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.