Rio Bravo qWeek

Episode 123: Spontaneous Bacterial Peritonitis. Kaitlen defines spontaneous bacterial peritonitis (SBP) and also explains the diagnosis and management. Written by Kaitlen Roy-Ross, MS4, Ross University School of Medicine. Moderated by Hector Arreaza, MD. Definition:An ascitic fluid infection with no obvious surgically treatable intra-abdominal source (bowel perforation, abscess, perforated ulcer). Commonly seen in patients with cirrhosis and ascites. Patients may have symptoms of fever, abdominal pain, abdominal tenderness, altered mental status, and hypotension. Etiology: The most common pathogens (75%) are gram-negative aerobic organisms. Klebsiellapneumoniae accounts for 50% of the cases. Gram-positive aerobic bacteria (Streptococcus pneumoniae or viridans group streptococcus) account for the remaining cases. Some report E. coli as the most common cause of SBP. Random information: in Korea, Aeromonas hydrophila is an important pathogen of SBP during the summer. Diagnosis: To diagnose SBP, a paracentesis should be performed to analyze the ascitic fluid prior to treating the patient with antibiotics. The ascitic fluid should be analyzed for the following: PMN (Polymorphonuclear cell) count: > or = to 250 cells/mm3 Aerobic and anaerobic culturesSerum ascites albumin gradient (serum albumin-ascitic albumin): this measures portal pressure.If the gradient is > 1.1 = portal HTN is present (cirrhosis, heart failure, large liver malignancy, alcoholic hepatitis, portal vein thrombosis) – SBP is likely. If the gradient is Ascites fluid total protein concentration: (Glucose: > 50 mg/dLLDH: 43 +/- 20Amylase- will be increased in pancreatitis or gut perforation. No SBP.Bilirubin- increased bilirubin in ascitic fluid greater than serum bilirubin or > 6 mg/ suggests a gallbladder perforation. No SBP. Treatment:The treatment for spontaneous bacterial peritonitis is broad-spectrum antibiotics. Empiric treatment is indicated if a patient with ascites has any of the following:Temperature > 100 FAbdominal pain or tendernessAltered mental statusPMN in ascitic fluid > 250 (but if there is bacteria in ascitic fluid, start antibiotics stat)Alcohol-induced hepatitis *Important note: Patients on beta blockers should have them permanently discontinued prior to treatment for SBP as beta blockers are associated with worse outcomes. In one study, patients on beta blockers had a 58% increase in mortality risk compared to patients not treated with beta-blockers. Beta-blockers were also associated with higher rates of hepatorenal syndrome and longer lengths of hospital stay. 1st line treatment- 3rd generation Cephalosporin Cefotaxime 2g IV Q8H (preferred) or Ceftriaxone 2 g per day2nd line treatment- Carbapenems. Usually reserved for patients with severe disease/critical illness.3rd line- Fluoroquinolones- Cipro 400 mg IV BID to patients with normal renal function. (Patients should not get this if they already receiving it prophylactically.) Duration of treatment:5 days, then re-assess the patient’s PMN count:PMN PMN >250 or greater than pre-treatment PMN count > look for a surgical source of infection.If PMN is > 250 but less than pre-treatment value, continue ABX for 48 more hours and then repeat paracentesis. Note: In general, ascitic fluid PMN count should be reduced by at least 25% after 48 hours of antibiotic therapy. Renal failure is the major cause of death in patients with SBP and develops in 30-40 % of the patients. We can decrease this risk by administering IV albumin. IV albumin should be given when the creatinine is > 1 mg/dl, the blood urea nitrogen is > 30 mg/dl, or the total bilirubin is > 4 mg/dl. Treatment with octreotide or midodrine is helpful if renal failure develops. Prevention:Antibiotic prophylaxis can be given to patients with risk factors for SBP. Some risk factors include prior history of SBP, variceal hemorrhage, or an ascites fluid protein concentration of Early preventative measures in patients with risk factors are:Early diagnosis and treatment of infections to prevent bacteremia (any infections). (Add comments)Diuretic therapy. (Add comments)Restriction of PPI’s. (Add comments)Prophylaxis with antibiotics is indicated for:Patients with cirrhosis who are hospitalized for reasons other than SBP or GI bleeding:Oral TMP-SMX (1 DS tablet daily) with discontinuation of the drug at discharge. Patients with a history of 1 or more SBP episodes and patients with low protein ascites along with either renal or liver failure:Prolonged outpatient TMP-SMX (1 tablet DS daily). Alternative: Ciprofloxacin 500 mg per day. Patients with advanced cirrhosis and GI bleeding Ceftriaxone 1 g IV and switch to oral TMP-SMX (1 DS tablet 2x daily) once bleeding has stopped and the patient is stable.____________________________ Conclusion: Now we conclude our episode number 123 “Spontaneous Bacterial Peritonitis.” Let’s not hesitate in the diagnosis of SBP in patients with cirrhosis who present with typical symptoms. The analysis of p

Episode 122: Chronic Kidney Disease OverviewFuture Dr. Westwood discusses with Dr. Arreaza the evaluation and treatment of CKD before renal replacement therapy. This is a broad overview of CKD.Written by Daniel Westwood, MSIV, Ross University School of Medicine. Comments and editing by Hector Arreaza, MD.Definition of CKD:CKD is defined as abnormal kidney structure or function lasting more than three months with associated health implications. Indicators include albuminuria, urine sediment abnormalities, abnormal renal imaging findings, serum electrolyte or acid-base derangements, and decreased glomerular filtration rate (GFR).Stages of CKD are based on GFR - CKD1 normal or high >90, CKD2 60-89, CKD3 CKD can progress to advanced renal failure, end-stage renal disease, and even death; early detection is critical for initiating timely therapeutic interventions, limiting nephrotoxin exposure, preventing further reduction in GFR, and preparing for renal replacement therapy. Screening guidelines:Annual screening for CKD in pts with DM or HTN (AAFP and National Kidney Foundation)Other risk factors that may indicate screening: cardiovascular disease, older age, hx of low birth weight, and family hx of CKD.USPSTF recommends against screening asymptomatic adultsAmerican College of Physicians recommends against screening asymptomatic adults without risk factors.How to screen? Multiple guidelines recommend at least annual screening with serum creatinine, urine albumin/creatinine ratio, and urinalysis (especially in diabetes mellitus, hypertension, and a history of cardiovascular disease).Assessment of a patient with CKD:Full medical history, including:Exposure to potential nephrotoxins (NSAIDS, aminoglycosides, amphotericin B, IV contrasts.)Review past and present blood pressure.Dietary history: Western diet, high in calories, high in animal proteins, and low in fruit and vegetable content.Recent weight gain is essential for CKD evaluation because weight gain may be a sign of fluid retention.Obesity can be a risk for CKD.Review of systems: Generalized weakness, decreased exercise tolerance, impaired cognitive function, decreased urination, foamy urine (proteinuria), anorexia, altered taste (dysgeusia), vomiting, skin changes, lower extremity edema, periorbital edema, shortness of breath, hallucinations (advanced stages).Physical examination:Clinical findings vary with the severity and chronicity of symptoms. It would be difficult to explain all the physical findings in a short time, but it is important to mention that some signs and symptoms may take years of chronic disease to develop, and sometimes patients may have CKD and not know it.General exam: Chronically ill, tired, chronically ill, slow responses due to the accumulation of multiple toxins, including urea. Vitals: BP is elevated, or the patient is currently taking antihypertensives. The skin can be extremely dry, scaly, itchy, pale, or darker than usual for the patient, or you may see a rash.Edema: pitting, bilateral, generalized, especially around the eyes.Auscultation: Signs of fluid overload (bibasilar crackles, cardiac gallops, murmurs)Signs of severe uremia: Uremic fetor (urine smelling), encephalopathy, uremic frost (urea crystals over the skin).Laboratory:Spot urine for albumin-to-creatinine ratio (ACR) to detect albuminuriaSerum creatinine to estimate glomerular filtration rate (GFR), serum electrolytes, fasting lipids, hemoglobin A1CUrinalysis: High sensitivity for heavy proteinuria (> 300 mg in 24 hours, estimated from the spot urine protein/creatinine ratio) but may not detect clinically significant lower levels (30 to 300 mg).24-hour urine collections are no longer recommended as an initial diagnostic tool because of the potential for inadequate collection, inconvenience to patients, and the lack of diagnostic advantage over the urine albumin/creatinine ratio.Imaging: Renal ultrasound to evaluate for structural abnormalities.Markers of Kidney Damage:Proteinuria: Identifies increased risk of cardiovascular disease and mortalityAlbuminuria:microalbuminuria and macroalbuminuria have been replaced withnormal to mildly increased (albumin/creatinine ratio less than 30 mg/g)moderately increased (30 to 300 mg/g)severely increased (greater than 300 mg/g)severe albuminuria independently predicts mortality and end-stage renal disease.Common etiologies of CKDhypertensive kidney diseasediabetic nephropathyprimary or secondary glomerulonephritisManagement of CKDTreat reversible causes of CKDAvoid nephrotoxic drugs (NSAIDs)Identify and treat urinary tract obstructionsSlow the rate of progression by treating underlying causes:Control BPDiabetes mellitusObesityAutosomal dominant polycystic kidney disease (ADPKD)Glomerular disease (steroids)Viral infections: Hep B, C, HIVHematologic disorders: Renal amyloidosisCardiac or Hepatic disorders: Cardiorenal and hepatorenal syndromesFor patients with proteinuria: Control blood pressure with ACE inhibitors or ARBs and SGLT

Episode 121: Genital Herpes. Wendy and Grace discuss the signs, symptoms, diagnosis, and management of genital herpes. Written by Jaspreet Johal, MS4, Ross University School of Medicine. Edits by Grace Yi, MS2, University of California Los Angeles; and Wendy Collins, MS3, Ross University School of Medicine. Comments by Hector Arreaza, MD. December 1, 2022.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 & EpidemiologyGenital herpes is a common sexually transmitted infection caused by a virus called herpes simplex virus (HSV for short). There are two types of HSV. HSV type 1 commonly causes orolabial herpes (known as cold sores), and HSV type 2 typically causes genital herpes, which can present as painful blisters or ulcers in the genital regions. In recent years, an increasing number of genital herpes cases have been associated with HSV-1, especially in women. HSV infections are widespread among the global population and spread person to person through oral-to-oral contact or vaginal, anal, and oral sexual contact. Transmission can occur during periods of subclinical viral shedding, as in even when individuals are asymptomatic. In 2020, the seroprevalence of HSV-2 in the United States was approximately 13 percent among patients aged 15 to 49, with more women affected than men. Fifty to 80 percent of American adults have oral herpes (HSV-1), which causes cold sores or fever blisters in or around the mouth. HSV is a lifelong infection characterized by periodic reactivations that can be triggered by fatigue, stress, or illness, among other factors. Antiviral therapy can shorten symptom duration in primary infection and can also treat and prevent recurrences. Types of InfectionGenital HSV infection can be classified into three types: primary, nonprimary, and recurrent. Primary – Primary infection refers to an infection in a patient without preexisting antibodies to either HSV-1 or HSV-2.Nonprimary infection, a patient has a first occurrence of a genital HSV lesion but already has pre-existing HSV antibodies that are different from the HSV type related to the genital lesion.Recurrent – Recurrent infection refers to the reactivation of genital HSV (so the patient already has pre-existing antibodies in the serum)Clinical Features The incubation period for developing genital herpes after exposure ranges anywhere from 2 to 12 days.Most patients with primary HSV infection are asymptomatic or mildly symptomatic. However, in more severe cases, individuals can present with painful genital ulcers, dysuria, fever, tender local inguinal lymphadenopathy, and headache. HSV infection also presents with characteristic 2-4mm wide skin lesions that are vesicular or ulcerated. The vesicles are often clustered and can be fluid-filled with underlying erythema. Sometimes vesicles might have a depression in the center (called “umbilicated” vesicles.” It’s important to note, though, that the clinical presentation can vary based on the type of infection (primary, nonprimary, or recurrent). As a general rule of thumb, the initial presentation of a non-primary genital infection tends to be milder (as in, fewer systemic symptoms and lesions) than that of a primary infection. Recurrent infections also tend to be less severe than primary or nonprimary infections. Also, around 50% of patients with symptomatic recurrent infections might experience prodromal symptoms in recurrent infections, like burning, pain, or pruritus, before lesions become visible.Symptoms in patients with primary infections typically resolve after an average of 19 days, whereas symptoms in nonprimary or recurrent infections resolve within 10 days. Also, there are no clear differences in a clinical presentation based on whether the virus is caused by HSV-1 or HSV-2. However, infections due to HSV-2 are associated with a higher recurrence rate than infections due to HSV-1. Extragenital complications Genital HSV infection can cause extragenital manifestations that typically occur during the primary episode of HSV infection but can reappear with subsequent episodes. Complications include aseptic meningitis, urinary bladder retention, proctitis, and lumbosacral radiculitis. Other areas that can be affected outside of the genital area are fingers, eyes, and other skin areas.Diagnosis.A clinical diagnosis of genital herpes is usually initiated by the finding of vesicular or ulcerated genital lesions. The diagnosis can be confirmed with lab testing like viral culture, polymerase chain reaction (PCR), direct fluorescence antibody, and type-specific serologic testing. The most appropriate test for a patient depends on their clinical present

Episode 120: Immune Reconstitution Inflammatory Syndrome (IRIS) Abeda Faharti and Dr. Schlaerth present the definition, diagnosis, and treatment of IRIS. Moderated by Dr. Arreaza. Written by Abeda Farhati, MS4, Ross University School of Medicine. Editing and comments by Katherine Schlaerth, 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.Definition.Have you heard of IRIS? No, not the color portion of our eyes. IRIS is short for Immune Reconstitution Inflammatory Syndrome. This condition occurs in immunocompromised patients with HIV/AIDS due to an overactive inflammatory response. In most cases, it occurs after initiating antiretroviral therapy (ART). To understand IRIS in HIV patients, we must first understand HIV.HIV.The Human Immunodeficiency Virus (HIV) infection was first reported in 1981. The virus attacks the immune system, destroying white blood cells called CD4+ T lymphocytes, which are part of our body's defense mechanism. These cells are also known as "helper T cells" and are responsible for destroying viruses, bacteria, and other germs that make us sick.When your CD4+ count is low, you are more likely to get serious infections from viruses, bacteria, and fungi, which usually do not cause problems in otherwise healthy individuals. These infections are called Opportunistic infections, and they can be deadly. To restore CD4+ T lymphocytes, HIV patients are started on ART to normalize their immune response to pathogens. As a result of these treatments, HIV patients' lives have been significantly improved and prolonged. [Comment by Dr. Arreaza: It is paradoxical, but some HIV patients are among the healthiest patients I have seen.]Despite this, no treatment is guaranteed to be without side effects. Increases in CD4+ T lymphocytes trigger the immune system to respond to any persisting antigen, regardless of whether it is fragments or intact organisms. As a result, a hyperinflammatory response may occur.Diagnosis.There are no established criteria for diagnosing IRIS. It is generally accepted that IRIS requires the worsening of an existing infection or an unrecognized, preexisting infection in the context of improved immune function. For a diagnosis to be made, most, if not all of the following features must be present:The presence of a low CD4 count (less than 100 cells) before initiating treatment with ART (Except IRIS secondary to preexisting TB infection can occur with CD4 counts >200 cells).The presence of an inflammatory condition, especially after ART is initiated.The absence of drug-resistant infection, bacterial superinfection, drug allergy, or other adverse drug reactions.The absence of patient noncompliance or reduced drug levels due to drug-drug interactions or malabsorption.Clinical Manifestations.IRIS can be presented in patients in 2 ways:Patient’s with a preexisting infectious disease that has NOT been treated, getting paradoxically worse after initiating treatment with ART ---this is known as “unmasking IRIS” ORPatient’s with a preexisting infectious disease that has been previously diagnosed and treated but regained capacity after treatment with ART, causing it to mount an inflammatory response – this is known as “paradoxical IRIS.”In summary: Unmasking IRIS and paradoxical IRIS.Patients with IRIS have clinical features that vary widely. The presentations are strongly dependent on the type of preexisting opportunistic infection. For example, about 75% of patients with a mycobacterial or cryptococcal-related infection will develop a fever. In contrast, fever is rarely seen in cytomegalovirus (CMV) infections.Risk & Prevention.Researchers have found that lower CD4 cell counts or high HIV RNA levels at the time of anti-retroviral treatment initiation increase the risk of developing IRIS. One way to prevent IRIS development is to treat opportunistic infections prior to starting ART. Although this reduces the risk of IRIS development, it does not guarantee it.Treatment.In “unmasking IRIS,” patients can be treated with antibiotics, antivirals, or antifungals against the underlying infectious organism. In severe cases, steroids can also be used to suppress inflammation until the infection has been eradicated. Unfortunately, there is no treatment for paradoxical IRIS. Most patients who experience “paradoxical IRIS” reactions will get better spontaneously without additional therapy.Incidence of IRIS.The overall incidence of IRIS is unknown; however, studies have shown that anywhere from 25 to 30% of HIV patients who start antiretroviral treatment develop IRIS in the first six months. You may ask, which preexisting infections can lead to pa

Episode 119: Nurse Practitioner WeekAmy Arreaza is a family nurse practitioner who explains what this career is all about. She tells the history and the future of this profession. By Amy Arreaza, FNP. Comments by Hector Arreaza, MD.Hector: When I moved to Utah from my home country, I went to a clinic to investigate why I was so fatigued. I wasn’t a practicing physician at that time. I got seen by a family physician who was very brief and somewhat cold. During my follow-up appointment, I was attended to by a very pleasant lady doctor. She made good eye contact, smiled, and explained the results in a simple and easy way. In summary, my second visit was very enjoyable. Later, I learned that this lady was a nurse practitioner. I had no idea what it meant, but after many positive interactions, I became a fan of nurse practitioners in general. Today, I want you to learn more about this profession, and I invited my favorite nurse practitioner in the whole world, my wife Amy. Welcome, Amy Arreaza.Tell us who you are.Amy: First of all, thank you for inviting me to your podcast to talk about this wonderful profession. And second, I must reciprocate in kind, you are my favorite family physician. So, as you said, I am a nurse practitioner, but more specifically, I am a family nurse practitioner, or FNP for short. I’ve been an FNP for 14 years and currently work in central CA in a federally qualified health center as a primary care provider for the medically vulnerable. Caring for this patient population is where my passion truly lies. What is a Nurse Practitioner?A nurse practitioner is an advanced practice registered nurse. This means they are RNs who have completed either a master's degree or a doctorate degree in nursing practice. With their extra education and training, they have similar job duties as a physician, and there is actually a lot of overlap in the roles of nurse practitioners and physicians. NPs' serve as primary care providers or as specialty care providers. They examine and assess patients’ needs, order and interpret labs and imaging tests, diagnose disease, and provide treatment, which includes prescribing medication. In the United States, the scope of practice of a nurse practitioner is regulated by state law. As of this year, NPs have full practice authority in 26 states, the District of Columbia, and 2 US territories. This means that NPs can work independently in those states without the supervision of a physician. In the remaining states, NPs need to have a collaborative agreement with a physician or work under the supervision of a physician. How was this career created?Well, in the 1960s, Loretta Ford, a public health nurse in Colorado, recognized a deficit in health care in rural communities. She believed nurses could fill the healthcare gaps in rural America, and through the Western Interstate Commission for Higher Education in Nursing, she was given an opportunity to help develop a specialized clinical curriculum for community health nurses. In 1965, Loretta Ford joined forces with Dr. Henry Silver, a pediatrician, to create the first pediatric nurse practitioner program at the University of Colorado. So, 57 years ago, the NP profession was created to help alleviate the physician shortage at that time. And today, with a continued shortage of physicians, the NP profession has become essential in meeting primary care needs across the United States. Hector: There are 24 states that still do not offer full practice authority to NPs. Those states are more likely to have “geographic health care disparities, higher chronic disease burden, primary care shortages, higher costs of care and lower standings on national health rankings.”Amy: That’s right, research shows that states with full practice authority for NPs' rank highest in the nation for best access to care, while 9 of the bottom 10 states ranked as the least healthy states in the US have not yet granted NPs full practice authority.How do you become an NP?The first step in becoming an NP is to become a registered nurse with either an Associate's Degree or Bachelor's Degree in Nursing Science. You can then enroll in an associate’s-to-master’s degree NP program or a bachelor's to master's degree NP program. At the minimum, you must complete a Master of Science in Nursing (or MSN) Degree. However, you may choose to advance your education with a Doctorate of Nursing Practice (or DNP) degree. After graduation, NPs take a national certification exam to get certification from the specialty board that oversees their practice area. For example, I graduated from the University of Utah family nurse practitioner program and then took the national Family Nurse Practitioner Certification Exam from the American Nurses Credentialing Center. This makes me a board-certified FNP. How many kinds of NPs are there?There are multiple kinds of NPs. I am a family nurse practitioner, meaning I can treat patients from infancy through their golden years to the end of lif

Episode 118: Wernicke’s Encephalopathy Dr. Malave explains the diagnosis and treatment of Wernicke’s encephalopathy. Editing and comments by Hector Arreaza. Written by Maria Fernanda Malave, 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.Definition.As a reminder for everyone, vitamin B1 and thiamine are the same substance with different names. Wernicke’s encephalopathy (WE) is a neurological syndrome secondary to severe, short-term B1 deficiency. In the past, but less frequently nowadays, it was more commonly associated with alcohol use disorder. However, today we know that any condition that decreases dietary intake and increases thiamine use, or its elimination, puts patients at risk of developing this encephalopathy. Causes:Chronic alcoholism is the most important cause of WE. Around 70-80% of the causes are associated with chronic alcohol consumption. Non-alcoholic WE may be caused by Decreased intake: Some types of WE may be caused by a psychiatric illness that decreases the dietary intake of B1, such as anorexia nervosa, schizophrenia, or dementia. Arreaza: Also, prolonged fasting or starvation.Lack of absorption of B1: Other causes might be related to malabsorptive syndromes, bariatric surgeries, or hyperemesis gravidarumIncreased use of B1: Any disease that increases the use of B1 and, therefore, low levels of thiamine, such as cancer, thyrotoxicosis, and systemic illnesses like infections. High-carb diets are associated with high thiamine use. Also, patients who receive IV glucose w/o supplements are at risk of developing Wernicke’s encephalopathy.Increased elimination of B1: Other causes are related to increased elimination of B1, such as dialysis.Immunodeficiencies: Immunodeficiency syndromes and transplantation also cause WE.Why is thiamine important?Thiamine is one of the main cofactors in three key enzymes for energy metabolism: alpha-ketoglutarate dehydrogenase, pyruvate dehydrogenase, and transketolase. If we go back to biochemistry in med school, we can remember these enzymes play a significant role in the Krebs cycle and pentose phosphate pathways. Thiamine uses Mg+2 as a cofactor, so a magnesium deficiency can mimic WE.Pathophysiology.B1 deficiency causes lactic acid accumulation due to anaerobic glycolysis, leading to neuronal cytotoxic edema and vasogenic edema with petechial hemorrhages. MRI of the brain shows symmetrical hyperintensities, most commonly in the thalamus, mammillary bodies, cerebellum, and the periaqueductal area surrounding the third and fourth ventricles. The diagnosis of WE is made clinically, even though the MRI is a useful complementary tool to the clinical diagnosis. Diagnosis.WE presentation has always been described as the classic triad of ophthalmoplegia (or nystagmus), encephalopathy (confusion or memory impairment), and gait ataxia. However, this presentation is present only in less than 20% of patients, and most of the patients present with a neurologic syndrome that includes 2 out of the classic triad plus nonspecific symptoms such as hallucinations, hypothermia, hypotension, indifference or inattentiveness, seizures, behavioral disturbances, and bilateral lower extremity weakness. In 1997, Caine et al. suggested that a diagnosis of WE can be made if 2 out of 4 of these criteria were present in a patient with ophthalmoplegia/nystagmus + ataxia + memory impairment or confusion and clinical evidence of malnutrition or from laboratory data. Thiamine levels can be normal in patients with WE, so thiamine level is not a requirement for diagnosis.Almost 80% of WE cases are diagnosed on autopsy, which means this disease goes undiagnosed most of the time. The diagnosis is clinical, and MRI can assist in cases that are uncertain. Treatment.Thiamine supplementation is inexpensive, accessible, and easy to administer, so if we have a patient with a suspicious neurologic syndrome that could be WE, B1 must be given as soon as possible. Treatment should not be delayed while waiting for MRI results, The treatment consists of IV thiamine 500mg TID for 2-3 days, followed by 250 IM or IV for additional 5 days, in combination with other B vitamins. Because GI absorption of thiamine is impaired in alcoholics and malnourished patients, oral administration is contraindicated during initial treatment for WE. Thiamine 100 mg PO should be continued after the completion of parenteral treatment and after discharge from the hospital until patients are no longer considered at risk. Magnesium and other vitamins are replaced as well, along with other nutritional deficits if present.B1 blood levels or erythrocyte transketolase activ

Episode 117: Anxiety Screening. Adriana and Ikleel explain the new recommendation given by the USPSTF in October 2022 regarding screening for anxiety in children and adolescents 8-18 years old. Dr. Arreaza discusses the SCARED tool to screen for anxiety in pediatric patients. By Adriana Rodriguez, MS3, and Ikleel Moshref, MS3. Ross University School of Medicine. Moderated 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.Recommendation.The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years. Grade of recommendation: B (offer this service to your patients)The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in children 7 years or younger. Grade of recommendation: I (insufficient evidence, unknown benefits vs. harms)USPSTF concludes this new screening guideline for anxiety in this population has a moderate net benefit. For children 7 and younger, evidence is insufficient to determine screening tools accuracy and its effects, and benefit-to-risk balance. Anxiety. Anxiety disorder is characterized by excessive, persistent worry and or fear that is difficult to control, resulting in significant distress or impairment. Anxiety disorder manifests in psychological/emotional and physical/somatic symptoms. DSMV recognizes 7 types of anxiety disorders: GAD, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism. Comment: Anxiety is not your patient’s fault. In some cultures, anxiety is seen as a weakness. America seems to be a highly stressful society.Epidemiology.Anxiety disorder is a common mental health condition in the United States. According to the National Survey of Children’s Health in 2018-2019, 7.8% of people aged 3-17 yrs. old had an anxiety disorder that was current. In the adult population, past studies have shown ~3% past-year prevalence and ~5-12% lifetime prevalence of anxiety disorder in adults. Topic Importance.Anxiety disorders are the most common childhood-onset mental health condition. Childhood and adolescent anxiety disorder is associated with an increased likelihood of poor academic performance and co-occurring psychiatric conditions. It is also associated with future anxiety disorder, secondary depression, substance abuse, psychosocial functional impairment, chronic mental/somatic health conditions, and/or suicide. Screening anxiety disorder in youth may serve to improve potential prevent burdens in the future. Assessment of Risk. Although this new screening guideline is meant for children and adolescents aged 8-18 who have not been diagnosed with an anxiety disorder and without signs and symptoms, it is important to note what factors would increase their chances of developing any of the aforementioned anxiety disorders: Genetic, personality, and environmental factors: biopsychological vulnerability, attachment difficulties, child maltreatment, adverse childhood experience Demographic factors: poverty, low socioeconomic statusRacial and ethnic factors: racial discrimination, historic trauma, structural racismOther factors: LGBTQ youth, older adolescents 12-17Screening Tools.Although there are many screening tests for anxiety, two are widely utilized in clinical practice for screening purposes: (1) SCARED (Screen for Child Anxiety Related Disorders), and (2) Social Phobia Inventory. These screening instruments are insufficient for the actual diagnosis of any particular anxiety disorder listed earlier; if positive, however, a confirmatory assessment and follow-up is required to establish diagnosis using DSM V criteria for any of the recognized anxiety disorders (GAD, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism).SCARED (Screen for Children Anxiety Related Disorders): It is a 41-Item questionnaire, each question can be answered from 0-2 (0=not true or hardly true, 1=somewhat true or sometimes true, 2=very true or often true). A score greater than or equal to 25 is highly associated with anxiety disorder; panic disorder, significant somatic symptoms, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and significant school avoidance. SCARED is available online (here). There is a child version and a parent version. The only difference between the two is the different pronouns, for example, question 17 is “My child worries about going to school” vs “I worry about going to school”. Although the USPSTF could not find optimal screening intervals, these screenings may

Episode 116: Benefits of breastfeedingBy Timiiye Yomi, MD. Editing and comments by Hector Arreaza, MD.Dr. Yomi explains the benefits of breastfeeding for mother and baby. Three doctor listeners share their experiences with breastfeeding. 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.Breastfeeding is the process by which a child is fed breast milk. It is an ancient practice that dates to pre-historic times. The American Academy of Pediatrics recommends breastfeeding as the sole source of nutrition for babies for about 6 months and can be continued for as long as both mother and baby desire it, while the World Health Organization recommends exclusive breastfeeding for the first 6 months of life and up to 2 years with appropriate complementary foods.Human milk has many advantageous anti-infective and immunologic properties, making it the ideal nutritional source to optimize the infant's well-being. Of the over 130 million babies born every year in the world, only 42% of mothers breastfeed their newborn within the first hour of life, 38% practice exclusive breastfeeding, and over 50% breastfeed for up to 2 years. In this segment, we will be talking about the many benefits of breastfeeding to both children and mothers.Benefits to the baby: Breast milk has the right amount of nutrients and fluids needed for a baby’s growth and development.It is easier to digest than formula, and breastfed babies have less gas, fewer feeding problems, and less constipation.It contains antibodies that protect infants from illnesses like otitis media, gastroenteritis, and respiratory illnesses like asthma and allergies, especially in children breastfed beyond 6 months. It reduces the risk of atopic dermatitis, NEC, Celiac Disease, Crohn’s Disease and ulcerative colitis, Late-onset sepsis in the preterm infant, and childhood leukemia.Reduces the risk of childhood obesity, HTN, and type 1 and 2 diabetes Breastfed infants have a lower risk of sudden infant death syndrome (SIDS).Breastfed infants have been shown to have better cognitive development.Benefits to the mother:Promotes weight loss and some degree of contraceptive for mothersWomen who breastfeed longer have been shown to have lower rates of type 2 diabetes and high blood pressure, breast and ovarian cancer in premenopausal women, thyroid cancers, rheumatoid arthritis, and osteoporosisReduces the risk of post-Partum depressionBreastfeeding triggers the release of oxytocin that promotes uterine involution and may decrease the amount of postpartum hemorrhage.Additional benefits:Promotes mother-infant bonding Cheap and economical for families and societyConvenientIn summary, breastfeeding delivers a lot of health, nutritional and emotional benefits to both children and mothers. When not contraindicated, we encourage mothers to engage in this practice as it presents babies with a healthy start in life.The benefits of breastfeeding cannot be overstated. However, we recognize that some mothers have challenges breastfeeding. For those mothers, we say you are a great mother if you take good care of your baby, even if you cannot breastfeed him/her.Testimonials:Breastfeeding is highly recommended by healthcare professionals, and in most cases, it is a natural and smooth process. However, it is not always free of challenges. You will listen to testimonials about three different breastfeeding experiences. All these testimonials are anonymous and written by advanced-level healthcare providers. Their experiences fall on a spectrum ranging from positive and easy to negative and difficult.Testimonial #1: My grandma told me so.When I was pregnant with my first child, I was already keenly aware of the benefits of breastfeeding because by that time, I was established in my profession as a health care provider. I looked forward to breastfeeding my newborn. However, when my baby was born, I found that my breast anatomy made it extremely difficult for my baby to latch on. While it is possible for women to breastfeed with inverted nipples, for me and my baby, it did not work out. I felt like a failure as a new mother. When my grandma came to visit me and my newborn, I told her how frustrated I was with my body. She replied, “yah, sorry about that; you got those from me!” Yes, inverted nipples are a genetic trait, and 10-20% of women are born with inverted nipples. I had been feeling alone in my plight, but after talking with my grandma, I realized there were other women struggling just like me! Although I was very disappointed that I couldn’t breastfeed, I didn’t let that deter me from giving breast milk to my baby. Where there is a will, there is a way! I decided to b

Episode 115: Erectile Dysfunction Diagnosis. Discussion about the diagnosis of erectile dysfunction with Andrew, Adriana, and Dr. Arreaza. Causes, labs, and physical exam is briefly discussed. Written by Andrew Kim, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Adriana Rodriguez, MS3, Ross University School of Medicine; and Hector Arreaza, MD.September 22, 2022.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.In episode 39 o erectile dysfunction, Dr. Ihejirika gave us an overview, but today we will be more detailed about the diagnosis of ED. Definition.The American Urological Association (AUA) published an erectile dysfunction guideline in May 2018, which is available online at no cost. Based on that guideline, erectile dysfunction can be defined as “the consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual satisfaction, including satisfactory sexual performance.” Comment: This guideline provides 25 principles for diagnosing and treating ED. Diagnosis.Getting a good history is important when diagnosing erectile dysfunction. The patient should be asked about the onset of symptoms, severity, how much it hinders his sexual performance, whether the patient can get and maintain an erection, psychological factors, social factors, and presence of morning erections. One can use different questionnaires: the five-question International Index of Erectile Function (IIEF-5) or a single-question self-assessment. Single-question self-assessment:Impotence means not being able to get and keep an erection that is rigid enough for satisfactory sexual activity. How would you describe yourself?Not impotent: always able to get and keep an erection good enough for sexual intercourse.Minimally impotent: usually able to get and keep an erection good enough for sexual intercourse.Moderately impotent: sometimes able to get and keep an erection good enough for sexual intercourse.Completely impotent: never able to get and keep an erection good enough for sexual intercourse.Comment: Basically, the single-question self-assessment is a self-diagnosis of erectile dysfunction; the patient is giving you the severity of his condition. This questionnaire seems to be very subjective. International Index of Erectile Function (IIEF-5):IIEF-5 asks five questions, and the patient answers on a scale of 1 to 5 (1 is the worst, 5 is the best)How do you rate your confidence that you could get and keep an erection?When you had erections with sexual stimulation, how often were your erections hard enough for penetration?During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?When you attempted sexual intercourse, how often was it satisfactory for you?Diagnosis can be made based on the total score. 1 to 7: severe ED, 8 to 11: moderate ED, 12 to 16: mild-moderate ED, 17 to 21: mild ED, and 22 to 25: no ED.This is a self-reported questionnaire, and the score should be interpreted in a clinical context. Answers will likely be biased if, for example, the questionnaire is asked by a female medical assistant. Causes of ED:It is important to assess for medical conditions, psychological conditions, and medications because ED can be caused by vascular, neurological, psychological, and hormonal problems. Cardiovascular: Some common conditions related to ED are cardiovascular disease (PAD, CAD) and HTN.Endocrine: DM, HLD, obesity, testosterone deficiency (hypogonadism), hyperprolactinemia, thyroid disorder, metabolic syndrome.Neurologic: Neurologic conditions (multiple sclerosis, stroke, spine injury), trauma, and venous leakage.Lifestyle causes: sedentary lifestyle, tobacco use.Psychological: Performance anxiety, relationship issues, anxiety, depression, and stress are common psychological causes.Medications and substances: Alcohol, illicit drugs, and nicotine are important causes of ED, but some medications also cause or worsen ED: opiates, diuretics (spironolactone), antifungals (azoles), anticonvulsants, antidepressants (SSRIs), antihistamines, H2 blocker (cimetidine) antihypertensives, nasal decongestants, and antipsychotics. Remember to ask about over-the-counter medications and supplements.Physical exam: Measure blood pressure, BMI, and a complete exam, especially a genital exam. A comprehensive genitourinary exam should include the inspection of the testicles (atrophy, varicocele, signs of hypogonadism). The penis should be inspected and palpated (look for scar tissue a

Episode 114: Diabetes care updateYvette presents updates from ADA on diabetes care regarding SGLT-2 inhibitors, GLP-1 receptor agonists, and finerenone. Written by Yvette Singh, MSIV, American University of the Caribbean. Comments and text edition 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 American Diabetes Association (ADA) released revisions in May 2022; specifically regarding sodium-glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RA), and finerenone for cardiovascular and renal comorbidities. What are SGLT2 inhibitors and GLP-1 receptor agonists?SGLT2 inhibitor class of oral antidiabetic drugs, including empagliflozin, canagliflozin, dapagliflozin, and more. They increase the excretion of glucose and sodium in the urine by inhibiting SGLT2 in the kidney, thus lowering blood glucose levels. In other words, it has a glucoretic effect. GLP-1 receptor agonists are a class of non-insulin drugs, including exenatide, liraglutide, semaglutide, and more. They mimic the intestinal hormone incretin and bind to its receptor, which slows the rate at which foods leave the stomach, controls appetite, and regulates insulin and glucagon secretion.What is the NEW use of SGLT-2 Inhibitors and GLP-1 RA in treatment?Traditional glucocentric approaches recommend initial medications such as metformin for most adults with type 2 diabetes, leaving SGLT-2 inhibitors and GLP-1 receptor agonists as alternative options mainly for patients with high risk for atherosclerotic cardiovascular disease in whom additional glucose lowering was needed after metformin treatment. Current guidelines now recommend these agents (SGLT-2 inhibitors and GLP-1 RA) for any T2DM patient with current or high-risk for ASCVD, chronic kidney disease (CKD), or heart failure (HF). This guideline stands regardless of the need for additional glucose lowering and/or metformin use. This has now changed through trials, demonstrating that cardiovascular disease and chronic kidney disease benefits independent of a medication’s glucose-lowering potential.HbA1c has long been used to guide clinical decision-making about type 2 diabetes. However, systematic reviews have revealed minimal benefits in the normalization of HbA1c.Moreover, the cardiovascular and kidney protection of SGLT-2 inhibitors and GLP-1 receptor agonists are unrelated to their impact on HbA1c. Double-blinded randomized clinical trials showed that SGLT-2 inhibitors reduced the risk of cardiovascular death and hospitalization for heart failure in patients with or without diabetes. Therefore, cardiovascular and kidney risk, rather than HbA1c, constitutes a possible indication for the two medication classes. If patients with ASCVD remain above goal A1C despite the addition of an SGLT-2 inhibitor or GLP-1 RA, then adding the agent the patient is not currently on out of the two is recommended before dipeptidyl peptidase-4 aka (DPP-4) inhibitors, basal insulin, or sulfonylureas because the combined use of an SGLT-2 inhibitor and GLP-1 RA can produce an additive risk reduction for cardiovascular and renal adverse events.What is Finerenone, and how does it help with diabetes? Finerenone (Kerendia®) selectively blocks sodium reabsorption and overactivation of mineralocorticoid receptors within epithelial and non-epithelial tissues. This, in turn, reduces fibrosis and inflammation of both the kidneys and blood vasculature.Finerenone use for patients with advanced CKD, i.e., moderately elevated albuminuria, eGFR of 25- 60 mL/min, and diabetic retinopathy, is encouraged for nephroprotection. However, Patients with less-advanced CKD, i.e., stages 1-2, do not receive any benefit. Regardless of the severity of CKD, SGLT-2 inhibitors remain first-line therapy.Although Finerenone improves cardiovascular outcomes and reduces CKD progression for patients, it is still unknown if there are any additive cardioprotective effects if used with SGLT2 inhibitors and/or GLP-1 receptor agonists.Some Closing Pearls: The use of SGLT2 inhibitors in patients with eGFR > 25 decreased from 30 previously.If the A1c goal is not being met, combination therapy of insulin with a GLP receptor agonist can be considered, as this combination treatment has been shown to increase the efficacy and duration of insulin.Overall, this new change could be very beneficial if accepted internationally. Though understandably, there could be some limitations to this guideline given the availability and cost of these medications, as well as their contraindication of use in specific populations such as pregnancy, ages >65 with concurrent risk factors for

Episode 112: Statins in Primary CareDr. Tiwana explains the use of statins for the primary prevention of cardiovascular disease.Written by Ripandeep Tiwana, MD (Post-Doctoral Research Fellow at Cedar Sinai Medical Center – Heart Institute). Edition of text 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.Definition.Statins commonly referred to as lipid-lowering medications, are important in primary care as they serve multiple long-term benefits than just lipid lowering alone. They are HMG-CoA reductase inhibitors. As a refresher, this is the rate-controlling enzyme of the metabolic pathway that produces cholesterol. This enzyme is more active at night, so statins are recommended to be taken at bedtime instead of during the day. Statins are most effective at lowering LDL cholesterol. However, they also help lower triglycerides and raise HDL cholesterol.Statins are not limited to just patients with hyperlipidemia. They reduce illness and mortality in those who have diabetes, have a history of cardiovascular disease (including heart attack, stroke, peripheral arterial disease), or are simply at high risk for cardiovascular disease. Statins are used for primary and secondary prevention.Types of statins.How do we determine which statin our patients need?First, we need to know that not all statins are created equal. They vary by intensity and potency thus, and they are categorized as either low, moderate, or high intensity.Several statins are available for use in the United States. They include Atorvastatin (Lipitor), Fluvastatin (Lescol XL), Lovastatin (Altoprev), Pitavastatin (Livalo, Zypitamag), Pravastatin (Pravachol), Rosuvastatin (Crestor, Ezallor), Simvastatin (Zocor)Commonly used in clinics: Simvastatin, Atorvastatin, and Rosuvastatin.Statin Dosing and ACC/AHA Classification of Intensity Low-intensity Moderate-intensity High-intensityAtorvastatin NA 1 10 to 20 mg 40 to 80 mgFluvastatin 20 to 40 mg 40 mg 2×/day; XL 80 mg NALovastatin 20 mg 40 mg NAPitavastatin 1 mg 2 to 4 mg NARosuvastatin NA 5 to 10 mg 20 to 40 mgSimvastatin 10 mg 20 to 40 mg NAOf note, atorvastatin and rosuvastatin are only for moderate or high-intensity use, and do not use simvastatin 80 mg.Identifying patients at risk.How do we determine who needs statin therapy?Once we become familiar with the different statins, we must figure out which intensity is advised for our patient. Recommendations for statin therapy are based on guidelines from The U.S. Preventive Services Task Force (USPSTF), American Diabetes Association (ADA), and the American College of Cardiology/American Heart Association (ACC/AHA) which recommend utilizing the ASCVD risk calculator in those patients who do not already have established cardiovascular disease.ASCVD stands for atherosclerotic cardiovascular disease, defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease presumed to be of atherosclerotic origin. ASCVD remains a leading cause of morbidity and mortality in the United States, especially in individuals with diabetes.The ASCVD risk score determines a patient’s 10-year risk of cardiovascular complications, such as a myocardial infarction or stroke. This risk estimate considers age, sex, race, cholesterol levels, use of blood pressure medication, diabetic status, and smoking status. Regarding age, this calculator only applies to the age range of 40-79 as there is insufficient data to predict risk outside this age group.There are several online and mobile applications available to calculate this score. Once calculated it gives a recommendation for which intensity statin to use. However, as this is a recommendation, it is essential to use your own clinical judgment to decide what is best for your individual patient. Please refer to the above table as a reference for which statin and dose you may consider using.Keeping the above calculator in mind, additional statin guidelines are recommended by the ACC:Patients ages 20-75 years and LDL-C ≥190 mg/dl use high-intensity statin without risk assessment. (You do not need the calculator.)People with type 2 diabetes and aged 40-75 years use moderate-intensity statins, and risk estimate to consider high-intensity statins. (It means moderate for all diabetics older than 40, high for some.)Age >75 years, clinical assessment, and risk discussion. Age 40-75 years and LDL-C ≥70 mg/dl and Risk 5% to Risk ≥7.5-20% (intermediate risk). Risk discussion: use moderate-intensity statins and increase to high-intensity with risk enhancers.Risk ≥20% (high risk). Risk discussion to initiate high-in

Introduction: False positive RPR. By Hector Arreaza, MD. Read by Alinor Mezinord, MS III, Ross University School of Medicine. Today we will talk about syphilis. Significant research has been done to determine the origin of this ancient infection. Some experts support that syphilis originated in the New World (the Americas) because the first cases in Europe were reported after the Christopher Columbus crew returned from their expeditions. On the other hand, some people defend the idea of the origin of syphilis in the Old World. Whatever its origin, syphilis is still affecting thousands of people worldwide. According to the World Health Organization, “syphilis in pregnancy is the second leading cause of stillbirth globally and also results in prematurity, low birth weight, neonatal death, and infections in newborns.”[1] The cases in the US are not as high as in other countries, but certain areas have cases higher than the national or state average. Such is the case in Kern County. Our incidence of syphilis is higher than the national average.That’s why it is important to screen for this disease. RPR is the most common test to screen for syphilis; however, it may not be completely accurate. RPR is a non-treponemal test that can cause false positive results. On December 20, 2021, the CDC released a letter announcing an FDA alert regarding a high RPR false positive rate when done with Bio-Rad Laboratories BioPlex 2200 Syphilis Total & RPR kit. You may not know which kit was used for the test, but you need to know what to do with a positive RPR. Some conditions associated with false positive RPR include COVID-19 vaccines, tuberculosis, endocarditis, rickettsial disease, recent immunizations (smallpox), and pregnancy. In case of RPR positive, you need to confirm syphilis with a treponemal test, which will be more reliable regardless of the possibility of a false positive RPR. We still need to screen because syphilis continues to increase in our nation. I hope you enjoy this episode.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.___________________________Latent Syphilis. By Carol Avila, MD. Comments by Hector Arreaza, MD. Dr. Avila: I had the amazing opportunity to do inpatient pediatrics during my first rotation at a local hospital, and I often treated patients with neonatal syphilis. I was curious to know what is happening in this area (Bakersfield) that made syphilis (seems to me) a very frequent diagnosis of admission in peds, especially because newborns are impacted by a preventable disease.Epidemiology:The latest update available on the CDC website is the 2020 Surveillance Report of Nationally Notifiable STDs which showed:-In 2020, the national rate of syphilis was about 40 per 100,000 population (all stages).-The rate of national congenital syphilis was about 57 cases per 100,000 live births.-During that year, California was ranked #7 for primary and secondary syphilis (P&S), with a 19.5 per 100,000 population. Nevada was the number #1 state.Local data:In 2018 data, the Kern County Public Health Services Department reported:-A total of 1,520 cases of syphilis (all stages) were diagnosed during that year, about 4 cases/day. It is important to mention that there was a spike in the number of cases of syphilis by 86% compared to the prior year, 2017.-In 2020, 250 cases of congenital syphilis per 100,000 live births were reported in Kern County. Significantly higher than the national average (mentioned above, 40 cases per 100,000 residents). -For primary and secondary syphilis, Kern County was 62% higher than the state average, with almost 35 per 100,000 population, and was ranked #6 in the state of California. -San Francisco was ranked #1.-Bottomline: The rate of syphilis and congenital syphilis in Kern County is higher than the state and national average.Definition:Syphilis is a systemic bacterial infection caused by the gram-negative spirochete Treponema pallidum. Transmission:Syphilis is well known as a sexually transmitted disease; however, while many cases happen due to sexual activity, there are a few other ways that syphilis can also be spread.-It can be transmitted during pregnancy, resulting in congenital syphilis.-Also, passing on syphilis via blood transfusions was very common but is now rare thanks to blood supply screening.-Syphilis transmission is also possible through an organ donor, which nowadays is very rare.-Before healthcare providers were wearing gloves as a standard precaution, it was common for syphilis lesions to appear on their fingers and noses.-It can also be transmitted through close and repetitive contact with mucosal or skin lesions of people with act

Episode 111: Pregnancy FAQ Dr. Urso answers commonly asked questions during pregnancy. 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.Written by Carmen Urso, MD. Edited by Hector Arreaza, MD.Pregnancy is one of the most exciting moments of a woman’s life, but at the same time, it could be a little scary because whatever the mother does may affect the baby. This is why it is so important to make sure about general recommendations during pregnancy. The information I present here is evidence-based. 1. Should I take prenatal vitamins?The goal of prenatal supplements is to provide the vitamins and minerals needed to promote normal fetal development. Some studies have shown that in high-income countries where the food is vitamin-fortified, and typically people are well-nourished, vitamin supplementation has not proved to improve maternal and neonatal outcomes. However, a Cochrane review of randomized trials in low- and middle-income countries with vitamin and mineral diet deficiency found that supplementation reduces the risk of low birth weight and small for gestational age. Because you don’t always know the nutritional status of a patient, it is advised to use a standard prenatal vitamin. What are the most important vitamins in the prenatal period? The 2 most important elements are folic acid and iron, which can be found in regular prenatal vitamins. The American College of Obstetrics and Gynecology (ACOG) recommends multivitamins with: -Folic acid: 400mcg to 800mcg daily to reduce the risk of neural tube defects. It is recommended to start before pregnancy until the end of the first trimester (12 weeks). Patients with a history of fetal neural tubal defect should take 4000 mcg (4mg) daily. The USPSTF recommends (Grade A, 2017) to supplement with folic acid for all women of childbearing before pregnancy. Supplementation should start at least one month before pregnancy, according to CDC. -Iron: 30 mg/day to prevent maternal anemia. The formulation should contain 15-30 mg/dl. Most prenatal contain about 30 mg, which is considered a “low” dose, and 65 mg of elemental iron is equivalent to 325 mg of ferrous sulfate, which is a common supplement given to patients in our clinics. So, patients could take one tablet of 325 mg of ferrous sulfate daily and have enough for their pregnancy, or take it every other day if they are intolerant to iron]-Vitamin D: Vitamin D deficiency is associated with preterm birth and preeclampsia. 200-600 international units are recommended. ACOG does not recommend screening for vitamin D deficiency before or during pregnancy. The USPSTF concluded there is insufficient evidence to recommend for or against Vitamin D deficiency screening in asymptomatic adults. This is a Grade I recommendation.-Calcium: Supplements should contain 1000 mg/dL. Most multivitamins have 200-300mg; the rest of the daily calcium should come from dietary sources. Foods rich in calcium include dairy products such as milk, yogurt, cheese, soybeans, seeds, beans, lentils, and dark-green leafy vegetables like kale, spinach, and collard greens. Another source of vitamin D is sun exposure. We do not recommend sun exposure as a source of vitamin D, but there are benefits to sun exposure for other reasons, for example, mood.2. Should I be eating for 2 while I am pregnant?It is a misconception. Pregnant women do not have to eat for 2. Caloric intake will depend on the number of fetuses (single or multiple), the trimester, and the pre-pregnancy weight. During the first trimester, no extra daily calories are needed. In the second trimester, a pregnant person will need 340 extra calories/day, and in the third, 450 extra calories/day for a total of 2200 to 2900 kcal/day. The weight gain will be based on pre-pregnancy BMI (body mass index). For example, a patient who is overweight (BMI 20-29) should gain 15-25 lbs. in the whole pregnancy, but a patient with obesity (BMI above 30) should gain 11-20 lbs. only. These are the recommendations by the National Academy of Medicine.Interestingly, if you are underweight before pregnancy, you can gain 30-40 pounds.National Academy of Medicine Recommendations for Weight Gain in Pregnancy:Pre-pregnancy BMI Category (kg/m2) Recommended Weight Gain (lbs.) Underweight (less than 18.5) 28–40 Normal weight (18.5-24.9) 25-30Overweight (25.0-29.9) 15-25Obese (30 or greater) 11-203. Can I drink alcohol?There is not a safe level of alcohol during pregnancy. Alcohol can cause life-long birth defects. Even little amounts can cause problems to the baby, such as coordination, behavior, attention, and learning disability. Heavy drinking can cause fetal alcohol syndrome, charac

Episode 110: Pulse Ox in Dark-skinned People. Learn about the most recent findings in pulse oximeters in dark-skinned people. Bahar and Arianna explain the new recommendations by FDA regarding this topic. Written by Bahar Hamidi, MS4; and Arianna Crediford, MS4. American University of the Caribbean (AUC). Comments by Hector Arreaza, MD. ________________This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice._________________Bahar: When I first saw this news breakout on CNN I was stunned! A cohort study just published (7/11/22) in JAMA called “Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit” revealed that Asian, Black, and Hispanic patients received less supplemental oxygen than White patients, because of the differences in pulse oximeter performance, which may contribute to known race and ethnicity–based disparities in care. I cannot believe this discovery has not been given the attention it deserves earlier. I believe maybe COVID had a lot to do with it; as checking the pulse ox deciphered the patients’ treatment plan. Let’s think about it for a moment, how important is the pulse ox accuracy?Arianna: Well, we know that insufficient administration of supplemental oxygen can make changes in the initiation and management of noninvasive verse invasive mechanical ventilation. The study mentions some other important points like pulse oximeter performance disparities playing a role in decision-making regarding fluid management, specialty service consultation, and even intensive care unit (ICU) admission. Bahar: It states, “artificially high SpO2 readings in the emergency department could also affect the perceived need for cardiology service admission for heart failure management, possibly explaining the finding that Black and Hispanic patients were less likely than White patients to be admitted to a cardiology service.”Arianna: So how you may ask the study really put this to the test? The large cohort study had 3,069 patients in the intensive care unit, so what they did was they took the average hemoglobin oxygen saturation for each patient and tracked how much supplemental oxygen was given to the patients and lo and behold, the data revealed that Asian, Black, and Hispanic patients had a higher adjusted time-weighted average pulse oximetry reading and were administered significantly less supplemental oxygen compared with White patients even with adjusting for potential confounders.Bahar: And what is the solution you may ask? Well, the FDA issued a new draft guidance that recommends companies making medical products submit a “race and ethnicity diversity plan” to the agency early in their development of products, and that a plan should include enrolling diverse groups of people into their clinical trials as of April 2022. As a reminder, it's been a year since CDC declared racism a public health threat. Arianna: Rutendo Jakachira is a Ph.D. student in Brown University's Department of Physics. She is studying racial disparities in pulse oximetry. She stated that COVID-19 likely helped uncover the suspected pulse oximeter limitations in dark-skinned people. Kimani Toussaint is a professor and senior associate dean in the School of Engineering at Brown University. Jakachira, Toussaint, and their colleagues from Engineering at Brown University are developing non-invasive methods to make pulse oximeters more accurate in blood oxygen readings for people with dark skin tones.Bahar: Toussaint stated that they are “trying to mitigate the skin tone issues by doing something interesting with the light, but it’s a significant challenge and this really highlights the need to have diversity and inclusion.” Pulse oximeters work by sending beams of light through the fingertips to measure blood oxygen levels, they are actually measuring how much oxygen has been absorbed by hemoglobin. Melanin is the brown pigment that gives color to our skin, hair, and eyes. It turns out that both hemoglobin and melanin absorb light at similar wavelengths and it can be challenging to separate their contributions to the detected level of oxygen. Arianna: Toussaint explains that melanin will overlap with the absorption properties of the hemoglobin in your blood, which can lead to inaccurate pulse oximeter readings because people have different amounts of melanin.Bahar: Jakachira and Toussaint are trying to cancel out the effect of melanin on how pulse oximeters measure blood oxygen levels. The result of this work would be a contribution that can be applied to other similar-based technologies that measure levels of substances through the skin, but they co

Episode 105: Renal Cell Carcinoma. Manpreet and Jon-Ade explain how to diagnose renal cell carcinoma. Introduction about age and kidney transplant by Dr. Arreaza and Dr. Yomi. [Due to technical difficulties this episode was not posted as scheduled, so it had to be reposted on 9/9/2022] Introduction: Too old for a new kidney?By Hector Arreaza, MD. Discussed with Timiiye Yomi, MD.Today we will be talking about the kidneys, those precious bean-shaped organs that detoxify your blood 24/7. Amazingly, we can live normal lives with one kidney, but when the kidney function is not good enough to meet the body’s demands, patients need to start kidney replacement therapy. Modern medicine has made a lot of advances with dialysis, but the perfection of a kidney has not been outperformed by any machine yet. That’s why kidney transplant is the hope for many of our patients with end-stage kidney disease.The need for a kidney transplant is growing, likely due to increasing chronic diseases such as diabetes and hypertension, and also because of an increase in elderly population. About 22% of patients on the kidney transplant waiting list are over age 65. A cut-off age to receive kidney transplant has not been established across the globe. Different countries use different criteria for the maximum age for transplant. The American Society of Transplantation’s guidelines states “There should be no absolute upper age limit for excluding patients whose overall health and life situation suggest that transplantation will be beneficial.” So, if your patient is older than 65 and needs a kidney, they may qualify for a transplant, and age should not be an absolute contraindication to receive it. Actually, older patients may have lower risk of rejection due to a theoretically weaker immune system. A live donor is likely to be a better option for elderly patients. A condition that would make your elderly patient a poor candidate for kidney transplant would be frailty. Common contraindications to kidney transplant include active infections or malignancy, uncontrolled mental illness, ongoing addiction to substances, reversible kidney failure, and documented active and ongoing treatment nonadherence.So, remember to take these factors into consideration when deciding if you need to refer your elderly patients for a kidney transplant, there is no such thing as being too old for a new kidney if your patient meets all the criteria for a transplant.This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. Renal Cell Carcinoma. By Manpreet Singh, MS3, Ross University School of Medicine, and Jon-Ade Holter, MS3 Ross University School of Medicine. Moderated by Hector Arreaza, MD. Definition:Renal cell carcinoma is a primary neoplasm arising form the renal cortex. 80-85 percent of renal tumors are renal cell carcinomas followed closely by transitional cell renal cancer and Wilms tumor. Epidemiology: In 2022, 79,000 new cases of kidney cancer were diagnosed with almost 14,000 mortalities. There is a 2:1 male to female ratio and the average age is 64 and normally 65-74. African Americans and American Indians have a higher prevalence rate compared to other racial groups. The lifetime risk for developing kidney cancer in men is about 1 in 46 (2.02%) and 1 in 80 (1.03%) in women. Risk Factors associated with RCC: Anything that causes assault to the kidneys and affects its function would cause increased demand, injury, and inflammation. This assault can lead to cell derangement and lead to cancer. The risk factors that have been associated with RCC are smoking, obesity, HTN, family history of kidney cancer, Trichloroethylene (a metal degreaser used in large manufacturing factories), acetaminophen, and patients with advanced kidney disease needing dialysis. Patients with syndromes that cause multiple types of tumors: VHL (von Hippel-Lindau) deficiency, a tumor suppressor, gives rise to clear cell renal cell carcinoma. Familial inheritance of VHL deficiency is mostly found in patients that have RCC at a very young age, before 40 y/o. Other tumors can be found in the eye, brain, spinal cord, pancreas, and pheochromocytomas.Hereditary leiomyoma-renal cell carcinoma due to FH gene mutations causing women who have leiomyomas to have a higher risk of developing papillary RCC.Birt-Hogg-Dube (BHD) syndrome mutation in FLCN gene who develop various skin and renal tumors.Cowden syndrome is a mutation in the PTEN gene giving rise to cancers associated with breast, thyroid , and kidney cancers.Tuberous sclerosis causes benign tumors of the skin, brain, lungs, eyes, kidneys, and heart. Although kidney tumors are most often benign, occasiona

Episode 109: Shingles vaccine before 50Prabhjot and Dr. Arreaza discuss the indications and contraindications of the zoster recombinant vaccine (Shingrix®). Shingrix is now FDA-approved to be used in people younger than 50 years old. Magic mushroom as a therapy for alcohol use disorder._________________Introduction: “Magic mushroom” as a potential treatment for alcohol addictionBy Hector Arreaza, MD. Addiction is one of the biggest challenges in medicine. Patients with addictions are at risk of adverse events or even death from overdose but also are at risk of withdrawal when trying to quit. As medical providers, our goal is to assist our patients to stop using substances that may be toxic and cause detrimental effects on their health in the short and long term. It is not easy to help patients overcome the discomfort, cravings, and even life-threatening symptoms that result from withdrawal. Out of the many addictions, alcohol use disorder is one of the most destructive addictions, and the harms from it go beyond the personal effects, as it affects families, communities, and the whole nation. It is a serious public health issue. It is estimated that 15 million people (12 and older) in the US have alcohol use disorder, and about 140,000 people die every year from alcohol-related causes. Many patients would like to stop drinking, but the withdrawal symptoms may be more than just discomfort and may become unbearable and even fatal. Today I want to share the news published on August 24, 2022, on JAMA and many news outlets regarding the potential use of Psylocibin as an adjunct therapy to quit drinking alcohol. This was a double-blind randomized clinical trial that compared Psilocybin with diphenhydramine. Psilocybin is also known as “magic mushroom”. Participants were offered 12 weeks of psychotherapy and were randomly assigned to receive psilocybin vs. diphenhydramine during 2-day-long medication sessions at weeks 4 and 8. There were 93 participants. The percentage of heavy drinking days during a 32-week period after the first dose of medication was 9.7% for the psilocybin group and 23.6% for the diphenhydramine group. So, patients in the Psylocibin group had decreased heavy drinking, and the mean alcohol consumption was also lower. Blinding was an issue during the study because many participants could guess which medication they were receiving. Some participants described “flying over landscapes, seeing [their] late father and merging telepathically with historical figures.” The bottom line of the study is that administration of Psilocybin in combination with psychotherapy produced a significant reduction in the percentage of heavy drinking days over and above those produced by active placebo and psychotherapy. These are exciting news for those who are trying to quit alcohol, and it provides a foundation for additional research on psilocybin-assisted treatment for AUD._____________________This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.________________________________________________________________________________________________________________Shingrix before 50. By Prabhjot Kaur, MS4, Ross University School of Medicine. 1. What is Shingrix?It’s a recombinant zoster vaccine to protect against Herpes Zoster (Shingles) in adults over 50 years old. 2. What is Herpes Zoster?Prabhjot: It’s a viral infection that is caused by the Varicella-Zoster virus, which also causes chickenpox. Chickenpox, also called varicella, can happen in children and adults. After a person is infected with chickenpox, the virus remains dormant in the dorsal root ganglia, which are the clusters of neurons along the spinal column. As the person grows older, or his or her immunity decreases due to conditions such as an infection, malignancy, or pregnancy, the dormant virus becomes reactivated. Prabhjot: When the virus reactivates in adults, it presents with a painful, blistering, itchy rash over the specific dermatomes. The rash mostly occurs on the torso, face, or upper extremities, and it is usually only on one side of the body. Arreaza: A common belief in the Latino culture (since our audience sees a lot of patients of Latino descent) is that if the rash crosses the midline of your body and it makes a circle around your chest, you will die. If you, as a doctor, get that question from a patient, the answer is: herpes zoster normally affects the root ganglia on one side of the body. If your patient has bilateral herpes zoster, you must rule out immunodeficiency. The rash may be preceded or followed by pain, burning, numbing, or tingling of the skin. Some patients might even have fevers, chills, fati

Episode 105: Antidotes to toxidromes. Some poisonings share common signs and symptoms and may be treated with antidotes without laboratory confirmation of the offending agent. Dr. Francis discussed with Dr. Arreaza some of those toxidromes and how to treat them. Written by Aida Francis, MD. Participation by Hector Arreaza, MD. Definitions: • Antidotes are substances given as a remedy that inhibit the effects of another drug of abuse or poison. Most are not 100% effective and fatality is still possible after administration. • Toxidrome is a constellation of signs and symptoms caused by an overdose or exposure to chemicals or drugs that interact with neuroreceptors. Toxidrome is the combination of the word “toxin” and “syndrome”. Management strategies of toxidromes are determined by the signs and symptoms even when the causative agent has not been identified. A little bit of Background: The World Health Organization reported that 13% of deaths caused by poisonings are children and young adults. Intentional poisoning attempts are more frequent among adolescent women than men. It is difficult to evaluate poisoned patients because they are too altered to provide history and there is often not enough time to perform a physical exam or obtain serum studies prior to life-saving interventions. To diagnose a toxidrome clinically, you need three elements: pupil size, temperature, and bowel sounds. For example: Pinpoint pupils with hyperactive bowel sounds point to cholinergic toxidrome, and dilated pupils with high temperature, and hypoactive bowel sounds point to anticholinergic (see details below). Pinpoint pupils -> Bowel sounds -> Hyperactive: CHOLINERGIC -> Hypoactive: OPIOIDS Normal or dilated pupils -> Temperature -> High -> Bowel sounds -> Hyperactive: SYMPATHOMIMETIC -> Hypoactive: ANTICHOLINERGIC -> Normal or Low -> Bowel sounds -> Hyperactive: HALLOCUNOGENIC -> Hypoactive: SEDATIVE-HYPNOTICS Anticholinergic Toxidrome and the Physostigmine antidote: • Anticholinergics inhibit the binding of acetylcholine to the muscarinic receptors in the central nervous system and the parasympathetic nervous system. Examples of anticholinergics include atropine and tiotropium. Other substances that may cause anticholinergic toxidrome include antihistamines (especially first-generation: diphenhydramine), antipsychotics (quetiapine), antidepressants (TCAs, paroxetine), and antiparkinsonian drugs (benztropine). Symptoms of toxicity include tachycardia, non-reactive mydriasis, anhidrosis, dry mucous membranes, skin flushing, decreased bowel sounds, and urinary retention. Neurological symptoms include delirium, confusion, anxiety, agitation, mumbling, visual hallucination, and strange behavior. Neurological symptoms last longer because of the anticholinergic lipophilic properties which cause them to distribute into fatty organs and tissues like the brain. “Mad as a hatter, red as a beet, blind as a bat, hot as a hare, dry as a bone” [Spanish: loco como una cabra, rojo como un tomate, ciego como un topo, seco como una piedra, caliente como el infierno] • The antidote for anticholinergic toxidrome is physostigmine. It is an acetylcholinesterase inhibitor and prevents the metabolism of acetylcholine. This increases the level of acetylcholine in both the central nervous system and peripheral nervous system. Physostigmine can cause seizures and arrhythmia, so close monitoring in the hospital is required during treatment. Cholinergic toxidrome and its antidotes atropine and pralidoxime: Acetylcholine is part of the parasympathetic nervous system and cholinergic substances can induce a parasympathetic response. Some of these substances include pesticides, organophosphates, carbamate, and nerve gas. Chlorpyrifos had been used to control insects in homes and fields since 1965. It has been used in our crops in Bakersfield, and the most recent mass exposure was in May 2017. it was banned on food crops in the US in August 2021. It has been banned for residential use for a longer period. Repeated exposure to chlorpyrifos causes autoimmune disorders and developmental delays in children and fetuses. The symptoms of cholinergic toxidrome can be summarized with the SLUDGE/ “triple” BBB acronym. This includes salivation, lacrimation, urination, defecation, gastrointestinal cramping, emesis, bradycardia, bronchorrhea, and bronchospasm. There can also be muscle fasciculations and paralysis. • The antidote is Atropine. Pralidoxime is used for organophosphates only because it cleaves the organophosphate-acetylcholinesterase complex to release the enzyme to degrade acetylcholine. Pralidoxime should be used in combination with atropine, not as monotherapy. It requires hospital admission, and a note for organophosphate, remember that the patient needs external decontamination (shower). Let’s go to part 2 of our discussion, environmental exposure. Carbon Monoxide Toxidrome and the antidote oxygen: Carbon monoxide intoxication is usually due to smoke inha

Episode 107: Weight Gain Meds. Medications that cause weight gain are also called weight positive medications. Sapna, Danish, and Dr. Arreaza mention some of those medications in this episode. Introduction: Some meds cause weight gainBy Hector Arreaza, MD.You will see patients who keep gaining weight regardless of their sincere efforts to eat better and exercise. Some people experience serious difficulties to lose weight. If you want to know how frustrating it can be, imagine your doctor telling you to add one more inch to your height when you are 35 years old. For some people, losing weight is just as hard. One important step you can take to help your patients lose weight is performing a detailed medication reconciliation. Review the medication list, and you may find some meds that are proven to cause weight gain. Today we will discuss some of those medications, but it takes practice to learn all of them. I hope this episode is helpful for you. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________Weight Gain Meds. By Sapna Patel, MS4, and Danish Khalid, MS4. Ross University School of Medicine. Comments by Hector Arreaza, MD. S: Medications associated with weight gain: See Table 1.1 for medications associated with weight gain and alternatives. Antipsychotic agents:A: Ziprasidone is an antipsychotic medicine that causes the least amount of weight gain.Antidepressants:There are many antidepressants which are associated with weight gain, including the tricyclics, monoamine oxidase inhibitors (MAOIs), and some of the selective serotonin reuptake inhibitors (SSRIs). Tricyclic antidepressants, in particular amitriptyline, clomipramine, doxepin, and imipramine, are associated with significant weight gain.Selective serotonin reuptake inhibitors, paroxetine exhibited the greatest weight gain in its class. Whereas fluoxetine exhibited little to no weight gain and remains weight neutral in the class. Amongst the monoamine oxidase inhibitors, phenelzine had the greatest weight gain. Antiepileptics/Antiseizure: Amongst the antiepileptic drugs used to treat seizures, neuropathic pain, or other psychiatric conditions, valproate, carbamazepine, and gabapentin are associated with weight gain. Gabapentin is virtually used by all our diabetic patients. Antihypertensive agents: Beta BlockersBeta receptors, specifically beta-2 receptors, stimulate the release of insulin. Thus, patients on beta blockers may experience weight gain as a side effect. There are two beta blockers that cause the least amount of weight gain: Carvedilol (Coreg) and nebivolol (Bystolic). Hypoglycemic medications: Although intended to regulate blood sugar levels, several anti-diabetic medications are associated with weight gain, specifically sulfonylureas, Actos, and insulin. As mentioned earlier, metformin as well as GLP-1 agonists are associated with weight loss. Metformin can be considered weight neutral. Steroids: Steroid hormones such as corticosteroids or progestational steroids are associated with weight gain. Steroids may increase levels of cortisol, one of the end pathways in steroidogenesis. Cortisol, also known as the stress hormone, functions by increasing insulin resistance, and decreasing glucose utilization, thus causing weight gain. Antihistamine Medications: Diphenhydramine (Benadryl): commonly used for allergies…or how my mom used it, puts you to sleep right before a flight. However, a side effect of using this medication includes weight gain.Cyproheptadine: an antihistamine, used for antidote to serotonin syndrome and migraines, has an appetite stimulant effect causing weight gain. It can be used off-label as an appetite stimulant in children who do not gain weight. Fun Fact: Although it is a common belief that combined oral contraceptives cause weight gain, data suggest that significant weight gain is not a common side effect of combined oral contraceptives. A good practice: Medication reconciliation: Weight positive, weight neutral, or weight negative. Weight positive: Deprescribe or change for another medication if possible. Weight neutral and weight negative: Keep them. Don’t be afraid to prescribe anti-obesity meds. We should learn about them, become familiar with side effects, contraindications, dosing, and more, and prescribe them appropriately as part of a weight loss program. Also, don’t forget that these medications are used in conjunction with a proper diet. CategoryDrug ClassWeight GainAlternatives Psychiatric agentsAntipsychoticsClozapine, risperidone, olanzapine, quetiapine, haloperidol, perphenazineZiprasidone, aripiprazoleAntidepressants/mood stabilizers: tri

Episode 106: Weight Loss Meds. Anti-obesity medications are FDA-approved drugs to support your patient’s efforts to lose weight. It is important for primary care providers to learn about these medications to continue fighting against obesity in our communities.Introduction: Obesity is a chronic disease.By Hector Arreaza, MD. Obesity has all the characteristics of a chronic disease. Let’s use our imagination and think about a patient with hypertension, for example. Let’s imagine you are the doctor or Mr. Lee. He is 45 years old and his blood pressure has been persistently high, around 150/100, even after lifestyle modifications. You decide to start chlorthalidone 25 mg and Mr. Lee takes chlorthalidone every day. Four weeks later you see Mr. Lee again and you review his labs with him. He has normal renal function and normal electrolytes. His blood pressure is now 119/75. He is feeling great and reports no side effects to chlorthalidone. Would you stop the medication at this time? Think about it. The most obvious answer is NO, you will not stop chlorthalidone. Today you will listen to a discussion about anti-obesity medications, common indications, contraindications, cautions, and more. We will learn that obesity requires chronic treatment with medications just like any other chronic disease. I hope you enjoy it.This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________Weight Loss Meds. By Sapna Patel, MS4; and Danish Khalid, MS$. Ross University School of Medicine. Moderated by Hector Arreaza, MD. S: Hello and welcome back to our nutrition series! If you haven't already listened to our previous episodes, pause this and make sure to give them a listen. We have talked about physical activity, meal plans, and intermittent fasting. Today we are going to talk about the clinical management of obesity, specifically the pharmacotherapy that is used. We will divide these drugs into drugs that reduce food intake primarily acting on the CNS, drugs that reduce fat absorption and medications that are associated with weight gain. D: Can anyone who is considered obese take medications to help them lose weight? Pharmacotherapy should be considered if the patient will be taking the medication in conjunction with the overall weight management program, including changes in eating habits, increased physical activity, and realistic expectations of the medication therapy. Adjuvant pharmacologic treatments should be considered for patients with a BMI >30 kg/m2 or with BMI >27 kg/m2 who have concomitant obesity related diseases. A: You are going to find doctors who are pretty much against anti-obesity drugs, but that’s not my case. S: Drugs that reduce food intake primarily acting on the CNS: Let's start with Phentermine and other sympathomimetic drugs A: Phentermine has been in the market over 60 years and it is well tolerated by most patients. It is effective, expect 5-8 lbs weight loss a month when taken with dietary changes and increased physical activity. The weight loss happens mostly the first 3-6 months when you take anti-obesity medications. S: One of the longest clinical trials of the drugs in this group lasted 36 weeks and compared placebo treatment to treatment with continuous phentermine and intermittent phentermine. Both the continuous and intermittent phentermine therapy produced more weight loss than placebo. D: Other options are Phentermine and topiramate ER which is known as “Qsymia”. These drugs combine a catecholamine releaser and anticonvulsant respectively. Topiramate is currently approved by the USFDA as an anticonvulsant for treatment of epilepsy and for prophylaxis of migraine headaches. Weight loss was seen as an unintentional side effect during clinical trials for epilepsy.The mechanism responsible for this is thought to be mediated through the modulation of GABA receptors, inhibition of carbonic anhydrase and antagonism of glutamate to reduce food intake The common adverse effects include cognitive impairment, paresthesia, and increased risk for kidney stones. Topiramate is also a teratogenic drug, so patients need to be in a good birth control to take it. It causes cleft palate in the fetus.The 2 phase-III trials called EQUIP and CONQUER, both 1 year randomized placebo-controlled double-blinded clinical trials, 3 different strengths of a once-a day formulation were tested: full strength dose (15 mg of phentermine and 92 mg of topiramate ER), mid-dose (7.5mg of phentermine and 92 mg topiramate ER) and low dose (3.75mg of phentermine and 23 mg of topiramate ER). Subjects randomized to the full strength dose in EQUIP and CONQUER trials lost an averag

Episode 104: What is Monkeypox. Monkeypox is a rare disease caused by the monkeypox virus that belongs to the orthopoxvirus (smallpox) family. Nabhan, Dr. Schlaerth, and Dr. Arreaza discuss the basics of what is known about this disease. Introduction: Monkeypox By Hector Arreaza, MD. As of June 29, 2022, there are 5,115 confirmed cases of monkeypox in the world. The country with the most cases is the United Kingdom with >1,000 cases. In the United States, there are 351 confirmed cases, distributed in 28 states, and the state with the highest number of cases is California with 80 cases. Today we will briefly discuss the history, epidemiology, transmission, and management of monkeypox. By the way, by the time you listen to this episode, this disease may have a different name, as the World Health Organization is planning to rename it to minimize stigma and racism. Monkeypox is still rare, but because of the current outbreak, we need to include it in our list of differentials when we see rashes. Symptoms of monkeypox can include fever, chills, headache, myalgias, lymphadenopathies, and general malaise. The rash resembles pimples or blisters that appear on the face, inside the mouth, and on other parts of the body, like the hands, feet, chest, genitals, or anus. The rash goes through different stages before healing completely. The illness typically lasts 2-4 weeks. Monkeypox spreads by direct or indirect contact with rash, respiratory secretions, and vertical transmission from mother to fetus. Sometimes, people get a rash first, followed by other symptoms. Others only experience a rash. Currently, there is not a formal treatment for the disease. The information will continue to evolve in the future. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________What is monkeypox. By Nabhan Kamal, MS3, American University of the Caribbean School of Medicine. Comments by Katherine Schlaerth. Moderated by Hector Arreaza, MD. Background.Monkeypox is a viral zoonotic infection that results in a rash similar to smallpox. It is estimated that humans have been infected by the monkeypox virus for centuries in sub-Saharan Africa. Monkeypox is an orthopoxvirus that was first isolated in the decade of 1950s from a colony of sick monkeys. The variola virus and the vaccinia virus are in the same genus as the monkeypox virus. Variola is the smallpox virus, and vaccinia is the virus in the smallpox vaccine. The virion that has been seen in cells infected with the monkeypox virus looks exactly the same as the virions of variola or vaccinia viruses. It has a characteristic brick-like appearance. The two strains of monkeypox identified in different regions of Africa are Central Africa and Western Africa. It seems like the strain of Western Africa is less virulent and lacks a number of genes present in the Central African strain. Transition to talking about Epidemiology Why is understanding the epidemiology of monkeypox important? I think it’s important to touch on the epidemiology of the virus because it will help healthcare providers better understand the disease and have a more productive discussion with their patients about this illness if they, unfortunately, happen to fall victim to it. Epidemiology In the 70s, the first time monkeypox was identified as a cause of disease in humans. It happened in the Democratic Republic of the Congo (formerly the Republic of Zaire). After that, only 59 cases of human monkeypox were identified in the decade between 1970 and 1980, with a mortality rate of 17%. All of these cases occurred in the rain forests of Western and Central Africa. These cases occurred in people exposed to rodents, squirrels, and monkeys. An important fact to note is that despite the virus being called “monkeypox”, monkeys and humans are incidental hosts; the reservoir remains unknown but is likely to be rodents. Despite the current common belief that this is the first outbreak of monkeypox in the US, the actual first outbreak of monkeypox in the Western Hemisphere occurred in the United States in 2003. Transition to talking about Transmission Is the monkeypox virus extremely virulent and transmissible just like SARS COV-2? All people born after 1972 have not been vaccinated against smallpox. Routine vaccination of the American public against smallpox stopped in 1972 after smallpox was eradicated in the United States. The virus can spread between animals and humans, just like COVID-19 is believed to be. Transmission Animal-to-human transmission – A person gets infected by monkeypox by contact with body fluids coming from an infected animal or through a bite. Monkeypox

Episode 103: Caring for LGBTQ+ Patients. Salwa, Pat, and Dr. Arreaza explain how to care for patients who identify themselves as LGBTQ+. Answered questions include, what screenings are needed? Any special needs? Introduction: LGBTQ+ Information. By Hector Arreaza, MD. Recently the media has been flooded with information about LGBTQ+. If you wonder what LGBTQ+ means, it means lesbian, gay, bisexual, transgender, queer or questioning, and the “+” sign acknowledges other orientations such as asexual, intersex, and more. June was designated as “pride month”. I think we have received more information within the last year than in the previous century. Many people consider this an overrepresentation of the calculated 3.5% to 8% of the population who identify themselves as LGBTQ+, many others consider this a revolution to promote equality in our society by reaffirming gay rights, while others consider this a part of an agenda to destroy the “American way of living” or even the US Armed Forces. You can come to your own conclusion about the origin and validity of this movement, but as medical providers, especially as family medicine providers, we must be prepared to care for any patient we encounter, including members of the LGBTQ+ community, and treat them with the same respect and compassion as any other patient. This episode was done to increase your awareness of this topic and motivate you to keep learning about it. By the way, there are now specific fellowships you can take to become more specialized on this topic, and you can find more information on the American Medical Association website.[3] This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________Caring for LGBTQ+ patients. By Salwa Sadiq-Ali, MS IV Ross University School of Medicine, and Pattamestrige Perera, MS IV, American University of the Caribbean. Comments by Hector Arreaza, MD. Salwa: So, I was browsing the internet as we all do these days and I came across a short film, The Clinic, by a Canada-based organization, the Get REAL movement. Have you heard about this Dr. Arreaza? Arreaza: No, I haven’t, but this sounds interesting. What was the film about? Salwa: Essentially, it’s about LGBTQ+ patients and how healthcare is not inclusive. The film shows two patients with the same concern, one of which is from the LGBTQ+ community. It goes on to show how they are treated differently by the physician. Arreaza: That’s not how it should be. Unfortunately, healthcare disparity is very real, especially in minority groups like the LGBTQ+. One study found that 3.5% of Americans identify as lesbian, gay, or bisexual and 0.3% identify as transgender. They also found that these individuals are more likely to get poor care because of stigma and lack of awareness. Salwa: Exactly! And since June is PRIDE month, I thought this would be a great topic! Especially because we as students or healthcare providers don’t learn too much about this in school or training. Arreaza: I think that’s a great idea. I’ve heard a lot about PRIDE celebrations and the memorials that are held. How about we start with what exactly is PRIDE?Pat: PRIDE is a celebration, a movement. It’s celebrated to commemorate the 1969 Stonewall Riots or Uprising. The riots began after the police raided a gay club in New York City leading to almost a week of violent clashes. This event marked the beginning of the gay rights movement as we know it today. Arreaza: And today PRIDE is celebrated with parades and many hold memorials for members of the community who were victims of hate crimes. By the way, you can listen to our episode 14, “Gender Diversity”, to learn about the definitions of gender, sexual orientation, and more.Pat: As you said earlier, LGBTQ+ individuals are part of a minority group and face discrimination. Arreaza: Let’s talk about the health care gaps the “community” faces. Tell us more. Salwa: Yes absolutely! Let’s get into it! Did you know that LGBTQ+ youth are at a higher risk for substance abuse, STDs, cancers, cardiovascular disease, obesity, bullying, isolation, rejection, anxiety, depression, and suicide in comparison to the general population? Arreaza: The AAFP says suicide rates are 4 times higher among LGBTQ+ and even higher among trans youth compared to heterosexual youths. Also, members of the community, specifically men who have sex with men, are at a much higher risk of being affected by HIV/AIDS.Pat: In fact, family physicians, and all primary care providers, are key to providing care for the LGBTQ+ community and the special needs of the community including gender-affirming care. Arreaza: So, what should primary care pro

Episode 102: Fluoride supplementation in kids.Steven and Dr. Cha explained the importance of fluoride recommendations to prevent dental decay in kids who live in areas where water fluoride is low.A: When I moved to Bakersfield, my children were 3 and a 5 years old, we took them to a pediatrician, and they got a prescription for fluoride supplements, that was something I had never seen before, so I was curious, and for many years I wanted to know the fluoride content of my water. Recently, I discovered the page nccd.cdc.gov thanks to the American Family Physician article about the fluorination of water, and I found the content of Bakersfield. Because in Family Medicine we see patients from the cradle to the tomb and from head to toe, today we will talk about dental health. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________Fluoride Supplementation in Kids. Written by Steve Beebe, MS3, Ross University School of Medicine. Editions by Hector Arreaza, MD; and Gina Cha, MD.G: Let’s start with the definition of fluoride, What is fluoride?S: Fluoride is a mineral – a substance that occurs in nature in its well-defined crystalline form. Put another way, fluoride is the negatively charged form of the element fluorine -- one of the elements on the periodic table. Fluoride is considered one of the essential/beneficial trace elements that our body uses for a variety of purposes. Other common trace elements include copper, iodine, iron, and zinc.[1] Where can fluoride be found?G: Fluoride is commonly found in groundwater. It can also be found in tea, bones, shells, medical supplements, and fluoridated toothpaste. The fluoride takes the place of hydroxyl groups in the tooth matrix thereby making teeth more resistant to acidic substances which reduces dental caries.A: Why is fluoride a controversial topic?S: Although fluoride and dental caries/cavities are inversely correlated, it has yet to be shown that fluoride is strictly essential.[2]A: Also, fluoride is not innocuous, it can be detrimental if taken in excess. Why is the fluorination of water important?G: Dental caries is the most common chronic disease in children. The National Health & Nutrition Examination Survey showed that over 23% of children between ages 2-5 had dental cavities.[3] Unfortunately, having dental caries is associated with localized pain, tooth loss, impaired growth, impaired weight gain, and poor school performance, and it carries a risk for dental caries in the future as an adult.[4]A: Some parents think that having caries on your baby teeth does not matter because those teeth are going to fall anyways.G: The American Academy of Pediatric Dentistry explains that fluorination of the water supply helps balance the risk of getting dental caries with the risk of fluorosis or tooth mottling from excessive fluoride intake.[5] How much fluoride is enough for human consumption?S: The National Academic Press recommends a maximum of 2.5mg of fluoride each day to avoid fluorosis (mottling of teeth). The NAP recommends 0.1 to 1mg from birth to 1 year of age and 0.5 to 1.5mg from 1-3 years of age as safe and adequate.[6]The United States Preventive Services Task Force (USPSTF) recommends starting an oral fluoride supplement at 6 months of age in areas where the water supply is deficient in fluoride. S: Topical application of fluoride is seen as safe as early as the eruption of primary teeth.[7] (A: dental varnishing we do in well-child exams). Unfortunately, the USPSTF mentions that there have been no studies done to adequately address the dosage of oral fluoride supplementation in children with poor water fluoridation. Is there such a thing as too much fluoride?G: Yes. Symptoms are dose-dependent and range from generalized pain, nausea, vomiting, diarrhea, staining of the teeth (fluorosis), renal dysfunction, cardiac dysfunction, coma, and death. When do we start giving fluoride supplements to our patients if needed?S: The American Dental Association (ADA) recommends cleaning the teeth of children under the age of 2 years old with water and a brush as soon as teeth protrude into the mouth – a grain of rice-sized smear of fluoridated toothpaste can be used. At 3-6 years of age, the ADA recommends children use a pea-sized amount of fluoride toothpaste when brushing with a toothbrush.[8] (A: we have an obsession with comparing staff to food)G: The American Academy of Pediatric Dentistry (AAPD) recommends a community fluorination level of 0.7 ppm in the water supply. They recommend against supplementing children under 6 months of age. However, they recommend the following daily oral supplementation

Episode 101: Fasting Precautions. By Danish Khalid, MS4; and Sapna Patel, MS4. Ross University School of Medicine. Comments by Valerie Civelli, MD; and Hector Arreaza, MD. Fasting is a healthy lifestyle that may impact your health but fasting is not for everyone. Sapna, Danish, Dr. Civelli, and Dr. Arreaza explain some precautions to be taken in certain populations. We’ve talked about intermittent fasting, but we need to add a very big caveat: fasting isn’t for everyone. It carries certain risks. Some people who should absolutely not attempt fasting include those severely malnourished or underweight, children under eighteen years of age, pregnant women, and breastfeeding women. And the concern for these individuals involves providing adequate nutrition for normal growth or development. We also have to be cautious in patients with chronic heart problems, renal issues, eating disorders, fragile diabetics, or recently hospitalized patients. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice._________________________ S: The normal growth spurt in puberty requires a tremendous amount of nutrients. Underfeeding during this period may result in stunted growth, which may be irreversible. D: Or in pregnant women, the developing fetus requires adequate nutrients for optimal growth, and nutritional deficiency may cause irreversible harm during this critical period. It’s for this reason many women take specialty formulated pregnancy multivitamins. S: The same concept applies to breastfeeding mothers. Developing babies receive all their nutrients from the mother. So, if the mom becomes deficient in vitamins and minerals, then the baby may also be deficient. Which again would result in irreversible growth retardation. D: Others that should take caution when fasting but don’t necessarily need to avoid it include those who have gout, diabetes, gastroesophageal reflux disease, or are taking medications. For these individuals, it is wise to seek medical advice from a healthcare professional. A: Chances are that you may not find a physician who is pro-fast, but after reading about it and trying it myself, I think it is a safe way to lose weight or maintain a healthy weight. S: Gout is an inflammatory arthritis caused by excess uric acid in the joints. It can be either due to decreased uric acid excretion through urine or increased production of uric acid through breakdown of nucleic acid. Fasting decreases the elimination of uric acid through urine. Thus, theoretically worsening gout. Now although most patients with a history of gout tolerate fasting without any exacerbation, knowing the potential risk is important. D: If you have type 1 or type 2 diabetes, it's essential to be particularly careful while fasting or even just changing dietary patterns. This is especially true if you are taking medications. If you continue to use the same dose of medication but reduce food intake, you run the risk of your blood sugar getting low - a situation called hypoglycemia. Symptoms include shaking, sweating, irritability or nervousness, feeling faint, confusion, delirium, seizures, and if left untreated may even lead to death. What is even more worrisome, these symptoms may appear very rapidly, so understanding your body and the cues it provides is essential. Thus, you must consult with your physician to adjust the doses of diabetic medication before starting any dietary program to avoid having any hypoglycemic episodes as they can be potentially life-threatening. A: The risk of hypoglycemia is high in patients with diabetes who are taking medications, but it’s less likely to happen in patients with obesity without diabetes. The body fat (stores) acts as the fuel for your body functions. Patients will not die if they stop eating. S: If you have GERD (heartburn) this is oftentimes due to increased pressure on the stomach which forces food and stomach acid back up. This can be made worse during fasting because there is nothing in the stomach to absorb the stomach acid. Sometimes, fasting can improve symptoms because food stimulates the production of stomach acid, so fasting reduces it. A: My GERD improves with fasting. D: Patients who are taking regular medication for any condition need close follow-up as certain medications are best taken with meals. The most common medications that cause problems during fasting include aspirin, metformin, iron, and magnesium supplements. S: Myth: Women shouldn’t fast. One area of specific concern with women is that fasting could affect reproductive hormones, LH and FSH, similar to that seen in anorexia. This can lead to amenorrhea and difficulty conceiving. However,

Episode 100: Sexercise. Written by Valerie Civelli, MD. Comments by Namdeep Grewal, MD; and Hector Arreaza, MD. Have you ever wondered if sex is a good workout? Drs. Civelli, Grewal and Arreaza discuss the topic based on evidence offered by science. The following episode is not recommended for young children or people who consider sex a sensitive topic. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________Sexercise. Written by Valerie Civelli, MD. Comments by Namdeep Grewal, MD; and Hector Arreaza, MD. A: If I say “bow chika wow wow” what’s the first thing that comes to mind? The Chipmunks movie right?B: Yes, exactly, I can hear Alvin in his high-pitched voice, [higher tone] “bowchicka wow wow”. For those of you unfamiliar with this movie, don’t feel too left out because even Alvin was hinting to exactly what you’re thinking.A: Yep, we’re going there today people. Let’s talk about sex. Medically speaking of course. B: That’s right because 1. If you’re doing it, your risk for heart attacks and strokes are decreased after age 50 and 2. If you’re not doing it, ask you’re doctor, we should be discussing it and why not.A: Yes, that is the guideline-directed recommendation actually. We’re recognizing more and more the importance of sexual activity in medicine and its impact on overall health, quality of life and even level of risk for mortality. However, given the sensitive nature of sexuality, few studies have been done to better correlate and define exactly what this means for our health specifically. Sex can be an embarrassing topic to discuss by patients, doctors and researchers which has been largely influenced by culture, religion and other societal norms. Well, today let’s break this proverbial glass. B: I agree, let’s talk about sexuality activity and what research do we have.A: It has been said that Dr. Masters and Dr. Johnson were the earliest pioneers of this type of investigation. They published the first study of its kind in 1966, which examined the physiological responses of sexual activity. This was an 11-year observational study involving 382 females, ages 18 to 78, and 312 male volunteers, 21 to 89 years of age. The study identified a progressive increase in respiratory rates, up to 40 per minute, an increased heart rate 110 to 180 beats/min and an increase in systolic blood pressure by 30 to 80mmhg during sexual activity. In 1970, Hellerstein and Friedman identified the mean heart rate at the time of orgasm was 117.4 beats per minute with a range of 90 to 144. This was done in middle-age men, average age 47.5. Interestingly, the 24-hr ekg monitoring also identified a lower peak post coital heart rate, which was usually lower than the heart rates achieved with normal daily activities (around 120.1 beats per minute). In 1984, Bohlen et al. did a racier study with 10 couples using ECG, oxygen consumption (measured using a fast-responding polarographic O2 gas analyzer), heart rate and blood pressure monitoring before and during 4 types of sexual activity. This study obtained data during self-stimulation, partner stimulation, man-on-top and woman-on-top coitus. The men were aged 25 to 43 years of age. Results showed that self-stimulation increased the heart rate by 37 % from baseline to orgasm compared with a 51 % increase with man-on-top coitus. B: So already it was clear in 1966 to 1984 that physical exertion in the bedroom correlates to physiologic responses like increased heart rate, blood pressure, etc. However, our question of the day is, does sexual activity count as exercise, and to that question we ask why or why not?A: When I think about exercise, I think about heart rate and blood pressure. I think about indicators of energy expenditures and/or intensity. And specifically, while I’m working out…I’m talking about at the gym, and I’m running on the treadmill for example, my mental state is, how much longer until I can quit. Duration and level of intensity while under this physical exertion feels most important. And according to the AHA, this has been heavily studied. That’s why 150 active intentional minutes of exercise are recommended per week to improve cardiovascular health. Does this translate to sexual activity? B: Well before we answer this, let’s first mention the Bruce protocol. Have you ever heard of this? The Bruce protocol is a standard test of cardiovascular health, comprised of multiple stages of exertion on a treadmill, with three minutes spent per stage. Also at each stage, the incline and speed of the treadmill are elevated to increase cardiac work output, which is called METS. Stage 1 of the Bruce protocol is per

Episode 99: Intermittent Fasting 99. By Danish Khalid, MS4; Sapna Patel, MS4; Ross University School of Medicine. Comments by Valerie Civelli, MD; and Hector Arreaza, MD.Intermittent caloric restriction may seem like a new trend, but Sapna and Danish discussed that actually fasting is practiced in different cultures and it has many health benefits, including weight loss. . This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.D: Welcome and thank you for tuning back to our Nutrition series! Today, we want to give a shout out to one of our listeners. She brought up a topic that has recently gained public interest. Intermittent fasting. So, if you’re listening, Hina Asad, this one's for you! Let’s jump in! V: 2/3 women are overweight and obese. 1.5 pounds gained/yr on avg age 50-60’s.S: So like we said earlier, intermittent fasting has recently gained much public interest as a weight loss approach. Or should I say, revitalized itself, as it has been around for years. It describes an eating pattern in which you alternate between periods of eating and fasting (or not eating). The length of each fast can vary in duration. A: There are feasting and fasting periods, or fed states and fasting states. What is more effective: Intermittent restriction of calories or continuous restriction of calories? D: Before we dive in, let’s go back. We know that calorie reduction has been consistently found to produce reduction in body weight and improve overall health. We talked about how to calculate our basal metabolic rate and subtracting calories from our daily caloric intake to result in weight loss. However, this can be difficult to sustain over a long period. Additionally, it requires that you adjust your caloric needs every so often as you lose weight, which can further make it difficult. So how is intermittent fasting different from this? S: Well, in contrast to calorie reduction, intermittent fasting focuses on when calories are consumed and the total quantity consumed. Intermittent fasting works through an altered liver metabolism, referred to as the “metabolic switch.” It’s where the body periodically switches from liver-derived glucose to adipose-derived ketones. In doing so, it stimulates an adaptive response including improved glucose regulation, improved insulin sensitivity, and increased stress resistance via conditioning. V: When you eat is more important than what you eat. Benefits: reducing cancer, Alzheimer's, DM risk, better sleep, less hangry(*find evidence). D: What happens when we fast? In our previous podcast we mentioned ketosis, but let's talk about the physiology behind fasting.Feeding: blood sugar levels rise as we absorb food and insulin levels rise in response to move glucose into the cell. Excess glucose is stored as glycogen in the liver to convert it to fat.S: Postabsorptive phase (6-24hrs after beginning fasting): Blood glucose and insulin start to drop. To supply energy ,the liver starts to breakdown glycogen, releasing glucose. Glycogen stores last 24-36hrs. V: Insulin levels are low, and fat stores are available and improves mental clarityD: Gluconeogenesis (24hrs - 2 days after beginning fasting): Glycogen stores run out. The liver manufactures new glucose from amino acids called “gluconeogenesis” ( literally “making new glucose) S: Ketosis (2- 3 days after beginning fasting). A: Autophagy: “Auto” means self and “phagy” means eat. So the literal meaning of autophagy is “self-eating.”S: The protein conservation phase (5 days after beginning fasting): High levels of growth hormone maintain muscle mass and lean tissues. The energy for basic metabolism is mostly supplied by fatty acids and ketones. Blood glucose levels are maintained by gluconeogenesis using glycerol. Increased adrenaline levels prevent any decrease in metabolic rate. There is a normal amount of protein turnover, but it is not being used for energy. V: How long should we fast for? D: Fasts can range from 12 hours to three month or more. We can categorize them as short (24 hours). However, shorter regimens are generally used by those mostly interested in weight loss. The short daily fasting regimens can be divided into the length of fasting - 12 hours fasts, 16 hours fasts, and 20 hours fasts. S: Daily 12 hour fasting introduces a period of very low insulin levels during the day with 3 equally spaced meals throughout the day. This prevents the development of insulin resistance, making the 12 hour fast effective against obesity. Although a great preventative strategy, it is not the most effective at reversing weight gain. D: Fun Fact: In years past, the 12 hour fasting period was considered a n

Episode 98: Apretude and code blue. Apretude is a new injectable medication for HIV pre-exposure prophylaxis (PrEP), Dr. Yomi presents how to use it. Then, Mandeep, Jon, and. Introduction: Apretude, a new injectable for HIV PrEP. By Timiiye Yomi, MD. Moderated by Jennifer Thoene, MD. What is HIV PrEP? Pre-exposure prophylaxis (or PrEP) consists of taking medication when a patient has a high risk of contracting HIV to lower their chances of getting infected. Who can take HIV PrEP? Individuals who may benefit from PrEP include but are not limited to: Male who have sex with male (MSM), people with multiple sexual partners with no consistent use of condoms, or people who have been diagnosed with an STD in the past 6 months, IV drug users who share needles, syringes, or other injection equipment. History of HIV PrEP: In 2012, the first medication for HIV PrEP was approved—Truvada® (tenofovir-emtricitabine). Truvada is a once-daily oral prescription drug. Seven years later, in 2019, the next medication for HIV PrEP was approved— Descovy® (tenofovir alafenamide and emtricitabine). It is also a daily PO medication. But today we want to introduce you to the newest medication for HIV PrEP—Apretude® (cabotegravir). On Dec 20, 2021, FDA approved Apretude (cabotegravir), an extended-release injectable for HIV-1 pre-exposure prophylaxis for at-risk adolescents and adults who weigh at least 35 kg (77 lbs). Mechanism of action: Apretude is a long-acting integrase inhibitor that works by binding to the HIV integrase active site and blocking the strand transfer step of retroviral DNA integration. How is it given? Comes as a 600-mg (3-mL) injection. Patients receive 2 initiation injections administered 1 month apart, thereafter every 2 months. Patients can start medication immediately or first take the oral formulation for 4 weeks to assess how well they tolerate the medication before beginning the injection. Trials: The safety and efficacy of Apretude in reducing the risk of contracting HIV-1 were evaluated in two randomized double-blind trials comparing Apretude and Truvada (once-daily oral medication).Trial 1: Participants who took Apretude had a 69% less risk of contracting HIV compared to Truvada.Trial 2: Participants who took Apretude had a 90% less risk of contracting HIV compared to Truvada. Common side effects: Fever, malaise, fatigue, sleep problems, myalgias and arthralgias, headache, rash, red and swollen eyes, edema of face, lips, mouth, tongue; GI discomfort, hepatotoxicity, and depression. Note: Some drug-resistant HIV variants have been identified in people with undiagnosed HIV prior to beginning Apretude. People who test positive for HIV while on Apretude must transition to a complete HIV treatment regimen as Apretude is not approved for HIV treatment. Requirements to receive Apretude: -Patient must be HIV-1 negative-Patient must remain negative to continue receiving Apretude-Patient must not miss any injections as this increases their risk of contracting the virus Apretude does not protect against other sexually transmitted infections. Patients must be sexually responsible and use other forms of protection such as condoms during sexual intercourse. This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________A code blue in clinic. By Manpreet Singh, MS3; Jon-Ade Holter, MS3; and Sheinnera Gerongay, MS3. Ross University School of Medicine. What is a code blue?Arreaza: Today we will present to you a case to remind you about some principles of cardiopulmonary resuscitation (CPR). The term “code blue” in the United States refers to a situation where a patient is in cardiac arrest, respiratory arrest, unresponsive, or experiencing another medical emergency that requires immediate attention. “Code blue” is commonly used in hospitals and clinics to call a rapid response team to arrive immediately to evaluate the patient. We hope you can benefit from this brief review and feel ready for your next code blue. Of course, you will need more than we provide during these few minutes, but we hope it triggers your curiosity to keep learning or practicing. By the way, “code blue” is not standard for medical emergency in the whole world. For example, in the United Kingdom, they call it “code red”. Case presentation: Mr. DD 56-year-old man with a past medical history of coronary artery disease, recent MI, DM2, and CHF presents today to our clinic for hospital follow. He had an MI 2 weeks ago. He reports that when he was at home working in the yard, he suddenly had 8/10 retrosternal chest pain, pressure-like, accompanied by shortness of breath and diaphoresis. The pain radi

Episode 97: EAT and NEAT. Your body burns calories not only if you exercise. Sapna, Danish, and Dr. Arreaza explain the different ways you can burn more calories.Introduction: Energy in and Energy outBy Hector Arreaza, MD. Read by Suraj Amrutia. Our bodies are not machines. The simplistic concepts of energy balance, i.e., “energy in and energy out,” are influenced by a myriad of physiological processes and systems that include neurotransmitters, hormones, genetic and epigenetic factors, and many more. The combination of all these processes is called metabolism. The use of energy varies greatly among humans, that is why we come in many shapes and forms. If we apply the principles of thermodynamics to humans, people who eat the same amount of calories, have the same body weight, and have the same level of physical activity should have the same weight. But that theory has been debunked by multiple studies. That explains, for example, why some people who are naturally “thin” can remain thin regardless of their caloric intake and their physical activity. Today we will explain how our bodies use the energy that goes in, or in other words, how we spend our calories. We hope you enjoy this conversation. This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.___________________________EAT and NEAT. By Hector Arreaza, MD; Sapna Patel, MS IV; and Danish Khalid, MS IV. A: Energy expenditure is the amount of energy people need to carry out their physical functions. Energy expenditure is made up of resting metabolic rate, physical activity, and dietary thermogenesis. The widest variance in energy expenditure among most individuals is physical activity.S: For individuals with moderate physical inactivity the distribution of energy expenditure is:~70% resting metabolic rate, ~20% physical activity, ~10% diet-induced thermogenesis.D: Exercise Activity Thermogenesis (EAT) consists of physical activity that is planned, structured and repetitive done with the purpose of improving our well-being. Some EAT include sports, gym, etc. Just like gasoline for motor vehicles, available energy in muscle (ATP) is used for mechanical work, and some energy is released as heat (thermogenesis). The efficiency in converting ATP to mechanical work is ~30%; it means that out of 100 ATPs produced, 30 result in muscle work. A: An increase in body temperature triggers the CNS to cool the body via increased dilation of skin smooth muscle blood vessels, increased heart rate, and increased sweat production – all that help facilitate the release of heat during physical exercise. S: Non-Exercise Activity Thermogenesis (NEAT) consists of physical activity that is not typically considered exercise (e.g., maintaining posture, standing, walking, stair climbing, fidgeting, cleaning, singing, and other activities of daily living.) Walking can be considered EAT or NEAT.NEAT often represents the widest variance in total energy expenditure among individuals. NEAT can range between 150-500 kcal/day, which is often greater than bouts of exercise. D: NEAT is an example of a behavioral factor to explain the perception that some people are “naturally skinny” and can maintain a healthier body weight compared to others, even with the same caloric intake and same routine “exercise” activity. Increasing your number of steps per day can be achieved by altering daily activity, or by scheduled walking/running. S: For example: Parking far away, taking the stairs instead of the elevator, going to your coworker’s office instead of calling.A: You can monitor your number of steps per day with a pedometer or other tracking device (cell phone). The number of steps recorded by different pedometers can vary.D: Less than 5,000 steps/day is average for U.S. adults, and it is considered sedentary.S: 5,000 – 7,5000 steps/day is low active, and 7,500 – 10,000 steps/day is somewhat active.A: More than 10,000 steps/day is desirable (active). 10,000 steps per day x 7 days per week x one calorie per 20 steps = 3,500 calories burned per week.D: On average, 1 calorie is “burned” for every 20 steps, it means 4,000 steps / 20 = 200 calories.S: Definition of rest days. Rest days are any days that don’t involve heavy lifting and focus on cardio or core exercises. Rest days are an important part of any exercise routine as it gives your body a chance to repair and recover. At least one rest every week. D: On the other hand, workout days involve heavy lifting: push, pull, legs, etc. For example, on rest days I do cardio and abs.Conclusion: Now we conclude our episode number 97 “EAT and NEAT.” Keep in mind the ways your body uses the energy you put in. Energy is used b

Episode 96: Tirzepatide. By Maria Beuca, MS3, Ross University School of Medicine. Comments by Hector Arreaza, MD. Today is May 19, 2022, and we want to talk about a new drug that was recently approved by the FDA on May 13, 2022, for the treatment of type 2 diabetes. This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.This drug is known as tirzepatide, also known by the brand name Mounjaro®. It is an injection given once a week that mimics the effects of two hormones: GIP (Glucose-dependent Insulinotropic Polypeptide) and GLP-1 (Glucagon-Like Peptide-1). These two hormones are involved in lowering blood glucose levels after eating by stimulating insulin release, they are “incretin” hormones. What is unique about this new drug, tirzepatide, is that it is the first and only approved single molecule that binds and activates BOTH GIP and GLP-1 receptors. Because of this dual incretin action, it has also been referred to as a “twincretin.” It increases first and second-phase insulin secretion AND decreases glucagon levels in a glucose-dependent manner, and this lowers both fasting blood glucose levels and post-meal glucose levels. It is also an appetite suppressant, causing significant weight loss in patients with type 2 diabetes. Tirzepatide vs semaglutide: Semaglutide (Ozempic®) was approved for the treatment of type 2 Diabetes in December 2017, and then approved for weight loss in June 2021 under the brand name Wegovy®. Semaglutide is a GLP-1 receptor agonist, but it does not work on GIP receptors. Due to this dual incretin action of tirzepatide, it has now been shown to be superior at all doses to semaglutide. Evidence: There was a 40-week study done in July 30, 2019- February 15, 2021, called “SURPASS-2” where 1879 patients were assigned in a 1:1:1:1 ratio to either semaglutide 1 mg or to the 3 different doses of tirzepatide (5 mg, 10 mg, 15 mg). The patients all had a mean HbA1c of 8.28% at the start of the study. By the end of the study, the patients on tirzepatide at the different doses had an A1c of 6.2% for the 5mg dose, 6 % for the 10 mg dose, and 5.9% for the 15 mg dose, whereas the patients on semaglutide had their HbA1c at 6.42%. On tirzepatide, about 82-86% of patients decreased their HbA1c below 7.0%, compared to 79% of the patients on semaglutide. Comment: It seems like a race: All GLP-1 RA are competing to reach the lowest A1C and get the lowest weight. What is more amazing is that up until now, an A1c level Fasting Serum glucose levels prior to treatment: 173. Fasting Serum glucose after treatment with:Tirzepatide 5 mg: 117.0, 10 mg: 111.3, 15 mg: 109.6. Semaglutide 1 mg: 124.4.Comment: No hypoglycemia. Weight loss for patients on Tirzepatide was also greater, patients lost about 4 to 12 lbs more (1.9 to 5.5 kg) than with semaglutide. Weight loss in 40 weeks: Tirzepatide: 5mg: 16 lbs (7.6 kg), 10 mg: 20 lbs (9.3 kg), 15 mg: 24 lbs (11.2 kg). Semaglutide: 12 lbs (5.7 kg). Other positive effects that many patients experience were: improved lipid profile, blood pressure, liver enzymes, and improved biomarkers of insulin sensitivity. Another Phase 3 clinical trial of tirzepatide that is currently ongoing is the SURMOUNT-1, which focuses on the weight loss benefits of the drug, and results are expected in 2023. Preliminary data shows that tirzepatide has similar weight loss as bariatric surgery. Cost: Tirzepatide (Mounjaro) is a rival for Novo Nordisk’s semaglutide sold as Ozempic and Wegovy. Institute for Clinical and Economic Review (ICER) released the final report for tirzepatide cost: $5,500-5,700/year. Semaglutide: Ozempic, Wegovy ~ $16,000/year without insurance. Comment: [3 times cheaper]. 4x more expensive in the US, rarely covered by health insurance for weight loss Administration: 1x week, any time, with or without meals. Doses: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg. Week 1-Week 4: Start with 2.5 mg injection 1x week. Treatment initiation, not intended for glycemic control. Week 5-Week 8: Increase to 5.0 mg 1x week. >Week 9: may increase dose another 2.5 mg every 4 weeks as needed for glycemic control. Maximum dose: 15 mg 1x week. Adverse Reactions: Nausea, diarrhea, decreased appetite, vomiting, constipation, dyspepsia, abdominal pain. Drug Interactions: Delays gastric emptying, can affect absorption of oral medications taken at the same time. Warfarin = monitor more closely. Contraindications: Type 1 diabetes, pregnancy, personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2: medullary thyroid cancer, parathyroid tumors, and pheochromocytoma). Thyroid c-cell tumors were noticed in rats. Sympt

Episode 95: Exercise Medicine. Exercise can be used as medicine if given at the right dose and frequency. Sapna and Danish explain some principles of exercise medicine. [Add brief summary for posting on website]Introduction: Is the monkeypox a hoax? By Hector Arreaza, MD. Today is May 27, 2022. Before we dig into exercise, I want to share some information about a trending topic.I remember my lectures on public health in medical school in the late 90s when my teachers taught me about the tremendous accomplishment of humanity in eradicating smallpox. The last natural outbreak of smallpox in the United States occurred in 1949, and the last case of smallpox was recorded in Somalia (Africa) in 1977. Until it was wiped out, smallpox had plagued humanity for at least 3000 years, killing 300 million people in the 20th century alone, but the World Health Organization declared smallpox eradicated in 1980. No cases of natural smallpox have happened ever since, and if you discovered a case of smallpox, I was told by my teachers, you would be awarded one million dollars by the WHO. I did my research online and I could not confirm that information, but I learned that the variola virus (smallpox virus) is kept only in two locations in the planet: the CDC in Atlanta, Georgia, United States and the VECTOR Institute in Koltsovo, Russia. Why am I talking about smallpox? Because the monkeypox is a new trending topic in the media. Now as the COVID-19 panorama starts to look somehow comforting, monkeypox is starting to gain more attention in the media. Even the name “monkeypox” sounds terrifying. The CDC issued a health alert on May 20, 2022, about the most recent confirmed case of monkeypox in the United States, but this is not the first case of monkeypox in the US. In 2021 there were two travel-associated cases, and in 2003 there was an outbreak of 47 cases associated with imported small mammals. Cases of monkeypox have been identified in several non-endemic countries since early May 2022; many of the cases have involved men who have sex with men (MSM) without a history of travel to an endemic country. Cases of monkeypox outside of Western and Central Africa are extremely rare, and we hope they continue to be rare. Is monkeypox a hoax? Is it real? Only time will tell. For now, let’s be optimistic and hope for a world free of dangerous pandemics. Whether monkeypox will continue to spread or not is still unknown. This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.[Brief music]This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.[Music continues and fades…] ___________________________Exercise Medicine. By Danish Khalid, MS4, and Sapna Patel, MS4, Ross University School of MedicineToday is May 12, 2022. D: Welcome back to our Nutrition Series! Thank you for joining us again! Nutrition is such a big part of medicine, it’s the answer to many chronic diseases and yet it’s the most neglected subject in medicine. Our goal here is to educate not only ourselves but our patients and bring awareness of this discrepancy we’ve created in medicine. S: If you’re new to this series, I suggest you pause this and listen to the first few episodes as we build upon them each time. In our previous episode, we discussed how the term “diet” brings upon a negative connotation as well as explored various popular meal plans. A: Exercise prescription. FITTE (Obesity Medicine Association): Frequency, Intensity, Time, Type, Enjoyment. D: As healthcare professionals, time and time again we advise our patients “diet and exercise,” because that’s what we were taught and research has backed for many years. It’s so easily said, yet the words carry such weight. But what does that really mean? Well, that’s what we’re here to explore. At least the latter part, exercise. S: extra fries? D:Or shall I say, “physical activity?” Again, just like the word “diet,” “exercise” has similar negative connotations. Thus, let’s avoid saying “exercise” and resort to words such as “physical activity or workout.” Disclaimer: What we discuss here today is focused directly towards those who are beginners. For those of you who are more experienced, this may benefit as a reminder of the foundations. A: Screen your patients. 95% of patients will benefit from exercise, and most do not need a special test. Only 5% of your patients may require additional testing. S: So what is the best workout for me, you, or our listeners? Well, as simple as that sounds, it’s not that simple. Especially nowadays, where information is at the tips of our fingers, it is so easy to get confused on how to start. But let’s start by establishing your fitness goals. Do you want to lose fat, gain muscle, or gain muscle while losing f

Episode 94: Elevated Alk Phos. Akhil explains what to do when the alkaline phosphatase is elevated, including labs, imaging and other studies. This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.Elevated Alk Phos. By Akhil Patel, MS4, American University of the Caribbean. Comments by Hector Arreaza, MD. Serum alkaline phosphatase: When you find elevated serum alkaline phosphatase, you must consider the two most common sources: the liver and bones. Other sources to consider include the third-trimester placenta, intestine, and kidneys. To determine if the abnormal elevation of alkaline phosphatase has clinical significance, you need to consider if it is a physiological or pathological elevation first. Ruling out physiological concerns: Typically, you should rule out physiological causes first as they are fewer and easier to determine via patient history. This can be even quicker to determine but also sometimes bypassed if a patient’s history and labs present with more concerning etiologies of pathological elevation.Common causes of physiological elevations in alkaline phosphatase include pregnancy, patients with blood type O and B after eating a fatty meal, and younger children. Pregnancy: During pregnancy women in their third trimester will have elevated serum alk phos from the placenta. Blood type: During digestion, alk phos is released from the intestines in patients of blood type O and B. A postprandial increase can be 1.5 to 2 times the upper limit of normal in these patients, however, there is no clinical significance. Children: Younger children tend to have higher alk phos due to increased bone turnover. You can find a reference range chart online for different age groups. It is possible for alk phos to be up to three times higher in infancy and adolescence reflecting the ages with the highest bone growth velocity. Fun fact: Alkaline Phosphatase (also known as ALP) is a natural enzyme present in raw milk. Complete pasteurization will inactivate the enzyme in milk, therefore, presence of alkaline phosphatase in milk is an indicator of failed pasteurization. This is because the most heat-stable bacteria found in milk, Mycobacterium paratuberculosis, is destroyed by temperatures lower than those required to denature ALP.Evaluation of pathological alkaline phosphatase: Degree of elevation: Another consideration is the level of alk phos elevation. If alk phos is at least four times the upper limit of normal, then cholestasis is the likely cause with many specific etiologies to consider. If alk phos is not markedly elevated (four times the upper limit) then the cause is likely not as specific and many different etiologies should be considered whether hepatic or non-hepatic. Liver source: Common symptoms: Jaundice, abdominal pain, ascites, easy bruising, nausea and/or vomiting, choluria, acholia or hypocholia, unexplained weight loss, fatigue, or anasarca.If alk phos is elevated along with liver function testing and bilirubin, it is easier to determine the liver etiology (hepatitis, cirrhosis). However, if it is an isolated elevation in alkaline phosphatase, then other sources must be considered more carefully. A helpful test at this point is to look at is GGT or serum 5’-Nucleotidase for elevation. Typically, these will be elevated with alk phos if it is of liver origin. If they are not increased, you should consider bone-related etiologies.-If a hepatic cause is determined, a right upper quadrant ultrasound is the best initial test to determine intrahepatic or extrahepatic causes. This imaging will look at the hepatic parenchyma and bile ducts. Biliary dilation on ultrasound suggests an extrahepatic cause while no dilation suggests an intrahepatic cause. Liver source with biliary dilation: CBD is considered dilated when >6mm. If biliary dilation is present suggesting an extrahepatic cause, ERCP or MRCP is the next best step in visualizing the cause with choledocholithiasis being the most common cause. Other causes to consider: malignant obstruction, primary sclerosing cholangitis strictures, chronic pancreatitis causing strictures, and AIDS cholangiopathy. Malignant obstructions can be from the pancreas, gallbladder, ampulla of vater, bile duct, or distant metastasis. If the results of these tests are inconclusive the next best step is to consider a liver biopsy. Liver source without biliary dilation: Without biliary dilation on ultrasound, there is a larger pool of etiologies to consider for intrahepatic causes: drug toxicity, primary biliary cirrhosis, primary sclerosing cholangitis, viral hepatitis, cholestasis of pregnancy, and total parenteral nutrition (TPN). Tests: A

Episode 93: Hyponatremia treatment. Catherine and Dr. Saito discuss how to treat hyponatremia in an effective and safe way, especially when the hyponatremia is severe.Introduction: What is sodium?By Hector Arreaza, MD. Read by Alyssa Der Mugrdechian, MD; and Gina Cha, MD. Sodium is a white metal that does not exist in nature in its free form. In its solid form, it’s so soft that you could cut it like butter with a knife. It is the sixth most common element in the earth’s crust. Even though sodium only makes up to 0.2% of our body weight, it plays a key role in nerve conduction, muscle contraction, and most importantly regulating water balance. Today we will be talking about low sodium, known as hyponatremia. We will focus on how to treat hyponatremia and will mention some common causes and symptoms. We hope you can learn something from us today.This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.___________________________Hyponatremia treatment. By Catherine Nguyen, MS4, Ross University School of Medicine. Comments by Steven Saito, MD; and Hector Arreaza, MD. DEFINITION: Serum sodium concentration CAUSES:-Advanced renal impairment > impairment in free water excretion > hypoosmolality of serum-Diuretics (thiazides first 1-2 weeks) -SIADH (Syndrome of inappropriate ADH, I call it the syndrome of EXCESSIVE ADH to help me remember it), caused by common meds.-Heart failure (low cardiac output) & cirrhosis (arterial vasodilation impairment) > decreased tissue perfusion (baroreceptors in carotid sinus senses reduction in pressure) > stimulus of ADH-GI fluid loss (diarrhea, vomiting)-CNS disturbances (stroke, hemorrhage, infections, psychosis, trauma) > increases ADH release-Malignancies > ectopic production of ADH (small cell carcinoma)-Drugs > SSRI, carbamazepine, cyclophosphamide -Potomania > patient drinks large amounts of beer and decreased intake of foods (solids). PRESENTATION:-Asymptomatic-Nausea & malaise earliest findings (125-130)-Headache, lethargy, muscle cramps, confusion/AMS, and eventually seizures, coma, and respiratory arrest (115-120)-Acute hyponatremia encephalopathy may be reversible, but permanent neurologic damage or death can occur. TREATMENT: Clinic: Chronic cases of hyponatremia may require spread-out treatment. Hyponatremia is never normal. -Mild hyponatremia > concentration of 130 to 134 mEq/L: NO treatment with hypertonic saline. Rather, the initial approach includes general measures that are applicable to all hyponatremic patients (i.e., identify and discontinue drugs that could be contributing to hyponatremia; identify and, if possible, reverse the cause of hyponatremia; and limit further intake of water [e.g., fluid restriction, discontinue hypotonic intravenous infusions]. -Moderate hyponatremia > concentration of 120 to 129 mEq/L ASYMPTOMATIC - 50 mL bolus of 3 percent saline (ie, hypertonic saline) to prevent the serum sodium from falling further.SYMPTOMATIC – (call ICU) 100 mL bolus of 3 percent saline, followed, if symptoms persist, with up to two additional 100 mL doses (to a total dose of 300 mL); each bolus is infused over 10 minutes. -Severe hyponatremia > concentration of INITIATE intravenous 3 percent saline beginning at a rate of 15 to 30 mL/hour, administered via a peripheral vein. ALTERNATIVE OPTION is to give 1 mL/kg (maximum, 100 mL) boluses of 3 percent saline intravenously every six hours, with dose modification as needed. Some patients may also require desmopressin (dDAVP) to prevent overly rapid correction. Osmotic demyelination syndrome:-Brain adaptations that reduce the risk of cerebral edema makes the brain vulnerable to injury if chronic hyponatremia is too rapidly corrected. -Large cohort study has shown that correction by less than 5 mEq/L per day was not associated with neurologic complications.-More common when Na is -Symptoms include dysarthria, dysphagia, paraparesis or quadriparesis, behavioral disturbances, movement disorders, seizures, lethargy, altered mental status, and even coma. MONITORING:-Monitor the patient for symptoms and remeasure the serum sodium concentration hourly to determine the need for additional therapy. -Monitoring can be spaced out when the serum sodium has been raised by 4 to 6 mEq/L to every 12 hours until the serum sodium is 130 mEq/L or higher.-The rate of correction of hyponatremia should be 6 to 12 mEq per L in the first 24 hours and 18 mEq per L or less in 48 hours.-Fluid restriction — Restriction to 50 to 60 percent of daily fluid requirements. In general, fluid intake should be less than 800 mL/day. ____________________________Conclusion: Now we conclude our episode number 93 “Hyponat

Episode 92: Paleo vs Keto vs Mediterranean. Sapna and Danish explain the main differences between three meal plans: Paleo, Keto, and Mediterranean. Intro about fad diets.Introduction: Fad diets. By Hector Arreaza, MD. It is estimated that 2/3 of Americans are overweight or have obesity (73% of men and 63% of women), but only 19% of people claim to “be on a diet”, and 77% of people are trying to “eat healthier”[1]. It seems like many of us are on the weight-loss wagon together, hoping for a cure for this disease.These days it is commonplace to hear about fad diets. Fad diets are short-lived eating patterns that make unrealistic claims about weight loss and improving health, with little to no effort on your part. “The Super-Duper diet will make you lose 100 pounds, eliminate your cellulite, erase stretch marks, remove your wrinkles, and give you extra energy to fly to the moon and back, buy the super-duper diet now!” We surely have a lot of products that make senseless promises, claim many victims, and leave people with empty pockets. Today is May 6, 2022. Sapna and Danish will enlighten us again with more nutrition discussions. When you go around your grocery store, have you wondered what “keto-friendly” really means? We hope after today, you get a better idea about it. Today we are presenting a brief discussion to compare three common dietary approaches for weight loss: Keto, Paleo, and Mediterranean. I’m sure you have heard some things about these diets, but we want to add to your fund of knowledge. Whether they are fad diets or not, we’ll let you decide. Enjoy it! This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.___________________________Paleo vs Keto vs Mediterranean. Prepared by Sapna Patel, MS4, and Danish Khalid, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.Welcome back to our Nutrition series!D: In our previous episode, we talked about calorie balance and macronutrients. The basics of nutrition. So, if you haven’t already listened to that, pause this, and go listen to that first. As we will only continue to build on that knowledge. Now, let’s begin…S: Whether your goals are to lose fat or gain muscle. Nowadays, we’ve got so many ways to achieve our nutritional goals. It can be difficult and overwhelming to know which one is best for you. So today, we will talk about some of the main “diets'' that are well known to all.Comment: People hate the word “Diet”, should we call them meal plans or Nutrition plans?S: The Paleo meal plan. The Ketogenic meal plan. The Mediterranean meal plan. And as we go through each of them, we will compare them and discuss which fit certain nutritional goals.Comment: These meal plans are very trendy right now, some people call them fad diets, but only time can tell if these diets really work long term or not. D: Let’s start with the Paleo meal plan. What is it? Also known as the Paleolithic diet, Caveman diet, or Stone-Age diet, this meal plan revisits the way humans ate almost 2.5 million years ago—The hunter-gatherer lifestyle. Overall, the meal plan is high in protein, moderate in fat (mainly unsaturated fats), low-moderate in carbohydrates (restricting high-glycemic carbohydrates), high in fiber, and low in sodium and refined sugars. It includes mainly lean meats, fish, fruits, vegetables, nuts, and seeds.Comment: It is low in carbs because carbs were so rare and uncommon in nature before agriculture was introduced to humanity. Animals (including humans) had to wait until the season when the fruit was ripe to enjoy something sweet.S: So, what are some of the benefits of the Paleo meal plan? Well, studies have shown that the paleo meal plan produces greater short-term benefits, including- Greater weight loss- Reduced waist circumference- Decreased blood pressure- Increased insulin sensitivity- Improved cholesterolD: You must be wondering, what’s the catch? Aside from the diminishing long-term effects. Although the meal plan focuses on many essential food groups, it also omits others such as whole grains, dairy, and legumes. This could lead to suboptimal intake of important nutrients. Additionally, the restrictive nature of the meal plan may also make it difficult for people to adhere to such a meal plan in the long run. With these confounding facts, there hasn’t been a strong link that the paleo meal plan improves cardiovascular risk or metabolic disease.S: Basically, for those looking for a cleaner meal plan, the paleo meal plan is geared towards eliminating high-fat and processed foods that have little nutritional value and too many calories. Moving on to the Ketogenic Meal plan.D: What is the Ketogenic Mea

Episode 91: Nutrition Introduction. Sapna Patel and Danish Khalid present the basics of macronutrients and the definition of basic energy expenditure (BEE), they explain basic concepts on macronutrients. Introduction: Unable to control the epidemic of obesity By Hector Arreaza, MD. Today is April 27, 2022. In this episode, we will cover the very basics of classic nutrition. As we know, obesity is reaching epidemic proportions in the United States. Regardless of all the advances in science, we have not been able to control one of the most detrimental diseases in our communities. Obesity is among the most difficult to treat chronic diseases. There are countless recommendations about what to eat and not to eat, best workouts, miraculous shakes, magical weight-loss supplements, innovative devices, promising programs, novel medications, and the latest surgeries, however, we still have millions of patients who are suffering every day the consequences of undiagnosed and untreated obesity. We are hoping this is the first of multiple episodes addressing the problem of obesity, we hope you enjoy it. This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________Nutrition Introduction. By Sapna Patel, MS4, and Danish Ross University School of Medicine. Comments by Hector Arreaza, MD. Obesity is a disease when the patient has excessive body fat resulting in “sick fat disease” with metabolic consequences or “fat mass disease.” Excessive body fat is caused by genetic or developmental errors, infections, hypothalamic injury, adverse reactions to medications, nutritional /energy imbalance, and/or adverse environmental factors. Let us talk about one of the pillars of the treatment of obesity. S: Hi, my name is Sapna Patel. I am a 4th-year medical student. I am passionate about fitness and cooking. I have been active all my life doing soccer, taekwondo, kickboxing, and weightlifting. I am joined here today with Danish. D: Hi, my name is Danish. I am also a fourth-year medical student. I have a background in mixed martial arts, boxing, and karate. And just like Sapna, I too am passionate about fitness, and nutrition. S: Today we are here to talk about nutrition. One of the most neglected subjects in medicine, yet the most important subjects. As we speak, we are sitting in Kern County, which has the highest obesity rate in the whole state of California with more than 60% of the population considered overweight. Poor nutrition is the leading cause of people being overweight and obese, and in turn, obesity leads to various other medical conditions. It is important to educate ourselves on nutrition, not only as medical professionals but as someone who lives in the most obese country. And it is as simple as knowing how to balance calories and macronutrients. D: To maintain a healthy weight and lifestyle over time, it is important that we maintain caloric balance. Oftentimes we tend to overeat, tipping us into a caloric surplus. This leads us to being overweight and obese which are the most important factors associated with poor health outcomes. It is associated with premature mortality as well as increased incidence of cardiovascular disease, diabetes, hypertension, cancer, and other important conditions. Calculating total energy expenditure for recommended daily caloric intake is based on age, sex, weight, and activity level.Basal Energy Expenditure (BEE) (male/female): 66.5 + (13.5/9.5 x weight (kg)) + (5/2 x height (cm)) - (7/5 x age).S: Another easier way to know your basal energy expenditure, is to use the table made by the USDA guideline which has an average estimate energy expenditure per day based on age, sex, activity level. Or a lot of bodybuilders use a rough calculation for basal energy expenditure which is: Formula = BW (lbs) x 14-16 (where 14=moderately active, and 16=very active) For example, one of my goals is to increase muscle mass. And based on the calculations, my BEE is 1458 kcal/day with my current activity level. Thus, if I wanted to gain muscle without gaining fat, I would have to keep to this number. Whereas, Danish I know you have a different goalD: Yes so, one of my goals is to achieve fat loss. For me, my basal energy expenditure is 2400 kcal/day with my current activity level. However, this number is to maintain my current weight. If I need to lose weight, I will have to subtract calories from my daily balance. Typically, I would subtract 500 kcal/day, as this allows for a fat loss of 1 pound per week or 3500 kcal/week. Many should aim for 0.5 pounds to 2 pounds per week, but nothing more than 2 pounds as this could lead to undesirable appearances such a

Episode 90: Vaccines and Acne. Updates on pneumococcal and COVID-19 vaccines. Sarah explains the treatment of acne.New Pneumococcal Vaccine Recommendations. Written by Harkiran Bhattal, MS4, Ross University School of Medicine; Timiiye Yomi, MD; and Hector Arreaza, MD.During the recording, we used brand names because they are easier to use. We are not sponsored by the manufacturers of these vaccines. Terminology of pneumococcal vaccines: PCV13: Prevnar13®PPSV23: Pneumovax23®PCV15: Vaxneuvance® PCV20: Prevnar20®Tips about pneumococcal vaccines:-Prevnar13 is no longer used in adults. -Pneumovax23 is still being used in adults.-The two newer members of the pneumococcal vaccines are: Prevnar20® (PCV20) and Vaxneuvance® (PCV15). The following groups of patients are all adults 19-64 with underlying conditions OR >65 years old. Group A: Unknown or no prior doses of Prevnar13 or Pneumovax 23Option 1: Prevnar20 given as a single doseOption 2: Vaxneuvance followed by a dose of Pneumovax23 at least a year later (Consider >8 weeks in patients >19 at the highest risk)Group B: Previously received Pneumovax 23Give Prevnar20 or Vaxneuvance (at least 1 year since the last Pneumovax 23)Group C: Previously Received Prevnar13Give Pneumovax23 or Prevnar20 (if Pneumovax 23 is not available) >1 year since last dose of Prevnar13Group D: Previously completed series of Prevnar13 and Pneumovax23 in any orderNo additional doses are needed. Scenario 1: 68 yo M who has not previously received PCV or whose previous vaccination history is unknown (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by a dose of Pneumovax23. Scenario 2: 25 yo F with HIV not previously received PCV or whose vaccination history is unknown (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed bya dose of Pneumovax 23 given 8 weeks later. This patient is in the highest risk group. Scenario 3: 50 yo M with chronic alcoholism who has not received any vaccine or unknown status (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by Pneumovax 23 one year later. Scenario 4: 43 yo M with previous Pneumovax 23 only (Group B). This patient should receive either: a single dose of Prevnar20 or Vaxneuvance and be done with either vaccine. Give either vaccine at least 1 year after Pneumovax 23. Scenario 5: 25 yo F with CSF leak and previously received Prevnar13 (Group C). This patient should receive Pneumovax23 or Prevnar 20 (if Pneumovax 23 is unavailable) at least one year after her las Pneumovax dose. Scenario 6: 35 yo M who previously completed Prevnar13 and Pneumovax in any order because he has a cochlear implant (Group D). This patient should NOT receive any additional dose. Research and MonitoringCDC and ACIP will continue to assess the safety of Vaxneuvance and Prevnar20 vaccines (the new kids on the block), monitor the impact of the implementation of new recommendations, and assess post-implementation effectiveness and recommendations as appropriate. Examples of risk factors to consider administration of pneumococcal vaccines: Chronic renal failure, HIV infection, alcoholism, cigarette smoking, chronic heart, liver, and lung disease. For a complete list of conditions, visit CDC.gov.___________________ A second booster shot of COVID-19 vaccines. By Hector Arreaza, MD.On March 29 and 30, 2022, CDC announced that a second booster dose of any mRNA COVID-19 vaccine may be given to certain individuals who are at risk of severe outcomes from COVID-19(1). Individuals who may choose to receive a second booster are: 1. People older than 12 years of age who have a moderate to severe immunocompromising condition. Remember, use Pfizer for older than 12 yo, and Moderna for older than 18 yo.2. People older than 50 years of age who are NOT moderately or severely immunocompromised.3. People 18-49 years of age who are NOT immunocompromised but received the J&J COVID-19 vaccine as both the primary and booster dose. When can you receive the second booster shot? At least 4 months after the first booster dose.Who is considered up to date? A person is considered up to date when he/she has received all recommended doses in their primary vaccine series, and a booster dose when eligible. A second booster dose is not required to be considered up to date at this time.Underlying medical conditions associated with higher risk for severe COVID-19 include: Cancer, obesity, cerebrovascular disease, diabetes mellitus, HIV, obesity, COPD, smokers, and chronic liver disease.Comment: Remember to give the second booster to your patients. ____________________Acne Treatment. By Sarah Park, MS3, University of California Los Angeles. Discussed with Hector Arreaza, MD. Definition: Acne vulgaris is a common inflammatory disorder of the pilosebaceous unit, which includes the hair follicle and sebaceous gland. It is characterized by chronic or recurrent development of papules, pus

Episode 89: Gonorrhea Basics. Written by Robert Besancenez. Robert, Dr. Schlaerth, and Dr. Arreaza discuss the basics of gonorrhea, including presentation, treatment, and even a potential gonococcal vaccine.Introduction: Gonorrhea is commonly known as “the clap” or “the drip”. This ancient disease, described as “the perilous infirmity of burning” in a book called The History of Prostitution, has been treated with many remedies throughout history, including mercury, sulfur, silver, multiple plants, and even gold. Today we will discuss the clinical features, diagnosis, and current therapy of gonorrhea. By the way, did you know that gonorrhea in Spanish is used as an insult in Colombia? Well, now you know it. Definition: Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae (common name gonococcus), which is a gram-negative, intracellular, aerobic, diplococci. This disease leads to genitourinary tract infections such as urethritis, cervicitis, pelvic inflammatory disease (PID), and epididymitis. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Gonorrhea. Written by Robert Besancenez, MS4, Ross University School of Medicine. Moderated and edited by Hector Arreaza, MD. Discussion participation by Katherine Schlaerth, MD. Epidemiology: The disease primarily affects individuals between 15–24 years of age (half of the STI patients in the US). CDC estimates that approximately 1.6 million new gonococcal infections occurred in 2018. Incidence rates are highest among African Americans, American Indians, and Hispanic populations.Transmission is sexual (oral, genital, or anal) or perinatal (causing gonococcal conjunctivitis in neonates). Risk factors include unsafe sexual behaviors (lack of barrier protection, multiple partners, men who have sex with men (MSM), and asplenia, complement deficiencies. Individuals with low socioeconomic status are at the highest risk: poor access to medical treatment and screening, poor education, substance use, and sex work. Presentation: The incubation period is ~ 2–7 days, and sometimes patients do not develop any symptoms. Urogenital infection: Gonorrhea is commonly asymptomatic, especially in women, which increases the chance of further spreading and complications. When symptoms are present, typical symptoms include purulent vaginal or urethral discharge (purulent, yellow-green, possibly blood-tinged). Discharge is less common in female patients. Urinary symptoms include dysuria, urinary frequency, and urgency. Male: - Typical presentation is urethritis. - Penile shaft edema without other signs of inflammation.- Epididymitis: unilateral scrotal fullness sensation, scrotal swelling, redness, tenderness, relief of pain with elevation of scrotum —Prehn Sign— and positive cremasteric reflex.- Robert: Prostatitis: fever, chills, general malaise, pelvic or perineal pain, cloudy urine, prostate tenderness (examine prostate gently). Female: - Cervicitis: Friable cervix and discharge (purulent, yellow, malodorous), - PID: pelvic or lower abdominal pain, dyspareunia, fever, cervical discharge, cervical motion tenderness but also uterine or adnexal tenderness, abnormal intermenstrual bleeding. PID can be subclinical and diagnosed retroactively when tubal occlusion is discovered as part of a workup for infertility. PID can cause Fitz-Hugh-Curtis syndrome (perihepatitis with RUQ pain).- Bartholinitis presents with introitus pain, edema, and discharge from the labia. - Vulvovaginitis may occur but is rare (due to the tissue preference of gonococci)Extragenital infection: Proctitis: Rectal purulent discharge, possible anorectal bleeding and pain, rectal mucosa inflammation, or rectal abscess (less common).Pharyngitis: sore throat, pharyngeal exudate, cervical lymphadenitis. Disseminated gonococcal infection (DGI): Triad of arthritis, pustular skin lesions, and tenosynovitis. As mentioned in Episode 46, on December 23, 2020, the California Department of Public Health (CDPH) sent a “Dear Colleague” letter to warn the medical community about the increased cases of DGI in California and Michigan. Increased cases may be caused by decreased STD testing and treatment because of the COVID-19 pandemic, and not necessarily because of a more virulent strain of gonorrhea. Later, treatment of gonorrhea was updated because of resistance. Epidemiology: ∼ 2% of cases. Most common in individuals younger than 40 years old, the female to male ratio is 4:1. A history of recent symptomatic genital infection is uncommon. Asymptomatic infections increase the risk of dissemination due to delayed diagnosis and treatment. Clinical features: Two distinct clinical presentations are possible. Arthritis-dermatitis syndrome:Polyarthralgias: migratory, asymme

Episode 88: EVALI. Nugdeep and Jeffrey present E-cigarette and Vaping Associated Lung Injury (EVALI), including symptoms, diagnosis, and treatment. Introduction includes a word of advice for matching and not matching students in 2022. Introduction: The Match 2022 is over. By Hector Arreaza, MD. Read by Valeri Civelli, MD. Another Match season is behind us. It’s time to celebrate and prepare for a new stage of your career. As an interesting fact, the American Association of Family Physicians announced that in 2022 the highest number of family medicine residents matched.Positions for family medicine residencies have been steadily growing for the last 13 years in a row. There are 756 family medicine categorical and combined residency programs, that’s 15 more programs than in 2021. Also, in 2022, osteopathic medical schools had the historic highest number of students matching into family medicine, to be exact 1,496 DO seniors matched to family medicine this year, that’s 58 more students than 2021.During this season, the number of U.S. medical grads matching into family medicine “did not increase despite a larger number of positions available.”[1]If you did not match this year, the Match can also be a time of reflection and goal setting as you prepare with optimism for the next season. To increase your chances to match next year, Dr. Margarita Loeza advised in an AMA article[2] to stay in touch with your medical school, find a job in a clinical setting, take Step 3, and try a new approach during next season. For example, you may consider applying to a higher number of programs or even more than one specialty. Residency training is the primary way to get licensed to see patients, but there are hundreds of alternative ways to pursue your passion for medicine. Do not give up on your goals. “Never give up on something that you can’t go a day without thinking about.” ―Winston Churchill.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Page BreakEVALI.By Nugdeep Singh, MS4; and Jeffrey Nguyen, MS4. Ross University School of Medicine. Participated in the discussion: Hector Arreaza, MD. N: Good afternoon listeners. My name is Nugdeep Singh, and I am a fourth-year medical student. J: Hello, and I’m Jeffrey Nguyen, also a fourth-year medical student. Thank you for having us today Dr. Arreaza. N: Today we will be talking about E-cigarette and vape-associated lung injury (EVALI), also known as vaping-associated pulmonary injury (VAPI). But, before we get into the medical pathology of E-cigarettes and vapes, why don’t we give a little background on them.Arreaza: EVALI and VAPI sound like another Indian holiday or an Italian dessert, but EVALI and VAPI are certainly no joke. J: Sure, let’s get started. So, E-cigarettes are battery-operated devices that heat liquids containing nicotine to produce an aerosol that the user inhales. Long-term health effects and whether they help an individual quit smoking has been controversial, as there has not been much research on it. These E-cigarettes have raised public health concerns on smoking prevalence and their potential use by children. In 2019, over 5 million children and adolescents were using 3-cigarettes. This represented an increase in e-cigarette use by high school students from 12% in 2017 to 28% in 2019. In fact, Massachusetts legislation bans the sale of all flavored tobacco products starting in June 2020. Nicotine is the main ingredient in the liquid, however, there are other constituents that are carcinogenic potential. Nugdeep, can you go over some of these ingredients? N: Yea, let’s start with nicotine. The level of nicotine varies between 0 to 36mg/mL, though it can be higher in some. Nicotine salt is another variant that can provide a different sensation in a user’s throat. Next is propylene glycol, which are humectants, and they are the main component of most E-cigarette liquids. Arreaza: When you mentioned proPYlene glycol, I immediately thought of “PEG”. PolyEthylene Glycol, does it ring a bell? Yes, it’s a common laxative, but besides that it’s used in the mRNA COVID-19 vaccines. Having allergy to PEG is one of the few contraindications of the COVID-19 vaccine. But you are not talking about PEG, you are talking about propylene glycol, which is a lightly sweet substance used in e-cigarettes, which can cause chemical conjunctivitis or respiratory irritation. The consequences of chronic inhalation of propylene glycol are still unknown.N: Finally, there are flavorings and there are about 7000 flavors available. Some examples include candy, fruits, sodas, and alcohol flavors. J: Can I add something real quick? N: Yea, of course. J: Although these flavorings do add taste to the experience, it attracts E-cigarettes in the youths, especially those who do not alrea

Episode 87: Latent TB Infection. By Mariana Gomez, MD (Romulo Gallegos University School of Medicine, Carillion Clinic Infectious Disease), and Hector Arreaza, MD (Romulo Gallegos University School of Medicine, Rio Bravo Family Medicine Residency Program). Dr. Gomez explains how to screen for and treat Latent TB infection. Today is March 18, 2022.Dr. Mariana Gomez graduated from medical school at the Romulo Gallegos University in Venezuela. She completed her residency in Internal Medicine in St Barnabas Hospital, which is affiliated with the Albert Einstein School of Medicine, Bronx, New York. She then completed a fellowship in Infectious Diseases at Carilion Clinic, which is affiliated with Virginia Tech School of Medicine. She currently works in Virginia, United States. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Some questions discussed during this episode: Who should be screened for latent TB infection? A CDC questionnaire can determine the risk for latent TB infection. Some patients who may be screened are those who resided for 1 month in a country with high TB prevalence, those who are currently immunosuppressed or planning immunosuppression in the near future (50 mg of prednisone or equivalent a day for 1 month), and those who had close contact with patients with TB infection (Latent Tuberculosis Infection: A Guide for Primary Health Care Providers (cdc.gov)). The USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk.Screening Tests: Currently, there are two types of screening tests for LTBI in the United States: the tuberculin skin test (TST, also known as PPD) and the Interferon Gamma Release Assay (IGRA, brand names QuantiFERON®-TB and T-SPOT®.TB). The TST requires intradermal placement of purified protein derivative and interpretation of response 48 to 72 hours later. The induration is measured in millimeters. The induration is the palpable, raised, hardened area or swelling, not the erythema.IGRA requires a single venous blood sample, and the result is obtained in 1-2 days. Two types of IGRAs are currently approved by the US Food and Drug Administration: T-SPOT.TB (Oxford Immunotec Global) and QuantiFERON-TB Gold In-Tube (Qiagen). The CDC recommends screening with either test (TST or IGRA) but not both. IGRAs is preferred for patients who received a BCG vaccine (bacille Calmette–Guérin) or if they are unlikely to return for TST interpretation.Why should we screen for LTBI? How can we decide between Questionnaire only vs PPD vs QuantiFERON Gold? What is the next step in assessing asymptomatic individuals with positive PPD?A useful resource is the online TST/IGRA Interpreter (tstin3d.com). You can calculate the risk of latent TB infection and the risk of INH-induced hepatitis. How can we decide to treat LTBI? What are the recommended regimens? CDC recommends three preferred regimens. These are chosen for effectiveness, safety, and high treatment completion rates. These regimens are rifamycin-based. They are:INH+rifapentine for 3 months: once-weekly isoniazid plus rifapentine for adults and children older than age 2, regardless of HIV status.Rifampin for 4 months: daily rifampin.INH+rifampin for 3 months: daily isoniazid plus rifampin. ____________________________Now we conclude our episode number 86 “Latent TB Infection.” Dr. Gomez taught us how to screen and treat latent TB infections. Remember to screen only those who are at risk of TB infection. Once you get a positive screen test, select the patients who will receive treatment of LTBI to prevent reactivation of TB infection. You have at least 4 regimens to treat LTBI. The regimens that include rifamycin are recommended by the CDC. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza and Mariana Gomez. Audio edition: Suraj Amrutia. See you next week! _____________________References: Latent Tuberculosis Infection: Screening, September 06, 2016, United States Preventive Services Taskforce, uspreventiveservicestaskforce.org. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening. Lewinsohn, David M., et al, Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clinical Infectious Diseases, 2017;64(2):e1–e33, Infection Diseases Society of

Episode 86: Abdominal Pain Case. Spikevax® is the brand name of the Moderna COVID-19, and it received full FDA approval in January 2022. Hepatitis B vaccine is now universally recommended to all adults between 19-59 years of age, or older than 60 with risk factors. Deidra Sieck presents a case of abdominal pain in pregnancy and differential diagnosis are discussed. Introduction: Spikevax ® and Hepatitis B universal vaccination. Written by Hector Arreaza, MD. Participation by Cecilia Covenas, MD.Spikevax®. This is the brand name given to the mRNA COVID-19 vaccine manufactured by Moderna. It was given full FDA approval for the prevention of COVID-19 in adults 18 years and older. This is the second vaccine approved by the FDA for the prevention of COVID-19 (the first vaccine was Comirnaty®, formerly known as Pfizer Vaccine.) The primary series of Spikevax for immunocompetent adults is comprised of 2 doses, 4 weeks apart. Immunocompromised patients receive a 3rd dose as part of the primary series, one month after the second dose. A booster shot of Spikevax is given at least 5 months after completing the primary series. Spikevax was also authorized for use as a “mix and match” single booster dose following completion of primary vaccination with a different COVID-19 vaccine. It means that recipients of the Pfizer and J&J vaccines who are 18 years and older may receive a single booster dose of Spikevax. The full FDA approval was granted to Spikevax on January 31, 2022.Did you know that Hepatitis B has killed 40 times more unvaccinated healthcare workers than HIV? Yes, that’s right. Hepatitis B is 50 to 100 times more infectious than HIV. It is transmitted by percutaneous or mucosal exposure to infected blood or other bodily fluids. As a reminder, immunizations against many diseases have been required for health care workers for decades, and hepatitis B is one of those required vaccines. That’s not new, what’s new is the new recommendation about universal Hep B vaccination. In November 2021, the ACIP (Advisory Committee on Immunization Practices from CDC) recommended universal adult Hepatitis B vaccination. After reviewing clinical evidence, the ACIP has unanimously voted to recommend the Hep B vaccine for all adults ages 19-59. Patients who should receive hep B vaccines are: all adults between 19 and 59 years of age, and adults older than 60 with risk factors for hepatitis B infection. However, adults older than 60 without risk factors may also receive hep B vaccines. Vaccinating against Hep B is done to decrease new infections, prevent transmission, and reduce health disparities. HHS has called for the elimination of viral hepatitis as a public health threat by 2030. There are some reasons to recommend universal Hep B vaccination for adults: many infected patients did not have any risk factors for infection and still got infected; almost 85% of adults in the U.S. fall into a higher-risk group, including patients with diabetes and kidney disease; hepatitis B cases in the U.S. rose by 11% between 2014 and 2018 despite having highly effective vaccines; Hep B is one of the primary causes of liver cancer, one of the deadliest cancers; universal vaccination of newborns started in 1991 in the U.S., so, many adults are not immune to Hep B, but now they can be vaccinated without the many restrictions imposed in the past.Remember, Spikevax is the new name for the Moderna vaccine; and you can start vaccinating all adults between 19 and 59 years of age against hep B, regardless of risk factors.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.___________________________Abdominal Pain Case. By Deidra Sieck, MS4, Ross University School of Medicine. Hosted by Hector Arreaza, MD. Abdominal pain in pregnancy is quite common and has a wide differential. I want to begin with a case and then highlight a few of the “do-not-miss” diagnoses when a patient comes with the chief complaint of abdominal pain during her pregnancy. Case presentation: 23-year-old G2P1 at 32 weeks of gestation complains of 12 hours of right lower quadrant abdominal pain, anorexia, and nausea with vomiting. She denies vaginal bleeding or leakage of fluid from the vagina. Denies diarrhea or eating stale foods. No medical history and has been in good health. Denies dysuria and has had no previous surgeries. Her vital signs include a blood pressure of 100/70 mm Hg, heart rate of 105 beats per minute, and temperature of 101.5 F. On abdominal examination, bowel sounds are hypoactive. The abdomen is tender in the right lower quadrant to right flank with significant involuntary guarding. The cervix is closed. The fetal heart tones are in the range of 160 BMP (modified vignette from case files obstetrics and gynecology 5th ed.)What are some of the differentials

Episode 85: Detecting Dementia and Evusheld®. Parneeta Singh explained a new blood test to predict Alzheimer’s disease and an artificial-intelligence cognitive test for early detection of dementia. Dr Saito and Dr Arreaza present Evusheld, a monoclonal antibody for pre-exposure prophylaxis against COVID-19. Today is March 4, 2022. Today marks the 2-year anniversary of our podcast. We have been bringing you relevant clinical information for 2 years, almost every week. We hope you have found this podcast useful. If you have learned at least one thing from us, our goal has been reached. This podcast started as an experiment and it has become an enriching experience for students, residents, faculty, and all of you who listen to us throughout the world. We look forward to many more years of education, updates, and fun! Thanks for listening.Introduction: Innovative ways to detect dementia: Alzosure Predict® and CognICA® By Parneeta Singh, MD, Ross University School of Medicine; comments by Hector Arreaza, MD. Alzheimer’s disease (AD) is a neurocognitive disorder that is the most common cause of dementia. More than 6 million Americans aged 65 and older have the late-onset subtype while many more between ages 30 and 60s have the early-onset subtype although the latter is very rare. One of the first signs of AD is memory issues. A decline in other aspects of thinking, impaired judgment or reasoning, visual/spatial problems can also indicate early stages of AD. Mild cognitive impairment (MCI) can also be considered an early sign of AD. However, not everyone with MCI will develop the disease. As the disease progresses, people with AD have trouble performing daily activities such as cooking, driving, managing their finances while some have personality changes as well. According to the Alzheimer’s Association, two abnormal structures called plaques (deposits of a protein fragment called beta-amyloid that builds up between neurons) and tangles (twisted fibers of another protein called tau that builds up inside neurons) are most probably responsible for the damaging effects seen in AD. Patients with AD develop plaques and tangles initially in parts of the brain involved in memory, such as the entorhinal cortex and hippocampus, before affecting other parts of the brain such as the cerebral cortex which is responsible for reasoning, social behavior, and language. Today, AD is at the forefront of biomedical research with earlier diagnoses and interventions improving drastically. New research conducted by Diadem (a diagnostic company that focuses on AD research) exhibited that a novel blood test called Alzosure Predict® identifies a variant of the protein p53 which seems to predict AD’s progression up to 6 years before a clinical diagnosis is made. This blood test measures a derivative of p53 (U-p53AZ) which is implicated in AD pathogenesis. Blood samples from patients aged 60 years and older who had different levels of cognitive function were analyzed which showed that the test predicted a decline from MCI to AD at the end of 6 years. The test can also classify a patient’s cognition stage. The positive predictive value (PPV) and negative predictive value (NPV) were at 90%. Knowing which patients will progress to AD allows them to try treatments earlier on the disease when therapies are most likely to be more effective. Additionally, using the test could speed up the approval of prospective drug treatments and allow those patients with a likelihood of developing AD to enroll in clinical studies. Patients can also be monitored during a study instead of relying on costly PET scans and painful lumbar punctures. These findings were presented at the 14th Clinical Trials on Alzheimer's Disease (CTAD) conference in November 2021.Another way to detect dementia early on is by an artificial intelligence cognitive assessment called Cognetivity's Integrated Cognitive Assessment (CognICA®) which has been cleared by the US Food and Drug Administration in October 2021. It is a 5-minute computerized cognitive assessment that is completed using an iPad. It has numerous advantages over traditional pen and paper-based cognitive tests such as avoidance of cultural or educational bias, absence of learning effect upon repeat testing, its high sensitivity to detect early-stage cognitive impairment, and since it is computer-based, it can be self-administered and performed remotely. In conclusion, reliable, simple, cost-effective measures of cognition are critical for providing quality care whether it is in the field of family medicine, neurology, or geriatrics. According to Percy Griffin, Ph.D., MSc, director of scientific engagement at the Alzheimer's Association, the ability of such technologies to detect dementia before significant loss of brain cells “would be game-changing” for individuals, their families, and the healthcare system at large. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine R

Episode 84: Smells in medicine. Intro about race in algorithms. Self-reported case of anosmia by Dr. Arreaza. Some common smells in medicine are discussed with Dr Grewal, for example, halitosis, bromhidrosis, and fetor hepaticus. Parosmia is also mentioned as a sequela after COVID-19 infection. Intro: Race in clinical algorithms. By Brandy Truong, MS4, Ross University School of Medicine. The year 2020 was not only the beginning of the pandemic but also a time when our country finally took the time to learn more about systemic racism. Many members in the medical community have been fighting racism in medicine for years and unfortunately have often gone unheard. However, in the past few years, people decided to start listening. The New England Journal of Medicine published an article in 2020 looking at different algorithms that have a race component and how that can be harmful to patients and perpetuates systemic racism. Let’s take a dive into some of those clinical algorithms. Something that has gained a large movement, is getting rid of a test that helps determine kidney function based on race. This test is called estimated glomerular filtration rate, or what we call eGFR which considers a person’s age, gender, race, and levels of creatinine. When it comes to the race category, it considers if someone is African American or not. Therefore, there are different normal eGFR values for African American and then all others. The test was based on an assumption that Black people have higher muscle mass on average which led to higher kidney function. This becomes problematic because assuming all Black people have higher kidney function can delay a patient’s referral to a specialist or getting a transplant. This leads to higher rates of end-stage kidney disease and death due to kidney failure compared to the overall population. Many physicians and medical students at top universities have pushed their administration to get rid of the eGFR values based on race. Some hospitals like Mass General no longer use eGFR based on race. The National Kidney Foundation and American Society of Nephrology are still evaluating if they recommend the current algorithms. When it comes to looking at heart failure risk, the American Heart Association recommends a Heart Failure Risk Score that predicts the risk of death in patients admitted to the hospital. When a patient identifies as not Black, their score increases by 3 points which puts Black patients at lower risk due to a lower score. This score helps us decide on referrals to cardiology and general care. This becomes problematic because Black patients may not receive the care they need if assumed they are lower risk. This was shown when a study done in 2019 showed that Black and Latinx patients that presented to an emergency department in Boston with heart failure were less likely than White patients to be admitted to the cardiology unit.Another algorithm that puts Black patients at lower risk is the STONE score which predicts the likelihood of kidney stones in patients who present in the ER with flank pain. The score increases by 3 points for patients who don’t identify as Black, which once again puts Black patients at lower risk due to a lower score. Black maternal mortality is drastically much higher compared to White women. Something that can contribute to it is an algorithm called Vaginal Birth after Cesarean which predicts the risk in a trial of labor for someone who had a prior cesarean section. This algorithm predicts a lower level of success for mothers identified as Black or Hispanic. It’s also important to note that the study used to create the algorithm found that variables like marital status and insurance type also correlated with the success of vaginal birth after cesarean, but those factors weren’t included in the algorithm. The benefits of having a vaginal delivery include lower rates of surgical complications, faster recovery time, and fewer complications in future pregnancies. Nonwhite women have higher rates of c-section than white women which decreases the chances of nonwhite women from having the benefits of vaginal delivery.We have to ask ourselves, why continue to use algorithms based on race? A lot of these algorithms were based and created on flawed assumptions. And while geneticists want physicians to take race seriously, studies showed there is more variation within the same racial groups than between different ones. And racial differences that are found, it was most likely due to the effects of racism such as the experience of being Black in America. It’s harmful because these algorithms guide clinical decisions which may direct more attention or resources to White patients than patients of color, which is harmful and increases health disparities. This segment touches only the surface of algorithms using race to determine clinical outcomes and how that is flawed. There are also many other factors rooted in systemic racism in why these algorithms consid

Episode 83: Solitary Rectal Ulcer. Dr Singh explains how we can diagnose and treat solitary rectal ulcer syndrome (SURS) and Brandy gave an introduction regarding Elvis Presley’s death. Introduction: Did Elvis Die Pooping?By Brandy Truong, MS4, Ross University School of Medicine. A pop culture trivia fact I always found interesting was that Elvis Presley may have died from trying to have a bowel movement. There are different statements on the cause of death ranging from cardiac arrest, drug overdose, anaphylactic shock, and straining to have a bowel movement. But we’re not here to figure out which one is accurate or debate all that. Elvis was found in the bathroom on the floor and many people described it as if he was on the toilet and then fell forward. If he died from pooping, how does that even happen? We’re going to explore that a little.When we strain to have a bowel movement, it’s called the Valsalva maneuver. This maneuver is divided into 4 stages. Phase 1 is when one first starts straining or bears down. This causes an increase in chest pressure and blood being forced out from the large veins. This is reflected in a rise in blood pressure and a decrease in heart rate. In phase 2, there is reduced venous return to the heart because the blood was forced out of the large veins. Because there is less return to the heart, the heart doesn’t pump out as much as it normally would which leads to a fall in blood pressure. The body senses this fall in blood pressure and will compensate by increasing the heart rate significantly. Phase 3 is when one stops bearing down which results in a release of chest pressure. This causes a fall in blood pressure which causes the heart rate to increase as a reflex. In phase 4, the decreased venous return seen in phase 2 is now restored, which causes an increase in blood pressure. The heart rate then decreases as a reflex response. Both blood pressure and heart rate will return to normal. This entire process occurs over a span of a little over 10 seconds.Elvis was known to have a drug addiction and later some doctors found that he had hypertrophic cardiomyopathy which is a condition in which the heart is unable to pump blood well. He abused a variety of pain medications including opioids. Opioids often cause constipation; therefore, if Elvis was constipated and straining, the Valsalva maneuver compounded by heart disease and other unhealthy lifestyles he had would have caused his cardiac arrest. Intense straining during the process of defecation can result in subarachnoid hemorrhage in people with congenital berry aneurysms, for example. If you end up googling to find out how Elvis died, let us know what you think and if you think he died from pooping. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Solitary Rectal Ulcer Syndrome. By Parneeta Singh, MD, Ross University School of Medicine. Discussed with Hector Arreaza, MD.Solitary Rectal Ulcer Syndrome (SRUS) is a benign, rare, underdiagnosed disorder that can mimic and be incorrectly diagnosed as inflammatory bowel disease (IBD) or rectal cancer. The exact prevalence is unknown but in general, it is reported as an annual prevalence of one in 100,000 people. It mostly occurs in the third decade in men and fourth decade in women, with men and women being equally affected. However, cases have been identified in the pediatric and geriatric populations as well. SRUS is a misnomer because although some patients may present with a solitary ulcer, many present with multiple ulcers that may also involve the sigmoid colon. Presentation. Rectal bleeding (with the amount varying from a little fresh blood to severe hemorrhage that may require blood transfusions), mucus discharge, excessive straining, abdominal and perineal pain, constipation, or diarrhea, feeling of incomplete defecation, tenesmus, and rarely rectal prolapse are clinical symptoms associated with SRUS. Presentation may resemble intestinal parasites such as Entamoeba histolytica (amebiasis) and Enterobius vermicularis (pinworm).The underlying etiology is unknown, but a number of mechanisms have been suggested including ischemic injury from the pressure of impacted fecal matter and local trauma due to repetitive self-digitation, although the latter remains unproven. Ulcers usually occur in the mid-rectum which cannot be reached by self-digitation. Additionally, it has been proposed that the perineum’s descent along with the abnormal contraction of the puborectalis muscle during defecation results in trauma or a prolapsed rectum with mucosal prolapse being the most common underlying pathogenesis in SRUS. Diagnosis. The diagnosis of SRUS is based on clinical features and proctosigmoidoscopy findings, with histological examination and biopsies being the key to the

Episode 82: Eczema Basics. By Lam Chau, MS3, Ross University School of Medicine; and Brandy Truong, MS4, Ross University School of Medicine. Edited and moderated by Hector Arreaza, MD. Brandy and Lam discuss the basics of pathophysiology, presentation, and general treatment of eczema. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Atopic dermatitis (eczema). A common skin disorder among children is atopic dermatitis, commonly known as eczema. At least 1 in 10 children have eczema; however, it affects many adults as well. About 31.6 million people, which is 10% in the U.S., have some form of eczema. Some other statistics worth noting are that children born outside of the U.S. have a 50% lower risk of developing eczema. The risk increases after living in the U.S. for 10 years. Also, 80% of individuals with eczema experience the onset at younger than 6 years old, and at least 80% will outgrow it by adolescence or adulthood. Pathophysiology. Eczema is caused by a disruption of the skin barrier. The outer layer of the skin contains a protein called “filaggrin” which helps form a barrier between the skin and environment. If a person has less of this protein, it’s harder for the skin to retain water and lock in that moisture. Genetics and environment play a role and it often runs in families. People with eczema often have other allergic conditions such as asthma, seasonal allergies, and/or food allergies. Presentation. Eczema rashes can present differently for each person. It can be all over the body or just a few spots and people go through exacerbations or flare ups where the rash worsens and then gets better, which we call remission. In babies, eczema tends to start on the scalp and face. You’ll sometimes see red, dry rashes on the cheeks, forehead, and around the mouth. For young children, rashes can occur in the elbow creases, on the back of the knees, the neck, and around the eyes. Sometimes the rash will ooze and crust. There’s different severities in eczema which helps guide treatment. Mild: some mild areas of dry skin, mild itching (with or without small areas of redness), little or no impact on everyday activities, sleep, and psychosocial well-being.Moderate: moderate areas of dry skin, pruritus becomes more frequent, redness is moderate, moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.Severe: widespread areas of dry skin, continuous itching, redness, bleeding, oozing, cracking, severe limitation of everyday activities and psychosocial functioning, and loss of sleep each night. Exacerbating factors. Factors that exacerbate eczema include excessive bathing without moisturizing, low humidity environments, stress, overheating, and exposure to solvents and detergents. Management. Explaining in detail the management of eczema would take a long time, but we will give you some of the basic principles of treatment. Patient follow up is key to succeed in the management of eczema. You may need to see these patients every 2-4 weeks in some cases and escalate treatment depending on severity. Eczema can be very frustrating for parents and patients. The management requires a multi approach including - eliminating factors that exacerbate eczema, restoring the skin barrier, treating infection, hydrating the skin, patient education, and oral medications. In terms of patient education, a study was done where it showed a 6-week education program that had 2-hour weekly sessions that talked about medical, nutritional, and psychological issues associated with eczema. It resulted in an overall decrease in severity after one year. Moisturizing cannot be overstressed. It is the mainstay of the treatment. Use as much creams as you can. The best moisturizers have a high content of oil, and they are recommended instead of lotions, which contain a percentage of alcohol. So, use emollients or thick creams liberally. Emollients should be applied two times daily and after bathing or handwashing. Some common moisturizers that can be found at common drug stores include Lubriderm, Aveeno, Aquaphor, Cetaphil, and CeraVe. Keeping the skin hydrated and moisturized will also help with the itching. Itching can be very disrupting in the patients’ lives and it can worsen symptoms if left untreated. Itching can result in lichenification, infection, bleeding, crusting, oozing, and cause permanent scars. Topical steroids is another basic treatment for mild to moderate cases of eczema. Steroids can be used intermittently to prevent and treat exacerbations. For prevention, for example, topical steroids can be used two days a week (weekends) for 16 weeks. To treat exacerbations, prescribe twice a day topical steroid for 2-4 weeks. When using topical corticosteroids, there should be cautio

Episode 81: The Tongue Talks. By Idean Pourshams, MD; Golriz Asefi, MD; and Hector Arreaza, MD. Drs Asefi, Pourshams, and Arreaza discuss how to discover local or systemic diseases of the tongue. Includes jokes about tongue. In Traditional Chinese Medicine (TCM), regions of the tongue reflect information about specific organ systems, for example the tip of the tongue traditionally depicts ailments of the heart while the anterior-lateral sections of the tongue represent the lungs, and the posterior-lateral regions reflect the health of the liver and gallbladder. But, today we will focus on common tongue lesions. Normal tongue.The tongue is a muscular organ, highly vascularized and highly innervated. It is normally covered by pink mucosa and has a rough surface caused by the presence of papillae (taste buds). It is vital for chewing and swallowing food and it is essential for speaking. The tongue contains an abundance of blood vessels and is constantly regenerating. The top layer of the tongue is replaced every 2-3 days! A healthy tongue should appear slightly wet, light red or pink with possibly a normal thin white coating. There should not be any fissures, teeth marks or swelling. On physical exam, ensure that the patient has full range of motion of the tongue. It is very important to look at a patient's tongue during physical examination to note the shape, size, color and texture of the tongue body and coat. Findings can suggest the state of organ functions and progression of any underlying conditions. Today we will describe certain physical findings on tongue examination and discuss what clues could be drawn when diagnosing or treating our patients. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Abnormal tongue. What would be your suspicions if a tongue was described as having patches resembling smooth red islands or patches located on the top or side of the tongue, and the patches may actually change location, size and shape? Any ideas on a diagnosis? This could be a geographic tongue also called benign migratory glossitis which is considered harmless and related to allergic rhinitis and other allergies, but it can also be linked to psoriasis and reactive arthritis. What about a tongue that is described as dark and furry or hairy, along with a patient complaining of a metallic taste in their mouth? On physical examination you also note halitosis or bad breath. This could be a diagnosis of black hairy tongue or lingua villosa nigra. Any idea on what may cause black hairy tongue? Possible causes include antibiotic use, tobacco use, mouth breathing, poor oral hygiene, radiation therapy, chronic use of bismuth. Now let’s talk about some vitamin deficiencies that may be represented by changes in the tongue’s appearance. If the patient’s tongue appears purple, and the corners of the mouth display angular stomatitis, it would be wise to suspect a vitamin B2 deficiency. B2: Eyes and mouth. B2 is also known as riboflavin. Patients can have painful cracks in the corners of the mouth and on the lips known as angular cheilitis, also scaly patches on the head, and a magenta mouth and tongue. It is seen in patients who do not eat enough meats (vegans), but also in chronic disorders such as chronic diarrhea, liver disease, alcohol use disorder, malabsorption, and chronic use of barbiturates. Giving Vitamin B supplements by mouth may solve the problem. Vitamin B intoxication is virtually impossible, so you can supplement vitamin B along with other vitamins by mouth confidently, especially patients who are on hemodialysis or peritoneal dialysis. Foods rich in riboflavin include grains, mushrooms, and dairy products. Vitamin B2 deficiency is normally not seen just by itself but combined with other vitamin B deficiencies. Another presentation of a patient’s tongue may be inflammation of the tongue, or glossitis, that is extremely uncomfortable or painful. Any suspicion on what vitamin may be deficient? You might suspect vitamin B3 deficiency, also known as… niacin! While we mentioned angular stomatitis with riboflavin deficiency, that is, cracks on the corners of the mouth; with niacin deficiency, the lips may appear cracked along the surface of the lips themselves. Foods that are rich in niacin include meats and poultry, fish, and nuts. Let’s remember the condition associated with niacin (B3) deficiency: Pellagra. This is an Italian word that translates to “rough skin.” Although nutritional deficiency may be less frequent now than centuries ago, we still may see pellagra in cases of gastrointestinal disease in which absorption of nutrients is diminished, or in patients with malnourishment, possibly from alcoholism. In addition to manifestations of the tongue, pellagra can progress to cause a red rash on the c

Episode 80: Oral Meds for COVID-19. The US department of human health and services recently launched the COVID19 Therapeutics Locator website to allow providers find locations where they can send prescriptions for Paxlovid and Molnupiravir. Find the COVID19 therapeutics locator online: https://arcg.is/iuuW50Yasmin and Arti discuss oral medications under emergency use authorization for COVID-19: Paxlovid and Molnupiravir. Introduction: Meds for COVID-19. By Hector Arreaza, MD. For the last 2 years, humanity has faced the challenge to find an effective way to fight COVID-19. This pressing charge has not been free of obstacles. It has been hindered by politics, misinformation, greed, jealousy, and many other not-so positive human traits. For me, living through the pandemic has been somewhat frustrating and shaming. Stupidity, vulgarity, and mediocrity are a few of the attributes that have flourished during the last 2 years all around us. But not everything about the pandemic has been negative. Many talented people with good intentions have engaged in serious research and have made tremendous contributions to science and humanity. Vaccines have been developed using cutting-edge technology and their efficacy has been very positive so far. Many medications have been tried to fight COVID-19 since the beginning. Some clinicians have tried to repurpose old medications in their honest desires to fight COVID-19. Examples include ACE inhibitors, statins, azithromycin, hydroxychloroquine, and chloroquine, which have not proven to be effective against this virus so far. Ivermectin, for example, has been very controversial since the beginning of the pandemic. Ivermectin is not approved by the FDA for the treatment of COVID-19. Until today, the National Institutes of Health do not have enough data to recommend for or against using ivermectin for COVID-19. “Results from adequately powered, well-designed, and well-conducted clinical trials are needed to provide more specific, evidence-based guidance on the role of ivermectin in the treatment of COVID-19.” Ivermectin is still being used by some clinicians in the United States based on personal experience and opinions.At this time, remdesivir (brand name Veklury®) is the only medication approved by the FDA to treat COVID-19. IV remdesivir won full FDA approval in October 2020 for hospitalized patients, and its use has been expanded a couple days ago to include use in non-hospitalized high-risk patients. The NIH recommends against IL-6 inhibitors, such as tocilizumab or sarilumab, in COVID-19 patients who are not in the ICU. At this moment, there is not enough data for the NIH to make a recommendation for patients who are in the ICU. Baricitinib is an oral medication used to treat rheumatoid arthritis authorized in November 2020 to be used in combination with remdesivir for the treatment of COVID-19 in certain hospitalized children and adults who require supplemental oxygen, mechanical ventilation, or Extracorporeal membrane oxygenation (ECMO). Baricitinib is now authorized to be used without remdesivir against COVID-19 in hospitalized patients. We cannot forget the use of dexamethasone in hospitalized patients requiring oxygen.Today we want to give you a little taste of two oral medications: Paxlovid® and molnupiravir. You will listen to two brave medical students presenting what they have found about these medications. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Paxlovid®. By Yasmin Fazli, MS3, Ross University School of Medicine. What is it?Paxlovid® is the first oral treatment for mild-to-moderate coronavirus disease (COVID-19) in patients over 12 years-old to be issued by the FDA. The FDA issued an emergency use authorization (EUA) on December 22, 2021. It is made up of two different medications: nirmatrelvir and ritonavir. Nirmatrelvir is a protease inhibitor while ritonavir helps decrease the breakdown of nirmatrelvir. The combination authorized is nirmatrelvir 300 mg plus ritonavir 100 mg. You may remember ritonavir use in combination with other antiretrovirals for the treatment of HIV/AIDS. At the end of the 2021, Pfizer announced that results from a trial comparing between Paxlovid® versus a placebo revealed that Paxlovid® reduced proportion of mortality and morbidity by 88% compared to placebo after a 5-day course. When and how to prescribe it?To use Paxlovid® some criteria must be met by the patient. First, a positive result of COVID-19 viral testing, second, the patient must be at high risk for illness progression to a more severe state, including hospitalization and death; and third, the patient must be 12 years or older. Paxlovid® should be started as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset. It is to be taken

Intimate Partner Violence. Dr Yomi discusses how to screen for intimate partner violence (IPV), she shares statistics, risk factors, and how to prevent it. Introduction about steroid injections and hyperglycemia with Dr Kooner.Today is January 18, 2022.Introduction: Intra-Articular Corticosteroid Injections and HyperglycemiaBy Gagan Kooner, MD, Government Medical College of Amritsar, India.There is a physiologic association between hyperglycemia and corticosteroids. Do intra-articular steroids induce hyperglycemia? According to the Spine Intervention Society’s Patient Safety Committee, the answer is yes. These researchers reviewed studies done on both diabetic and non-diabetic patients. In non-diabetic patients, transient and self-limited hyperglycemia was reported following peripheral intraarticular injections. The increase in blood glucose was less than 40 mg/dl, and levels returned to near baseline by 24 hours. The hyperglycemia in patients with diabetes is more significant. In patients with well-controlled diabetes (hemoglobin A1C of The effects of epidural steroid injections vs injections in other joints were compared in patients with and without diabetes. Three consecutive injections were given. On day 1 following the injection, there was a significant increase in post-prandial glucose in all groups. However, on day 7, only patients who had received intra-articular injections, did not return to baseline. The hyperglycemia is likely to happen because the steroid spreads in a larger area when injected in a large joint. Also, a caveat is that the group of patients who received intra-articular steroid injections had a higher proportion of diabetic patients. Spine Intervention Society recommendations: All patients with diabetes should have a provider to contact if their glucose levels become difficult to control.The informed consent process should include the potential for hyperglycemia after the procedure. Patients with diabetes should check their glucose consistently for at least two days before the procedure. A rule of thumb is to cancel the procedure if the glucose is above 200 mg/dl.The number of joints and the total amount of steroid given should be considered. If the procedure is only a diagnostic block; only local anesthetic should be used (avoid unnecessary steroids).After the procedure, patients should monitor their glucose until levels return to baseline and adjust their treatment accordingly. In conclusion, it appears there is a definite correlation between intra-articular steroid injections and hyperglycemia. Although the risk may be minimal, in my opinion, following these recommendations would ensure we are providing adequate healthcare to our patients, especially those more vulnerable, such as diabetic patients. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Intimate Partner Violence. By Timiiye Yomi, MD. Discussion with Hector Arreaza, MD. INTRODUCTIONThe CDC defines domestic violence (also called Intimate Partner Violence or IPV) as physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner (spouse, boyfriend/girlfriend, sexual partner, etc.). According to the National Coalition Against Domestic Violence, it is the willful intimidation, physical assault, battery, sexual assault and/or other abusive behavior perpetrated by one intimate partner against another. A FEW THINGS TO NOTE:The CDC considers IPV a serious public health issue affecting men and women globally. It begins at an early age. Research has shown that it is most prevalent among adolescents and young adults and it declines with age. An estimated 8.5 million women and 4 million men in the US who have reported experiencing IPV in their lifetime all say they first experienced it before they turned 18 years of age. Women are more frequently victims of IPV. Data from the National Intimate Partner Sexual Violence Survey (NISVS) reveals 1:4 women (23%) and 1:7 men (14%) in the US report having experienced severe physical assault from an intimate partner, 16 % of women and 7% of men have experienced sexual violence, and 47% of women and men have gone through some form of psychological aggression like humiliating and controlling behaviors from an intimate partner. However, men are less likely to report it. Frequency and severity can vary but there is always a consistent effort by one partner to maintain power or control over the other. Abusers may often seem harmless and perfect initially but over time, they become increasingly aggressive and controlling towards their partner. [Dead little fly] IPV can happen in all types of intimate relationship: homosexual or heterosexual. Many racial/ethnic and sexual minority groups are more disproportion

Episode 78: Infantile Hemangioma. Dr Shelat discusses with Dr Schlaerth and Dr Arreaza the definition, pathophysiology, diagnosis and treatment of infantile hemangioma.___________________________Infantile Hemangioma. By Tejal Shelat, MD (Lady Hardinge Medical College). Discussed with Katherine Schlaerth, MD; and Hector Arreaza, MD. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. What is infantile hemangioma?Infantile hemangioma is vascular overgrowth that leads to tangled blood vessels that appear as a reddish plaque on the skin as early as days to weeks after birth. It is the most common benign vascular tumor in infants, with a prevalence of 4-5% in mature neonates and is about 2.5 times more common in female (ratio female:male is 3:1) and Caucasian children. Risk factors: There are several risk factors, including prematurity, low birth weight less than 1000g, family history of infantile hemangioma, placental anomalies, and eclampsia. Progression of infantile hemangioma. Hemangiomas typically undergo three phases:First is the proliferation phase that occurs between 0 to 6 months of age, with about 80% growing to their final size by age 3 months. During this time there is growth of a bright red, soft, raised, non-blanching plaque that is visible on the skin. This occurs to due proliferation of rapidly dividing endothelial cells in the blood vessels.This is followed by a plateau phase.Next is the involution phase, that occurs after 6 months of age. The lesion/s now turn deep red or violet and spontaneously begin to regress in size. Pathogenesis. Several hypotheses have been described to explain the reason behind the occurrence of hemangiomas. We now know that they occur due to dysregulation in angiogenesis and vasculogenesis. The most likely trigger is thought to be hypoxia, which induces transcription of the Vascular Endothelial Growth Factor (VEGF) gene, leading to overexpression of angiogenic factors such as VEGF. This leads to differentiation of endothelial cells, influx of other cells such as mast cells, myeloid cells and also tissue inhibitors of metalloproteinases (TIMPs). Regression. The mast cells produce interferon and transforming growth factor, which, along with the TIMPs that we just talked about all work together to halt the proliferation of endothelial cells. The endothelial cells then become senescent and that leads to passive involution of the hemangioma. Diagnosis. The diagnosis of infantile hemangiomas is clinical. If you are not familiar with how a hemangioma looks, search in your favorite dermatology atlas. A hemangioma may be red if it involves the papillary dermis (called superficial strawberry hemangiomas), but they can also be purple, blue, or colorless if they involve the reticular dermis or subcutaneous fat (called deep, cavernous hemangiomas). Early white discoloration of infantile hemangioma may be an early sign of imminent ulceration. Additional workup. Further investigation is also required in specific situations: If there are 5 or more cutaneous lesions, we would need a liver ultrasound to rule out involvement of the liverFor facial or segmental involvement, echocardiogram and MRI of the head are recommended to rule out posterior fossa malformations, hemangioma (usually localized on the face), arterial anomalies, cardiovascular anomalies, eye anomalies, sternal clefting and/or supraumbilical raphe PHACE Syndrome: posterior fossa brain malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities. By definition, PHACE is diagnosed when there is at least one hemangioma >5 cm on head/scalp PLUS one major or two minor criteria OR hemangioma of any size on neck, upper trunk and proximal upper extremity plus two major criteria.Major criteria include arterial anomalies such as anomaly of major cerebral or cervical arteries, retinal vascular anomalies, sternal defect. Minor criteria include cerebral artery aneurysm, ventricular septal defect, etc. Laryngoscopy should be done if there is cervicofacial involvement, i.e., beard distribution Spinal ultrasound should be performed if the hemangioma is in the lumbosacral region Management-Most hemangiomas will not require treatment, and most need observation only. -When treatment is needed, treatment is usually medical depending on severity, location, and extension of hemangioma/s, you may decide to go with topical or systemic therapy.-Topical therapies include beta blockers (propranolol 1% applied TID for 1 year), corticosteroids, and imiquimod, but data on efficacy is limited.-Systemic therapies: Beta blocker therapy (with propranolol by mouth) is indicated when there is concern for ulceration or scarring in large, facial, segmental and or rapidly growing hemangiomas, for vi

Intrahepatic Cholestasis of Pregnancy (ICP).Amel and Dr Wonderly discuss the signs, symptoms, and management of ICP. A reminder for alcohol use disorder screening.Introduction: Screening for alcohol use disorder. Written by Hector Arreaza, MD. Reviewed by Jacqueline Uy, MD. Today is December 3, 2021.Substance misuse occurs in about 20% of patients seen in primary care settings. For example, alcohol-related disorders are present in up to 26% of general clinic patients, “a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes”[1]. The USPSTF recommends screening for unhealthy alcohol use in adults 18 years or older, including pregnant women, and provide those engaged in risky drinking with brief behavioral counseling to reduce alcohol use (this is a Grade B recommendation). This brief introduction is to encourage everyone to screen adults for alcohol use disorder. Let’s start with the basics. It is important to know the size of a standard drink so you can counsel your patients appropriately. According to the CDC, a standard drink is equal to 14 grams (0.6 ounces) of pure alcohol. Generally, this amount of pure alcohol is found in:12 ounces of beer (5% alcohol content).8 ounces of malt liquor (7% alcohol content).5 ounces of wine (12% alcohol content).1.5 ounces or a “shot” of 80-proof (40% alcohol content) distilled spirits or liquor (such as gin, rum, vodka, whiskey).Moderate alcohol drinking means 2 drinks or less in a day for men and 1 drink or less in a day for women. Binge drinking means drinking enough to bring your blood alcohol concentration (BAC) level to 0.08% or more. This may be different in each patient, as humans metabolize alcohol differently, but usually it corresponds to 5 or more drinks on a single occasion for men or 4 or more drinks on a single occasion for women, generally within about 2 hours[2]. A good approach to screen for alcohol use disorder is by asking: “Do you sometimes drink alcoholic beverages?”, and then the single screening question, “How many times in the past year have you had 5 or more drinks (men) OR 4 or more drinks (women) in a day?”[3] The screening is considered positive if the patient answers one or more times a year. If positive, then you may continue your assessment with another tool such as AUDIT. This can be a topic for a whole episode. For now, we just want to remind you to screen your patients for alcohol use because the prevalence is very high and we as primary care physicians can make a big difference in the prevention and treatment of alcohol misuse in our communities. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Intrahepatic Cholestasis of Pregnancy (ICP). Written by Amel Tabet, MS3, American university of the Caribbean. Discussion with Sally Wonderly, MD; and Hector Arreaza, MD.What is Intrahepatic Cholestasis of Pregnancy and why does it matter?As its name implies, Intrahepatic Cholestasis of Pregnancy (ICP) is a multifactorial liver dysfunction in some pregnant women that occurs during their either second or third trimester of pregnancy and resolves spontaneously after parturition. It is defined by the presence of pruritus -- previously called pruritus gravidarum or recurrent jaundice of pregnancy-- and abnormally elevated serum bile acid levels and mildly increased hepatic aminotransferase levels, in the absence of diseases that may yield similar laboratory findings and symptoms. Key symptoms are pruritus, high bile acid and high transaminases. How common is ICP?In the US incidence ranges from 0.32 percent to 5.6 percent, depending on the area. The Los Angeles area has a high incidence compared to other areas in the US. The highest rates in Europe are in Scandinavia. It is very frequent in Chile (South America). The indigenous people known as Araucanos have the highest incidence worldwide at 27.6 percent.PathogenesisThe pathogenesis of ICP remains unclear. It is mainly attributed to changes in various sex steroid levels but more recent research points towards an etiology that relates to various mutations in the many genes involved in the control of the hepatocellular transport systems such as the ABCB4 gene, which encodes multidrug resistance protein 3 (MDR3) linked to progressive familial intrahepatic cholestasis, errors of the ABCB11 gene that encodes for the bile salt export pump, and more recently on FXR/NR1H4 and PXR/NR1I2 genes that encode for proteins that critically regulate bile acid synthesis and transport, and the transcription of ABCB11 in humans and the role of epigenetics influence by means of methylation of these genes. Dangers for mother: Beside the discomfort of pruritus, ICP is transient and of little maternal risk generally. The mother may be uncomfortable but it’s not fatal. Dang

Episode 76: Eating Disorders. The malaria vaccine is announced by Dr Parker, eating disorders such as anorexia and bulimia are briefly discussed by Sophia, Jeffrey and Dr Arreaza. Introduction: Introducing the malaria vaccine (RTS,S)Written by Hector Arreaza, MD; read by Tana Parker, MD. Today is November 26, 2021.Malaria is a devastating disease that continues to kill thousands of people every year around the world. Since the year 2000, there have been 1.5 billion cases of malaria and 7.6 million deaths. In 2019, there were 229 million new cases, and 409,000 deaths, mostly children under 5 years of age.Effective vaccines for many protozoal diseases are available for animals (for example, the vaccine against toxoplasmosis in sheep, babesiosis in cows, and more.) However, vaccines for protozoal disease in humans had not been widely available … until now. The RTS,S is a vaccine against malaria approved by the European Medicines Agency in July 2015 for babies at risk, and it was rolled out in pilot projects in Malawi, Ghana and Kenya in 2019. In October 2021, the World Health Organization announced the recommendation of this anti-malaria vaccine. The trade name of this vaccine is Mosquirix®. The vaccination is recommended for children in sub-Saharan Africa and other regions with moderate to high transmission of Plasmodium falciparum, which is considered the deadliest parasite in humans. The approved vaccine has shown low to moderate efficacy, preventing about 30% of severe malaria after 4 doses in children younger than five years old. Implementation of vaccination is not free from challenges, and it should be executed not as the solution for the disease, but as part of the solution, along with other efforts such as mosquito control, effective health care, and more.RTS,S is an add-on to continue the fight against malaria worldwide. Hopefully we can lighten the heavy burden of malaria for more than 87 countries that suffer the severe consequences of poor control of this devastating disease. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Eating Disorders. Written by Sophia Dhillon, MS3, Jeffrey Nguyen, MS3. Discussion with Hector Arreaza, MD. This is not intended to be a comprehensive lecture on eating disorders. This episode is intended to give you basic information, hoping to motivate you keep learning about it. Let’s start talking about eating disorders today, specifically anorexia nervosa and bulimia nervosa. What is an eating disorder? An eating disorder is a disturbance of eating that interferes with health. As a reminder, health is “a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity.” So, an eating disorder, in a wide context, is any eating pattern that is out of what is considered “normal”, and that variation in feeding causes health problems. But in general, when we talk about eating disorders in medicine, we refer to anorexia nervosa and bulimia nervosa, but it includes also avoidant/restrictive food intake disorder, binge eating disorder, night eating disorder, pica, and rumination disorder. ANOREXIAIn general, anorexia is characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure or an irrational fear of weight gain as well as distorted body self-perception. There are 2 main subtypes of anorexia: restricting type vs binge-eating/purging type. Tell us the difference between anorexia restrictive type and binge eating-purging type.Anorexia, restrictive type is when weight loss is achieved by diet, fasting and/or excessive exercise, meanwhile the binge-eating/purging type entails eating binges followed by self-induced vomiting and/or using laxatives, enemas or diuretics. These patients will have intense fear of gaining weight or becoming fat. They will have a distorted perception of body weight and shape or denial of the medical seriousness of one’s low body weight.Anorexia nervosa is different than avoidant/restrictive food intake disorder. In anorexia, you have an altered perception of your body (“I’m fat”), but in avoidant/restrictive food intake disorder, your perception of your body weight and shape is not abnormal. “I’m skinny, and I’m OK with that.” This is new information for me. I thought anorexia was present always when a patient refused to eat, whether you liked your body or not.Why do people develop eating disorders? There are so many reasons why people develop eating disorders. First, it can be psychological due to low self-esteem, feelings of inadequacy or failure, feeling of being out of control, response to change (i. e. puberty) or response to stress. Second, it can be due to interpersonal issues like having trouble with family

Episode 75: Multisystem Inflammatory Syndrome in Children (MIS-C). Dr Schlaerth explains the signs, symptoms, and basic management of MIS-C. Lam explain the role of anti-obesity medications in weight management. Introduction: The Role of Drugs in Weight Loss Management By Lam Chau, MS3, Ross University School of Medicine Today about 70% of adult Americans are overweight or obese. Obesity is associated with increased risk of heart disease, stroke, and diabetes, among many other diseases. Studies have shown losing 5-10% of your body weight can substantially reduce your risk of cardiovascular disease. Traditional belief is that weight loss can only be attributed to diet and exercise. While there are certainly elements of truth to that statement, medication is a safe and proven method for weight management that is often overlooked. The fact of the matter is that weight loss is an ongoing field of study with constant new research and innovations. In June of this year, a medication named Wegovy was approved for weight loss management by the FDA. This drug is indicated for chronic weight management in patients with a BMI of 27 or greater with an accompanying weight-related ailment or in a patient with a BMI of 30 or greater. Rachel Batterham, PhD, of the Centre for Obesity Research at University College London, shared: "The findings of this study represent a major breakthrough for improving the health of people with obesity. No other drug has come close to producing this level of weight loss — this really is a game changer.” Despite breakthroughs like these, the use of medication for weight loss is still relatively low. Dr. Erin Bohula, a cardiologist and assistant professor at Harvard Medical School, believes “there are probably a few reasons for this, including cost, if not covered by insurance, and a perception these agents are not safe in light of the history with weight loss agents.” A study from 2019 examined the medical records from eight geographically dispersed healthcare organizations. They found that out of 2.2 million patients who were eligible for weight loss medication, only 1.3% filled at least 1 prescription. Weight loss is a dynamic process with many different variables. While it may not necessarily be for everyone, medication can help tremendously and is an option you should consider if you are interested in weight loss[1,2]. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Multisystem Inflammatory Syndrome in Children (MIS-C). By Katherine Schlaerth, MD, and Hector Arreaza, MD. History and epidemiologyMost children who get COVID-19 have either no symptoms or very mild symptoms. However, about 18 months ago, a new pediatric complication of COVID-19, possibly postinfectious, was described. The eight children who were initially described had a clinical presentation which was similar to either Kawasaki Disease or perhaps toxic shock syndrome, and since these children had signs of a hyperinflammatory state coupled with shock, the new syndrome was named Multisystem Inflammatory Syndrome in Children, or MIS-C for short. By midsummer of 2021, the United States had about two thousand cases and 30 deaths in children under 21. Other name for this condition is Pediatric Hyperinflammatory Shock. DiagnosisWhat are the criteria for a diagnosis of Multisystem Inflammatory Syndrome? They include:Age below 21Fever above 100.4 degrees Fahrenheit or 38 degrees centigrade for 24 hours (a subjective fever for more than 24 hours counts too). Laboratory evidence of inflammation which should include at least two of the following tests: elevated CRP, elevated ESR, elevated fibrinogen level, procalcitonin, D-dimer, ferritin, lactic acid dehydrogenase (LDH), interleukin-6, and neutrophil counts, low lymphocyte count and low albumin.Severe disease necessitating hospitalization with multisystem organs affected. The systems affected include cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, and neurologic (at least three systems need to be involved). No creditable other diagnosis. Other symptoms include:GI complaints (diarrhea, vomiting, abdominal pain)Skin rashConjunctivitisHeadacheLethargyConfusionRespiratory distressSore throatMyalgiasSwollen hands/feetLymphadenopathyCardiac signs and symptoms include troponin/BNP elevation and arrhythmia. Findings on ECHO may include depressed LVEF, coronary artery abnormalities, including dilation or aneurysm, mitral regurgitation, and pericardial effusion. There also must be a positive test for SARS-CoV-2 and this test can be either a reverse transcriptase polymerase chain reaction (RT-PCR), serologic, or antigen testing. Exposure to someone who has had or is suspected of having had COVID-19 within the last 4 weeks also counts

Episode 74: Breast Cancer Screening. Salwa and Veronic discuss who, how, and when to screen for breast cancer. The Pfizer COVID-19 vaccine was authorized for use in children 5-11 years of age.Introduction: Pediatric COVID-19 VaccinesBy Lam Chau, MS3, Ross University School of MedicineOn November 2nd, 2021, the CDC endorsed a unanimous recommendation to allow the use of the Pfizer COVID-19 vaccine for children ages 5-11 years of age. The White House has secured 28 million pediatric doses of the Pfizer vaccine, enough to cover every child ages 5-11 within the United States without cost. The official CDC recommendation is that all children aged 5 and older get vaccinated, regardless of past infection history. The Pfizer vaccine for children is given in two doses, 3 weeks apart.Individuals older than 12 are given a 30-microgram dose, while pediatric individuals are given a 10-microgram dose. For extra precaution, the pediatric vaccine vials are being shipped with a unique orange cap to clearly distinguish itself from higher dose vaccines. Clinical trials with the lower dose vaccine demonstrated a strong antibody response and a prevention rate of symptomatic COVID-19 of 90%. The reported side effects were minimal, and no serious adverse events or myocarditis were reported during the trials. The vaccination of children cannot be understated. The benefits go well beyond just the physiological processes of vaccination. It will foster a safer environment for our children and help improve their emotional and social development. While there is still a lot to be done to end the pandemic, this recent announcement is an enormous step in the right direction in returning to normalcy. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Breast Cancer. By Salwa Sadiqali, MS3, Ross University Medical School; Veronica Phung, MS3, Ross University School of Medicine; and Hector Arreaza, MD. Salwa: Welcome back from Spooky season! Did you see all the flyers and advertisements about Breast cancer awareness last month? Veronica: I did! It’s because October was breast cancer awareness month.Salwa: And spooky season, and of course pumpkin spice season! I got my dose of pumpkin spice this morning. Well, every morning to be exact, Starbucks is my second home. What do you know about breast cancer? Veronica: Well...breast cancer is the most commonly diagnosed cancer worldwide. And, fun fact, I know that Angelina Jolie had an increased risk of breast cancer, so she had surgery to remove them.Arreaza: I remember it being all over the news back in 2013. It caused “The Angelina Effect.” There was an increase in people searching about breast cancer on the internet. Let’s dive into this topic a bit more. What exactly is breast cancer?Salwa: It’s a process in which normal cells of the breast start growing too quickly, out of control. It can happen in males too, but it’s much rarer.Veronica: And there are different types of breast cancers that originate from the different types of tissue in the breast. There’s ductal carcinoma, lobular, inflammatory, Paget’s, and phyllodes to name a few. Salwa: Not only are there different types of breast cancers, but some can also be hereditary meaning mutated genetic information is passed on from generation to generation.Arreaza: That’s what happened with Angelina Jolie. She had a BRCA1 gene mutation. Veronica: BRCA1 and BRCA2 mutations are the most common causes of hereditary breast cancer. Normally, the BRCA gene helps make proteins that repair damaged DNA. When this gene is mutated, it can’t make those proteins, so damaged DNA stays damaged. But this only makes up 5-10% of all breast cancers.Salwa: Exactly! Here’s an interesting fact, women of Ashkenazi Jewish heritage are at a much higher risk of developing a BRCA mutation. There are several other genes that are also linked to hereditary breast cancer. But those genes aren’t that common. Non-hereditary breast cancers are much more common - they make up about 85% of breast cancers. Arreaza: Ok so you two gave us a lot of good information, but do you know how to screen for breast cancer?Salwa: When and how often you screen depends on which guidelines your physician is following. Generally, you’ll get a mammogram, basically an X Ray of the breast. Veronica: The US Preventative Screening Task Force or USPSTF is a panel of experts that uses medicine-based evidence to make screening and vaccination guidelines. These guidelines are reviewed and updated yearly. For breast cancer, the USPSTF recommends women ages 50-74 have a mammogram every other year. Salwa: The American College of Obstetrics and Gynecologists recommends mammograms starting at the age of 40 and repeating the test every year or every other year. While the American