral treatment.  

Bottom line: Shingrix is now recommended not only for those over 50 years old but also for those who are 18 and older and are immunosuppressed or will be on immunosuppressive therapy. This new change will benefit those who are receiving treatment and those who are awaiting treatment. Keep in mind to use the vaccine to prevent shingles and its complications.  

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Conclusion: Now we conclude our episode number 109, “Shingles vaccine before 50.” We are used to giving Shingrix to patients older than 50, but we were reminded today that it is also indicated in patients older than 18 who are or will be immunosuppressed. Shingrix should be given in 2 doses 2-6 months apart. Your patients may not notice it, but by giving this vaccine, you are PREVENTING a painful rash that can have long-term effects. This week we thank Jennifer Thoene, Hector Arreaza, Prabhjot Kaur, and Arianna Lundquist. Audio edition by Adrianne Silva.

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! 

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References:

Episode 107: Weight Gain Meds. 

Medications that cause weight gain are also called weight positive medications. Sapna, Danish, and Dr. Arreaza mention some of those medications in this episode. 

Introduction: Some meds cause weight gain
By Hector Arreaza, MD.

You will see patients who keep gaining weight regardless of their sincere efforts to eat better and exercise. Some people experience serious difficulties to lose weight. If you want to know how frustrating it can be, imagine your doctor telling you to add one more inch to your height when you are 35 years old. For some people, losing weight is just as hard. One important step you can take to help your patients lose weight is performing a detailed medication reconciliation. Review the medication list, and you may find some meds that are proven to cause weight gain. Today we will discuss some of those medications, but it takes practice to learn all of them. I hope this episode is helpful for you. 

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.

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Weight Gain Meds. 
By Sapna Patel, MS4, and Danish Khalid, MS4. Ross University School of Medicine. Comments by Hector Arreaza, MD.

S: Medications associated with weight gain: See Table 1.1 for medications associated with weight gain and alternatives. 

Antipsychotic agents:

A: Ziprasidone is an antipsychotic medicine that causes the least amount of weight gain.

Antidepressants:

There are many antidepressants which are associated with weight gain, including the tricyclics, monoamine oxidase inhibitors (MAOIs), and some of the selective serotonin reuptake inhibitors (SSRIs). Tricyclic antidepressants, in particular amitriptyline, clomipramine, doxepin, and imipramine, are associated with significant weight gain.Selective serotonin reuptake inhibitors, paroxetine exhibited the greatest weight gain in its class. Whereas fluoxetine exhibited little to no weight gain and remains weight neutral in the class. Amongst the monoamine oxidase inhibitors, phenelzine had the greatest weight gain. 

Antiepileptics/Antiseizure: 

Amongst the antiepileptic drugs used to treat seizures, neuropathic pain, or other psychiatric conditions,  valproate, carbamazepine, and gabapentin are associated with weight gain. Gabapentin is virtually used by all our diabetic patients. 

Antihypertensive agents: Beta Blockers

Beta receptors, specifically beta-2 receptors, stimulate the release of insulin. Thus, patients on beta blockers may experience weight gain as a side effect. There are two beta blockers that cause the least amount of weight gain: Carvedilol (Coreg) and nebivolol (Bystolic).

Hypoglycemic medications: 

Although intended to regulate blood sugar levels, several anti-diabetic medications are associated with weight gain, specifically sulfonylureas, Actos, and insulin. As mentioned earlier, metformin as well as GLP-1 agonists are associated with weight loss. Metformin can be considered weight neutral. 

Steroids: 

Steroid hormones such as corticosteroids or progestational steroids are associated with weight gain. Steroids may increase levels of cortisol, one of the end pathways in steroidogenesis. Cortisol, also known as the stress hormone, functions by increasing insulin resistance, and decreasing glucose utilization, thus causing weight gain. 

Antihistamine Medications: 

Diphenhydramine (Benadryl): commonly used for allergies…or how my mom used it, puts you to sleep right before a flight. However, a side effect of using this medication includes weight gain.Cyproheptadine: an antihistamine, used for antidote to serotonin syndrome and migraines, has an appetite stimulant effect causing weight gain. It can be used off-label as an appetite stimulant in children who do not gain weight.

Fun Fact: Although it is a common belief that combined oral contraceptives cause weight gain, data suggest that significant weight gain is not a common side effect of combined oral contraceptives.

A good practice: Medication reconciliation: Weight positive, weight neutral, or weight negative. 

Weight positive: Deprescribe or change for another medication if possible. Weight neutral and weight negative: Keep them. Don’t be afraid to prescribe anti-obesity meds. We should learn about them, become familiar with side effects, contraindications, dosing, and more, and prescribe them appropriately as part of a weight loss program. Also, don’t forget that these medications are used in conjunction with a proper diet. 

Table 1.1: Medications associated with weight gain and alternatives.4

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Conclusion: Now we conclude our episode number 107 “Weight Gain Meds.” Sapna and Danish did an excellent job in this episode. Performing a good medication reconciliation is a key element in a weight loss visit. Some patients cannot stop taking medications that cause weight gain, also called weight-positive medications. I recommend you be cautious when discontinuing any medication. If you are not the prescriber, consult with the prescriber to discuss the possibility to lower the dose, finding an alternative medication, or determining if the medication can be discontinued. If none of those options are feasible, you may consider starting metformin if not contraindicated, I hope you learned something new today. 

This week we thank Hector Arreaza, Sapna Patel, Danish Khalid, Valerie Civelli, and Arianna Lundquist. Audio edition by Adrianne Silva.

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! 

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References:

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/contents/obesity-in-adults-overview-of-management.

Perreault, L. (2022). Obesity in adults: Drug therapy. Pi-Sunyer,  F.X., & Kunins, L. (Eds.) UpToDate. Available from: https://www.uptodate.com/contents/obesity-in-adults-drug-therapy.

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/contents/glucagon-like-peptide-1-based-therapies-for-the-treatment-of-type-2-diabetes-mellitus

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/contents/obesity-in-adults-etiologies-and-risk-factors

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.

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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! 

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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&sectionRank=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 105: Renal Cell Carcinoma. 

Manpreet and Jon-Ade explain how to diagnose renal cell carcinoma. Introduction about age and kidney transplant by Dr. Arreaza and Dr. Yomi. 

[Due to technical difficulties this episode was not posted as scheduled, so it had to be reposted on 9/9/2022] 

Introduction: Too old for a new kidney?
By Hector Arreaza, MD. Discussed with  Timiiye Yomi, MD.

Today we will be talking about the kidneys, those precious bean-shaped organs that detoxify your blood 24/7. Amazingly, we can live normal lives with one kidney, but when the kidney function is not good enough to meet the body’s demands, patients need to start kidney replacement therapy. Modern medicine has made a lot of advances with dialysis, but the perfection of a kidney has not been outperformed by any machine yet. That’s why kidney transplant is the hope for many of our patients with end-stage kidney disease.

The need for a kidney transplant is growing, likely due to increasing chronic diseases such as diabetes and hypertension, and also because of an increase in elderly population. About 22% of patients on the kidney transplant waiting list are over age 65. 

A cut-off age to receive kidney transplant has not been established across the globe. Different countries use different criteria for the maximum age for transplant. The American Society of Transplantation’s guidelines states “There should be no absolute upper age limit for excluding patients whose overall health and life situation suggest that transplantation will be beneficial.” So, if your patient is older than 65 and needs a kidney, they may qualify for a transplant, and age should not be an absolute contraindication to receive it. Actually, older patients may have lower risk of rejection due to a theoretically weaker immune system. A live donor is likely to be a better option for elderly patients. 

A condition that would make your elderly patient a poor candidate for kidney transplant would be frailty. Common contraindications to kidney transplant include active infections or malignancy, uncontrolled mental illness, ongoing addiction to substances, reversible kidney failure, and documented active and ongoing treatment nonadherence.

So, remember to take these factors into consideration when deciding if you need to refer your elderly patients for a kidney transplant, there is no such thing as being too old for a new kidney if your patient meets all the criteria for a transplant.

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.

Renal Cell Carcinoma. 

By Manpreet Singh, MS3, Ross University School of Medicine, and Jon-Ade Holter, MS3 Ross University School of Medicine. Moderated by Hector Arreaza, MD.

Definition:

Renal cell carcinoma is a primary neoplasm arising form the renal cortex. 80-85 percent of renal tumors are renal cell carcinomas followed closely by transitional cell renal cancer and Wilms tumor. 

Epidemiology: 

In 2022, 79,000 new cases of kidney cancer were diagnosed with almost 14,000 mortalities. 

There is a 2:1 male to female ratio and the average age is 64 and normally 65-74. African Americans and American Indians have a higher prevalence rate compared to other racial groups. The lifetime risk for developing kidney cancer in men is about 1 in 46 (2.02%) and 1 in 80 (1.03%) in women. 

Risk Factors associated with RCC: 

Anything that causes assault to the kidneys and affects its function would cause increased demand, injury, and inflammation. This assault can lead to cell derangement and lead to cancer. The risk factors that have been associated with RCC are smoking, obesity, HTN, family history of kidney cancer, Trichloroethylene (a metal degreaser used in large manufacturing factories), acetaminophen, and patients with advanced kidney disease needing dialysis.

Patients with syndromes that cause multiple types of tumors: 

Screening For RCC:

Screening is unnecessary because of the low prevalence of this cancer in the general population, though certain groups require annual repeat imaging via US, CT, or MRI. 

Clinical Picture: 

Most patients with RCC are asymptomatic until cancer grows large enough to cause disruption of local organs, such as the kidney, bladder, or renal vein, and dysregulates other organs via metastasis. Therefore, it’s important to look at other signs and symptoms caused by RCC. 

The patient most likely will be an older male who presents with the classic triad of: 

Though this presents only in 9% of patients during the presentation, having physical symptoms is a sign of advanced disease and 25% of patients with these signs tend to have distant metastasis. 

The paraneoplastic syndrome can also arise from RCC

Other disorders present include hepatic dysfunction, cachexia, secondary amyloidosis, and thrombocytosis.

Workup 

If a patient comes in with painless hematuria, then the first test should be abdominal CT or abdominal ultrasound. A CT is more sensitive than the US but it can quickly indicate if the abdominal mass felt can be a cyst or a solid tumor. 

US of kidneys should show if it’s a simple cyst:

-The cyst is round and sharply demarcated with smooth walls

- It’s anechoic – appears solid black

-There is a strong posterior wall echo

-Use the Bosniak classification to classify mass 

Bosniak I: benign simple cyst with thin wall less than equal to 2mm, no septa or calcifications. No future workup is needed.

Bosniak II: benign cyst, <1mm septa with thin calcification, high attenuation due to contents other than simple water in cyst. No further workup needed.

Bosniak IIF: Minimally complex cyst with multiple hairline thin septa with thickened walls, calcification present, and high attenuation lesions >3 cm diameter, requires f/u with US/CT/MRI at 6 months, 12 months, and annually for the next 5 years. Chance of malignancy: 5%. 

Bosniak III: indeterminate cystic mass with thick, irregular or smooth walls. This requires nephrectomy or radiofrequency ablation. Chance of malignancy: 55% 

Bosniak IV: Clearly a malignancy its grade III with enhancing soft tissue components that its independent from the wall or septum. Requires total or partial nephrectomy. Chance of malignancy 100%. 

CT of the kidneys for a neoplasm should show:

-Thickened irregular walls or septa 

-Enhancement after contrast injection are suggestive of malignancy

-CT can also help detect invasion in local tissue areas such as renal vein and perinephric organs 

MRI is used if the patient cannot use contrast or kidney function is poor. MRI can also evaluate the growth of the cancer.

Other imaging studies:Other imaging studies that may be useful for assessing for distant metastases include bone scan, CT of the chest, magnetic resonance imaging (MRI), and positron emission tomography (PET)/CT.

Treatment and staging 

Nephrectomy, partial or total, will be used as the initial tissue collection for pathology. If the patient is not a surgical candidate, you can also obtain a percutaneous biopsy. The nephrectomy is preferred because first, it serves as a definitive treatment option, but also it allows for definitive staging of the cancer with tumor and nodal staging. Regardless of the size, any solid mass may indicate malignancy and point towards RCC, requiring resection. 

TNM staging

Stage I: Tumor is 7cm across or smaller and only in the kidney with no lymph nodes or distant mets. T1N0M0

Stage IIa: Tumor size is larger than 7cm but still in the kidney but no invasion of lymph node or mets. T2N0M0

Stage IIb: Tumor is growing into the renal vein or IVC, but not into neighboring organs such as adrenals or Gerota’s fascia and still lacks lymph node invasion and mets. T3N0M0. 

Stage III: Tumor can be any size but has not invaded outside structures such as adrenals, though nearby lymph node invasion is present but not distant. There is no distant mets. T3N1M0.

Stage IV:  The main tumor is beyond the Gerota’s fascia and may grow into the adrenal gland . It may or may not spread to the lymph nodes or may not have distant mets. Stage IV also consists of any cancer that has any number of distant mets. T4

Adjuvant therapy can be done with immune therapy.

Conclusion: Now we conclude our episode number 105 “Renal cell carcinoma.” This type of cancer may be asymptomatic until it is large enough to cause symptoms. Keep it on your list of differentials on patients with hematuria, flank pain, weight loss, and abnormal imaging. Keep in mind the features of simple kidney cysts vs complex cysts when assessing kidney ultrasounds. Your patient will be grateful for an early diagnosis of RCC and a prompt treatment. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Timiiye Yomi, Manpreet Singh, Jon-Ade Holter. 

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! 

Bibliography:

Is There a Cut Off Age for Kidney Transplant?, Mayo Clinic Connect, Jul 18, 2017, https://connect.mayoclinic.org/blog/transplant/newsfeed-post/is-there-a-cut-off-age-for-kidney-transplant/

Atkins, Michael. “Clinical Manifestations, Evaluation, and Staging of Renal Cell Carcinoma.” UpToDate, January 21. https://www.uptodate.com/contents/clinical-manifestations-evaluation-and-staging-of-renal-cell-carcinoma

American Cancer Society. “Key Statistics About Kidney Cancer”. Cancer.Org, 2022, https://www.cancer.org/cancer/kidney-cancer/about/key-statistics.html.

Escudier B, Porta C, Schmidinger M, Rioux-Leclercq N, Bex A, Khoo V, Grünwald V, Gillessen S, Horwich A; ESMO Guidelines Committee. Electronic address: clinicalguidelines@esmo.org. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2019 May 1;30(5):706-720. doi: 10.1093/annonc/mdz056. PMID: 30788497. https://pubmed.ncbi.nlm.nih.gov/30788497/.

Gaillard, F., Bell, D. Bosniak classification system of renal cystic masses. Reference article, Radiopaedia.org. (accessed on 20 May 2022) https://doi.org/10.53347/rID-1006.

Kopel J, Sharma P, Warriach I, Swarup S. Polycythemia with Renal Cell Carcinoma and Normal Erythropoietin Level. Case Rep Urol. 2019 Dec 11;2019:3792514. doi: 10.1155/2019/3792514. PMID: 31934488; PMCID: PMC6942735. https://pubmed.ncbi.nlm.nih.gov/31934488/.

Leslie SW, Sajjad H, Siref LE. Varicocele. [Updated 2022 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448113/.

Maguire, Claire. “Understanding Endoscopic Ultrasound and Fine Needle Aspiration.” Educational Dimension, Educational Dimensions, 1 Jan. 2007, educationaldimensions.com/eLearn/aspirationandbiopsy/eusterm.php.

Maller, V., Hagir, M. Renal cell carcinoma (TNM staging). Reference article, Radiopaedia.org. (accessed on 20 May 2022) https://doi.org/10.53347/rID-4699.

Palapattu GS, Kristo B, Rajfer J. Paraneoplastic syndromes in urologic malignancy: the many faces of renal cell carcinoma. Rev Urol. 2002 Fall;4(4):163-70. PMID: 16985675; PMCID: PMC1475999. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1475999/.

Episode 104: What is Monkeypox. 

Monkeypox is a rare disease caused by the monkeypox virus that belongs to the orthopoxvirus (smallpox) family. Nabhan, Dr. Schlaerth, and Dr. Arreaza discuss the basics of what is known about this disease. 

Introduction: Monkeypox 
By Hector Arreaza, MD. 

As of June 29, 2022, there are 5,115 confirmed cases of monkeypox in the world. The country with the most cases is the United Kingdom with >1,000 cases. In the United States, there are 351 confirmed cases, distributed in 28 states, and the state with the highest number of cases is California with 80 cases. Today we will briefly discuss the history, epidemiology, transmission, and management of monkeypox. By the way, by the time you listen to this episode, this disease may have a different name, as the World Health Organization is planning to rename it to minimize stigma and racism. 

Monkeypox is still rare, but because of the current outbreak, we need to include it in our list of differentials when we see rashes. Symptoms of monkeypox can include fever, chills, headache, myalgias, lymphadenopathies, and general malaise. The rash resembles pimples or blisters that appear on the face, inside the mouth, and on other parts of the body, like the hands, feet, chest, genitals, or anus. The rash goes through different stages before healing completely. The illness typically lasts 2-4 weeks. Monkeypox spreads by direct or indirect contact with rash, respiratory secretions, and vertical transmission from mother to fetus. Sometimes, people get a rash first, followed by other symptoms. Others only experience a rash. Currently, there is not a formal treatment for the disease. The information will continue to evolve in the future. 

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

___________________________

What is monkeypox. 

By Nabhan Kamal, MS3, American University of the Caribbean School of Medicine. Comments by Katherine Schlaerth. Moderated by Hector Arreaza, MD.

Background.

Monkeypox is a viral zoonotic infection that results in a rash similar to smallpox. It is estimated that humans have been infected by the monkeypox virus for centuries in sub-Saharan Africa. Monkeypox is an orthopoxvirus that was first isolated in the decade of 1950s from a colony of sick monkeys. The variola virus and the vaccinia virus are in the same genus as the monkeypox virus. Variola is the smallpox virus, and vaccinia is the virus in the smallpox vaccine. The virion that has been seen in cells infected with the monkeypox virus looks exactly the same as the virions of variola or vaccinia viruses. It has a characteristic brick-like appearance. 

The two strains of monkeypox identified in different regions of Africa are Central Africa and Western Africa. It seems like the strain of Western Africa is less virulent and lacks a number of genes present in the Central African strain.

Transition to talking about Epidemiology

Why is understanding the epidemiology of monkeypox important? I think it’s important to touch on the epidemiology of the virus because it will help healthcare providers better understand the disease and have a more productive discussion with their patients about this illness if they, unfortunately, happen to fall victim to it. 

Epidemiology

In the 70s, the first time monkeypox was identified as a cause of disease in humans. It happened in the Democratic Republic of the Congo (formerly the Republic of Zaire). After that, only 59 cases of human monkeypox were identified in the decade between 1970 and 1980, with a mortality rate of 17%. All of these cases occurred in the rain forests of Western and Central Africa. These cases occurred in people exposed to rodents, squirrels, and monkeys. An important fact to note is that despite the virus being called “monkeypox”, monkeys and humans are incidental hosts; the reservoir remains unknown but is likely to be rodents. Despite the current common belief that this is the first outbreak of monkeypox in the US, the actual first outbreak of monkeypox in the Western Hemisphere occurred in the United States in 2003. 

Transition to talking about Transmission

Is the monkeypox virus extremely virulent and transmissible just like SARS COV-2? All people born after 1972 have not been vaccinated against smallpox. Routine vaccination of the American public against smallpox stopped in 1972 after smallpox was eradicated in the United States. The virus can spread between animals and humans, just like COVID-19 is believed to be.

Transmission

Animal-to-human transmission – A person gets infected by monkeypox by contact with body fluids coming from an infected animal or through a bite. Monkeypox infection has been found in many types of animals in Africa, including rope squirrels, tree squirrels, Gambian poached rats, dormice, and different species of monkeys.

Human-to-human transmission – In general, humans get infected from other humans through large respiratory droplets, which are produced during cough or sneezing. Also, a person can get infected by close contact with infectious skin lesions and particles or from sexual contact with skin lesions.

Currently, transmission from person-to-person is very low. An outbreak of monkeypox was reported in May 2022 in non-endemic countries with over 90 confirmed cases. Non-endemic countries are all countries outside of Central and Western Africa. However, in this new outbreak, it appears that close contact with infectious skin lesions during sexual contact may be the most likely mode of transmission based on the majority of initial cases in Europe being recorded amongst men who have sex with men. 

As of this recording on June 8, 2022, there are a total of 1088 cases in 29 countries. The UK leads the world with 302 confirmed cases while the US only has 34 confirmed cases. 

Incubation period

The classic incubation period of monkeypox virus infection is usually from 6 to 13 days but can range from 5 to 21 days. Important to note, however, is that persons with a history of an animal bite or scratch may have a shorter incubation period than those with tactile exposures (9 versus 13 days, respectively). So, the infection shows up earlier in people who get an animal bite or scratch.

Management 

Most patients with monkeypox will have mild disease and recover without medical intervention. For patients who are symptomatic, most of them will not require hospitalization. Unlike chickenpox, the vesicular rash caused by monkeypox occurs all at once rather than new lesions appearing as old ones start to crust over and heal.

Antivirals: In some rare cases, antiviral medications can be used for patients that become severely ill as a result of being immunocompromised from HIV, various cancers, organ transplant recipients, etc. The antiviral drug of choice is Tecovirimat. It’s a potent inhibitor of an orthopoxvirus protein required for dissemination within an infected host. This medication protects nonhuman primates from lethal monkeypox virus infections and is also likely to be efficacious against infection in humans. It’s interesting that these medications have been approved for smallpox treatment. 

In patients that have severe disease, dual therapy with Tecovirimat and Cidofovir is recommended. It has in vitro activity against monkeypox and has been shown to be effective against lethal monkeypox in animal models. However, there isn’t any clinical data regarding Cidofovir’s efficacy against monkeypox infection in humans specifically, and it also has significant side effects including nephrotoxicity.

In June 2021, brincidofovir was approved for use in the US for the treatment of smallpox. Brincidofovir is an analog of cidofovir (meaning that it is almost the same with some small tweaks) that can be given orally. Given how new it is, however, its clinical availability is uncertain at this time.

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Conclusion: Now we conclude our episode number 104 “What is Monkeypox.” Monkeypox is a developing story and we have presented information that may become obsolete in the future. For now, remember to rule out monkeypox in your patients who are highly suspicious to have it, for example, patients with STI-related rashes or with a viral illness followed by a papular rash. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Katherine Schlaerth, Nabhan Kamal, and Lillian Petersen.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! 

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References:

Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/poxvirus/monkeypox/, accessed on June 30, 2022. 

Muller, Madison, WHO Will Rename Monkeypox Virus to Minimize Stigma and Racism, TIME, June 14, 2022.

Isaacs, Stuart, MD, Monkeypox, UpToDate, https://www.uptodate.com/contents/monkeypox, accessed on Jun 06, 2022.

Episode 103: Caring for LGBTQ+ Patients. 

Salwa, Pat, and Dr. Arreaza explain how to care for patients who identify themselves as LGBTQ+. Answered questions include, what screenings are needed? Any special needs? 

Introduction: LGBTQ+ Information.  
By Hector Arreaza, MD. 

Recently the media has been flooded with information about LGBTQ+. If you wonder what LGBTQ+ means, it means lesbian, gay, bisexual, transgender, queer or questioning, and the “+” sign acknowledges other orientations such as asexual, intersex, and more. June was designated as “pride month”. I think we have received more information within the last year than in the previous century. Many people consider this an overrepresentation of the calculated 3.5% to 8% of the population who identify themselves as LGBTQ+, many others consider this a revolution to promote equality in our society by reaffirming gay rights, while others consider this a part of an agenda to destroy the “American way of living” or even the US Armed Forces. 

You can come to your own conclusion about the origin and validity of this movement, but as medical providers, especially as family medicine providers, we must be prepared to care for any patient we encounter, including members of the LGBTQ+ community, and treat them with the same respect and compassion as any other patient. This episode was done to increase your awareness of this topic and motivate you to keep learning about it. By the way, there are now specific fellowships you can take to become more specialized on this topic, and you can find more information on the American Medical Association website.[3] 

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.

___________________________

Caring for LGBTQ+ patients. 

By Salwa Sadiq-Ali, MS IV Ross University School of Medicine, and Pattamestrige Perera, MS IV, American University of the Caribbean. Comments by Hector Arreaza, MD.

Salwa: So, I was browsing the internet as we all do these days and I came across a short film, The Clinic, by a Canada-based organization, the Get REAL movement. Have you heard about this Dr. Arreaza? 

Arreaza: No, I haven’t, but this sounds interesting. What was the film about? 

Salwa: Essentially, it’s about LGBTQ+ patients and how healthcare is not inclusive. The film shows two patients with the same concern, one of which is from the LGBTQ+ community. It goes on to show how they are treated differently by the physician. 

Arreaza: That’s not how it should be. Unfortunately, healthcare disparity is very real, especially in minority groups like the LGBTQ+. One study found that 3.5% of Americans identify as lesbian, gay, or bisexual and 0.3% identify as transgender. They also found that these individuals are more likely to get poor care because of stigma and lack of awareness. 

Salwa: Exactly! And since June is PRIDE month, I thought this would be a great topic! Especially because we as students or healthcare providers don’t learn too much about this in school or training. 

Arreaza: I think that’s a great idea. I’ve heard a lot about PRIDE celebrations and the memorials that are held. How about we start with what exactly is PRIDE?

Pat: PRIDE is a celebration, a movement. It’s celebrated to commemorate the 1969 Stonewall Riots or Uprising. The riots began after the police raided a gay club in New York City leading to almost a week of violent clashes. This event marked the beginning of the gay rights movement as we know it today. 

Arreaza: And today PRIDE is celebrated with parades and many hold memorials for members of the community who were victims of hate crimes. By the way, you can listen to our episode 14, “Gender Diversity”, to learn about the definitions of gender, sexual orientation, and more.

Pat: As you said earlier, LGBTQ+ individuals are part of a minority group and face discrimination. 

Arreaza: Let’s talk about the health care gaps the “community” faces. Tell us more. 

Salwa: Yes absolutely! Let’s get into it! Did you know that LGBTQ+ youth are at a higher risk for substance abuse, STDs, cancers, cardiovascular disease, obesity, bullying, isolation, rejection, anxiety, depression, and suicide in comparison to the general population? 

Arreaza: The AAFP says suicide rates are 4 times higher among LGBTQ+ and even higher among trans youth compared to heterosexual youths. Also, members of the community, specifically men who have sex with men, are at a much higher risk of being affected by HIV/AIDS.

Pat: In fact, family physicians, and all primary care providers, are key to providing care for the LGBTQ+ community and the special needs of the community including gender-affirming care. 

Arreaza: So, what should primary care providers do?

Salwa: That’s a great question! First, let’s go back to the basics. Bedside manners are key. Being open and welcoming will open the door for you to find relevant health information. Having open conversations and being empathetic and mindful will help you build that patient-doctor relationship you want to have with your patients. I’ll share a story from when I was rotating in surgery. I had a transgender patient in the clinic, male to female. That’s what is called a transgender woman. When I was reviewing the chart, I couldn’t tell what pronouns the patient used. The first thing I did when I got into the room was to ask, “What pronouns would you like me to use?”. Even though she was wearing a mask I could tell that her face lit up just by looking at her eyes, and she said, “Thank you, that was very kind of you to ask.” Small things like this can really make a difference. 

Arreaza: And that’s becoming a routine question when our medical assistants encounter a patient for the first time. Their preferred pronoun is listed next to the patient’s name. What about the other health issues for LGBTQ+ patients? What should we do for that?

Salwa: For the other concerns – depression, anxiety, suicide, and more – follow the current guidelines for cisgender patients (cisgender patients are those who identify themselves with their gender assigned at birth). The AAFP and USPSTF have screening guidelines in place that can be utilized to help determine what someone may need further management for. 

Pat: The PHQ9 – a screening questionnaire for depression – will help you determine if you need to start treatment for depression or refer to behavioral health. There’s a similar questionnaire for anxiety – the GAD 7. 

Salwa: When I was doing my psychiatry rotation, I had a transgender male patient who didn’t have a support system. His family had essentially rejected him, and he was so isolated that he became depressed and suicidal. So, I’d say ask your patients about bullying, their support system, ask them about their friends. Maybe even talk to their parents if the patient is a minor, if they consent you to do so, or refer to family therapy. 

Pat: And of course, there is STD testing, HPV vaccination, obesity and related comorbidity screening, PAP smears for anyone with a cervix, maybe even consider an anal PAP smear when appropriate.

Arreaza: Beverly Hills rotation: A gynecologist for men.

People at increased risk of anal cancer:
-Men who have sex with men
-Iatrogenic immunosuppression (e.g., solid organ transplant recipients, long-term oral corticosteroids)
-Women with a history of cervical, vulvar, or vaginal SIL (also termed intraepithelial neoplasia) or cancer
-Women with a history of cervical HPV 16 infection
-Individuals with a history of anogenital warts

Pat: Depression is important to detect on time given the higher rate of suicide in this population, aside from following current guidelines, are there any unique health-related questions we should ask our LGBTQ+ patients? I hope you guys said yes! two common health topics are gender-affirming care and complications related to chest binding. Dr. Arreaza, have you had any patient encounters for gender-affirming care?

Arreaza: Yes actually. I’ve had a few patients who requested gender-affirming care. It requires a multi-disciplinary care team. You must consider hormone replacement, mental health, and surgeries. At the primary care level, you are there as the patient’s support system to help them navigate through everything and provide them with all the information. Hormone replacement is generally done by an endocrinologist or by a primary care provider who has been trained to do it. Of course, when appropriate, we will refer the patients to surgeons for certain procedures. 

Salwa: Exactly! Individuals who, from my understanding, are transgender or non-binary, as in they identify as males but tend to have female sexual characteristics such as breasts, may do something called chest binding. It involves compressing the breast tissue with a wrap to have a more masculine gender expression. Usually, individuals will use commercial binders, elastic bandages, duct tape, or plastic wrap. When you have a patient who practices chest binding, it’s important to address safe practices. They commonly develop dermatological conditions like acne, scarring, fungal infections. But they can also develop other complications like chronic pain, restrictive respiration, rib fractures, syncope, lightheadedness, and heartburn. 

Pat: A study showed that 88.9% of participants experienced a negative side effect of binding, but only 15% sought care. Cleveland Clinic suggests that individuals use a commercial, breathable binder or a sports bra. It’s also important to stay hydrated, have at least one day a week when a binder is not used, and avoid using a binder while sleeping. Most importantly, if you experienced any side effects, to get help from a doctor. 

Arreaza: Asylum seekers due to sexual orientation is possible. People in different parts of the world suffer persecution due to their sexual orientation. LGBTQ+ individuals are target for “killings, sexual and gender-based violence, physical attacks, torture, arbitrary detention, accusations of immoral or aberrant behavior, denial of the rights to assembly, expression and information, and discrimination in employment, health, and education in all regions around the world.

Pat: So, I think we covered most of it. Do you two think we mentioned the important parts?

Salwa: On that note, we want to end this podcast with a small message to LGBTQ+ individuals

listening in. We want you to know that you are not alone and that you matter.

And if you’re listening right now and know someone who is LGBTQ+, check in on them and let

them know how much they mean to you.

Pat: We encourage you to go to your PCP and talk to them about your concerns and how you’re doing. And we encourage all PCPs, all healthcare providers even, to implement these principles when encountering their LGBTQ+ patients.

Arreaza: If you do not feel comfortable caring for LGBTQ+ patients, you can refer them to a provider with the knowledge and skills to care for them.

Available Resources:

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Conclusion: Now we conclude our episode number 103 “Caring for LGBTQ+ Patients.” Remember to screen your patients for conditions related to their gender assigned at birth but take into consideration the effects of hormones in those who have changed their gender. While caring for LGBTQ+ patients, remember to apply the same ethical principles you apply to the rest of your patients: beneficence, non-maleficence, autonomy, and justice. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Salwa Sadiq-Ali, and Pat Perera.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Powell, Lauren. We Are Here: LGBTQ+ Adult Population in United States Reaches At Least 20 Million, According to Human Rights Campaign Foundation Report, December 9, 2021, Human Rights Campaign, hrc.org, https://www.hrc.org/press-releases/we-are-here-lgbtq-adult-population-in-united-states-reaches-at-least-20-million-according-to-human-rights-campaign-foundation-report, accessed on June 30, 2022. 

How Many People are Lesbian, Gay, Bisexual, and Transgender? UCLA School of Law Williams Institute, April 2011, https://williamsinstitute.law.ucla.edu/publications/how-many-people-lgbt/

National LGBTQ+ Fellowship Program, American Medical Association Foundation, https://amafoundation.org/programs/lgbtq-fellowship/

Guidelines on International Protection No. 9, United Nations High Commission for Refugees, unhcr.org, published on October 23, 2012, online at: https://www.unhcr.org/509136ca9.pdf, accessed on June 30, 2022. 

The Clinic, short film. The Get Real Movement, thegetrealmovement.com, https://www.thegetrealmovement.com/theclinicfilm. Accessed on June 30, 2022. 

June is LGBT Pride Month, Youth.Gov, https://youth.gov/feature-article/june-lgbt-pride-month, accessed on June 30, 2022.

Stonewall Riots, The History Channel, history.com, https://www.history.com/topics/gay-rights/the-stonewall-riots, Accessed on June 30, 2022. 

Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus. 2017 Apr 20;9(4):e1184. doi: 10.7759/cureus.1184. PMID: 28638747; PMCID: PMC5478215. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478215/

Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning (LGBTQ+) Health, American Academy of Family Physicians, accessed on June 30, 2022. https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/equality/BKG-LGBTQ+Health.pdf.

Creating a welcoming clinical environment for lesbian, gay, bisexual, and transgender (LGBT) patients, rainbowwelcome.org, https://www.rainbowwelcome.org/uploads/pdfs/Creating%20a%20Welcome%20Clinical%20Environment%20for%20LGBT%20Patients.pdf

Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study. Cult Health Sex. 2017 Jan;19(1):64-75. doi: 10.1080/13691058.2016.1191675. Epub 2016 Jun 14. PMID: 27300085. https://pubmed.ncbi.nlm.nih.gov/27300085/

Moffa, Jamie. Chest Binding: A Physician’s Guide, Pride in Practice, April 6, 2019. https://www.prideinpractice.org/articles/chest-binding-physician-guide/

Cleveland Clinic Health Essentials, How to Bind Your Chest Safely, July 26, 2021, https://health.clevelandclinic.org/safe-chest-binding/

Episode 102: Fluoride supplementation in kids.

Steven and Dr. Cha explained the importance of fluoride recommendations to prevent dental decay in kids who live in areas where water fluoride is low.

A: When I moved to Bakersfield, my children were 3 and a 5 years old, we took them to a pediatrician, and they got a prescription for fluoride supplements, that was something I had never seen before, so I was curious, and for many years I wanted to know the fluoride content of my water. Recently, I discovered the page nccd.cdc.gov thanks to the American Family Physician article about the fluorination of water, and I found the content of Bakersfield.  Because in Family Medicine we see patients from the cradle to the tomb and from head to toe, today we will talk about dental health. 

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

___________________________

Fluoride Supplementation in Kids. 
Written by Steve Beebe, MS3, Ross University School of Medicine. Editions by Hector Arreaza, MD; and Gina Cha, MD.

G: Let’s start with the definition of fluoride, What is fluoride?

S: Fluoride is a mineral – a substance that occurs in nature in its well-defined crystalline form. Put another way, fluoride is the negatively charged form of the element fluorine -- one of the elements on the periodic table. Fluoride is considered one of the essential/beneficial trace elements that our body uses for a variety of purposes. Other common trace elements include copper, iodine, iron, and zinc.[1] Where can fluoride be found?

G: Fluoride is commonly found in groundwater. It can also be found in tea, bones, shells, medical supplements, and fluoridated toothpaste. The fluoride takes the place of hydroxyl groups in the tooth matrix thereby making teeth more resistant to acidic substances which reduces dental caries.

A: Why is fluoride a controversial topic?

S: Although fluoride and dental caries/cavities are inversely correlated, it has yet to be shown that fluoride is strictly essential.[2]

A: Also, fluoride is not innocuous, it can be detrimental if taken in excess. Why is the fluorination of water important?

G: Dental caries is the most common chronic disease in children. The National Health & Nutrition Examination Survey showed that over 23% of children between ages 2-5 had dental cavities.[3] Unfortunately, having dental caries is associated with localized pain, tooth loss, impaired growth, impaired weight gain, and poor school performance, and it carries a risk for dental caries in the future as an adult.[4]

A: Some parents think that having caries on your baby teeth does not matter because those teeth are going to fall anyways.

G: The American Academy of Pediatric Dentistry explains that fluorination of the water supply helps balance the risk of getting dental caries with the risk of fluorosis or tooth mottling from excessive fluoride intake.[5] How much fluoride is enough for human consumption?

S: The National Academic Press recommends a maximum of 2.5mg of fluoride each day to avoid fluorosis (mottling of teeth). The NAP recommends 0.1 to 1mg from birth to 1 year of age and 0.5 to 1.5mg from 1-3 years of age as safe and adequate.[6]

The United States Preventive Services Task Force (USPSTF) recommends starting an oral fluoride supplement at 6 months of age in areas where the water supply is deficient in fluoride. S: Topical application of fluoride is seen as safe as early as the eruption of primary teeth.[7] (A: dental varnishing we do in well-child exams). Unfortunately, the USPSTF mentions that there have been no studies done to adequately address the dosage of oral fluoride supplementation in children with poor water fluoridation. Is there such a thing as too much fluoride?

G: Yes. Symptoms are dose-dependent and range from generalized pain, nausea, vomiting, diarrhea, staining of the teeth (fluorosis), renal dysfunction, cardiac dysfunction, coma, and death. When do we start giving fluoride supplements to our patients if needed?

S: The American Dental Association (ADA) recommends cleaning the teeth of children under the age of 2 years old with water and a brush as soon as teeth protrude into the mouth – a grain of rice-sized smear of fluoridated toothpaste can be used. At 3-6 years of age, the ADA recommends children use a pea-sized amount of fluoride toothpaste when brushing with a toothbrush.[8] (A: we have an obsession with comparing staff to food)

G: The American Academy of Pediatric Dentistry (AAPD) recommends a community fluorination level of 0.7 ppm in the water supply. They recommend against supplementing children under 6 months of age. However, they recommend the following daily oral supplementation:

Average:              

6 m-3 years: 0.25 mg.

3-6 years: 0.5.

6-16 y: 0.5 – 1 mg

The dose changes based on how much fluoride you have in your water:

•             0.25 mg of Fluoride in areas with <0.3ppm Fluoride in children aged 6 months to 3 years

•             0.5 mg of Fluoride in areas <0.3ppm Fluoride for children aged 3-6 years

•             0.25mg of Fluoride in areas 0. 3 to 0.6ppm Fluoride for children aged 3-6 years

•             1mg of Fluoride in areas <0.03 ppm Fluoride for children aged 6-16 years

•             0.5 mg of Fluoride in areas 0.3 to 0.6ppm Fluoride for children aged 6-16 years

 [9]

A: In Bakersfield, the fluoride concentration0.14 mg/L. What does this mean?

This water system has fluoride from natural sources, but at a level below what is recommended for the prevention of tooth decay. So, counsel your patients about the prevention of decay during clinic and prescribe as needed. The U.S. Department of Health and Human Services recommends a level of 0.7 mg/L of fluoride in your drinking water. This is the level that prevents tooth decay and promotes good oral health. For additional information on fluoride in drinking water please visit the CDC Water Fluoridation Page.

G: The American Academy of Family Physicians agrees with these guidelines provided by the AAPD.[10] When should we stop giving fluoride supplements to our patients? 

Oral supplementation does not seem to be recommended past 16 years of age.

A piece of advice from a dentist: “Only brush and floss the teeth you want to keep.”

Conclusion: Now we conclude our episode number 102 “Fluoride supplementation in kids.” Dr. Cha and future doctor Steven explained the importance of dental decay prevention. Fluorination of water varies in different areas of the US. Remember to check the fluoride in your city water, and if it is below 0.7 milligrams per liter, kids in your area may need fluoride supplementation to prevent caries. Adjust the dose accordingly to prescribe the right amount. Visit “My water’s fluoride” website at nccd.cdc.gov for more information. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Gina Cha, and Steve Beebee.

Audio edition: Suraj Amrutia. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email atRioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!

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References:

[1] S. Pazirandeh, MD, D. L. Burns, MD, I. J. Griffin, MB ChB. Overview of Dietary Trace Elements. UpToDate. Accessed 5/30/2022.

[2] Subcommittee on the Tenth Edition of the Recommended Dietary Allowances. Recommended Dietary Allowances, 10th Edition. Page #235. Available at: https://www.nap.edu/catalog/1349/recommended-dietary-allowances-10th-edition (Accessed on 5/30/2022).

[3] Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Centers for Disease Control and Prevention; 2019.

[4] Chou R, Pappas M, Dana T, Selph S, Hart E, Schwarz E. Screening and Prevention of Dental Caries in Children Younger Than Five Years of Age: A Systematic Review for the U.S.Preventive Services Task Force. Evidence Synthesis No. 210. Agency for Healthcare Research and Quality; 2021. AHRQ publication No. 21-05279-EF-1.

[5] American Academy of Pediatric Dentistry. Fluoride therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:302-5.

[6] Subcommittee on the Tenth Edition of the Recommended Dietary Allowances. Recommended Dietary Allowances, 10th Edition. Page #238. Available at: https://www.nap.edu/catalog/1349/recommended-dietary-allowances-10th-edition (Accessed on 5/30/2022).

[7] USPSTF. Prevention of Dental Caries in Children Younger than 4 years: Screening and interventions. December 7th, 2021.

[8] American Dental Association. Healthy habits. https://www.mouthhealthy.org/en/babies-and-kids/healthy-habits (Accessed on May 30, 2022).

[9] American Academy of Pediatric Dentistry. Fluoride therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:302-5.

[10] H. Silk, MD, MPH. Fluoride: The Family Physician's Role. https://www.aafp.org/pubs/afp/issues/2015/0801/p174.html. Accessed 5/30/2022.

Episode 101: Fasting Precautions.  
By Danish Khalid, MS4; and Sapna Patel, MS4. Ross University School of Medicine. 
Comments by Valerie Civelli, MD; and Hector Arreaza, MD. 

Fasting is a healthy lifestyle that may impact your health but fasting is not for everyone. Sapna, Danish, Dr. Civelli, and Dr. Arreaza explain some precautions to be taken in certain populations.  

We’ve talked about intermittent fasting, but we need to add a very big caveat: fasting isn’t for everyone. It carries certain risks. Some people who should absolutely not attempt fasting include those severely malnourished or underweight, children under eighteen years of age, pregnant women, and breastfeeding women. And the concern for these individuals involves providing adequate nutrition for normal growth or development. We also have to be cautious in patients with chronic heart problems, renal issues, eating disorders, fragile diabetics, or recently hospitalized patients.

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.

_________________________

S: The normal growth spurt in puberty requires a tremendous amount of nutrients. Underfeeding during this period may result in stunted growth, which may be irreversible.

D: Or in pregnant women, the developing fetus requires adequate nutrients for optimal growth, and nutritional deficiency may cause irreversible harm during this critical period. It’s for this reason many women take specialty formulated pregnancy multivitamins.

S: The same concept applies to breastfeeding mothers. Developing babies receive all their nutrients from the mother. So, if the mom becomes deficient in vitamins and minerals, then the baby may also be deficient. Which again would result in irreversible growth retardation.

D: Others that should take caution when fasting but don’t necessarily need to avoid it include those who have gout, diabetes, gastroesophageal reflux disease, or are taking medications. For these individuals, it is wise to seek medical advice from a healthcare professional.

A: Chances are that you may not find a physician who is pro-fast, but after reading about it and trying it myself, I think it is a safe way to lose weight or maintain a healthy weight.

S: Gout is an inflammatory arthritis caused by excess uric acid in the joints. It can be either due to decreased uric acid excretion through urine or increased production of uric acid through breakdown of nucleic acid. Fasting decreases the elimination of uric acid through urine. Thus, theoretically worsening gout. Now although most patients with a history of gout tolerate fasting without any exacerbation, knowing the potential risk is important.

D: If you have type 1 or type 2 diabetes, it's essential to be particularly careful while fasting or even just changing dietary patterns. This is especially true if you are taking medications. If you continue to use the same dose of medication but reduce food intake, you run the risk of your blood sugar getting low - a situation called hypoglycemia. Symptoms include shaking, sweating, irritability or nervousness, feeling faint, confusion, delirium, seizures, and if left untreated may even lead to death. What is even more worrisome, these symptoms may appear very rapidly, so understanding your body and the cues it provides is essential. Thus, you must consult with your physician to adjust the doses of diabetic medication before starting any dietary program to avoid having any hypoglycemic episodes as they can be potentially life-threatening.

A: The risk of hypoglycemia is high in patients with diabetes who are taking medications, but it’s less likely to happen in patients with obesity without diabetes. The body fat (stores) acts as the fuel for your body functions. Patients will not die if they stop eating.

S: If you have GERD (heartburn) this is oftentimes due to increased pressure on the stomach which forces food and stomach acid back up. This can be made worse during fasting because there is nothing in the stomach to absorb the stomach acid. Sometimes, fasting can improve symptoms because food stimulates the production of stomach acid, so fasting reduces it.

A: My GERD improves with fasting.

D: Patients who are taking regular medication for any condition need close follow-up as certain medications are best taken with meals. The most common medications that cause problems during fasting include aspirin, metformin, iron, and magnesium supplements.

S: Myth: Women shouldn’t fast. One area of specific concern with women is that fasting could affect reproductive hormones, LH and FSH, similar to that seen in anorexia. This can lead to amenorrhea and difficulty conceiving. However, these problems only arise when body fat percentages fall too low. And women with excessively low body fat should not be fasting in the first place. As mentioned earlier, these individuals are severely malnourished and should stop immediately.

V: Women: 12-13 hrs. fasting, increase to 1 hr. up to 16 hrs. 8hr feeding window. 6-8 wks. for full benefit.

A: Exercise is allowed during fasting.

Conclusion: Now we conclude episode 101, “Fasting precautions.” Fasting is safe for most patients but be cautious in certain patients such as pregnant women and diabetics. Make sure you take the necessary steps to avoid side effects or complications during fasting. Even without trying, every night you go to bed being a little wiser. Today we thank Sapna Patel, Danish Khalid, Valerie Civelli, and Hector Arreaza.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Fung, Jason, MD; and Jimmy Moore. “The Complete Guide to Fasting.” Victory Belt Publishing. 2016. p179-189;199-209.

Episode 100: Sexercise. 

Written by Valerie Civelli, MD. Comments by Namdeep Grewal, MD; and Hector Arreaza, MD.

Have you ever wondered if sex is a good workout? Drs. Civelli, Grewal and Arreaza discuss the topic based on evidence offered by science. 

The following episode is not recommended for young children or people who consider sex a sensitive topic. 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.

___________________________

Sexercise. 
Written by Valerie Civelli, MD. Comments by Namdeep Grewal, MD; and Hector Arreaza, MD.

A: If I say “bow chika wow wow” what’s the first thing that comes to mind? The Chipmunks movie right?

B: Yes, exactly, I can hear Alvin in his high-pitched voice, [higher tone] “bowchicka wow wow”. For those of you unfamiliar with this movie, don’t feel too left out because even Alvin was hinting to exactly what you’re thinking.

A: Yep, we’re going there today people.  Let’s talk about sex.  Medically speaking of course. 

B: That’s right because 1. If you’re doing it, your risk for heart attacks and strokes are decreased after age 50 and 2. If you’re not doing it, ask you’re doctor, we should be discussing it and why not.

A: Yes, that is the guideline-directed recommendation actually. We’re recognizing more and more the importance of sexual activity in medicine and its impact on overall health, quality of life and even level of risk for mortality. However, given the sensitive nature of sexuality, few studies have been done to better correlate and define exactly what this means for our health specifically. Sex can be an embarrassing topic to discuss by patients, doctors and researchers which has been largely influenced by culture, religion and other societal norms.  Well, today let’s break this proverbial glass. 

B: I agree, let’s talk about sexuality activity and what research do we have.

A: It has been said that Dr. Masters and Dr. Johnson were the earliest pioneers of this type of investigation. They published the first study of its kind in 1966, which examined the physiological responses of sexual activity. This was an 11-year observational study involving 382 females, ages 18 to 78, and 312 male volunteers, 21 to 89 years of age. The study identified a progressive increase in respiratory rates, up to 40 per minute, an increased heart rate 110 to 180 beats/min and an increase in systolic blood pressure by 30 to 80mmhg during sexual activity. 

In 1970, Hellerstein and Friedman identified the mean heart rate at the time of orgasm was 117.4 beats per minute with a range of 90 to 144. This was done in middle-age men, average age 47.5. Interestingly, the 24-hr ekg monitoring also identified a lower peak post coital heart rate, which was usually lower than the heart rates achieved with normal daily activities (around 120.1 beats per minute). 

In 1984, Bohlen et al. did a racier study with 10 couples using ECG, oxygen consumption (measured using a fast-responding polarographic O2 gas analyzer), heart rate and blood pressure monitoring before and during 4 types of sexual activity. This study obtained data during self-stimulation, partner stimulation, man-on-top and woman-on-top coitus.  The men were aged 25 to 43 years of age.  Results showed that self-stimulation increased the heart rate by 37 % from baseline to orgasm compared with a 51 % increase with man-on-top coitus. 

B: So already it was clear in 1966 to 1984 that physical exertion in the bedroom correlates to physiologic responses like increased heart rate, blood pressure, etc.  However, our question of the day is, does sexual activity count as exercise, and to that question we ask why or why not?

A: When I think about exercise, I think about heart rate and blood pressure.  I think about indicators of energy expenditures and/or intensity. And specifically, while I’m working out…I’m talking about at the gym, and I’m running on the treadmill for example, my mental state is, how much longer until I can quit.  Duration and level of intensity while under this physical exertion feels most important. And according to the AHA, this has been heavily studied.  That’s why 150 active intentional minutes of exercise are recommended per week to improve cardiovascular health. Does this translate to sexual activity? 

B: Well before we answer this, let’s first mention the Bruce protocol. Have you ever heard of this? The Bruce protocol is a standard test of cardiovascular health, comprised of multiple stages of exertion on a treadmill, with three minutes spent per stage. Also at each stage, the incline and speed of the treadmill are elevated to increase cardiac work output, which is called METS. Stage 1 of the Bruce protocol is performed at 1.7 miles per hour and a 10% incline. Stage 2 is 2.5 mph and 12%, while Stage 3 goes to 3.4 mph and 14%. If you’re a pilot for example, the FAA expects testing to achieve 85-100% of Maximum Predicted Heart Rate (220 minus your age) for a 9-minute duration.  

With the Bruce protocol in mind, we circle back to our question of the day, does sex count as exercise?

A: In 2007, Palmeri et al. reported that in 19 men and 13 women aged 40-75 years old, the intensity of sexual activity was comparable to stage II of the standard multistage Bruce protocol (moderate intensity) on a treadmill for men and stage I (low intensity) for women. In addition, maximal heart rate and blood pressure during sexual activity was approximately 75 % of that attained during maximum treadmill stress testing of the Bruce protocol. Collectively, based on these above studies, the physiological responses of sexual activity seem to be at a moderate intensity.

B: Okay, so “you’re saying there’s a chance.” Right, one in a million Lloyd. Another movie reference, if you’ve seen the American classic Dumb and Dumber, you can appreciate it.  The point is, the level of intensity was identified by Palmeri’s research but are we convinced sex may be used as exercise based on studies that were conducted more than a quarter of a century ago? As a studious, thriving resident physician, with a heavy background in research, I turned to Up to date for more data, and recommendations.  I had zero findings. 

Naturally I turned to Men’s Health magazine to see what is out there to the general public:

A: “You’re in bed with your partner and you just finished a vigorous sex session. You’re hot and sweaty, worked past that side cramp you got while thrusting, and are convinced you just burned as many calories as you would at the gym. You figure you can skip the treadmill today since your sex workout—a.k.a sex exercises, a.k.a sexercises—got you plenty of cardio.

Well, we may have bad news: it depends on the type of sex you’re having—specifically, how active you are during it, and how long you’re having it—but unless you’re really going at it for a couple of hours, odds are, it wasn’t that great of a workout.

To better quantify this, couples were evaluated while running on a treadmill for 30 minutes and compared to their sexercise.

The results, which were published in the journal PLOS ONE, concluded that men burn 100 calories during the average sex session, while women burn about 69 calories. The researchers estimated that men burn roughly 4.2 calories per minute during sex, while women burn 3.1 calories.

B: Men may be more physically active during sex which potentially explains why they burn more calories, study author Antony Karelis. But the main reason, Karelis told Time, is that “Men weigh more than women, and because of this, the energy expenditure will be higher in men for the same exercise performed.”

It's also worth knowing that sex sessions in the study lasted an average of 25 minutes That's far longer than average. Times varied in the study, ranging from 10 to 57 minutes. 

A: The longer the session, the more calories burned. 

B: One study in the New England Journal of Medicine found that most sex sessions last six minutes.

A: Here are some tips for burning more calories during sex:

Make some moans and sighs to burn some extra calories.

Change your position to make it more of a workout, especially women. If you're on top, move your hips like a belly dancer. It will feel good while giving you a workout.

Experiment with a position where you squat on top of your partner and then bounce up and down. That's a great way to work out your thighs and rear.

Try being on top rather than on the bottom, because research suggests that requires more energy.

Kiss in unusual positions. Have the guy on his back. Do a push up on top of him. Come down to kiss him and then push back up.

Take off your clothes in ways that burn calories. Draw it out and make it part of your foreplay. Or tease him as you get undressed. Do a seductive dance with a silk scarf, for example.

Give a good massage to get your heart rate up. Ramp things up by going deeper. It's more sensual and works different muscles. Take turns so you can both get the calorie burn and its arousing impact.

B: Harvard source: During sexual intercourse, a man's heart rate rarely gets above 130 beats a minute, and his systolic blood pressure nearly always stays under 170. All in all, average sexual activity ranks as mild to moderate in terms of exercise intensity. 

A: As for oxygen consumption, it comes in at about 3.5 METS (metabolic equivalents), which is about the same as taking a walk or playing ping pong. Sex burns about five calories a minute; that's four more calories used than watching TV.

B: How do we decide if one is fit enough for sexual activity? For a 50-year-old man, the risk of having a heart attack in any given hour is about one in a million; sex doubles the risk, but it's still just two in a million. For men with heart disease, the risk is 10 times higher — but even for them, the chance of suffering a heart attack during sex is just 20 in a million. In short, if you are able to climb 3 flights of stairs, you are safe to proceed. 

A: Circling back to exercise, keep in mind 4-5 calories burned per minute is still better than zero. Any time spent engaging in any level of physical activity is better than sitting on the couch. 

B: Further, “Having sex for at least 10 minutes contributes to your cardiorespiratory health, increased serotonin levels (the happy hormone), and improved sleep,” Silberstang says. Studies have found that sex can relieve everything from anxiety and depression to high blood pressure. 

A: When men orgasm, their bodies release serotonin, oxytocin, and prolactin, all hormones associated with better moods, relaxation, and lowered stress. Multiple studies have also found links between regular sex and a reduced risk for heart disease and prostate cancer, and a stronger immune system. One reason that sex isn’t classified as a workout is due to its average duration: 3 to 13 minutes,” Silberstang explains. “So, naturally, one of the ways to make sex more of a cardio workout is to increase the time of the act.”

C: The present study indicates that energy expenditure during sexual activity appears to be approximately 85 kcal or 3.6 kcal/min and seems to be performed at a moderate intensity in young healthy men and women. These results suggest that sexual activity may potentially be considered, at times, as a significant exercise. Moreover, both men and women reported that sexual activity was a highly enjoyable and more appreciated than the 30 min exercise session on the treadmill. Therefore, this study could have implications for the planning of intervention programs as part of a healthy lifestyle by health care professionals. 

B: We look forward to future studies that may further show the relationship between psychosocial/qualitative factors and energy expenditures which could explain how these variables could affect overall health and quality of life.

____________________________

Now we conclude episode 100, “Sexercise.” If you ever wondered if sexual intercourse was a good workout, today we learned that in general it is not an energy-demanding activity. The average man burns just 24 kilocalories during sex, but with some adjustments you can burn more calories, especially if the activity takes longer. If your patient is not having sex, they do not have to start having it just to exercise, remind everyone to be sexually responsible to prevent the spread of sexually transmitted infections and unintended pregnancies. Even without trying, every night you go to bed being a little wiser.

Today we thank doctors Valerie Civelli, Namdeep Grewal, and Hector Arreaza. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week!

_____________________

References:

Frappier, Julie; Isabelle Toupin, Joseph J. Levy, Mylene Aubertin-Leheudre, and Antony D. Karelis. Energy Expenditure during Sexual Activity in Young Healthy Couples, PLOS One, plos.org, Published: October 24, 2013, https://doi.org/10.1371/journal.pone.0079342.

Casazza, Krista, Ph.D., R.D.; Kevin R. Fontaine, Ph.D.; Arne Astrup, M.D., Ph.D.; et al. Myths, Presumptions, and Facts about Obesity, N Engl J Med 2013; 368:446-454 DOI: 10.1056/NEJMsa1208051

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DeBusk R, Drory Y, Goldstein I, Jackson G, Kaul S, Kimmel SE, Kostis JB, Kloner RA, Lakin M, Meston CM, Mittleman M, Muller JE, Padma-Nathan H, Rosen RC, Stein RA, Zusman R. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of The Princeton Consensus Panel. Am J Cardiol. 2000 Jul 15;86(2):175-81. doi: 10.1016/s0002-9149(00)00896-1. PMID: 10913479.

Davey Smith G, Frankel S, Yarnell J (1997) Sex and death: are they related? Findings from the Caerphilly Cohort Study. BMJ 315: 1641-1644. doi:https://doi.org/10.1136/bmj.315.7123.1641. 

Ebrahim S, May M, Ben Shlomo Y, McCarron P, Frankel S et al. (2002) Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study. J Epidemiol Community Health 56: 99-102. doi:https://doi.org/10.1136/jech.56.2.99. 

Laumann EO, Glasser DB, Neves RC, Moreira ED Jr. (2009) A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int J Impot Res 21: 171-178. doi:https://doi.org/10.1038/ijir.2009.7. 

Lindau ST, Gavrilova N (2010) Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ 340: c810. doi:https://doi.org/10.1136/bmj.c810. 

Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA et al. (2007) A study of sexuality and health among older adults in the United States. N Engl J Med 357: 762-774. doi:https://doi.org/10.1056/NEJMoa067423. 

McCall-Hosenfeld JS, Jaramillo SA, Legault C, Freund KM, Cochrane BB et al. (2008) Correlates of sexual satisfaction among sexually active postmenopausal women in the Women's Health Initiative-Observational Study. J Gen Intern Med 23: 2000-2009. doi:https://doi.org/10.1007/s11606-008-0820-9. 

Bartlett RG Jr. (1956) Physiologic responses during coitus. J Appl Physiol 9: 469-472. 

Bohlen JG, Held JP, Sanderson MO, Patterson RP (1984) Heart rate, rate-pressure product, and oxygen uptake during four sexual activities. Arch Intern Med 144: 1745-1748. doi:https://doi.org/10.1001/archinte.144.9.1745.  

Hellerstein HK, Friedman EH (1970) Sexual activity and the postcoronary patient. Arch Intern Med 125: 987-999. doi:https://doi.org/10.1001/archinte.125.6.987.  

Larson JL, McNaughton MW, Kennedy JW, Mansfield LW (1980) Heart rate and blood pressure responses to sexual activity and a stair-climbing test. Heart Lung 9: 1025-1030.

Masini V, Romei E, Fiorella AT (1980) Dynamic electrocardiogram in normal subjects during sexual activity. G Ital Cardiol 10: 1442-1448. 

Nemec ED, Mansfield L, Kennedy JW (1976) Heart rate and blood pressure responses during sexual activity in normal males. Am Heart J 92: 274-277. doi:https://doi.org/10.1016/S0002-8703(76)80106-8.  

Palmeri ST, Kostis JB, Casazza L, Sleeper LA, Lu M et al. (2007) Heart rate and blood pressure response in adult men and women during exercise and sexual activity. Am J Cardiol 100: 1795-1801. doi:https://doi.org/10.1016/j.amjcard.2007.07.040. 

Casazza K, Fontaine KR, Astrup A, Birch LL, Brown AW et al. (2013) Myths, presumptions, and facts about obesity. N Engl J Med 368: 446-454. doi:https://doi.org/10.1056/NEJMsa1208051. 

Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN et al. (2007) Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 39: 1423-1434. doi:https://doi.org/10.1249/mss.0b013e3180616b27.  

Drenowatz C, Eisenmann JC (2011) Validation of the SenseWear Armband at high intensity exercise. Eur J Appl Physiol 111: 883-887. doi:https://doi.org/10.1007/s00421-010-1695-0.  

Johannsen DL, Calabro MA, Stewart J, Franke W, Rood JC et al. (2010) Accuracy of armband monitors for measuring daily energy expenditure in healthy adults. Med Sci Sports Exerc 42: 2134-2140. doi:https://doi.org/10.1249/MSS.0b013e3181e0b3ff. 

Mackey DC, Manini TM, Schoeller DA, Koster A, Glynn NW et al. (2011) Validation of an armband to measure daily energy expenditure in older adults. J Gerontol A Biol Sci Med Sci 66: 1108-1113.  

Mignault D, St-Onge M, Karelis AD, Allison DB, Rabasa-Lhoret R (2005) Evaluation of the Portable HealthWear Armband: a device to measure total daily energy expenditure in free-living type 2 diabetic individuals. Diabetes Care 28: 225-227. doi:https://doi.org/10.2337/diacare.28.1.225-a.

Ryan J, Gormley J (2013) An evaluation of energy expenditure estimation by three activity monitors. Eur J Sport Sci: 1-8.

St-Onge M, Mignault D, Allison DB, Rabasa-Lhoret R (2007) Evaluation of a portable device to measure daily energy expenditure in free-living adults. Am J Clin Nutr 85: 742-749. 

Welk GJ, McClain JJ, Eisenmann JC, Wickel EE (2007) Field validation of the MTI Actigraph and BodyMedia armband monitor using the IDEEA monitor. Obesity (Silver Spring) 15: 918-928. doi:https://doi.org/10.1038/oby.2007.624. 

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Brazeau AS, Karelis AD, Mignault D, Lacroix MJ, Prud'homme D et al. (2011) Test-retest reliability of a portable monitor to assess energy expenditure. Appl Physiol Nutr Metab 36: 339-343. doi:https://doi.org/10.1139/h11-016. 

Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN et al. (2007) Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation 116: 1081-1093. doi:https://doi.org/10.1161/CIRCULATIONAHA.107.185649. 

Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr. et al. (2011) 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc 43: 1575-1581. doi:https://doi.org/10.1249/MSS.0b013e31821ece12. 
 

Steinke EE, Jaarsma T, Barnason SA, Byrne M, Doherty S et al. (2013) Sexual Counseling for Individuals With Cardiovascular Disease and Their Partners: A Consensus Document From the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP). Circulation. 

Episode 99: Intermittent Fasting 99. 

By Danish Khalid, MS4; Sapna Patel, MS4; Ross University School of Medicine. Comments by Valerie Civelli, MD; and Hector Arreaza, MD.

Intermittent caloric restriction may seem like a new trend, but Sapna and Danish discussed that actually fasting is practiced in different cultures and it has many health benefits, including weight loss. .  

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.

D: Welcome and thank you for tuning back to our Nutrition series! Today, we want to give a shout out to one of our listeners. She brought up a topic that has recently gained public interest. Intermittent fasting. So, if you’re listening, Hina Asad, this one's for you! Let’s jump in!

V: 2/3 women are overweight and obese. 1.5 pounds gained/yr on avg age 50-60’s.

S: So like we said earlier, intermittent fasting has recently gained much public interest as a weight loss approach. Or should I say, revitalized itself, as it has been around for years. It describes an eating pattern in which you alternate between periods of eating and fasting (or not eating). The length of each fast can vary in duration.

A: There are feasting and fasting periods, or fed states and fasting states. What is more effective: Intermittent restriction of calories or continuous restriction of calories?

D: Before we dive in, let’s go back. We know that calorie reduction has been consistently found to produce reduction in body weight and improve overall health. We talked about how to calculate our basal metabolic rate and subtracting calories from our daily caloric intake to result in weight loss. However, this can be difficult to sustain over a long period. Additionally, it requires that you adjust your caloric needs every so often as you lose weight, which can further make it difficult. So how is intermittent fasting different from this?

S: Well, in contrast to calorie reduction, intermittent fasting focuses on when calories are consumed and the total quantity consumed. Intermittent fasting works through an altered liver metabolism, referred to as the “metabolic switch.” It’s where the body periodically switches from liver-derived glucose to adipose-derived ketones. In doing so, it stimulates an adaptive response including improved glucose regulation, improved insulin sensitivity, and increased stress resistance via conditioning.

V: When you eat is more important than what you eat. Benefits: reducing cancer, Alzheimer's, DM risk, better sleep, less hangry(*find evidence).

D: What happens when we fast? In our previous podcast we mentioned ketosis, but let's talk about the physiology behind fasting.

Feeding: blood sugar levels rise as we absorb food and insulin levels rise in response to move glucose into the cell. Excess glucose is stored as glycogen in the liver to convert it to fat.

S: Postabsorptive phase (6-24hrs after beginning fasting): Blood glucose and insulin start to drop. To supply energy ,the liver starts to breakdown glycogen, releasing glucose. Glycogen stores last 24-36hrs.

V: Insulin levels are low, and fat stores are available and improves mental clarity

D: Gluconeogenesis (24hrs - 2 days after beginning fasting): Glycogen stores run out. The liver manufactures new glucose from amino acids called “gluconeogenesis” ( literally “making new glucose)

S: Ketosis (2- 3 days after beginning fasting).

A: Autophagy: “Auto” means self and “phagy” means eat. So the literal meaning of autophagy is “self-eating.”

S: The protein conservation phase (5 days after beginning fasting): High levels of growth hormone maintain muscle mass and lean tissues. The energy for basic metabolism is mostly supplied by fatty acids and ketones. Blood glucose levels are maintained by gluconeogenesis using glycerol. Increased adrenaline levels prevent any decrease in metabolic rate. There is a normal amount of protein turnover, but it is not being used for energy.

V: How long should we fast for?

D: Fasts can range from 12 hours to three month or more. We can categorize them as short (<24 hours) and long (>24 hours). However, shorter regimens are generally used by those mostly interested in weight loss. The short daily fasting regimens can be divided into the length of fasting - 12 hours fasts, 16 hours fasts, and 20 hours fasts.

S: Daily 12 hour fasting introduces a period of very low insulin levels during the day with 3 equally spaced meals throughout the day. This prevents the development of insulin resistance, making the 12 hour fast effective against obesity. Although a great preventative strategy, it is not the most effective at reversing weight gain.

D: Fun Fact: In years past, the 12 hour fasting period was considered a normal eating pattern. This probably explains why prior to the 1970s, there was much less obesity. It wasn’t until the 1970s when the USDAs made dietary changes making a higher-carb and lower-fat diet a staple. That’s when obesity started to rise.

S: On the other hand, during the 16 hour fasts most people skip the morning meal to account for the extra hours. In this regimen, you have an 8-hour eating window period, this is why it’s also called time-restricted eating. Although you can still eat 3 meals most people tend to stick to 2 meals. The 16 hour fast certainly has more power than the 12 hour fast, but it should be combined with low-carb diets to allow for a slow and steady weight loss.

A: Feasting periods should not be so liberal, and over time it becomes easier to control hunger.

V: Feeding hours: healthy fats, proteins, fish, avocados, grass fed butter, unprocessed carbs (especially Low glycemic berries, squash, quinoa, vegetables, Low sugar, low alcohol intake

… eating healthy basically.

D: Fun Fact: A Swedish bodybuilder named Martin Berkha popularized this regimen, which is why you will also hear it being called the LeanGains method.

V: Skipping breakfast reduces caloric intake by 20-40%, addresses visceral fat.

S: Lastly, the 20-hour fasting regimen, also known as “the Warrior diet.” Ancient warrior tribes such as Spartans and Romans devised a “warrior diet” in which all meals are eaten in the evening during a 4 hour window. This results in a 20-hour fasting period each day. This diet also emphasizes natural, unprocessed foods and high-intensity interval training.

A: Summary: 12-hour, 16-hour, 20-hour. Dr. Jason Fung also recommends 24-hour fasting. It is basically skipping breakfast every day and skipping lunch 3 times a week. “Hunger is your friend”.

D: Before we move forward, I just want to add that not all fasts are the same. For instance, I’m a Muslim, and there’s a month where we fast for religious purposes, called Ramadan. During this time we fast from sunrise to sunset, or dawn to dusk. In contrast to traditional fasting, this fasting differs in that we don’t eat or drink anything. Even water. Whereas in intermittent fasting it’s different. Now, there have been studies done where they studied individuals during this time to see if there was any weight loss during this period. It was found that people typically lost about 1-2 pounds of weight. However, I do want to clarify this weight loss could be fat loss or muscle loss.

A: Another group of people who fast are Mormons. They traditionally fast once a month, the first Sunday of every month. It’s a complete abstinence of food and water for 24 hours, skipping 2 meals. Fasting periods are linked to improve your spiritual well-being as well.

S: Certain Hindu festivals and holy days require devotees to observe fasting as part of their

worship.

For example, Navarātrī, the nine-night celebration that occurs yearly. Some people take only water during these nine days, while some eat fruit while some eat one meal a day.

Hindus will observe fasts of varying strictness depending on individual beliefs or practices. Here are some examples of common fasts observed by Hindus:

not partaking any food or water for a set number of days.

limiting oneself to one specific vegetarian meal during the day.

eating or drinking only certain food types for a set number of days.

Avoiding eating certain food types for a set number of days.’

S: So what can I consume when I fast?Do I have to completely stop eating and drinking for those hours?

D: Only certain fluids can be consumed during fasting periods: water, tea and coffee ( iced or hot) and homemade bone broth. It's important for you to drink water frequently throughout the day. You can enjoy flat, mineral or carbonated water.

V: While Fasting: ok to have coffee, tea and water. Fasting creates a state of alertness.

S: What can you add to your water? Limes, lemons, sliced fruit (do not eat the fruit itself), vinegar, Himalayan salt, chia, and ground flaxseeds ( 1 tbsp in 1 cup water). Do not add sweetened powders even if it's sugar-free.

D: You can consume up to 6 cups of caffeinated or decaffeinated coffee on a fasting day. Black coffee is preferred, but you can add up to 1 tbsp of certain fats in your coffee. These include: coconut oil, medium chain triglyceride oil (MCT oil), butter, ghee, heavy whipping cream (35% fat), half and half, whole milk, ground cinnamon for flavor.

V: Ghee butter is clarified butter with no lactose.

A: You can curve appetite by drinking water, eating grains of salt, and drinking pickle juice (use a straw to avoid dental problems)

S: You can consume unlimited herbal tea during your fasting period. I know Danish and I both are Tea Connoisseurs. Right Danish? Teas can suppress your appetite, lower your blood sugar levels and are otherwise beneficial (positivi-tea). Bitter melon tea, black tea, cinnamon chai tea and oolong tea, help lower blood sugar levels. Peppermint tea and green tea help suppress appetite. Peppermint is good for GI discomfort such as gas and bloating.

A: Peppermint oil is good for IBS.

D: It's not uncommon to experience some lightheadedness during your first few days of fasting periods. This is often caused by dehydration and decreased levels of electrolytes. An easy remedy is a good homemade broth. Both vegetable and meat or bone broth will work. Things you can include in your broth: any vegetable that grows above the ground, leafy greens, carrots, onions, bitter melon, animal meat and bones (mostly bones, any animal), Himalayan salt, any herbs or spices, ground flaxseeds. Avoid vegetable puree, potatoes, yams, beets or turnips and store bought broths. (Dr. Fung).

A: This is the end of this part on “How to fast”. Some people think fasting includes being hungry the whole day, but the “hungry” feeling goes away after 1 hour, and you learn to recognize the cues from your body about hunger and satiety.

___________________________________________________________________________

Now we conclude our episode number 99 “Intermittent Fasting 99.” This is not a complete guide to fasting, it’s only a brief overview. Fasting has become a new nutritional trend with proven benefits. Remind your patients that one of the secrets of fasting is “delay, don’t deny”, meaning they can delay eating a few hours and then enjoy what they like the most. Sapna, Danish and Dr. Civelli also reminded us to eat with moderation after breaking our fast to maintain the benefits of fasting. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Sapna Patel, Danish Khalid and Valerie Civelli. Audio edition: Suraj Amrutia. 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!

_____________________

Resources:

Fung, Jason, MD; and Jimmy Moore. “The Complete Guide to Fasting.” Victory Belt Publishing. 2016. p179-189;199-209.

Episode 98: Apretude and code blue. 

Apretude is a new injectable medication for HIV pre-exposure prophylaxis (PrEP), Dr. Yomi presents how to use it. Then, Mandeep, Jon, and.  

Introduction: Apretude, a new injectable for HIV PrEP.  
By Timiiye Yomi, MD. Moderated by Jennifer Thoene, MD.  

What is HIV PrEP?Pre-exposure prophylaxis (or PrEP) consists of taking medication when a patient has a high risk of contracting HIV to lower their chances of getting infected. 

Who can take HIV PrEP?Individuals who may benefit from PrEP include but are not limited to: Male who have sex with male (MSM), people with multiple sexual partners with no consistent use of condoms, or people who have been diagnosed with an STD in the past 6 months, IV drug users who share needles, syringes, or other injection equipment.

History of HIV PrEP: In 2012, the first medication for HIV PrEP was approved—Truvada® (tenofovir-emtricitabine). Truvada is a once-daily oral prescription drug. Seven years later, in 2019, the next medication for HIV PrEP was approved— Descovy® (tenofovir alafenamide and emtricitabine). It is also a daily PO medication. But today we want to introduce you to the newest medication for HIV PrEP—Apretude® (cabotegravir). On Dec 20, 2021, FDA approved Apretude (cabotegravir), an extended-release injectable for HIV-1 pre-exposure prophylaxis for at-risk adolescents and adults who weigh at least 35 kg (77 lbs).

Mechanism of action:Apretude is a long-acting integrase inhibitor that works by binding to the HIV integrase active site and blocking the strand transfer step of retroviral DNA integration.

How is it given? 

Comes as a 600-mg (3-mL) injection. Patients receive 2 initiation injections administered 1 month apart, thereafter every 2 months. Patients can start medication immediately or first take the oral formulation for 4 weeks to assess how well they tolerate the medication before beginning the injection.

Trials: The safety and efficacy of Apretude in reducing the risk of contracting HIV-1 were evaluated in two randomized double-blind trials comparing Apretude and Truvada (once-daily oral medication).

Trial 1: Participants who took Apretude had a 69% less risk of contracting HIV compared to Truvada.

Trial 2: Participants who took Apretude had a 90% less risk of contracting HIV compared to Truvada.

Common side effects:Fever, malaise, fatigue, sleep problems, myalgias and arthralgias, headache, rash, red and swollen eyes, edema of face, lips, mouth, tongue; GI discomfort, hepatotoxicity, and depression.

Note:Some drug-resistant HIV variants have been identified in people with undiagnosed HIV prior to beginning Apretude. People who test positive for HIV while on Apretude must transition to a complete HIV treatment regimen as Apretude is not approved for HIV treatment. 

Requirements to receive Apretude: 

-Patient must be HIV-1 negative

-Patient must remain negative to continue receiving Apretude

-Patient must not miss any injections as this increases their risk of contracting the virus 

Apretude does not protect against other sexually transmitted infections. Patients must be sexually responsible and use other forms of protection such as condoms during sexual intercourse.

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.

___________________________

A code blue in clinic.  

By Manpreet Singh, MS3; Jon-Ade Holter, MS3; and Sheinnera Gerongay, MS3. Ross University School of Medicine.

What is a code blue?

Arreaza: Today we will present to you a case to remind you about some principles of cardiopulmonary resuscitation (CPR). The term “code blue” in the United States refers to a situation where a patient is in cardiac arrest, respiratory arrest, unresponsive, or experiencing another medical emergency that requires immediate attention. “Code blue” is commonly used in hospitals and clinics to call a rapid response team to arrive immediately to evaluate the patient. We hope you can benefit from this brief review and feel ready for your next code blue. Of course, you will need more than we provide during these few minutes, but we hope it triggers your curiosity to keep learning or practicing. By the way, “code blue” is not standard for medical emergency in the whole world. For example, in the United Kingdom, they call it “code red”.

Case presentation:Mr. DD56-year-old man with a past medical history of coronary artery disease, recent MI, DM2, and CHF presents today to our clinic for hospital follow. He had an MI 2 weeks ago. He reports that when he was at home working in the yard, he suddenly had 8/10 retrosternal chest pain, pressure-like, accompanied by shortness of breath and diaphoresis. The pain radiated to the left side of his neck/jaw and down his left shoulder and arm. 

Jon: Nitroglycerin was taken by Mr. DD 3 times without resolution of symptoms. The patient was taken by EMS to Kern Medical ER. In the hospital, there was a 4mm ST elevation on ECG on leads II, III, and aVF. Q waves were also seen in anterior leads V4-V6. Patient was taken to cath lab and stent was placed in the RCA. ECHO showed decreased left ventricle wall motion and dilated left ventricle with an ejection fraction of 28%. Mr. DD was discharged after 5 days in the hospital.

M: He is currently on lisinopril, carvedilol, atorvastatin, aspirin, clopidogrel, metformin, and digoxin. He states he is not compliant with all the medications because he forgets to get refills at times. He has a 35-pack year history of smoking and drinks 3-4 4oz drinks every day after work. He states he has used methamphetamine and cocaine intermittently within the last 6 months.

J: Today, he lets the MA know that he is having some chest pain at night, shortness of breath with minimal activity for the last week, and at times he feels his heart is beating too fast. He has a follow-up appointment with cardiology in 2 weeks. The MA tells you that the patient vitals today are BP:195/105, HR: 108, RR: 28, and O2% 89% on room air. 

M: You are reviewing the patient’s chart when you hear a loud thud coming from the room, you rush into the room and find the patient on the ground. The patient is unresponsive and is not moving. What is your next action? 

A. Try to lift the patient off the ground and back onto the chair or bed 

B. Give the patient nitroglycerin sublingually 

C. Call and wait for the EMS before proceeding 

D. Obtain IV access

E. See if the patient is arousable and check pulse and breathing 

E is the correct answer to this question because before initiating any type of treatment, first, you must assess the patient for alert response and their basic vitals such as their pulse and breathing.

J: We do this because we need to know if the cardiopulmonary systems are intact. When they are not intact, regardless of the level of medical training, we must start CPR protocol. 

M: This patient most likely suffered a tachyarrhythmia, a very common post-MI-complication that causes the highest mortality rates. The most common cause of death are ventricular fibrillation and ventricular tachycardia. 

J: These are the steps we must take in order to start resuscitation of the cardiopulmonary system in any environment before the patient can be taken to a higher level of care. In this situation, Doctor Holter and Doctor Singh will perform 2-patient CPR. This is only an introduction of basic life support and advanced cardiac life support. You will need additional training to get the BLS and ACLS certificates. 

M: First, assure your environment is safe before preceding to render care. You want to be able to give the best uninterrupted care to your patient without becoming a patient yourself. 

Jon: Doctor Holter. Mandeep: Doctor Singh.

J - Doctor Holter: I will reach down and check the patient. “Sir, Sir, are you okay” – I am assessing for reactions from visual or verbal cues given by me. When the patient is unresponsive to verbal and visual cues, I will give a painful stimulus to the patient such as a nail bed pinch or sternal rub. Next, it is necessary to assess the pulse and breathing of the patient. 

Narrator: The reason we check if the patient is alert is to assess the neurologic activity. The lack of response to painful stimuli indicates there is no self-protect response. To assess the carotid pulse, you must palpate the carotid artery by placing the index and middle fingers near the upper neck between the sternomastoid and trachea roughly at the level of the cricoid cartilage. Assess breathing by checking the rise and fall of the chest. Lack of responsiveness, pulse, and breathing indicates that immediate Cardiopulmonary Resuscitation (CPR) needs to be initiated. 

J - Doctor Holter: Please call 911 and get an AED.

M - Doctor Singh: I will call 911 and get an AED.

J- Doctor Holter: I will place the person on their back and start single-person CPR until Doctor Singh comes back. 

Narrator: CPR is performed by placing the patient flat on their back on an even surface. Place the heel of your hand on the center of the person’s chest (on the mid sternum) then place the palm of your other hand on top. Press down 5-6 cm (2-2.5 inches) at a rate of 100-120 beats per minute. Compressions should not be interrupted because they serve as an artificial way of contracting the heart and circulating the blood to maintain blood perfusion. 

For 1 or 2 person CPR on an adult: Give 5 cycles of 30 compressions to 2 breaths.

For 1 person CPR on a child: Give 5 cycles of 30 compressions to 2 breaths.

For 2 person CPR on a child: Give 5 cycles of 15 compressions to 2 breaths.

M - Doctor Singh : Doctor Holter, continue the compressions and I will give rescue breaths and start to place the AED pads on the patient. Let me know if you are tired and we can switch to give high-quality CPR with adequate depth and rate. 

Narrator: The AED comes with a diagram made on the pads to instruct where to place the pads. Once an AED is positioned correctly on the patient’s chest, let it detect if a shockable rhythm is present. Shockable rhythms include ventricular fibrillation and ventricular tachycardia. If there is not a shockable rhythm detected, then continue with CPR until a higher level of care is reached. If a shockable rhythm is detected, the AED will advise the users to step back and verbalize “clear” in order to ensure that everyone is clear of the patient. It will then administer a shock to the patient in the range of 120-200 Joules, based on the device manufacturer’s recommendation.

M - Doctor Singh: Doctor Holter, stay clear of the patient. The AED advises shocking the patient. I will press the button to administer the shock now.

Narrator: After administration of the first shock, ACLS guidelines recommend continuing CPR for 2 minutes without checking for a pulse, as effective cardiac contractility lags behind the restoration of an organized electrical rhythm. After the next 2-minute cycle of CPR, the AED will reanalyze the patient’s rhythm to determine if the rhythm is once again shockable. 

J - Doctor Holter: Doctor Singh , continue high-quality CPR while I initiate ACLS protocol. I will get an IV and start epinephrine. 

M- Doctor Singh: I will continue CPR in the meantime. 

Narrator: ACLS starts with again CPR, AED rhythm reading, and shock administration but with a higher level of care (ACLS). You must obtain IV or IO access. Epinephrine is administered every 3-5 minutes during the cycle in doses of 1 mg at a time. After each dose of epinephrine and CPR for 2 minutes the AED should reassess if the rhythm is shockable, and then continue CPR for another 2 minutes. At this time, it is recommended to use amiodarone or lidocaine. CPR will continue but at this time patient will likely be in the ambulance on the way to the hospital, and EMS will be managing the cycles. The cycles will continue until return of spontaneous circulation is obtained.

J: Myocardial infarction is the most common cause of shock-refractory ventricular fibrillation, along with coronary artery disease. If CPR does not resume spontaneous circulation within 40-50 minutes, there is a decreased chance of recovery. Spontaneous circulation may be achieved in patients with refractory Vfib with coronary revascularization. Therefore, in addition to traditional CPR, venoarterial ECMO (extracorporeal membrane oxygenation) can be used as an adjunct and can result in much better systemic perfusion. Essentially, this is a technique in which blood is drained from the body and circulated outside through an oxygen and heat exchanger and is then reintroduced into the body. This technique can be used if preparing for coronary revascularization. 

M: Vfib is a great risk in the acute phase after MI, up to 72 hours after revascularization, due to the recent ischemia and reperfusion. After the first 72 hours and up to a month following, Vfib remains a risk due to the continued remodeling of the heart. This newly remodeled tissue can cause interruptions in the normal electrical signaling of the heart leading to dissociated contractions and subsequent lack of perfusion through the body, which can quickly lead to death within minutes if not recognized and managed immediately with CPR and defibrillation as described.

J: Clinicians should be aware of their patients who would be more susceptible to serious events such as this and be on top of their training about management. This may not be a common occurrence in clinics, but it is a very serious event and requires a prompt and appropriate response.

Conclusion: Now we conclude our episode number 98 “Apretude and code blue.” Dr. Yomi concisely explained how to use the new injectable medication for HIV Pre-Exposure Prophylaxis (PrEP). Then, Manpreet, Jon, and Sheinnera presented a case that can actually happen in clinic and anywhere. CPR is a life-saving skill that needs to be learned and practiced over and over so we are not taken by surprise. Remember that heart disease continues to be the number 1 killer in the United States. So, make sure you know where your AED is and be ready to use it when needed. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Timiiye Yomi, Jennifer Thoene, Manpreet Singh, Jon-Ade Holter, and Sheinnera Gerongay.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week!

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References:

American Heart Association 2022 CPR cheat sheet. American Heart CPR Class, BLS, ACLS Ft. Myers all Lee County. (n.d.). Retrieved June 2, 2022, from https://www.cprblspros.com/cpr-cheat-sheet-2022.

Algorithms. CPR & First Aid, Emergency Cardiovascular Care, American Heart Association, cpr.heart.org. Retrieved June 2, 2022, from https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms.

Bhar-Amato J, Davies W, Agarwal S. Ventricular Arrhythmia after Acute Myocardial Infarction: 'The Perfect Storm'. Arrhythm Electrophysiol Rev. 2017 Aug;6(3):134-139. doi: 10.15420/aer.2017.24.1. PMID: 29018522; PMCID: PMC5610731.

Farkas, J. (2021, November 29). Post-mi complications. EMCrit Project. Retrieved June 2, 2022, from https://emcrit.org/ibcc/post-mi-complications/#ventricular_tachycardia.

Episode 97: EAT and NEAT. 

Your body burns calories not only if you exercise. Sapna, Danish, and Dr. Arreaza explain the different ways you can burn more calories.

Introduction: Energy in and Energy out
By Hector Arreaza, MD. Read by Suraj Amrutia. 

Our bodies are not machines. The simplistic concepts of energy balance, i.e., “energy in and energy out,” are influenced by a myriad of physiological processes and systems that include neurotransmitters, hormones, genetic and epigenetic factors, and many more. The combination of all these processes is called metabolism. The use of energy varies greatly among humans, that is why we come in many shapes and forms. If we apply the principles of thermodynamics to humans, people who eat the same amount of calories, have the same body weight, and have the same level of physical activity should have the same weight. But that theory has been debunked by multiple studies. That explains, for example, why some people who are naturally “thin” can remain thin regardless of their caloric intake and their physical activity. Today we will explain how our bodies use the energy that goes in, or in other words, how we spend our calories. We hope you enjoy this conversation. 

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.

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EAT and NEAT. 
By Hector Arreaza, MD; Sapna Patel, MS IV; and Danish Khalid, MS IV.  

A: Energy expenditure is the amount of energy people need to carry out their physical functions. Energy expenditure is made up of resting metabolic rate, physical activity, and dietary thermogenesis. The widest variance in energy expenditure among most individuals is physical activity.

S: For individuals with moderate physical inactivity the distribution of energy expenditure is:

~70% resting metabolic rate, ~20% physical activity, ~10% diet-induced thermogenesis.

D: Exercise Activity Thermogenesis (EAT) consists of physical activity that is planned, structured and repetitive done with the purpose of improving our well-being. Some EAT include sports, gym, etc. 

Just like gasoline for motor vehicles, available energy in muscle (ATP) is used for mechanical work, and some energy is released as heat (thermogenesis). The efficiency in converting ATP to mechanical work is ~30%; it means that out of 100 ATPs produced, 30 result in muscle work. 

A: An increase in body temperature triggers the CNS to cool the body via increased dilation of skin smooth muscle blood vessels, increased heart rate, and increased sweat production – all that help facilitate the release of heat during physical exercise. 

S: Non-Exercise Activity Thermogenesis (NEAT) consists of physical activity that is not typically considered exercise (e.g., maintaining posture, standing, walking, stair climbing, fidgeting, cleaning, singing, and other activities of daily living.) Walking can be considered EAT or NEAT.

NEAT often represents the widest variance in total energy expenditure among individuals. NEAT can range between 150-500 kcal/day, which is often greater than bouts of exercise. 

D: NEAT is an example of a behavioral factor to explain the perception that some people are “naturally skinny” and can maintain a healthier body weight compared to others, even with the same caloric intake and same routine “exercise” activity. Increasing your number of steps per day can be achieved by altering daily activity, or by scheduled walking/running. 

S: For example: Parking far away, taking the stairs instead of the elevator, going to your coworker’s office instead of calling.

A: You can monitor your number of steps per day with a pedometer or other tracking device (cell phone). The number of steps recorded by different pedometers can vary.

D: Less than 5,000 steps/day is average for U.S. adults, and it is considered sedentary.

S: 5,000 – 7,5000 steps/day is low active, and 7,500 – 10,000 steps/day is somewhat active.

A: More than 10,000 steps/day is desirable (active). 

10,000 steps per day x 7 days per week x one calorie per 20 steps = 3,500 calories burned per week.

D: On average, 1 calorie is “burned” for every 20 steps, it means 4,000 steps / 20 = 200 calories.

S: Definition of rest days. Rest days are any days that don’t involve heavy lifting and focus on cardio or core exercises. Rest days are an important part of any exercise routine as it gives your body a chance to repair and recover. At least one rest every week. 

D: On the other hand, workout days involve heavy lifting: push, pull, legs, etc. For example, on rest days I do cardio and abs.

Conclusion: Now we conclude our episode number 97 “EAT and NEAT.” Keep in mind the ways your body uses the energy you put in. Energy is used by our resting metabolic rate, our exercise activity thermogenesis (EAT), our non-exercise activity thermogenesis (NEAT), and our food-associated thermogenesis (the energy we burned while we eat). We tend to underestimate the power of NEAT, but parking your car far away, taking the stairs, and increasing your daily steps can make a big difference in your daily energy expenditure. Let’s remember the virtues of physical activity to promote good health. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Sapna Patel, and Danish Khalid. Audio edition: Suraj Amrutia. 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:

Levine JA. Nonexercise activity thermogenesis (NEAT): environment and biology. Am J Physiol Endocrinol Metab. 2004 May;286(5):E675-85. doi: 10.1152/ajpendo.00562.2003. Erratum in: Am J Physiol Endocrinol Metab. 2005 Jan;288(1):E285. PMID: 15102614.

Bays, Harold E. and William McCarthy, Obesity Algorithm® 2021©, Obesity Medicine Association. 

Episode 96: Tirzepatide. 

By Maria Beuca, MS3, Ross University School of Medicine. Comments by Hector Arreaza, MD. 

Today is May 19, 2022, and we want to talk about a new drug that was recently approved by the FDA on May 13, 2022, for the treatment of type 2 diabetes. 

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.

This drug is known as tirzepatide, also known by the brand name Mounjaro®. It is an injection given once a week that mimics the effects of two hormones: GIP (Glucose-dependent Insulinotropic Polypeptide) and GLP-1 (Glucagon-Like Peptide-1). These two hormones are involved in lowering blood glucose levels after eating by stimulating insulin release, they are “incretin” hormones. 

What is unique about this new drug, tirzepatide, is that it is the first and only approved single molecule that binds and activates BOTH GIP and GLP-1 receptors. Because of this dual incretin action, it has also been referred to as a “twincretin.” It increases first and second-phase insulin secretion AND decreases glucagon levels in a glucose-dependent manner, and this lowers both fasting blood glucose levels and post-meal glucose levels. 

It is also an appetite suppressant, causing significant weight loss in patients with type 2 diabetes. 

Tirzepatide vs semaglutide: Semaglutide (Ozempic®) was approved for the treatment of type 2 Diabetes in December 2017, and then approved for weight loss in June 2021 under the brand name Wegovy®. 

Semaglutide is a GLP-1 receptor agonist, but it does not work on GIP receptors. Due to this dual incretin action of tirzepatide, it has now been shown to be superior at all doses to semaglutide. 

Evidence: There was a 40-week study done in July 30, 2019- February 15, 2021, called “SURPASS-2”where 1879 patients were assigned in a 1:1:1:1 ratio to either semaglutide 1 mg or to the 3 different doses of tirzepatide (5 mg, 10 mg, 15 mg). The patients all had a mean HbA1c of 8.28% at the start of the study. 

By the end of the study, the patients on tirzepatide at the different doses had an A1c of 6.2% for the 5mg dose, 6 % for the 10 mg dose, and 5.9% for the 15 mg dose, whereas the patients on semaglutide had their HbA1c at 6.42%.

On tirzepatide, about 82-86% of patients decreased their HbA1c below 7.0%, compared to 79% of the patients on semaglutide.

Comment: It seems like a race: All GLP-1 RA are competing to reach the lowest A1C and get the lowest weight. What is more amazing is that up until now, an A1c level < 5.7% without a risk of hypoglycemia was not considered attainable with current treatment options, but with tirzepatide, this goal was met. 

Fasting Serum glucose levels prior to treatment: 173. Fasting Serum glucose after treatment with:

Tirzepatide 5 mg: 117.0,     10 mg:  111.3,    15 mg:  109.6. Semaglutide 1 mg: 124.4.

Comment: No hypoglycemia.

Weight loss for patients on Tirzepatide was also greater, patients lost about 4 to 12 lbs more (1.9 to 5.5 kg) than with semaglutide. Weight loss in 40 weeks: Tirzepatide:  5mg: 16 lbs (7.6 kg), 10 mg: 20 lbs (9.3 kg), 15 mg: 24 lbs (11.2 kg). Semaglutide: 12 lbs (5.7 kg).

Other positive effects that many patients experience were: improved lipid profile, blood pressure, liver enzymes, and improved biomarkers of insulin sensitivity.

Another Phase 3 clinical trial of tirzepatide that is currently ongoing is the SURMOUNT-1,which focuses on the weight loss benefits of the drug, and results are expected in 2023. Preliminary data shows that tirzepatide has similar weight loss as bariatric surgery. 

Cost:Tirzepatide (Mounjaro) is a rival for Novo Nordisk’s semaglutide sold as Ozempic and Wegovy. 

Institute for Clinical and Economic Review (ICER) released the final report for tirzepatide cost: $5,500-5,700/year. Semaglutide: Ozempic, Wegovy ~ $16,000/year without insurance. 

Comment: [3 times cheaper]. 4x more expensive in the US, rarely covered by health insurance for weight loss

Administration: 1x week, any time, with or without meals.  Doses: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg. Week 1-Week 4:Start with 2.5 mg injection 1x week. Treatment initiation, not intended for glycemic control. Week 5-Week 8: Increase to 5.0 mg 1x week. >Week 9:may increase dose another 2.5 mg every 4 weeks as needed for glycemic control. Maximum dose: 15 mg 1x week.

Adverse Reactions: Nausea, diarrhea, decreased appetite, vomiting, constipation, dyspepsia, abdominal pain. 

Drug Interactions:  Delays gastric emptying, can affect absorption of oral medications taken at the same time. Warfarin =monitor more closely.

Contraindications:Type 1 diabetes, pregnancy, personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2: medullary thyroid cancer, parathyroid tumors, and pheochromocytoma). Thyroid c-cell tumors were noticed in rats. Symptoms of thyroid cancer: mass in neck, dysphagia, dyspnea, persistent hoarseness.

Warnings & Precautions:

Pancreatitis: Has been reported in clinical trials. Discontinue if suspected. 

Hypoglycemia: May cause hypoglycemia if used with insulin or insulin secretagogues (sulfonylurea). Reducing dose of these may be necessary.

Hypersensitivityis possible.

Acute Kidney Injury: No dosage adjustment needed, but monitor renal function if patient has renal impairment with severe GI reactions. It may cause nausea, vomiting and diarrheaà dehydrationà acute kidney injury. Can worsen chronic renal disease or renal impairment.

Severe gastrointestinal disease: May cause Gastrointestinal adverse reactions, sometimes severe. Not recommended in patients with severe gastrointestinal disease, may aggravate symptoms, has not been studied.

Acute gallbladder disease:Also has occurred in 0.6% of patients in trials. monitor and follow-up if cholelithiasis is suspected. 

Diabetic retinopathy: Not studied, monitor for complications. Rapid glucose control can cause temporary worsening of diabetic retinopathy, monitor these patients. 

Pregnancy:May cause fetal harm.

Females of Reproductive potential: If using oral contraceptives, switch to non-oral contraceptive or add a barrier method for 4 weeks after starting drug and for 4 weeks after increasing dose.

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Now we conclude our episode number 96 “Tirzepatide.” Maria explained that tirzepatide has a dual effect on both GLP-1 and GIP receptors. The medication has been approved for the treatment of type 2 diabetes, but it has been proven to be very effective for weight loss also, almost comparable to bariatric surgery. Remember the contraindications and side effects of this medication to use it appropriately. The good news with tirzepatide is the cost —almost 3 times lower cost than its main competitor. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza and Maria Beuca.

Audio edition: Suraj Amrutia. 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! 

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References:

Dockrill, Peter. “Experimental Drug Breaks Record for Weight Loss in Latest Clinical Trial Results.” ScienceAlert, 9 May 2022, https://www.sciencealert.com/experimental-drug-breaks-record-for-weight-loss-in-latest-clinical-trial-results.

Frías, Juan P., et al. “Tirzepatide versus Semaglutide Once Weekly in Patients with Type 2 Diabetes: Nejm.” New England Journal of Medicine, 5 Aug. 2021, https://www.nejm.org/doi/full/10.1056/NEJMoa2107519.

“Label as Approved by FDA. - Pi.lilly.com.” Mounjaro Prescribing Information, Lilly USA, LLC, May 2022, https://pi.lilly.com/us/mounjaro-uspi.pdf.

Mounjaro. Prescribing Information. Lilly USA, LLC.  May 2022. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi

Episode 95: Exercise Medicine. 

Exercise can be used as medicine if given at the right dose and frequency. Sapna and Danish explain some principles of exercise medicine. 

[Add brief summary for posting on website]

Introduction: Is the monkeypox a hoax?   
By Hector Arreaza, MD.  

Today is May 27, 2022. Before we dig into exercise, I want to share some information about a trending topic.

I remember my lectures on public health in medical school in the late 90s when my teachers taught me about the tremendous accomplishment of humanity in eradicating smallpox. The last natural outbreak of smallpox in the United States occurred in 1949, and the last case of smallpox was recorded in Somalia (Africa) in 1977. Until it was wiped out, smallpox had plagued humanity for at least 3000 years, killing 300 million people in the 20th century alone, but the World Health Organization declared smallpox eradicated in 1980. No cases of natural smallpox have happened ever since, and if you discovered a case of smallpox, I was told by my teachers, you would be awarded one million dollars by the WHO. I did my research online and I could not confirm that information, but I learned that the variola virus (smallpox virus) is kept only in two locations in the planet: the CDC in Atlanta, Georgia, United States and the VECTOR Institute in Koltsovo, Russia.  

Why am I talking about smallpox? Because the monkeypox is a new trending topic in the media. Now as the COVID-19 panorama starts to look somehow comforting, monkeypox is starting to gain more attention in the media. Even the name “monkeypox” sounds terrifying. The CDC issued a health alert on May 20, 2022, about the most recent confirmed case of monkeypox in the United States, but this is not the first case of monkeypox in the US. In 2021 there were two travel-associated cases, and in 2003 there was an outbreak of 47 cases associated with imported small mammals. Cases of monkeypox have been identified in several non-endemic countries since early May 2022; many of the cases have involved men who have sex with men (MSM) without a history of travel to an endemic country. Cases of monkeypox outside of Western and Central Africa are extremely rare, and we hope they continue to be rare. 

Is monkeypox a hoax? Is it real? Only time will tell. For now, let’s be optimistic and hope for a world free of dangerous pandemics. Whether monkeypox will continue to spread or not is still unknown. 

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

[Brief music]

This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.

[Music continues and fades…] 

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Exercise Medicine. 
By Danish Khalid, MS4, and Sapna Patel, MS4, Ross University School of Medicine

Today is May 12, 2022.

D: Welcome back to our Nutrition Series! Thank you for joining us again! Nutrition is such a big part of medicine, it’s the answer to many chronic diseases and yet it’s the most neglected subject in medicine. Our goal here is to educate not only ourselves but our patients and bring awareness of this discrepancy we’ve created in medicine.

S: If you’re new to this series, I suggest you pause this and listen to the first few episodes as we build upon them each time. In our previous episode, we discussed how the term “diet” brings upon a negative connotation as well as explored various popular meal plans.

A: Exercise prescription. FITTE (Obesity Medicine Association): Frequency, Intensity, Time, Type, Enjoyment.

D: As healthcare professionals, time and time again we advise our patients “diet and exercise,” because that’s what we were taught and research has backed for many years. It’s so easily said, yet the words carry such weight. But what does that really mean? Well, that’s what we’re here to explore. At least the latter part, exercise.

S: extra fries?

D:Or shall I say, “physical activity?” Again, just like the word “diet,” “exercise” has similar negative connotations. Thus, let’s avoid saying “exercise” and resort to words such as “physical activity or workout.” Disclaimer: What we discuss here today is focused directly towards those who are beginners. For those of you who are more experienced, this may benefit as a reminder of the foundations.

A: Screen your patients. 95% of patients will benefit from exercise, and most do not need a special test. Only 5% of your patients may require additional testing.

S: So what is the best workout for me, you, or our listeners? Well, as simple as that sounds, it’s not that simple. Especially nowadays, where information is at the tips of our fingers, it is so easy to get confused on how to start. But let’s start by establishing your fitness goals. Do you want to lose fat, gain muscle, or gain muscle while losing fat?

S: Once you’ve figured that out, then it's all about small steps and achievable goals. Oftentimes, individuals start their journey to healthy living with unrealistic goals, hoping to achieve them within a few weeks or months when in actuality it takes longer. This often leads to falling off or reverting back to their unhealthy habits. But small tricks such as reducing the amount of sedentary behavior can do wonders. With technology ruling over our lives, we’ve adapted to this sedentary lifestyle, became comfortable and left physical activity behind. In fact, the National Center of Health Statistics found that only 26% of men, 19% of women, and 20% of adolescents meet sufficient activity levels.

D: So the first step: Move more, sit less. And for those with a busy lifestyle, some physical activity is better than none. According to the Physical Activity Guidelines published by the US Department of Health and Human Services, for substantial health benefits, adults should do:

At least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity aerobic physical activity.

Or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity aerobic physical activity.

And muscle-strength training of moderate or greater intensity that involved all major muscle groups on 2 or more days a week.

S: How many of you understood that? What does this all mean? Let's break it down. The amount of time for exercise is self-explanatory, but what does moderate or vigorous intensity aerobic physical activity mean? Putting it in simple terms, aerobic physical activity means “cardio”. The level of intensity varies based on the activity you perform. Moderate-intensity activities include a brisk walk or walking on the treadmill at 2.5 to 4mph, playing double tennis, or raking the yard. Whereas, vigorous or high-intensity activities include jogging, running, carrying heavy groceries or objects upstairs, shoveling snow, or participating in a strenuous fitness class. You may have heard of the terms of: low-intensity steady state (LISS) cardio and high-intensity interval training (HIIT) cardio.

A: In general, if you’re doing moderate-intensity activity, you can talk but not sing during the activity. Vigorous-intensity activity, you will not be able to say more than a few words without pausing for a breath.

D: So what’s the best cardio routine? LISS or HIIT? Well, there’s a lot of potential options. In terms of the best form of cardio for fat burning, there’s one thing you need to prioritize, that is preventing muscle loss. This enables your physique to dramatically improve as you lose weight.

S: Ok, give us the evidence.

D: One study claimed that HIIT cardio workouts should be included due to its potential muscle sparing properties. HITT training can be done in a fraction of a time as LISS and is a great cardio workout to burn fat. Furthermore, the study recommended performing lower body cardio workouts, rating bicycling as the most effective method of HIIT. However, HIIT is very demanding on the body as it may cause potential muscle recovery issues, which is why you should also combine it with a few LISS sessions per week as well. And one of the best methods of LISS include doing the stairmaster at 2.5 speed to 4. Furthermore, those looking for a fat burning effect should aim for an effective heart rate level during cardio. To keep it simple, those performing HIIT should aim to keep the heart rate 140-160 beats per minute and for LISS should aim for 110-130 beats per minute, keeping your heart rate elevated will optimize fat-burning effects from cardio.

S: When should you perform cardio? What’s the best time? Well, studies have shown that the best time to perform cardio sessions should be when you’re not strength training or right after. It was found that participants who performed cardio before strength training experienced greater muscle loss than those who performed it after, or when not strength training.

And while we’re on this topic, let’s address a myth regarding cardio: Sweating more does not equal more calories burnt. Each individual has a temperature setpoint for sweating. Once you meet that body temperature limit, you start to sweat as your body’s way of cooling down. For example, those from the midwest or east coast deal with a colder climate. Their setpoint is lower than those on the west coast or where the climate is hotter year-round. Thus, these people sweat more than others and easier.

D: How about those whose goals are to gain muscle? Is it the same or different? Don’t worry we haven’t forgotten about you guys. Although, going on a jog, or run, or riding a bike, is an effective way to help you burn some additional calories, and help you get into that hypocaloric state. It doesn’t allow you to build lean muscle tissue to achieve the desired physique many of us want. The only way to obtain that is by incorporating strength training into your regular exercise regimen. This is why the guideline, as mentioned earlier, recommends strength training in addition to cardio, notice the “AND”. Yes, I’m talking about hitting the weight on a regular basis.

S: Show me some more evidence.

D: Multiple studies have compared diet alone versus diet + weight training and diet + weight lifting + cardio after. And every single time, those with weight training wins out, especially if it’s the muscular physique you are looking to build. Now, don’t overlook this subtle difference that all exercises are created equal, because it’s not. Well, what training split should I follow then? Does it matter? The total body split, or push pull legs, or the “bro split”? You see, oftentimes people get confused as to which to choose, and that confusion can lead to no choice at all. Do whichever you like, but just make sure you’re doing this, and here’s the key: progressive overload. Adding more weight to allow more strength to build from workout to workout, or phase to phase. Or increasing metabolic overload or demand by keeping the rest time shorter and getting more work accomplished from workout to workout. Whatever strategy you choose, as long as you are striving to push yourself to a higher level of fitness and strength. That’s going to do the job.

A: Use PT to assist you to design a good physical activity plan, depending on disability or limitations of movements.

S: Yup I agree, personally I choose to increase each set by at least 10-15lbs, and rest for 30 secs to 1 mins since my goal is to increase my strength and endurance.

You know what I’ve noticed, Danish? A lot of women refused to lift weights. They want to get fit and toned, but they don’t want to look “bulky”. So, they skip the weights, and perform hours of cardio, or worse - they avoid exercising all together. A common misconception about heavy weight training, especially among women, is that lifting heavy weight will lead to a bulky looking physique. It’s true that lifting heavy will promote hypertrophy in muscles leading to a size increase. However, the idea that it leads to a “bulky” look is untrue.

The true culprit that leads to bulky physiques is fat accumulation. Excessive body fat is what causes both men and women to look bulky. The most important aspect of someone’s physique is his or her body fat percentage. A good physique nearly always requires a fairly low body fat percentage to achieve. Lifting heavy can help accomplish this.

D: What about the hormones?

S: Testosterone, or the lack thereof, is one of the main reasons that women won’t get bulky from lifting weights. Testosterone is a natural anabolic steroid, which directly stimulates muscle growth. And, on average, women only have one seventh the amount of testosterone as men. So, as usual, that means women have to work harder. But it also means you don’t really need to worry about bulking up. Heavy weight training has a plethora of benefits that can help develop muscle, shed fat, increase metabolism and ultimately lead to anyone’s desired physique.

D:Another question that gets asked a lot: which workouts will help me lose my belly fat? Should I do a lot more abdominal workouts? Although there’s so much more to this question. The simple answer: None. You cannot specifically target belly fat. Your body has its own way of allocating fat distribution, different areas in men and women. Similarly, when you lose fat, you’ll oftentimes notice different areas losing more fat first. Don’t get discouraged and be patient. As the results will come. One advise, take weekly pictures for comparison. It is said and accepted by many that it takes 4 weeks for you to see your body change, 8 weeks for friends and family to notice, and 12 weeks for the rest of the world. So keep grinding.

And last but not least, it’s important that we reiterate: physical activity only supports and aids your eating lifestyle. It will not combat a poor eating lifestyle. Proper eating habits are 80% (relative number). So keep your eating habits in check.

S:Well, that’s all we’ve got for today. If you liked this and found this helpful, feel free to reach out and let us know. It’s always a pleasure to hear from our listeners and motivates us to do more. And before we end this episode, we’d like to know: What do you want to hear about next? What questions do you have? Or something you don’t completely understand? Let us know and we’d be happy to learn with you. Till next time. Take care!

A: Email riobravoqweek@clinicasierravista.org

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[Music to end: Your Choice]

Now we conclude our episode number 95 “Exercise Medicine.” Sapna and Danish reminded us that the US Department of Health & Human Services recommends 150-300 minutes a week of MODERATE-intensity aerobic exercise AND  muscle-strength training 2 or more days a week. Most of your patients will benefit from exercise, only a minority may have contraindications to exercise, in such cases, make sure you perform a proper evaluation, even a cardiology referral, before sending them to the gym.

This week we thank Hector Arreaza, Danish Khalid, and Sapna Patel. 

Audio edition: Suraj Amrutia. 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! 

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References:

Wilson JM, Marin PJ, Rhea MR, Wilson SM, Loenneke JP, Anderson JC. Concurrent training: a meta-analysis examining interference of aerobic and resistance exercises. J Strength Cond Res. 2012 Aug;26(8):2293-307.

Wisloff, Ulrik; Ellingsen, Oyvind; Kemi, Ole J.High-Intensity Interval Training to Maximize Cardiac Benefits of Exercise Training?, Exercise and Sport Sciences Reviews: July 2009 - Volume 37 - Issue 3 - p 139-146.

Ratamess NA, Kang J, Porfido TM, Ismaili CP, Selamie SN, Williams BD, Kuper JD, Bush JA, Faigenbaum AD. Acute Resistance Exercise Performance Is Negatively Impacted by Prior Aerobic Endurance Exercise. J Strength Cond Res. 2016 Oct;30(10):2667-2681.

Foster C, Farland CV, Guidotti F, Harbin M, Roberts B, Schuette J, Tuuri A, Doberstein ST, Porcari JP. The Effects of High Intensity Interval Training vs Steady State Training on Aerobic and Anaerobic Capacity. J Sports Sci Med. 2015 Nov 24;14(4):747-55.

Michael A. Wewege, Imtiaz Desai, Cameron Honey, Brandon Coorie, Matthew D. Jones, Briana K. Clifford, Hayley B. Leake, Amanda D. Hagstrom. The Effect of Resistance Training in Healthy Adults on Body Fat Percentage, Fat Mass and Visceral Fat: A Systematic Review and Meta-Analysis. Sports Medicine, 2021.

Demco, Sonja. “Why Women Will Not Get Bulky Lifting Weights.” Demcofitness, 21 Oct. 2019, https://www.demcofitness.com/single-post/Why-Women-Will-Not-Get-Bulky-Lifting-Weights.

Episode 94: Elevated Alk Phos. 

Akhil explains what to do when the alkaline phosphatase is elevated, including labs, imaging and other studies. 

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.

Elevated Alk Phos. 
By Akhil Patel, MS4, American University of the Caribbean. Comments by Hector Arreaza, MD.

Serum alkaline phosphatase:When you find elevated serum alkaline phosphatase, you must consider the two most common sources: the liver and bones. Other sources to consider include the third-trimester placenta, intestine, and kidneys. To determine if the abnormal elevation of alkaline phosphatase has clinical significance, you need to consider if it is a physiological or pathological elevation first. 

Ruling out physiological concerns:Typically, you should rule out physiological causes first as they are fewer and easier to determine via patient history. This can be even quicker to determine but also sometimes bypassed if a patient’s history and labs present with more concerning etiologies of pathological elevation.

Common causes of physiological elevations in alkaline phosphatase include pregnancy, patients with blood type O and B after eating a fatty meal, and younger children. 

Pregnancy: During pregnancy women in their third trimester will have elevated serum alk phos from the placenta. 

Blood type: During digestion, alk phos is released from the intestines in patients of blood type O and B. A postprandial increase can be 1.5 to 2 times the upper limit of normal in these patients, however, there is no clinical significance. 

Children: Younger children tend to have higher alk phos due to increased bone turnover. You can find a reference range chart online for different age groups. It is possible for alk phos to be up to three times higher in infancy and adolescence reflecting the ages with the highest bone growth velocity. 

Fun fact:Alkaline Phosphatase (also known as ALP) is a natural enzyme present in raw milk. Complete pasteurization will inactivate the enzyme in milk, therefore, presence of alkaline phosphatase in milk is an indicator of failed pasteurization. This is because the most heat-stable bacteria found in milk, Mycobacterium paratuberculosis, is destroyed by temperatures lower than those required to denature ALP.

Evaluation of pathological alkaline phosphatase: 

Degree of elevation: Another consideration is the level of alk phos elevation. If alk phos is at least four times the upper limit of normal, then cholestasis is the likely cause with many specific etiologies to consider. If alk phos is not markedly elevated (four times the upper limit) then the cause is likely not as specific and many different etiologies should be considered whether hepatic or non-hepatic.  

Liver source: 

Common symptoms: Jaundice, abdominal pain, ascites, easy bruising, nausea and/or vomiting, choluria, acholia or hypocholia, unexplained weight loss, fatigue, or anasarca.

If alk phos is elevated along with liver function testing and bilirubin, it is easier to determine the liver etiology (hepatitis, cirrhosis). However, if it is an isolated elevation in alkaline phosphatase, then other sources must be considered more carefully. 

A helpful test at this point is to look at is GGT or serum 5’-Nucleotidase for elevation. Typically, these will be elevated with alk phos if it is of liver origin. If they are not increased, you should consider bone-related etiologies.

-If a hepatic cause is determined, a right upper quadrant ultrasound is the best initial test to determine intrahepatic or extrahepatic causes. This imaging will look at the hepatic parenchyma and bile ducts. Biliary dilation on ultrasound suggests an extrahepatic cause while no dilation suggests an intrahepatic cause. 

Liver source with biliary dilation: CBD is considered dilated when >6mm.

If biliary dilation is present suggesting an extrahepatic cause, ERCP or MRCP is the next best step in visualizing the cause with choledocholithiasis being the most common cause. Other causes to consider: malignant obstruction, primary sclerosing cholangitis strictures, chronic pancreatitis causing strictures, and AIDS cholangiopathy. 

Malignant obstructions can be from the pancreas, gallbladder, ampulla of vater, bile duct, or distant metastasis. If the results of these tests are inconclusive the next best step is to consider a liver biopsy. 

Liver source without biliary dilation: Without biliary dilation on ultrasound, there is a larger pool of etiologies to consider for intrahepatic causes: drug toxicity, primary biliary cirrhosis, primary sclerosing cholangitis, viral hepatitis, cholestasis of pregnancy, and total parenteral nutrition (TPN). 

Tests: Antimitochondrial antibody (AMA) testing is a good place to start at this point which would suggest primary biliary cirrhosis (PBC) and indicate confirmation with a liver biopsy. Other tests to order at this point include hepatitis panel, EBV and CMV, and possibly pregnancy testing. If patient history and these tests are all negative, the next best step to consider is a liver biopsy if alk phos is significantly elevated more than two times the upper limit of normal. 

Summary: GGT, Liver US, Dilated? -> MRCP, ERCP, CT scan of abdomen and pelvis. Non dilated? AMA, Hepatitis panel, EBV, CMV, pregnancy test.

Fun fact:When Alkaline phosphatase is elevated you can order the test called Alkaline Phosphatase isoenzymes. You will get a result with percentages for each isoenzyme: ALPI – intestinal, ALPL – nonspecific, but mainly expressed in liver, bone, and kidney; ALPP – placental, and ALPG – germ cells.

Nonhepatic evaluation:

With an isolated alkaline phosphatase elevation and normal GGT or serum 5’-Nucleotidase, the first thing to consider is bone-related pathologies involving high bone turnover: Healing fractures, osteomalacia, Paget’s disease of bone, osteogenic sarcoma, bone metastasis, hyperparathyroidism, and hyperthyroidism. Patient history, ordering thyroid and parathyroid function testing, imaging with bone scintigraphy are all important in sorting through the differential of bone-related pathologies. 

Other extrahepatic diseases to consider that have shown elevated alkaline phosphatase include myeloid metaplasia, peritonitis, diabetes mellitus, subacute thyroiditis, uncomplicated gastric ulcer, and sepsis. Each of these has its own work up and an elevated alk phos level has little significance clinically.

Paget’s disease of bone: 

Paget disease of bone is a benign disorder that presents with focal areas of increased bone turnover in one or more skeletal sites. 

Mostly affects male older adults, but female patients can also be affected. Commonly affects the bones of the pelvis, spine, skull, and long bones. 

Pain is the most common symptom, and the presentation of the disease may depend on which bones are affected, the extent of involvement, and the presence of complications. 

Paget’s disease of bone may be asymptomatic, incidental elevated serum alkaline phosphatase levels on routine labs or abnormal imaging tests performed for other reasons can point to Paget’s disease of bone. Other common symptoms include deafness, and tight hats. 

Diagnosis is normally done by plain radiography and serum alkaline phosphatase. Radionuclide scans is used to determine the extent of disease. Treatment with nitrogen-containing bisphosphonates (zoledronic acid, risedronate, and alendronate).

Complications of the disease include arthritis, gait changes, hearing loss, nerve compression syndromes, and osteosarcoma. 

Use serum alkaline phosphatase for assessing treatment response. Early diagnosis of Paget disease of bone is key in the management and patients have a better prognosis when treatment is initiated before complications. Consult with a specialist to confirm the diagnosis and start treatment.

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Conclusion: Now we conclude our episode number 94 “Elevated Alk Phos”. Elevated Alk Phos can be normal in some circumstances, mainly in pregnancy and childhood. You can start a workup when the alk phos is persistently elevated 4 times above the upper limit of normal. The most common causes can be grouped as hepatic and non-hepatic, and the bones is the most common non-hepatic source. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, and Akhil Patel. Audio edition: Suraj Amrutia. 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! 

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References:

Williams, J., & Nieuwsma, J. (2016). Screening for depression in adults. In J. A. Melin (Ed.), UpToDate. Retrieved February 1, 2017, from https://www.uptodate.com/contents/screening-for-depression-in-adults.

Lawrence S Friedman, MD (2020). Approach to the patient with abnormal liver biochemical and function tests. Shilpa Grover (Ed.), UpToDate. Retrieved Maye 12, 2022 from https://www.uptodate.com/contents/approach-to-the-patient-with-abnormal-liver-biochemical-and-function-tests. 

Lawrence S Friedman, MD (2020). Enzymatic measures of cholestasis (eg, alkaline phosphatase, 5'-nucleotidase, gamma-glutamyl transpeptidase). Shilpa Grover (Ed.), UpToDate. Retrieved Maye 12, 2022 from https://www.uptodate.com/contents/enzymatic-measures-of-cholestasis-eg-alkaline-phosphatase-5-nucleotidase-gamma-glutamyl-transpeptidase.

Episode 93: Hyponatremia treatment.    

Catherine and Dr. Saito discuss how to treat hyponatremia in an effective and safe way, especially when the hyponatremia is severe.

Introduction: What is sodium?
By Hector Arreaza, MD. Read by Alyssa Der Mugrdechian, MD; and Gina Cha, MD.  

Sodium is a white metal that does not exist in nature in its free form. In its solid form, it’s so soft that you could cut it like butter with a knife. It is the sixth most common element in the earth’s crust. Even though sodium only makes up to 0.2% of our body weight, it plays a key role in nerve conduction, muscle contraction, and most importantly regulating water balance. 

Today we will be talking about low sodium, known as hyponatremia. We will focus on how to treat hyponatremia and will mention some common causes and symptoms. We hope you can learn something from us today.

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 physician for additional medical advice.

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Hyponatremia treatment.   
By Catherine Nguyen, MS4, Ross University School of Medicine. Comments by Steven Saito, MD; and Hector Arreaza, MD. 

DEFINITION: Serum sodium concentration <135 mEq/L.

CAUSES:

-Advanced renal impairment > impairment in free water excretion > hypoosmolality of serum

-Diuretics (thiazides first 1-2 weeks)  

-SIADH (Syndrome of inappropriate ADH, I call it the syndrome of EXCESSIVE ADH to help me remember it), caused by common meds.

-Heart failure (low cardiac output) & cirrhosis (arterial vasodilation impairment) > decreased tissue perfusion (baroreceptors in carotid sinus senses reduction in pressure) > stimulus of ADH

-GI fluid loss (diarrhea, vomiting)

-CNS disturbances (stroke, hemorrhage, infections, psychosis, trauma) > increases ADH release

-Malignancies > ectopic production of ADH (small cell carcinoma)

-Drugs > SSRI, carbamazepine, cyclophosphamide

-Potomania > patient drinks large amounts of beer and decreased intake of foods (solids).

PRESENTATION:

-Asymptomatic

-Nausea & malaise earliest findings (125-130)

-Headache, lethargy, muscle cramps, confusion/AMS, and eventually seizures, coma, and respiratory arrest (115-120)

-Acute hyponatremia encephalopathy may be reversible, but permanent neurologic damage or death can occur.

TREATMENT:

Clinic: Chronic cases of hyponatremia may require spread-out treatment. Hyponatremia is never normal.

-Mild hyponatremia > concentration of 130 to 134 mEq/L: NO treatment with hypertonic saline. Rather, the initial approach includes general measures that are applicable to all hyponatremic patients (i.e., identify and discontinue drugs that could be contributing to hyponatremia; identify and, if possible, reverse the cause of hyponatremia; and limit further intake of water [e.g., fluid restriction, discontinue hypotonic intravenous infusions].

-Moderate hyponatremia > concentration of 120 to 129 mEq/L

ASYMPTOMATIC - 50 mL bolus of 3 percent saline (ie, hypertonic saline) to prevent the serum sodium from falling further.

SYMPTOMATIC – (call ICU) 100 mL bolus of 3 percent saline, followed, if symptoms persist, with up to two additional 100 mL doses (to a total dose of 300 mL); each bolus is infused over 10 minutes.

-Severe hyponatremia > concentration of <120 mEq/L (call ICU)

INITIATE intravenous 3 percent saline beginning at a rate of 15 to 30 mL/hour, administered via a peripheral vein. 

ALTERNATIVE OPTION is to give 1 mL/kg (maximum, 100 mL) boluses of 3 percent saline intravenously every six hours, with dose modification as needed. Some patients may also require desmopressin (dDAVP) to prevent overly rapid correction.

Osmotic demyelination syndrome:

-Brain adaptations that reduce the risk of cerebral edema makes the brain vulnerable to injury if chronic hyponatremia is too rapidly corrected.

-Large cohort study has shown that correction by less than 5 mEq/L per day was not associated with neurologic complications.

-More common when Na is <120 mEq/L.

-Symptoms include dysarthria, dysphagia, paraparesis or quadriparesis, behavioral disturbances, movement disorders, seizures, lethargy, altered mental status, and even coma.

MONITORING:

-Monitor the patient for symptoms and remeasure the serum sodium concentration hourly to determine the need for additional therapy. 

-Monitoring can be spaced out when the serum sodium has been raised by 4 to 6 mEq/L to every 12 hours until the serum sodium is 130 mEq/L or higher.

-The rate of correction of hyponatremia should be 6 to 12 mEq per L in the first 24 hours and 18 mEq per L or less in 48 hours.

-Fluid restriction — Restriction to 50 to 60 percent of daily fluid requirements. In general, fluid intake should be less than 800 mL/day.

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Conclusion: Now we conclude our episode number 93 “Hyponatremia treatment.” Remember to correct sodium appropriately, especially in case of severe hyponatremia. Use hypertonic saline in patients with acute hyponatremia with sodium below 129, especially if they are symptomatic. Sodium should be corrected at a rate of 6 to 12 milliequivalents per liter in 24 hours, or less than 18 milliequivalents per liter in 48 hours. If done at a higher rate, there is a risk of causing the osmotic demyelinating syndrome. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Catherine Nguyen, Steven Saito, Alyssa Der Mugrdechian and Gina Cha. Audio edition by Suraj Amrutia. 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:

Sterns, Richard H, MD. Overview of the treatment of hyponatremia in adults, UpToDate, June 11, 2021, https://www.uptodate.com/contents/overview-of-the-treatment-of-hyponatremia-in-adults. Accessed on May 11, 2022.

Sterns, Richard H, MD. Manifestations of hyponatremia and hypernatremia in adults, UpToDate, January 10, 2022. https://www.uptodate.com/contents/manifestations-of-hyponatremia-and-hypernatremia-in-adults. Accessed on May 11, 2022. 

Osmotic demyelination syndrome (ODS) and overly rapid correction of hyponatremia, UpToDate, March 14, 2022, https://www.uptodate.com/contents/osmotic-demyelination-syndrome-ods-and-overly-rapid-correction-of-hyponatremia. Accessed on May 11, 2022.

Goh KP. Management of hyponatremia. Am Fam Physician. 2004 May 15;69(10):2387-94. PMID: 15168958.

Episode 92: Paleo vs Keto vs Mediterranean. 

Sapna and Danish explain the main differences between three meal plans: Paleo, Keto, and Mediterranean. Intro about fad diets.

Introduction: Fad diets.  
By Hector Arreaza, MD.  

It is estimated that 2/3 of Americans are overweight or have obesity (73% of men and 63% of women), but only 19% of people claim to “be on a diet”, and 77% of people are trying to “eat healthier”[1]. It seems like many of us are on the weight-loss wagon together, hoping for a cure for this disease.

These days it is commonplace to hear about fad diets. Fad diets are short-lived eating patterns that make unrealistic claims about weight loss and improving health, with little to no effort on your part. “The Super-Duper diet will make you lose 100 pounds, eliminate your cellulite, erase stretch marks, remove your wrinkles, and give you extra energy to fly to the moon and back, buy the super-duper diet now!” We surely have a lot of products that make senseless promises, claim many victims, and leave people with empty pockets.   

Today is May 6, 2022. Sapna and Danish will enlighten us again with more nutrition discussions. When you go around your grocery store, have you wondered what “keto-friendly” really means? We hope after today, you get a better idea about it. Today we are presenting a brief discussion to compare three common dietary approaches for weight loss: Keto, Paleo, and Mediterranean. I’m sure you have heard some things about these diets, but we want to add to your fund of knowledge. Whether they are fad diets or not, we’ll let you decide. Enjoy it!  

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.

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Paleo vs Keto vs Mediterranean. 
Prepared by Sapna Patel, MS4, and Danish Khalid, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.

Welcome back to our Nutrition series!

D: In our previous episode, we talked about calorie balance and macronutrients. The basics of nutrition. So, if you haven’t already listened to that, pause this, and go listen to that first. As we will only continue to build on that knowledge. Now, let’s begin…

S: Whether your goals are to lose fat or gain muscle. Nowadays, we’ve got so many ways to achieve our nutritional goals. It can be difficult and overwhelming to know which one is best for you. So today, we will talk about some of the main “diets'' that are well known to all.

Comment: People hate the word “Diet”, should we call them meal plans or Nutrition plans?

S: The Paleo meal plan. The Ketogenic meal plan. The Mediterranean meal plan. And as we go through each of them, we will compare them and discuss which fit certain nutritional goals.

Comment: These meal plans are very trendy right now, some people call them fad diets, but only time can tell if these diets really work long term or not.

D: Let’s start with the Paleo meal plan. What is it? Also known as the Paleolithic diet, Caveman diet, or Stone-Age diet, this meal plan revisits the way humans ate almost 2.5 million years ago—The hunter-gatherer lifestyle. Overall, the meal plan is high in protein, moderate in fat (mainly unsaturated fats), low-moderate in carbohydrates (restricting high-glycemic carbohydrates), high in fiber, and low in sodium and refined sugars. It includes mainly lean meats, fish, fruits, vegetables, nuts, and seeds.

Comment: It is low in carbs because carbs were so rare and uncommon in nature before agriculture was introduced to humanity. Animals (including humans) had to wait until the season when the fruit was ripe to enjoy something sweet.

S: So, what are some of the benefits of the Paleo meal plan? Well, studies have shown that the paleo meal plan produces greater short-term benefits, including

- Greater weight loss

- Reduced waist circumference

- Decreased blood pressure

- Increased insulin sensitivity

- Improved cholesterol

D: You must be wondering, what’s the catch? Aside from the diminishing long-term effects. Although the meal plan focuses on many essential food groups, it also omits others such as whole grains, dairy, and legumes. This could lead to suboptimal intake of important nutrients. Additionally, the restrictive nature of the meal plan may also make it difficult for people to adhere to such a meal plan in the long run. With these confounding facts, there hasn’t been a strong link that the paleo meal plan improves cardiovascular risk or metabolic disease.

S: Basically, for those looking for a cleaner meal plan, the paleo meal plan is geared towards eliminating high-fat and processed foods that have little nutritional value and too many calories. Moving on to the Ketogenic Meal plan.

D: What is the Ketogenic Meal plan? Basically, the ketogenic meal plan is a high fat, moderate protein, and low carb lifestyle. It’s about creating ketones. For example, beta-hydroxybutyrate, acetoacetate, and acetone. Ketones are basically a fourth macronutrient. Although we don’t find it in our day-to-day food, it’s what our body creates.

So why do we need ketones, and why does our body create them in the first place? Our body uses carbohydrates, more specifically glucose, as the major source of energy for its daily needs. So, imagine, when we are in periods of starvation and deprive ourselves of carbohydrates. The body would resort to breaking down protein to create glucose for our demanding body in a process called gluconeogenesis. That seems illogical, right? Why would our body break down muscle? That is where ketones come in. While our body is trying to keep up with demands, our liver is working on creating another source of energy. A process called ketogenesis, where ketones are made through fat, more specifically medium-chain fatty acids, to fuel our body.

S: So, what’s so great about the Ketogenic Meal plan? Well, for starters, during ketogenesis due to low blood glucose feedback, the stimulus for insulin secretion becomes low, which sharply reduces the stimulus for fat and glucose storage. Additionally, people will initially experience rapid weight loss up to 10 lbs. in the first 2 weeks or less. Although the first few pounds may be water weight loss due to the diuretic effect of this meal plan, eventually you obtain fat loss.

In this meal plan, lean body muscle is largely spared. So those who are overweight individuals with metabolic syndrome, insulin resistance, and type II diabetes mellitus, are more likely to see improvements in clinical markers for disease risk. Additionally, reducing weight, mainly truncal obesity, may help improve blood pressure, blood glucose regulation, triglyceride levels, and HDL cholesterol.

D: That sounds awesome! What do I have to eat? Well, the dietary macronutrients are divided into approximately 55-60% fats, 30-35% protein, and 5-10% carbohydrates. Specifically, no more than 50 grams of carbohydrates.

Comment: The difference between ketosis and ketoacidosis is a frequent question done by patients and medical providers. The main difference is that in ketosis your glucose level is normal or low and your pH is still physiologic, but in ketoacidosis, the pH is lower than 7.35 and glucose is above 250 mg/dL. So, when a person is in ketosis, you will not see the, for example, Kussmaul’s breathing pattern, but in ketoacidosis, you will see that breathing pattern. If you want more info about the keto meal plan, you can listen to our episode 59, done by a great medical student Constance.

S: Finally, the Mediterranean meal plan.

The hallmark of this meal plan is simple…minimally processed foods. The main characteristic of a Mediterranean meal plan includes a low-moderate protein intake (very low consumption of red meat, moderate consumption of fish and shellfish), moderate-high fat (rich in unsaturated fats, lower in saturated fats), and moderate to high carbohydrates (legumes, unrefined grains). A very different take from the previous two meal plans.

D: What is the hype all about? Why year after year does the Mediterranean meal plan come out on top? Well, the reason why it’s one of the better options is because of the style of eating. It encourages vegetables and good fats (limiting bad fats) and discriminates against added sugar. No preservation, no packaging, no processing. This style of eating plays a big role in preventing heat disease, and reducing risk factors such as obesity, diabetes, high cholesterol, or high blood pressure.

S: In fact, numerous studies have shown that the Med meal plan promotes weight loss and prevents heart attacks and helps with type 2 diabetes by improving levels of hemoglobin A1c, blood sugar levels, and decreasing insulin resistance. No wonder why out of all these meal plans, it’s the only one that meets the AHA dietary recommendations.

D: In a meta-analysis of randomized trials including the large PREDIMED trial, a Mediterranean meal plan reduced the risk of stroke compared with a low-fat diet (HR 0.60, 95% CI 0.45 to 0.80) but did not reduce the incidence of cardiovascular or overall mortality. By contrast, in observational studies, a Mediterranean meal plan was associated with lower overall mortality and cardiovascular mortality.

Following a Mediterranean meal plan may lead to a reduction in total cholesterol. For example, in a 2011 meta-analysis of six randomized trials comparing the Mediterranean approach with a low-fat diet in 2650 individuals with overweight or obesity, a Mediterranean meal plan led to a greater reduction in total cholesterol (-7.4 mg/dL, 95% CI -10.3 to -4.4) but a nonsignificant reduction in LDL cholesterol (-3.3 mg/dL, 95% CI -7.3 to +0.6 mg/dL [5]. A Mediterranean meal plan may also decrease LDL oxidation.

S: Additionally, in observational studies, a Mediterranean meal plan was also associated with a decreased incidence of Parkinson disease, Alzheimer disease, and cancers, including colorectal, prostate, aerodigestive, oropharyngeal, and breast cancers.

Comment: I am excited to try the Mediterranean meal plan when I visit Spain this coming summer. It will be my first time in Valencia.

Keep in mind, with any meal plan, it will work differently for everyone. Just because it worked for an individual doesn’t mean it’ll work for you. And vice versa. Besides, everyone has different goals we want to achieve, like all of us here.

What do you call someone who can't stick with a meal plan? A deserter.

Conclusion: Now we conclude our episode number 92 “Paleo vs Keto vs Mediterranean.” The take-home messages are: Paleo is a style of eating that encourages unprocessed foods, mainly lean meats, fruits and vegetables in their natural state; Keto consists of eating less than 50 carbs a day and encourages high-fat foods; and the Mediterranean plan promotes good quality fats from vegetable sources, moderate protein and low to moderate carbs. These meal plans have a main goal in common: help your patients lose weight, improve their overall health, and decrease mortality. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Sapna Patel, Danish Khalid, and Shantal Urrutia. 

Audio edition: Suraj Amrutia. 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! 

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References:

Weight Loss Industry Analysis 2020, Cost & Trends, franchisehelp.com, https://www.franchisehelp.com/industry-reports/weight-loss-industry-analysis-2020-cost-trends/. Accessed on May 2, 2022. 

Masood W, Annamaraju P, Uppaluri KR. Ketogenic Diet. [Updated 2021 Nov 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.

Taylor B, Rachel M, Adrien B, et al. The Paleo Diet For Health Professionals. In: University of California, Davis - Nutrition. 2018.

Miguel A. Martínez-González,Alfredo Gea andMiguel Ruiz-Canela, originally published on 28 Feb 2019, https://doi.org/10.1161/CIRCRESAHA.118.313348. Circulation Research. 2019;124:779–798.

Gerber, M., & Hoffman, R. (2015). The Mediterranean diet: Health, science and society. British Journal of Nutrition, 113(S2), S4-S10. doi:10.1017/S0007114514003912.

Colditz, Graham A. “ Healthy Diet in Adults.” UpToDate, 11 Dec 2019, https://www.uptodate.com/contents/healthy-diet-in-adults.

Fitó M, Guxens M, Corella D, Sáez G, Estruch R, de la Torre R, Francés F, Cabezas C, López-Sabater MDC, Marrugat J, García-Arellano A, Arós F, Ruiz-Gutierrez V, Ros E, Salas-Salvadó J, Fiol M, Solá R, Covas MI; PREDIMED Study Investigators. Effect of a traditional Mediterranean diet on lipoprotein oxidation: a randomized controlled trial. Arch Intern Med. 2007 Jun 11;167(11):1195-1203. doi: 10.1001/archinte.167.11.1195. PMID: 17563030.

Episode 91: Nutrition Introduction. 

Sapna Patel and Danish Khalid present the basics of macronutrients and the definition of basic energy expenditure (BEE), they explain basic concepts on macronutrients. 

Introduction: Unable to control the epidemic of obesity 
By Hector Arreaza, MD.  

Today is April 27, 2022. In this episode, we will cover the very basics of classic nutrition. As we know, obesity is reaching epidemic proportions in the United States. Regardless of all the advances in science, we have not been able to control one of the most detrimental diseases in our communities. 

Obesity is among the most difficult to treat chronic diseases. There are countless recommendations about what to eat and not to eat, best workouts, miraculous shakes, magical weight-loss supplements, innovative devices, promising programs, novel medications, and the latest surgeries, however, we still have millions of patients who are suffering every day the consequences of undiagnosed and untreated obesity. We are hoping this is the first of multiple episodes addressing the problem of obesity, we hope you enjoy it.  

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

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Nutrition Introduction. 
By Sapna Patel, MS4, and Danish Ross University School of Medicine. Comments by Hector Arreaza, MD. 

Obesity is a disease when the patient has excessive body fat resulting in “sick fat disease” with metabolic consequences or “fat mass disease.” Excessive body fat is caused by genetic or developmental errors, infections, hypothalamic injury, adverse reactions to medications, nutritional /energy imbalance, and/or adverse environmental factors. Let us talk about one of the pillars of the treatment of obesity.

S: Hi, my name is Sapna Patel. I am a 4th-year medical student. I am passionate about fitness and cooking. I have been active all my life doing soccer, taekwondo, kickboxing, and weightlifting. I am joined here today with Danish. 

D: Hi, my name is Danish. I am also a fourth-year medical student. I have a background in mixed martial arts, boxing, and karate. And just like Sapna, I too am passionate about fitness, and nutrition. 

S: Today we are here to talk about nutrition. One of the most neglected subjects in medicine, yet the most important subjects. As we speak, we are sitting in Kern County, which has the highest obesity rate in the whole state of California with more than 60% of the population considered overweight. Poor nutrition is the leading cause of people being overweight and obese, and in turn, obesity leads to various other medical conditions. 

It is important to educate ourselves on nutrition, not only as medical professionals but as someone who lives in the most obese country. And it is as simple as knowing how to balance calories and macronutrients. 

D: To maintain a healthy weight and lifestyle over time, it is important that we maintain caloric balance. Oftentimes we tend to overeat, tipping us into a caloric surplus. This leads us to being overweight and obese which are the most important factors associated with poor health outcomes. It is associated with premature mortality as well as increased incidence of cardiovascular disease, diabetes, hypertension, cancer, and other important conditions. Calculating total energy expenditure for recommended daily caloric intake is based on age, sex, weight, and activity level.

Basal Energy Expenditure (BEE) (male/female): 66.5 + (13.5/9.5 x weight (kg)) + (5/2 x height (cm)) - (7/5 x age).

S: Another easier way to know your basal energy expenditure, is to use the table made by the USDA guideline which has an average estimate energy expenditure per day based on age, sex, activity level. Or a lot of bodybuilders use a rough calculation for basal energy expenditure which is: 

Formula = BW (lbs) x 14-16 (where 14=moderately active, and 16=very active) 

For example, one of my goals is to increase muscle mass. And based on the calculations, my BEE is 1458 kcal/day with my current activity level. Thus, if I wanted to gain muscle without gaining fat, I would have to keep to this number. Whereas, Danish I know you have a different goal

D: Yes so, one of my goals is to achieve fat loss. For me, my basal energy expenditure is 2400 kcal/day with my current activity level. However, this number is to maintain my current weight. If I need to lose weight, I will have to subtract calories from my daily balance. Typically, I would subtract 500 kcal/day, as this allows for a fat loss of 1 pound per week or 3500 kcal/week. 

Many should aim for 0.5 pounds to 2 pounds per week, but nothing more than 2 pounds as this could lead to undesirable appearances such as excess skin. If you are looking to gain weight, it is the same concept, however the opposite. You add calories instead. Of course, it is not as simple as just over-eating. That is where macronutrients come in, it is important to balance your proteins, fats, and carbohydrates. 

S: On that note, let us talk about macronutrients. Macronutrients are the chemical compounds consumed in the largest quantities and provide bulk energy. The three primary macronutrients include proteins, carbohydrates, and fats. Let us start with protein. 

D: Protein should make up 10- 35% of total caloric intake, as recommended by the United States Dietary Guidelines. Or consume 0.8-1.2 grams of your body weight in pounds. 

Common sources of dietary protein include whole foods such as fish, eggs, lean meat, vegetables (specifically peas, lentils, soybeans), and protein powders such as casein, whey, and soy. 

S: So, for me being a vegetarian, I must only rely on eggs, vegetables, and milk proteins.

In terms of milk protein, there are two different types, rapidly versus slowly digested. Rapidly digested milk proteins are what we see termed whey or soy protein. Whereas slowly digested milk proteins are termed casein.

Whey hydrolysate and soy are digested and absorbed quickly, only 90 mins after you consume whey. It delivers essential amino acids, branched-chain amino acids, and leucine, making it the perfect end to your workouts, as it will kickstart the muscle repair and rebuilding process. 

Casein protein provides your body with a slow, steady release of amino acids, and stay elevated in your blood for 4-5hrs after you consume it. making it ideal before fasting situations, such as sleep. The peptides found in casein work similarly to ACE-I (angiotensin converting enzyme inhibitors) and lower blood pressure and reduce the formation of blood clots.  It also contains several bioactive peptides that are beneficial to your digestive system.

D: Let's move on to fats. Fat should make up 20- 35% of total caloric intake, as recommended by the United States Dietary Guidelines. The type of fat consumed is more important than the amount of total fat. There are technically 4 types of fats: saturated, trans, mono- and polyunsaturated fats. 

Saturated and trans fats contribute to coronary heart disease, while mono/polyunsaturated fats are protective. The major sources of saturated fats include butter, ghee, ice creams, sausages, bacon, and cheese with the list going on.  

The major sources of trans fats include margarine and partially hydrogenated vegetable fats. Guidelines recommend limiting consumption of saturated and trans-fat to under 10% of calories per day. The major sources of mono/polyunsaturated fats include omega-3, fish oil, avocados, nuts, and seeds. Furthermore, some evidence shows that long-term consumption of fish oil and n-3 fatty acids reduces the risk of cardiovascular disease. So, the next time you are out shopping, keep an eye on those fats. 

S: Last but not least, carbohydrates. As recommended by US Dietary Guidelines, carbs should make up 45-65% of total caloric intake. Here quantity and type of carbohydrate matter because they can have different effects on postprandial (after meal) glucose levels, termed glycemic index. Studies have shown that diets with a high glycemic index (foods that increase your blood sugar levels substantially) have been associated with developing type 2 diabetes mellitus and coronary heart disease. 

One important way of achieving a healthy diet is to replace carbohydrates having a high glycemic index (e.g., white rice, pancakes) with a low glycemic index (e.g., fruits, vegetables).  Additionally, adding sugars should be limited and comprise no more than 10% of total calories consumed. These added sugars often come from sweetened beverages and almost all processed foods. They should be substituted with naturally occurring sugars in fruits or milk. 

S: As you can see, nutrition is not as simple as just eating the right things. It includes knowing your caloric balance and having the appropriate number of macronutrients. However, it does not just stop there. There is no “whey” we can fit all this information into just one podcast so stay tuned as we continue to further discuss nutrition. 

D: Before we leave, just a few tips. With any goal, diet is 80% of the work whereas exercise is 20%. If your diet is not healthy, it will not matter how much you work out. And lastly, keep consistent and be disciplined. Good day to you all. 

Walle, Gavin Van De. “What's the Difference between Casein and Whey Protein?” Healthline, Healthline Media, 30 Aug. 2018, https://www.healthline.com/nutrition/casein-vs-whey#benefits. 

Tang JE, Moore DR, Kujbida GW, Tarnopolsky MA, Phillips SM. Ingestion of whey hydrolysate, casein, or soy protein isolate: effects on mixed muscle protein synthesis at rest and following resistance exercise in young men. J Appl Physiol (1985). 2009 Sep;107(3):987-92. doi: 10.1152/japplphysiol.00076.2009. Epub 2009 Jul 9. PMID: 19589961.

Dietary Guidelines for Americans, 2020-2025. U.S. Department of Agriculture, USDA, https://www.dietaryguidelines.gov/.

Episode 90: Vaccines and Acne. 

Updates on pneumococcal and COVID-19 vaccines. Sarah explains the treatment of acne.

New Pneumococcal Vaccine Recommendations. 
Written by Harkiran Bhattal, MS4, Ross University School of Medicine; Timiiye Yomi, MD; and Hector Arreaza, MD.

During the recording, we used brand names because they are easier to use. We are not sponsored by the manufacturers of these vaccines. 

Terminology of pneumococcal vaccines: 

PCV13: Prevnar13®

PPSV23: Pneumovax23®

PCV15: Vaxneuvance® 

PCV20: Prevnar20®

Tips about pneumococcal vaccines:

-Prevnar13 is no longer used in adults. 

-Pneumovax23 is still being used in adults.

-The two newer members of the pneumococcal vaccines are: Prevnar20® (PCV20) and Vaxneuvance® (PCV15).

The following groups of patients are all adults 19-64 with underlying conditions OR >65 years old.

Group A: Unknown or no prior doses of Prevnar13 or Pneumovax 23

Option 1: Prevnar20 given as a single dose

Option 2: Vaxneuvance followed by a dose of Pneumovax23 at least a year later (Consider >8 weeks in patients >19 at the highest risk)

Group B: Previously received Pneumovax 23

Give Prevnar20 or Vaxneuvance (at least 1 year since the last Pneumovax 23)

Group C: Previously Received Prevnar13

Give Pneumovax23 or Prevnar20 (if Pneumovax 23 is not available) >1 year since last dose of Prevnar13

Group D: Previously completed series of Prevnar13 and Pneumovax23 in any order

No additional doses are needed.

Scenario 1: 68 yo Mwho has not previously received PCV or whose previous vaccination history is unknown (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by a dose of Pneumovax23.

Scenario 2: 25 yo F with HIVnot previously received PCV or whose vaccination history is unknown (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by

a dose of Pneumovax 23 given 8 weeks later. This patient is in the highest risk group.

Scenario 3: 50 yo M with chronic alcoholism who has not received any vaccine or unknown status (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by Pneumovax 23 one year later.

Scenario 4: 43 yo M with previous Pneumovax 23 only (Group B). This patient should receive either: a single dose of Prevnar20 or Vaxneuvance and be done with either vaccine. Give either vaccine at least 1 year after Pneumovax 23.

Scenario 5: 25 yo F with CSF leak and previously received Prevnar13 (Group C). This patient should 

receive Pneumovax23 or Prevnar 20 (if Pneumovax 23 is unavailable) at least one year after her las Pneumovax dose.

Scenario 6:35 yo M who previously completed Prevnar13 and Pneumovax in any order because he has a cochlear implant (Group D). This patient should NOT receive any additional dose.

Research and Monitoring

CDC and ACIP will continue to assess the safety of Vaxneuvance and Prevnar20 vaccines (the new kids on the block), monitor the impact of the implementation of new recommendations, and assess post-implementation effectiveness and recommendations as appropriate.

Examples of risk factors to consider administration of pneumococcal vaccines: Chronic renal failure, HIV infection, alcoholism, cigarette smoking, chronic heart, liver, and lung disease. For a complete list of conditions, visit CDC.gov.

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A second booster shot of COVID-19 vaccines. 
By Hector Arreaza, MD.

On March 29 and 30, 2022, CDC announced that a second booster dose of any mRNA COVID-19 vaccine may be given to certain individuals who are at risk of severe outcomes from COVID-19(1). 

Individuals who may choose to receive a second booster are: 

1. People older than 12 years of age who have a moderate to severe immunocompromising condition. Remember, use Pfizer for older than 12 yo, and Moderna for older than 18 yo.

2. People older than 50 years of age who are NOT moderately or severely immunocompromised.

3. People 18-49 years of age who are NOT immunocompromised but received the J&J COVID-19 vaccine as both the primary and booster dose. 

When can you receive the second booster shot? At least 4 months after the first booster dose.

Who is considered up to date? A person is considered up to date when he/she has received all recommended doses in their primary vaccine series, and a booster dose when eligible. A second booster dose is not required to be considered up to date at this time.

Underlying medical conditions associated with higher risk for severe COVID-19 include: Cancer, obesity, cerebrovascular disease, diabetes mellitus, HIV, obesity, COPD, smokers, and chronic liver disease.

Comment: Remember to give the second booster to your patients. 

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Acne Treatment.  
By Sarah Park, MS3, University of California Los Angeles. Discussed with Hector Arreaza, MD.  

Definition: Acne vulgaris is a common inflammatory disorder of the pilosebaceous unit, which includes the hair follicle and sebaceous gland. It is characterized by chronic or recurrent development of papules, pustules, or nodules commonly on the face, chest, or upper back.(1,2) Acne affects nearly 50 million people in the U.S. per year and can cause significant psychological distress in those who are affected. It primarily begins at puberty when the production of androgens and/or sensitivity of androgen receptors increase, thereby commonly affecting adolescents and young adults.(2) 

Pathophysiology:The pathophysiology of acne involves four main processes: 1) sebum overproduction, 2) hyperkeratinization of the follicle, 3) bacterial colonization by Cutibacterium acnes, and 4) inflammation.(2,3) It can be classified as mild, moderate, or severe based on the extent and types of lesions.3

Treatment:Treatment is selected based on the severity of the condition, patient preference, and tolerability. Acne treatment often requires long-term, consistent use of one or more medications.(3) The main objective of treatment is to decrease sebum production, get rid of extra keratin, treat infection and decrease inflammation. You can warn your patients that their skin may feel dryer and more scaly than usual, but that’s part of the treatment. 

For mild and exclusively comedonal acne, topical retinoids like tretinoin are the treatment of choice(4), but topical retinoids can be used in any level of severity for maintenance. Examples: Adapelene, tazarotene, and tretinoin, 

For mild inflammatory papulopustular acne or mild mixed comedonal and papulopustular acne, topical retinoids may be used in combination with antimicrobial therapy (either combined with benzoyl peroxide or combined with benzoyl peroxide plus clindamycin or erythromycin). If patients cannot tolerate a topical retinoid, alternatives include salicylic acid and azelaic acid. Of note, oral or topical antibiotics should only be used in combination with benzoyl peroxide and retinoids for a maximum of 12 weeks. 

If unresponsive to these topical therapies, namely retinoids, benzoyl peroxide, and/or clindamycin, alternative therapies may be initiated. These include topical dapsone, minocycline, and clascosterone.

Topical dapsone is an effective treatment for both inflammatory papulopustular and comedonal acne lesions. 

Topical minocycline is an alternative topical antibiotic used for specifically moderate to severe acne. 

And last but not least is topical clascosterone, a relatively new topical (specifically an androgen receptor inhibitor) approved by the FDA in 2020.(4)

Treatment for moderate to severe acne:For moderate to severe acne vulgaris, management is systemic therapy. This includes oral antibiotics or hormonal therapies, often used in conjunction with topical therapy, or monotherapy with oral isotretinoin. 

1. Oral antibiotics for acne vulgaris include doxycycline, minocycline, and sarecycline. Treatment should be limited to three to four months.(5)

2. For female patients, hormonal therapy with oral contraceptives and/or spironolactone is also an option. A meta-analysis comparing oral contraceptive therapy and oral antibiotic therapy suggests similar efficacy for the treatment of acne. OCP treatment is often the first-line choice for hormonal therapy, especially for patients who desire the added benefit of contraception. Spironolactone is often used for patients who have contraindications to OCP therapy or prefer to avoid OCPs. Both methods work to inhibit acne by reducing the effects of androgen on the pilosebaceous unit.5

3. For severe, extensive, nodular acne vulgaris, oral isotretinoin is the drug of choice. It is given as a monotherapy and is often used when all other treatment modalities fail.  Oral isotretinoin is the only medication that can permanently affect the natural course of acne by affecting all four factors in acne pathogenesis. Isotretinoin is most notably known for its teratogenic adverse effects and so is contraindicated in pregnant women and pregnancy must be avoided during therapy by using two forms of birth control.(5)

Comment about isotretinoin use:Although prescribing isotretinoin (brand name Accutane®) is within the scope of family medicine, many providers choose not to prescribe it because of lack of training, monitoring hassles, fear of side effects, especially due to concerns with teratogenicity. Isotretinoin is an effective treatment for a condition that can not only disfigure and scar the face but can also cause significant psychosocial dysfunction. Dr. Van Durme recommended when you prescribe isotretinoin, you should have a regular schedule of monthly laboratory tests (including pregnancy test), then office visit, and then prescription, in that order. This schedule will improve the likelihood that side effects are managed promptly and medication is taken appropriately(7). If you would like more information about prescribing isotretinoin, visit https://ipledgeprogram.com.

Conclusion: Use topical retinoids alone for mild cases of acne; topical retinoids combined with benzoyl peroxide or topical clindamycin or erythromycin for moderate cases; and topical retinoids combined with benzoyl peroxide and oral antibiotics in severe cases. Remember that isotretinoin is an oral treatment reserved for severe inflammatory papules and pustules with nodules. Treating acne effectively can certainly improve the quality of life of your patients. 

Now we conclude Episode 90 “Vaccines and Acne”. We gave you an update on pneumococcal and COVID-19 vaccines. Prevnar 20 seems to be the new star in the show. PCV15 is also useful but it needs to be followed by a shot of Pneumovax 23. Regarding COVID-19 vaccines, a second shot may be given to patients older than 12 who are immunocompromised or patients older than 50 who are NOT immunocompromised. Then we finished with a discussion about acne and we learned that topical is usually enough for mild cases, but oral therapy may be needed in moderate to severe cases of acne. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. Send us your feedback by email to RioBravoqWeek@clinicasierravista.org, or in 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, Timiiye Yomi, Amardeep Chetha and Sarah Park. Audio edition: Suraj Amrutia. See you next week! 

References:

Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:109–117. DOI: http://dx.doi.org/10.15585/mmwr.mm7104a1

2. Pneumococcal Vaccination Timing for Adults, CDC. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf, accessed on March 30, 2022.

Interim Clinical Considerations for Use of COVID-19 Vaccines, Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html#considerations-covid19-vax-booster, accessed April 5, 2022. 

Thiboutot, Diane, MD; and Andrea L Zaenglein, MD. Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/pathogenesis-clinical-manifestations-and-diagnosis-of-acne-vulgaris

Leung AK, Barankin B, Lam JM, Leong KF, Hon KL. Dermatology: how to manage acne vulgaris. Drugs Context. 2021 Oct 11;10:2021-8-6. doi: 10.7573/dic.2021-8-6. PMID: 34691199; PMCID: PMC8510514.

Oge' LK, Broussard A, Marshall MD. Acne Vulgaris: Diagnosis and Treatment. Am Fam Physician. 2019 Oct 15;100(8):475-484. PMID: 31613567.

Graber, Emmy, MD, MBA. Acne vulgaris: Overview of management, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/acne-vulgaris-overview-of-management

Harris C. Clascoterone (Winlevi) for the Treatment of Acne. Am Fam Physician. 2021 Jul 1;104(1):93-94. PMID: 34264597.

Acne vulgaris: Management of moderate to severe acne, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/acne-vulgaris-management-of-moderate-to-severe-acne

Van Durme DJ. Family physicians and accutane. Am Fam Physician. 2000 Oct 15;62(8):1772, 1774, 1777. PMID: 11057835. https://www.aafp.org/afp/2000/1015/p1772.html

Episode 89: Gonorrhea Basics. 

Written by Robert Besancenez.  

Robert, Dr. Schlaerth, and Dr. Arreaza discuss the basics of gonorrhea, including presentation, treatment, and even a potential gonococcal vaccine.

Introduction:Gonorrhea is commonly known as “the clap” or “the drip”. This ancient disease, described as “the perilous infirmity of burning” in a book called The History of Prostitution, has been treated with many remedies throughout history, including mercury, sulfur, silver, multiple plants, and even gold. Today we will discuss the clinical features, diagnosis, and current therapy of gonorrhea. By the way, did you know that gonorrhea in Spanish is used as an insult in Colombia? Well, now you know it. 

Definition:Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae(common name gonococcus), which is a gram-negative, intracellular, aerobic, diplococci. This disease leads to genitourinary tract infections such as urethritis, cervicitis, pelvic inflammatory disease (PID), and epididymitis. 

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. 

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Gonorrhea. 
Written by Robert Besancenez, MS4, Ross University School of Medicine. Moderated and edited by Hector Arreaza, MD. Discussion participation by Katherine Schlaerth, MD.

Epidemiology:The disease primarily affects individuals between 15–24 years of age (half of the STI patients in the US). CDC estimates that approximately 1.6 million new gonococcal infections occurred in 2018. Incidence rates are highest among African Americans, American Indians, and Hispanic populations.

Transmission is sexual (oral, genital, or anal) or perinatal (causing gonococcal conjunctivitis in neonates). 

Risk factors include unsafe sexual behaviors (lack of barrier protection, multiple partners, men who have sex with men (MSM), and asplenia, complement deficiencies. Individuals with low socioeconomic status are at the highest risk: poor access to medical treatment and screening, poor education, substance use, and sex work.

Presentation: 

The incubation period is ~ 2–7 days, and sometimes patients do not develop any symptoms.

Urogenital infection:Gonorrhea is commonly asymptomatic, especially in women, which increases the chance of further spreading and complications. 

When symptoms are present, typical symptoms include purulent vaginal or urethral discharge (purulent, yellow-green, possibly blood-tinged). Discharge is less common in female patients. Urinary symptoms include dysuria, urinary frequency, and urgency. 

Male: - Typical presentation is urethritis. 

- Penile shaft edema without other signs of inflammation.

- Epididymitis: unilateral scrotal fullness sensation, scrotal swelling, redness, tenderness, relief of pain with elevation of scrotum —Prehn Sign— and positive cremasteric reflex.

- Robert: Prostatitis: fever, chills, general malaise, pelvic or perineal pain, cloudy urine, prostate tenderness (examine prostate gently).

Female: - Cervicitis: Friable cervix and discharge (purulent, yellow, malodorous), 

- PID: pelvic or lower abdominal pain, dyspareunia, fever, cervical discharge, cervical motion tenderness but also uterine or adnexal tenderness, abnormal intermenstrual bleeding. PID can be subclinical and diagnosed retroactively when tubal occlusion is discovered as part of a workup for infertility. PID can cause Fitz-Hugh-Curtis syndrome (perihepatitis with RUQ pain).

- Bartholinitis presents with introitus pain, edema, and discharge from the labia. 

- Vulvovaginitis may occur but is rare (due to the tissue preference of gonococci)

Extragenital infection: 

Proctitis: Rectal purulent discharge, possible anorectal bleeding and pain, rectal mucosa inflammation, or rectal abscess (less common).

Pharyngitis: sore throat, pharyngeal exudate, cervical lymphadenitis. 

Disseminated gonococcal infection (DGI):Triad of arthritis, pustular skin lesions, and tenosynovitis. 

As mentioned in Episode 46, on December 23, 2020, the California Department of Public Health (CDPH) sent a “Dear Colleague” letter to warn the medical community about the increased cases of DGI in California and Michigan. Increased cases may be caused by decreased STD testing and treatment because of the COVID-19 pandemic, and not necessarily because of a more virulent strain of gonorrhea. Later, treatment of gonorrhea was updated because of resistance.

Epidemiology: ∼ 2% of cases. Most common in individuals younger than 40 years old, the female to male ratio is 4:1. A history of recent symptomatic genital infection is uncommon. Asymptomatic infections increase the risk of dissemination due to delayed diagnosis and treatment.

Clinical features: Two distinct clinical presentations are possible.

Arthritis-dermatitis syndrome:

Polyarthralgias: migratory, asymmetric arthritis that may become purulent.

Tenosynovitis: simultaneous inflammation of several tendons (e.g. fingers, toes, wrist, ankle).

Dermatitis: vesicular, pustular, or maculopapular lesions, possibly with a necrotic or hemorrhagic center. Most commonly distributed on the trunk, extremities (sometimes involving the palms and soles). Typically, < 10 lesions with a transient course (subside in 3–4 days). Additional manifestations: fever and chills (especially in the acute phase).

Purulent gonococcal arthritis: Abrupt inflammation in up to 4 joints (commonly knees, ankles, and wrists). No skin manifestations, rarely tenosynovitis. Genitourinary manifestations in only 25% of affected individuals. Not to be confused withreactive arthritis. 

Health care providers living in California: Order Nucleic acid amplification test (NAAT) and culture specimens from urogenital, extragenital mucosal sites (e.g., pharyngeal and rectal), and from disseminated sites (e.g., skin, synovial fluid, blood, and cerebrospinal fluid) before initiating empiric antimicrobial treatment for patients with suspected DGI. Report within 24 hours of diagnosis to the California Department of Public Health.

Complications of DGI: sepsis with endocarditis, meningitis, osteomyelitis, or pneumonia.

Diagnosis of gonorrhea:The test of choice isNucleic acid amplification testing (NAAT) of first-catch urine or swabs of urethra, endocervix and pharynx, and synovial fluid in disseminated infection. 

Other possible tests: gram stains and bacterial cultures (Thayer-Martin agar, useful for antibiotic resistance, results may take 48 hours, sensitivity is lower than NAAT.)

Synovial fluid analysis: Appearance of fluid can be clear or cloudy (purulent), high Leukocyte count (up to 50,000 cells/mm3): especially segmented neutrophils, gram stain positive in < 25% of cases.

Treatment: Ceftriaxone and doxycycline for uncomplicated cases, but may require different approaches in case of allergies or intolerance to these antibiotics, or in severe cases. 

Uncomplicated gonorrhea (affecting cervix, urethra, rectum, pharynx)

First-line treatment: single-dose ceftriaxone 500 mg IM (1 G for patients >150 Kg) PLUS doxycycline 100 mg PO twice a day for 7 days If a chlamydial infection has not been excluded.

During pregnancy: Ceftriaxone PLUS single-dose azithromycin 1 gram PO(doxy is contraindicated – teratogen)

Complicated gonorrhea (salpingitis, adnexitis, PID/ epididymitis, orchitis)

Single-dose ceftriaxone IM PLUS doxycycline PO for 10–14 days (women may require additional administration of Metronidazole PO for 14 days). 

DGI

Ceftriaxone IV every 24 hours for 7 days

In case Chlamydia infection has not been ruled out: PLUS doxycycline PO twice a day for 7 days

Drainage of purulent joint(s)

Sequelae: Without treatment, a prolonged infection may lead to complications, such as hymenal and tubal synechiae that lead to infertility in women.

Prevention:

-Screening for gonorrhea (USPSTF recommendations, September 2021, Grade B): Annual NAAT screening of gonorrhea AND chlamydia for sexually active women ≤ 24 years (including pregnant persons) or > 25 years with risk factors (e.g. new or multiple sex partners, sex partner with an STI, etc.). Evaluate for other STIs if positive (e.g. chlamydia, syphilis, and HIV). 

There is insufficient evidence to recommend for or against screening gonorrhea in asymptomatic males (Grade I).

In all patients:Evaluate and treat the patient's sexual partners from the past 60 days. Provide expedited partner therapy if the timely evaluation of sexual partners is not feasible. Single-dose cefixime PO (if chlamydia has been excluded in the patient) OR Single-dose cefixime PO PLUS doxycycline PO for 7 days. Sexual partners must be treated simultaneously to avoid reinfections.

A possible gonococcal vaccine: A gonococcal vaccine is theoretically possible, let’s remember that the meningococcal vaccine exists. Meningococcus is closely related to gonococcus. A study published in 2017 showed that MeNZB® (a vaccine used in New Zealand until 2011 to fight against a meningitis epidemic) provided partial protection against gonorrhea. Food for thought for you guys. 

Conclusion: Let’s remember to screen asymptomatic women for gonorrhea, identify symptomatic patients and start treatment promptly, and prevent serious complications, and more importantly, let’s promote safe sex practices to prevent this disease.

Now we conclude our episode number 89 “Gonorrhea Basics”. Gonorrhea affects mainly the urogenital area, but it can spread to the pharynx, rectum, skin, and even joints. When you see septic arthritis in patients with high risk for gonorrhea, suspect disseminated gonococcal infection and start treatment promptly. 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, Robert Besancenez, and Katherine Schlaerth. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Seña, Arlene C, MD, MPH; and Myron S Cohen, MD.  Treatment of uncomplicated Neisseria gonorrhoeae infections, UpToDate, updated on Jan 27, 2022. Accessed on April 5, 2022. https://www.uptodate.com/contents/treatment-of-uncomplicated-neisseria-gonorrhoeae-infections

Ghanem, Khalil G, MD, PhD. Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents, UpToDate, updated on Sep 17, 2021, accessed on April 5, 2022. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-neisseria-gonorrhoeae-infection-in-adults-and-adolescents

Klausner, Jeffrey D, MD, MPH. Disseminated gonococcal infection, UpToDate, updated on March 3, 2022. Accessed on April 5, 2022. https://www.uptodate.com/contents/disseminated-gonococcal-infection

Petousis-Harris H, Paynter J, Morgan J, et al. Effectiveness of a group B OMV meningococcal vaccine on gonorrhea in New Zealand – a case control study. Abstract presented at: 20th International Pathogenic Neisseria Conference. Manchester, UK; 2016. 

Episode 88: EVALI. 

Nugdeep and Jeffrey present E-cigarette and Vaping Associated Lung Injury (EVALI), including symptoms, diagnosis, and treatment. Introduction includes a word of advice for matching and not matching students in 2022. 

Introduction: The Match 2022 is over.  
By Hector Arreaza, MD. Read by Valeri Civelli, MD. 

Another Match season is behind us. It’s time to celebrate and prepare for a new stage of your career. As an interesting fact, the American Association of Family Physicians announced that in 2022 the highest number of family medicine residents matched.

Positions for family medicine residencies have been steadily growing for the last 13 years in a row. There are 756 family medicine categorical and combined residency programs, that’s 15 more programs than in 2021. 

Also, in 2022, osteopathic medical schools had the historic highest number of students matching into family medicine, to be exact 1,496 DO seniors matched to family medicine this year, that’s 58 more students than 2021.

During this season, the number of U.S. medical grads matching into family medicine “did not increase despite a larger number of positions available.”[1]

If you did not match this year, the Match can also be a time of reflection and goal setting as you prepare with optimism for the next season. To increase your chances to match next year, Dr. Margarita Loeza advised in an AMA article[2] to stay in touch with your medical school, find a job in a clinical setting, take Step 3, and try a new approach during next season. For example, you may consider applying to a higher number of programs or even more than one specialty. 

Residency training is the primary way to get licensed to see patients, but there are hundreds of alternative ways to pursue your passion for medicine. Do not give up on your goals. “Never give up on something that you can’t go a day without thinking about.” ―Winston Churchill.

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. 

Page Break

EVALI.

By Nugdeep Singh, MS4; and Jeffrey Nguyen, MS4. Ross University School of Medicine. Participated in the discussion: Hector Arreaza, MD.

N: Good afternoon listeners. My name is Nugdeep Singh, and I am a fourth-year medical student. 

J: Hello, and I’m Jeffrey Nguyen, also a fourth-year medical student. Thank you for having us today Dr. Arreaza. 

N: Today we will be talking about E-cigarette and vape-associated lung injury (EVALI), also known as vaping-associated pulmonary injury (VAPI). But, before we get into the medical pathology of E-cigarettes and vapes, why don’t we give a little background on them.

Arreaza: EVALI and VAPI sound like another Indian holiday or an Italian dessert, but EVALI and VAPI are certainly no joke. 

J: Sure, let’s get started. So, E-cigarettes are battery-operated devices that heat liquids containing nicotine to produce an aerosol that the user inhales. Long-term health effects and whether they help an individual quit smoking has been controversial, as there has not been much research on it. 

These E-cigarettes have raised public health concerns on smoking prevalence and their potential use by children. In 2019, over 5 million children and adolescents were using 3-cigarettes. This represented an increase in e-cigarette use by high school students from 12% in 2017 to 28% in 2019. In fact, Massachusetts legislation bans the sale of all flavored tobacco products starting in June 2020. Nicotine is the main ingredient in the liquid, however, there are other constituents that are carcinogenic potential. Nugdeep, can you go over some of these ingredients? 

N: Yea, let’s start with nicotine. The level of nicotine varies between 0 to 36mg/mL, though it can be higher in some. Nicotine salt is another variant that can provide a different sensation in a user’s throat. Next is propylene glycol, which are humectants, and they are the main component of most E-cigarette liquids. 

Arreaza: When you mentioned proPYlene glycol, I immediately thought of “PEG”. PolyEthylene Glycol, does it ring a bell? Yes, it’s a common laxative, but besides that it’s used in the mRNA COVID-19 vaccines. Having allergy to PEG is one of the few contraindications of the COVID-19 vaccine. But you are not talking about PEG, you are talking about propylene glycol, which is a lightly sweet substance used in e-cigarettes, which can cause chemical conjunctivitis or respiratory irritation.  The consequences of chronic inhalation of propylene glycol are still unknown.

N: Finally, there are flavorings and there are about 7000 flavors available. Some examples include candy, fruits, sodas, and alcohol flavors. 

J: Can I add something real quick? 

N: Yea, of course. 

J: Although these flavorings do add taste to the experience, it attracts E-cigarettes in the youths, especially those who do not already smoke. So, kids, don’t start smoking these just because of the different flavors. Sorry for interrupting you, you can continue. 

N: It’s all good. To continue where I left off, metals such as tin, lead, nickel, chromium, and arsenic have also been found in these liquids. In addition to these, people can also use aerosolized THC or cannabinoid oils with these E-cigarettes. 

J: Wow, there are so many ingredients found in these liquids that the public is not aware of. Now that we know a little more about E-cigarettes, let’s talk about how they affect the lungs. 

N: Yea, let’s get to it. E-cigarette and Vape Associated Lung Injury was first recognized in the summer of 2019 and to date, there are more than 2800 cases that have been reported to CDC as of February 2020. Among those, 68 deaths have been recorded.  Approximately 66% are male users and nearly 80% are under the age of 35. Unfortunately, 22% of the patients have underlying asthma. 

J: Currently, we still don’t fully understand how E-cigarettes affect the lungs. Reported cases have hypothesized that lung diseases are associated with acute eosinophilic pneumonia, diffuse alveolar hemorrhage, acute and subacute hypersensitivity pneumonitis, respiratory bronchiolitis-associated pneumonitis, and interstitial lung disease, suggesting that more than one mechanism of injury may be involved. It is important to understand that there is no evidence of an infectious etiology. 

N: One interesting fact is that when they took fluid samples from the lungs (called bronchoalveolar lavage) from patients with lung injury from E-cigarettes, they noticed that the sample contained THC and/or Vitamin E acetate. Of course, other additives were included, however, these two were in the majority of fluid samples. In fact, the product Juul® was recently found to have a strong association with EVALI. 

Arreaza: JUUL was a commercial success, compared to Uber and Airbnb, but it has been involved in a lot of controversies around the world. 

J: Vitamin E acetate? But isn’t that found in many other products that we use on a daily basis? 

N: Definitely, Vitamin E is found in many foods including vegetable oils, cereals, meats, fruits, and vegetables. It is also available as dietary supplements and is in cosmetic products such as skin creams. There are no known harms when Vitamin E acetate is ingested or applied to the skin, however, research suggests that it interferes with normal lung functions. 

J: Interesting, who knew something as simple as Vitamin E can cause harm to the lungs when used differently. To continue, let’s talk about symptoms that patients present with. Respiratory symptoms include shortness of breath, cough, chest pain, pleuritic chest pain, and hemoptysis. Patients may have subjective fever and chills. GI symptoms include abdominal pain, nausea, vomiting, and diarrhea. Vital signs can be remarkable for tachycardia, tachypnea, and hypoxemia that may progress to respiratory failure. Nugdeep, are there any criteria to meet the diagnosis of E-cigarette and Vape Associated Lung Injury? 

N: Before I talk about how to make the diagnosis, I want to mention that CDC recommends obtaining detailed information on the type of vaping device used, type of substance used, frequency of vaping, and where these devices were obtained. To answer your question, in order to make the diagnosis, you need:

Use of e-cigarettes in the past 90 days.

Chest x-ray or CT chest showing lung opacities without any signs of lung infection.

Negative influenza PCR, respiratory viral panel, and other respiratory infections like urine antigen test for legionella. (COMMENT: COVID-19?)

Once the diagnosis has been made, what are the treatment options? 

J: Since this is a new and upcoming problem, there are no known treatments to date. The most important thing is to rule out infectious processes, such as community-acquired pneumonia. However, patients diagnosed with EVALI can be started on antibiotics empirically to cover pathogens of community-acquired pneumonia. Systemic glucocorticoids have been used; however, the efficacy has not been formally studied. The decision to initiate systemic glucocorticoids is challenging due to various presentations, but it has been suggested to initiate systemic glucocorticoids for patients who meet the criteria for EVALI and have progressively worsening symptoms and hypoxemia. So, what does supportive care entail?

N: 95% of patients with this diagnosis will require hospitalization for supportive care, such as supplemental oxygen with a target pulse oxygen saturation of 88-92%. If hypoxemia worsens, management follows that for acute respiratory distress syndrome. In order to discharge a patient, it is important to ensure vital signs, oxygen saturation and exercise tolerance are stable for 24-48 hours prior to discharge. Jeffrey, to conclude this podcast, can you talk about the prognosis of EVALI? 

J: Sure. When comparing fatal vs nonfatal cases of EVALI, the proportion of fatal cases was higher among patients over the age of 35 and those with a history of asthma, cardiac or mental health conditions. Case reports among adolescents suggest residual lung dysfunction, like short-term diffusion abnormalities. However, it remains unclear whether abnormalities persist in the long term. We would need to wait while they do more research about this condition. 

Arreaza: E-cigarette use is increasing, and we need to be aware of the signs and symptoms of E-cigarette and vape-associated lung injury (EVALI) to start treatment appropriately. Remember to include e-cigarettes and vaping when you ask questions about smoking. 

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Now we conclude our episode number 87 “EVALI.” EVALI stands for E-cigarette and vape-associated lung injury. The medical community has been increasingly concerned about the safety and health consequences of e-cigarettes and vaping. When you encounter a patient with respiratory complaints, remember to ask about any form of tobacco use, including e-cigarettes and vaping. If you suspect a patient has EVALI, confirm the diagnosis with a chest x-ray or CT scan and rule out any infectious etiology. Consider hospital admission if symptoms are severe, for example, if the patient has shortness of breath or requires oxygen. 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. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Valerie Civelli, Nugdeep Singh, and Jeffrey Nguyen. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Mitchell, David, Family Medicine Welcomes Largest Class of Residents Ever, American Association of Family Physicians, aafp.org, March 18, 2022, https://www.aafp.org/news/education-professional-development/2022-match-day.html.

Smith, Timothy M., What if you don’t match? 3 things you should do, American Medical Association (ama-assn.org), https://www.ama-assn.org/residents-students/match/what-if-you-don-t-match-3-things-you-should-do.

Kaplan, Sheila, Andrew Jacobs, and Choe Sang-Hun, The World Pushes Back Against E-Cigarettes and Juul, The New York Times, nytimes.com, March 30, 2020 https://www.nytimes.com/2020/03/30/health/vaping-juul-international.html.

Episode 87: Latent TB Infection.  

By Mariana Gomez, MD (Romulo Gallegos University School of Medicine, Carillion Clinic Infectious Disease), and Hector Arreaza, MD (Romulo Gallegos University School of Medicine, Rio Bravo Family Medicine Residency Program). 

Dr. Gomez explains how to screen for and treat Latent TB infection. 

Today is March 18, 2022.

Dr. Mariana Gomez graduated from medical school at the Romulo Gallegos University in Venezuela. She completed her residency in Internal Medicine in St Barnabas Hospital, which is affiliated with the Albert Einstein School of Medicine, Bronx, New York. She then completed a fellowship in Infectious Diseases at Carilion Clinic, which is affiliated with Virginia Tech School of Medicine. She currently works in Virginia, United States. 

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. 

Some questions discussed during this episode:

Who should be screened for latent TB infection? 

A CDC questionnaire can determine the risk for latent TB infection. Some patients who may be screened are those who resided for 1 month in a country with high TB prevalence, those who are currently immunosuppressed or planning immunosuppression in the near future (50 mg of prednisone or equivalent a day for 1 month), and those who had close contact with patients with TB infection (Latent Tuberculosis Infection: A Guide for Primary Health Care Providers (cdc.gov)). 

The USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk.

Screening Tests: Currently, there are two types of screening tests for LTBI in the United States: the tuberculin skin test (TST, also known as PPD) and the Interferon Gamma Release Assay (IGRA, brand names QuantiFERON®-TB and T-SPOT®.TB). 

The TST requires intradermal placement of purified protein derivative and interpretation of response 48 to 72 hours later. The induration is measured in millimeters. The induration is the palpable, raised, hardened area or swelling, not the erythema.

IGRA requires a single venous blood sample, and the result is obtained in 1-2 days. Two types of IGRAs are currently approved by the US Food and Drug Administration: T-SPOT.TB (Oxford Immunotec Global) and QuantiFERON-TB Gold In-Tube (Qiagen). 

The CDC recommends screening with either test (TST or IGRA) but not both. 

IGRAs is preferred for patients who received a BCG vaccine (bacille Calmette–Guérin) or if they are unlikely to return for TST interpretation.

Why should we screen for LTBI?

How can we decide between Questionnaire only vs PPD vs QuantiFERON Gold?

What is the next step in assessing asymptomatic individuals with positive PPD?

A useful resource is the online TST/IGRA Interpreter (tstin3d.com). 

You can calculate the risk of latent TB infection and the risk of INH-induced hepatitis.

How can we decide to treat LTBI?

What are the recommended regimens? 

CDC recommends three preferred regimens. These are chosen for effectiveness, safety, and high treatment completion rates. These regimens are rifamycin-based. They are:

INH+rifapentine for 3 months: once-weekly isoniazid plus rifapentine for adults and children older than age 2, regardless of HIV status.

Rifampin for 4 months: daily rifampin.

INH+rifampin for 3 months: daily isoniazid plus rifampin.

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Now we conclude our episode number 86 “Latent TB Infection.” Dr. Gomez taught us how to screen and treat latent TB infections. Remember to screen only those who are at risk of TB infection. Once you get a positive screen test, select the patients who will receive treatment of LTBI to prevent reactivation of TB infection. You have at least 4 regimens to treat LTBI. The regimens that include rifamycin are recommended by the CDC. 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 and Mariana Gomez. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Latent Tuberculosis Infection: Screening, September 06, 2016,  United States Preventive Services Taskforce, uspreventiveservicestaskforce.org. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening.

Lewinsohn, David M., et al, Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clinical Infectious Diseases, 2017;64(2):e1–e33, Infection Diseases Society of America, https://www.idsociety.org/globalassets/idsa/practice-guidelines/official-american-thoracic-society.infectious-diseases-society-of-america.centers-for-disease-control-and-prevention-clinical-practice-guidelines-diagnosis-of-tuberculosis-in-adults-and-children.pdf.  

Sterling TR, Njie G, Zenner D, et al. Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recomm Rep 2020;69(No. RR-1):1–11. DOI: http://dx.doi.org/10.15585/mmwr.rr6901a1.

The Online TST/IGRA Interpreter, McGill University and McGill University Health Center Montreal Quebec, Canada, http://tstin3d.com/. 

Episode 86: Abdominal Pain Case. 

Spikevax® is the brand name of the Moderna COVID-19, and it received full FDA approval in January 2022. Hepatitis B vaccine is now universally recommended to all adults between 19-59 years of age, or older than 60 with risk factors. Deidra Sieck presents a case of abdominal pain in pregnancy and differential diagnosis are discussed.  

Introduction: Spikevax ® and Hepatitis B universal vaccination.  
Written by Hector Arreaza, MD. Participation by Cecilia Covenas, MD.

Spikevax®. This is the brand name given to the mRNA COVID-19 vaccine manufactured by Moderna. It was given full FDA approval for the prevention of COVID-19 in adults 18 years and older. This is the second vaccine approved by the FDA for the prevention of COVID-19 (the first vaccine was Comirnaty®, formerly known as Pfizer Vaccine.) 

The primary series of Spikevax for immunocompetent adults is comprised of 2 doses, 4 weeks apart. Immunocompromised patients receive a 3rd dose as part of the primary series, one month after the second dose. A booster shot of Spikevax is given at least 5 months after completing the primary series. Spikevax was also authorized for use as a “mix and match” single booster dose following completion of primary vaccination with a different COVID-19 vaccine. It means that recipients of the Pfizer and J&J vaccines who are 18 years and older may receive a single booster dose of Spikevax. The full FDA approval was granted to Spikevax on January 31, 2022.

Did you know that Hepatitis B has killed 40 times more unvaccinated healthcare workers than HIV?  Yes, that’s right. Hepatitis B is 50 to 100 times more infectious than HIV. It is transmitted by percutaneous or mucosal exposure to infected blood or other bodily fluids. As a reminder, immunizations against many diseases have been required for health care workers for decades, and hepatitis B is one of those required vaccines. That’s not new, what’s new is the new recommendation about universal Hep B vaccination. 

In November 2021, the ACIP (Advisory Committee on Immunization Practices from CDC) recommended universal adult Hepatitis B vaccination. After reviewing clinical evidence, the ACIP has unanimously voted to recommend the Hep B vaccine for all adults ages 19-59. Patients who should receive hep B vaccines are: all adults between 19 and 59 years of age, and adults older than 60 with risk factors for hepatitis B infection. However, adults older than 60 without risk factors mayalso receive hep B vaccines. 

Vaccinating against Hep B is done to decrease new infections, prevent transmission, and reduce health disparities. HHS has called for the elimination of viral hepatitis as a public health threat by 2030. There are some reasons to recommend universal Hep B vaccination for adults: many infected patients did not have any risk factors for infection and still got infected; almost 85% of adults in the U.S. fall into a higher-risk group, including patients with diabetes and kidney disease; hepatitis B cases in the U.S. rose by 11% between 2014 and 2018 despite having highly effective vaccines; Hep B is one of the primary causes of liver cancer, one of the deadliest cancers; universal vaccination of newborns started in 1991 in the U.S., so, many adults are not immune to Hep B, but now they can be vaccinated without the many restrictions imposed in the past.

Remember, Spikevax is the new name for the Moderna vaccine; and you can start vaccinating all adults between 19 and 59 years of age against hep B, regardless of risk factors.

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.

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Abdominal Pain Case.  

By Deidra Sieck, MS4, Ross University School of Medicine. Hosted by Hector Arreaza, MD.  

Abdominal pain in pregnancy is quite common and has a wide differential. I want to begin with a case and then highlight a few of the “do-not-miss” diagnoses when a patient comes with the chief complaint of abdominal pain during her pregnancy. 

Case presentation:23-year-old G2P1 at 32 weeks of gestation complains of 12 hours of right lower quadrant abdominal pain, anorexia, and nausea with vomiting. She denies vaginal bleeding or leakage of fluid from the vagina. Denies diarrhea or eating stale foods. No medical history and has been in good health. Denies dysuria and has had no previous surgeries. Her vital signs include a blood pressure of 100/70 mm Hg, heart rate of 105 beats per minute, and temperature of 101.5 F. On abdominal examination, bowel sounds are hypoactive. The abdomen is tender in the right lower quadrant to right flank with significant involuntary guarding. The cervix is closed. The fetal heart tones are in the range of 160 BMP (modified vignette from case files obstetrics and gynecology 5th ed.)

What are some of the differentials that come to mind? 

The 6 differentials that should come to mind that are do not miss diagnoses include:  

Placental abruption

Appendicitis 

Cholecystitis 

Ectopic Pregnancy 

Hemorrhagic cyst 

Ovarian Torsion

I want to discuss each of these diagnoses and then devise a plan for the patient in this case. 

Placental abruption

This is the most common cause of third trimester bleeding and is an obstetric emergency. It occurs during the second and third trimesters and is described as a midline persistent suprapubic pain. The pain is also accompanied by vaginal bleeding as well as an abnormal fetal heart rate tracing.  Mothers at risk have had a previous abruption, hypertension during the pregnancy, cocaine use, smoking, or preterm premature rupture of the membranes, or trauma as the most common cause of the abruption. This diagnosis is made clinically. The ultrasound is an unreliable modality to see the abruption. If the mother is stable and it is not a complete abruption, the mother usually delivers the baby very quickly vaginally. However, if the abruption is complete, the fetal heart tracing is category III, or the mother is hemodynamically unstable, it is best to deliver by c-section. 

Appendicitis. 

Appendicitis can occur any trimester during pregnancy and has been found to occur in 0.1-1.4/1000 pregnancies. 

The typical nonpregnant patient with appendicitis will come with complaints of right lower quadrant pain that may radiate to the right upper quadrant. This is usually associated with other complaints of nausea, vomiting, anorexia, or fever. [Anorexia: 80% sensitive, The sign of the hamburger] 

However, this diagnosis may be missed later in pregnancy because of an atypical presentation. As the gravid uterus grows, it can displace the appendix upward and lateral toward the flank. This leads to a presentation that appears to be more consistent with pyelonephritis, leading to a missed diagnosis. Because of the delay in diagnosis pregnant women are 2-3 times more likely to have a ruptured appendix, and the resulting peritonitis increases the likelihood of morbidity and mortality for the patient.  

If appendicitis progresses to appendiceal rupture, there is a 30% chance of spontaneous abortion of the fetus. These patients need an ultrasound to make the diagnosis since they cannot have a CT scan in pregnancy despite a CT scan being the preferred modality in nonpregnant patients. The ultrasound should show a non-compressible, blind-ended tubular structure in the right lower quadrant with a maximal diameter greater than 6mm.

After the ultrasound confirms the diagnosis, these patients should be taken immediately for an appendectomy. However, the decreased resolution of imaging seen with ultrasound can also lead to delays in these patients receiving the appendectomy.

Cholecystitis. 

Cholecystitis is more common in pregnancy, with occurrence in 1/1600 pregnancies. This can occur anytime in pregnancy after the first trimester. Pregnant women are especially high risk of cholecystitis since they are female and fertile. The other two “f’s” that are commonly listed as risk factors for cholecystitis include forty, and obesity. [the F word is banned in this podcast]. 

Pathophysiology: The increased progesterone and estrogen increase bile lithogenicity. Progesterone also decreases gallbladder contractility. This increase in gallbladder volume and decreased contractility lead to an increase in “biliary sludge” in the gallbladder. The biliary sludge acts as a precursor to gallstones and obstruction of the cystic duct or the common bile duct. The patient with cholecystitis typically comes with complaints of pain in the right upper quadrant which can be associated with nausea, vomiting, anorexia, and fever. This is the same presentation as a patient in pregnancy. 

The complication of missing this diagnosis includes secondary infection with enteric flora such as: E. coli, Klebsiella, and Enterococcus faecalis.  Fetal loss is seen in 3-20% of pregnancies complicated by cholecystitis. 

The diagnosis is made with a careful history as well as an ultrasound showing gallstones with dilation and thickening of the gallbladder and gallbladder wall. 

Treatment should be started with bowel rest, IV hydration, correction of electrolytes, analgesics. They should be given antibiotics if no improvement after 12-24 hours or are experiencing systemic symptoms. If the medical management does not work, these patients should have a cholecystectomy.  

The cholecystectomy will most likely be laparoscopic due to the gravid uterus making it difficult to perform an open approach. If in the third trimester and the patient is stable, the surgeon may opt to wait until after delivery to remove the gallbladder.

Ectopic pregnancy. 

This is the leading cause of maternal mortality in the first and second trimesters. It usually presents during the first trimester as pelvic or abdominal pain that is usually unilateral. The patient could also complain of nausea, vomiting, syncope, or vaginal spotting. The diagnosis is made using a serum hCG that meets the threshold and transvaginal ultrasound. 

The treatment can be surgical or medical. If the pregnancy is early, methotrexate can be used. 

However, the hCG needs to be trended and followed to zero. A D&C can also be used to treat ectopic pregnancy. Surgery is the first treatment in a patient that is hemodynamically unstable. This diagnosis is not likely in our patient.

Ruptured corpus luteum or ruptured hemorrhagic cyst. 

The corpus luteum cyst is part of a normal endocrine function or a result of prolonged progesterone. In pregnancy, the corpus luteum produces progesterone until 7-10 weeks’ gestation until the placenta can produce steroids including hCG and progesterone to maintain the pregnancy. However, intrafollicular bleeding can occur because of the thin-walled capillaries that invade the granulosa cells from the theca interna. If there is excessive hemorrhage, the cyst can enlarge and rupture. 

The patients presenting with this complaint present with unilateral cramping and lower abdominal pain 1-2 weeks before the rupture. If the corpus luteum becomes hemorrhagic, a hemoperitoneum can develop. These women should undergo an ultrasound, which will show free intraperitoneal fluid. This could also include some fluid around the ovary. The confirmatory method for diagnosis is laparoscopy. 

Culdocentesis is a procedure that checks for abnormal fluid in the space just behind the vagina. This area is called the cul-de-sac. During a culdocentesis, a long thin needle is inserted through the vaginal wall just below the uterus and a sample is taken of the fluid within the abdominal cavity.

Once the bleeding is controlled, there is no further treatment needed. However, if the patient requires a cystectomy due to continued bleeding and the pregnancy is less than 10 weeks, she will need exogenous progesterone because of the loss of the corpus luteum. 

Ovarian Torsion. 

Pregnancy is a risk factor for ovarian torsion, especially around 14 weeks and after delivery. Torsion is most likely between 10-17 weeks, and more likely to happen in masses 6-8 cm in diameter. Pregnant and nonpregnant patients have the same presentation, suprapubic or lower quadrant pain, nausea, and vomiting, up to 20% can have a fever.

Plan for the patient in the case:

1. Ultrasound: Showed a non-compressible, blind-ended tubular structure in the right lower quadrant with a maximal diameter of 7mm.

2. Appendectomy: Take the patient to the OR.

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Now we conclude our episode number 86 “Abdominal Pain Case.” We started by giving you an update on Spikevax®, formerly known as “the Moderna vaccine”. This is the newest COVID-19 vaccine fully approved by the FDA for patients 18 years and older. Also, Hepatitis B vaccination is now recommended universally to all adults 19-59 regardless of risk factors. Then, Deidra presented a case of a patient who was pregnant and had abdominal pain. Surprisingly, her diagnosis was appendicitis. This is a good reminder that pregnant and nonpregnant patients can get appendicitis. 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 for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Cecilia Covenas, and Deidra Sieck. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Coronavirus (COVID-19) Update: FDA Takes Key Action by Approving Second COVID-19 Vaccine, US Food and Drug Administration, January 31, 2022. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/spikevax-and-moderna-covid-19-vaccine.

ACIP fully recommends Spikevax, as CDC expands wastewater surveillance, University of Minnesota, Center for Infectious Disease Research and Policy (CIDRAP), February 04, 2022. https://www.cidrap.umn.edu/news-perspective/2022/02/acip-fully-recommends-spikevax-cdc-expands-wastewater-surveillance. 

ACIP recommends universal hepatitis B vaccination for adults aged 19 to 59 years, Healio.com, https://www.healio.com/news/infectious-disease/20211103/acip-recommends-universal-hepatitis-b-vaccination-for-adults-aged-19-to-59-years.

Landmark vote by CDC’s Advisory Committee on Immunization Practices (ACIP) to recommend universal hepatitis B vaccination, Hepatitis B Foundation, November 4, 2021. https://www.hepb.org/news-and-events/news-2/the-cdcs-advisory-committee-on-immunization-practices-acip-voted-to-recommend-universal-hepatitis-b-vaccination/

Ananth, Cande Vanessa V, and Wendy L Kinzler. “Placental Abruption: Pathophysiology, Clinical Features, Diagnosis, and Consequences.” Edited by Charles J Lockwood, and Vanessa A Barss, 22 Feb. 2021, https://www.uptodate.com/contents/placental-abruption-pathophysiology-clinical-features-diagnosis-and-consequences. 

Brooks, David C. Edited by Stanley W Ashley et al., Gallstone Disease in Pregnancy, 26 July 2021, https://www.uptodate.com/contents/gallstone-diseases-in-pregnancy.

H., De Cherney Alan, et al. “Chapter 25: Surgical Disorders In Pregnancy.” Current Diagnosis and Treatment: Obstetrics and Gynecology, McGraw Hill Medical Publishing Division, 2019.

“Obstetrics and Gynecology.” Case Files: Obstetrics and Gynecology 5th Edition, by Eugene C. Toy et al., McGraw-Hill Medical, 2016, pp. 135–144.

Rebarber, Andrei, et al. “Acute Appendicitis in Pregnancy.” Edited by Martin Weiser et al., Up To Date, 17 Sept. 2021, https://www.uptodate.com/contents/acute-appendicitis-in-pregnancy.

Runowicz, Carolyn D, and Molly Brewer. “Adnexal Mass in Pregnancy.” Edited by Barbara Goff and Alana Chakrabarti, UpToDate, 10 Feb. 2022, https://www.uptodate.com/contents/adnexal-mass-in-pregnancy.

Tulandi, Togas. “Ectopic Pregnancy: Clinical Manifestations and Diagnosis.” Edited by Deborah Levine et al., UpToDate, 18 Jan. 2022, https://www.uptodate.com/contents/ectopic-pregnancy-clinical-manifestations-and-diagnosis.

Episode 85: Detecting Dementia and Evusheld®. 

Parneeta Singh explained a new blood test to predict Alzheimer’s disease and an artificial-intelligence cognitive test for early detection of dementia. Dr Saito and Dr Arreaza present Evusheld, a monoclonal antibody for pre-exposure prophylaxis against COVID-19.  

Today is March 4, 2022. Today marks the 2-year anniversary of our podcast. We have been bringing you relevant clinical information for 2 years, almost every week. We hope you have found this podcast useful. If you have learned at least one thing from us, our goal has been reached. This podcast started as an experiment and it has become an enriching experience for students, residents, faculty, and all of you who listen to us throughout the world. We look forward to many more years of education, updates, and fun! Thanks for listening.

Introduction: Innovative ways to detect dementia: Alzosure Predict® and CognICA® 
By Parneeta Singh, MD, Ross University School of Medicine; comments by Hector Arreaza, MD.   

Alzheimer’s disease (AD) is a neurocognitive disorder that is the most common cause of dementia. More than 6 million Americans aged 65 and older have the late-onset subtype while many more between ages 30 and 60s have the early-onset subtype although the latter is very rare. 

One of the first signs of AD is memory issues. A decline in other aspects of thinking, impaired judgment or reasoning, visual/spatial problems can also indicate early stages of AD. Mild cognitive impairment (MCI) can also be considered an early sign of AD. However, not everyone with MCI will develop the disease. As the disease progresses, people with AD have trouble performing daily activities such as cooking, driving, managing their finances while some have personality changes as well. 

According to the Alzheimer’s Association, two abnormal structures called plaques (deposits of a protein fragment called beta-amyloid that builds up between neurons) and tangles (twisted fibers of another protein called tau that builds up inside neurons) are most probably responsible for the damaging effects seen in AD. Patients with AD develop plaques and tangles initially in parts of the brain involved in memory, such as the entorhinal cortex and hippocampus, before affecting other parts of the brain such as the cerebral cortex which is responsible for reasoning, social behavior, and language. 

Today, AD is at the forefront of biomedical research with earlier diagnoses and interventions improving drastically. New research conducted by Diadem (a diagnostic company that focuses on AD research) exhibited that a novel blood test called Alzosure Predict® identifies a variant of the protein p53 which seems to predict AD’s progression up to 6 years before a clinical diagnosis is made. 

This blood test measures a derivative of p53 (U-p53AZ) which is implicated in AD pathogenesis. Blood samples from patients aged 60 years and older who had different levels of cognitive function were analyzed which showed that the test predicted a decline from MCI to AD at the end of 6 years. The test can also classify a patient’s cognition stage. The positive predictive value (PPV) and negative predictive value (NPV) were at 90%. Knowing which patients will progress to AD allows them to try treatments earlier on the disease when therapies are most likely to be more effective. 

Additionally, using the test could speed up the approval of prospective drug treatments and allow those patients with a likelihood of developing AD to enroll in clinical studies. Patients can also be monitored during a study instead of relying on costly PET scans and painful lumbar punctures. These findings were presented at the 14th Clinical Trials on Alzheimer's Disease (CTAD) conference in November 2021.

Another way to detect dementia early on is by an artificial intelligence cognitive assessment called Cognetivity's Integrated Cognitive Assessment (CognICA®) which has been cleared by the US Food and Drug Administration in October 2021. It is a 5-minute computerized cognitive assessment that is completed using an iPad. It has numerous advantages over traditional pen and paper-based cognitive tests such as avoidance of cultural or educational bias, absence of learning effect upon repeat testing, its high sensitivity to detect early-stage cognitive impairment, and since it is computer-based, it can be self-administered and performed remotely. 

In conclusion, reliable, simple, cost-effective measures of cognition are critical for providing quality care whether it is in the field of family medicine, neurology, or geriatrics. According to Percy Griffin, Ph.D., MSc, director of scientific engagement at the Alzheimer's Association, the ability of such technologies to detect dementia before significant loss of brain cells “would be game-changing” for individuals, their families, and the healthcare system at large. 

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. 

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Evusheld. 

Written by Brandy Truong, MS4, Ross University School of Medicine. Edited by Hector Arreaza, MD. Collaboration: Steven Saito, MD.

This monoclonal antibody is for pre-exposure prophylaxis (PrEP) of COVID-19, which means it is given prior to exposure to the virus. Evusheld is not a replacement for COVID-19 vaccines, and everyone eligible to receive one of the safe and effective COVID-19 vaccines should do so.

It is meant to give protection to those who are unable to mount an adequate immune response against COVID 19 after vaccination. It was given an emergency authorization use by FDA on December 8, 2021. EVUSHELD is tixagevimab co-packaged with cilgavimab, two long-acting antibodies. This medication may be effective for pre-exposure prevention up to six months.

It was designed to be given to the immunocompromised population and for anyone who cannot receive the vaccine, as long as the patient is older than 12 years and more than 88 pounds.  (We totally make the cut). If your patient has a health condition that won’t allow their immune system to develop a strong enough response to the COVID-19 vaccine, for example, they are immunocompromised because of cancer, they can receive Evusheld. 

If they are taking medications that prevent a strong enough response to the COVID-19 vaccine, for example, chemotherapy or transplant anti-rejection medications, they can receive Evusheld.

If they are unable to get the vaccine due to anaphylaxis to all of the COVID-19 vaccines or their ingredients, they can receive Evusheld.

Monoclonal antibodies are lab-made proteins that mimic the immune system’s way of fighting off infections. The two antibodies in Evusheld are long-acting and are made to specifically fight off against SARS-CoV-2. Evusheld is administered by two injections immediately given one after another.

In a recent study done looking at how effective Evusheld was, it showed a 77% reduced risk of developing COVID-19 compared to individuals who received placebo. This study was a randomized, double-blind, placebo-controlled trial in adults older than 59 years old or with a prespecified chronic medical condition or at increased risk for COVID-19 and for other reasons didn’t receive the vaccine and have no prior history of COVID-19. 

Some side effects of the medication include hypersensitivity reactions, bleeding at injection site, headache, fatigue, and cough. 

If you would like to provide this monoclonal antibody Evusheld to your patients, as well as other treatments such as Paxlovid, Molnupiravir, sotrovimab, and bebtelovimab, consult the COVID-19 Therapeutics Locator provided by the office of the Assistant Secretary for Preparedness & Response. You can do a Google search for HHS COVID-19 Therapeutics locator or you can find the link in the notes of this episode. [https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com/]

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Now we conclude our episode number 85 “Detecting Dementia and Evusheld” You listened to Dr Singh present some new promising ways to recognize Alzheimer’s disease early and detect those who are at risk of progression. We are all hoping for a simple way to diagnose Alzheimer’s, and in the near future, we may have a blood test that can help us diagnose this devastating disease. Also, you heard about Evusheld, the new monoclonal antibody given Emergency Use Authorization by FDA for pre-exposure prophylaxis for COVID-19. Consult the Therapeutics Locator to see the availability 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 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, Parneeta Singh, Brandy Truong, and Steven Saito. Audio edition: Suraj Amrutia. See you next week! 

References:

Alzheimer’s Association: What is Alzheimer’s Disease? https://www.alz.org/alzheimers-dementia/what-is-alzheimers, accessed on 30 December 2021. 

National Institute of Aging: What is Alzheimer’s Disease? https://www.nia.nih.gov/health/what-alzheimers-disease, accessed on December 30, 2021. 

New Blood Test May Detect Preclinical Alzheimer's Years in Advance, https://www.medscape.com/viewarticle/963509?uac=242448MJ&faf=1&sso=true&impID=3825884&src=WNL_trdalrt_211126_MSCPEDIT#vp_1, accessed on 30 December, 2021.

FDA Clears 5-Minute Test for Early Dementia, https://www.medscape.com/viewarticle/961277?uac=242448MJ&faf=1&sso=true&impID=3729166&src=wnl_newsalrt_211020_MSCPEDIT, accessed on 30 December, 2021.

Cognetivity Neurosciences, https://cognetivity.com/cognica/, accessed on December 30, 2021. 

Evusheld Antibody Treatment for COVID-19 High-risk Groups, South Carolina Department of Health and Environmental Control, December 8, 2021, https://scdhec.gov/covid19/monoclonal-antibodies/evusheld-antibody-treatment-covid-19-high-risk-groups.

HHS Therapeutics Locator, office of the Assistant Secretary for Preparedness & Response,  https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com/

Episode 84: Smells in medicine. 

Intro about race in algorithms. Self-reported case of anosmia by Dr. Arreaza. Some common smells in medicine are discussed with Dr Grewal, for example, halitosis, bromhidrosis, and fetor hepaticus. Parosmia is also mentioned as a sequela after COVID-19 infection. 

Intro: Race in clinical algorithms.  
By Brandy Truong, MS4, Ross University School of Medicine.

The year 2020 was not only the beginning of the pandemic but also a time when our country finally took the time to learn more about systemic racism. Many members in the medical community have been fighting racism in medicine for years and unfortunately have often gone unheard. However, in the past few years, people decided to start listening. 

The New England Journal of Medicine published an article in 2020 looking at different algorithms that have a race component and how that can be harmful to patients and perpetuates systemic racism. Let’s take a dive into some of those clinical algorithms. 

Something that has gained a large movement, is getting rid of a test that helps determine kidney function based on race. This test is called estimated glomerular filtration rate, or what we call eGFR which considers a person’s age, gender, race, and levels of creatinine. When it comes to the race category, it considers if someone is African American or not. Therefore, there are different normal eGFR values for African American and then all others. 

The test was based on an assumption that Black people have higher muscle mass on average which led to higher kidney function. This becomes problematic because assuming all Black people have higher kidney function can delay a patient’s referral to a specialist or getting a transplant. This leads to higher rates of end-stage kidney disease and death due to kidney failure compared to the overall population. 

Many physicians and medical students at top universities have pushed their administration to get rid of the eGFR values based on race. Some hospitals like Mass General no longer use eGFR based on race. The National Kidney Foundation and American Society of Nephrology are still evaluating if they recommend the current algorithms. 

When it comes to looking at heart failure risk, the American Heart Association recommends a Heart Failure Risk Score that predicts the risk of death in patients admitted to the hospital. When a patient identifies as not Black, their score increases by 3 points which puts Black patients at lower risk due to a lower score. This score helps us decide on referrals to cardiology and general care. This becomes problematic because Black patients may not receive the care they need if assumed they are lower risk. 

This was shown when a study done in 2019 showed that Black and Latinx patients that presented to an emergency department in Boston with heart failure were less likely than White patients to be admitted to the cardiology unit.

Another algorithm that puts Black patients at lower risk is the STONE score which predicts the likelihood of kidney stones in patients who present in the ER with flank pain. The score increases by 3 points for patients who don’t identify as Black, which once again puts Black patients at lower risk due to a lower score. 

Black maternal mortality is drastically much higher compared to White women. Something that can contribute to it is an algorithm called Vaginal Birth after Cesarean which predicts the risk in a trial of labor for someone who had a prior cesarean section. This algorithm predicts a lower level of success for mothers identified as Black or Hispanic. 

It’s also important to note that the study used to create the algorithm found that variables like marital status and insurance type also correlated with the success of vaginal birth after cesarean, but those factors weren’t included in the algorithm. 

The benefits of having a vaginal delivery include lower rates of surgical complications, faster recovery time, and fewer complications in future pregnancies. Nonwhite women have higher rates of c-section than white women which decreases the chances of nonwhite women from having the benefits of vaginal delivery.

We have to ask ourselves, why continue to use algorithms based on race? A lot of these algorithms were based and created on flawed assumptions. And while geneticists want physicians to take race seriously, studies showed there is more variation within the same racial groups than between different ones. And racial differences that are found, it was most likely due to the effects of racism such as the experience of being Black in America. It’s harmful because these algorithms guide clinical decisions which may direct more attention or resources to White patients than patients of color, which is harmful and increases health disparities. 

This segment touches only the surface of algorithms using race to determine clinical outcomes and how that is flawed. There are also many other factors rooted in systemic racism in why these algorithms considered race in the first place, why we continue to use them, and the disparities in healthcare and clinical outcomes. 

As we end this segment, I want to take the time to thank the folks fighting racism in medicine as it’s not an easy task. As people continue to bring awareness, we need to listen, acknowledge, and make changes accordingly so that all patients can have the care they need and deserve.

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.

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Smells in medicine.  
By Hector Arreaza, MD. Discussed with Namdeep Grewal, MD.

Some of my happiest memories are linked to smells, I’m sure specific smells bring back memories to you. In my case, the smell of wet dirt on a rainy day accompanied by the aroma of boiling hot chocolate are some of the smells that remind me of my childhood. From my teen and youth years, I remember some of the trendy colognes among young people: Calvin Klein One, Paco Rabanne, and Hugo Boss are some of those smells that have a little space in my limbic system. 

Olfaction is one of the special senses that we take for granted until we lose it. The term anosmia became more popular after March 2020 because anosmia is one of the symptoms of infection by coronavirus. I got COVID-19 recently and experienced anosmia for the first time in my life. I had a feeling of emptiness in my life. I felt incomplete. I will not deny it was pleasant to drive by a particularly stinky road by my house without gagging or covering my nose, but I was missing the smell of foods and other pleasant smells in my life. 

While I was experiencing anosmia I was not working, but I thought about the effect of my anosmia on my work as a physician. What smells could I miss if I did not recover my olfaction? I also reflected on the smells that I have experienced as a doctor. Some smells have helped me guide a diagnosis or start an investigation. Today, I want to discuss the olfactory system as a diagnostic tool in medicine.

Nowadays, clinicians rely less on their olfactory systems to make a diagnosis, but smells can certainly be helpful in some cases. I was blessed with a very sensitive sense of smell, but honestly, I have a hard time tolerating farts, B.O., bad breath, and other unpleasant smells. 

Halitosis: Also known as “bad breath” can be an indication of poor oral hygiene causing dental decay and gingivitis. Halitosis can be a deal-breaker in a relationship, but it can also be a sign of infections such as tonsillitis, lower respiratory infections (viral or bacterial), Vincent's angina (acute necrotizing ulcerative gingivitis), gastroesophageal reflux, Helicobacter pylori infection, and Zenker's diverticulum (which is a pouch or diverticulum that forms in the upper esophagus causing dysphagia, and food and saliva may get stuck in the pouch and decompose over time, no wonder it may cause a smell, remember the mnemonics for your test “Zenker” = “Stenker”). In patients with foul, feculent breath who are acutely ill you will need to rule out intestinal obstruction or diverticulitis.

An ammonia-like smell can be detected in patients with chronic or acute uremia. If the ammonia is accumulated in the blood to a level that makes it perceptible to your nose, you may be in front of a severe case of renal disease, so refer the patient promptly for 

Bromhidrosis (body odor): Body odor is the perceived unpleasant smell that results from bacteria metabolism of fatty acid by bacteria that normally live on the skin. The apocrine glands are located on the axilla, anogenital area, and breasts. These glands develop around puberty and their function is the secretion of pheromones. Sweat is normally odorless, but the bacteria degrade the sweat, oils, and proteins into substances that produce a strong smell. Body odor is normal. Excessive body odor that interferes with social life and self-esteem is considered bromhidrosis. What is considered “excessive” can vary from one patient to another. The treatment of localized bromhidrosis (mostly axilla) is focused on decreasing the amount of sweat by applying antiperspirants and improving hygiene. Recalcitrant cases of bromhidrosis may be related to infections such as intertrigo and erythrasma and require the use of topical or systemic antibiotics, and severe cases may even require a dermatology evaluation. 

Alcohol breath: I’m very familiar with this smell after many years of encounters with intoxicated people, not only patients but friends, uncles, cousins, etc. The smell of alcohol in exhaled air is used to determine blood alcohol content (BAC) by using a machine called a breathalyzer. All states, including California, consider a BAC above 0.08% as the standard to be legally intoxicated while driving. A caveat about BAC by breathalyzer is that patients following a ketogenic diet may have a falsely elevated BAC. So, make sure to inform the officer about your eating habits to avoid getting an unfair DUI sentence. A BAC level above 0.04% is applied to drivers of commercial vehicles, including moving trucks and rental cars, and a BAC above 0.01% for drivers under the age of 21. Most states have a zero-tolerance for underage drinkers and drivers, and harder penalties for those who have exceptionally high BACs. Alcohol intoxication is more than just a smell, you need to have many other signs and symptoms for diagnosis. If you feel your nose and your judgment are inaccurate, you can confirm by measuring a direct alcohol level in the blood, especially when you are in the hospital and need an exact diagnosis. 

Anaerobic infection smell: Anaerobic bacteria cause wound infections that are characteristically foul-smelling. You can find free gas in tissues, abscesses, and pungent discharge. After smelling infected wounds several times, your nose may be able to recognize the typical foul-smelling odor of anaerobic bacteria. But not all bacteria have an unpleasant smell, according to medical literature, I cannot attest to it, pseudomonas smell like grapes or tortillas, streptococcus smells like butterscotch, and proteus smells like burned chocolate or cocoa.

Diabetic Ketoacidosis (DKA): Patients with DKA may have a fruity smell. Acetone and ethyl acetate are elevated in DKA, and they have a scent similar to nail polish remover. If your patient smells like a beauty salon and is breathing fast and deeply (Kussmaul breathing), there is no time to spare, start immediate treatment of DKA. Remember that DKA can be the initial presentation of diabetes in some patients, particularly young patients, and it is fatal if left untreated.

Fetor hepaticus breath: The description of this smell is somewhat confusing. Some people describe it as a combination of rotten eggs and garlic, others describe it as a smell like clover, or Sulphur with a hint of fecal matter, it is also known as the “breath of death”. The components responsible for this smell are “thiols” that enter the systemic circulation through a portosystemic shunt caused by portal hypertension in liver disease. The thiols reach the lungs and from there they are exhaled giving the chronic liver patient the fetor hepaticus breath. Some people also describe it as a “musty” odor. 

Musty smell: You can think of musty as a synonym of moldy. Musty is likely a variant of the word “moisty,” or “moist.” Musty means having an odor (or flavor) suggestive of mold, such as old buildings or stale food, or like sweaters left in an attic for a long time. Mousy means that it smells like a “mouse”. It can be challenging to know what a mouse smells like. If you want to experience a “mousy” odor, walk into a pet store on a summer day and you may be able to recall the smell when you examine a patient. Why are we talking about musty/mousy odor? Because it can be clinically relevant if you find it in a child’s breath, urine or skin, as this can mean accumulation of phenylalanine in the body, known as phenylketonuria. Detecting a “musty” odor during a physical exam may be less common now because phenylketonuria is included in the newborn screening program in the United States and many other countries. Remember that keyword for your exams, “musty” odor means phenylketonuria.

We have discussed different smells in medicine: halitosis, ammonia, body odor, alcohol breath, anaerobic infection, DKA, fetor hepaticus, and musty smell. We did not cover all smells in medicine, but this is a good starting point for you to keep learning about smells in medicine. 

As for anosmia and COVID-19, let’s remember that most people recover their sense of smell within a few days or weeks, but some patients have reported a long-term abnormal sense of smell, either anosmia or parosmia.

Parosmia is an altered perception of odors that causes normally pleasant smells to be perceived as foul or disgusting. For example, smelling coffee can feel like smelling rotten food. Many patients have reported this symptom after recovery from COVID-19. Parosmia may last 3-6 months, and resolution is normally spontaneous.The cause of parosmia is still uncertain, but it is thought to be a result of direct inflammation of nervous tissue in the olfactory system. As we know, COVID-19 is a multisystemic infection that involves not only the respiratory system but also the nervous system, GI tract, cardiovascular system, and other organs that we are still discovering. There is not a specific treatment for parosmia, but some believe in “smell therapy” which consists of smelling strong scents such as ammonia, eucalyptus, citrus, and perfumes to re-train the brain on the normal process of smelling. 

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Conclusion: Now we conclude our episode number 84 “Smells in medicine.” What is a memorable smell you have? Some smells are characteristic findings of certain diseases. For example, a “musty” odor is a keyword for phenylketonuria. Your nose can point you in the right direction to a diagnosis. If you are among the 1 in 10,000 people with congenital anosmia, don’t worry, there are other ways to sense your surroundings, you can still be an excellent clinician without a sense of smell. 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, Namdeep Grewal, and Brandy Truong. Audio edition: Suraj Amrutia. See you next week! 

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References:

Gaffney, Theresa, et al. “A Yearslong Push to Remove Racist Bias from Kidney Testing Gains New Ground.” STAT, 16 July 2020, www.statnews.com/2020/07/17/egfr-race-kidney-test/. 

Vyas, Darshali A., et al. “Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms.” New England Journal of Medicine, vol. 383, no. 9, 2020, pp. 874–882., doi:10.1056/nejmms2004740. 

Miller, Jami L., Bromhidrosis, UpToDate, last updated: Oct 18, 2021, https://www.uptodate.com/contents/bromhidrosis?csi=b679769a-2e96-4c17-bac5-ad299491751d&source=contentShare.

California Driver Handbook, Alcohol and Drugs, California DMV, English 2020,  https://www.dmv.ca.gov/portal/handbook/california-driver-handbook/alcohol-and-drugs/

Parosmia After COVID-19: What Is It and How Long Will It Last? Office of Public Affairs, University of Utah Health, September 3, 2021, https://healthcare.utah.edu/healthfeed/postings/2021/09/parosmia.php.

Episode 83: Solitary Rectal Ulcer. 

Dr Singh explains how we can diagnose and treat solitary rectal ulcer syndrome (SURS) and Brandy gave an introduction regarding Elvis Presley’s death.  

Introduction: Did Elvis Die Pooping?
By Brandy Truong, MS4, Ross University School of Medicine. 

A pop culture trivia fact I always found interesting was that Elvis Presley may have died from trying to have a bowel movement. There are different statements on the cause of death ranging from cardiac arrest, drug overdose, anaphylactic shock, and straining to have a bowel movement. But we’re not here to figure out which one is accurate or debate all that. Elvis was found in the bathroom on the floor and many people described it as if he was on the toilet and then fell forward. If he died from pooping, how does that even happen? We’re going to explore that a little.

When we strain to have a bowel movement, it’s called the Valsalva maneuver. This maneuver is divided into 4 stages. 

Phase 1 is when one first starts straining or bears down. This causes an increase in chest pressure and blood being forced out from the large veins. This is reflected in a rise in blood pressure and a decrease in heart rate. In phase 2, there is reduced venous return to the heart because the blood was forced out of the large veins. Because there is less return to the heart, the heart doesn’t pump out as much as it normally would which leads to a fall in blood pressure. The body senses this fall in blood pressure and will compensate by increasing the heart rate significantly. Phase 3 is when one stops bearing down which results in a release of chest pressure. This causes a fall in blood pressure which causes the heart rate to increase as a reflex. In phase 4, the decreased venous return seen in phase 2 is now restored, which causes an increase in blood pressure. The heart rate then decreases as a reflex response. Both blood pressure and heart rate will return to normal. This entire process occurs over a span of a little over 10 seconds.

Elvis was known to have a drug addiction and later some doctors found that he had hypertrophic cardiomyopathy which is a condition in which the heart is unable to pump blood well. He abused a variety of pain medications including opioids. Opioids often cause constipation; therefore, if Elvis was constipated and straining, the Valsalva maneuver compounded by heart disease and other unhealthy lifestyles he had would have caused his cardiac arrest. 

Intense straining during the process of defecation can result in subarachnoid hemorrhage in people with congenital berry aneurysms, for example. If you end up googling to find out how Elvis died, let us know what you think and if you think he died from pooping. 

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. 

Solitary Rectal Ulcer Syndrome.  
By Parneeta Singh, MD, Ross University School of Medicine. Discussed with Hector Arreaza, MD.

Solitary Rectal Ulcer Syndrome (SRUS) is a benign, rare, underdiagnosed disorder that can mimic and be incorrectly diagnosed as inflammatory bowel disease (IBD) or rectal cancer. The exact prevalence is unknown but in general, it is reported as an annual prevalence of one in 100,000 people. It mostly occurs in the third decade in men and fourth decade in women, with men and women being equally affected. However, cases have been identified in the pediatric and geriatric populations as well. SRUS is a misnomer because although some patients may present with a solitary ulcer, many present with multiple ulcers that may also involve the sigmoid colon. 

Presentation. 

Rectal bleeding (with the amount varying from a little fresh blood to severe hemorrhage that may require blood transfusions), mucus discharge, excessive straining, abdominal and perineal pain, constipation, or diarrhea, feeling of incomplete defecation, tenesmus, and rarely rectal prolapse are clinical symptoms associated with SRUS. Presentation may resemble intestinal parasites such as Entamoeba histolytica(amebiasis) and Enterobius vermicularis (pinworm).

The underlying etiology is unknown, but a number of mechanisms have been suggested including ischemic injury from the pressure of impacted fecal matter and local trauma due to repetitive self-digitation, although the latter remains unproven. 

Ulcers usually occur in the mid-rectum which cannot be reached by self-digitation. Additionally, it has been proposed that the perineum’s descent along with the abnormal contraction of the puborectalis muscle during defecation results in trauma or a prolapsed rectum with mucosal prolapse being the most common underlying pathogenesis in SRUS. 

Diagnosis. 

The diagnosis of SRUS is based on clinical features and proctosigmoidoscopy findings, with histological examination and biopsies being the key to the diagnosis. Imaging studies including defecating proctography, dynamic MRI and anorectal functional studies also aid in the diagnosis with the latter showing that 25% to 82% of SRUS patients have dyssynergia with paradoxical anal contraction. A thorough evaluation is important in ruling out IBD, ischemic colitis, and malignancy.

Histology evaluation of biopsy establishes the diagnosis of solitary rectal ulcer syndrome. Findings include fibromuscular obliteration of the lamina propria. This obliteration causes hypertrophy and disorganization of the muscularis mucosa and regenerative changes. There is an abnormal crypt organization. In cases were polypoid lesions are prevalent, the mucosa has a villiform configuration, and in some cases, the glands may be trapped in the submucosa, which is called colitis cystica profunda.

Treatments.

Various treatment options are available for SRUS with the treatment choice depending on symptom severity and the presence of rectal prolapse. 

The initial steps, especially in asymptomatic patients, include patient education and behavioral modifications which include a high-fiber diet, straining discontinuation, and a discussion of psychosocial factors. 

Biofeedback is the next step in those who fail to respond to conservative measures. Biofeedback seems to help by altering efferent autonomic pathways to the gut that reduces straining with defecation by correcting abnormal pelvic-floor behavior. 

Topical treatments used include corticosteroids, salicylate, sulfasalazine, mesalazine, sucralfate suppositories and topical fibrin sealant. 

Unfortunately, surgery is necessary in almost one-third of adults with associated rectal prolapse who do not respond to the above treatment options. Surgical treatments include ulcer excision, treatment of internal or overt rectal prolapse, and de-functioning colostomy. Open rectopexy and mucosal resection have shown a success rate of 42% to 100%. 

In conclusion, SRUS is an uncommon disease that can mimic IBD and rectal cancer. Thus, a thorough and complete patient history and work-up is required to accurately diagnose SRUS, following which patient education, reassurance that the lesion is benign and a conservative, stepwise individualized approach is important in the management of this syndrome.

Conclusion: Now we conclude our episode number 83 “Solitary Rectal Ulcer.” Rectal bleeding, constipation, diarrhea, abdominal pain… yes, it sounds like Chron’s syndrome, but your list of differentials may be very long. You may want to add to that list Single Rectal Ulcer Syndrome. The treatment goes beyond medications for inflammation and includes pelvic floor training. 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 for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Brandy Truong, and Parneeta Singh. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

“Elvis Presley.” Wikipedia, Wikimedia Foundation, 21 Jan. 2022, https://en.wikipedia.org/wiki/Elvis_Presley#Cause_of_death. 

Markel, Dr. Howard. “Elvis' Addiction Was The Perfect Prescription for an Early Death.” PBS, Public Broadcasting Service, 16 Aug. 2018, https://www.pbs.org/newshour/health/elvis-addiction-was-the-perfect-prescription-for-an-early-death.  

Srivastav, Shival. “Valsalva Maneuver.” StatPearls [Internet]., U.S. National Library of Medicine, 28 July 2021, www.ncbi.nlm.nih.gov/books/NBK537248/. 

Zipes, Douglas. “Valsalva Maneuver.” Valsalva Maneuver - an Overview,ScienceDirect Topics, www.sciencedirect.com/topics/neuroscience/valsalva-maneuver . 

Qing-Chao Zhu, Rong-Rong Shen, Huan-Long, Yu Wang. Solitary rectal ulcer syndrome: Clinical features, pathophysiology, diagnosis, and treatment strategies. World J Gastroenterology. 2014 Jan 21; 20(3): 738–744. doi: 10.3748/wjg.v20.i3.738. PMID: 24574747; PMCID: PMC3921483. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921483/

Young Min Choi, Hyun Joo Song, Min Jung Kim, Weon Young Chang, Bong Soo Kim, Chang Lim Hyun. Solitary Rectal Ulcer Syndrome Mimicking Rectal Cancer. The Ewha Medical Journal. 2016 Jan 29; 39(1): 28-31. doi: https://doi.org/10.12771/emj.2016.39.1.28. Department of Internal Medicine, Surgery, Radiology and Pathology, Jeju National University School of Medicine, Jeju, Korea. https://synapse.koreamed.org/articles/1058669

Sachin B Ingle, Yogesh G Patle, Hemant G Murdeshwar, Chitra R Hinge Ingle. An unusual case of solitary rectal ulcer syndrome mimicking inflammatory bowel disease and malignancy. Arab J Gastroenterol. 2012 Jun 13(2):102. doi: 10.1016/j.ajg.2012.02.004. Epub 2012 Apr 11. Department of Pathology. PMID: 22980604. https://pubmed.ncbi.nlm.nih.gov/22980604/

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 81: The Tongue Talks.  

By Idean Pourshams, MD; Golriz Asefi, MD; and Hector Arreaza, MD.   

Drs Asefi, Pourshams, and Arreaza discuss how to discover local or systemic diseases of the tongue. Includes jokes about tongue.

In Traditional Chinese Medicine (TCM), regions of the tongue reflect information about specific organ systems, for example the tip of the tongue traditionally depicts ailments of the heart while the anterior-lateral sections of the tongue represent the lungs, and the posterior-lateral regions reflect the health of the liver and gallbladder. But, today we will focus on common tongue lesions.

Normal tongue.

The tongue is a muscular organ, highly vascularized and highly innervated. It is normally covered by pink mucosa and has a rough surface caused by the presence of papillae (taste buds). It is vital for chewing and swallowing food and it is essential for speaking. The tongue contains an abundance of blood vessels and is constantly regenerating. The top layer of the tongue is replaced every 2-3 days! A healthy tongue should appear slightly wet, light red or pink with possibly a normal thin white coating. There should not be any fissures, teeth marks or swelling. 

On physical exam, ensure that the patient has full range of motion of the tongue. It is very important to look at a patient's tongue during physical examination to note the shape, size, color and texture of the tongue body and coat. Findings can suggest the state of organ functions and progression of any underlying conditions. 

Today we will describe certain physical findings on tongue examination and discuss what clues could be drawn when diagnosing or treating our patients.

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 tongue. 

What would be your suspicions if a tongue was described as having patches resembling smooth red islands or patches located on the top or side of the tongue, and the patches may actually change location, size and shape? Any ideas on a diagnosis?

This could be a geographic tongue also called benign migratory glossitis which is considered harmless and related to allergic rhinitis and other allergies, but it can also be linked to psoriasis and reactive arthritis. 

What about a tongue that is described as dark and furry or hairy, along with a patient complaining of a metallic taste in their mouth? On physical examination you also note halitosis or bad breath. 

This could be a diagnosis of black hairy tongue or lingua villosa nigra. Any idea on what may cause black hairy tongue? Possible causes include antibiotic use, tobacco use, mouth breathing, poor oral hygiene, radiation therapy, chronic use of bismuth.

Now let’s talk about some vitamin deficiencies that may be represented by changes in the tongue’s appearance. If the patient’s tongue appears purple, and the corners of the mouth display angular stomatitis, it would be wise to suspect a vitamin B2 deficiency. B2: Eyes and mouth. 

B2 is also known as riboflavin. Patients can have painful cracks in the corners of the mouth and on the lips known as angular cheilitis, also scaly patches on the head, and a magenta mouth and tongue. It is seen in patients who do not eat enough meats (vegans), but also in chronic disorders such as chronic diarrhea, liver disease, alcohol use disorder, malabsorption, and chronic use of barbiturates. 

Giving Vitamin B supplements by mouth may solve the problem. Vitamin B intoxication is virtually impossible, so you can supplement vitamin B along with other vitamins by mouth confidently, especially patients who are on hemodialysis or peritoneal dialysis. Foods rich in riboflavin include grains, mushrooms, and dairy products.

Vitamin B2 deficiency is normally not seen just by itself but combined with other vitamin B deficiencies. 

Another presentation of a patient’s tongue may be inflammation of the tongue, or glossitis,that is extremely uncomfortable or painful. Any suspicion on what vitamin may be deficient?

You might suspect vitamin B3 deficiency, also known as… niacin!

While we mentioned angular stomatitis with riboflavin deficiency, that is, cracks on the corners of the mouth; with niacin deficiency, the lips may appear cracked along the surface of the lips themselves. Foods that are rich in niacin include meats and poultry, fish, and nuts.

Let’s remember the condition associated with niacin (B3) deficiency: Pellagra. This is an Italian word that translates to “rough skin.” Although nutritional deficiency may be less frequent now than centuries ago, we still may see pellagra in cases of gastrointestinal disease in which absorption of nutrients is diminished, or in patients with malnourishment, possibly from alcoholism.

In addition to manifestations of the tongue, pellagra can progress to cause a red rash on the cheeks or around the neck, constipation that then leads to diarrhea, nervousness and depression which lead to dementia, and if left untreated patients will die. 

These are the 4 D’s of Pellagra: Dermatitis, Diarrhea, Dementia and Death. 

The next description of a tongue is of a patient with a pale, light-colored tongue. What could be a possible diagnosis?

This patient may have iron deficiency anemia, and along with the changing color, there may be soreness, atrophy of the taste buds as well as angular stomatitis. These patients may also have fatigue and feeling cold especially in the extremities. While ferrous sulfate can be prescribed for anemia it is important to remember its irritating effect on the stomach mucosa and possible gastrointestinal side effects such as constipation. That’s why supplementation by iron-rich foods is preferred if the anemia is not severe. Food sources with heme iron include red meat, fish and poultry. Non-heme sources of iron include spinach and other dark leafy green vegetables, as well as egg yolks. The food with the highest content of iron is… liver. Remember that iron absorption is improved by vitamin C.

Now what if a patient's tongue looks beefy, red, and inflamed with the patient complaining of soreness?

This may be vitamin B12 deficiency also known as cobalamin, which is critical for red blood cell maturation. Without cobalamin, patients develop pernicious anemia with symptoms of fatigue, irritability, confusion, depression, numbness and tingling of the extremities and eventually psychosis. 

Vitamin B12 is found in many foods such as meat, fish, dairy and eggs, and fermented foods including sauerkraut, yogurt, and kimchi. Do you remember what parietal cells within the gastric mucosa release, which is essential for absorption of vitamin B12 from the digestive tract? If you said intrinsic factor you are correct. 

And it is important to remember that the use of antacids can diminish levels of intrinsic factor and contribute to vitamin B12 deficiency, as well as other medications such as PPIs, metformin, colchicine, and aminosalycilic acid (an anti-tuberculosis medication which I’ve never seen prescribed). Interestingly, co-administration of Vitamin B12 with vitamin C may reduce the available amount of Vitamin B12 in your body. So, take vitamin C two or more hours apart from Vitamin B12.

Let’s describe another patient, a child with congenital hypothyroidism. What would you expect to see on examination of the mouth or tongue?

Such patients may have a thick tongue, that may not even properly fit in the space of the mouth, thus protruding from the mouth. The same is true for adults with enlarged tongues as well as other symptoms of hypothyroidism. The medical term for enlarged tongue is macroglossia. This can also be seen in Down’s syndrome. 

Another case can be a patient with thick white patches on the tongue which spread onto the cheeks. These white patches wipe off easily with a gauze.

The obvious suspicion would be oral thrush, or to be more specific pseudomembranous oropharyngeal candidiasis, which is a yeast infection seen in both immunocompetent and immunosuppressed children and adults. We cannot talk about the tongue without mentioning oral candidiasis. It is normally associated with infants and children who are bottle-fed or have used antibiotics or corticosteroids to treat asthma or allergic rhinitis, or patients with HIV/AIDS. Also, adults who use dentures are at increased risk of oral thrush.

The treatment of oral candidiasis must be individualized, based on the severity of the infection and immune status of the patient, but it is normally treated with topical antifungal in immunocompetent patients with mild disease or systemic therapy in severe cases or immunosuppressed patients. 

Also, in cases of white tongue in adults, you should consider leukoplakia also called smoker's keratosis which may or may not be cancerous. Please be vigilant because leukoplakia could be an early sign of cancer.

Leukoplakia is a descriptive clinical term used for a white plaque or lesion on the tongue or oral cavity that cannot be wiped off with a gauze. A biopsy for a definite diagnosis may be needed after a 6-week observation to rule out other causes such as mechanical friction. The differential diagnosis of white lesions on the tongue is extensive, and it includes lichen planus, leukoedema, tobacco chewer’s white lesion, chemical burns, HPV, and squamous cell carcinoma.

Another patient presents with small shallow sores on the inside of the mouth, at the base of the gums, and on the sides or surface of the tongue. What do you think the diagnosis might be here?

This may be a canker sore or aphthous ulcer. The sores can be painful, making it difficult for the patient to eat and talk. Treatments include oral rinses with benzydamine hydrochloride, and pastes such as benzocaine or steroids like triamcinolone can also be used to reduce inflammation.

Finally let's describe a patient who comes in with a trembling tongue. What would be a potential diagnosis in such a patient?

It would be important to rule out a stroke, and immediate medical attention is important. Fasciculations of the tongue may indicate a lower motor neuron injury, which can lead to dysarthria or dysphagia, and new onset of fasciculations may be a sign of ALS or amyotrophic lateral sclerosis. Let’s also include the differential of seizure in that case, but the shaking would not only include the tongue, but also the larynx, pharynx, and face in a rare condition called palatal tremor. 

We did not cover viral infections, strawberry tongue, lichen planus, Plummer-Vinson Syndrome, ankyloglossia, macroglossia, angioedema, and many more but we’ll leave it for part 2.

Conclusion: The tongue talks. The tongue can show signs of disease specific to the tongue but also signs of systemic disease. Let’s remember to check the tongue of our patients. Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. When we find tongue abnormalities, let’s keep in mind viral and fungal infections, vitamin deficiencies, immunodeficiencies, premalignant and malignant lesions.

Now we conclude our episode number 81 “The Tongue Talks.” Drs Asefi, Pourshams, and Arreaza discussed common findings of the tongue. By examining the tongue you can find clues for significant local or systemic diseases. Keep in mind infections, vitamin deficiencies, benign lesions and even cancer. The tongue is more than an organ for speaking, breathing, swallowing and testing. It is a symbol of the way we talk to others: “A tongue has no bones but it's strong enough to break a heart, so be careful with your words.” 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, Idean Pourshams, and Golriz Asefi. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Anastasi JK, Chang M, Quinn J, Capili B. Tongue Inspection in TCM: Observations in a Study Sample of Patients Living with HIV. Med Acupunct. 2014 Feb 1;26(1):15-22. doi: 10.1089/acu.2013.1011. PMID: 24761186; PMCID: PMC3929461. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929461/

Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010 Mar 1;81(5):627-34. PMID: 20187599. https://www.aafp.org/afp/2010/0301/p627.html

Geographic tongue - Symptoms and causes - Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/geographic-tongue/symptoms-causes/syc-20354396

Wolff, Klaus; Richard Johnson, and Arturo P. Saavedra. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 7th edition, McGraw Hill Education, 2013, p. 819.

Episode 80: Oral Meds for COVID-19. 

The US department of human health and services recently launched the COVID19 Therapeutics Locator website to allow providers find locations where they can send prescriptions for Paxlovid and Molnupiravir. Find the COVID19 therapeutics locator online:https://arcg.is/iuuW50

Yasmin and Arti discuss oral medications under emergency use authorization for COVID-19: Paxlovid and Molnupiravir. 

Introduction: Meds for COVID-19.  
By Hector Arreaza, MD.  

For the last 2 years, humanity has faced the challenge to find an effective way to fight COVID-19. This pressing charge has not been free of obstacles. It has been hindered by politics, misinformation, greed, jealousy, and many other not-so positive human traits. For me, living through the pandemic has been somewhat frustrating and shaming. Stupidity, vulgarity, and mediocrity are a few of the attributes that have flourished during the last 2 years all around us. 

But not everything about the pandemic has been negative. Many talented people with good intentions have engaged in serious research and have made tremendous contributions to science and humanity. Vaccines have been developed using cutting-edge technology and their efficacy has been very positive so far. Many medications have been tried to fight COVID-19 since the beginning. Some clinicians have tried to repurpose old medications in their honest desires to fight COVID-19. Examples include ACE inhibitors, statins, azithromycin, hydroxychloroquine, and chloroquine, which have not proven to be effective against this virus so far. 

Ivermectin, for example, has been very controversial since the beginning of the pandemic. Ivermectin is not approved by the FDA for the treatment of COVID-19. Until today, the National Institutes of Health do not have enough data to recommend for or againstusing ivermectin for COVID-19. “Results from adequately powered, well-designed, and well-conducted clinical trials are needed to provide more specific, evidence-based guidance on the role of ivermectin in the treatment of COVID-19.” Ivermectin is still being used by some clinicians in the United States based on personal experience and opinions.

At this time, remdesivir (brand name Veklury®) is the only medication approved by the FDA to treat COVID-19. IV remdesivir won full FDA approval in October 2020 for hospitalized patients, and its use has been expanded a couple days ago to include use in non-hospitalized high-risk patients. 

The NIH recommends against IL-6 inhibitors, such as tocilizumab or sarilumab, in COVID-19 patients who are not in the ICU. At this moment, there is not enough data for the NIH to make a recommendation for patients who are in the ICU. Baricitinib is an oral medication used to treat rheumatoid arthritis authorized in November 2020 to be used in combination with remdesivir for the treatment of COVID-19 in certain hospitalized children and adults who require supplemental oxygen, mechanical ventilation, or Extracorporeal membrane oxygenation (ECMO). Baricitinib is now authorized to be used without remdesivir against COVID-19 in hospitalized patients. We cannot forget the use of dexamethasone in hospitalized patients requiring oxygen.

Today we want to give you a little taste of two oral medications: Paxlovid® and molnupiravir. You will listen to two brave medical students presenting what they have found about these medications. 

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. 

Paxlovid®.   
By Yasmin Fazli, MS3, Ross University School of Medicine.  

What is it?

Paxlovid® is the first oral treatment for mild-to-moderate coronavirus disease (COVID-19) in patients over 12 years-old to be issued by the FDA. The FDA issued an emergency use authorization (EUA) on December 22, 2021. It is made up of two different medications: nirmatrelvir and ritonavir. Nirmatrelvir is a protease inhibitor while ritonavir helps decrease the breakdown of nirmatrelvir. 

The combination authorized is nirmatrelvir 300 mg plus ritonavir 100 mg. You may remember ritonavir use in combination with other antiretrovirals for the treatment of HIV/AIDS.

At the end of the 2021, Pfizer announced that results from a trial comparing between Paxlovid® versus a placebo revealed that Paxlovid® reduced proportion of mortality and morbidity by 88% compared to placebo after a 5-day course.

When and how to prescribe it?

To use Paxlovid® some criteria must be met by the patient. First, a positive result of COVID-19 viral testing, second, the patient must be at high risk for illness progression to a more severe state, including hospitalization and death; and third, the patient must be 12 years or older. 

Paxlovid® should be started as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset. It is to be taken by mouth 2 times a day for 5 days straight with or without food. You take 3 pills twice a day. It is not authorized for more than 5 days. 

It is not authorized for the pre-exposure or post-exposure prevention of COVID-19. It’s not meant to be a replacement for the vaccine. 

Side effects?

Possible side effects of Paxlovid® include dysgeusia (altered or impaired sense of taste), diarrhea, increased blood pressure, and myalgia (muscle aches). Nirmatrelvir and ritonavir, which comprise Paxlovid®, also interact with other medications, which may lead to serious or life-threatening adverse reactions. 

It’s contraindicated in patients taking medications that are dependent on CYP3A metabolism for clearance, for example, warfarin, amiodarone, clozapine, midazolam, sildenafil (for pulmonary hypertension), etc. A list of these medications has been reviewed by the FDA and you can find it online. 

Liver problems have occurred in patients receiving ritonavir. Therefore, caution should be exercised when administering Paxlovid® to patients with pre-existing liver diseases, liver enzyme abnormalities, or hepatitis. Furthermore, Paxlovid® is not recommended for patients with severe kidney problems, and if they do use it, the dose should be adjusted.

Because nirmatrelvir is co-administered with ritonavir, there may be a risk of HIV-1 developing resistance to HIV protease inhibitors in individuals with uncontrolled or undiagnosed HIV-1 infection. 

As for pregnancy or lactation, there currently is no data available for it to understand any potential effects on miscarriages, birth defects, or maternal and fetal outcomes. 

Considering all of this, please review your patients’ list of medications and supplements and medical history prior to initiating Paxlovid®.

Concerns?

Due to its limited clinical data availability, other adverse effects that have not been reported may also occur while using Paxlovid® on top of the side effect list we are aware of. Ritonavir is a well-known medication, but nirmatrelvir is brand new. 

Another concern is its limited availability. So even though it has shown positive results, it is not widely available yet, which leads to having to prioritize certain populations such as the unvaccinated patients. This may prove to be a moral and ethical concern. 

Effectiveness?

There is no long-term data on Paxlovid® yet; however, from what we do know, it is proving to be effective more than placebo by almost 90% which shows much promise. It works against current or previous variants of COVID-19. 

EPIC-HR is the randomized, double-blind, 2-arm study done to prove Paxlovid®. It included 2246 patients with laboratory-confirmed SARS-CoV-2 infection, mild to moderate symptoms, and at least one comorbidity with increased risk of developing severe illness from COVID-19. Patients were randomly assigned 1:1 to receive either Paxlovid or placebo orally every 12 hours for 5 days.

Results: Paxlovid significantly reduced the risk of COVID-19-related hospitalization or death from any cause by 89% (within 3 days of symptom onset) compared with placebo. Through day 28, 0.7% (5/697) of patients in the Paxlovid® arm were hospitalized compared with 6.5% (44/682) of those in the placebo arm. The study also showed that nobody died taking Paxlovid® while 12 people died taking placebo. These are promising results and Pfizer will be announcing more information on the effectiveness as time passes by. 

Pricing?

The original pricing was announced to be $530.00; however, it’s been added that it’ll be at no cost to the people in the United States. 

Molnupiravir.   
By Arti Patel, MS3, Ross University School of Medicine.  

1. What is molnupiravir? 

Molnupiravir is an antiviral medication that can be used to treat COVID-19. Molnupiravir is a nucleoside analog that inhibits viral replication. The active drug of molnupiravir (N-hydroxycytidine) tricks the RNA polymerase enzyme into incorporating the drug instead of uridine or cytidine. Nucleobases continue to get added to the RNA chain and eventually the new RNA molecule has accumulated enough errors that the virus cannot replicate further. 

2. When and how to prescribe it? 

Molnupiravir is available for Emergency Use Authorization for “mild to moderate COVID-19 disease in adults with positive results of direct viral testing who are at risk of developing severe COVID-19, including hospitalization or death or those in whom alternative COVID-19 treatment options approved by the FDA are not accessible or clinically appropriate.” 

FDA provided EUA status on December 23, 2021. It should be taken as soon as COVID-19 is diagnosed, and within 5 days of symptom onset. It is not to be used as a method to prevent COVID-19 disease. Not for prophylaxis. 

Benefits of treatment have not been seen after hospitalization, so administration of molnupiravir in patients hospitalized due to COVID-19 is not recommended. Adults above the age of 18 should take 800 mg orally every 12 hours for 5 days, with or without food. Use for longer than 5 days has not been studied. 

3. Side effects? 

Most common adverse effects are diarrhea, nausea, and vomiting. 

4. Concerns? 

Pediatric patients: Molnupiravir may not be used in patients under the age of 18 due to effects on bone and cartilage growth. Studies in rats with repeated doses of molnupiravir showed bone and cartilage toxicity. 

Pregnancy: Fetal toxicity was observed when given to pregnant individuals in animal reproduction studies. Risk of adverse maternal or fetal outcomes or birth defects have not been studied in humans as of now. Use of molnupiravir in pregnant individuals may be considered once the prescribing physician has assessed the potential risks and benefits. Prior to initiating treatment of molnupiravir, if clinically indicated, assess whether a patient is pregnant. If a patient is having irregular menstrual cycles, first day last menstrual period is unknown, or patient is not using an effective method of contraception, a pregnancy test is advised. 

Females of childbearing age are advised to use an effective method of contraception while under treatment of molnupiravir and for 4 days after the final dose. Effects of molnupiravir on sperm are not known, thus effective contraception must be used while under treatment of molnupiravir and for 3 months after the last dose. 

Additionally, breastfeeding is not recommended during treatment and for 4 days after the last dose. 

5. Effectiveness? 

Although molnupiravir is not substitute in patients for whom COVID-19 vaccination and booster are recommended, it can be used for treatment of non-hospitalized patients with COVID-19 who have a high risk of progression to severe disease. 

In, MOVe-OUT, a randomized, double-blind, placebo-controlled clinical trial, almost 7% of about 700 individuals who received molnupiravir were hospitalized compared to almost 10% of 700 individuals who received the placebo. During the follow up period, one person who received molnupiravir died compared to 9 people who received the placebo. The safety and effectiveness of molnupiravir continues to be studied. 

Availability and pricing?

Not available in pharmacies yet, and preliminary pricing for a 5-day course of molnupiravir was about $700.

Conclusion of episode:

Now we conclude our episode number 80 “Oral Meds for COVID-19.” We hope you got enough information about these two medications: Pax-lovid and Mol-nu-pira-vir. Remember that they are authorized (not approved yet) by the FDA for the treatment of COVID-19. They are both oral medications, taken twice a day for 5 days. Their use in pregnant patients is not recommended yet. Paxlovid can be used in patients older than 12 years old, and molnupiravir in patients older than 18 years old. We’ll keep learning together about these medications in the future. 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, Arti Patel and Yasmin Fazli. Audio edition: Suraj Amrutia. See you next week! 

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References:

F.D.A. Approves Remdesivir for Patients Not Hospitalized, The New York Times, nytimes.com, January, 21, 2022, https://www.nytimes.com/2022/01/21/world/remdesivir-fda-approval-expanded-covid.html.

“Frequently Asked Questions on the Emergency Use Authorization for Paxlovid for Treatment of COVID-19”, U.S. Food and Drug, December 22, 2021, https://www.fda.gov/media/155052/download. Accessed on Jan 24, 2022.

“Pfizer Receives U.S. FDA Emergency Use Authorization for Novel COVID-19 Oral Antiviral Treatment,” pfizer.com, December 22, 2021. https://www.pfizer.com/news/press-release/press-release-detail/pfizer-receives-us-fda-emergency-use-authorization-novel. 

Ahmad, B., Batool, M., Ain, Q. U., Kim, M. S., & Choi, S. (2021). Exploring the Binding Mechanism of PF-07321332 SARS-CoV-2 Protease Inhibitor through Molecular Dynamics and Binding Free Energy Simulations. International journal of molecular sciences, 22(17), 9124. https://doi.org/10.3390/ijms22179124

Coronavirus (COVID-19) Update: FDA Authorizes Additional Oral Antiviral for Treatment of COVID-19 in Certain Adults, fda.gov, December 23, 2021. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-oral-antiviral-treatment-covid-19-certain. Accessed on January 24, 2022.

Fact Sheet for Healthcare Providers: Emergency Use Authorization for Molnupiravir, fad.gov, December 23, 2021, https://www.fda.gov/media/155054/download, accessed on January 24, 2022. 

Intimate Partner Violence.  

Dr Yomi discusses how to screen for intimate partner violence (IPV), she shares statistics, risk factors, and how to prevent it. Introduction about steroid injections and hyperglycemia with Dr Kooner.

Today is January 18, 2022.

Introduction: Intra-Articular Corticosteroid Injections and Hyperglycemia
By Gagan Kooner, MD, Government Medical College of Amritsar, India.

There is a physiologic association between hyperglycemia and corticosteroids. Do intra-articular steroids induce hyperglycemia? According to the Spine Intervention Society’s Patient Safety Committee, the answer is yes. These researchers reviewed studies done on both diabetic and non-diabetic patients.

In non-diabetic patients, transient and self-limited hyperglycemia was reported following peripheral intraarticular injections. The increase in blood glucose was less than 40 mg/dl, and levels returned to near baseline by 24 hours. The hyperglycemia in patients with diabetes is more significant. In patients with well-controlled diabetes (hemoglobin A1C of <7), glucose levels rose to the 300s at 1-2 days after administration. Less significant elevations persisted for up to 5-7 days! This effect was evidenced with injections into different joints, with different preparations such as methylprednisolone and betamethasone.

The effects of epidural steroid injections vs injections in other joints were compared in patients with and without diabetes. Three consecutive injections were given. On day 1 following the injection, there was a significant increase in post-prandial glucose in all groups. However, on day 7, only patients who had received intra-articular injections, did not return to baseline. The hyperglycemia is likely to happen because the steroid spreads in a larger area when injected in a large joint. Also, a caveat is that the group of patients who received intra-articular steroid injections had a higher proportion of diabetic patients. 

Spine Intervention Society recommendations: 

All patients with diabetes should have a provider to contact if their glucose levels become difficult to control.

The informed consent process should include the potential for hyperglycemia after the procedure. Patients with diabetes should check their glucose consistently for at least two days before the procedure. A rule of thumb is to cancel the procedure if the glucose is above 200 mg/dl.

The number of joints and the total amount of steroid given should be considered.

If the procedure is only a diagnostic block; only local anesthetic should be used (avoid unnecessary steroids).

After the procedure, patients should monitor their glucose until levels return to baseline and adjust their treatment accordingly.

In conclusion, it appears there is a definite correlation between intra-articular steroid injections and hyperglycemia. Although the risk may be minimal, in my opinion, following these recommendations would ensure we are providing adequate healthcare to our patients, especially those more vulnerable, such as diabetic patients.

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. 

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Intimate Partner Violence. 
By Timiiye Yomi, MD. Discussion with Hector Arreaza, MD.

INTRODUCTION

The CDC defines domestic violence (also called Intimate Partner Violence or IPV) as physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner (spouse, boyfriend/girlfriend, sexual partner, etc.). According to the National Coalition Against Domestic Violence, it is the willful intimidation, physical assault, battery, sexual assault and/or other abusive behavior perpetrated by one intimate partner against another. 

A FEW THINGS TO NOTE:

The CDC considers IPV a serious public health issue affecting men and women globally. 

It begins at an early age. Research has shown that it is most prevalent among adolescents and young adults and it declines with age. An estimated 8.5 million women and 4 million men in the US who have reported experiencing IPV in their lifetime all say they first experienced it before they turned 18 years of age.

Women are more frequently victims of IPV. Data from the National Intimate Partner Sexual Violence Survey (NISVS) reveals 1:4 women (23%) and 1:7 men (14%) in the US report having experienced severe physical assault from an intimate partner, 16 % of women and 7% of men have experienced sexual violence, and 47% of women and men have gone through some form of psychological aggression like humiliating and controlling behaviors from an intimate partner. However, men are less likely to report it.

Frequency and severity can vary but there is always a consistent effort by one partner to maintain power or control over the other. 

Abusers may often seem harmless and perfect initially but over time, they become increasingly aggressive and controlling towards their partner. [Dead little fly]

IPV can happen in all types of intimate relationship: homosexual or heterosexual.

Many racial/ethnic and sexual minority groups are more disproportionately affected by IPV. Studies have shown that Native American and Alaska Native women experience higher rates of IPV. Also, IPV is more prevalent among same sex couples compared to heterosexual relationships. 

IPV is grossly underreported and underrecognized by healthcare professionals and even when reported, remains under-addressed. 

IPV is preventable. 

RISK FACTORS:

Being a woman

Age: More prevalent among adolescent and young adults

Low income

Low educational attainment

Unemployment/Job loss

Alcohol consumption

Childhood history of exposure to violence (for example, between parents)

Childhood abuse and neglect

Stress and anxiety and other psychiatric illnesses

Antisocial personality traits, history of delinquency

Peer violence (gangs)

Hostile communication methods

Unhealthy cultural and religious beliefs

The health and economic consequences of IPV are very significant. 

Survivors suffer various adverse health outcomes, including physical and mental issues, many of which become chronic. 

Population based surveys suggest 52% women and 17% men who are victims of IPV suffer PTSD. 

Sadly, many victims have also lost their lives to IPV. Over 1,000 homicidal deaths in the US are due to IPV. Apart from harm to victims, healthcare costs and decreased productivity from paid work are significantly increased. It costs the US an estimated $2-8 billion dollars annually to cater to the needs of survivors. 

What role do primary care providers play in minimizing the impact of IPV on both victims and the society?

SCREENING

The USPSTF recommends screening of all female patients of childbearing age for IPV. Women who are positive should receive intervention services. (Grade B recommendation).

There are no recommendations on screening males. 

There are various screening tools developed that have been found to be effective. 

HITS: (Hurt, Insult, Threaten, Scream): Self-reported or physician administered; greater than or equal to 10 points is positive. 

How often does your partner physically hurt you? 

How often does your partner insult or talk down to you? 

How often does your partner threaten you with physical harm? 

How often does your partner scream at you?

Scoring: never = 1 point, rarely = 2 points, sometimes = 3 points, fairly often = 4 points, frequently = 5 points. A score of greater than 10 points is a positive screen.

WAST: (Women Abuse Screening Tool): Self-reported; screening is subjective, physician uses clinical judgement. The questionnaire has 8 questions, you can ask the first 2 and then decide if you want to ask the rest of the questions. There is no minimal score. It is provider dependent.

1. In general, how would you describe your relationship? A lot of tension, Some tension, No tension.

2. Do you and your partner work out arguments with: Great difficulty, Some difficulty, No difficulty.

Research shows that patients are in favor of being asked about IPV by their primary care providers at wellness visits. But even though physicians generally feel their patients should be screened for IPV, only a small amount of them do and this is largely due to physicians not feeling comfortable with asking the questions related to IPV. Below are some tips to help with discussing IPV with patients.

TIPS

Explain the rationale behind asking the questions

Show compassion and avoid being judgmental

Use a more open-ended questions approach as opposed to directly questioning patients about specific abuse as this can make patients uncomfortable

Respect confidentiality (conditional)

Discuss with patients in private

Believe and validate patient experience

Listen respectfully

Provide/refer for proper intervention

Assess high risk of harm on every visit including homicide

Be aware of mandatory reporting/confidentiality laws in your state and inform patients of any limits to patient-doctor confidentiality before you begin any discussions.

Reporting IPV:

Physicians are mandatory reporters. Health care providers are required to make a report if they provide medical services to a patient whom they suspect is suffering from a physical injury due to a firearm or assaultive or abusive conduct.

As physicians, we must be aware that many patients who test positive may not be ready or even willing to leave such abusive relationships. This may be due to factors such as financial and safety concerns, kids in the relationship, and even hope that their partners would change. Even if we do not agree with their decisions, we must.

Respect autonomy and allow patients make their own decisions about situations 

Be supportive; provide access to community services, give info on local shelters and the National domestic violence hotline.

Offer info on safety planning: have copies of keys, information on local shelters, have a bag packed with essentials, copies of personal documents, establish coded words with trusted family and friends, etc. This prepares the victims to leave the situation in the face of immediate harm.

PREVENTION:

The World Health Organization recommends legislative reform and media campaign to increase awareness on IPV.

School-based education programs that deal with dating violence. 

Early intervention services in at risk families: housing programs, strengthen household financial security and work-family support. 

Bystander empowerment and education.

RESOURCES:

National Domestic Violence Hotline 
Call 1-800-799-7233and TTY1-800-787-3224.

Love is Respect National Teen Dating Abuse Helpline 
Call 1-866-331-9474 or TTY 1-866-331-8453

Rape, Abuse & Incest National Network’s (RAINN) National Sexual Assault Hotline 
Call 800-656-HOPE (4673) to be connected with a trained staff member from a sexual assault service provider in your area.

Conclusion:Now we conclude our episode number 79 “Intimate Partner Violence.” This is a worldwide problem that affects primarily women but can also affect men. We discussed how to screen women in clinic and what to do in case you detect a positive case. Make sure you provide support and offer referrals as needed to assist patients who are being abused. As physicians, you may be the only person who knows about these abusive relationships, so your intervention is key in preventing, treating, and stopping intimate partner violence in our communities. 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, Timiiye Yomi, and Gagan Kooner. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Patel, Jaymin; Byron Schenider and Clark Smith, Intra-Articular Corticosteroid Injections and Hyperglycemia, Spine Intervention Society Patient Safety Committee, SpineIntervention.Org, published online on October 4, 2017, https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/FactFinder_2017-10_Hyperglyc.pdf.

California’s Domestic Violence & Mandatory Reporting Law: Requirements for Health Care Practitioners, Futures without Violence, https://www.futureswithoutviolence.org/userfiles/file/HealthCare/mandatory_calif.pdf. Accessed on November 11, 2021.

Dicola D, Spaar E. Intimate Partner Violence. Am Fam Physician. 2016 Oct 15;94(8):646-651. PMID: 27929227. https://www.aafp.org/afp/2016/1015/p646.html

Centers for Disease Control and Prevention. Intimate Partner Violence. Preventing Intimate Partner Violence Across the Lifespan: A Technical Package of Programs, Policies, and Practices, https://www.cdc.gov/violenceprevention/pdf/ipv-technicalpackages.pdf. Accessed on November 11, 2021. 

National Coalition Against Domestic Violence, https://ncadv.org/. Accessed on November 11, 2021.

Episode 78: Infantile Hemangioma. 

Dr Shelat discusses with Dr Schlaerth and Dr Arreaza the definition, pathophysiology, diagnosis and treatment of infantile hemangioma.

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Infantile Hemangioma. 
By Tejal Shelat, MD (Lady Hardinge Medical College). 
Discussed with Katherine Schlaerth, 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.

What is infantile hemangioma?

Infantile hemangioma is vascular overgrowth that leads to tangled blood vessels that appear as a reddish plaque on the skin as early as days to weeks after birth. 

It is the most common benign vascular tumor in infants, with a prevalence of 4-5% in mature neonates and is about 2.5 times more common in female (ratio female:male is 3:1) and Caucasian children. 

Risk factors: 

There are several risk factors, including prematurity, low birth weight less than 1000g, family history of infantile hemangioma, placental anomalies, and eclampsia.

Progression of infantile hemangioma. 

Hemangiomas typically undergo three phases:

First is the proliferation phase that occurs between 0 to 6 months of age, with about 80% growing to their final size by age 3 months. During this time there is growth of a bright red, soft, raised, non-blanching plaque that is visible on the skin. This occurs to due proliferation of rapidly dividing endothelial cells in the blood vessels.

This is followed by a plateau phase.

Next is the involution phase, that occurs after 6 months of age. The lesion/s now turn deep red or violet and spontaneously begin to regress in size.

Pathogenesis. 

Several hypotheses have been described to explain the reason behind the occurrence of hemangiomas. We now know that they occur due to dysregulation in angiogenesis and vasculogenesis. 

The most likely trigger is thought to be hypoxia, which induces transcription of the Vascular Endothelial Growth Factor (VEGF) gene, leading to overexpression of angiogenic factors such as VEGF. This leads to differentiation of endothelial cells, influx of other cells such as mast cells, myeloid cells and also tissue inhibitors of metalloproteinases (TIMPs).

Regression. 

The mast cells produce interferon and transforming growth factor, which, along with the TIMPs that we just talked about all work together to halt the proliferation of endothelial cells. The endothelial cells then become senescent and that leads to passive involution of the hemangioma.

Diagnosis. 

The diagnosis of infantile hemangiomas is clinical. If you are not familiar with how a hemangioma looks, search in your favorite dermatology atlas. 

A hemangioma may be red if it involves the papillary dermis (called superficial strawberry hemangiomas), but they can also be purple, blue, or colorless if they involve the reticular dermis or subcutaneous fat (called deep, cavernous hemangiomas).

Early white discoloration of infantile hemangioma may be an early sign of imminent ulceration.

Additional workup.  

Further investigation is also required in specific situations: 

If there are 5 or more cutaneous lesions, we would need a liver ultrasound to rule out involvement of the liver

For facial or segmental involvement, echocardiogram and MRI of the head are recommended to rule out posterior fossa malformations, hemangioma (usually localized on the face), arterial anomalies, cardiovascular anomalies, eye anomalies, sternal clefting and/or supraumbilical raphe 

PHACE Syndrome: posterior fossa brain malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities. By definition, PHACE is diagnosed when there is at least one hemangioma >5 cm on head/scalp PLUS one major or two minor criteria OR hemangioma of any size on neck, upper trunk and proximal upper extremity plus two major criteria.

Major criteria include arterial anomalies such as anomaly of major cerebral or cervical arteries, retinal vascular anomalies, sternal defect. 

Minor criteria include cerebral artery aneurysm, ventricular septal defect, etc.

Laryngoscopy should be done if there is cervicofacial involvement, i.e., beard distribution

Spinal ultrasound should be performed if the hemangioma is in the lumbosacral region

Management

-Most hemangiomas will not require treatment, and most need observation only. 

-When treatment is needed, treatment is usually medical depending on severity, location, and extension of hemangioma/s, you may decide to go with topical or systemic therapy.

-Topical therapies include beta blockers (propranolol 1% applied TID for 1 year), corticosteroids, and imiquimod, but data on efficacy is limited.

-Systemic therapies: Beta blocker therapy (with propranolol by mouth) is indicated when there is concern for ulceration or scarring in large, facial, segmental and or rapidly growing hemangiomas, for visual impairment in periorbital involvement, high output heart failure in hepatic involvement and airway obstruction in subglottic involvement. The dose of propranolol is 1mg/kg to 3mg/kg in the form of an oral solution, depending on the response to therapy and weight of the child. Initiation of therapy may require hospital admission to watch for side effects to beta blockers.

-Second-line treatments include systemic corticosteroids

-Surgical intervention is rarely needed, and it´s usually avoided because surgical scars may be worse than the resulting lesion after spontaneous regression. 

Prognosis. 

The prognosis is very good for most uncomplicated hemangiomas, with about 50% undergoing complete involution by age 5 years and about 90% by age 9 years. Permanent cutaneous residua are seen for hemangiomas that involute slowly, after 6 years of age and hemangiomas involving the eyelid, nasal tip, ear and lip. Functional impairment or obstruction may occur when the hemangioma is located near natural orifices and/or in the head and neck area. In these cases, surgical intervention may be needed.

Conclusion. 

You may find hemangiomas during routine physical exam of a newborn. It is important to remember the natural progression of uncomplicated hemangiomas. Make sure to educate parents about concerning features and how to determine if treatment is needed. In most cases, when treatment is needed, a dermatology evaluation is needed.

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[Music to end: JERUSALEMA]

Now we conclude our episode number 78 “Infantile Hemangioma.” We learned about the natural progression of most hemangiomas. They grow for up to 3 years, then remain unchanged until around 6 years of age when they gradually regress without treatment. In most cases, monitoring is all what’s needed. However, it’s important to identify the hemangiomas with concerning features that require additional work up or early treatment. Treatment is mainly medical. Surgery is rarely recommended or required. 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, Tejal Shelat. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Léauté-Labrèze, C., Harper, J. I., & Hoeger, P. H. (2017). Infantile haemangioma. The Lancet, 390(10089), 85-94.

Kowalska, M., Dębek, W., & Matuszczak, E. (2021). Infantile Hemangiomas: An Update on Pathogenesis and Treatment. Journal of clinical medicine, 10(20), 4631.

Metry D.W. Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications. UpToDate. Accessed December 5, 2021. https://www.uptodate.com/contents/infantile-hemangiomas-epidemiology-pathogenesis-clinical-features-and-complications#H22.

Antaya R.J. Infantile Hemangioma. Medscape. Accessed December 5, 2021. https://emedicine.medscape.com/article/1083849-overview#a1.

Intrahepatic Cholestasis of Pregnancy (ICP).

Amel and Dr Wonderly discuss the signs, symptoms, and management of ICP. A reminder for alcohol use disorder screening.

Introduction: Screening for alcohol use disorder. 
Written by Hector Arreaza, MD. Reviewed by Jacqueline Uy, MD.

Today is December 3, 2021.

Substance misuse occurs in about 20% of patients seen in primary care settings. For example, alcohol-related disorders are present in up to 26% of general clinic patients, “a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes”[1]. The USPSTF recommends screening for unhealthy alcohol use in adults 18 years or older, including pregnant women, and provide those engaged in risky drinking with brief behavioral counseling to reduce alcohol use (this is a Grade B recommendation). This brief introduction is to encourage everyone to screen adults for alcohol use disorder. Let’s start with the basics. 

It is important to know the size of a standard drink so you can counsel your patients appropriately. According to the CDC, a standard drink is equal to 14 grams (0.6 ounces) of pure alcohol. Generally, this amount of pure alcohol is found in:

12 ounces of beer (5% alcohol content).

8 ounces of malt liquor (7% alcohol content).

5 ounces of wine (12% alcohol content).

1.5 ounces or a “shot” of 80-proof (40% alcohol content) distilled spirits or liquor (such as gin, rum, vodka, whiskey).

Moderate alcohol drinking means 2 drinks or less in a day for men and 1 drink or less in a day for women. Binge drinking means drinking enough to bring your blood alcohol concentration (BAC) level to 0.08% or more. This may be different in each patient, as humans metabolize alcohol differently, but usually it corresponds to 5 or more drinks on a single occasion for men or 4 or more drinks on a single occasion for women, generally within about 2 hours[2].

A good approach to screen for alcohol use disorder is by asking: “Do you sometimes drink alcoholic beverages?”, and then the single screening question, “How many times in the past year have you had 5 or more drinks (men) OR 4 or more drinks (women) in a day?”[3] 

The screening is considered positive if the patient answers one or more times a year. If positive, then you may continue your assessment with another tool such as AUDIT. This can be a topic for a whole episode. 

For now, we just want to remind you to screen your patients for alcohol use because the prevalence is very high and we as primary care physicians can make a big difference in the prevention and treatment of alcohol misuse in our communities. 

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. 

Intrahepatic Cholestasis of Pregnancy (ICP). 

Written by Amel Tabet, MS3, American university of the Caribbean. Discussion with Sally Wonderly, MD; and Hector Arreaza, MD.

What is Intrahepatic Cholestasis of Pregnancy and why does it matter?

As its name implies, Intrahepatic Cholestasis of Pregnancy (ICP) is a multifactorial liver dysfunction in some pregnant women that occurs during their either second or third trimester of pregnancy and resolves spontaneously after parturition. It is defined by the presence of pruritus -- previously called pruritus gravidarum or recurrent jaundice of pregnancy-- and abnormally elevated serum bile acid levels and mildly increased hepatic aminotransferase levels, in the absence of diseases that may yield similar laboratory findings and symptoms. Key symptoms are pruritus, high bile acid and high transaminases. 

How common is ICP?

In the US incidence ranges from 0.32 percent to 5.6 percent, depending on the area. The Los Angeles area has a high incidence compared to other areas in the US. The highest rates in Europe are in Scandinavia. 

It is very frequent in Chile (South America). The indigenous people known as Araucanos have the highest incidence worldwide at 27.6 percent.

Pathogenesis

The pathogenesis of ICP remains unclear. It is mainly attributed to changes in various sex steroid levels but more recent research points towards an etiology that relates to various mutations in the many genes involved in the control of the hepatocellular transport systems such as the ABCB4 gene, which encodes multidrug resistance protein 3 (MDR3) linked to progressive familial intrahepatic cholestasis, errors of the ABCB11 gene that encodes for the bile salt export pump, and more recently on FXR/NR1H4 and PXR/NR1I2 genes that encode for proteins that critically regulate bile acid synthesis and transport, and the transcription of ABCB11 in humans and the role of epigenetics influence by means of methylation of these genes. 

Dangers for mother: Beside the discomfort of pruritus, ICP is transient and of little maternal risk generally. The mother may be uncomfortable but it’s not fatal.

Danger to fetus: The elevated bile acids enter the fetal circulation because it crosses the placenta. Bile acids cause major fetal and neonatal complications, such as abnormal intrapartum fetal heart rate and meconium-stained amniotic fluid that can lead to fetal distress and prematurity or intrauterine demise and to neonatal respiratory distress syndrome associated with bile acids entering the lungs.

Who is at risk for ICP?

Multifetal pregnancies.

Genetics: There is also a significant genetic influence that leads to variability of incidence by population. In North America, cholestasis is infrequent with an overall incidence approximating 1 case in 500 to 1000 pregnancies. Whereas its rate is high in indigenous women from Chile and Bolivia and nears 5.6 % among Hispanic women in Los Angeles. In other countries, for example Sweden, China, and Israel, the incidence varies from 0.25 to 1.5 %.

Diet and environment can also have an influence. Research has shown an association of ICP with environmental and dietary factors such as seasonal changes of mineral dietary components and with gut-derived endotoxins subsequent to increased gastrointestinal permeability. This complex nature-nurture interaction suggests that ICP is strongly modulated by epigenetic mechanisms.

Liver disease: Women with preexisting liver disease are at risk. Other risks include in vitro fertilization, cholelithiasis, advanced maternal age, and Hepatitis C and fatty liver disease. 

History of ICP is an important risk, because it also recurs during subsequent pregnancies in 60 to 70 % of patients.

Signs and symptoms:

The main clinical presentation is an often-generalized pruritus in late second or third trimester, that usually starts and predominates on the palms and soles and is worse at night. It could range from mild to intolerable pruritus that may precede laboratory findings by several weeks and evidenced by possible presence of scratch marks and excoriations on physical examination. Jaundice arises in 14 to 25 % of patients and it typically develops 1 to 4 weeks after the onset of itching. Other accompanying symptoms may also occur such as nausea, RUQ pain, steatorrhea, poor appetite and sleep deprivation. Other signs include dark urine, pale stools.

Diagnosis:

To establish a diagnosis, careful history taking, physical examination, and laboratory evaluation are performed. Thus, in the absence of any other liver disease, ICP is diagnosed by the presence of pruritus that is associated with elevated total serum bile acid levels, elevated aminotransferases (seldom exceed 250 U/L), hyperbilirubinemia (4 to 5 mg/dL) and elevated alkaline phosphatase. In severe cases that account for 20%, cholestasis manifests as bile acids levels > 40 micromol/L.

Differential diagnosis include: Preeclamptic liver disease, which is ruled out if blood pressure elevation or proteinuria are absent and cholelithiasis and biliary obstruction are excluded by sonography. Moreover, because of mild transaminitis in case of ICP, acute viral hepatitis is an improbable diagnosis. 

Liver biopsy is generally not needed. Even though not necessary for diagnosis, liver biopsy for research purposes, showed occurrence of changes with presence of cholestasis with bile plugs in the hepatocytes and canaliculi of the centrilobular regions, without inflammation or necrosis. These changes were found to fade after delivery with recurrence in successive pregnancies or with estrogen-containing contraceptives.

Management:

Management focuses mainly on reducing maternal discomfort due to pruritus and prevention of more serious fetal outcomes and reduce the risks of prenatal morbidity and mortality. 

For patients that have persistent clinical findings consistent with ICP without any biochemical evidence of ICP, we only treat with antihistamines and topical emollients such as calamine lotion and we perform a weekly evaluation of maternal total serum bile acid (TSBA) level. 

In symptomatic patients with positive biochemical evidence of ICP we treat with ursodeoxycholic acid (UDCA) 300 mg BID or TID until delivery. UDCA was found in clinical trials to relieve pruritus, lower bile acid and serum enzyme levels, and to reduce preterm birth, fetal distress, respiratory distress syndrome, and neonatal intensive care unit admission. Along with treatment, we continue the weekly evaluation of the TSBA level with a warranted earlier delivery if TSBA ≥100 micromol/L and the related high risk of stillbirth. 

Thus, delivery management is mainly based on the highest TSBA level at any time during pregnancy. 

If TSBA level is <40 micromol/L, delivery is advised at 37 to 38 6/7 weeks (Grade 2C). 

For TSBA within 40-99 micromol/L range, delivery is advised at 36 to 37 weeks (Grade 2C). 

For TSBA ≥100 micromol/L, delivery is recommended at 36 weeks.  

For any patient with worsening liver function tests and relentless symptoms despite treatment, or a prior history of ICP and fetal death before 36 weeks and recurring ICP in the present pregnancy, delivery before 36 weeks is warranted.

Postpartum women with persistent clinical symptoms should undergo liver function and TSBA level check and should be referred to liver specialist if unresolved dysfunction. Check liver function tests and bile acids 6-8 weeks after delivery and investigate other causes if these labs are abnormal.

There is a risk for recurrence in up to 90% of future pregnancies and it can present with hormonal contraceptives as well. 

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Now we conclude our episode number 77 “Intrahepatic Cholestasis of Pregnancy” or ICP. If you have a pregnant patient who complains of severe pruritus, remember to check total serum bile acids and liver function tests. Elevated bile acids in pregnancy should not be taken lightly. Act promptly and wisely. Delivery may be warranted even before 36 weeks in patients with worsening liver function, unrelenting symptoms or prior ICP with fetal death before 36 weeks. 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, Amel Tabet, Sally Wonderly, and Jacqueline Uy. Audio edition: Suraj Amrutia. See you next week! 

References:

Sullivan Eleanor and Michael Fleming, A Guide to Substance Abuse Services for Primary Care Clinicians, Treatment Improvement Protocol (TIP) Series, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, www.samhsa.gov,   https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/SMA08-4075_508.pdf

Alcohol Questions and Answers, Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/alcohol/faqs.htm#bingeDrinking, accessed on November 16, 2021.

Helping Patients Who Drink Too Much: A CLINICIAN’S GUIDE, Updated 2005 Edition, National Institutes of Health, www.nih.gov, 

Dermatological Disorders. In: Cunningham F, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, Spong CY. eds. Williams Obstetrics, 25e. McGraw Hill; 2018. Accessed October 11, 2021. https://accessmedicine-mhmedical-com.aucmed.idm.oclc.org/content.aspx?bookid=1918&sectionid=141465503

Hashemi N, Ukomado C. Hepatic Complications of Pregnancy. In: Greenberger NJ, Blumberg RS, Burakoff R. eds. CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, 3e. McGraw Hill; 2016. Accessed October 11, 2021. https://accessmedicine-mhmedical-com.aucmed.idm.oclc.org/content.aspx?bookid=1621&sectionid=105182308.   

Hepatic, Biliary, and Pancreatic Disorders. In: Cunningham F, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, Spong CY. eds. Williams Obstetrics, 25e. McGraw Hill; 2018. Accessed October 12, 2021. https://accessmedicine-mhmedical-com.aucmed.idm.oclc.org/content.aspx?bookid=1918&sectionid=148216133.

Intrahepatic cholestasis of pregnancy. Keith D Lindor, Richard H Lee. UpToDate. Sep 2021. https://www.uptodate.com/contents/intrahepatic-cholestasis-of-pregnancy?search=intrahepatic%20cholestasis%20of%20pregnancy&source=search_result&selectedTitle=1~60&usage_type=default&display_rank=1#references    

Klauser CK, Saltzman DH. Gastrointestinal Disorders in Pregnancy. In: DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 12e. McGraw Hill; 2019. Accessed October 11, 2021. https://accessmedicine-mhmedical-com.aucmed.idm.oclc.org/content.aspx?bookid=2559&sectionid=206962251.

Cabrerizo R, Castaño GO, Burgueño AL, Fernández Gianotti T, Gonzalez Lopez Ledesma MM, Flichman D, Pirola CJ, Sookoian S. Promoter DNA methylation of farnesoid X receptor and pregnane X receptor modulates the intrahepatic cholestasis of pregnancy phenotype. PLoS One. 2014 Jan 31;9(1):e87697. doi: 10.1371/journal.pone.0087697. PMID: 24498169; PMCID: PMC3909199. https://pubmed.ncbi.nlm.nih.gov/24498169/

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 partof 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. 

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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. 

ANOREXIA

In 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 body

Since 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 anorexia

There 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]. 

BULIMIA

By 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 for

A 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 constipation

This 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.

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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! 

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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. 

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Multisystem Inflammatory Syndrome in Children (MIS-C).   
By Katherine Schlaerth, MD, and Hector Arreaza, MD.

History and epidemiology

Most 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.

Diagnosis

What are the criteria for a diagnosis of Multisystem Inflammatory Syndrome? 

They include:

Age below 21

Fever 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 rash

Conjunctivitis

Headache

Lethargy

Confusion

Respiratory distress

Sore throat

Myalgias

Swollen hands/feet

Lymphadenopathy

Cardiac 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 Disease

The 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. 

Pathophysiology

The 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.

Treatment

What 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). 

Antivirals

The role of antiviral therapy is unclear and remdesivir should be reserved for children with acute COVID-19. 

COVID-19 vaccination-associated myocarditis

Another 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.

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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! 

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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 74: Breast Cancer Screening. 

Salwa and Veronic discuss who, how, and when to screen for breast cancer. The Pfizer COVID-19 vaccine was authorized for use in children 5-11 years of age.

Introduction: Pediatric COVID-19 Vaccines
By Lam Chau, MS3, Ross University School of Medicine

On November 2nd, 2021, the CDC endorsed a unanimous recommendation to allow the use of the Pfizer COVID-19 vaccine for children ages 5-11 years of age. The White House has secured 28 million pediatric doses of the Pfizer vaccine, enough to cover every child ages 5-11 within the United States without cost. 

The official CDC recommendation is that all children aged 5 and older get vaccinated, regardless of past infection history. The Pfizer vaccine for children is given in two doses, 3 weeks apart.

Individuals older than 12 are given a 30-microgram dose, while pediatric individuals are given a 10-microgram dose. For extra precaution, the pediatric vaccine vials are being shipped with a unique orange cap to clearly distinguish itself from higher dose vaccines. Clinical trials with the lower dose vaccine demonstrated a strong antibody response and a prevention rate of symptomatic COVID-19 of 90%. 

The reported side effects were minimal, and no serious adverse events or myocarditis were reported during the trials. The vaccination of children cannot be understated. The benefits go well beyond just the physiological processes of vaccination. It will foster a safer environment for our children and help improve their emotional and social development. 

While there is still a lot to be done to end the pandemic, this recent announcement is an enormous step in the right direction in returning to normalcy. 

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. 

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Breast Cancer.   
By Salwa Sadiqali, MS3, Ross University Medical School; Veronica Phung, MS3, Ross University School of Medicine; and Hector Arreaza, MD.  

Salwa: Welcome back from Spooky season! Did you see all the flyers and advertisements about Breast cancer awareness last month? 

Veronica: I did! It’s because October was breast cancer awareness month.

Salwa: And spooky season, and of course pumpkin spice season! I got my dose of pumpkin spice this morning. Well, every morning to be exact, Starbucks is my second home. What do you know about breast cancer? 

Veronica: Well...breast cancer is the most commonly diagnosed cancer worldwide. And, fun fact, I know that Angelina Jolie had an increased risk of breast cancer, so she had surgery to remove them.

Arreaza: I remember it being all over the news back in 2013. It caused “The Angelina Effect.” There was an increase in people searching about breast cancer on the internet. Let’s dive into this topic a bit more. What exactly is breast cancer?

Salwa: It’s a process in which normal cells of the breast start growing too quickly, out of control. It can happen in males too, but it’s much rarer.

Veronica: And there are different types of breast cancers that originate from the different types of tissue in the breast. There’s ductal carcinoma, lobular, inflammatory, Paget’s, and phyllodes to name a few. 

Salwa: Not only are there different types of breast cancers, but some can also be hereditary meaning mutated genetic information is passed on from generation to generation.

Arreaza: That’s what happened with Angelina Jolie. She had a BRCA1 gene mutation. 

Veronica: BRCA1 and BRCA2 mutations are the most common causes of hereditary breast cancer. Normally, the BRCA gene helps make proteins that repair damaged DNA. When this gene is mutated, it can’t make those proteins, so damaged DNA stays damaged. But this only makes up 5-10% of all breast cancers.

Salwa: Exactly! Here’s an interesting fact, women of Ashkenazi Jewish heritage are at a much higher risk of developing a BRCA mutation. There are several other genes that are also linked to hereditary breast cancer. But those genes aren’t that common. Non-hereditary breast cancers are much more common - they make up about 85% of breast cancers. 

Arreaza: Ok so you two gave us a lot of good information, but do you know how to screen for breast cancer?

Salwa: When and how often you screen depends on which guidelines your physician is following. Generally, you’ll get a mammogram, basically an X Ray of the breast. 

Veronica: The US Preventative Screening Task Force or USPSTF is a panel of experts that uses medicine-based evidence to make screening and vaccination guidelines. These guidelines are reviewed and updated yearly. For breast cancer, the USPSTF recommends women ages 50-74 have a mammogram every other year. 

Salwa: The American College of Obstetrics and Gynecologists recommends mammograms starting at the age of 40 and repeating the test every year or every other year. While the American Cancer Society recommends annual mammograms from 40 to 54 years of age and then every other year for women 55 years or older. 

Veronica: Dr. Arreaza, you see a lot of patients and I’m sure you’ve referred plenty of them for breast cancer screening. How do you decide which guidelines to follow? 

Arreaza: When you have a patient between 40-50 years old, you have an opportunity to talk about screening, and make a shared decision. 

The USPSTF recommends that women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or an ancestry associated with BRCA1/2 gene mutation be screened with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.

Some instruments use to assess the need for BRCA mutation screening include Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, 7-Question Family History Screening Tool, International Breast Cancer Intervention Study instrument (Tyrer-Cuzick).

Salwa: What about the self-breast exams? I remember those were recommended all the time.

Veronica: That’s a great question! Current research suggests that doing a self-breast exam doesn’t necessarily help detect tumors early – whether cancerous or not. And, sometimes, while doing self-breast exams you may feel a lump that’s actually normal breast tissue and it may cause unnecessary anxiety. That being said, you should always know how your breasts normally look - as in are they symmetrical, how the nipples look, how the skin normally looks. And of course, if you notice any changes or have any concerns, please visit your primary care provider. 

Arreaza: Breast awareness. The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects.

Salwa: As medical students, we have the opportunity to work with different departments in the hospital. I’m currently doing my surgery rotation and Veronica completed hers in September. As part of the rotation, we had the opportunity to work at the Breast Clinic with Dr. Snyder. We saw a lot of patients from CSV because their PCPs were screening them for breast cancer and all those women were able to get the higher level of care they needed. Find available resources in your community for free screening mammograms. For example, Cancer Detection Program/Every Woman Counts by Clinica Sierra Vista.

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Now we conclude our episode number 74 “Breast Cancer Screening.” October was breast cancer awareness month, but it is not too late to remind everyone of the need to screen for breast cancer. Whether you follow the American Cancer Society, the USPSTF or the ACOG guidelines, just do not forget to screen. 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, Lam Chau, Salwa Sadiqali, and Veronica Phung. Audio edition: Suraj Amrutia. See you next week! 

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References:

AAFP Signs Off on Pediatric COVID-19 Vaccine Recommendations, American Academy of Family Physicians, November 3, 2021. https://www.aafp.org/news/health-of-the-public/20211103covidvaccchildren.html?%20cid=DM63464&bid=188450701

ACS Breast Cancer Early Detection Recommendations. American Cancer Society. (n.d.). Retrieved October 11, 2021, from https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html.

Basu, N.N., Hodson, J., Chatterjee, S. et al. The Angelina Jolie effect: Contralateral risk-reducing mastectomy trends in patients at increased risk of breast cancer. Sci Rep 11, 2847 (2021). https://doi.org/10.1038/s41598-021-82654-x

Breast cancer information and support. Breastcancer.org. (n.d.). Retrieved October 10, 2021, from https://www.breastcancer.org/.

Breast cancer: Screening. Recommendation: Breast Cancer: Screening | United States Preventive Services Taskforce. (2016, January 11). Retrieved October 10, 2021, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening. 

Practice Bulletin Number 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women. (2017). Obstetrics and gynecology, 130(1), e1–e16. https://doi.org/10.1097/AOG.0000000000002158

Episode 73: Anticoagulation in Afib. 

When should you start anticoagulation in atrial fibrillation? What medications are appropriate? Virginia Bustamante, Charizza Besmanos and Dr Arreaza discuss this topic.  
By Charizza Besmanos, MS4; Virginia Bustamante, MS4; and Hector Arreaza, MD

Charizza: Hello, welcome to today’s episode of Rio Bravo qWeek Podcast. My name is Charizza Besmanos, a 4th year medical student from American University of the Caribbean and I am joined here today by Virginia Bustamante. 

Virginia: I’m Virginia Bustamante, an incoming 4th year medical student from Ross University. 

Arreaza: And I’ll be here just to make sure that you guys behave during this episode.

Charizza: Before we get started on our discussion, I have a quick patient case to share with you. 

This is a 66-year-old woman who is brought to the ED with sudden onset of severe difficulty speaking and weakness while having breakfast. She has hypertension, hyperlipidemia, severe left atrial enlargement seen on previous ECHO, and is noncompliant with her medications. She is a lifetime nonsmoker and does not drink alcohol. On admission, her blood pressure is 152/90 and pulse is 124/min and irregularly irregular. She is awake and alert but has difficulty finding words while trying to speak. She has severe right lower facial droop and marked weakness and sensory loss in the right arm and mild weakness in right leg. Fingerstick glucose is at 105. ECG shows atrial fibrillation. Acute stroke management is started right away. CT shows occlusion of the left MCA. What management could have prevented this complication? 

Virginia: This patient clearly has multiple risk factors for thromboembolism events but given her irregularly irregular pulse consistent with atrial fibrillation, she would’ve warranted long-term anticoagulation to prevent stroke, which she most likely had. 

Charizza: Exactly. Today’s topic is atrial fibrillation, specifically the use of anticoagulation.

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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. 

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Virginia: Anticoagulation is indicated to decrease the risk of thromboembolic events such as ischemic stroke in patients with atrial fibrillation (A-fib). Not all patients receive anticoagulation. Like most things in medicine, you must decide to start anticoagulation when the benefits of decreasing the risk of stroke outweighs the risk of bleeding. So, for assessing the risk of stroke in A-fib, the American College of Cardiology along with American Heart Association and the Heart Rhythm Society published a guideline in the Journal of the American College of Cardiology in 2014 and was recently updated in 2019[1] detailing in which patients anticoagulation is recommended. 

Charizza: Yes, according to the guideline, “high risk patients” are all patients with valvular A-fib, and those with nonvalvular A-fib with a CHADVASC score of >/= 2 in men or >/= 3 in women, and those with nonvalvular Afib and hypertrophic cardiomyopathy. Those with “medium risk” are patients with nonvalvular Afib with CHAD2VASc score of 1 in men or 2 in women. In these patients, anticoagulation is considered but the risk and benefits are discussed with the patient. Those with “low risk” are patients with CHAD2VASc score of 0 in men or 1 in women and anticoagulation is not routinely recommended in these patients. Can you tell us briefly what CHA2DVASc score is? 

Virginia: CHA2DS2-VASc score is the stroke risk assessment tool of choice by the AHA/ACC/HRS guideline. It is great because it is a mnemonic. Each letter is assignment 1 point except for 2 criteria. C stands for congestive heart failure, H for HTN defined as >140/90, A2 is for or Age>75 which is for 2 points, D for diabetes, S2 is for stroke or TIA and it’s for 2 points, V for vascular disease such as MI, A for age 65-74, S for female sex. 

Charizza: That certainly makes it easy to remember. Not only that, but you can also find CHA2DS2-VASc score of MDCalc to make it even easier.

Virginia: Now that we’ve established which patients should receive anticoagulation, how do we choose which anticoagulant? 

Charizza: For this discussion today, I would like to focus on nonpregnant patients. There really are 2 main anticoagulants, DOACs (or the direct oral anticoagulants) and warfarin. DOACs are the direct thrombin INH (dabigatran) and the direct factor Xa INH (rivaroxaban, apixaban, and edoxaban). DOAC is recommended as first-line in the long-term management of nonvalvular afib as trials have shown DOACs are more successful at reducing risk of thromboembolic events and have a lower risk of bleeding than warfarin and warfarin requires INR monitoring with dose adjustments. Although, in patients with valvular Afib, warfarin is preferred.

Arreaza: All of them are by mouth. 

Virginia: Dosing of DOACs depends on the kidney function, so it is important to obtain the creatinine clearance. For dabigatran, the direct thrombin INH, the recommended dose for patients with CrCl >30 mL/min is 150mg PO twice daily based on the results from the RE-LY trial (2), which evaluated the efficacy and safety of dabigatran with warfarin in patients with Afib. For patients with CrCl of 15-30 mL/min, the recommended dose is 75mg PO BID. Those with CrCl <15 mL/min or on dialysis, dabigatran is not recommended. 

Charizza: For the apixaban (Eliquis®), a direct factor Xa inhibitor, the dosing is 5mg BID for patient with normal renal function. For those with moderate kidney dysfunction such as Cr is >1.5, patient who is > 80years old or body weight <60kg, dosing of apixaban is decrease to 2.5 mg PO BID. There is not enough data for use of apixaban in patients with CrCl <15 or in dialysis. 

Virginia: For another direct factor Xa INH rivaroxaban (Xarelto®), dose is 20 mg once per day for CrCl >50 mL/min, 15 mg once per day for CrCl 15 to 50 mL/min, and for CrCl <15 mL/min do not use rivaroxaban.

Charizza: Essentially, any DOACs is not recommended for severe kidney impairment which is CrCl <15 mL/min or those on dialysis. 

Virginia: Yes, and for those patients where DOAC cannot be used, warfarin can be initiated. 

Charizza: Initiating warfarin for long-term anticoagulation in patient with atrial fibrillation does not necessarily require heparin bridge(4). 

Virginia: Before starting warfarin, a baseline INR is obtained. Usually, the initial dose of warfarin is 5mg PO daily for 3 days (5). And on day 4, INR is check in the morning and adjusting the dose of warfarin depending on the INR. 

Charizza: Warfarin dose is adjusted for a target INR of 2-3(6). Warfarin can be complicated to maintain, however, there are anticoagulation clinic to make sure they compliant with theirs and INR is therapeutic.

Thank you for your attention.

Now we conclude our episode number 73 “Anticoagulation in Afib.” Anticoagulation is an essential part of the management of Afib, mainly to prevent embolic stroke. 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, Virginia Bustamante, and Charizza Besmanos. Audio edition: Suraj Amrutia. See you next week! 

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References:

January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., & Yancy, C. W. (2019, January 28). 2019 AHA/ACC/HRS FOCUSED update of the 2014 Aha/acc/hrs guideline for the management of patients with atrial fibrillation: A report of the American College of Cardioloy /American Heart Association Task force on clinical practice guidelines and the heart Rhythm Society. Journal of the American College of Cardiology. https://www.sciencedirect.com/science/article/pii/S0735109719302098?via%3Dihub . 

Bavry, Anthony A., MD, MPH, FACC, Randomized evaluation of long-term anticoagulant therapy RE-LY. American College of Cardiology. (2020, August 25). https://www.acc.org/latest-in-cardiology/clinical-trials/2013/07/19/12/25/rely. 

Warren J Manning, MD; Daniel E Singer, MD; Gregory YH Lip, MD, FRCPE, FESC, FACC. Atrial fibrillation in adults: Use of oral anticoagulants. Up to Date. (n.d.). https://www.uptodate.com/contents/atrial-fibrillation-use-of-oral-anticoagulants?search=atrial+fibrillation&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H416912985 .

Ebell MH. Evidence-based initiation of warfarin (Coumadin). Am Fam Physician. 2005 Feb 15;71(4):763-5. PMID: 15742915. https://www.aafp.org/afp/2005/0215/p763.html. 

Episode 72: Depression in Adolescents.  

COVID-19 vaccine updates including booster shots and mix and match options. Depression in adolescents is discussed by Virginia Bustamante, Charizza Besmanos, and Hector Arreaza. 

Introduction: COVID Vaccines Update October 2021
Written by Hector Arreaza, MD. Participation: Lillian Petersen, RN, and Nathan Heathcoat, MS3.  

The FDA granted emergency use authorization for a booster shot with the Pfizer/BioNtech COVID-19 vaccine in September 2020.

On October 20, 2021, the FDA also granted emergency use authorization for a booster shot with the Moderna AND Johnson & Johnson (also known as Janssen or J&J) COVID-19 vaccines. 

Pfizer/BioNtech: Brand name Comirnaty®. It has full FDA approval for patients who are 18 years and older for the prevention of COVID-19. The rest of the indications of this vaccine are under the Emergency Use Authorization (EUA). It is authorized for 12 years and older. Total of two doses, 21 days apart. Authorized for 3rd dose in immunocompromised patients (on active cancer treatment, organ transplant recipients, taking immunosuppressive or high dose corticosteroids, have moderate to severe immunodeficiency). 3rd dose is given at least 1 month after the second dose. It is authorized for a single booster shot in special populations (older than 65 years of age OR 18-64 years of age at high risk of severe COVID-19 or with frequent occupational exposure). The booster shot must be given 6 months after the primary series is complete.

Moderna: No brand name yet. All uses are under emergency use authorization. It is authorized for 18 years and older for the prevention of COVID-19. Give a total of two doses, 4 weeks apart. A third dose is authorized to be given 1 month after the second dose. Patients who can receive a third dose include patients on active cancer treatment, organ transplant recipients, taking immunosuppressive or high dose corticosteroids, or have an immunodeficiency. It is authorized for a single booster shot 6 months after completing primary series. The booster shot of Moderna should be half dose. People who may receive a booster shot are those who are older than 65 years of age OR 18-64 years of age at high risk of severe COVID-19 or with frequent occupational exposure.

Johnson & Johnson (Janssen): No brand name yet. Authorized as a single dose vaccine. Authorized for a single booster shot 2 months after the first dose. 

Mix and Match Approval: The FDA authorized on October 20, 2021, heterologous booster dose for currently approved or authorized COVID-19 vaccines. You can give a booster shot with a different vaccine than the one you received primarily. For example, a patient who received J&J vaccine may receive a booster shot with Pfizer or Moderna 2 months later. Another example, a patient received primary series of Pfizer vaccine, may receive a booster shot with Moderna, Pfizer or J&J 6 months after completing primary series. Booster shots are authorized, again, for patients who are 65 years and older, 18-64 years of age at high-risk for severe COVID-19 or with frequent occupational exposure.

The vaccination of children 5-11 years old is still under discussion, more updates coming soon.

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. 

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Depression in Adolescents. 

By Virginia Bustamante, MS4; Charizza Besmanos, MS4; and Hector Arreaza, MD.  

Vicky: We will talk about adolescence and depression today. I was reading a piece on the Impact of COVID-19 Pandemic on Adolescent Mental Health on Psychiatry Advisor by Tori Rodriguez. She is a licensed professional counselor with a master’s in arts in counseling psychology. 

This article really got me thinking, how prevalent is depression in adolescents? Even before COVID-19. I read the article and I wasn't even aware of the numbers. So, I decided to do some research on the topic. 

Charizza: When you brought up the topic for discussion, I asked myself how much do I even know? I found that the CDC reported that “more than 1 in 3 high school students had experienced persistent feelings of sadness or hopelessness in 2019.” This was a 40% increase since 2009. 

It also said that, “in 2019 about 1 in 6 youth reported making a suicide plan in in the past year. That was a 44% increase since 2009.” 44% increase! That is almost unbelievable. Now I’m asking myself what is causing such a drastic increase.

Vicky: When I read Rodriguez’s piece it really got me thinking. What is or are there even known causes linked to this huge increase?

Charizza: Are adolescents more open to talk about mental illness? Or are there other factors affecting their mental illness? For example, increasing social media presence or other home/ social pressures. 

Vicky: Actually, that may be partially why. The U.S. News and World Report wrote a piece that highlighted the possible contributing factors that have led to this increase. They stated that data hasn’t really shown a conclusive answer but there are some common themes that have emerged. And I’d like to spend much of this podcast really going into those themes and discussing them. 

The U.S. News and World Report listed five common themes. Theme one, what they called “a modern-day diagnosis” - where they reference a John Hopkins Health Review which explained that adolescent depression is somewhat of a new diagnosis. 

Charizza: Up until about the 1980’s mental health professionals were reluctant to diagnose adolescents with a mood disorder. Because their brains were still developing, they thought it was not appropriate to diagnose someone so young with, for example depression. 

Vicky: Yes exactly, so the current thought is, that perhaps this change of thinking has played a part in the increasing numbers in the form of increased reporting and/or documentation. 

The second theme they listed was “hyper-connected & overstimulated.” This stems from how our world is today. Where electronic devices and social media are a big part of young people’s lives. The idea that they have a life in the real world and the virtual world. 

Charizza:  I read a study on Teens, Social Media and Technology, a Pew Research Center study, that more than 95% of teenagers have access to a smartphone and 45% of them described themselves as being online “almost constantly.”  

Vicky: To think, how does this affect the way they see themselves? For maybe a lot of us listening right now we’ve been on social media. That could be Facebook, Instagram, Tik-Tok, and going way back Myspace. We know that social media can be an amazing place to share our lives but can also be filled with a lot of criticism.

Arreaza: Have you heard of “FOMO”? It’s “Fear of Missing Out”. It’s a condition that can cause severe anxiety because others are having fun, or you missed a particular event, memorable experience, or an opportunity to connect with someone famous, or an online investment. People with FOMO need to stay always connected. 

Vicky: The Journal of Abnormal Psychology explained that the spike in depression and suicidal tendencies may be connected to social media among young people. They went on to describe how it's not uncommon for young people to measure their self-worth based on the likes. I've been there. Questioning myself whether to post or not post a picture based on whether it's “Instagram worthy”? Will it get enough likes to be posted? Rather than sharing moments of my life with friends and family as the platform was intended to. 

Charizza: It’s not something I’m proud of but I’ve gotten sucked into the fake reality of online. That's why I reduced my social media presence. 

Vicky: Was there a specific reason or situation that led to that?

Charizza: I just felt like that it was taking more energy than it was meant for. And honestly I’ve felt happier since not really using my Facebook anymore. 

Vicky: If that makes you happier, I support it. I mean I might consider it myself. 

Arreaza: Yes, a social media “fasting” may be beneficial for some people. 

Vicky: For the third theme, the article referred to what they called “uncertain times.”

Charizza: What does that even mean?

Vicky: Each generation is influenced and shaped, in a positive or negative way, by the events happening at that time in history. And sadly, today’s young people have grown up in a post-9-1-1 world, mass terrorist attacks, and shootings whether that be high schools, malls, and even churches. All these events mean that young people may know the fear of terrorism. A sense of security has been taken from them by these awful and cowardly attacks of others. 

Charizza: I had a friend who was afraid to go to the movies after the 2012 Aurora Colorado shooting. For a long time, every time she went, she couldn’t sit there and enjoy the movie. She kept turning around looking at the door every time it opened. Afraid something would happen. So, thinking of that and thinking that others may be going through similar and even more difficult times, I can completely understand this contributing depression among young people. 

Vicky: This fear and stress appears to be contributing to the increase in depression. The fourth theme was “not enough sleep.” The Nation Sleep Foundations recommends teens get 8.5 to 9.5 hours and instead teens get around 7 hours. When I am well rested, I perform my best. My energy, memory and overall mood is better. But with school, work, and everything else it’s hard sometimes to get the hours I need. I mean I don't know about you Charizza, but I can work on getting more sleep. 

Charizza: Sadly, I struggle with it too. But for adolescents where they're still developing and undergoing different physiological changes those hours are especially important. The Sleep Foundation stressed the importance of sleep for teens. 

They talk about how it helps with physical development - with all the changes they are undergoing, academic achievement - by promoting attention, improving memory (like you brought up), and definitely helps with emotional health. The website states that mental health disorders for example anxiety, depression, and even bipolar disorder have been linked to poor sleep. They even stated that sleep deprivation in teenagers can increase the risk for suicide.

Arreaza: A poor sleep also can lead to obesity in adolescents and adults. Something we should remember is also the timing of sleep for adolescents. The sleep pattern changes over the lifetime of people, and it’s not only in duration, but also the time they sleep. Normally, a teenager tends to go to bed late and wake up late. For this reason, high school schedules are being changed in California to start at 8:00 AM. 

Vicky: It sounds like improving sleep in adolescents can be a great way of preventing mental health disorders or even reducing their symptoms. The last and fifth theme discussed in The U.S. News and World Report as a possible contributing factor to the increase in adolescent depression is a “lack of community.” 

This goes back to the world we live in today. We live with this - what the article quotes as - “go-go mentality” and the community we would have previously built or created around us have gotten smaller. So as they quoted “our face-to-face connections” have decreased.

Charizza: Is there anything they suggest?

Vicky: The U.S. Preventive Services Task Force recommends primary caregivers screen adolescents 12-18 for depression. But this doesn't always happen. They suggested that identifying adolescent depression should NOT be something that only falls on the medical provider but something we should ALL be responsible for. We can do this by building healthy and trusting relationships with our young people. Hopefully also rebuild this sense of community. 

Today we highlighted some themes that are possibly related to the increase in adolescent depression. Those were: the idea of a modern-day diagnosis, second being hyper-connected & overstimulated, third the uncertain times we live in, fourth not enough sleep, and lastly the sense of a lack of community. 

Charizza: We hope you guys all really enjoyed listening. And remember if you are or know someone struggling with depression and/or suicide thoughts reach out to someone. Let someone know how you are doing. Tell a teacher, adult, someone.

Vicky: If you for whatever reason don't feel comfortable doing that or feel you may not have someone to reach out to and are in danger of hurting yourself or others please call 911. 

Charizza: There are also national suicide prevention hotlines. That is 1-800-SUICIDE and that’s 1-800-SUICIDE. There is also 1-800-273-TALK, again that's 1-800-273-TALK

Vicky: There is also the Mary K Shell Mental Health Center with a walk-in crisis center. They are located here in Bakersfield on College and Mt. Vernon. They are actually in the same parking lot as Kern Medical Center. Their number is 661- 868-8123.

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Conclusion: Now we conclude our episode number 72 “Depression in Adolescents.” Our adolescent patients are a special population, so special that you can even do a fellowship after finishing your residency. Our adolescents are under a lot of pressure, especially during this era of social media. Remember to screen for depression and start treatment right away with behavioral therapy and medications as needed or refer your depressed patients to a psychiatrist to start treatment promptly. Do not forget to assess risk of suicide and act fast to prevent suicide in your patients. 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, Lillian Petersen, Nathan Heathcoat, Virginia Bustamante, and Charizza Besmanos. Audio edition: Suraj Amrutia. See you next week! 

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References:

Mental Health, Adolescent and School Health, Centers for Disease Control and Prevention, CDC.gov,  https://www.cdc.gov/healthyyouth/mental-health/index.htm, accessed on September 20, 2021. 

Lohmann, Rachel Cassada, What's Driving the Rise in Teen Depression?, US News, April 22, 2019. https://health.usnews.com/wellness/for-parents/articles/2019-04-22/teen-depression-is-on-the-rise. 

Anderson, Monica and Jingjing Jiang, Teens, Social Media and Technology 2018, Pew Research Center, May 31, 2018. https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/. 

Rodriguez, Tori, Impact of the COVID-19 Pandemic on Adolescent Mental Health, Psychiatry Advisor, April 30, 2021, https://www.psychiatryadvisor.com/home/topics/child-adolescent-psychiatry/adolescent-mental-health-issues-are-further-exacerbated-by-the-covid-19-pandemic/. 

Episode 71: Metabolic Syndrome. 

Dr Yomi defines metabolic syndrome and describes the basic principles of management. Nathan gives updates about aspirin use in primary prevention of cardiovascular disease.

Introduction: Aspirin Update.  
By Nathan Heathcoat, MS3, Ross University School of Medicine.  

Arreaza (comment): This week I was checking the list of the top 10 countries where we have the highest number of listeners, and I’m happy to see the Kingdom of Spain as the number 2 country with the most listeners. Out top 1 country is the United States, we also have listeners in Canada, Mexico, the Netherlands, Brazil, Ireland, Australia, South Africa, Mexico, and England. I send my greetings to you wherever you are. I hope you all enjoy today’s episode, from wherever you are, and please send us an email torbresidency@clinicasierravista.orgif you have any feedback. We would like to hear from you.

Hello, my name is Nathan Heathcoat I am a 3rd year medical student at Ross University School of Medicine. I will be giving a quick update on aspirin. 

Aspirin has been examined quite a bit by the USPSTF recently. In episode 68, Doctors Arreaza and Civelli discussed the continued recommendations for the use of aspirin for the prevention of preeclampsia in high-risk patients. 

Now as of October 12, 2021, The USPSTF has been working on draft changes on how we utilize aspirin for the prevention of cardiovascular disease (CVD) events.

The previous guideline from 2016 gave aspirin use as CVD event prophylaxis a grade B (as in Bravo) recommendation in patients aged 50-59 who’s 10-year ASCVD risk was 10% or greater. Additionally, for those patients aged 60-69 with a 10-year risk of 10% or more, aspirin use is said to be an individual based approach and received a grade C recommendation. (1)

Now with these new draft recommendations, those patients aged 40-59, aspirin only adds marginal benefit. Its recommendation has been tentatively changed to grade C and its use should be an individual based approach. Most notably, for those patients aged 60-69, the USPSTF is suggesting that aspirin confers no net benefit for primary prevention of CVD, and they changed its recommendation to grade D as in delta. (2)

So going forward keep in mind that these practice guidelines are under draft review and the official recommendation should be finalized mid to late November 2021. 

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. 

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Metabolic Syndrome.    
By Timiiye Dawn Yomi, MD; and Hector Arreaza, MD.  

INTRODUCTION                                                                                                                                                           Obesity, especially abdominal obesity, is associated with an increase in insulin resistance which causes abnormal glucose and fatty acid utilization in peripheral muscles, among other consequences. 

Obesity can often result in type 2 diabetes. 

The hyperinsulinemia and hyperglycemia resulting from insulin resistance can result in vascular endothelial dysfunction, abnormal lipid profile, hypertension, and vascular inflammation and together, can increase the risk for developing ASCVD. 

A constellation of metabolic risk factors for type 2 diabetes and cardiovascular disease is what constitutes metabolic syndrome or insulin resistance syndrome.

What is a syndrome? It is a group of symptoms that are present together, or a condition characterized by a set of associated symptoms.

DEFINITION

The National cholesterol education program ATP III updated its definition of metabolic syndrome in 2005 and defined it as the presence of any 3 of the following 5 traits.

Abdominal obesity: waist circumference ≥ 102cm (40in) in men and 88 cm (35in) in females 

Serum triglycerides ≥150 mg/dl (1.7 mmol/L) or drug treatment for elevated triglycerides.

Serum high density lipoprotein (HDL) cholesterol < 40 mg/dl (1mmol/l) in males and < 50 mg/dl (1.3mmol/l) in females or drug treatment for low HDL cholesterol.

Blood pressure ≥ 130/85 mmHg or drug treatment for elevated blood pressure.

Fasting plasma glucose 100mg/dl or drug treatment for elevated blood glucose.

The International Diabetes Federation: 2009 –same criteria, except waist circumference has specific cut off points based on ethnicity and OGTT. 

Increased waist circumference with ethnic-specific cut off points (Look for table 2 in this handbook).

Serum triglycerides ≥150 mg/dl (1.7 mmol/L) or drug treatment for elevated triglycerides.

Serum high density lipoprotein cholesterol < 40 mg/dl (1mmol/l) in males and < 50 mg/dl (1.3mmol/l in Females or drug treatment for low HDL cholesterol.

Systolic blood pressure ≥ 130, diastolic blood pressure ≥85 or treatment for hypertension.

Fasting plasma glucose 100mg/dl (5.6 mmol/l) or previously diagnosed type 2 diabetes or oral glucose tolerance test which is recommended for patients with an elevated fasting plasma glucose.

As a side note, metabolic syndrome cannot be diagnosed in children <10 years but clinicians must be vigilant if waist circumference is ≥ 90th percentile for age

Risk factors

Weight is the most important risk factor: Increased body weight is a major risk factor in developing metabolic syndrome. In the National Health and Nutrition Examination Survey III, metabolic syndrome was present in 5 percent of those at normal weight, 22 percent of those with overweight, and 60 percent of those with obesity.

Other risk factors include age, race, postmenopausal status, smoking, low household incomes, high carbohydrate diet, no alcohol consumption, physical inactivity/poor cardiorespiratory fitness, soft drinks and sugar sweetened beverages, atypical antipsychotics– clozapine, and family history/genetics.

Clinical implication

A diagnosis of metabolic syndrome would help clinicians identify patients who are at increased risk for developing Type 2 DM and or CVD and as such helps to identify those needing aggressive lifestyle modification which focuses on weight loss and increased physical activity ultimately reducing the risk of developing Type 2 DM and CVD.  

It has become increasingly prevalent in our society. According to the 2001 Adults Treatment Panel III (ATP III) criteria, which evaluated about 8,800 adults in the US, who participated in the National Health and Nutrition Examination Survey (NHANES) from 1988-1994, 22% of participants met criteria for metabolic syndrome with an age dependent increase. 

Mexican Americans were found to have the highest age-adjusted prevalence of 31.9%, and prevalence was higher in females than males amongst the African and the Mexican Americans. 

Data from NHANES from1988 to 1994, 1999 to 2000 and from 2017 to 2018, revealed that obesity increased from 22.9 to 30.5 to 42.4 percent respectively in each studied period. The implication of this is an increase in the prevalence of metabolic syndrome and its attendant morbidities and mortality

The ASCVD score which assesses patient's 10-year risk for developing CVD, Framingham Risk Score and the Systematic Coronary Risk Score Evaluation Score are useful tools in targeting individuals needing medical intervention to help lower the blood pressure and cholesterol.

Management

In 2001, ATP 3 recommended two major therapeutic goals in patients with metabolic syndrome and these goals were reinforced by the National Institutes of Health (NIH) and American Heart Association (AHA) 

Treat underlying causes such as overweight/obesity and physical inactivity though aggressive lifestyle modification, weight lost and increase physical activity.

Treat CVD risk factors if they persist despite lifestyle modification.

Weight loss: This can be achieved through changes in eating habits (instead of “diet”), increased physical activity (instead of “exercise”), medications, behavioral therapy, or surgery. 

Examples of healthy eating to promote weight loss are the Mediterranean diet, the DASH diet, ketogenic diet, and intermittent fasting. If you would like to know more about the keto diet, listen to our episode 59, on The Keto diet. 

Exercise: The physical activity guidelines recommends that patients exercise daily minimum 30 minutes of moderate intensity exercise (150 minutes a week of brisk walking, for example) plus strengthening exercise twice a week. Exercise is important for health, even when it is not the best tool to lose weight.

Why are clinicians not diagnosing metabolic syndrome amongst patients?

The American Diabetes Association and the European Association for the Study of Diabetes published a joint statement raising questions about whether the components of metabolic syndrome, as defined above, warrant classification as a true "syndrome". Some arguments raised include:

Lack of clarity of definition

Multiple different phenotypes included within the syndrome

Not enough evidence for setting thresholds for the components of the syndrome.

Unclear pathogenesis.

Other risk factors for CVD that are not components of the syndrome, such as, inflammatory markers.

CVD risk associated with metabolic syndrome has not been shown to be greater than the sum of its individual components.

Whether patients will benefit from a diagnosis of metabolic syndrome with such uncertain characteristics remains a topic of debate. However, the consensus is to treat individual risk factors when present in patients with obesity and multiple risk factors, and to promote aggressive lifestyle modification with the focus on weight loss and increased physical activity.

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Conclusion: Now we conclude our episode number 71 “Metabolic Syndrome.” Think about metabolic syndrome in patients with enlarged abdomen, elevated glucose and triglycerides, low HDL, and high blood pressure. By identifying and treating these patients you may decrease mortality in your community. 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, Timiiye Yomi, and Nathan Heathcoat. Audio edition: Suraj Amrutia. See you next week! 

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References:

Bibbins-Domingo, K. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2016 Jun 16; 164(12): 836-845 https://doi.org/10.7326/M16-0577.

Guirguis-Blake, J. et al. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: An Evidence Update for the U.S. Preventive Services Task Force. AHRQ Publication No. 21-05283-EF-1. 2021 Sep. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/document/draft-evidence-review/aspirin-use-to-prevent-cardiovascular-disease-preventive-medication on October 12, 2021.

James BM. Metabolic syndrome (insulin resistance syndrome, syndrome X). In: Lisa K, ed. UpToDate. Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com/contents/metabolic-syndrome-insulin-resistance-syndrome-or-syndrome. Accessed Aug 1, 2021.

The IDF consensus worldwide definition of the METABOLIC SYNDROME, International Diabetes Federation, published in 2006, last update July 29, 2020. PDF available for download: https://www.idf.org/e-library/consensus-statements/60-idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html. 

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 AIDS
By 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.

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HIV Series IV: HIV Prevention. 
By Robert Dunn, MS3.
Participation by Huda Quanungo, MS3; Bahar Hamidi, MS3; and Hector Arreaza, MD.  

HIV Prevention
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 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. Pneumocystispneumonia – 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 HIV

HIV 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 stable

Age 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 Screening

The 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 pregnancies

Also 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 HIV

Including 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. 

Condoms

A 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 PrEP

Descovy 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 – 60

Truvada is associated with acute and chronic kidney disease whereas Descovy is safe for patients with a GFR greater than 30

Patients with osteoporosis

Truvada 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. 

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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 69: Asymptomatic Bacteriuria. 

When do you screen for and treat asymptomatic bacteriuria? Find out what the IDSA recommends during this episode. PARTNER studies demonstrated that HIV transmission is minimal with condom-less sex if viral load is undetectable.

Introduction: Urine.  

Urine is a straw-colored, pale yellow, or colorless liquid, which is a by-product of metabolism. It is normally sterile when excreted under normal conditions, but it can also have bacteria even in the absence of infection. When you have bacteriuria with no symptoms, it is called asymptomatic bacteriuria or ASB. Today you will hear Dr Covenas, Dr Civelli and Dr Lundquist discussing when to screen and treat asymptomatic bacteriuria.

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. [Music continues and fades…]

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Asymptomatic bacteriuria (update by the IDSA)
Written by Hector Arreaza, MD. 
Participation by Cecilia Covenas, MD; Valeri Civelli, MD; and Ariana Lundquist, MD.

Case: 19-year-old female who came to clinic to review lab results with you. She is coming from another clinic and brings her results on paper. Routine labs were done 1 week ago. Her complete blood count is normal, TSH (thyroid stimulating hormone) is normal, hemoglobin A1C of 5.3, and a urine culture showing >100,000 CFU of E. coli. Patient denies dysuria, polyuria, or any urinary symptoms. She has a negative pregnancy test in clinic today. What are you going to do with this significant bacteriuria?

This is an Asymptomatic Bacteriuria (ASB). The first question you may ask is “why did she get a urine culture in the first place?” The Infectious Disease Society of America (IDSA) published in its journal “Clinical Infectious Disease” an update in the management of ASB. It is a 28-page long document with answers to 14 questions regarding ASB screening and management in different patient populations.

Recommended ASB screening and treatment: IDSA concluded that the only two groups of patients who benefit from screening and treatment of asymptomatic bacteriuria are: Pregnant women and patients who undergo traumatic urologic interventions that result in mucosal bleeding.

Pregnant women: Recommend one urine culture at one of the initial visits early in pregnancy. There is insufficient evidence to recommend for or against repeat screening during the pregnancy for a woman with an initial negative screening culture or following treatment of an initial episode of ASB. Treatment: IDSA suggests 4–7 days of antimicrobial treatment rather than a shorter duration, the optimal duration of treatment will vary depending on the antimicrobial given; the shortest effective course should be used.

Patients who will undergo endoscopic urologic procedures associated with mucosal trauma: Screening for ASB and treating prior to surgery is RECOMMENDED. The goal is to avoid serious post-operative complication of sepsis. IDSA suggests a urine culture prior to the procedure and targeted antimicrobial therapy prescribed rather than empiric therapy. If bacteriuria is detected, a short course (1 or 2 doses) rather than more prolonged antimicrobial therapy is recommended, and antibiotic should be initiated 30–60 minutes before the procedure.

Against ASB screening and treatment: IDSA suggests no screening for or treating ASB in these patients:

Pediatric patients

Healthy nonpregnant women

Community-dwelling persons who are functionally impaired

Older persons residing in long-term care facilities

Patients with diabetes

Patients who had a renal transplant over 1 month ago (insufficient evidence for less than 1 month ago)

Patients with nonrenal solid organ transplant

Individuals with impaired voiding following spinal cord injury (consider atypical symptoms of UTI when deciding treatment vs nontreatment of bacteriuria in these patients)

Short-term indwelling urethral catheter (<30 days)

Patients with long-term indwelling catheters (>30 days)

Patients undergoing elective nonurologic surgery

Patients planning to undergo surgery for an artificial urine sphincter or penile prosthesis implantation (these patients should receive standard preop antibiotics before surgery)

Patients living with implanted urologic devices

Insufficient evidence to recommend for or against ASB screening and treatment: Evidence is insufficient to recommend ASB screening and treatment in patients with high-risk neutropenia (absolute neutrophil count <100 cells/mm3, >7 days duration after chemotherapy). These patients should be treated with prophylactic antibiotics and start antibiotics promptly in there is fever. For low-risk neutropenic patients (neutrophils >100, <7 days, clinically stable) ASB risk is not greater than in patients with normal neutrophil count. In patients with indwelling catheters, IDSA makes no recommendation for or against screening and treating ASB at the time of catheter removal.

Special populations: In older patients with cognitive impairment with bacteriuria and confusion WITHOUT urinary symptoms or other signs of infection, such as fever or hemodynamic instability: Look for causes of altered mental status other than UTI, have close monitoring of symptoms, antibiotics are NOT recommended as a first line treatment unless you have signs or symptoms of infection.

If a patient with these characteristics (older, cognitively impaired, nonlocalizing symptoms) experienced a fall, the recommendation is the same: assess for other causes and observation rather than antimicrobial treatment of bacteriuria. 

The reason behind this recommendation is avoiding adverse outcomes of antibiotic therapy (C. diff, increased antibiotic resistance, or adverse drug effects). 

Sepsis: For patients with BACTERIURIA, fever, and other systemic signs potentially consistent with sepsis and without a localizing source, broad-spectrum antimicrobial therapy directed against urinary and nonurinary sources should be initiated. 

As for our non-pregnant 19-yo female patient with significant bacteriuria and no urinary symptoms, the answer is do not treat.

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HIV Series Part III: PARTNER 1 and PARTNER 2

Hello everyone! Welcome back to the introduction to HIV series with the Rio Bravo qWeek Podcast. Today we will focus on the PARTNER-1 and PARTNER-2 studies. Let’s review these studies together. 

The PARTNER-1 and PARTNER-2 studies were important in providing evidence-based support for the claim undetectable equals untransmissible, or U=U. SO in this podcast, we can break down what these studies are. 

Previous studies

In 2011, the HIV Prevention Trials Network (HPTN) 052 study team conducted a clinical trial demonstrating a 96% reduction in HIV transmission amongst heterosexual couples when one partner is HIV positive and the other is HIV negative. However, in this study and other, there was still consistent condom use and PrEP use and no data concerning anal sex. 

PARTNER 1 study

The PARTNER 1 (Partners of People on ART – A New Evaluation of the Risks) study was the first observational study to assess the risk of HIV transmission between couples, including both heterosexual and homosexual couples, without condoms, and including anal sex. It was conducted from September 2010 to May 2014, enrolled 1166 couples, and reported 22,000 condomless sex acts amongst men who have sex with men (MSM) and 36,000 condomless sex acts amongst heterosexual couples. The HIV positive partner had to maintain their viral load below 200 copies/mL and the HIV negative patient was not to use condoms or be on pre-exposure prophylaxis (PrEP) in order to be eligible for the study. The results showed that there were no documented cases of within-couple HIV transmission, with a 95% confidence limit.

Some limitations to the study include that there were 11 patients who were HIV negative that contracted HIV during the study time. However, none of the HIV genotypes were phylogenetically linked to the HIV positive partner. Furthermore 8 of these patients endorsed that they were engaging in sex with people other than their partner. Another limitation was that this was an observational study, so all the parameters of the study are self-reported. And the study was conducted for 4 years, so a longer study would need to be conducted to give a stronger estimate of risk. 

PARTNER 2 study

In the PARTNER 2 study, the observational study was focused on only homosexual men (MSM), enrolled some patients from PARTNER 1 study, and therefore included data from September 2010 to April 2018. Once again, the study collected data about their sexual behavior, required the HIV positive partner to maintain a viral load below 200 copies/mL, and required condomless sex and no use of PrEP or post-exposure prophylaxis (PEP) to be eligible for the study. This study enrolled 972 gay couples, contributing to 1596 couple years (years they have been together) and documented 77000 condomless sex acts. The findings once again demonstrated no HIV transmission within couples.

A limitation to this study is that 15 patients did contract HIV, however, none of the new infections could be phylogenetically linked to their partner from the study. Furthermore, it is important to note that 37% of the couples were in open relationships, 24% of the HIV negative partners contracted at least one STI and 27% of the HIV positive patients contracted at least one STI. 

Significance

The significance of this study demonstrates the effectiveness of HAART therapy in not only treating a patient with HIV, but also demonstrates that “undetectable” levels of HIV viral loads does mean it is untransmissible. The common campaign symbol “U=U” (undetectable = untransmissible) is often used to promote this concept. And these studies finally give us evidence-based data to demonstrate U=U. Hopefully with more education, the prejudice surrounding people living with HIV can be removed. 

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Conclusion: Now we conclude our episode number 69 “Asymptomatic Bacteriuria.” When do you screen for and treat asymptomatic bacteriuria? The answer is, in pregnant women and in patients who will undergo traumatic urology procedures. Robert also explained in his HIV series that the PARTNER 1 and PARTNER 2 studies showed no transmission of HIV to a seronegative partner when the seropositive partner has undetectable viral load, even without use of condoms. 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, Cecilia Covenas, Valerie Civelli, Arianna Lundquist, and Robert Dunn. Audio edition: Suraj Amrutia. See you next week! 

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References:

Nicolle LE, Gupta K, Bradley SF, Colgan R, DeMuri GP, Drekonja D, Eckert LO, Geerlings SE, Köves B, Hooton TM, Juthani-Mehta M, Knight SL, Saint S, Schaeffer AJ, Trautner B, Wullt B, Siemieniuk R. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110. doi: 10.1093/cid/ciy1121. PMID: 30895288. [https://pubmed.ncbi.nlm.nih.gov/30895288/]  

Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, Hakim JG, Kumwenda J, Grinsztejn B, Pilotto JH, Godbole SV, Mehendale S, Chariyalertsak S, Santos BR, Mayer KH, Hoffman IF, Eshleman SH, Piwowar-Manning E, Wang L, Makhema J, Mills LA, de Bruyn G, Sanne I, Eron J, Gallant J, Havlir D, Swindells S, Ribaudo H, Elharrar V, Burns D, Taha TE, Nielsen-Saines K, Celentano D, Essex M, Fleming TR; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493-505. doi: 10.1056/NEJMoa1105243. Epub 2011 Jul 18. PMID: 21767103; PMCID: PMC3200068. [https://www.nejm.org/doi/full/10.1056/nejmoa1105243] 

Rodger AJ, Cambiano V, Bruun T, et al. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA. 2016;316(2):171–181. doi:10.1001/jama.2016.5148. [https://jamanetwork.com/journals/jama/fullarticle/2533066] 

Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, Degen O, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. The Lancet. 2019; 393(10189): 2428-2438. Doi: 10.1016/S0140-6736(19)30418-0. [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30418-0/fulltext]

Episode 68: Prevention - Aspirin, STIs, and Diabetes. 

Updates on aspirin use for preeclampsia prevention, updated STIs screening guidelines, and new age to start screening for diabetes.  

Introduction:  COVID-19 Booster Shots.  

Every week there is a lot of information to cover about COVID-19. I’m sure you are aware of some of this information, but here you have it again for historical purposes. 

Pfizer and BioNtech announced on September 20, 2021, that their COVID-19 vaccine is protective in pediatric patients between 5 and 11 years of age. 

Let’s remember that this vaccine is being used for patients older than 12, but so far none of the vaccines have been authorized for younger patients. A submission to FDA has been sent, but no approval has been given yet.

Recently, we mentioned to you that a booster shot for the mRNA COVID-19 vaccines were likely to be authorized by the FDA around September 20. Indeed, an authorization for a booster was given on September 22, 2021. This authorization was given to the Pfizer/BioNtech vaccine only, and it can be given at least 6 months after the completion of the primary series.

The patients who are authorized to receive the booster shot are: Patients who are 65 years of age and older; patients between 18 and 64 years of age at high risk of severe COVID-19; and individuals 18 through 64 years of age with frequent occupational exposure to COVID-19.

The Moderna vaccine has not been authorized for a booster shot.

Let’s remember that both Pfizer and Moderna have been authorized for a third dose in patients who are immunocompromised. The third dose can be given 4 weeks after completing he initial 2 doses of these vaccines. Patient who may receive a third dose are those who are receiving active cancer treatment, recipients of an organ transplant, or have a moderate or severe immunodeficiency. 

Stay tuned for more updates in the future.

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. 

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Prevention - Aspirin, STIs and Diabetes
By Hector Arreaza, MD, and Valerie Civelli, MD

The USPSTF has been very active lately. They have released several recommendations in the last few months. 

Aspirin and preeclampsia: On September 28, 2021, the USPSTF released their recommendation about the use of aspirin to prevent preeclampsia in pregnant persons at high risk. This recommendation is consistent with the previous recommendation given in 2014. New evidence has reinforced that aspirin is effective at reducing risk of perinatal mortality when used properly.

The recommendation states: “The USPSTF recommends the use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia.” This is a grade B recommendation. A grade B recommendation means the net benefit of this preventive intervention is moderate to substantial.

Who is at risk for preeclampsia? You can classify the risk as High, Moderate, and Low.

High: Preeclampsia during previous pregnancies (especially if you had an adverse outcome), multifetal gestation, chronic hypertension, type 1 or 2 diabetes before pregnancy, kidney disease, autoimmune disease, or a combination of multiple moderate-risk factors. Recommend aspirin if a woman has 1 or more of those high-risk factors. 

Moderate: Nulliparity, obesity, history of preeclampsia in mother or sister, black persons, low income, age 35 years or older, personal history factors (e.g. low birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval, and in vitro conception. Recommend aspirin if patient has 2 or more of these moderate risk factors. You may recommend aspirin even to women with 1 of these risk factors. 

Low: Do not recommend aspirin to pregnant women who have low risk for preeclampsia. A patient is considered low risk if she had a previous uncomplicated term delivery and has none of the risk factors mentioned above.

As a side note, given the current movement for diversity, equality and inclusion, the article also states that “black persons have higher rates of preeclampsia and are at increased risk for serious complications due to various societal and health inequities,”not due to biological propensities.

When do you stop aspirin in pregnancy?

The decision to continue aspirin in the presence of obstetric bleeding (or bleeding risk) should be considered on a case-by-case basis. You can decide to stop at 36 weeks or continue until delivery based on your clinical judgement or local protocol.

Bottom-line: Recommend low-dose aspirin to pregnant women who are at increased risk for preeclampsia after 12 weeks of gestation.

Chlamydia and gonorrhea screening: On September 14, 2021, the USPSTF recommended screening women younger than 24 years old who are sexually active for BOTH chlamydia and gonorrhea infection. Also, screen all women 25 years and older who are at increased risk.

Increased risk means: a previous or coexisting STI, history of incarceration, and any kind of sexual intercourse out of a mutually monogamous relationship (new partner, more than one partner, partner who has sex with other partners, partner with an STI, history of exchanging sex for money or drugs). 

The screening for GC/Chlamydia in women is a grade B recommendation.

In this recommendation, the term “women” refers to persons born with female genitalia and does not apply to persons who identify as women but have male genitalia. 

This recommendation also includes pregnant persons and adolescents.

The evidence is insufficient (Grade I) to assess the balance and benefits and harms of screening for chlamydia and gonorrhea in asymptomatic men. Remember, a grade I recommendation is not a recommendation for or against a preventive intervention. To make it easy to remember “I stands for I don’t know, more research is needed”.

Recommendations about the age to start screening or the frequency of screening is not given explicitly, but the population with the highest incidence is women between 15-24 years old. Use your clinical judgement to determine when to start and how often.

Prediabetes and diabetes screening: On August 24, 2021, the USPSTF updated their recommendation for prediabetes and diabetes screening.

The recommendations states: “The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity (BMI above 25). Clinicians should offer or refer patients with prediabetes to effective preventive interventions. This is a Grade B recommendation.

The age to start screening is now 35 years old (instead of the previous recommended age of 40). This is an update from the recommendation given in 2015.

We should consider screening at a younger age in:

Persons from groups with high incidence and prevalence. These groups are American Indian/Alaska Native, Asian American, Black, Hispanic/Latino, or Native Hawaiian/Pacific Islander persons. 

Persons with family history of diabetes, history of gestational diabetes, or a history of polycystic ovarian syndrome.

Screen Asian Americans with a BMI of 23 or greater after age 35.

How to screen for prediabetes and diabetes? You have three options: 

Fasting glucose (normal below 100, prediabetes below 125, diabetes above 126)

Hemoglobin A1C (normal Below 5.6, prediabetes below 6.4%, diabetes above 6.5%). Do not use point of care A1C for screening, use a venous sample instead.

Oral glucose tolerance test in the morning (fasting); measure glucose 2 hours after ingesting 75 g of oral glucose (normal below 140, prediabetes below 200, diabetes above 200). The diagnosis of prediabetes or type 2 diabetes should be confirmed with repeat testing before starting intervention.

Random glucose above 200 is highly suggestive of diabetes. 

     The diagnosis of diabetes should be confirmed before starting interventions.

Summary: Aspirin for preeclampsia prevention, screen for gonorrhea and chlamydia all women younger than 24, and screen for diabetes everyone older than 35 with overweight or obesity.

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HIV Series Part II: HIV Transmissibility
By Robert Dunn, MS3, Ross University School of Medicine.

People infected with HIV are often thought to be contagious even by touch; though the reality is transmission is primarily transmitted via sexual contact, bodily fluids, from mother to baby during pregnancy, shared needles, or accidental needle sticks in the medical workplace. And when it comes to sex, it is common that a person is afraid to engage in any sexual contact with a HIV positive person, even though the patient may have their infection controlled with medicine.

Per the CDC, the most common ways of contracting HIV are through sex without protection, shared needles, and perinatal transmission from mother to child.

Sexual transmission:

With anal sex, the receptive partner, or bottom, is at higher risk of contracting HIV because the rectal mucosa is thin, more prone to micro-abrasions and create an opportunity to contract HIV. The insertive partner, or top is also at risk of infection via the opening of the urethra, the foreskin of an uncircumcised penis, or any cuts, scratches or open sores on the penis. 

With vaginal sex, the woman can be infected via the mucus membranes that line the vagina and cervix. And the man can become infected from the vaginal fluid or blood that may carry HIV. 

Needlesticks:

Sharing needles is high risk for contracting HIV. If one person has HIV and uses a needle, the blood of that person is carried on the needle and can inject the virus directly into anyone else who uses that needle. This can occur if people are sharing injected drugs, medications, or even in a needle stick accident that may occur when treating patients in the hospital with HIV. 

Vertical transmission:

Perinatal transmission occurs when the mother infected with HIV passes the infection to her newborn. It is now recommended to test every pregnant woman for HIV and treat as needed. This can occur while the fetus is in the womb or upon delivery. It is recommended that the mother be placed on HIV medication immediately to reduce the risk of infecting the baby. 

These are ways how HIV is NOT transmitted: kissing on the cheeks, hugging, holding hands, sharing silverware, talking to someone, mosquitos, or sharing toilet.

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Now we conclude our episode number 68 “Prevention – Aspirin, STIs, and Diabetes.” Dr Arreaza and Dr Civelli explained the most recent updates by the USPSTF regarding use of aspirin to prevent preeclampsia, screening for gonorrhea and chlamydia in women, and screening for diabetes in patients older than 35. Robert continued with his HIV series and explained how HIV is mostly transmitted, a good reminder for all of us that the most common way of transmission continues to be sexual transmission. 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, Hasaney Sin, Valerie Civelli and Robert Dunn. Audio edition: Suraj Amrutia. See you next week! 

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References:

Erman, Michael, Pfizer/BioNTech say data show COVID-19 vaccine safe and protective in kids, Reuters, reuters.com, September 20, 2021. https://www.reuters.com/business/healthcare-pharmaceuticals/pfizerbiontech-say-data-show-covid-19-vaccine-safe-protective-kids-2021-09-20/, accessed on September 29, 2021.

Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication, United States Preventive Services Taskforce, September 28, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication.

Chlamydia and Gonorrhea: Screening, United States Preventive Services Taskforce, September 14, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening.

Prediabetes and Type 2 Diabetes: Screening, United States Preventive Services Taskforce, August 24, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes

Ways HIV can be Transmitted. CDC, April 21, 2021. https://www.cdc.gov/hiv/basics/hiv-transmission/ways-people-get-hiv.html. Accessed on September 21, 2021.