Rio Bravo qWeek

Episode 173: Acute OsteomyelitisFuture Dr. Tran explains the pathophysiology of osteomyelitis and describes the presentation, diagnosis and management of acute osteomyelitis. Dr. Arreaza provides information about Written by Di Tran, MSIII, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is osteomyelitis?Osteomyelitis, in simple terms, is an infectious disease that affects both bone and bone marrow and is either acute or chronic. According to archaeological findings of animal fossils with a bone infection, osteomyelitis was more than likely to be known as a “disease for old individuals”.Our ancestors over the years have used various vocabulary terms to describe this disease until a French surgeon, Dr. Nelaton, came up with the term “Osteomyelitis” in 1844. This is the beauty of medical terms, Latin sounds complicated for some people, but if you break up the term, it makes sense: Osteo = bone, myelo = marrow, itis = inflammation. So, inflammation of the bone marrow.Traditionally, osteomyelitis develops from 3 different sources:First category is the “hematOgenous” spread of the infection within the bloodstream, as in bacteremia. It is more frequent in children and long bones are usually affected. [Arreaza: it means that the infection started somewhere else but it got “planted” in the bones]Second route is “direct inoculation” of bacteria from the contiguous site of infection “without vascular insufficiency”, or trauma, which may occur secondary to fractures or surgery in adults. In elderly patients, the infection may be related to decubitus ulcers and joint replacements.And the third route is the “contiguous” infection “with vascular insufficiency”, most seen in a patient with a diabetic foot infection.Patients with vascular insufficiency often have compromised blood supply to the lower extremities, and poor circulation impairs healing. In these situations, infection often occurs in small bones of the feet with minimal to no pain due to neuropathy.They can have ulcers, as well as paronychia, cellulitis, or puncture wounds.Thus, the importance of treating onychomycosis in diabetes because the fungus does not cause a lot of problems by itself, but it can cause breaks in the nails that can be a port of entry for bacteria to cause severe infections. Neuropathy is an important risk factor because of the loss of protective sensation. Frequently, patients may step on a foreign object and not feel it until there is swelling, purulent discharge, and redness, and they come to you because it “does not look good.”Acute osteomyelitis often takes place within 2 weeks of onset of the disease, and the main histopathological findings are microorganisms, congested blood vessels, and polymorphonuclear leukocytes, or neutrophilic infiltrates.What are the bugs that cause osteomyelitis?Pathogens in osteomyelitis are heavily depended on the patient’s age. Staph. aureus is the most common culprit of acute hematogenous osteomyelitis in children and adults. Then comes Group A Strep., Strep. pneumoniae, Pseudomonas, Kingella, and methicillin-resistant Staph. aureus. In newborns, we have Group B Streptococcal. Less common pathogens are associated with certain clinical presentations, including Aspergillus, Mycobacterium tuberculosis, and Candida in the immunocompromised.Salmonella species can be found in patients with sickle cell disease, Bartonella species in patients with HIV infection, and Pasteurella or Eikenella species from human or animal bites.It is important to gather a complete medical history of the patient, such as disorders that may put them at risk of osteomyelitis, such as diabetes, malnutrition, smoking, peripheral or coronary artery disease, immune deficiencies, IV drug use, prosthetic joints, cancer, and even sickle cell anemia. Those pieces of information can guide your assessment and plan.What is the presentation of osteomyelitis?Acute osteomyelitis may present symptoms over a few days from onset of infection but usually is within a 2-week window period. Adults will develop local symptoms of erythema, swelling, warmth, and dull pain at the site of infection with or without systemic symptoms of fever or chills.Children will also be present with lethargy or irritability in addition to the symptoms already mentioned.It may be challenging to diagnose osteomyelitis at the early stages of infection, but you must have a high level of suspicion in patients with high risks. A thorough physical examination sometimes will show other significant findings of soft tissue infection, bony tenderness, joint effusion, decre

Episode 172: NAFLD and ObesityFuture Dr. Nguyen explains the pathophysiology of non-alcoholic fatty liver disease and how it relates to obesity. Dr. Arreaza gives information about screening and diagnosis of NAFLD. Written by Ryan Nguyen, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction/PathophysiologyNonalcoholic fatty liver disease (NAFLD) refers to the buildup of excess fat in liver cells, occurring without the influence of alcohol or drugs. Nonalcoholic steatohepatitis (NASH) represents a more severe form of NAFLD, characterized by inflammation and liver cell injury due to fat accumulation. If left untreated, NASH can progress to liver fibrosis or cirrhosis. Typically, NAFLD/NASH is diagnosed after other liver conditions are ruled out, making it a diagnosis of exclusion.NAFLD -> NASH -> Cirrhosis -> Liver failure. Another term for NAFLD is metabolic dysfunction-associated steatotic liver disease. Fatty liver disease is identified when more than 5% of liver weight consists of fat, whereas, NASH is diagnosed when this fat accumulation is accompanied by inflammation and liver cell injury, sometimes leading to fibrosis. Understanding these distinctions is crucial in recognizing and managing the spectrum of liver conditions associated with obesity and metabolic syndrome.BMI serves as a tool to gauge body fat levels: individuals are categorized as normal weight if their BMI falls between 18.5 and 24.9, overweight if it ranges from 25 to 29.9. Class I obesity is diagnosed with a BMI of 30 to 34.9, class II obesity between 35 and 39.9, and class III obesity when BMI exceeds 40.Obesity puts you at risk of NAFLD, but you can also see NAFLD in non-obese patients, but the prevalence is very low, about 5%. What did you learn about the demographics of NAFLD?NAFLD is most widespread in regions like South Asia, the Middle East, Mexico, Central and South America, with prevalence rates exceeding 30%. In the United States, prevalence varies with approximately 23-27%, notably higher among Asians at 30%, followed by Hispanic individuals at 21%, White individuals at 12.5%, and Black individuals at 11.6%. Across all racial groups, obesity plays a significant role, affecting more than two-thirds of individuals diagnosed with NAFLD. Understanding these demographics underscores the global impact of obesity on NAFLD prevalence.Diagnosis: Screening/Labs/Imaging/ToolsThe American Association for the Study of Liver Diseases does not recommend screening for NAFLD, but if it is discovered an appropriate workup is warranted. AST/ALT RatioLiver health can be assessed by a series of tests aimed at assessing fat accumulation, inflammation, and fibrosis. Initial screening often includes laboratory tests such as measuring the ratio between aspartate transaminase (AST) and alanine transaminase (ALT), where a ratio less than 1 may suggest possible NAFLD, although it is not diagnostic on its own. Normally, AST is slightly more elevated than ALT. So, if the AST/ALT ratio is lower, then means that ALT is higher than AST. FibroSure®.Additionally, you can measure indirect markers of fibrosis with tests such as FibroSure or FibroTest blood tests that combine several biomarkers including age, sex, gamma-glutamyl-transferase (GGT), total bilirubin, alpha-2-macroglobulin, apolipoprotein A1, haptoglobin, and ALT to provide insights into liver health.Some people may be more familiar with FibroSure before Hepatitis C treatment. You can get a fibrosis score (F0-F4), and it is considered significant fibrosis if the score is > or equal to F2. Imaging plays a crucial role in diagnosing NAFLD without the need for invasive procedures like liver biopsy. Vibration-controlled transient elastography (Fibroscan) uses ultrasound to measure liver stiffness, indicating potential fibrosis and inflammation. While noninvasive and portable, it focuses solely on liver ultrasound and may not be universally accessible. MRI with proton density fat fraction (MRI-PDFF) offers a comprehensive assessment of liver fat content, commonly used in clinical and research settings for NAFLD and NASH evaluation.For evaluating hepatic fibrosis in patients with suspected NAFLD, tools like the Fibrosis-4 Index (FIB-4) incorporate age, AST, ALT, and platelet count to estimate the likelihood of liver disease progression. These screening methods collectively aid in diagnosing and monitoring NAFLD, particularly in individuals at risk due to factors like prediabetes, type 2 diabetes, obesity, and abnormal liver enzyme ratios. With the FIB-4 you can get a faster answer than FibroSure b

Episode 171: Postpartum Blues, Depression, and PsychosisFuture Dr. Nguyen defines and explains the difference between baby blues, depression, and psychosis. Dr. Arreaza added comments about screening and management of these conditions. Written by Vy Nguyen, OMSIII, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.Pregnancy is one of the most well-celebrated milestones in one’s life. However, once the baby is born, the focus of the family and society quickly shifts to the new member. It is important to continue to care for our mothers and offer them support physically and mentally as they begin their transition into their role. Peripartum mood disorders affect both new and experienced mothers as they navigate through the challenges of motherhood. The challenges of motherhood are not easy to spot, and they include sleep deprivation, physical exhaustion, dealing with pain, social isolation, and financial pressures, among other challenges. Let’s focus on 3 aspects of the postpartum period: Postpartum Blues (PPB), Post-partum Depression (PPD) and Post-partum Psychosis (PPP). By the way, we briefly touched on this topic in episode 20, a long time ago. Postpartum blues (PPB) present as transient and self-limiting low mood and mild depressive symptoms that affect more than 50% of women within two or three days of childbirth and resolve within two weeks of onset. Symptoms vary from crying, exhaustion, irritability, anxiety, appetite changes, and decreased sleep or concentration to mood lability. Women are at risk for PPB.Several factors are thought to contribute to the increased risk of postpartum blues including a history of menstrual cycle-related mood changes, mood changes associated with pregnancy, history of major depression, number of lifetime pregnancies, or family history of postpartum depression. Pathogenesis of PPB: While pathogenesis remains unknown, hormonal changes such as a dramatic decrease in estradiol, progesterone, and prolactin have been associated with the development of postpartum blues. In summary, PPB is equivalent to a brief, transient “sad feeling” after the delivery. Peripartum depression (PPD) occurs in 20% of women and is classified as depressive symptoms that appear within six weeks to 1 year after childbirth. Those with baby blues have an increased risk of developing postpartum depression. About 50% of “postpartum” major depressive episodes begin before delivery, thus the term has been updated from “postpartum” to “peripartum” depressive episodes. Some risk factors include adolescent patients, mothers who deliver premature infants, and women living in urban areas. Interestingly, African American and Hispanic mothers are reported to have onset of symptoms within two weeks of delivery instead of six like their Caucasian counterparts. Additional risks include psychological risks such as a personal history of depression, anxiety, premenstrual syndrome, and sexual abuse; obstetric risks such as emergency c-sections and hospitalizations, preterm or low birth infant, and low hemoglobin; social risks such as lack of social support, domestic violence in form of spousal physical/sexual/verbal abuse; lifestyle risks such as smoking, eating sleep patterns and physical activities. Peripartum depression can present with or without psychotic features, which may appear between 1 in 500 or 1 in 1,000 deliveries, more common in primiparous women. Pathogenesis of PPD: Much like postpartum blues, the pathogenesis of postpartum depression is unknown. However, it is known that hormones can interfere with the hypothalamic-pituitary-adrenal axis (HPA) and lactogenic hormones. HPA-releasing hormones increase during pregnancy and remain elevated up to 12 weeks postpartum. The body receptors in postpartum depression are susceptible to the drastic hormonal changes following childbirth which can trigger depressive symptoms. Low levels of oxytocin and prolactin also play a role in postpartum depression causing moms to have trouble with lactation around the onset of symptoms. The USPSTF recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. Edinburgh Postnatal Depression Scale (EPDS) can be used in postpartum and pregnant persons (Grade B recommendation).Postpartum psychosis (PPP) is a psychiatric emergency that often presents with confusion, paranoia, delusions, disorganized thoughts, and hallucinations. Around 1-2 out of 1,000 new moms experience postpartum psychosis with the onset of

Episode 170: Schizophrenia: An OverviewFuture Dr. Chng explains the diagnostic criteria and describes how to treat schizophrenia. Dr. Arreaza mentions additional risk factors and social aspects of schizophrenia. Written by Tiffanny Chng, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Schizophrenia may be an intriguing disease for many, even for health care providers. Schizophrenia is frequently misunderstood and stigmatized. Receiving a diagnosis of schizophrenia can be life-altering and cause significant distress in patients and their families, but it can also impact their work, relationships, and even their communities.Epidemiology of schizophrenia: Schizophrenia has a prevalence of about 1% worldwide, and a prevalence of about 0.6% in the US. Although the distribution between males and females is comparable, males will typically present with their first episode, sometimes known as a “psychotic break” in the early 20’s as opposed to women who may present in their late 20s or early 30s. Despite having a low prevalence, the NIH lists schizophrenia as one of the top 15 leading causes of disability and disease burden in the world. In 2019 the economic burden of schizophrenia in the US was $343 billion. For comparison, in 2019, diabetes had an economic burden of $760 billion in the US, however, the prevalence of diabetes that year was 11.6%, more than 10 times that of schizophrenia. Patients who are diagnosed with schizophrenia are also at increased risk of a multitude of co-occurring medical conditions: alcohol and substance abuse disorders, mood disorders, and metabolic disturbances (diabetes, hyperlipidemia, and obesity, which may be exacerbated with the use of antipsychotics). These patients have a two-to-four-fold increased risk of premature mortality with an estimated potential life loss of ~28.5 years. Of note, 4-10% of patients with schizophrenia die secondary to suicide.Pathogenesis:The exact pathogenesis of schizophrenia is unknown, but we do know that it is a combination of genetic, neurological, and environmental factors. Genetics: Twin studies conducted in mono and dizygotic twins have shown that schizophrenia is highly inheritable (~80%). Although there are no specific genes that directly cause the disease state, genome-wide association studies have shown polygenic additive effects of 108 single nucleotide polymorphisms. This includes genes involved in the dopaminergic and glutamate pathways, which are the basis of antipsychotic medications. Epigenetics: Studies have also shown that epigenetics is a potential factor that plays into the risk of developing schizophrenia. Having a history of obstetric complications, for example, has an almost two-fold increased risk of schizophrenia in the child during early adulthood. Such complications include maternal infections, preterm labor, and fetal hypoxia. Certain infections and pro-inflammatory disease states, such as Celiac and Graves’ disease have also been associated with schizophrenia. The suggested pathophysiology is thought to involve pro-inflammatory cytokines crossing the blood-brain barrier inducing or exacerbating psychosis or cognitive impairment. Trauma: As in many other psychiatric conditions, childhood trauma or severe childhood adversities, especially emotional neglect, have also been shown to increase the risk of schizophrenia later in life.Cannabis and Immigration: So, you mentioned the role of genetics, epigenetics, and inflammation. I’d like to mention the use of cannabis as a risk factor for developing psychosis as well, more specifically the THC component of cannabis. Something to keep in mind during these times when cannabis is being studied in more detail. Also, this is interesting: immigration puts you at risk for schizophrenia, and the risk can be as high as four-fold, depending on the study. Some explanations for this are increased discrimination, stress, and even low vitamin D. Tiffany, how do we diagnose schizophrenia?DSM-5 Diagnostic Criteria: The DSM-5 identifies 5 diagnostic criteria for schizophrenia: Patient must have two or more active phase symptoms for one month or longer: (1) Delusions, (2) Hallucinations (auditory, visual, or tactile) (3) Disorganized speech, (4) Negative symptoms (flat affect, avolition, social withdrawal, anhedonia), or (5) Catatonic behavior (which can be a collection of abnormal physical movements, the lack of movement or resistance to movement, psychomotor agitation). For the first criterion to be met, the patient must have delusions, hallucinations, or disorganized speech as one of their two p

Episode 169: Food insecurity and Obesity in Kern CountyFuture Dr. Kim presents the problem of food insecurity in Kern County and how it is linked to obesity and liver disease. She shared several resources available to address food insecurity. Dr. Arreaza reminds us of the importance of improving access to fresh and healthy foods. Written by Judy Kim, OMS3; Mira Patel, OMS3; and Vy Nguyen, OMS3. Western University of Health Sciences. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: Why did you pick this topic?Judy: While Kern County is known as one of the top-producing agricultural counties in the country, food insecurity is a major health disparity within this county. In order to dissect the problem of food insecurity in Kern County, we must first discuss the demographics and significance of this current topic. Among residents of Kern County, 23.1% are at or below 100% of the federal poverty level (FPL) and 47.7% are low-income (200% of FPL or below), which is higher than that of California. Arreaza: What is food insecurity? In February 2023, we discussed the definition in Episode 128, but it is important to remember what it is. “Food insecurity is having limited, uncertain, or inconsistent access to the food necessary for a healthy life.” Another interesting fact is that it is estimated that 45% of undocumented immigrants in California are affected by food insecurity, including 64% of undocumented children (Source: 2021 CHIS).Judy: Food insecurity is strongly tied to numerous conditions such as hypertension, coronary artery disease, diabetes, hepatitis, stroke, cancer, asthma, arthritis, chronic obstructive pulmonary disease, and kidney disease. Thus, this problem must be explored and discussed to find ways to improve health outcomes. However, the first steps must focus on bridging gaps in accessing healthy and affordable foods. For example, consumers have consistently noted that reliable transportation is a barrier when even applying for assistance before accessing their benefits. Oftentimes, families experiencing poverty, a large number of residents in Kern County, are part of the migrant community, move frequently, and experience difficulties even completing the necessary paperwork for programs such as the Migrant Childcare Alternative Payment program. Arreaza: It may be off-topic, but I had to search what MCAP is. The Migrant Childcare Alternative Payment (MCAP) Program provides childcare services to migrant farm worker families in Kern and other counties in California, such as Merced and Fresno. MCAP allows parents to work while children are taken care of by licensed childcare centers, licensed family childcare homes, license-exempt (relatives), and in-home providers. I think many families may not be aware of this program. This is a reminder for our residents and students that this is available for your patients. Judy: Going back to food insecurity, when looking at the distribution and locations of large supermarkets in the greater Bakersfield area, such as Albertsons, Smart & Final, and Vallarta, the northwest area has many large stores and without a high density of households in poverty. In contrast, Oildale, the southwest and southeast areas do not have many large markets nearby. Thus, it is also important to examine how and where our patients can access healthy and affordable food.Obesity and Fatty Liver Disease in Kern County.Judy: I would like to describe the relationship between food insecurity with liver disease. The food insecurity that is prevalent in Kern County contributes to the increasing number of overweight and obese populations we see here. Almost 78% of adults in Kern County are considered either overweight or obese. This is concerning because increased rates of obesity are correlated with higher rates of liver disease. As we know, the liver is responsible for breaking down fats, creating new small and medium-chain fatty acids, and transporting fats. With obesity, fat tends to accumulate in the liver since it is unable to properly break down the fat. This leads to steatosis. Short-term fatty liver disease does not have many clinical findings associated with it, but long term if left uncontrolled it can lead to cirrhosis and death. Arreaza: According to a review of the liver transplant list done in 2022, Non-alcoholic steatohepatitis (NASH) is currently the second leading cause of liver transplant overall, and in females, it is the number-one cause. In California, we see about 13.8 deaths per 100,000 persons from liver-related disease, but Kern County has a high 15.9 deaths per 100,000 persons, which exce

Episode 168: UTI in MalesFuture Dr. Tran gives a summary of UTIs in Males, including epididymitis, orchitis, urethritis, prostatitis, and pyelonephritis. Diagnosis and treatment were briefly described and some differences with female patients were mentioned by Dr. Arreaza. Written by Di Tran, MS-3, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.WHAT ARE URINARY TRACT INFECTIONS?Urinary Tract Infection (UTI) is an infection of any part of the urinary tract system. It may involve any part of the renal system, the kidneys, the ureters, the bladder, the prostate, and the urethra. Different from men, a woman may get a UTI more easily due to their anatomical difference. A woman’s urethra is shorter and lies close in proximity to both the vagina and the anus, which allows easy access for bacteria to travel up to the bladder.UTI is further subdivided into two different categories, depending on where the infection takes place within the urinary tract:Lower Tract Infection – cystitis and urethritis when the infection occurs on the bladder and the urethra, respectively. Common infections are a result of bacteria migrating from the skin (and also from sexual organs) to the urethra and ending up in the bladder.In males, other forms of lower tract infection can result in prostatitis, epididymitis, and orchitis.Upper Tract Infection - aka pyelonephritis, is a more concerning infection that involves the upper parts of the urinary system, in other words, the ureters, and kidneys.AGE DIFFERENCES IN UTI FOR MEN:For men, the incidence of UTI increases with age. Dr. John Brusch reports UTI rarely develops in young males and the prevalence of bacteriuria is 0.1% or less. Men who are 15-50 years of age often have urethritis due to sexually transmitted infection (STI), mainly by Neisseria gonorrhoeae and Chlamydia trachomatis. Symptoms include frequency, urgency, and dysuria (most common).Men who are 50 years or older, especially those with prostatic hyperplasia, will have signs and symptoms of incomplete bladder emptying, hesitancy, slow stream, difficulty initiating urination, and dribbling after urinating. Due to the enlargement of the prostate gland, there will be partial blockage of urine flow from the bladder, which in turn, creates a reservoir where bacteria can grow and cause an infection. The most common offending microorganism for this age group is Escherichia coli.Interestingly, while UTIs are rare among men under 60, by the age of 80, both women and men have similar incidence rates. The bladder tends to have a higher residual volume in older males because the prostate grows no matter what, it´s just a part of aging for males. Some may end up with more or less lower urinary tract symptoms, but the prostate is enlarged in general.Other risk factors for UTI in males are men who are not circumcised, urethral strictures, fistulas, hydronephrosis (or dilated ureters overfilled with urine due to failure of drainage to the bladder), and the use of urinary catheters. DIFFERENT TYPES OF UTIs IN MALES:EPIDIDYMITIS:The infection starts from the retrograde ascending route from the prostatic urethra, backing up to the vas deferens, and eventually ending in the epididymis.In men who are younger than 35 years of age, the usual pathogens are C. trachomatis and N. gonorrhoeae (sexually transmitted).In men who are older than 35 years of age, the usual offending agents are Enterobacteriaceae and gram-positive cocci (E. coli as mentioned previously).ORCHITIS:This unique UTI is caused by viral pathogens, such as mumps, coxsackie B, Epstein-Barr (EBV), and varicella (VZV) viruses. Several studies have shown that patients having orchitis have a history of epididymitis. Fortunately, this infection is uncommon, and it was the main reason to develop the MMR vaccine. It is caused by viruses other than mumps, so you can still have orchitis even if you are vaccinated. Antibiotics are not prescribed for viral orchitis.BACTERIAL CYSTITIS:Having a similar pathophysiology of ascending infection mechanism, male patients in this category often present frequency, urgency, dysuria, nocturia, and suprapubic pain. On a side note, having hematuria is concerning, especially without symptoms, because it’s automatically a red flag that should prompt an immediate evaluation in search of other causes besides infection, such as underlying malignancy. Possible etiologies are calculi, glomerulonephritis, and even schistosomiasis infection that can ultimately result in squamous cell carcinoma of the bladder. Arreaza: Let me share a little anecdote about hematu

Episode 167: Aspirin in PregnancyDr. Marquez explains the use of aspirin during pregnancy to prevent preeclampsia. Dr. Arreaza adds comments and questions and clarifies that aspirin is not used for the treatment of preeclampsia.Written by Verna Marquez, MD, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction to the topic: Pregnancy is a special time in a woman’s life, and we want to make sure that both the mother and the baby are safe and healthy. 1. What is aspirin? Aspirin is one of the most ancient medications in history, it is known as acetyl-salicylic acid (ASA) and it belongs to the family of non-steroidal anti-inflammatory drugs (NSAID), and it is also an anti-platelet, among other properties that may be unknown. It is widely used for pain, fever, and inflammation, but due to adverse effects during viral illness (i.e. Reye Syndrome), it is used less frequently during viral infections. As we know, aspirin is widely used to treat myocardial infarction and ischemic stroke, and especially for secondary prevention. The use of aspirin for primary prevention of cardiovascular disease has become less popular, but we are going to leave that discussion for another episode because today we will talk about the use of aspirin in pregnancy!2. Why should we use aspirin in pregnancy?Low-dose aspirin in pregnancy is most commonly used to prevent or delay the onset of preeclampsia. Aspirin lowers the risk of preeclampsia by 10% and its consequences (such as growth restriction and preterm birth). Several organizations have agreed on the risk factors we will mention briefly. These organizations are ACOG (American College of Obstetricians and Gynecologists), USPSTF (US Preventive Services Task Force), and SMFM (Society for Maternal-Fetal Medicine).3. Who should we start on aspirin in pregnancy? Aspirin is not for every pregnant patient, for example, a healthy nulliparous or any patient who had an uneventful, full-term delivery previously, is considered low risk and should NOT be started on aspirin because there is no benefit in preventing any condition. Low-dose aspirin is recommended for women who have at least a high-risk factor because the incidence of preeclampsia is about 8% in these patients. The risk factors are:•Previous pregnancy with preeclampsia (especially early onset and with an adverse outcome)•Type 1 or 2 diabetes mellitus.•Chronic hypertension.•Multifetal gestation.•Kidney disease.•Autoimmune disease with potential vascular complications (antiphospholipid syndrome, systemic lupus erythematosus).Your patient only needs 1 high-risk factor to be put on aspirin in pregnancy. 4. What are the moderate risk factors?A patient needs to have more than 1 moderate risk factor to meet the criteria for prenatal aspirin.•Nulliparity.•Obesity (BMI >30).•Family history of preeclampsia in mother or sister.•Age ≥35 years.•Sociodemographic characteristics (Black persons, lower income level [recognizing that these are not biological factors]).•Personal risk factors (for example, previous pregnancy with low birth weight or small for gestational age newborn, previous adverse pregnancy outcome [such as stillbirth], interval >10 years between pregnancies). However, low-dose ASA prophylaxis is not recommended solely for the indication of prior unexplained stillbirth in the absence of risk factor for preeclampsia.•In vitro conception.USPSTF/ACOG may also suggest aspirin in selected patients with only one moderate risk factor, but it would require consultation with a specialist in obstetrics. 5. When should we start aspirin?After 12 weeks of gestation, ideally before 16-20 weeks of gestation. If a patient is more than 16 weeks pregnant, aspirin can be started but most of the benefit has been noted when initiated before 16 weeks because many of the abnormalities that cause preeclampsia are developed early in pregnancy. It is not recommended to start before 11 weeks.It is important to mention also that low-dose aspirin appears to have little or no benefit in patients who already have developed preeclampsia. Starting aspirin in preeclampsia can even cause damage such as bleeding in cases of thrombocytopenia. 6. What is the dose?The dose is between 75 to 162 mg daily. Conveniently, we have an 81 mg presentation in the United States, and it falls within the recommended range. It can be taken in the morning or at night, and adherence of >90% is associated with better prevention.7. When do we stop aspirin?Expert opinion recommends stopping aspirin at the time of delivery. 8. What are the contraindications to ASA use during pregnancy?Absolute contraindications to aspirin: -Patien

Episode 166: Naturopathic Medicine InsightsFuture Dr. Luong talked about what she learned about naturopathic doctors (NDs). She discussed the principles of naturopathic medicine and mentioned some differences in regulations across states in the US. Dr. Arreaza shared his opinion about the pros and cons of naturopathic medicine. Written by Teresa Luong, MSIV, American University of the Caribbean. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: This may be a controversial topic. The term “natural” in medicine triggers strong reactions among allopathic doctors like me. Today we have a medical student who took up the challenge to talk about Naturopathic Doctors. Teresa:I am providing information based on research and living in Washington state, which is considered one of the birthplaces of modern naturopathic medicine, boasts the highest population of naturopathic doctors and a wide range of practice specialties. It's important to note that my responses are not personal opinions but rather informed insights. There are about 8,500 licensed naturopathic doctors in North America. Naturopathic Doctors may not use the title of physicians in California. What is a Naturopathic Doctor?While it’s true that in California naturopathic doctors are not legally permitted to use the term ”physician” to describe themselves, some still choose to refer to themselves as “naturopathic physicians” colloquially or in their practice branding. So, confusion can arise because naturopathic doctors, while legally not recognized as physicians in California, can function as primary care providers, this overlap in roles can lead to the informal use of terms like ”naturopathic physician.“ However, it’s important to recognize that legally, they are not recognized as physicians in this state. Naturopathic doctors (NDs) are healthcare professionals who embrace a holistic approach to healing, focusing on natural and non-invasive therapies to support the body's inherent ability to heal itself. Naturopathic medicine has its roots in traditional healing practices from around the world, blending ancient wisdom with modern scientific knowledge. The philosophy of naturopathy emphasizes the importance of treating the whole person—mind, body, and spirit—rather than just addressing isolated symptoms or diseases.What is an allopathic approach vs a holistic approach?Allopathic medicine: Allopathic medicine focuses on diagnosing and treating specific symptoms or diseases using pharmaceutical drugs, surgery, and other conventional interventions. Treatment is often targeted at managing symptoms or eradicating pathogens.Holistic medicine: Holistic medicine takes a broader approach, considering the whole person and aiming to address the root causes of illnesses. Treatment may involve a combination of conventional therapies and alternative modalities such as nutrition, herbal medicine, acupuncture, and lifestyle modifications. The focus is on promoting overall health and well-being rather than just treating isolated symptoms.Core Principles Naturopathic Practitioners: The six core principles of naturopathic medicine serve as guiding tenets for both diagnosis and treatment. These principles include: -first, do no harm. -the healing power of nature -identify and treat the root cause -treat the whole person, -the physician as a teacher; -and prevention as the best cure. Treatment modalities: Naturopathic doctors employ a wide range of therapeutic modalities to address the unique needs of each individual, such as:-Clinical nutrition, which focuses on using “food as medicine” to promote healing and prevent disease. -Herbal medicine utilizes the medicinal properties of plants to support various bodily systems and restore balance. -Acupuncture, everybody is familiar with acupuncture. -Other modalities may include hydrotherapy, homeopathy, physical medicine (such as massage and manipulation), and lifestyle counseling.The role of allopathic medications (NSAIDs, antibiotics) and surgical procedures.Naturopathic doctors typically prioritize natural therapies and lifestyle intervention, but may also integrate conventional medicine when necessary. Their views on traditional medications, such as NSAIDs, antibiotics, and surgical procedures vary depending on the individual practitioner and their approach to healthcare. Some may recommend them when appropriate, while others may prefer to explore alternative options first. Ultimately, their goal is often to promote holistic health and well-being. Education and Training: Pre-Medical Requirements: Aspiring naturopathic doctors typically complete unde

Episode 165: Early-Onset Sepsis Part 2Dr. Lovedip Kooner explains how to use the Kaiser Permanente early-onset sepsis calculator and explains other useful tools to assist in the diagnosis of EOS. Dr. Arreaza adds comments about the usefulness of this calculatorWritten by Lovedip Kooner, MD. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: As a recap, Early-onset sepsis is diagnosed within 72 hours (or within 7 days, according to some experts) after birth. We talked about GBS as the main culprit of EOS. 28% of EOS by GBS are babies born Using the Kaiser Permanente (KP) neonatal EOS calculator.Lovedip: It is a multivariate risk assessment tool that guides us in the management of neonatal early-onset sepsis. The Kaiser Permanente (KP) neonatal EOS calculator combines 2 predictive models. One model is based on risk factors known at birth and the other model is based on the newborn clinical condition during the early hours after birth. The risk factors are: gestational age, highest maternal antepartum temperature, maternal GBS status, duration of rupture of membranes, and antibiotics (type and duration). If that sounds familiar, it is. It’s mostly the same information used in the categorical risk assessment, except substituting maternal highest antepartum temperature for chorioamnionitis diagnosis. This information is input into the calculator and two values are obtained. The first value is the EOS risk at birth, the second value is the EOS risk after the clinical exam. The clinical exam is broken down into well-appearing, equivocal, and clinical illness.The well-appearing baby in general is described as alert and consolable, moving all extremities, good skin color no bruising, except possibly acrocyanosis, hungry and when put on mom’s breast will attempt to suckle, normal vital signs, good reflexes like Moro and grasp, tends to have flexed limbs, especially arms, regards faces but no tracking. In a previous episode, we mentioned that hypoglycemia is not a good indicator of EOS caused by GBS. Let’s talk about the criteria for a well-appearing baby in the Kaiser Permanente tool.Well-appearing for the purposes of the KP calculator means no persistent physiologic abnormalities. Equivocal means: “Tachy, Tachy, Temp, Resp”Persistent physiologic abnormality > 4 hrsTwo or more physiologic abnormalities lasting for > 2 hrsNote: abnormality can be intermittent.An ill newborn, in general, is described as having abnormal vital signs, either hyper or hypothermia, tachycardia, bradycardia or arrhythmia, flaccid, doesn’t regard faces, no or muted reflexes and poor suck, mottled color, cyanosis or bruising, petechiae, retractions, nasal flair or poor nasal breathing (with choanal atresia, pinks up only when crying), gasping respirations, poor bowel sounds, possibly distended OR scaphoid (with atresias will have scaphoid abdomen and with anomalies like TEF depending on type, emesis or difficulty breathing when fed) obvious congenital anomalies, etc.Clinical Illness in the Kaiser Permanentetool is defined as:Persistent need for Nasal CPAP / High flow nasal cannula / mechanical ventilation (outside of the delivery room)Hemodynamic instability requiring vasoactive medicationsNeonatal encephalopathy/Perinatal depression: Seizure, Apgar Score @ 5 minutes Need for supplemental O2 > 2 hours to maintain oxygen saturations > 90% (outside of the delivery room)After all that information is entered into the Kaiser Permanente calculator, the options for management are clinical monitoring, laboratory evaluation, or antibiotic administration. Example: -Incidence: 0.5/1,000 live births -Gestational age: 36 6/7 weeks-Highest maternal antepartum temperature: 102 F-ROM: 5 hours-Maternal GBS: Positive-Intrapartum antibiotics: Broad spectrum 3 hours prior to birth-RESULT: EOS risk at birth 2.34.Recommendations based on physical exam:1. Well-appearing baby, risk 0.96, RECOMMENDATIONS: No culture, no antibiotics, vitals every 4 hours for 24 hours.2. Equivocal, risk 11.61, RECOMMENDATIONS: Start empiric antibiotics and vitals per NICU.3. Clinical Illness, risk 47.46, RECOMMENDATIONS: Start empiric antibiotics and vitals per NICU.The Kaiser Permanente neonatal early-onset sepsis calculator was analyzed in a meta-analysis, as published in the American Family Physician in 2021. Six high-quality, non-randomized controlled trials were evaluated, including more than 170,000 neonates. The calculator was compared to the standard approach recommended by the CDC guidelines. The analysis showed there was a statistically significant reduction in antibiotic use, a reduction in th

Episode 164: More Than Just A HeadacheDr. Song presents a case of a subacute headache that required an extensive workup and multiple visits to the hospital and clinic to get a diagnosis. Dr. Arreaza added comments about common causes of subacute headaches. Written by Zheng (David) Song, MD. Editing and comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction to the episode: We are happy to announce the class of 2027 of the Rio Bravo / Clinica Sierra Vista Family Medicine Residency Program. Our new group will be (in alphabetical order): Ahamed El Azzih Mohamad, Basiru Omisore, Kenechukwu Nweke, Mariano Rubio, Nariman Almnini, Patrick De Luna, Sheila Toro, and Syed Hasan. We welcome all of you. We hope you can enjoy 3 enriching and fulfilling years. During this episode, you will hear a conversation between Dr. Arreaza and Dr. Song. Some elements of the case have been modified or omitted to protect the patient’s confidentiality. 1. Introduction to the case: Headache. A 40-year-old male with no significant PMH presents to the ED in a local hospital due to over a month history of headaches. Per the patient, headaches usually start from the bilateral temporal side as a tingling sensation, and it goes to the frontal part of the head and then moves up to the top of the head. 8 out of 10 severities were the worst. Pt reports sometimes hypersensitivity to outdoor sunlight but not indoor light. OTC ibuprofen was helpful for the headache, but the headache always came back after a few hours. The patient states that if he gets up too quickly, he feels slightly dizzy sometimes, but it is only for a short period of time. There was only one episode of double vision lasting a few seconds about 2 weeks ago but otherwise, the patient denies any other neurological symptom. He does not know the cause of the headache and denies any similar history of headaches in the past. The patient denies any vomiting, chest pain, shortness of breath, cough, abdominal pain, or joint pain. The patient further denies any recent traveling or sick contact. He does not take any chronic medication. The patient denies any previous surgical history. He does not smoke, drink, or use illicit drugs. What are your differential diagnoses at this moment? Primary care: Tension headache, migraines, chronic sinusitis, and more.2. Continuation of the case: Fever and immigrant.Upon further inquiries, the patient endorses frequent “low-grade fever” but he did not check his temperature. He denies any significant fatigue, night sweats, or weight loss. He migrated from Bolivia to the U.S. 12 years ago and has been working as a farm worker in California for the past 10 years. He is married. His wife and daughter are at home in Bolivia. He is currently living with friends. He is not sexually active at this moment and denies having any sexual partners. Differential diagnoses at this moment? Tension headache, migraine, infections, autoimmune disease, neurocysticercosis. 3. Continuation of the case: Antibiotics and eosinophilia. As we kept asking for more information, the patient remembered he visited a clinic about four months ago for a dry cough and was told he had bronchitis and was given antibiotics and the cough got better after that. He went to another local hospital ED one month after that because the cough came back, now with occasional phlegm and at that time he also noticed two “bumps” on his face but nothing significant. After a CXR at the ED, the patient was diagnosed with community-acquired pneumonia and sent home with cough medication and another course of antibiotics. His cough improved after the second round of antibiotics. We later found on the medical record that the CXR showed “mild coarse perihilar interstitial infiltrates of unknown acuity”. His blood works at the ED showed WBC 15.2, with lymphocyte 21.2%, monocyte 10.1%, neutrophil 61.7%, eosinophil 5.9% (normally 1-4%), normal kidney, liver functions, and electrolytes, and prescribed with benzonatate 100mg TID and doxycycline 100mg bid for 10 days. He went to the same ED one month before he saw us for headache and fever (we reviewed his EMR, and temp was 99.8F at the ED). After normal CBC, CMP and chest x-ray. The patient was diagnosed with a viral illness and discharged home with ibuprofen 400mg q8h.Due to the ongoing symptoms of headache and fever, the patient went back to the same clinic he went to four months ago for a dry cough and requested a complete physical and blood work. The patient was told he had a viral condition and was sent home with oseltamivir (Tamiflu®) for five days. However, the provider did order some blood work

Episode 163: Vascular Dementia Future Dr. Ruby explains gives a definition of vascular dementia and concisely explains the pathophysiology and presentation of this disease. Dr. Arreaza reminds us of the importance of treating diabetes to prevent dementia. Written by Carmen Ruby, MSIV, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is vascular dementia?Vascular dementia is a condition that arises due to damage to blood vessels that reduce or block blood flow to the brain. A stroke can block an artery and result in various symptoms, such as changes in memory, thinking, or movement. Other conditions like high blood pressure or diabetes can also damage blood vessels and lead to memory or thinking problems over time.Vascular dementia (VaD) is a type of dementia that slowly worsens cognitive functions and is thought to be caused by vascular disease within the brain. Patients with VaD often exhibit symptoms similar to Alzheimer's disease (AD) patients. However, the changes in the brain are not due to Alzheimer’s disease pathology (amyloid plaques and neurofibrillary tangles) but due to a chronic reduction in blood flow to the brain, eventually leading to dementia. Alzheimer’s disease pathophysiology is very complex, and studies have shown that patients with AD can experience simultaneously several vascular issues that can affect cognitive function. For example, patients with AD may experience mini-strokes and have a reduction of the flow of oxygen and nutrients to the brain tissue. So, AD can be worsened by vascular factors as well, but the vascular factors are not the main problem in AD.Clinically, patients with VaD can appear very similar to those with AD, which makes it difficult to distinguish between the two diseases. Nevertheless, some clinical symptoms and brain imaging findings suggest that vascular disease is contributing to, if not entirely explaining, a patient's cognitive impairment.Epidemiology.In the US, VaD is the 2nd most common type of dementia (15-20% of cases). Prevalence increases with age (∼ 1–4% in patients ≥ 65 years.) People affected by vascular dementia typically start experiencing symptoms after age 65, although the risk is significantly higher for people in their 80s and 90s.EtiologyVaD may occur as a result of prolonged and severe cerebral ischemia of any etiology, primarily:Large artery occlusion (usually cortical ischemia) *Acute*Lacunar stroke (small vessel occlusion resulting in subcortical ischemia) *Acute/Subacute**Chronic* subcortical ischemiaRisk factors:Advanced ageHistory of strokeUnderlying conditions associated with cardiovascular disease:Chronic hypertensionDiabetesDyslipidemiaObesitySmokingClinical Features:Symptoms depend on the location of ischemic events and, therefore, vary widely amongst individuals, but a progressive impairment of daily life is common. Because of the diverse clinical picture, the term "vascular cognitive impairment" is gaining popularity over Vascular Dementia.Dementia due to small vessel disease:Symptoms tend to progress gradually or in a stepwise fashion and comparatively slower than in multi-infarct dementia.Generally associated with signs of subcortical pathology:Dementia due to large vessel disease Usually, sudden onsetMulti-infarct dementia: typically, stepwise deterioration Generally associated with signs of cortical pathology:Early symptomsReduced executive functioningLoss of visuospatial abilitiesConfusion ApathyMotor disorders (e.g., gait disturbance, urinary incontinence)Later symptomsImpaired memoryFurther cognitive decline: loss of judgment, disorientationMood disorders (e.g., euphoria, depression)Behavioral changes (e.g., aggressiveness)Advanced stages: further motor deterioration: dysphagia, dysarthriaDementia due to large vessel disease Usually, sudden onsetMulti-infarct dementia: typically, stepwise deterioration Generally associated with signs of cortical pathology:Cognitive impairment in combination with asymmetric or focal deficits (e.g., unilateral visual field defects, hemiparesis, Babinski reflex present)Overall, the symptoms vary depending on which areas of the brain are affected.Management and TreatmentThere is hope when it comes to managing the symptoms of vascular dementia. Although there is no cure for the condition, there are medications available that can help make life easier for those living with it. Additionally, there are drugs commonly used to treat memory issues in Alzheimer's disease that may be effective for individuals with vascular dementia. Sometimes, people with vascular dementia may experience

Episode 162: Early-Onset Sepsis Dr. Kooner explains how to diagnose early-onset sepsis by using clinical evaluation and clinical tools. Dr. Schlaerths describes the signs and symptoms of sepsis in neonates, and Dr. Arreaza adds comments about GBS bacteriuria. Written by Lovedip Kooner, MD, editing Hector Arreaza, MD, and comments by Katherine Schlaerth, MD. Rio Bravo Family Medicine Residency Program.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction:Neonatal sepsis is defined as pathogenic bacterial growth from blood or cerebral spinal fluid culture within the first 28 days of life. Neonatal sepsis can be divided into two categories: early-onset sepsis (EOS) and late-onset. EOS is neonatal sepsis within 72 hours or 7 days after birth, depending on the specialist. How common is early-onset sepsis (EOS)?According to the CDC, the infant mortality rate rose for the first time in 20 years in the USA. In the U.S., the incidence of EOS is 0.5 in 1,000 live births and carries a mortality rate of about 3%. What causes EOS?Most infections are due to ascending lower vaginal tract flora. Other causes include intra-amniotic infections and maternal hematogenous spread of systemic infections. Group B streptococcus (S. agalactiae) accounts for about 1/3 of the infectious organisms, followed by E. coli which accounts for about 1/4, and Viridans streptococci account for about 1/5 of infections. Cases of E. coli are seen more often with prolonged rupture of membranes and intrapartum antibiotic exposure. Other notable infections are Listeria monocytogenes, coagulase-negative staphylococci (CoNS), herpes simplex virus, and enteroviruses. The role of GBS.Approximately 30% of women have vaginal and rectal GBS colonization and 50% will transmit it to the newborn. Without maternal antibiotic treatment, 1-2% of those infants will develop EOS. The American College of Obstetricians and Gynecologists (ACOG) recommends universal culture-based screening for GBS at 36-37 weeks and 6 days regardless of mode of delivery. GBS bacteriuria: Treat it (symptomatic and asymptomatic) if >105 CFU/mL. Do not treat it in asymptomatic patients if GBS Intrapartum antibiotic prophylaxis for GBS.The indications for intrapartum antibiotic prophylaxis for GBS EOS are: previous neonate with invasive GBS disease, positive GBS culture unless C-section is performed before rupture of membranes, GBS bacteriuria at any point during the current pregnancy.If GBS status is unknown: At least one of the following criteria must be met: prematurity, rupture of membranes >18 hours, intrapartum fever, or GBS positive in previous pregnancy.Nucleic acid amplification test: NAAT in pregnancy is not recommended to determine colonization status. However, if NAAT is obtained in the intrapartum period, give IAP if positive. But, you must also give IAP if negative + mentioned risk factors (18h, Maternal fever >100.4F)What is considered adequate intrapartum antibiotic prophylaxis? Penicillin and ampicillin are the recommended antibiotics for prophylaxis. Cefazolin can be given if there is a penicillin-allergy with a low risk for anaphylaxis. Clindamycin and vancomycin are reserved for cases of maternal penicillin allergy. Specifically, clindamycin can be used only if GBS is known to be sensitive to clindamycin. Vancomycin must be used if GBS is resistant to clindamycin. Do not use erythromycin. You will Administered at least 4 hours before delivery.IAP is believed to reduce neonatal GBS disease by: (1) temporarily reducing maternal vaginal GBS colonization; (2) preventing colonization of the fetus or newborn's surfaces and mucous membranes; and (3) achieving antibiotic levels in the newborn's bloodstream sufficient to surpass the minimum inhibitory concentration (MIC) for eliminating group B streptococci.Diagnosis of EOS:Clinical presentation: Tachycardia, tachypnea, temperature instability, supplemental oxygen requirement, and lethargy. Hypoglycemia should not be considered a sign of EOS.Diagnosing early-onset sepsis is achieved through blood or cerebrospinal fluid (CSF) cultures. Not effective methods for diagnosing EOS include laboratory tests, such as a complete blood cell count or C-reactive protein (CRP), as well as surface cultures, gastric aspirate analysis, or urine culture.Most infants will generally show signs of EOS GBS infection within the initial 24 hours of birth, with approximately 85% exhibiting symptoms during this timeframe.Waiting for cultures and/or signs can delay lifesaving treatment.Management:According to the American Academy of Pediatrics (AAP), the management of term and late-term infants is undertaken via the cli

Episode 161: Depression FundamentalsFuture doctors Madeline Tena and Jane Park define depression and explain different methods to diagnose it. Non-pharmacologic and pharmacologic treatment is mentioned briefly at the end. Written by Madeline Tena, MSIII, and Jane Park, MSIII. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Per the language of Mental Health, depression can be defined as a mood, a symptom, a syndrome of associated disorders, or a specific mental disorder. As a state of mood, depression is associated with feelings of sadness, despair, emptiness, discouragement, and hopelessness. The sense of having no feelings or appearing tearful can also be a form of depressed mood. A depressed mood also can be a part of a collection of symptoms that explain a syndrome. Depression as a mental disorder can encompass depressive syndromes. Per the American Psychiatric Association DSM-5-TR, depressive disorders commonly include sad, empty, irritable mood, accompanied by changes in one’s functional capacity. They can be classified by severity and recurrence, and associated with hypomania, mania, or psychosis. Depressive disorders include major depressive disorder (including major depressive episodes), persistent depressive disorder, premenstrual dysphoric disorder, substance-induced depressive disorder, depressive disorder due to medical condition, other specified depressive disorder, and unspecified depressive disorder.Today, we will cover unipolar depressive disorder, also known as major depressive disorder. MDD.Major depressive disorder is a mood disorder primarily characterized by at least one major depressive episode without manic or hypomanic episodes. Depressive episode is a period of at least 2 weeks of depressed mood or anhedonia in nearly all activities for most of the day nearly every day, with four or more associated symptoms in the same 2 weeks. We will discuss specific symptoms for diagnosis further on. Epidemiology of depression.Nationally or regionally representative surveys in 21 countries estimate that the 12-month prevalence of major depressive disorder across all countries is 5 percent. Furthermore, the prevalence of major depressive disorder plus persistent depressive disorder in developed countries (United States and Europe) is approximately 18 percent. Multiple studies consistently indicate that in the general population of the United States, the average age of onset for unipolar major depression and for persistent depressive disorder (dysthymia) is approximately 30 years old. During 2020, approximately ⅕ US adults have reported receiving a diagnosis by a healthcare provider, with the highest prevalence found among young adults age (18-24 year age… generation Z). Within the US there was considerable geographic variation in the prevalence of depression, with the highest state and county estimates of depression observed along the Appalachian and southern Mississippi Valley regions. Why do we care about depression?Because depression is associated with impaired life quality. It can impair a patient’s social, physical, and psychological functioning. Also, depression is associated with mortality. A study done by UPenn Family Practice and Community Medicine in 2005 showed that among older, primary-care patients over a 2-year follow-up interval, depression contributed as much to mortality as did myocardial infarction or diabetes. A prospective study from 2005-2017 that followed 186 patients for up to 38 years further showed that patients with major depressive disorder had 27 times higher incidence rate of suicide than the general population. (1, 2). Also, patients dying by suicide visit primary care physicians more than twice as often as mental health clinicians. It is estimated that 45% of patients who died by suicide saw their primary care physician in the month before their death. Only 20% saw a mental health professional a month before their death. (3)Suicidality in depression.It seems that primary care physicians often do not ask about suicidal symptoms in depressive patients. A 2007 study by Mitchell Feldman at the University of California San Francisco showed that 152 family physicians and internists who participated in a standardized patient with antidepressants, suicide was explored in only 36% of the encounters. (4)Physicians, including primary care physicians, should ask patients with depression about suicidality with questions such as: Do you wish you were dead? In the past few weeks, have you been thinking about killing yourself?

Episode 160: Artificial Intelligence in Primary Care. Future Dr. Manophinives explains the present and future of AI in diagnosing and treating diseases. Written by Rosalynn Manophinives, MS-IV, American University of the Caribbean. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today, we embark on an intriguing journey at the crossroads of technology and healthcare: The Future of Healthcare in Artificial Intelligence (AI) and Machine Learning (ML). Let’s start by establishing the groundwork for AI and ML. Artificial Intelligence involves machines mirroring cognitive functions like learning and problem-solving, while machine learning empowers machines to learn from data and refine their capabilities over time. In healthcare, these technologies aim to elevate diagnostic precision and treatment effectiveness which are pivotal aspects in primary care medicine.Accurate diagnosis is the cornerstone of effective patient care in all forms of medicine because an accurate diagnosis guides treatment decisions and influences patient outcomes. This is why the integration of AI and ML holds immense promise in this field.Section 1: AI in Diagnostic Assistance (4 mins)Let’s explore how AI utilizes algorithms to analyze extensive datasets, enhancing diagnostic accuracy significantly.AI serves as a revolutionary force in analyzing a large amount of data, particularly in medical imaging. Imagine AI algorithms as super brains, employing machine learning to decipher intricate details from X-rays, MRIs, and CT scans. Notably, studies have demonstrated their precision matching and even surpassing that of human experts. For instance, research published in the Journal of the American Medical Association revealed AI algorithms outperforming radiologists in detecting conditions like breast cancer.AI's skills extend beyond images. It digs into genetic information, medical history, and treatment outcomes, acting as a detective to spot patterns, predict responses, and customize interventions. Studies support this, showcasing AI models outperforming dermatologists in diagnosing skin cancer from images. Will AI replace doctors?The beauty of AI is that it does not replace doctors but acts as a super investigator in your healthcare corner, expediting diagnoses, and refining treatments. So, AI isn’t merely accelerating processes; it’s enhancing healthcare outcomes, making diagnoses quicker, and treatments more precise, and minimizing errors. The future appears very promising with AI leading the way to more precise and tailored healthcare.Section 2: Case Studies in Diagnosis (4 mins):Help in research: Let’s delve into real-life examples of AI in action, further amplifying diagnostic accuracy. In a research study, Rajkomar and collaborators crafted an AI algorithm predicting patient deterioration within hours, leveraging electronic health record data. This tool allowed for proactive care, identifying potential issues before they escalated. Taking it up a notch, Aliper and collaborators compared AI to human researchers, resulting in AI outsmarting human brains in designing drugs targeting age-related diseases. These experiments underscore AI's potential in diagnostics, from catching issues early to designing groundbreaking drugs.AI here enhances doctors' capabilities and acts as an additional set of eyes, boosting their superpowers, spotting nuances, and proposing game-changing solutions in medicine.Section 3: AI in Risk Prediction (4 mins):Let’s shift our focus to AI's role in predicting risks and prognosis, particularly in conditions like COPD.AI employs sophisticated algorithms to analyze patient data comprehensively, including demographics, hospital visits, diagnoses, prescribed medications, and lab results. In COPD, AI not only predicts mortality but also anticipates hospital readmissions for respiratory issues or flare-ups. By scrutinizing various markers, AI resembles Sherlock Holmes, unraveling clues within data.And AI doesn’t stop there, AI integrates risk predictions into medical practices, which fosters personalized care tailored to individual risk factors. A study led by Choi and their team analyzed retrospective patient data and they were able to identify individuals at risk of undiagnosed COPD, emphasizing the significance of catching potential issues early, finding those who might slip through the cracks otherwise, which is huge! Section 4: AI in Treatment Planning (4 mins):Let’s now explore how AI is revolutionizing treatment planning within medicine.AI, equipped with machine learning algorithms, tailors treatments by analyzing patient-specific data and medical history

Episode 159: Transcranial Magnetic Stimulation BasicsFuture Dr. Ameri explains how transcranial magnetic stimulation can be useful in the treatment of certain mental conditions. Written by Omeed Ameri, MS-IV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Transcranial Magnetic Stimulation (TMS)TMS is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and Obsessive-compulsive disorder (OCD). TMS uses the principles of electromagnetic inductions as described by Faraday’s Law. When an electric current passes through the TMS coil, it creates a rapidly charging magnetic field, which passes unimpeded through the scalp and skull, inducing a secondary current in neural tissues of the brain, causing depolarization of neuronal membranes in targeted brain regions, mainly in the superficial layers of the cortex 1.5 to 2.5 cm beneath the coil.How it works.Depending on the frequency and pattern of magnetic pulses, TMS can either increase or decrease cortical excitability. High-frequency TMS (Generally > 1 Hz) is associated with increased cortical excitability and is often used for depression treatment. In contrast, low-frequency TMS (This stimulation alters neurotransmitter release such as dopamine, serotonin, and norepinephrine. The repeated stimulation over sessions promotes synaptic plasticity, leading to more lasting changes in brain activity patterns associated with improved clinical outcomes. This is thought to have cascading effects throughout brain networks, and modulate dysfunctional circuits implicated in depression and restoring normal function. Effectiveness.The effectiveness of TMS can vary widely between individuals due to differences in anatomy, age, and specific conditions being treated. As such, ongoing research into how to personalize and optimize TMS parameters is ongoing. Research supporting the use of TMS in treatment-resistant depression.Research into the effectiveness of TMS and other therapy modalities targeting Treatment-Resistant Depression has been an ongoing effort for many years. In 2009, the American Academy of Family Physicians published Dr. Little’s article titled “Treatment-Resistant Depression,” which noted that there was little evidence that TMS could significantly treat patients with treatment-resistant depression. Since that time, the American Journal of Psychiatry published a groundbreaking study in 2020, led by Dr. Cole, which explores the effectiveness of a novel treatment for treatment-resistant depression. This trial, known as Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT, which demonstrates promising results in combating depression where traditional methods have failed. It was an open-label study that provides a new perspective on depression treatment, emphasizing rapid and targeted intervention. Twenty-two participants received 50 intermittent theta burst stimulation (iTBS), which is a more recent protocol for TMS treatment, over the course of five days. Each session included 1,800 pulses per session, with a 50-minute intersession interval, ten times a day. As a result of this intensive regimen, one participant withdrew from treatment, and 19 of the remaining 21 met remission criteria, with a score of less than 11 on the Montgomery-Asberg Depression Rating Scale. There were no serious adverse events reported, the participant who withdrew did so due to anxiety. Side effects included fatigue and some discomfort. 70% of participants continued to meet response criteria one-month post-treatment.TMS application for patients with OCD. Studies have shown promising results for the treatment of OCD with TMS. Typically, OCD is difficult to manage and requires the highest doses of SSRIs. In 2019, The American Journal of Psychiatry published Dr. Carmi’s Article titled: “Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial”, which presents a comprehensive study on the effectiveness of dTMS in treating OCD. This multicenter, randomized, double-blind, placebo-controlled trial involved 99 OCD patients across 11 centers, who were treated with either high-frequency dTMS or sham dTMS, and focused on changes in the Yale-Brown Obsessive Compulsive Scale (YBOCS) scores.The treatment phase extended to 6 weeks with a total of 29 treatment sessions, following a 3-week screening phase and a 4-week follow-up phase. Patients were aged 22-68, with YBOCS sc

Episode 158: Strength Training PrinciplesFuture Dr. Hasan explains the importance of adding muscle strength exercises to our routine physical activity. Dr. Arreaza asked questions about some terminology and reminded us of the physical activity guidelines for Americans. Written by Syed Hasan, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.An Introduction to Strength Training Principles.Arreaza: Hello, everyone. Welcome to episode 158. [Introduce myself]. We are recording this episode right before Christmas but by the time you listen to this episode it will be 2024, so Happy New Year! It has been a busy time in our residency, we had lots of interviews, parties, and, of course, lots of learning and teaching. I apologize for our absence in the last few weeks, but we are back for good. We have Syed today, hi, Syed, please introduce yourself.Syed: Hi Dr. Arreaza, and hello everybody. My name is Syed. I am a fourth-year medical student at Ross University School of Medicine. I’m also a lifting enthusiast. One of my many goals in life is to look like I lift. Until I reach that goal, I will take solace in the fact that at least I sound like I lift. Arreaza: You are getting there, keep going! Give us an intro for today’s episode. Syed: (laughs) Thanks! Well, today, I want to present a framework with which to approach resistance training. The benefits of weight training are well-known, and a quick Google search gives us plenty to learn about them. But a clear framework for resistance training is a bit more difficult to come by. So, in this podcast, I will attempt to provide you, the listeners, with such a framework. By the end of the episode, my goal is to get most of you to start thinking about strength training seriously. Arreaza: I’m excited to hear it. I’m ready to learn more. I exercise, but I have to confess that I need to add more lifting to my routines. I enjoy cardio exercise, especially if I’m listening to my favorite music or watching a Netflix show. So, today I will go to bed being a little wiser. I have low gym literacy, but I think many of our listeners will appreciate my silly questions. Syed: (laughs) If you’re thinking it, it’s not a silly question, Dr. Arreaza! Before we begin though, some housekeeping. Because there is some technical stuff like names of muscles, their function, and exercises to target them, we will add a quick glossary at the end of the attached transcript. I will also include sources for the information I present. As well, a lot of other sources on hypertrophy training and exercise science. Arreaza: So, let’s start with the definition of strength training, Syed. Syed: Yeah. So put simply, any exercise where you produce force against a resistance can be thought of as a resistance training exercise. Doing this kind of exercise over a long period of time is what causes strength and muscle gain. By the way, strength and muscle gains are like chicken and eggs. Scientists are not sure which comes first, just that both are correlated. Practically, it means that when we look at two people, the person with bigger muscles is probably going to be stronger.Arreaza: On the Physical Activity Guidelines for Americans, available online at health.gov, we find that it is recommended that adults engage in “muscle-strengthening activities of moderate or greater intensity… [involving] all major muscle groups on 2 or more days a week,” and that’s ON TOP of the 150-300 minutes of moderate physical activity a week for general health benefits.Syed: Yeah, and we are talking about it today because a lot of times it’s unclear to people what such exercise entails. Some common examples are bodyweight exercises like push-ups, pull-ups, and squats. Syed: In these exercises, our body is the resistance against which our muscles are producing force. So, in push-ups, it is our chest and triceps that are mostly involved. In pull-ups, it is our back and biceps that work the hardest. When it comes to squats, it is our quads and glutes that are used most. Quads are the muscles in the front part of the thighs, and glutes are the buttock muscles. Arreaza: Push-ups, pull-ups, and squats are examples of bodyweight exercises. Syed: Yeah, so now let’s talk about free weight exercises. Just like in body weight exercises, we are using our body weight as resistance, in free weight exercises we use free weights, like barbells or dumbbells, as resistance. So, instead of a push-up, we could do a bench press with a barbell or dumbbell, for example. Arreaza: Barbells and dumbbells. What’s the difference?Syed: The difference is the siz

Episode 157: Urine TestingThis episode includes the pitfalls of urine tests, how to detect adulterated urine, and more. Written by Janelli Mendoza, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD. Comments by Carol Avila, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: Urine drug screenings are valuable tools used every day by physicians to monitor illicit substance use, as well as proper use or misuse of prescription drugs. However, studies suggest that physicians using “clinical judgment” on who and when to test is often wrong and confounded by implicit racial bias. The implications of this are an inappropriate discontinuation of treatment.For example, a study by Gaither, Gordon, and Crystal et. al found that compared to white patients, black patients were 10% more likely to undergo urine drug screening. In addition, they were 2-3 times more likely to have long-term opioid medication abruptly discontinued as a result of a UTOX positive for marijuana.False positive urine tests:Before getting into the current guidelines, let’s discuss the interpretation of Urine Drug Screenings. It’s important to be aware of prescription drugs that may cause false positives:· Bupropion, labetalol, pseudoephedrine, trazodone → Amphetamines· HIV antivirals, sertraline → Benzodiazepines· HIV antivirals, NSAIDs, PPI’s → Cannabinoids· Diphenhydramine, Naloxone, Quetiapine, Quinolones, Verapamil → Opioids· Dextromethorphan, diphenhydramine, ibuprofen, tramadol, venlafaxine → PhencyclidineTampering of urine: Other factors to consider are the tampering of collected urine. The tampering of collected urine may include diluting the urine, or adding other chemicals and substances. Laboratory results that should prompt consideration of adulteration are: Creatinine 11, Specific gravity 1.035, Temp 100 FHow long urine tests are positive:The detection window for common substances in urine drug screenings are as follows:· Amphetamines: 2-3 days· Cocaine: 1-2 days· Opioids: 1-3 days, but up to 14 days if the patient is on methadone.· Phencyclidine: up to or less than 1 week, may be longer if chronic use.Cannabinoids are a little different as the THC component builds up and is stored in adipose tissue. Therefore, a patient's weight, body fat percentage, exercise level, and diet can all influence the detection window. This is more so an issue for chronic daily users.· For single-time use: 2-3 days.· Daily use: 2-4 weeks· Chronic heavy use: >6-8 weeks as we said, the exact time will be influenced by many factors depending on how long it takes to deplete THC molecules stored in adipose tissue.Monitoring use of prescription drugs:Dr. John Hayes and Dr. Kristen Fox at the Department of Family Medicine and Community Medicine College of Wisconsin have developed a patient-centered approach in utilizing urine drug screenings for monitoring the use of controlled prescription drugs. If physicians should not test based on suspected misuse of medications, then when should they test? The frequency of screening should be determined based on a patient’s risk for substance use disorder. This will be determined by use of evidence-based tools such as a risk calculator. On MD calc, clinicians can find the ORT (Opioid Risk Tool for Narcotic Abuse) created by Dr. Lynn Webster. This stratifies patients into high-risk, moderate risk and low- risk of opioid related aberrant behaviors. Factors contributing to high-risk include age between 16-45, history of preadolescent sexual abuse, history of depression, history of ADD, OCD, Bipolar disorder, or schizophrenia, illicit substance use, history of misuse of prescription drugs. Family history also significantly contributes to risk assessment independently taking into consideration FHx of alcohol abuse, illicit substance abuse, and prescription drug misuse.How often can we test the urine for patients on controlled medications?Based on the risk assessment the frequency of Urine drug screenings for patients on controlled medications should be as follows:· Low- risk patients should be tested annually· Moderate-risk patients should be tested at least 2x per year· High-risk patients should be tested at least 3x per yearBased on the results, if it is found that a patient is recurrently misusing their medication, rather than abruptly discontinuing a patient off of their medication, it is recommended that the provider share their concern with the patient to initiate an open discussion. Medication should be tapered, and the patient should receive a referral and support from an addiction specialist.Unhealthy Drug Use: Screening by USPSTF (published on June 09, 2

Episode 156: Obesity, Fertility, and PregnancyFuture Dr. Hamilton defines obesity and explains the pathophysiology of obesity and its effects on fertility and pregnancy. Dr. Arreaza adds some input about the impact of epigenetics on newborn babies. Written by Shelby Hamilton, MS3, American University of the Caribbean School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition of obesityObesity is a multifactorial chronic disease that is increasing in prevalence across the globe. It can be defined as a body mass index (or BMI) greater than 30 kg/m2. According to the CDC from 2017-March 2020, the prevalence of obesity in United States adults was 41.9%.Classification of obesity by BMI.Obesity can further be divided into three classes: class I which is a BMI between 30-34.9; class II which is a BMI between 35-39.5; and class III which is a BMI greater than 40. We recommend avoiding the term “morbid obesity” because of the negative connotation of the word “morbid.” Class III or severe are better terms in those cases. This classification is based on the individual risk of cardiovascular disease. One of the greatest health consequences affecting individuals with obesity is the cardiovascular effects including hypertension, dyslipidemia, and coronary artery disease. Other effects include insulin resistance and diabetes, cholelithiasis, non-alcoholic fatty liver disease, osteoarthritis, and even depression.How Does Obesity Affect Fertility?Obesity can have an extensive effect on the overall health of an individual. In addition to these commonly discussed effects, obesity can also influence a person’s fertility. This is especially observed in women with polycystic Ovary Syndrome (PCOS) who have a greater BMI and also have symptoms of anovulation. Excess adipose tissue plays a role in the effects that obesity has on fertility. White adipose tissue can secrete a specific group of cytokines known as ‘adipokines’. These adipokines include leptin, ghrelin, resistin, visfatin, chemerin, omentin, and adiponectin. With a greater percentage of adipose tissue, there are higher rates of hypothalamic gonadotropin hormonal dysregulation, which can be combined with insulin-related disorders, low sex hormone binding proteins, and high levels of androgens. The combination of these factors can result in decreased ovarian follicle development and decreased progesterone levels.Hormonal changesObesity is an endocrine disorder. One specific adipokine that affects the hypothalamic-gonadotropin axis is chemerin. Chemerin impairs the release of follicle-stimulating hormone (FSH) from the pituitary gland. This reduction in FSH release consequently leads to anovulation, meaning that no egg will be released from an ovarian follicle, contributing to infertility. Shelby: Another adipokine affecting fertility is adiponectin. The receptors of adiponectin are predominantly expressed in reproductive tissues, including the ovaries and endometrium. In individuals with a greater BMI, a decrease in adiponectin secretion has been observed, resulting in decreased stimulation of its receptors, especially in the endometrium, which has been linked to recurrent implantation failure. Adiponectin has also been shown to affect glucose uptake in the liver. With reduced adiponectin levels, there is reduced hepatic glucose uptake, leading to insulin resistance. As tissues become less sensitive to insulin, the body compensates by secreting higher amounts of insulin, leading to hyperinsulinemia. Higher levels of circulating insulin have also been proven to cause hyperandrogenemia in women by blocking the hepatic production of sex hormone-binding globulin. Insulin can also act on the IGF-1 receptors in the theca cells, increasing steroidogenesis, and thus, increasing androgens. With hyperandrogenemia, there is also increased granulosa cell apoptosis as well as increased peripheral conversion of androgens into estrogen. This creates negative feedback to the hypothalamic-pituitary axis to decrease the release of gonadotropins such as FSH which are critical in ovulation.Leptin is another adipokine that is shown to be increased in obesity. Studies on mice have shown that leptin impairs the development of ovarian follicles, resulting in a decrease in ovulation. In these studies, it was also observed that leptin reduces the production of estriol by the granulosa cells in the ovarian follicles as well as increases the rate of apoptosis in granulosa cells, both of which affect ovulation. Leptin decreases hunger, but persons with obesity may be resistant to its effects and that’s why they have highe

Episode 155: Diabetic Foot Infection GuidelinesFuture Dr. Perez presents the updates on lung cancer screening by the American Cancer Society. Future Dr. Danusantoso explains the classification, diagnosis, and treatment of diabetic foot infections according to the guidelines published by the International Working Group on the Diabetic Foot (IWGDF). Dr. Arreaza adds comments and anecdotes. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Intro: Lung cancer screening update.Written by Luz Perez, MSIII, Ross University School of Medicine. Editing by Hector Arreaza, MD.Hello, my name is Luz Perez and today I will talk about lung cancer screening.As a reminder, lung cancer is the top cause of cancer-related death in men and women worldwide. In the United States, lung cancer causes the death of about 154,000 people each year[4]. Smoking is the most significant risk factor for developing lung cancer, a risk that directly correlates to how much and how long a person has smoked[2]. Despite the efforts to decrease lung cancer-related deaths, which include screening of patients at risk and counseling on smoking cessation, many patients go undiagnosed in part because lung cancer can be asymptomatic but also because many people at risk did not meet the criteria for screening, according to previous guidelines… BUT On November 1, 2023, the American Cancer Society updated its guidelines for lung cancer screening to decrease mortality by lung cancer in the US. The updated lung cancer screening guidelines were published in November, which is Lung Cancer Awareness Month. This guideline aims to expand eligibility criteria for lung cancer screening. Previously, the guidelines covered people only between the ages of 55-74 who were current smokers or had quit within the past 15 years and had a 30 or more pack-year smoking history[3].The new guidelines recommend annual screening with low-dose CT (LDCT) scan for people who are 50-80 years old who are current or former smokers and who have a 20 or more pack-year of smoking history [1]. This change means that about 5 million people who would previously not qualify for screening are now eligible for this potentially lifesaving screening exam.Additionally, the American Cancer Society emphasizes the significance of shared decision-making between patients and healthcare providers on lung cancer screening and smoking cessation. This includes ways to help patients stop smoking by providing counseling and interventions including medications. For patients who are eligible for screening, having a full discussion of the lung cancer screening process including the purpose of the procedure, risks and benefits of low-dose CT, and recommendations from other organizations, is key in the shared decision-making process[1]. Perhaps, the most important step in the implementation of these new guidelines is ensuring that medical professionals talk to their patients about them and make them aware of the importance of screening for lung cancer. In this way, we can reduce mortality and other consequences of this devastating disease. Written by Maria Danusantoso, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.Update to Guidelines for Treatment of Diabetic Foot InfectionsIntroductionIn October 2023, the International Working Group on the Diabetic Foot (IWGDF) and the Infectious Disease Society of America (IDSA) collaborated and published an update to the 2019 guideline on the diagnosis and management of infections of the foot in persons with diabetes mellitus.The present guidelines include a list of 25 recommendations for diagnosis and management and clinically useful figures and tables including a treatment algorithm, a classification system for defining diabetic foot infections, and empirical antibiotic therapy according to clinical presentation and microbiological data.The goal of this episode is not to provide an exhaustive review of the updated guidelines and algorithms but to highlight what I believe are the most important recommendations. I hope this brief presentation is viewed as an introduction and that this encourages you, the listener, to independently read the guidelines in full and implement them into your own clinical practice.Wound Colonization Versus Wound InfectionBefore jumping into some of the recommendations, I want to take some time to discuss briefly how to classify diabetic foot infections. Most clinicians, including myself, will see a patient with diabetes with a foot ulcer or wound and want to treat it with antibiotics or admit the patient to the hospital. However, the updated guidelines propose that antibiotics and/or admission ar

Episode 154: Heart Failure and GDMTDr. Malave explains the four main medications that are part of the guideline-directed medical therapy of heart failure with reduced ejection fraction. Dr. Arreaza added comments and questions. Written by Maria Fernanda Malave, MD. Edits by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Brief introduction: Heart failure (HF) is a common condition that affects about 23 million people in the world, and it is estimated that 50% of cases are due to heart failure with reduced ejection fraction (HFrEF). It is a major public health concern because of the high morbidity and mortality with a 5-year survival rate of 25% after hospitalization due to HFrEF.In recent years, the management of HFrEF has evolved due to increased evidence in favor of certain medications. Guideline-directed medical therapy (GDMT) is the foundation of medical therapy for these patients, and it is the result of multiple randomized controlled trials and reviews favoring four main drug classes: 1. renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors -ACEi- and angiotensin receptor blockers -ARB), 2. evidence-based β-blockers, 3. mineralocorticoid inhibitors, and 4. sodium-glucose cotransporter 2 inhibitors -SGLT-2i-. The benefit of this therapy is mostly seen when these four groups of medications are used in conjunction. During this episode, we will provide some key elements about the prescription of these medications, but this is only an overview, and you are invited to continue learning from reputable sources.Definitions: HF is defined as the impairment of the heart to meet the metabolic demands of the body. It can be caused by multiple conditions that interfere with the filling up of the heart or conditions that prevent an effective ejection of blood out of the heart. Classification of HFrEF: Based on the EF by echocardiogram, heart failure can be classified as:Heart failure with preserved ejection fraction (HFpEF) when the EF is 50% or more.Heart failure with mildly reduced ejection fraction when EF ranges between 41-49%.Heart failure with reduced ejection fraction (HFrEF) when EF is 40% or less.GDMT: Once we make the diagnosis of HF, it is key to educate our patients and re-educate them every single visit about the importance of guideline-directed medical therapy (GDMT) and lifestyle modifications, because this can change the prognosis and exacerbation rates. Many patients think that since they are feeling well after starting GDMT they can stop it, but that’s going to increase exacerbations, hospitalizations, and decrease quality of life. Key points to discuss with patients.First, discuss that GDMT are disease-modifying drugs that regulate the neurohormonal system to stop the progression of the disease. We should explain to our patients that medications should be taken despite feeling well. Also, patients should be educated about regular follow-ups and medication titration. We can even instruct our patients about increasing their furosemide dose if they observe signs of overload, such as a weight increase of 2-3 kgs in 3-4 days, tight rings, socks or bracelets, also Paroxysmal nocturnal dyspnea, dyspnea on exertion, and more. Second, lifestyle modifications such as: quit smoking and alcohol. Additionally, in general, water restriction between 1.2-1.5L daily, salt restriction (there is no official recommendation about how many grams, but in general we recommend less than 2g daily). Third, it is highly recommended to do aerobic exercise that produces mild dyspnea since this improves cardiovascular capacity and decreases hospitalization risk. Patients should be encouraged to have their annual influenza vaccine and pneumococcal vaccine according to their own immunization schedule. According to the AFP journal, in September 2022, researchers found a clinically and statistically significant reduction in all-cause mortality for patients who received an influenza vaccine right after an MI, with a number needed to treat of 50, the effectivity of the vaccine may vary by season.GDMT, groups of medications:What are the basic medications any patient with HF should be on? At least, patients should be on angiotensin receptor blockers ARBs/ACEIs and Beta-blockers. Let’s keep in mind that beta-blockers should be given cautiously in cases of exacerbation, but in general low doses are safe. We also have the angiotensin receptor/neprilysin inhibitors (ARNIs), a group of medications whose representative is the combination of sacubitril/valsartan, aka Entresto®. This medication should be the target once ARBs/ACEIs are tolerated. ARBs/ACEIs/ARNIs should b

Episode 153: Sudden Infant Death Syndrome. Future doctors Nisha and Afolabi explain the way to prevent sudden infant death syndrome and Dr. Arreaza adds comments about prevention through vaccines. Written by Selena Nisha, MS4; and Oluwatoni Afolabi, MS4. Ross University School of Medicine. Comments by Hector Arreaza, MDYou are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today, we are going to talk about sudden infant death syndrome, also known by its acronym SIDS. This topic is a heavy one and it may be triggering for some parents or those who may personally know a family member affected by SIDS, so please refrain from listening to this podcast at any point you see fit. First and foremost, we tend to hear a lot about SIDS in the news or social media outlets that cover these tragic incidents, but let's define what exactly sudden infant death syndrome is. Sudden Infant Death Syndrome, or SIDS, is the abrupt and unexplained death of an infant It occurs mostly between 1-3 months. Q: What causes SIDs? The exact cause of SIDS is unfortunately unknown. However, there are many studies that have identified several risk factors for SIDS and most of them are definitely preventable. The most important risk factors for SIDS are related to the sleep position and the sleep environment of the baby. Babies placed to sleep on their side or their stomach are at increased risk for SIDs compared to babies placed to sleep on their back. In addition, bed-sharing is also strongly associated with increased risk for SIDs.Smoking during pregnancy and postnatal exposure to tobacco. Second-hand smoking exposure is probably the most important risk factor for SIDS.Drug use or alcohol use during pregnancyOverdressing/overheating the babyBabies that are born premature and/or low birth weightLate or no prenatal care.Q: Are there any ethnic or genetic components involved in SIDS? Yes, there are. According to the CDC, African American, American Indian or Native Alaskan babies have a higher risk.Surprisingly, some studies have even shown an increase in SIDS in baby boys compared to baby girls and if a baby’s sibling had died of SIDS, that may be linked to a genetic disorder.Asian babies are less likely to suffer from SIDS, and African Americans are disproportionally affected by SIDS.Interesting fact: Several people have been accused of killing their own babies and later forgiven because a diagnosis of SIDS was established after autopsy and extensive investigation. Some examples are: Kathleen Folbigg (Australia), Sally Clark (England), and Angela Cannings (UK).Q: What are the clinical recommendations to reduce the risk of SIDS that parents and caregivers should be aware of?It is important to know that although short episodes of tummy time are beneficial for the baby, we need to be sure to not put the baby to sleep on their belly or side. In fact, the incidence of SIDS has decreased more than 50% in the past 20 years, largely as a result of the “Back to Sleep” campaign in 1992 that recommended that babies be placed on their backs to sleep to reduce the risk of SIDs.When choosing a crib and mattress, make sure you pick a crib that is well made and sturdy and a mattress that is firm and flat. It is important for the angle of the mattress to not be higher than 10 degrees. I know that we all love to see fluffy and cute little blankets and toys in the baby’s crib, however, we also need to make sure none of those things are present while the baby is sleeping in order to avoid any chance of suffocation.Q: A friend of mine who recently had a baby always feels anxious when breastfeeding her baby because she feels that her baby is not getting enough air to breathe in. She actually feels the same way when her baby is using the pacifier too. Is it true that the baby is truly struggling to breathe in these instances? This is a common misconception that many mothers tend to have. Many women genuinely fear that their baby isn’t properly breathing while breastfeeding and are worried that this can increase the risk of SIDS. However, the opposite is actually the truth. Turns out that breastfeeding for 6 months to a year actually decreases the risk of SIDS.We know that many parents make use of pacifiers, especially in situations relating to soothing the baby but interestingly enough, pacifiers can decrease the risk of SIDS as well. The only important thing to know about pacifier use is that if the baby does not want the pacifier, please don’t force it. Also, make sure the pacifier does not have any hanging parts to it such as cords or straps and if they are sleeping, be sure to not put the pacifier back in the mouth.Q: After listening to

Episode 152: ALS FundamentalsFuture Dr. Rodriguez explains the symptoms of ALS, including UMN and LMN symptoms. Dr. Arreaza discusses the principles of symptomatic treatment by primary care. This is a brief introduction to ALS. Written by Adraina Rodriguez, MSIV, Ross University School of Medicine. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: It is rare but you may encounter it and you should be able to identify the most common symptoms. ALS Challenge in 2014: Ice bucket challenge. Adriana: Patrick Quinn was an ALS patient and activist who created the ICE Bicket Challenge and helped raise US$220 million for medical research.Arreaza: What is ALS?Adriana: ALS stands for Amyotrophic Lateral Sclerosis, formerly known as Lou Gehrig’s Disease. It is the most common form of acquired motor neuron disease. ALS is a progressive, incurable neurodegenerative motor neuron disorder with Upper motor neuron (UMN) and/or Lower motor neuron symptoms that cause muscle weakness, disability, and eventually death. There is no single diagnostic test that can confirm or entirely exclude the diagnosis of motor neuron disease. Arreaza: When should you suspect ALS in a patient?Adriana: The classic patient presentation is insidious, slowly progressive, and unremitting UMN and/or LMN symptoms present in one of four body segments - cranial/bulbar, cervical, thoracic, and lumbosacral - followed by spread to other segments over a period of months to years. Arreaza: What would you see on the physical exam when the Patient is in the clinic? There is a system to send signals from your brain to your muscles. It involves basically two neurons: Upper and lower motor neurons. The UMN goes from your cerebral cortex to your spinal cord and there it connects to a lower motor neuron through synapsis. The LMN then sends the signal to your muscles, causing contraction or relaxation. Tell us about the UMN and LMN symptoms.Adriana:LMN Symptoms: Weakness, Fasciculations, Muscular atrophy, Decreased muscle tone (flaccidity) and reduced or absent reflexes. UMN Symptoms: Increased tone and increased extremity deep-tendon reflexes, presence of any reflexes in muscles that are profoundly weak and wasted, pathological reflexes (crossed adductors, jaw jerk, Hoffman sign, Babinski sign 50%), syndrome of pseudobulbar affect (inappropriate laughing, crying, forced yawning).Arreaza: What are important factors to help narrow your differential to ALS?Multifocal motor neuropathy, cervical radiculomyelopathy, benign fasciculations, inflammatory myopathies, post-polio syndrome, monomelic amyotrophy, hereditary spastic paraplegia, spinobulbar muscular atrophy, myasthenia gravis, hyperthyroidism, and many others.There are pertinent negatives to look out for: Usually negative neuropathic or radiculopathic pain, sensory loss, sphincter dysfunction, ptosis, or extraocular muscle dysfunction (20-30% positive sensory symptoms or “pins and needles” and “electricity” in the affected limbs).Note: Cognitive dysfunction does not exclude ALSArreaza: What are the diagnostic criteria for ALSAdriana: Gold Coast Criteria 2019 proposed over El Escorial criteria:Progressive upper and lower motor neuron symptoms and signs in one limb or body segment, ORProgressive lower motor neuron symptoms and signs in at least two body segments, ANDAbsence of electrophysiologic, neuroimaging, and pathologic evidence of other disease processes that might explain the signs of lower and/or upper motor neuron degeneration.Arreaza: What diagnostic tests should be ordered for further evaluation?Adriana: Electrodiagnostic studies: Electromyogram and nerve conduction studies (EMG and NCS)Laboratory testing: creatine phosphokinase up to 1000u/LNeuroimaging: to exclude other causes mainly. Brain MRI whenever bulbar disease is present. Cervical and lumbosacral spine MRI for LMN findings in the arms and legs.Genetic testing: FALS 10% of ALS defect in C9ORF72 gene that makes motor neuron and brain nerve cell protein, the exact cause is unknown. Arreaza: Finally, how do you treat ALS?Adriana: Disease-modifying treatment: Riluzole is recommended for all patients with ALS. Shown to prolong survival and slow functional deterioration. The mechanisms of action that reduce glutamate-induced excitotoxicity: 1) inhibit glutamic acid release, 2) non-competitive block of N-methyl-D-aspartate (NMDA) receptor-mediated responses, 3) direct action on the voltage-dependent sodium channel. Arreaza: Riluzole is given 50 mg by mouth twice a day. It may cause drowsiness or somnolence, hepatic injury: Not recommended for patients with elevation of transaminases >5 times the upper limit of normal

Episode 151: Martian Medicine 102Future Dr. Collins discussed with Dr. Arreaza two common complications of astronauts in a hypothetical travel to Mars: Spaceflight-Associated Neuro-ocular Syndrome and mental illness. Written by Wendy Collins, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: We are back for another episode of Martian Medicine! A couple months ago we published the episode Martian Medicine 101. We talked about radiation and its health risks for astronauts going beyond Low Earth Orbit such as a crew going to Mars. Today, we are going to be covering Martian Medicine 102, where we discuss some more risks from the article “Red risks for a journey to the red planet”. So, let’s just jump into it! The next risk we are going to talk about is Spaceflight-Associated Neuro-ocular Syndrome or SANS. Wendy: Yes, so this used to be called Vision Impairment Intracranial Pressure because the syndrome affects astronauts' eyes and vision and can appear like idiopathic intracranial hypertension. But the name changed to SANS because is not associated with the classic symptoms of increased intracranial pressure in idiopathic intracranial hypertension such as severe headaches, transient vision obscurations, double vision, and pulsatile tinnitus. Also, it has never induced vision changes that meet the definiti on of vision impairment, as defined by the National Eye Institute. Its name change also reflects that the syndrome can affect the CNS well beyond the retina and optic nerve. Arreaza: Let’s talk about SANS some more. SANS presents with an array of signs including edema of the optic disc and retinal nerve fiber, and what else?Wendy: Edema of chorioretinal folds, globe flattening, and refractive error shifts. Flight duration is thought to play a role in the pathogenesis of SANS, as nearly all cases have been diagnosed during or immediately after long-duration spaceflight such as missions of 30 days duration or longer. But signs have been discovered as early as mission day 10. SANS has been studied in ISS crewmembers who are tested with optical coherence tomography (OCT), retinal imaging, visual acuity, a vision symptom questionnaire, Amsler grid, and ocular ultrasound.Arreaza: About 69% of the US crewmembers on the ISS experience an increase in retinal thickness in at least one eye, indicating the presence of optic disc edema. This can cause an astronaut to experience blind spots and reduced visual function. Fortunately, to date, blind spots are uncommon and have not had an impact on mission performance.Wendy: And chorioretinal folds if severe enough and located near the fovea, an astronaut can experience visual distortions or reduced visual acuity that cannot be corrected with glasses or contact lenses. Fortunately, and despite a prevalence of 15–20% in long-duration crewmembers, chorioretinal folds have not yet impacted astronauts’ visual performance during or after a mission. Arreaza: A change in your glasses prescription is due to a change in the distance between the cornea and the fovea, and it occurs in about 16% of crewmembers during long-duration spaceflight. This risk is reduced by giving crewmembers with several pairs of “Space Anticipation Glasses” (or contact lenses). The crewmember can then select the appropriate lenses to correct visual acuity. Wendy: From a longer-term perspective, SANS presents two main risks to crewmembers: optic disc edema and chorioretinal folds. It is unknown if a multi-year spaceflight like that to Mars will be associated with a higher prevalence, duration, and/or severity of optic disc edema compared to what has been experienced onboard the ISS. Since the retina and optic nerve are part of the CNS, if optic disc edema is severe enough, the crewmember risks a permanent loss of optic nerve and retinal nerve fiber tissue and thus, a permanent loss of visual function. But again, no astronaut has experienced SANS-related permanent vision loss and choroidal folds usually improved post-flight in affected crewmembers. Arreaza: It is important to understand the pathogenesis of SANS. In microgravity, fluid can distribute uniformly. The fluid that normally pools in your legs due to gravity can now move to your head and cause congestion of the cerebral veins. The pathophysiology of SANS is that CSF outflow can be blocked, which increases intracranial pressure. Wendy: There can be confounding variables such as exercise, high-sodium dietary intake, and high carbon dioxide levels. It is difficult to know much about SANS because there are not many crewmembers who have completed long

Episode 150: Re-update on COVID Vaccines and Cervical CancerCOVID vaccines have been updated (again). The bivalent m-RNA COVID-19 vaccines are no longer authorized in the US. Sabrina explains that the monovalent COVID-19 vaccines will be available soon to target XBB lineage and more. Future Dr. Rodriguez explains the USPSTF cervical cancer screening guidelines. Dr. Arreaza adds comments and insight. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Celebrating our episode 150.Written by Hector Arreaza, MD.In our previous episode, we gave you an update on COVID-19 vaccines, but we need to give a new update. This is the risk you take when you try to become a news agency instead of an educational podcast, so you need to keep giving updates, and we’ll tell you about the newest change in COVID-19 vaccines in a few minutes. This is episode number 150! And I wanted to take a moment to celebrate this milestone. Our first episode was released a few days before the lockdown for COVID-19 on March 3, 2020. Those were gloomy days. I was excited about having a weekly podcast, but I also was overwhelmed by COVID-19. I remember considering putting a hold on the podcast, but I decided to continue. We had a few episodes about COVID-19 and, as expected for a novel disease, we made some mistakes. For example, we gave the wrong recommendations to not wear a mask at the very beginning of the lockdown, but that was the initial recommendation. However, I got to accentuate the positive, I’m proud that we were probably the first place to report hiccups as a symptom of COVID. Soon I realized it would be impossible to keep up with the daily changes in recommendations and updates on COVID, so we focused on other topics, and it has been a great experience so far. This podcast was created for the Rio Bravo residents, and thankfully the medical students have become the main collaborators of this program. I have enjoyed every second I have spent with all our guests, including residents, nurses, medical assistants, specialists, scientists, and of course medical students. I feel very fortunate to have reviewed many relevant topics of family medicine with you. A colleague once mentioned to me that I may run out of topics, but I think it is impossible to run out of topics in family medicine, don’t you think? So, I’m hoping to continue bringing to you brief discussions and pearls of knowledge every week. Now, let’s listen to Sabrina.Re-update on COVID-19 Vaccines.Written by Sabrina Hawatmeh, MSIII, Ross University School of Medicine.Hi, my name is Sabrina Hawatmeh, I’m a 3rd-year medical student from Ross University School of Medicine. I’m so excited to be here today, huge thank you to Dr. Arreaza for having me here today! As mentioned by Dr. Arreaza, during our episode 149 we gave you an update on COVID-19 vaccines and now today it’s time for a new update. Most recently, Pfizer/BioNTech and Moderna have updated their vaccines to target specific strains of the virus, and the American Academy of Family Physicians has given its approval to federal actions allowing the use of these updated vaccines for the Fall/Winter of 2023. The decision follows FDA approval for these vaccines for children and adults aged 12 and older, as well as CDC recommendation of emergency use authorization for children aged 6 months to 11 years. The AAFP's Board Chair, Sterling Ransone, M.D., accepted the recommendation to approve these actions as of September 14th, 2023. The vaccines may be available soon for administration. Bivalent vaccines were the most recent formula administered for immunization. Studies had shown that there was continued protection against circulating sublineages of Omicron and XBB.1.5. However, the vaccine effectiveness against Omicron decreases over time. Neutralizing antibody titers against XBB sublineages via bivalent vaccines are lower compared to titers induced by the matched BA.4/BA.5 sublineage. So, it makes sense that all this data suggested that vaccine modification be directed toward more closely matched strain composition to current circulating sublineages. I also think it's worth noting that the original version of Omicron is no longer circulating—neither is the original strain of the SARS-CoV-2 virus. For that reason, updated vaccines were created by Moderna and Pfizer/BioNTech, so the bivalent vaccines are no longer authorized for use in the United States. The updated vaccine recommendations include eligibility criteria for different age groups, regardless of previous vaccination status, and specify the number of doses needed. The CDC has also updated its vaccine recommendations, especially for moderately o

Episode 149: COVID Vaccines Update [Historic episode]. Future Dr. Williams presented an update on COVID-19 vaccines. This update is only for immunocompetent individuals, and it was recorded on August 24, 2023. Dr. Arreaza added comments and insight. Written by John Williams, MS4, Ross University School of Medicine. Editing by Hector Arreaza, M.D. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Currently, there are two types of vaccines that have been approved by the FDA:Moderna and Pfizer developed mRNA vaccines.Novavax developed a lesser-known protein subunit vaccine.As of May 6, 2023, the vaccine developed by Johnson & Johnson has expired and is not available in the U.S.Novavax: This vaccine contains pieces (proteins) of the virus that causes COVID-19, the spike protein plus an adjuvant. It works by activating the immune system against the spike protein, so it will be ready to fight the actual virus when you get infected. Regardless of vaccine type, the shots are administered in the upper arm and have been demonstrated, for most people, to be safe and effective. There have now been hundreds of million vaccines administered in the US alone and the effectiveness of the vaccine to reduce the risks of severe illness, hospitalization, and death has been well documented. The most common side effects consist of mild to moderate cases of fever, chills, headache, and tiredness that are self-resolving.What is new about COVID-19 Vaccines?The updated vaccine is known as “bivalent”. This term is important because it refers to the vaccine’s ability to confer protection against both the original COVID-19 virus as well as new variants Omicron BA.4 and BA.5. Rollout of the updated vaccine began in September 2022 for those aged 12 years and older and became widespread in March 2023 with approval granted for use in children aged 6 months – 4 years. Selected individuals over age 65 or those who are immunocompromised may receive additional doses to provide comparable and safe protection. The receipt of the updated vaccine supersedes any previous doses and provides coverage against the most recent known variants determined to be either most widespread or that have been projected to be more prevalent.Children aged 6 months – 4 years who received the original Pfizer vaccineThose who received either 2 or 3 doses of the original vaccine should receive 1 dose of the updated vaccine.Those who received 1 dose of the original vaccine should receive 2 doses of the updated vaccine.You are considered up to date if you have received 3 vaccine doses, including at least 1 updated dose.Children aged 5 years who received the original Pfizer vaccineThose who received 1+ doses of the original vaccine should receive 1 dose of the updated vaccine.You are considered up to date if you have received at least 1 updated dose.Children aged 6 months – 4 years who received the original Moderna vaccineThose who received either 2 or 1 dose(s) of the original vaccine should get 1 updated vaccine.Children aged 5 years who received the original Moderna vaccineThose who received either 2 or 1 dose(s) of the original vaccine should get 1 updated vaccine.Unvaccinated children 6 m-4 years should receive the new bivalent vaccine, 2 doses ofModerna or 3 doses of Pfizer, but if you are 5 years old and unvaccinated, you will receive 1 dose of Pfizer or 2 doses of Moderna.For 6-11 yo patients who have been vaccinated with 1 or more doses of monovalent (Moderna or Pfizer) will receive 1 dose of Bivalent Moderna or Pfizer. If you already received 2 monovalent doses and 1 bivalent dose, you are done, no more vaccines are needed. If you have not received any COVID-19 vaccine and you are in this age group (6-11 yo), you only need 1 bivalent dose, and you are done.>12 yo and Adults. If you received 1 or more doses of monovalent or if you are not vaccinated, you need 1 dose of bivalent (Pfizer or Moderna). If you already had 2 doses of monovalent and 1 dose of bivalent, you are done!An FDA advisory committee convened on June 15, 2023, to discern the importance for additional updates to the most recent COVID-19 vaccine series. It was determined that the latest circulating variant currently making rounds is from the Omicron group known as XBB. The committee decided it is prudent to proceed with a preference for the XBB 1.5 variant. The updated vaccine will be a monovalent version available in the Fall of 2023. As with the previous version, the FDA will provide strict oversight and safety monitoring of the vaccine._______________________________Conclusion: Now we conclude episode number 149, “COVID Vaccines Updates.” Future Dr. Williams explained t

Episode 148: Leg CrampsFuture Dr. Weller explains the pathophysiology, management, and prevention of leg cramps. Hector Arreaza adds comments and anecdotes about leg cramps. Written by Olivia Weller, MS4, American University of the Caribbean School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition: Known also as “Charlie horses,” leg cramps are defined as recurrent, painful, involuntary muscle contractions. They can last anywhere from seconds to several minutes, with an average of nine minutes per episode. They are usually nocturnal and thus may be associated with secondary insomnia. Location: A muscle cramp can happen in any muscle in the body, but they occur most commonly in the posterior calf muscles, but they can also involve the thighs or feet. They are more common in women than men and the risk increases with age.Although they are experienced by 7% of children and up to 60% of adults, the exact mechanism remains unknown and there is no definitive treatment at this time. PathophysiologyThere is one leading hypothesis for nocturnal cramps that occur in the posterior calf muscles, and it is related to your sleeping position. When you are laying down in bed your toes are pointed which causes passive plantar flexion while the muscle fibers are shortened maximally. This causes uninhibited nerve stimulation with high-frequency involuntary discharge from lower motor neurons, which causes cramping. Another possible etiology is nerve damage because neurologic conditions such as Parkinson’s disease are associated with a higher-than-normal incidence of cramps. Peripheral neuropathy, or damage to the connection between motor nerves and the brain can lead to hyperactive nerves when they are not being properly regulated. Thus, diabetes mellitus is a major risk factor for nocturnal cramps due to the high blood sugar levels damaging the small blood vessels which supply the muscles. Decreased blood flow has also been attributed as a cause of leg cramps. People with diseases that affect their vasculature, such as varicose veins or peripheral arterial disease also have a higher incidence of leg cramps. Decreased blood flow to the muscles means less delivery of oxygen and nutrients to the muscles which makes them more susceptible to fatigue. Muscle overuse is one of the dominant explanations for cramping. This can be related to doing too much high-intensity exercise without adequate stretching before and after. Pregnant women have added weight which puts extra strain on the muscles, along with sitting or standing for long periods of time, poor posture and flat feet. Notably, when we age, our tendons naturally shorten and they cannot work as hard, or as quickly which makes them more susceptible to overuse. Additionally, there are mineral deficiencies such as magnesium and potassium or decreased levels of B and D vitamins. With this in mind, people with renal failure that are on hemodialysis have an increased risk of nocturnal leg cramps. And finally, we have medications, some of which are related to mineral deficiencies. The main contributors are statins, diuretics, conjugated estrogens, gabapentin or pregabalin, Zolpidem, clonazepam, albuterol, fluoxetine, sertraline, raloxifene, and teriparatide (analog for parathyroid hormone). Management and preventionThere is no magic treatment to make them go away immediately, however, there are different remedies you can try to help facilitate. My Grandma told me about an old wives' tale, that if you put a bar of soap in your bed at your feet while you sleep, you won’t get cramps at night. Maybe it works by the placebo effect, maybe there's a mechanism going on there I don't understand who knows, I’ll have to do a study on it. If you get them very often, you can keep a foam roller or a heating pad next to your bed in preparation for when they come. Stretching the muscle is known to be very effective, as well as applying heat or ice to the affected area. You can also try massaging the muscle with your hands or getting out of bed to stand or walk around. Elevating the leg while laying down in bed can also be beneficial. In terms of prevention, you can try out different sleeping positions to see if one works better for you. If you usually sleep on your back, you can stick a pillow under your feet to help keep your toes pointed upward. Or, if you sleep on your stomach you can try to keep your feet hanging off the bed. Another tip is loosening the sheets or blankets around your feet. Daily stretching, especially before and after exercise as well as before bed is useful. Make sure to exercise, stay hydrated

Episode 147: Routine Prenatal CareWritten by Elika Salimi, MSIV. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice._____________________Elika: So, we’re going to talk about some general principles of prenatal care and some of the most important diagnostic methods that we mainly use for taking care of pregnant women. I will forewarn you that there will be a ton of details in this talk, and I do recommend possibly taking notes as things can get easily confusing. This way you can have something to refer back to whenever you have a pregnant patient of your own.Arreaza: You can also download the episode notes from our website.Elika - So your patient is pregnant and she comes to you for care. How do we go about it? Well, this is assuming she had it at home urine pregnancy positive test and we got a blood hCG on her and everything’s good and we know she’s pregnant. Ok so now what happens next?Arreaza – We need to confirm the patient wants to keep the pregnancy.Elika - First, we’re going to talk about the frequency of the check-ups. In this case, we are talking about a situation where the mother is coming to her appointments as she was supposed to but we all know that sometimes that doesn’t happen if everything is going as it is supposed to then typically we get the initial examination at about 10 weeks of gestation and then until the 28th week there should be monthly visits, then from the 28th through the 36th there should be biweekly visits, and from the 36th week until birth, the visits are every week.Areaza – What´s next?Elika - Now I’d like to note that during the prenatal period, informed consent is very important and it should be obtained during this time because you want to prevent and manage any ethical conflicts that might exist between the mother and possibly the healthcare providers because we all know that any pregnancy can become high-risk at some point and pregnant individuals should be informed about the potential need for a c-section for example and be encouraged to discuss any concerns ahead of time. Elika - Now while we’re talking about ethics, if the doctor finds him/ or herself in a situation where the patient is asking for something that the Dr does not feel comfortable with such as a certain type of treatment or a certain method of delivery or if they’re, let’s say, desiring an abortion and the doctor doesn’t do abortions, then in this case you would refer the patient to a physician that is comfortable with the patient’s desired outcome or treatment. And this is perfectly legal and fine just as long as you help the patient find somebody else. Arreaza – Abortion is legal in most states, but check your local regulations.Elika - So as mentioned earlier, the initial visit occurs at about 10 weeks of gestation. We start with checking their personal and family history and finding out about any previous pregnancies including at what GA baby born and weight if they know, any complications, gestational diabetes or preeclampsia, any history of postpartum hemorrhage requiring blood transfusion, any abortions (if present at what GA), and the method of deliveries, whether it was vaginal or a cesarean and what kind of C-section they had done. These are very important for you to obtain from your patient. You will also assess for depression and domestic partner violence.Arreaza – In California, we have a wonderful service called CPSP: Comprehensive Perinatal Services Program. What comes next? Elika - Upon receiving the history, we will do the gynecological examination and send in some samples. We will also send her to do some lab work. Now what do those labs entail? Well, we are going to get a CBC such as screening for anemia, we will also do TSH but only in people who have possible signs of thyroid disorder so not everybody needs to get this. And, we are going to send for a blood typing to find out about their ABO group and the Rhesus status. We will also obtain a urine analysis to screen for proteinuria and asymptomatic bacteriuria because in pregnancy, unlike outside of pregnancy, you do need to treat asymptomatic bacteriuria. We will also ensure that the mother is on prenatal vitamins, so folic acid, if not already, and iron, if indicated, and vitamin B6 if the patient has signs of nausea or hyperemesis gravidarum and this can be combined with doxylamine. Usually, pregnant women don’t get a glucose screening test at the first visit unless let’s say they have high risk of diabetes or they there was glucose in the urine. Arreaza – I like the topic of

Episode 146: RA vs OA Future Dr. Magurany explains how to differentiate rheumatoid arthritis from osteoarthritis. Written by Thomas Magurany, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.1. Etiology: Rheumatoid Arthritis (RA): RA is an autoimmune disease wherein the immune system mistakenly attacks healthy tissues, particularly the synovial joints, usually between the ages of 30-50. Genetic predisposition, environmental factors such as smoking or infections, hormonal imbalances, and lower socioeconomic status have been associated with an increased risk of developing RA(1).Osteoarthritis (OA): OA primarily arises due to mechanical stress on the joints over time. Factors contributing to OA include age, obesity, joint injury or trauma, repetitive joint use or overuse, genetic abnormalities in collagen structure, and metabolic disorders affecting cartilage metabolism (2).The greatest risk factor for the development of OA is age with most patients presenting after 45 years of age. The greatest modifiable risk factor for OA is weight. People with a BMI >30 were found to have a 6.8 times greater risk of developing OA. (3) Primary OA is the most common and is diagnosed in the presence of associated risk factors such as: older age, female gender, obesity, anatomical factors, muscle weakness, and joint injury (occupation/sports activities) in the absence of trauma or disease. Secondary OA occurs alongside a pre-existing joint deformity including trauma or injury, congenital joint disorders, inflammatory arthritis, avascular necrosis, infectious arthritis, Paget disease, osteopetrosis, osteochondritis dissecans, metabolic disorders (hemochromatosis, Wilson’s disease), Ehlers-Danlos syndrome, or Marfan syndrome.2. Pathogenesis:Rheumatoid Arthritis (RA):In some patients, RA is triggered by some sort of environmental factor in a genetically predisposed person. The best example is tobacco use in a patient with HLA-DRB1. The immune response in RA starts at sites distant from the synovial joints, such as the lung, gums, and GI tract. In these tissues, modified proteins are produced by biochemical reactions such as citrullination. (4)In RA, an abnormal immune response leads to chronic inflammation within the synovium lining the joints. The inflammatory cytokines released cause synovitis and lead to the destruction of articular cartilage and bone erosion through pannus formation. Immune cells infiltrate the synovium causing further damage. (4) In summary: formation of antibodies to citrullinated proteins, these antibodies begin attacking wrong tissues.Osteoarthritis (OA):The primary pathological feature of OA is the degeneration of articular cartilage that cushions the joints causing surface irregularity, and focal erosions. These changes progress down the bone and eventually involve the entire joint surface. Mechanical stress triggers chondrocyte dysfunction, leading to an imbalance between cartilage synthesis and degradation that cause cartilage outgrowths that ossify and form osteophytes. This results in the release of enzymes that degrade the extracellular matrix, leading to progressive cartilage loss. As more of the collagen matrix is damaged, chondrocytes undergo apoptosis. Improperly mineralized collagen causes subchondral bone thickening; in advanced disease, bone cysts infrequently occur (5). In summary: Osteophytes formation and cartilage loss.3. Clinical Presentation:Rheumatoid Arthritis (RA):The most common and predominant symptoms include joint pain and swelling, usually starting insidiously over a period of weeks to months. RA typically affects multiple joints symmetrically, commonly involving small joints of the hands, wrists, feet and progresses to involve proximal joints if left untreated. Morning stiffness lasting more than an hour is a characteristic feature. The affected joint will be painful if pressure is applied to the joint or on movement with or without joint swelling. Synovial thickening with a "boggy" feel on palpation will be noted. The classical physical findings of ulnar deviation, metacarpophalangeal joint subluxation, swan neck deformity, Boutonniere deformity, and the "bowstring" sign (prominent and tight tendons on the dorsum of the hand) are seen in advanced chronic disease. (4) Around ¼ of patients with RA may present with rheumatoid noduleswhich are well demarcated, flesh-colored subcutaneous lumps. They are usually described as being doughy or firm and are not typically tender unless they are inflamed. They are usually found on areas susceptible to repeated trauma or pressure and inc

Episode 145: Family Planning for the LGBTQIA+Future Dr. Hoque explains how to assist with family planning for the LGBTQIA+ community. Some principles such as avoiding unintended pregnancies and reducing and early treatment of STIs are discussed. Written by Ashfi Hoque, MBA, MS4, Ross University School of Medicine. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: Welcome to episode 145 of the Rio Bravo qWeek podcast. My name is Hector Arreaza, a faculty member of the Rio Bravo Family Medicine Residency Program.Ashfi: Hello everyone, I am Ashfi Hoque a 4th-year medical student at Ross University School of Medicine. I am from Long Beach, California. Patient advocacy and patient-centered care have always been a priority of mine. I’ve volunteered for years at the LGBT+ center in Weho and Long Beach. Today we will be discussing Family Planning for everyone while learning ways to become LGBTQIA+ inclusive. Arreaza: Yes, family planning is important, and I’m glad you included all types of families. I believe medical care must be offered to everyone, and I also believe in freedom of conscience, that’s why I can freely express that I support traditional family for me. Why did you choose this topic?Ashfi: I chose this topic because my partner recently went to get her physical. Her provider had an extensive conversation about family planning and even discussed the anticipated cost of freezing her oocytes. I really loved the way this provider went about the conversation so I started researching ways I can support my community and also teach others to provide Queer inclusive medical care. What is LGBTQIA+?LGBTQIA+ stands for Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual, etc. The community will be referenced as the Queer community, an umbrella term for people who are not heterosexual or not cisgender. There are many inequalities that the community faces and we can do our due diligence to educate ourselves continuously and be aware that terminology and health needs may change. We have another Rio Bravo episode, Caring for LGBTQ+ Patients on Episode 103, that discusses healthcare disparities, but during this episode, we will be diving into an introduction to bridging health gaps, creating health equity, and building trust with the community. A 2023 Global Survey found that the self-identified Queer community represents 9% of the population, while the true estimate may be higher due to safety concerns. While diabetics are 10-13% of the population. These statistics show that as a medical provider, you'll encounter Queer patients more often than you think. One of the healthcare issues that Queer folks face is a lack of family planning.What is Family Planning?The World Health Organization (WHO) defines family planning as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through the use of contraceptive methods and the treatment of involuntary infertility.”Family planning serves three critical needs: Avoiding unintended pregnanciesReducing sexually transmitted diseases (STDs)Early treatment of STDs to reduce rates of infertilityWhen discussing family planning for patients, here are some examples of questions you can ask. What name may I use to address you?What are your pronouns?What is your gender? (Only if necessary for care, what is your assigned sex at birth?)Are you sexually active?What is the gender(s) of your partner(s)?Are you concerned about unintended pregnancy?Are you currently using any contraceptive measures?Are you taking any precautions to reduce STI/STD such as physical barriers like condoms, dental dams, or any harm reduction such as PrEP?What kind of STI/STD screening are you requesting?Do you need me to request additional labs such as oral or anal swabs?Those questions must be asked in a natural, non-judgmental way. While STD/STI screening and treatment is part of family planning, the part that we tend to neglect is the desire for Queer folks to build a family. Why is Family Planning Important for the LGBTQIA+ community?The Queer community gained the legal right to marry eight years ago, in 2015. They did not have the nationwide right to adopt until the last state, Mississippi, overturned the unconstitutional restrictions for the Queer community to adopt in 2016. A UCLA study in 2018 titled, “How many same-sex couples in the US are raising children?” reported cis-heterosexual couples: 3% are raising at least one adopted child and 95% are raising biological children while same-sex couples: 21.4% are raising at least one adopted child and 68% have a biological

Episode 144: Risk Factors for Pediatric Overweight and ObesityFuture Dr. Lal describes multiple risk factors associated with childhood overweight and obesity. Dr. Arreaza adds comments about caring for pediatric patients with obesity. Practice guidelines are mentioned throughout this episode.Written by Krustina Lal, MSIII, Western University College of Osteopathic of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction:Obesity is one of the most common pediatric chronic diseases affecting 14.4 million children and adolescents (about twice the population of New Jersey).A recent simulation study from the US found that by 2030, a staggering 55–60% of today’s children will be obese.1 in 4 children in California have obesity.Research shows that the ages between 0 and 5 years is a critical period in the development of overweight and obesity. Obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. Pediatricians and other primary care physicians need to be aware of the risk factors for pediatric obesity to provide early anticipatory guidance for prevention, close monitoring, and early intervention when the weight trajectory increases.We will discuss the risk factors for children and adolescents to develop overweight and obesity, we will be diving deep into general, environmental, and familial factors. This is based off the AAP (American Academy of Pediatrics) “Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.” This guideline was published in February 2023, it is available online for free, and this is the first edition.A. General Factors- Socioeconomic StatusA longitudinal analysis of predominantly non-Hispanic white children in the United States found that low socioeconomic status before 2 years of age was associated with higher obesity risk by adolescence in both boys and girls.Poverty is associated with toxic stress, limited access to healthy foods, and low physical activity.-Children in Families That Have Immigrated to the USRecently arrived immigrants tend to be healthier than their US-born counterparts. However, as immigrants try to adjust to a new culture, they may adopt Americanized foodways, which are high in fat, sugar, and salt.Second-generation Hispanic immigrants are 55% more likely to have obesity than nonimmigrant white children, whereas first-generation Asian immigrants had a 63% lower risk of having obesity.Larger body sizes may be an indication of health and wealth in some cultures. This cultural factor may make it more difficult for parents to understand the gravity of their children’s obesity.Comment: This is a common concern among Hispanic families that bring their children to the clinic to get “vitamins” to gain weight because they look “sick,” but their BMIs are normal. PCPs should be prepared to address that concern in the clinic.B. Neighborhood and Community Environments-School EnvironmentThe presence of fast foods, vending machines, and/or sweetened beverages in schools may negatively influence children’s food choices, this effect is larger in younger grades.One day I went to have lunch with Devin, I liked that they had to go through the salad bar before they went to get other foods. They had the choice between vegetables or fruits.-Lack of Fresh Food AccessNeighborhood food environment has been shown to have a mixed association with children’s BMI.Children and families in these settings may be unable to access fresh fruits and vegetables and safe physical activity spaces. There may be limitations in transportation, cost, affordability, and availability.-Fast food proximityLow-priced, calorie-rich fast foods with elevated levels of saturated fat, simple carbs, sugar, and sodium are commonly sold in fast food restaurants. Because they are easily available, they taste good, and they are strategically marketed, fast foods tend to be popular among children and adolescents.Some studies, not all, have shown an association between fast food locations near schools and obesity in children; a stronger association is seen in populations with lower socioeconomic status.-Access to safe physical activityGreater exposure to green space has been shown to be associated with higher levels of physical activity and a lower risk of obesity.That is something we have to recommend during our well-child visits. We are seeing a lot of aversion to going outside among the new generations. Going out seems to be torture when they find so much fun inside their houses (countless amounts of videos, video games, air conditioning/heater, etc...). A strategy f

Episode 143: Pulmonary Cocci BasicsDr. Lovedip Kooner explains the history, diagnosis, and treatment of pulmonary coccidioidomycosis (cocci for short.) Disseminated cocci infection was also discussed. Dr. Arreaza added some anecdotes of patients seen with this infection. Written by Lovedip Kooner, MD. Comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition:Coccidioidomycosis, also known as Valley Fever, is an infection caused by the fungi Coccidioides immitis and Coccidioides posadasii. Coccidioides is also referred to as cocci. Generally speaking, C. immitis is found in California and C. posadasii is found in Arizona, and Central and South America. More recently Cocci has also been found as far north as Washington and British Columbia. History:The fungal infection was first reported by Wernicke and Posadas in Argentina in 1892 where they described a case where a man had cutaneous cocci of the head, arm, and trunk. To this day, the head is preserved in Argentina. 4 For many years, only disseminated cases were recognized and described as “coccidioidal granulomas.” The work of Dixon and Gifford in 1935 elucidated that a pneumonic disease of unknown cause termed “San Joaquin Valley Fever” was, in fact, the primary coccidioidal infection and the port of entry of almost all coccidioidal disease. Initial infection occurs predominantly by inhalation of aerosolized arthroconidia and rarely by direct cutaneous inoculation.1,2Coccidioides spp. survive best in areas with low rainfall (12–50 cm per year), limited winter freezes, and alkaline soils. With climate change models, predicting the geographical range expansion.These dimorphic fungi exist in a mycelial form in the soil. Coccidioides species have been found in animal burrows near the Kern River and in Armadillo burrows in South American countries like Brazil. The mycelia produce arthroconidia (spores) that are ultimately airborne and inhaled.The inoculum required for infection is low and in animal models as few as a single arthroconidium may cause infection.3 Infection:Once arthroconidia are inhaled into the lung, there is typically a 1-3-week incubation period. The arthroconidia undergo morphologic changes into spherules, which are large structures that contain endospores.4 As spherules mature, they rupture and release endospores. Endospores can be spread hematogenous or through lymphatics to essentially any organ, leading to the development of new spherules and potentially disseminated disease.5 Not everyone who inhales the arthroconidia gets the infection. Clinical Manifestations.About 60% of patients who inhale arthroconidia are asymptomatic. 30% have a mild respiratory illness, like the flu. 10% have a more serious disease course and are diagnosed. Other symptoms may include fever, drenching night sweats, and weight loss. Extreme fatigue that limits baseline activity may also raise concerns. Symptom onset up to 2 months after endemic exposure should lead to coccidioidomycosis on the differential. Coccidioidomycosis cases have been documented in Michigan, Europe, and China. These cases were of people who traveled to endemic areas for as little as a few days and then were later diagnosed. 1-3% of all coccidioidomycosis cases are disseminated, severe, or chronic pulmonary infections. If undiagnosed, coccidioidomycosis may lead to significant morbidity and mortality. Dissemination sites include the skin, lymph nodes, bones, and Central Nervous System (CNS) which is the most severe. Any organ can be infected, including documented cases of the prostate and adrenal gland. Arreaza: Recap: 60% are subclinical, 30% are mild, 10% serious, 1-3% are disseminated. What are some risk factors for severe infection? Should I stop biking?Risk factors for severe infection:Severe pulmonary infections can happen in anyone but occur more commonly in diabetics, tobacco users, and people older than 65 years of age.Oceanic or Filipino ethnicity and black or African American have a higher rate of dissemination. Immunosuppression, including HIV, transplant patients, and immunosuppressive medications like corticosteroids or TNF-alpha inhibitors have been shown to be risk factors for dissemination. Pregnant patients, particularly in the third trimester have higher rates of severe infection as well.Arreaza: How do we diagnose the disease?Diagnosis:Diagnosis is commonly made serologically. EIA (enzyme immunoassay) is used more often. There are more false positives than false negatives and varies by manufacturer. Kern County Health Department uses Immunodiffusion IgG and IgM and Complement Fixation are used. Immunodiffusion I

Episode 142: Tirzepatide IIFuture Dr. Beuca explains that tirzepatide has shown benefits in patients with obesity that go beyond its weight-reducing effects and includes reduction of blood pressure, among others. Dr. Arreaza explains that Wegovy (semaglutide approved for weight loss) is also very beneficial for weight loss and explains. Written by Maria Beuca, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Maria: Hello everyone, today is June 2, 2023, and we want to re-visit our discussion about the drug Tirzepatide from our May 19th, 2022. A little re-cap for those of you who don’t know, tirzepatide, also known by the brand name Mounjaro, is a drug that was approved by the FDA a year ago for the treatment of type 2 Diabetes. It is similar to the drug Semaglutide, also known by the brand name Ozempic which many of you may be more familiar with, thanks to the Kardashians and other celebrities making it popular as a “weight loss” drug. Arreaza: The brand name for weight semaglutide is Wegovy.Maria: Both of these drugs are injected once a week and mimic the effect of the incretin hormone GLP-1 by binding to its receptor. Incretin hormones are a group of hormones that cause insulin to be released from the pancreas after eating to help lower blood sugar levels. These incretin hormones also help suppress the appetite, causing you to eat less and lose weight. Tirzepatide is different because it is the first drug to mimic the action of two hormones, both GLP-1 and GIP. In our last episode, we also discussed the SURPASS-2 study that showed tirzepatide to be superior to semaglutide because of this dual incretin action, with greater weight loss, lower HA1c levels, and lower triglyceride and VLDL levels. At that time, we also mentioned the SURMOUNT-1 Phase 3 clinical trial that was ongoing at the time. Well, it is now complete, and the results are in. There were 2,539 obese or overweight participants without diabetes in the study who lost between 16-22.5% of their starting weight on Tirzepatide. On 15 mg dose, participants lost about 52 lbs (24 kg), on 10 mg 49 lbs (22 kg) and on 5 mg about 35 lbs (16 kg), but those on the placebo lost only 2.4% or about 5 lbs (2 kg). As you can see there is very little difference in weight loss between the 10 mg dose and the 15 mg dose, although a big difference is seen compared to the 5 mg dose. It’s important to note that they took Tirzepatide for 72 weeks or a year and a half. Arreaza: That’s very significant weight loss. It is important to emphasize that these patients did NOT have diabetes. Maria: These weight loss results have proven to be comparable to bariatric surgery. The study also showed improvement in cardiovascular and metabolic risk factors such as lower blood pressure, fasting insulin, lipid levels and even aspartate aminotransferase levels in comparison to the placebo. By the end of the study, more than 95% of the participants who had pre-diabetes had converted to normal glucose levels. This study was so impressive that it was presented at the 82nd Scientific Sessions of the American Diabetes Association and was also published in The New England Journal of Medicine. Arreaza: It seems like tirzepatide is ahead of the game for weight loss.Maria: Although it is approved as a drug for diabetes, the next step is to approve it for weight loss and to begin treating obesity as a chronic disease that needs to be treated. Maria: And this makes sense. Currently, more than 4 in 10 American adults have obesity, and obesity is the cause of many other conditions. Just yesterday, I was seeing patients in the orthopedic clinic and I had several patients being seen for knee pain due to obesity, and they are postponing surgery because they have been losing weight on tirzepatide and are already feeling better. I think avoiding knee surgery alone is a pretty good reason to approve these drugs for weight loss, but there are many other conditions that are improved by weight loss. Arreaza: My anecdotes are related to semaglutide, but I can imagine that this may also apply to tirzepatide. I had a patient who was able to stop all antihypertensive medications because of 40-lb weight loss. Maria: Dr. Caroline Apovian, director of the Center for Weight Management and Wellness at Brigham Women’s Hospital, states that “If everybody who had obesity in this country lost 20% of their body weight, we would be taking patients off all these medications for reflux, for diabetes, for hypertension. We would not be sending patients for stent replacement.”Maria: Last month, officials from Eli Lilly, the com

Episode 141: Adrenal Insufficiency BasicsFuture doctor Wilson explains how to recognize an acute adrenal insufficiency and explains how to treat it. Also, chronic adrenal insufficiency is explained. Dr. Arreaza adds comments about congenital adrenal hyperplasia.Written by Candace Wilson, MSIV, American University of the Caribbean. Comments by Hector Arreaza, MD.June 2, 2023.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: After having seen patients with adrenal insufficiency when I did a rotation in ICU, I saw how important it is to be able to recognize it quickly to ensure that patients receive appropriate treatment as quickly as possible. Arreaza: AI is adrenal insufficiency but also AI stands for Artificial intelligence, so we had the idea to ask Chat GPT what are the adrenal glands and this is what we got: “The adrenal glands are small endocrine glands located on top of each kidney. They are small in size, but they play a vital role in producing and secreting essential hormones.” (end of quote)Glucocorticoids play an important role in the mobilization of energy reserves by increasing gluconeogenesis, glycogen synthesis, protein catabolism, lipolysis, appetite, and insulin resistance. Each adrenal gland is composed of two main parts: the outer region called the adrenal cortex and the inner region called the adrenal medulla. These two regions have distinct structures and functions.” The adrenal cortex has three zones, Zona glomerulosa (mineralocorticoids, mainly aldosterone), Zona fasciculata (cortisol), and Zona reticularis (androgens). Mineralocorticoids are a class of steroid hormones produced by the Zona glomerulosa of the adrenal gland that influence electrolyte and water balance through modifying renal absorption of sodium and potassium.Definition of AI: AI is “inadequate functioning of the adrenal glands”. Adrenal gland hormones: glucocorticoids, mineralocorticoids, and sex hormones.Primary vs. secondary adrenal insufficiency.Candace: Primary adrenal insufficiency is caused either by the abrupt destruction of the adrenal gland or by progressive destruction/atrophy, whereas secondary adrenal insufficiency is due to conditions that impair the hypothalamic-pituitary-adrenal axis leading to decreased ACTH production. Causes of primary adrenal insufficiency includes autoimmune adrenalitis (which is the most common cause in the US); infectious adrenalitis (tuberculosis being the most common cause worldwide); adrenal hemorrhage; infiltration of the adrenal gland by tumors, amyloidosis, or hemochromatosis; adrenalectomy; cortisol synthesis inhibitors (such as rifampin, fluconazole, phenytoin, ketoconazole); 21B-hydroxylase deficiency; and vitamin B5 deficiency. Fluconazole is commonly used to treat pulmonary cocci (Valley Fever in our community). What about secondary causes?Causes of secondary adrenal insufficiency include sudden discontinuation of chronic glucocorticoid therapy; stress (such as infection, trauma, or surgery) during prolonged glucocorticoid therapy; and hypopituitarism. Clinical presentation of adrenal crisis.Adrenal insufficiency can present acutely or chronically with more insidious symptoms. We will first discuss the acutemanifestation of adrenal insufficiency, also known as adrenal crisis. In any patient who demonstrates vasodilatory shock, unexplained severe hypoglycemia, or unexplained hyponatremia whether or not the patient is known to have adrenal insufficiency, adrenal crisis should be considered a possibility. Adrenal crisis is a life-threatening emergency that requires immediate medical treatment and can occur in either primary or secondary adrenal insufficiency, though it is most common in patients with primary adrenal insufficiency. The main feature of adrenal crisis is shock, but patients may also have vague symptoms such as anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, fever, confusion, or coma. In patients with adrenal crisis from primary adrenal insufficiency, volume depletion and hypotension are the major clinical features, resulting from mineralocorticoid deficiency. In contrast, the patients with adrenal crisis from secondary adrenal insufficiency (which is an isolated glucocorticoid deficiency) will have hypotension secondary to decreased vascular tone without volume depletion.Treatment of adrenal crisis.Signs of an adrenal crisis should be recognized quickly, and management should be started as quickly as possible. When adrenal crisis is suspected, do not wait for laboratory results before initiating treatment as this is a life-threatening medical emergency. After all necessary laboratory tests have

Episode 140: Bullous pemphigoid basicsFuture Dr. Stetkevych explains the diagnosis and treatment of bullous pemphigoid. She explains how to differentiate BP from pemphigus vulgaris. Dr. Arreaza added some comments and summaries. Written by Katherine Stetkévych, MSIV, Ross University School of Medicine.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Bullous pemphigoid is an autoimmune condition in which the body produces antibodies against hemidesmosomes at the basement membrane of the skin. (Hemidesmosomes anchor the epidermis to the dermis.) As a result of this autoimmune reaction, inflammatory cells, and fluid fill under the epidermis, creating a blister.As a reminder, a vesicle is a collection of free fluid Presentation.Typically, bullous pemphigoid affects adults over the age of 60. We can say that it is a disease of elderly patients; the mean age of diagnosis is 80. There is no race or gender preference. The initial presentation is hives and pruritus. Patients may be itchy for ~10 months before the diagnosis. After patients have plaques, erythema, and itching, they have blisters. What is notable about the blisters in bullous pemphigoid is that the blisters are taut. They bulge out from the skin; however, they do not spread when pressure is applied laterally to the blister, and pressing on an unaffected skin area will not cause a new blister to form. The spread or creation of a blister with pressure is called the Nikolsky sign, and the fact that bullous pemphigoid is negative for the Nikolsky sign helps differentiate this condition from pemphigus vulgaris. Another notable feature is that the blisters of bullous pemphigoid are painless.If the blisters rupture, patients may experience short-term pain, but the erosion on the skin after the blisters rupture heal fast without scarring. Bullous pemphigoid typically does not involve the oral mucosa; however, there is a subtype that does. Nonetheless, should a patient present with bullae that involve the oral mucosa, it is important to test for the Nikolsky skin, determine whether the blisters are painful, and work up the blisters to determine the correct diagnosis.Diagnosis.The differential diagnosis is extensive and includes dermatitis herpetiformis, bullous systemic lupus erythematous, bullous drug eruptions, bullous impetigo, even insect bites, burns, erythema multiforme, and contact dermatitis. You can find non-specific findings such as peripheral eosinophilia in 50% of the patients. Serum tests include pemphigoid antibodies ELISA: BP 180 and 230 autoantibodies, desmoglein (desmoglain) 1 and 3. To get to a definitive diagnosis, you need a skin biopsy for histology and immunofluorescence. Histology will show subepidermal cleavage and the presence of inflammatory infiltrate with eosinophils or neutrophils. The diagnosis will be confirmed by direct immunofluorescence (DIF). The biopsy should be taken from inflamed skin next to a blister with 2/3 of normal skin and 1/3 of inflamed skin. The sample can be transported in normal saline. Management.Bullous pemphigoid is treated with first-line topical high-potency corticosteroids, such as clobetasol. In cases of severe bullae, systemic corticosteroids or doxycycline may be prescribed. For patients with refractory bullous pemphigoid, the appropriate next step is to start biologic therapies.With treatment, the prognosis is generally good for bullous pemphigoid. Some patients have spontaneous remission of the disease within a few years; however, for many, the disease is chronic, with recurrence and remission over months to years. If left untreated, bullous pemphigoid is usually a chronic, progressive disease that may cause functional limitation. Mucous membranous pemphigoid, the subtype of bullous pemphigoid which involves mucous membranes, may potentially be life-threatening if it involves the airway.Pemphigus vulgaris. Pemphigus vulgaris is an autoimmune condition similar to bullous pemphigoid. In pemphigus vulgaris, autoantibodies attack desmosomes in the epidermis, specifically desmoglein. Desmoglein is a cadherin protein that holds cells within the spinous layers of the epidermis together. Autoimmune destruction of desmoglein causes blisters to form superior to the basement membrane.The average age of onset for pemphigus vulgaris is 40-60 years old. There is an increased prevalence of the disease in Ashkenazi Jewish, Indian, Southeast European, and Middle Eastern descent.Presentation.Because the basement membrane of the epidermis remains intact, and the protein responsible for cell-to-cell adhesion is destroyed by the immune system, bullae are easily formed. Thus, Nikols

Episode 139: What is PCOS Future Dr. Salimi explains the pathophysiology, signs, and symptoms of PCOS. Diagnostic criteria and the basics of treatment are also discussed. Dr. Arreaza adds some comments about the treatment of obesity. Written by Elika Salimi, MS3, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Hello there! My name is Elika and I am a third-year medical student at Western University of Health Sciences. Today I will be talking to you about polycystic ovary syndrome AKA PCOS.Do you have a female patient in her reproductive years with irregular menstrual cycles, or no menstrual cycles at all? Is she unable to conceive a child? Did she have an unexpected diagnosis of diabetes? Does she have more acne than she would like, or has hair in unwanted or unexpected areas such as her chin?Does she have a hard time losing weight? If you answered YES to many of these questions, it is possible that your patient is suffering from polycystic ovary syndrome also known as PCOS, which is one of the most common endocrine disorders in women. Pathophysiology:The exact pathophysiology behind this syndrome is unknown; however, per the American College of Obstetricians and Gynecologists committee, some studies have shown a strong association between PCOS and obesity. In a woman with obesity disorder, the excess adipose tissue ends up increasing peripheral estrogen synthesis and as a result, there is a decrease in peripheral sensitivity to insulin which means many of these women tend to have hyperinsulinemia. To be more detailed, it is important to mention that during these anovulatory cycles, the increase in estrogen, which is also unopposed estrogen with a lack of progesterone, can lead to endometrial hyperplasia and consequently increase the risk of endometrial carcinoma.Clinical Features: Unless there is a clear history and physical or if perhaps there was an incidental ultrasound finding of polycystic ovaries, the diagnosis of PCOS is not exactly black-and-white. That is why it is important to increase awareness so that women can put the pieces of the puzzle together and come in to get evaluated. Multiple cysts in ovaries can present in patients without PCOS, and they are common in teenagers. To use the multiple cysts as part of the diagnosis, the patient has to be 2 years after menarche (AAFP). Some of these clinical symptoms typically start during adolescence displaying menstrual irregularities such as she could’ve had her period and then stopped getting it or she has a very delayed onset of her menstrual cycle. It is also possible to have spotty menstrual cycles also known as breakthrough bleeding or menorrhagia. And very important to many women, she could be infertile or have difficulties conceiving.She could also have diabetes because of insulin resistance that comes with the metabolic syndrome that develops with PCOS, which is also increased if she has obesity. This obesity disorder going hand in hand with the metabolic syndrome, can also increase the risk of having sleep apnea, which could affect the quality of her sleep, finding herself more fatigued than she should be after adequate hours of rest. Other symptoms include skin conditions such as hirsutism which is basically male pattern hair growth in women in areas such as the upper lip, chin, around the umbilicus, back, or even buttocks. She could also have male pattern hair loss on the head or too much acne or oily skin or acanthosis nigricans which are these brown/velvety hyperpigmented streaks on the neck or axilla, or groin. She could also find herself more depressed or anxious.Diagnosis:The diagnostic criteria and treatments are mainly addressed in the Journal of Clinical Endocrinology & Metabolism, an evidence-based guideline for the assessment and management of polycystic ovary syndrome, and the American Family Physician Journal:The diagnosis of PCOS requires the presence of at least two criteria that are not due to any other endocrine disorder such as thyroid disease or hyperprolactinemia, or other. 1) Periods of oligo-ovulation and or anovulation which means she’s either having very low ovulatory cycles or she’s not ovulating at all. 2) hyperandrogenism and this could be based on her clinical features or laboratory studies showing elevated testosterone levels or LH to FSH ratio and 3) Seeing enlarged and/or polycystic ovaries on a pelvic ultrasound. This means that the pelvic ultrasound shows an ovarian volume of equal to or greater than 10 mL and/or there’s multiple cystic follicles that are about 2

Episode 138: SGLT-2 Inhibitors in heart failureFuture doctor Enuka explains the use of sodium-glucose-linked cotransporter-2 inhibitors (SGLT-2 inhibitors) in heart failure. Dr. Arreaza adds his experience with these medications and emphasizes their role as an effective treatment for type 2 diabetes. Written by Princess Enuka, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Intro:Heart failure is a major medical condition that affects millions of people worldwide. It is one of the leading causes of hospitalization and death in developed countries. Recently, SGLT2 inhibitors have emerged as a promising treatment option for heart failure. Today, we will discuss their benefits, their effectiveness, and their adverse effects.SGLT2 inhibitors, also known as sodium-glucose-linked cotransporter-2 inhibitors, are a relatively novel class of drugs that have shown promise in heart failure treatment. This transporter reabsorbs glucose from the glomerular filtrate back into the bloodstream. Under normal circumstances, SGLT-2 reabsorbs 100% of the filtered glucose unless it is saturated (as in hyperglycemia) or blocked by medications. SGLT2 inhibitors increase the amount of glucose excreted in the urine, which leads to blood glucose reduction. Examples include empagliflozin, dapagliflozin, and canagliflozin.SGLT-2 inhibitors have become a first-line therapy for diabetes mellitus. I heard before that it was used in Europe for T1DM, but it seems like they are no longer used, according to my most recent review of articles. SGLT2 inhibitors are not approved by the FDA for use in type 1 diabetes due to the risk of DKA. Princess, besides the benefits in diabetes, what else did you find in your review?Benefits/Efficacy:SGLT2 inhibitors have additional benefits beyond their glucose-lowering effects. One of the benefits of SGLT2 inhibitors is their ability to increase myocardial energy production, alleviate systemic microvascular dysfunction, and improve systemic endothelial function. Natriuresis and glucosuria mediated by SGLT2 inhibitors have been shown to lower cardiac pre-load and reduce pulmonary congestion and systemic edema, which is beneficial for heart failure management.Studies have shown that these drugs can also improve cardiovascular outcomes in patients with heart failure with a reduced ejection fraction. Some studies:The EMPEROR-Reduced trial demonstrated that empagliflozin, brand name Jardiance®, reduced the risk of cardiovascular death and hospitalization for heart failure in patients with reduced ejection fraction by 25% compared to placebo. Several clinical trials have also shown that this result is significant whether patients have type 2 diabetes or not. Also, in a multicenter, double-blind, randomized, placebo-controlled trial in patients with heart failure, treatment with dapagliflozin, brand name Farxiga®, improved heart failure-related symptoms and physical limitations after only 12 weeks of treatment. Patients treated with dapagliflozin had a significant, clinically meaningful improvement in the 6-minute walking test distance. The magnitude of these benefits was statistically and clinically significant, spanning all subgroups categorized. This included patients with and without type 2 diabetes and those with an ejection fraction above or below 60%.Anecdote:During a previous clinical rotation, I had a patient taking Jardiance for heart failure. He also had a history of chronic kidney disease and managed his condition well with medications and regular follow-ups. Interestingly, he was prescribed Jardiance®, which I initially believed was solely for diabetes management. When I asked him about it, he explained that his cardiologist prescribed Jardiance specifically for his heart. At the time, I did not understand the rationale behind prescribing Jardiance®, especially since the patient did not have type 2 diabetes. But after researching the medication, I figured that his cardiologist had chosen Jardiance® due to its demonstrated benefits in reducing the risk of cardiovascular death and hospitalization for heart failure. Although initially considered to be only glucose-lowering agents, the effects of SGLT2 inhibitors have expanded far beyond that. Their use has expanded to include heart failure and chronic kidney disease, even in patients without diabetes. It is, therefore, essential that cardiologists, diabetologists, nephrologists, and primary care physicians are familiar with this drug class.Adverse effects:It is worthwhile to note that SGLT2 inhibitors are not typically used as first-line treatment for h

Episode 137: Heart Transplant and LVADFuture Doctor My explains two treatments for advanced heart failure, heart transplant and Left Ventricle Assist Device (LAVD). Dr. Arreaza adds historical information about the first artificial heart implant and the first LAVD. Written by My Chau Nguyen, MSIV, American University of the Caribbean School of Medicine. Comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: Advanced heart failure is a major concern in the United States. Heart failure has a high 1-year mortality average of 33%. Although medical therapies have improved survival rates, some patients with progressive and advanced heart failure may still require heart transplantation or mechanical support such as left ventricular assist devices (LVADs) to prolong survival and improve quality of life.It is estimated that 23 million people in the world have heart failure, and many of them are in end-stage heart failure. When it comes to treating severe heart failure, there are two main options: heart transplantation and left ventricular assist devices (LVADs). Heart transplant: The operation to perform a heart transplant typically lasts between five to six hours but may take longer in patients who have undergone previous open-heart surgery or have an LVAD in place. However, because donors’ hearts are a scarce resource, not all patients are eligible for transplantation. The following are absolute indications for referral for Heart Transplant listing:Cardiogenic shock requiring continuous intravenous inotropic therapy (i.e., dobutamine, milrinone, etc.) or circulatory support with intra-aortic balloon pump counterpulsation devices or left ventricular assist device (LVAD) to maintain adequate organ perfusion.Peak oxygen consumption VO2 (VO2max) less than 10 mL/kg per minute.New York Heart Association NYHA class III or IV despite maximized medical and resynchronization therapy.Recurrent life-threatening arrhythmias unresponsive to medical therapy such as an implantable cardiac defibrillator, medical therapy, or catheter ablation.End-stage congenital heart failure with no evidence of pulmonary hypertension.Refractory severe angina without potential medical or surgical therapeutic options.Selected patients with restrictive and hypertrophic cardiomyopathies.My experience with a heart transplant: I consider myself extremely fortunate for witnessing the whole complex procedure involved in lung and heart transplantation at Jackson Memorial Hospital in Miami, FL. It was an incredible experience to join the transplant team in retrieving a donor organ. Timing plays a critical role in heart transplants. When a suitable donor becomes available, every second counts. We must quickly arrange transport and secure an operating room. It is essential that the distance between the donor and the hospital is within our designated region. For example, we are in Region 5, including Arizona, California, Nevada, New Mexico, and Utah. Once everything is in order, we divide into two teams. One team sets off to retrieve the donor while the other prepares the patient in the operating room. It is a race against time, as hearts and lungs must be transplanted within approximately four hours of removal from the donor. It was remarkable to see how everything was so precisely scheduled, from the arrival and departure of the teams to the transplantation of the organs. It is an inspiring experience to witness these life-saving procedures in action.History of the artificial heart.Arreaza: It is great to hear about your experience, but we know that not everyone can have a heart transplant. So, let us talk about other options. For example, an artificial heart. I lived in Utah for several years and I heard something about the first artificial heart being implanted there, so here is the information. William DeVries was the surgeon who led the implantation of the first artificial heart, the Jarvik-7, at the University of Utah on December 1, 1982. The patient was a retired dentist, Barney Bailey Clark, who survived 112 days connected to the device. Today, the modern version of the Jarvik-7 is known as the SynCardia temporary Total Artificial Heart. It has been implanted in more than 1,350 people as a bridge to transplantation.Left Ventricular Assist Device (LVAD):In recent years, LVADs have become increasingly popular as a viable alternative to transplantation, as they have demonstrated improved durability by using wear-free components, greatly improving mortality rates in heart failure patients. Arreaza: The first left ventricular assist device (LVAD) system was created by Domingo Liotta at B

Episode 136: Street Med 2. Future Dr. Bedi presents the history and purpose of street medicine and shares why she became interested in this topic. Dr. Saito tells his personal experience and shares the particular challenges of unhoused patients.Written by Indudeep Bedi, OMS III, MSIII, Western University of Health Sciences. Comments by Steven Saito, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Indu: I want to talk about street medicine in some general terms, as well as Tracy Kidder's article published in the NYT this year, called "You have to learn to listen," which is based on Kidder's book Rough Sleepers, on Dr. Jim O'Connell's work with the Boston homeless community. Dr. Saito: Let's start by talking about street medicine in general. What exactly is street medicine? Street medicine was a term coined by Dr. Jim Withers, from Pittsburgh, who has been practicing the art since the 90s. He founded the Street Medicine Institute (SMI) in 2009, which strives to connect providers worldwide to address homelessness. Providers practice healthcare, of course, but first and foremost, it is about building relationships and demonstrating you are one of them instead of the power differential that usually exists in our system. It requires a paradigm shift, and it's a shift in thinking. Dr. Jim Withers himself, for example, began to wear ragged clothes and put dirt in his hair to show these vulnerable individuals that he was accepting of who they were and respected them for it. In return, they respected him. Dr. Saito: Do you know of other programs which exist? There are a bunch of programs now that have spurred up, such as Doctors without Walls, San Francisco's community health center, of course, are very own CSV, and the Boston Pine Street shelter, which I will talk about more. The SMI publishes an annual report, and there are about 50 independent street medicine programs nationwide. Many global programs have sprung up, too. An international street medicine symposium was founded in 2005. In general, this is an excellent community of providers who can share best practices regarding this unique population. Even a student coalition at the SMI helps get student-run programs off the ground. Dr. Saito: What is one of the homeless community's biggest problems? That is a tricky question because of the complexity surrounding this issue. I will tackle this by answering that housing is one of the most considerable problems. The housing may be either transitional or permanent. Transitional operates to get the individual immediately off the street. In contrast, permanent housing takes longer to find, but many charities have bought real estate to create permanent housing. Permanent housing also includes the individual being vetted, in a lot of cases, to make sure that they will do okay if they have a place of their own. Are they able to be independent? Can they pay rent? Do they have a job? In 2009, however, a new program was implemented known as Housing First. This social program provided "a no-strings-attached" housing to the homeless population with substance use and mental health problems. What was great about this program is it was found that the relapse rate was much lower in this population when compared with other programs. In 2018, however, due to gentrification and rent increases, there was a very steep rise in homelessness in cities on the west coast, such as Seattle, San Francisco, and Los Angeles. To combat this, many state-wide programs were established that work with healthcare providers to provide these individuals with the help they need. Dr. Saito: What is the article "You have to learn to listen" about?I would first like to read a short excerpt from the article: "In American cities, visions of the miseries that accompany homelessness confront us every day — bodies lying in doorways, women standing on corners with their imploring cardboard signs dissolving in the rain. And yet, through a curious sleight of mind, we step over the bodies, drive past the mendicants, return to our own problems. O'Connell had spent decades returning, over and over, to the places that the rest of us rush by." Dr. O'Connell completed his IM residency at Mass General in Boston and was about to move on to an oncology fellowship when he was approached by some colleagues with a request to take a position as a physician for one year in a grant-funded program from the city of Boston to address homelessness in the 1980s. The program operated outside of Pine Street Inn homeless shelter. One of the initial experiences that Kidder describes Dr. O'Connell having was his first day of being there, being surrounded by

Episode 135: Exercise in Diabetes Kishan and Princess explain how exercise lowers or raises blood glucose levels in diabetes. Dr. Arreaza adds some comments about insulin resistance. Written by Kishan Ghadiya, MSIV, Ross University School of Medicine. Comments by Princess Enuka, MSIV, Ross University School of Medicine; and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today is April 7, 2023. Ep. 135.Intro:It is widely known exercise is paramount for all individuals. The American Heart Association recommends at least 150 minutes of moderate-intensity exercise weekly for general health. Exercise is particularly important in patients with diabetes, who require extensive lifestyle modification to manage their sugar levels. However, it is not well known how glucose metabolism changes when patients with diabetes exercise.My patient in the clinic.I recently saw in the clinic a young patient newly diagnosed with type 2 diabetes who asked about how his exercise was helping his sugar levels. He was confused because he heard that exercising allows for better glucose control but complained that his sugar levels were higher after exercising.To understand what is going on in this patient, it is important to understand the underlying pathophysiology of diabetes. First off, the two most common types of diabetes are type 1 and type 2. Type 1 occurs when the pancreas stops producing insulin altogether. Type 2 occurs when the insulin secreted by the pancreas is no longer effective in normalizing blood sugar levels; the body is not able to utilize glucose efficiently, the number of calories consumed exceeds the body’s demands, and thus increasing body weight, which leads to insulin resistance and eventually pancreatic beta-cell exhaustion. Diabetes is thus a disease state of prolonged hyperglycemia and confers many long-term complications such as accelerated cardiovascular disease, neuropathy, nephropathy, and retinopathy.How does exercise lower blood glucose? Once patients are diagnosed with diabetes, management is lifelong, and it takes considerable mental and physical effort to manage this change in health. Exercise is a key metric in diabetic management because lowering blood sugar is as simple as using excess glucose to create energy in our muscles. There are two main mechanisms in how exercise has a positive effect on diabetes. The first mechanism is that exercise directly increases insulin sensitivity by enhancing the muscles’ ability to effectively respond to insulin, thus allowing for better use of insulin on board (IOB). This benefit is not only seen during exercise itself but also up to 24 hours after exercise is complete. This means many patients with controlled diabetes can see a euglycemic effect up to 1 day after exercise.The second mechanism is that increased glucose uptake into muscle does not require insulin secretion. In other words, active muscle use during exercise allows for glucose uptake even without the use of any insulin and is very effective in lowering blood sugar levels. Muscles have a higher metabolic rate than fat tissue. It means that even without exercising, a person with a higher muscle mass has a higher basal metabolic rate.What type of exercise would be the most effective in controlling blood sugar? The data is very clear that there is no relationship between exercise technique and glucose level, but there is a relationship between exercise intensity and glucose levels. In other words, patients wanting better blood sugar outcomes may choose whatever exercise regimen as long as they are able to do high-intensity exercise (i.e., resistance training, strength training, High-intensity interval training, HIIT).Anaerobic vs. aerobicBlood sugar levels during exercise will be different based on the types of exercise patients choose. For example, high-intensity anaerobic exercise (such as weightlifting) causes large spikes of blood sugar because the liver creates large amounts of glucose for anaerobic glycolysis. On the other hand, high-intensity aerobic exercise (such as running) confers lower blood glucose. Keep in mind both types of exercise confer excellent long-term patient outcomes, but the disparity in blood sugar is important to note as it can lead to confusion in patients that are very actively monitoring their sugar levels.Hyperglycemia after anaerobic exercise.So, returning to my patient mentioned above, further history revealed that he does weightlifting two or three times a week. Hyperglycemia would therefore be expected during and immediately after anaerobic exercise due to large amounts of glycolysis requiring the liver to create suga

Episode 134: Martian Medicine 101. Future doctor Collins and Dr. Arreaza talk about the health risks of going to space and to Mars, especially the effect of radiation. Written by Wendy Collins, MSIII, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today is March 31, 2023.Arreaza: Wendy, I confess I am excited for today’s topic. My love for space began with E.T. (I know, I am old). I was exposed to that famous movie when I was a little kid, and ever since, I have had a tremendous curiosity about space and Mars. Honestly, I did not think this could be a topic for our podcast until I met you. Wendy: I got inspired to talk about space medicine because I want to go into this field. My college degree was in Physics, and I was fortunate to do Astrophysics and Particle Physics research as an undergraduate, as well as coral reef research. I am passionate about Medicine and treating patients, but I also love Aerospace Medicine because it’s so interdisciplinary. Flight surgeons get to scuba dive, work on oceanography, botany, engineering projects, and more, and collaborations like that sound exciting to me. Anyways let us talk about what is going on in the industry right now. Dr. Arreaza, do you know what humans are doing in space this year?Arreaza: I do! I like to watch the launches online and in person. I have seen several SpaceX rockets from my backyard (something I never imagined I could do), and there has been some big news, we are going back to the moon! Wendy: Yes! Artemis 1 was a successful unmanned mission to orbit the moon and it was launched in November and landed in December last year. Now we look to Artemis 2, which will be a manned lunar flyby. So, like Artemis 1, but with astronauts onboard. And the goal for future missions after that is to land on the moon, establish a lunar base, and eventually prepare us for a long-term space flight like that to Mars. And there is even a presidential order to land humans on Mars by 2033. Arreaza: Yes, it is very exciting! BUT there are many, many human health risks to space flight.Wendy: Even more for space flight outside of low earth orbit. Because of this, and because space flight is becoming commercialized, space medicine is a growing field, and growing in all medical specialties. Believe it or not, I was just in a talk by a NASA flight surgeon where it was mentioned that NASA is even looking for OB/GYN because 50% of their astronauts are women who need gynecological care, and they currently have to go off-site to receive it.Arreaza: That’s so cool! I’ve read of a handful of civilian and military aerospace medicine training programs for physicians after residency. And since we’re in Bakersfield and only a stone’s throw away from this campus, why don’t we briefly mention the University of California Los Angeles?Wendy: Yes, so UCLA established an aerospace fellowship very recently in 2021. That fellowship, unlike the rest of them, is actually for board-certified emergency medicine physicians only right now, I believe the only one that does not consider other specialties like internal medicine and family medicine, but the program is new so who knows that may change. The fellowship’s goal is to train the next generation of space flight surgeons. Part of the medical training includes working in arctic environments, Mars analog missions, which includes rotations at SpaceX and NASA’s jet propulsion laboratory. There are so many new avenues to pursue education and jobs in aerospace medicine but today we’re focusing on some research that’s near and dear, and revolves around how we get to Mars in one piece. You may ask, what are the health risks of going to Mars? Ultimately, I would like to chat about how we mitigate those risks, but first let’s define them.Arreaza: So, we got some ideas from a paper published in 2020 by Patel et al. It is titled: Red risks for a journey to the red planet: The highest priority human health risks for a mission to Mars. Let’s begin.Wendy: Spaceflight is dangerous with unique risks and challenges. As a space flight surgeon, your job revolves around ensuring the overall safety of the crew, as well as their physical and mental health and well-being. The major health hazards include radiation, altered gravity fields, and long periods of isolation and confinement. Each of these threats is associated with its own set of physiological and performance risks to the crew.Arreaza: But crews do not experience stressors independently, so it is important to also consider their combined impact. NASA’s Human Research Program researches over 30 categories of heal

Episode 133: Neonatal JaundiceJennifer explained the pathophysiology of neonatal jaundice and how to treat it and described why screening for hyperbilirubinemia is important. Written by Jennifer Lai, MS3, College of Osteopathic Medicine of the Pacific Western University of Health Sciences. Comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is neonatal jaundice? Jenni: Infant jaundice, also known as hyperbilirubinemia, is when there is a high level of serum bilirubin causing yellow discoloration of the newborn's skin and eyes. Bilirubin is a red-orange byproduct of hemoglobin catabolism that gives yellow pigment to skin and mucosa membranes. Arreaza: When we see jaundice on the eyes, it is actually the conjunctiva color we are seeing. So, the term “scleral icterus” should be changed to “conjunctival icterus,” but you may get corrected by unaware clinicians. Bilirubin actually binds elastin.What’s the pathophysiology/ big picture?Jenni: The key problem is the accumulation of high levels of bilirubin in serum and if left untreated, it can bind to tissues and cause toxicity. There are multiple reasons why there might be too much bilirubin in the serum. Excess bilirubin can be due to a benign normal condition, but it can also be due to a pathologic reason. It is important to differentiate between these two because the management and treatment can differ significantly. Arreaza: Highly bilirubin means that it is being either overproduced or under-eliminated. Physiologic jaundice Most of the time, hyperbilirubinemia is benign and physiologic, with yellowing typically occurring between 2-4 days. Normally, there is a period of transition caused by the turnover of the fetal red blood cells and the immaturity of the newborn’s liver to efficiently metabolize bilirubin and increased enterohepatic circulation. The most common reason is that the liver isn't mature enough to get rid of the bilirubin in the bloodstream or because the baby’s gut is sterile, so it does not have the bacteria to convert the bilirubin to get it out of the body. In general, newborns have a higher level of total serum or plasma bilirubin levels compared to adults for the following reasons: Newborns have more red blood cells (hematocrit between 50-60), and fetal red blood cells have a shorter life span (85 days vs. 120 days) than those of adults. After birth, there is an increased turnover of fetal red blood cells, so there is more bilirubin.Bilirubin clearance (conjugation and excretion) is decreased in newborns, mainly because of a deficiency of the hepatic enzyme UGT.Increase in the enterohepatic circulation of bilirubin as the amount of unconjugated bilirubin increases due to the limited bacterial conversion of conjugated bilirubin to urobilin.Pathologic JaundicePathologic jaundice includes severe neonatal hyperbilirubinemia, extreme neonatal hyperbilirubinemia, and bilirubin-induced neurologic disorders. We determine the severity of the jaundice using the total serum bilirubin (TSB). It is defined as a TSB >25 (severe) and TSB >30 (extreme). Other concerning signs include a TSB over the 95% percentile, a greater than 5mg/dL/day or 0.2mg/dL/hour, or jaundice that lasts for more than 2-3 weeks. Potential pathologic causes include but are not limited to: Increased bilirubin production from increased hemolysis which is when the red blood cells in the baby are being destroyed faster than normal, this can be due to blood group incompatibilities where the mom’s immune system starts to attack the baby’s red blood cells (such as Rh incompatibility) or from RBC membrane defects (spherocytosis).Birth Trauma when the head gets bruised after a vacuum or forceps is used to remove the baby from the vaginal canalInfection which prevents the bilirubin from being metabolized and excretedProblems with bilirubin clearance either from enzyme deficiencies such as Crigler-Najjar or Gilbert syndromeObstructed biliary systems causing bile to get stuck in the liverArreaza: Indirect bilirubin is the one elevated in newborns, but if you see direct hyperbilirubinemia, then you have to think of an obstruction.Jenni: Severe hyperbilirubinemia can cause brain damage. The amount of bilirubin and the duration of bilirubin ultimately determine the severity of the brain damage. This is because the bilirubin blocks some mitochondrial enzymes from being able to function properly, also it inhibits DNA synthesis/protein synthesis, and can cause DNA damage. This can ultimately lead to acute bilirubin encephalopathy which is described as 3 different phases: Phase 1 with poor feeding, lethargy, hypotonia, and seizures, Phas

Episode 132: Harm Reduction and Reproductive HealthMeghana explains how to implement harm reduction strategies in at-risk populations such as unhoused patients and injected drug users. Dr. Arreaza adds comments about PrEP for HIV and Expedited Partner Therapy (EPT) Written by Meghana Munnangi, MPH, third-year osteopathic medical student, College of Osteopathic Medicine of the Pacific Western University of Health Sciences. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: It can be frustrating for physicians trying to change “risky” behaviors in their patients and turn those behaviors into “healthy” behaviors. Doctors deal with this issue every day, but after reading more about the principle of harm reduction, I’m feeling more prepared to help our patients reduce their risks.What is harm reduction?Meghana: Harm reduction is a set of evidence-based interventions that arose within the public health community to reduce the harms associated with risky health behaviors. Most commonly, harm reduction refers to the policies and programs that aim to minimize the negative impacts associated with substance use disorder. The goal is to “meet people where they are” and to provide compassionate, judgment-free interventions and resources to at-risk populations.Examples of people who are part of the “at-risk population.”Some examples are injection-drug users and sex workers. With America experiencing the largest substance use and overdose epidemic we have ever faced, it is exceedingly important we provide services such as clean needle exchange, overdose reversal training, safer sex kits, and more to prevent unnecessary injury, disease, and death. Arreaza: In some countries where prostitution is legal, women are required to have regular check-ups to continue work. I see that as a harm-reduction strategy. I disagree with having sexual workers, but if we are unable to eliminate them, then harm reduction may be the way to go. Why is harm reduction important in medicine?Meghana: Healthcare providers have a unique opportunity to improve the quality of life and limit the negative outcomes associated with risky health behaviors by incorporating harm reduction strategies into their practice. Harm reduction interventions not only decrease health risks in an individual but also in the community. Examples of harm reduction strategies. Meghana: Studies have shown that areas that have introduced clean needle exchange interventions have lower HIV seroprevalence compared to areas that do not have similar interventions [1]. It is critical as health care providers to respect our patient’s choices and provide supportive care that will not deter patients from accessing care in the future. Patients who engage in risky activities often face stigma and are treated poorly by the medical system making behavioral changes even more difficult [2]. Understanding that many patients may not be willing to change their behaviors and using a practical approach to medical counseling can strengthen physician-patient relationships. Arreaza: I can think of another example. Pre-exposure prophylaxis for HIV in patients who have multiple sex partners. You wish those patients would have more insight into the risks associated with having multiple sexual partners, but if you cannot change them, you can still reduce the risk.What is harm reduction in the context of the reproductive health field?Meghana: Within Harm Reduction programs, there are many important strategies targeted toward improving sexual and reproductive health. Individuals who inject drugs and sex workers have limited access to family planning services and HIV testing. Studies have shown that individuals with substance use disorder have higher rates of unintended pregnancies, pregnancy-related mortality and morbidity, and lower rates of contraceptive use compared to the general population [3,4]. Harm reduction within the reproductive health field must include expanding access to condoms, contraceptive methods, STI and HIV testing, and prenatal care. Reproductive health harm reduction strategies can reduce rates of STIs, HIV, and unintended pregnancies. In addition to expanding access to condoms, STI screening, treatment, and partner therapy must be offered and encouraged to all patients. Arreaza: As a reminder to our listeners, Expedited Partner Therapy (EPT) consists in treating the partner(s) of a patient with chlamydia or gonorrhea. You, as a physician, treat a patient with STI, but you also give a prescription or medication to that patient, and he/she takes the prescription or medication to his/her partner(s) without me (the docto

Episode 131: Breastfeeding Part 2Lia and Aruna explain some updates given by the American Academy of Pediatrics regarding breastfeeding. Dr. Arreaza adds some comments about breastfeeding. Written by Aruna Sridharan, MS4, and Lia Khachikyan, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.The motivation for this episode was a recent publication by the American Academy of Pediatrics, on June 27, 2022, titled Policy Statement: Breastfeeding and the Use of Human Milk. During this episode, we included updated information along with other useful material.Duration of breastfeeding:The American Academy of Pediatrics (AAP), World Health Organization (WHO), and Center of Disease Control (CDC) recommend exclusive breastfeeding at least for the first 6 months, after which one can start to introduce complementary pureed foods. The US Department of Agriculture states that initiating complementary foods earlier than 6 months offers no benefit to the baby and can even be associated with a higher risk of overweight or obesity, especially if introduced before 4 months. Mothers are then encouraged to continue breastfeeding for at least one year and can further continue up to 2 years of age or longer - as long as mutually desired by mother and child. This is an update from previous recommendations regarding the duration of breastfeeding until 1 year of age.Composition of human breastmilk:As the sole source of nutrition for infants in the first 6 months of life, breast milk plays a critical role in development. Human milk has a unique composition of proteins, fats, and lactose, as well as vitamins, electrolytes, antimicrobial, anti-inflammatory immunoregulatory agents, and living leukocytes, all of which contribute to the developing immune system of the child. Breast milk is rich in Vitamins B1, B2, and B6, Vitamins C, A, E, Ca, Mg, phosphate, and folate. However, it is low in Vitamins K, D, B12, and iron, therefore supplementation of these nutrients is required. It is important for mothers to consume an adequate and healthy diet for their breastmilk to contain appropriate levels of these nutrients. Water-soluble and Fat-soluble vitamins can be low in breast milk if the mother has a deficiency. Selenium can be low if maternal serum levels are low. Dietary iodine deficiency may also be exacerbated by smoking; iron deficiency; and consumption of large amounts of foods that interfere with the production of thyroid hormones, known as goitrogens, including Brussels sprouts, kale, cabbage, cauliflower, and broccoli. Maternal diet:Mothers should consume iodine-rich foods, such as lean meat, eggs, dairy, beans, and lentils. It is important to choose a variety of whole grains, as well as fruits and vegetables, and continue taking multivitamins. Fun fact: Different foods will change the flavor of your breast milk. This will expose your baby to different tastes, which might help him or her more easily accept solid foods down the road! It is recommended that mothers consume 290 mcg of iodine and 550mg of choline a day. Is there anything that mothers should avoid in their diet?-Limit seafood: Although fish is a good source of protein and lean meat, it contains some mercury, which can be transferred to the baby’s diet. High amounts of mercury can have an adverse effect on the baby’s brain and nervous system.-Limit caffeine: Also, we know a lot of people love their morning dose of espresso! Low to moderate amounts, equivalent to 2-3 cups of coffee per day, do not adversely affect the infant. However, anything more than around 300 mg of caffeine can cause irritability, poor sleeping patterns, fussiness, and jitteriness. Remember! This also includes sodas, energy drinks, tea, and even chocolate! As a reminder, one cup of coffee can have 95mg of caffeine.Vegan mothers: Vegetarian/vegan mothers may have very limited amounts of vitamin B12 in their bodies, which can result in neurological damage to the baby. Iron levels may also be sparse since plant-based foods only contain non-heme iron, which is less absorbable than heme iron. The American Dietetic Association recommends supplementation of vitamin B12, iron, and other nutrients such as choline, zinc, iodine, or omega-3 fats. Benefits:For the baby: Studies show that exclusively breastfeeding for 6 months decreased rates of neonatal and infant mortality as well as pediatric disorders such as otitis media, diabetes mellitus, obesity, lower respiratory tract disorders, asthma, atopic dermatitis, sudden infant death syndrome (SIDS), severe diarrhea, and inflammatory bowel disease. The longer an inf

Episode 130: Epigenetics in childhood obesitySaakshi and Dr. Arreaza discuss some principles of epigenetics implicated in the development of obesity in children. Written by Saakshi Dulani, MS3, Western University College of Osteopathic Medicine of the Pacific. Edited by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.This topic is constantly expanding, and I’m excited to talk about it. It is a fact that epigenetic changes play a role in the development of certain diseases such as Prader-Willi syndrome, Fragile X syndrome, and various cancers. It has been demonstrated that certain foods can alter gene expression in animals, for example. What is epigenetics?Epigenetics is the regulation of gene expression without a change in the base sequence of DNA. Epigenetics means “on top of” the genes. Genes can be turned “on” or “off” as a response to external influences. Obesity and Epigenetics.The link between genetics and obesity is complex, but it is known that epigenetics plays a significant role in childhood obesity. Surprisingly, exposure to environmental factors starts in the uterus. Fetuses are exposed to intrauterine signals that increase their potential to develop obesity. Factors such as in-utero hyperglycemia, gestational diabetes mellitus, and early childhood diet and lifestyle practices can affect the development of the gut microbiome, modify gene expression through DNA methylation, and increase the risk of childhood obesity. These gene expression changes can be passed on to future generations. DNA methylation is the addition of a methyl group to part of the DNA molecule. That methyl group acts as a “chemical cap,” which prevents gene expression. Another example of epigenetics is histone modification. Histones are proteins that are used by DNA as spools to wrap around pieces of information that are “not needed”. The reason why a scalp cell and a neuron are different is that the expression of certain genes is suppressed while other genes are expressed.Factors that influence obesity.Some factors that increase the risk of childhood obesity through epigenetic changes include neonatal intestinal microbiome, C-section delivery, maternal insulin resistance, exposure to antibiotics and other environmental toxins, early introduction of complementary foods, parental diets high in carbohydrates and low in fruits and vegetables, and poor sleep. There are many other factors, but we will discuss only a few of them.Microbiome:The microbiome is a whole new world that is being explored by many investigators. The gut microbiome refers to the diverse community of organisms, including bacteria, fungi, and viruses, that reside in the human intestine. The neonatal intestinal microbiome is established during the first two years of life and may be influenced by factors such as the method of delivery, maternal obesity, and the maternal gut microbiome. Some bacteria worth mentioning are Bacteroides, Clostridium, and Staphylococcus. These gut bacteria are higher in pregnant women who have obesity, and they also have a low count of Bifidobacterium. Infants born to obese mothers have higher levels of bacteria associated with increased energy harvest compared to infants born to normal-weight mothers. The gut microbiome of infants delivered by C-section is different than infants delivered vaginally.Link to antibiotics:Early exposure to antibiotics is associated with the development of resistance in microorganisms. The intestinal microbiota exposed to antibiotics also shows reduced diversity. Antibiotics can decrease the number of mitochondria and impair their function, which is important in maintaining energy metabolism. Evidence suggests that some antibiotics can cause mutations in the mitochondrial genome, and they have a direct effect on the microbiome and influence metabolism. There is a strong association between early-life antibiotic exposure and childhood adiposity, with a strong dose-response relationship. A stronger association has been seen with exposure to broad-spectrum antibiotics and macrolides. Maternal insulin resistance (IR):Insulin resistance means that the mother needs levels of insulin that are higher than normal to stay normoglycemic. It means the insulin receptors are “exhausted” and do not respond to normal levels of insulin. Insulin does NOT cross the blood-placenta barrier, but glucose and other nutrients do. This causes the fetus to have an abundance of glucose that stimulates the secretion of high levels of insulin by the fetal pancreas to stay normoglycemic. The combination of insulin + glucose is the perfect combination for anabolism, adipocyte hyperplasia, a

Episode 129: Emergency ContraceptionBailey describes the available methods of emergency contraception in the United States. Written by Bailey Corona, MS4, American University of the Caribbean. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Emergency contraception refers to therapy used after intercourse to prevent pregnancy. The need for emergency contraception can happen for many reasons, such as a condom breaking or failure to use contraception. More than 11% of sexually active women in the United States between ages 15 and 44 reports using emergency contraception at least once. With such high demand, a multitude of options has become available to meet these needs. With so many options on the market, it may be difficult to decide which option best fits the needs of each individual, which makes it important for providers to have a clear understanding of the risks and benefits associated with each method. Emergency contraception may be commonly used by young patients as their main contraception method. Let’s talk about the types of emergency contraception.Levonorgestrel-only (Plan B®).Levonorge’strel-only emergency contraception is the most popular option on the market today. More commonly known as “Plan-B”, this therapy works because of levonorgestrel’s similar make-up to progesterone. Mechanism of action.High levels of progesterone delay follicular development so long as it is administered before the level of luteinizing hormone begin to rise. This gives contraceptive therapy of this class a therapeutic window of 72 hours which is the most limited window of all the methods discussed. Despite this shortcoming, Levonorgestrel contraception remains the most popular option because it can be purchased over the counter without the need of a physician and is available to women of all ages. Additionally, therapy includes only a single 1.5mg dose making noncompliance virtually non-existent. Side effects. Side effects include nausea in 12% of patients and headache in 19% of patients. According to one study, 16% of women reported self-resolving uterine bleeding within the first week after use.Selective progesterone modulators (Ella®).The second most commonly used form of emergency contraception are the selective progesterone receptor modulators or more widely known as Ella®. Mechanism of action.Treatment includes a single 30mg dose of ulipristal acetate, which inhibits follicular rupture even after the luteinizing hormone has begun to rise. Due to this mechanism of action, selective progesterone receptor modulators have a wider therapeutic window of 5 days.Side effects.Side effects resemble that of progesterone-only therapy, significant for nausea and headache. Treatment has 2 major barriers preventing it from being the most widely used. Firstly, efficacy is decreased in women with a BMI greater than 35, and secondly, treatment requires a prescription from a medical professional. Estrogen-progesterone combination.Estrogen-progesterone combination therapy is also a viable option for emergency contraception; however, it is no longer available as a dedicated product but can be made from a variety of oral contraceptives. Its decreased popularity is likely due to its increased incidence of nausea when compared to the other options available.Copper IUD.Lastly, Copper IUDs like Paragard can be used for emergency contraception despite not being FDA-approved for this purpose. Copper IUDs are highly effective if placed within 5 days of intercourse, but studies have shown therapy to be effective up to 10 days after. Mechanism of action.Copper IUDs prevent fertilization by altering sperm viability and oocyte-endometrium interaction. This method is the most invasive as it requires placement by a physician and carries the rare risk of uterine perforation, occurring in around 1/1000 IUD placements. That said, copper IUD placement carries with it the added benefit of continued contraception for 10 years. It is contraindicated, however, in patients with a history of heavy menstrual bleeding. FAQs about emergency contraception:Does increasing the availability of emergency contraception encourage risky sexual behavior?No, according to a systematic review by Maria Rodrigues, there was no significant increase in sexually risky behavior correlated with increased availability of emergency contraception.Rodriguez MI, et al.What is the greatest barrier to emergency contraception use in the United States?Education. A study by Abbott J, et al, interviewed adolescents receiving care in urban emergency rooms. The study showed that only 64% of patients had ever heard of eme

Episode 128: Food insecurity and obesity. Nausheen defines food insecurity, presents some statistics about obesity, and how food insecurity is linked to obesity. She ends her presentation with possible solutions to this problem.Written by Nausheen Hussain, OMS3, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.Welcome: You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: Hello, my name is Hector Arreaza. I am a family physician, currently practicing and teaching in the Central Valley of California. Today we will talk about an important and growing problem: Food insecurity and its relationship to obesity. I would like to introduce my guest today, Nasheen Hussain.Arreaza: Can you tell me what defines food insecurity? Nausheen: As defined by the U. S. Department of Agriculture (USDA), food insecurity is the limited availability of nutritionally adequate food or the limited access to this food. So, I want you to imagine you are living in a community where the closest grocery store is not within walking distance, you have no reliable access to transportation, and you are surrounded by liquor stores, McDonald’s, and Burger King. Now you can see the two parts of that definition: the grocery store with healthy food exists, but it is too far, and you can't get to it. Whereas within walking distance is nonnutritious food. I want to challenge our audience to pay attention to these two concepts in the communities around them.Arreaza: I have noticed a concentration of fast-food places lining certain streets. Now that we understand the concept, do we know if there is a way to quantify or measure food insecurity? Nausheen: Yes, Dr. Arreaza. So, the term “food swamp” actually describes what you just stated. To answer your question, yes. Food insecurity is actually measured by the USDA by a 6-18 item questionnaire - asking questions such as: Were you worried if food would run out before you got money to buy more? It is conducted as an annual supplement to the Current Population Survey. Arreaza: The Current Population Survey (CPS) is the primary source of labor force statistics for the population of the United States. It is sponsored jointly by the U.S. Census Bureau (bee-uro) and the U.S. Bureau of Labor Statistics (BLS). The CPS is conducted monthly. Nausheen: The 2021 questionnaire identified 12.5% of households in the U. S. as being food insecure. However, this may underestimate the true number of individuals who may be suffering from food insecurity. Arreaza: Screening for food insecurity is not been routinely done in many clinics. Food Insecurity: Preventive Services. An Update for This Topic is In Progress. LAST UPDATED: Jul 24, 2022. So now, let’s talk about the connection of this to obesity. What factors in general increase the likelihood of obesity?Nausheen: Sure! Obesity is classified based on a person’s body mass index or BMI, which is your weight in kilograms (or pounds) divided by the square of height in meters (or feet). A BMI of 30 or greater is considered to be in the obesity category. Obesity is affected by several factors, such as a person’s genetics, level of activity, and a high-calorie diet consisting of low-nutrition food.Arreaza: How does food insecurity play into this? Nausheen: Think back to the example we discussed earlier. If a person is experiencing food insecurity due to a lack of access, they will use what is around them (fast food, 24-hour mart without fresh foods) so they can put food on the table. If it is due to financial inaccessibility, they will choose to, say, go to Jack in the Box for their $5.00 deals. Both of these lead to a diet filled with non-nutritious food. This shouldn’t come as a surprise: most people that experience food insecurity are likely to be living in low-income communities. The generalization here is that these communities tend to have fewer parks, and if they are present, there tends to be a lot of litter and a cloud of unsafe space hovering over it. Arreaza: I see what you mean.Nausheen: These people will probably be less likely to go out for walks and take their kids out…leading to a sedentary lifestyle. The last association I see is that of mental health. People who are struggling to find food are likely to have stress due to their circumstances and there is a relationship that has been found between depression and the increased likelihood of developing obesity. As a recap, there are three effects of food insecurity that contribute to obesity: lack of adequate nutrition, lack of physical activity, and poor mental health. Arreaza: So, there are several factors of f

Episode 127: Obesity Update and Uterine CancerSaakshi presents some updates on the treatment of obesity in pediatric patients. Wendy explains a recent study connecting hair iron to uterine cancer. Updates on obesity management in pediatric patients.Written by Saakshi Dulani, MS3, Western University College of Osteopathic Medicine of the Pacific. Edited by Hector Arreaza, MD.Background information:The American Academy of Pediatrics has released new guidelines on obesity management in pediatric patients. This is the first update regarding childhood obesity in 15 years. According to the CDC, the rates of childhood obesity have tripled since the 1980s, and as of now, 1 in every 5 children suffers from obesity in the United States. It is important to recognize obesity is a chronic, multifaceted disease that comes with its own set of complications, such as type 2 diabetes mellitus, high blood pressure, asthma, sleep apnea, heart disease, and various mental and psychosocial health issues. The first-line treatment used to be comprised of behavioral health and lifestyle counseling, however, now, 1st line treatment for pediatric patients includes medications and surgery in addition to the previously suggested counseling. This is because research has shown that diet and level of physical activity are not the only factors that determine weight but also include genes, hormones, and metabolism. Similar to many other chronic diseases, the sooner the treatment is started, the better. There has been no benefit shown in waiting for adulthood to treat obesity. Who qualifies for which treatments?As a reminder, in the pediatric population, we use the BMI percentiles instead of the absolute number for BMI. Overweight is defined as BMI between 85-95th for patients of the same gender and age. Obesity is defined as being above the 95th percentile.Four drugs are now approved for obesity treatment in adolescents starting at age 12, which are Saxenda® (liraglutide), Qsymia® (phentermine-topiramate), Wegovy® (semaglutide), and Xenical® or Alli® (orlistat). Phentermine as monotherapy has been approved for teens aged 16 and older. Another drug called Imcivree® has been approved for children 6 and older affected by Bardet-Biedl syndrome. The problem with medications is that they are not available to everyone due to the cost, and there are many shortages occurring due to the high demand for these drugs. Surgical options:This is a MAJOR change in the recommendations for obesity treatment in children. The new guidelines recommend discussing SURGERY with patients that are 13 years old and have severe obesity. It has been shown that bariatric surgery provides lasting results but also that it can reverse health issues such as type 2 diabetes mellitus and hypertension. It is exciting that more research is being done to provide us with more evidence regarding the treatment of obesity in children. Obesity treatment is challenging, even more so in children. So, we encourage all listeners to review the new guidelines about the use of medications and surgery to treat obesity in children and put them to practice if appropriate for your patients.____________________________You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.____________________________Hair products and uterine cancer.Written by Wendy Collins, MS3, Ross University School of Medicine. Edited by Hector Arreaza, MD.What is the sister study? The Sister Study is a nationwide effort in the US conducted by the National Institute of Environmental Health Sciences, which includes over 50,000 sisters of women who have had breast cancer. This study aims to find environmental and genetic causes of breast cancer. The women in this study were breast cancer free and lived in the United States, including Puerto Rico. They were enrolled from 2003-2009 and were followed up until September 2019. If the sister study is made up of 50,000 women, why does this study only use about 30,000 of those women? Excluded women include those who withdrew from the study (n = 3), who self-reported a diagnosis of uterine cancer before enrollment (n = 380), had an uncertain uterine cancer history (n = 10), had an unclear timing of diagnosis relative to enrollment (n = 59), had a hysterectomy before enrollment (n = 15,585), who did not answer any hair product use questions (n = 736), and who did not contribute any follow-up time (n = 164), resulting in 33,947 eligible women. How was it done?The authors reviewed medical records and questionnaires about hair care within the past 12 months and compared women who developed uterine cancer with those who did not for about 10 years between 2003-2009. Of th

Episode 126: Caffeine and AKI. January 20, 2023. Olivia and Janelli explain that caffeine intake during pregnancy may cause short height in babies, and Anthony discusses the definition, evaluation, and management of AKI with Dr. Kooner. Introduction: Caffeine consumption during pregnancy. Written by Olivia Weller, MS3, American University of the Caribbean School of Medicine; and Janelli Mendoza, MS3, Ross University School of Medicine.Current Guidelines about caffeine during pregnancy: The American College of Obstetricians and Gynecologists (ACOG) current recommendations are to limit caffeine consumption during pregnancy to 200 mg of caffeine per day. Anything exceeding a moderate level of caffeine intake has been linked to an increased risk for preterm birth and miscarriage. [8 oz of brewed coffee has approximately 137mg of caffeine. Other drinks and foods contain caffeine: Brewed tea 48mg; Decaf coffee (12 oz), 9-15 mg; caffeinated soft drink (12 oz) 37mg, Dark chocolate (1.45 oz) 30mg] New Evidence: More recent data disclosed that moderate levels of caffeine consumed during pregnancy led to newborns being small for gestation age (SGA). This information was taken further, and scientists began to monitor these children as they aged. Researchers studied newborns born to mothers who consumed zero caffeine during pregnancy versus women who consumed moderate levels of caffeine. They tracked height, weight, BMI, and obesity risk but only found statistical differences in height. So far, they have only investigated children up to the age of 8 and found that the variance in height increased as the children got older. Therefore, even consuming a moderate level of caffeine during pregnancy can have lasting effects on a child’s height, which likely persists into adulthood. Some professionals are now saying there may be no amount of caffeine that is safe to consume during pregnancy. American Family Physician Journal, 2009: “Caffeine intake is directly correlated with small but notable fetal growth restriction. Although a safe threshold cannot be determined, maternal caffeine intake of less than 100 mg per day minimizes the risk of fetal growth restriction.”Why does smaller birth size matter? Caffeine crosses the placenta and acts as a vasoconstrictor which reduces the blood supply to the fetus and thus hinders proper growth. It is a sympathomimetic agent that can affect fetal stress hormones and increase the risk for rapid weight gain after birth. Although height is not a pressing issue, children are potentially more susceptible to increased risk for certain conditions later in life, such as obesity, heart disease, and diabetes. More research is needed on this front to make the conclusion that these differences do in fact persist into adulthood and lead to adverse health outcomes. Conclusions and limitations. Pregnant women and children remain as a group with the least amount of research due to the potential adverse life outcomes. For this reason, the studies that have been done on caffeine consumption during pregnancy are comprised of self-reported data. Due to the association between high caffeine consumption and smoking, it is difficult to distinguish the two. Therefore, there is no clear cause-and-effect relationship between caffeine and intrauterine growth restriction (IUGR), leading to shorter stature later in life. However, the potential adverse health outcomes outweigh the psychological benefits of caffeine during the gestational period. If mothers can give up alcohol, drugs, smoking, raw fish, and so much more during pregnancy, why not caffeine too? With the emergence of this new information, perhaps it is time for a review of those guidelines. Welcome: You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Acute Kidney Injury. January 20, 2023. Written by Anthony Floresca, MS4, American University of the Caribbean School of Medicine; edited by Hector Arreaza, MD; recording done with Gagan Kooner, MD.Definition of Acute Kidney Injury (AKI): Acute kidney injury is a clinically relevant disease process that often occurs during hospitalizations but can also occur as a result of pre-existing diseases such as diabetes mellitus, hypertension, and congestive heart failure, usually referred to as “AKI on CKD,” i.e., acute kidney injury can present as a worsening of renal function in a patient who already has decreased renal function at baseline. AKI is defined as a sudden onset decrease in renal function that can be diagnosed as early as 6 hours from disease onset. To diagnose AKI, specific parameters to consider are creatinine and urine output. Kidney Disease: Improving Global Outcomes or KDIG

Episode 125: Non-opioid Chronic Pain Management Dr. Axelsson and Jesse explain how to treat chronic pain without opioids. Written by Anika Soleyn, MS4, Ross University School of Medicine. Edited by Jesse Lamb, MS3, American University of the Caribbean; Hector Arreaza, MD; and Fiona Axelsson, MD.This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Axelsson:Welcome to the first episode of 2023, Happy new year! Today is January 10, 2023.What is chronic pain?According to the International Association for the Study of Pain, chronic pain is nonstop or reoccurring pain that lasts more than 3 months or beyond the expected clinical course of illness. Chronic pain can adversely affect well-being and quality of life. We used to think of pain as a response to tissue damage, and as the tissue heals, the pain dissipates, but chronic pain is much more complex than that because there may be no evidence of tissue damage, yet the nociceptors keep sending signals to the brain that there is damage.There are 3 options for the management of chronic pain: non-pharmacologic, nonopioid pharmacological and opioid management. CDC recommends a combination of nonpharmacological and non-opioid management for chronic pain. The 7 most common chronic pain conditions are neuropathic pain, fibromyalgia or chronic pain syndrome, osteoarthritis, inflammatory arthritis, low back pain, chronic headache, and sickle cell anemia.Opioids in long-term care facilities.The use of opioids for the treatment of pain is common in the post-acute and long-term care setting. From the AFP Journal, the Choosing Wisely Recommendation states: “Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.” The Society for Post-Acute and Long-Term Care Medicine published a statement in 2018 about the use of opioids. It states that the prescription of opioids should be based on an interprofessional assessment specifying why opioids are needed. When long-term opioids are not being used for cancer, palliative care, or end-of-life care in a long-term facility, a tapering plan must be “individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment with non-pharmacologic therapies and non-opioid medications”. Long-term opioid prescriptions should be reviewed regularly and take into consideration the potential harms of opioids. Clinicians are encouraged to offer alternatives such as behavioral therapy, non-opioid analgesics, and other non-pharmacologic treatments whenever available and appropriate.Initial assessment: Identify biopsychosocial factors and identify if the source is neuropathic, nociceptive, or central sensitization. This can be a challenging process and it may require several visits to determine the origin of pain. Neuropathic pain is due to nerve damage or irritation while nociceptive pain is due to tissue damage. Central sensitization is an abnormal response of the nociceptive system. There are changes in the nervous system that alter how it responds to sensory input that causes widespread pain with no apparent cause or in response to mild sensory input. Some examples include fibromyalgia, migraines in response to brushing hair, surgical scar pain, etc.Set goals and expectations: It is crucial to set up patient expectations if they have chronic pain. They should understand that pain can be improved to a manageable level but not always eliminated. Patients should have routine follow-up visits with education, and reassurance since they are shown to improve outcomes of pain management. Specific goals such as improved mobility and ability to do certain enjoyable tasks are more reasonable and specific goals than a goal of pain elimination. A good physician-patient relationship and clear communication are essential here. Patients could obviously become deeply upset at the prospect of pain that can’t be eliminated, and those who have received opioids for their pain in the past could be even more distraught at the thought of not getting them now or needing to reduce their dose. The physician should be ready to have this discussion with their patients that have chronic pain and be ready to address their concerns appropriately. Reduce catastrophic thinking: Pain is an alarm system letting someone know there is some sort of damage. Because of this, it makes sense that a patient would respond to pain with anxious and catastrophic thinking. Patients who understand their own chronic diseases are more likely to be actively involved in their treatment, so understanding is crucial in the management of pain. Reducing fearful though

Episode 124: Medical Spanish for Beginners.Drs. Axelsson, Kooner, and Arreaza explain the basics of medical Spanish.Hi! Thank you for joining us for this episode of Rio Bravo qWeek. This is a bonus episode on medical Spanish for beginners. We will teach you the most basic Spanish words you can use during interactions with Spanish-only speakers. Grab your notepad and follow along phonetically! We will also post a transcript of this episode so that you can see the words if you’re a visual learner.Introductions of participants:Fiona: Hi, my name is Fiona and I am a 3rd-year resident here at Rio Bravo Family Medicine. I’m also Canadian, so my Spanish was not good when I came to this program. I’m hoping this episode will help me brush up on my Spanish and that it will also help you! Whether you’re a medical student or resident, we could all use a refresher on basic medical Spanish. With me today I have Dr. Hector Arreaza and Dr. Gagan Kooner.Arreaza: Hi, I’m Hector Arreaza, and I’m a frequent host for this podcast. You may be used to my soft and somewhat unintelligible voice [humor]. I’m from Venezuela, I know some Spanish. Kooner: Hi, I’m Dr. Gagan Kooner. I am a PGY1 at Rio Bravo family medicine. I am Punjabi. grew up in Bakersfield. So, when I heard about this episode of the qWeek podcast, I knew I wanted to be a part of it.Fiona: He’s been modest, his wife is Hispanic.Preliminary information:Arreaza: Not everyone who looks “Hispanic” speaks Spanish. We have people in our community from different indigenous groups, mostly from Mexico, and Central America who speak Spanish as a second language. Hispanics have different levels of English proficiency.Fiona: Hispanic is not a race–it is a culture. Hispanics can be of different races, ranging from White Europeans, Black, Indigenous, and even of Asian descent.Kooner: Not all Hispanics are Mexicans: Mexico is the country with the highest number of Spanish speakers, but there are 20 Spanish-speaking countries in the world. Spanish has many variations in some countries.Basic pronunciation:Fiona: Thank you Dr. Arreaza and Dr. Kooner. Just to set the agenda, as all good clinicians do, let’s lay out what we will discuss. First, we’ll start with Greetings and Common Courtesies. Once we’ve mastered that, we will move on to body parts and family members. Is anyone feeling like they’re back in kindergarten? Next, we will focus on Critical Questions and a brief ROS. This will be helpful in your emergency medicine and hospital medicine rotations. We will then learn how to master a physical exam in Spanish and will end with Good-bye’s and a few miscellaneous items like “Más o Menos”. Dr. Arreaza, why don’t you give us a quick intro into Spanish vowels!Dr. Arreaza: Thank you Fiona, I think that’s a great idea. In Spanish, all of our vowels are pronounced exactly like they sound. A-E-I-O-UIntroduce yourself:Fiona: Alright, so let’s say I knock on my patient’s door and want to introduce myself by saying, “Good morning, my name is Dr. Axelsson.” Kooner: And as a side note: we will repeat the phrases a couple of times so that we can all master the language.Arreaza:—[good morning] Buenos días—[buenas tardes] Good afternoon—[buenas noches] Good evening —“Hola, Me llamo Fiona, estoy esperando al intérprete” [Hi, my name is Dr. Axelsson, I‘m waiting for the interpreter]—Kooner: Note that doctor is for male and doctora is for female.—Estoy aprendiendo español [I’m learning Spanish]. —Por favor, hable despacio [please speak slowly]—¿Cómo se llama? [what is your name?]Common courtesy words:Fiona: Okay, now that we can say hello and let them know who we are and what we’re doing, can we go over a few pleasantries?Gracias [thanks]Por favor [please]Mucho gusto [nice to meet you]Igualmente [same to you]Muy bien [okay]Bueno [good]Lo siento [excuse me, sorry] - DisculpeEspere un momento [one moment]Body parts: Fiona: Alright, now let’s throw it back to grade school and go over body parts from head to toe, or in medical lingo, craniocaudal!cabeza [head]ojos [eyes]nariz [nose]boca [mouth]oídos [ears]pecho [chest]corazón [heart] Spainpulmones [lungs]hombros [shoulders]brazos [arms]manos [hands]dedos de las manos [fingers]espalda [back]estómago [abdomen]pene [penis]vagina [vagina]ano or cola [anus]caderas [hips]piernas [legs]rodillas [knees]-Argentinadedos de los pies [toes].People:Kooner: Amazing! We are doing really well with this. I think I’ll be fluent by Friday. Fiona: Speak for yourself, Dr., Kooner.Kooner: Since we’re on a winning streak, let’s keep going and describe relationships in our lives.Familia [family]Yo soy [I am]mamá [mom]papá [dad]hermano [brother]hermana [sister]hijo [son] – Mijo - niñohija [daughter] – Mija - niñaniño [boy]niña [girl]esposo [husband]esposa [wife]abuelo [grandfather]abuela [grandmother]tío [uncle]tía [aunt]. Kooner: ROS: Fiona: So let’s run through a Review Of Systems, so that in an emergency, I can try to get as much information from my patient as I can, while wa