Rio Bravo qWeek

Episode 73: Anticoagulation in Afib. When should you start anticoagulation in atrial fibrillation? What medications are appropriate? Virginia Bustamante, Charizza Besmanos and Dr Arreaza discuss this topic. By Charizza Besmanos, MS4; Virginia Bustamante, MS4; and Hector Arreaza, MDCharizza: Hello, welcome to today’s episode of Rio Bravo qWeek Podcast. My name is Charizza Besmanos, a 4th year medical student from American University of the Caribbean and I am joined here today by Virginia Bustamante. Virginia: I’m Virginia Bustamante, an incoming 4th year medical student from Ross University. Arreaza: And I’ll be here just to make sure that you guys behave during this episode. Charizza: Before we get started on our discussion, I have a quick patient case to share with you. This is a 66-year-old woman who is brought to the ED with sudden onset of severe difficulty speaking and weakness while having breakfast. She has hypertension, hyperlipidemia, severe left atrial enlargement seen on previous ECHO, and is noncompliant with her medications. She is a lifetime nonsmoker and does not drink alcohol. On admission, her blood pressure is 152/90 and pulse is 124/min and irregularly irregular. She is awake and alert but has difficulty finding words while trying to speak. She has severe right lower facial droop and marked weakness and sensory loss in the right arm and mild weakness in right leg. Fingerstick glucose is at 105. ECG shows atrial fibrillation. Acute stroke management is started right away. CT shows occlusion of the left MCA. What management could have prevented this complication? Virginia: This patient clearly has multiple risk factors for thromboembolism events but given her irregularly irregular pulse consistent with atrial fibrillation, she would’ve warranted long-term anticoagulation to prevent stroke, which she most likely had. Charizza: Exactly. Today’s topic is atrial fibrillation, specifically the use of anticoagulation. __________________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. __________________ Virginia: Anticoagulation is indicated to decrease the risk of thromboembolic events such as ischemic stroke in patients with atrial fibrillation (A-fib). Not all patients receive anticoagulation. Like most things in medicine, you must decide to start anticoagulation when the benefits of decreasing the risk of stroke outweighs the risk of bleeding. So, for assessing the risk of stroke in A-fib, the American College of Cardiology along with American Heart Association and the Heart Rhythm Society published a guideline in the Journal of the American College of Cardiology in 2014 and was recently updated in 2019[1] detailing in which patients anticoagulation is recommended. Charizza: Yes, according to the guideline, “high risk patients” are all patients with valvular A-fib, and those with nonvalvular A-fib with a CHADVASC score of >/= 2 in men or >/= 3 in women, and those with nonvalvular Afib and hypertrophic cardiomyopathy. Those with “medium risk” are patients with nonvalvular Afib with CHAD2VASc score of 1 in men or 2 in women. In these patients, anticoagulation is considered but the risk and benefits are discussed with the patient. Those with “low risk” are patients with CHAD2VASc score of 0 in men or 1 in women and anticoagulation is not routinely recommended in these patients. Can you tell us briefly what CHA2DVASc score is? Virginia: CHA2DS2-VASc score is the stroke risk assessment tool of choice by the AHA/ACC/HRS guideline. It is great because it is a mnemonic. Each letter is assignment 1 point except for 2 criteria. C stands for congestive heart failure, H for HTN defined as >140/90, A2 is for or Age>75 which is for 2 points, D for diabetes, S2 is for stroke or TIA and it’s for 2 points, V for vascular disease such as MI, A for age 65-74, S for female sex. Charizza: That certainly makes it easy to remember. Not only that, but you can also find CHA2DS2-VASc score of MDCalc to make it even easier. Virginia: Now that we’ve established which patients should receive anticoagulation, how do we choose which anticoagulant? Charizza: For this discussion today, I would like to focus on nonpregnant patients. There really are 2 main anticoagulants, DOACs (or the direct oral anticoagulants) and warfarin. DOACs are the direct thrombin INH (dabigatran) and the direct factor Xa INH (rivaroxaban, apixaban, and edoxaban). DOAC is recommended as first-line in the long-term management of nonvalvular afib as trials have shown DOACs are more successful at reducing risk of thromboembolic events and have a lower risk of bleeding than warfarin and warfarin requires INR monitoring with dose adjustments. Although, in patients with valvular Afib, warfarin is preferred. Arreaza: All of them are by mouth. Virg

Episode 72: Depression in Adolescents. COVID-19 vaccine updates including booster shots and mix and match options. Depression in adolescents is discussed by Virginia Bustamante, Charizza Besmanos, and Hector Arreaza. Introduction: COVID Vaccines Update October 2021Written by Hector Arreaza, MD. Participation: Lillian Petersen, RN, and Nathan Heathcoat, MS3. The FDA granted emergency use authorization for a booster shot with the Pfizer/BioNtech COVID-19 vaccine in September 2020.On October 20, 2021, the FDA also granted emergency use authorization for a booster shot with the Moderna AND Johnson & Johnson (also known as Janssen or J&J) COVID-19 vaccines. Pfizer/BioNtech: Brand name Comirnaty®. It has full FDA approval for patients who are 18 years and older for the prevention of COVID-19. The rest of the indications of this vaccine are under the Emergency Use Authorization (EUA). It is authorized for 12 years and older. Total of two doses, 21 days apart. Authorized for 3rd dose in immunocompromised patients (on active cancer treatment, organ transplant recipients, taking immunosuppressive or high dose corticosteroids, have moderate to severe immunodeficiency). 3rd dose is given at least 1 month after the second dose. It is authorized for a single booster shot in special populations (older than 65 years of age OR 18-64 years of age at high risk of severe COVID-19 or with frequent occupational exposure). The booster shot must be given 6 months after the primary series is complete.Moderna: No brand name yet. All uses are under emergency use authorization. It is authorized for 18 years and older for the prevention of COVID-19. Give a total of two doses, 4 weeks apart. A third dose is authorized to be given 1 month after the second dose. Patients who can receive a third dose include patients on active cancer treatment, organ transplant recipients, taking immunosuppressive or high dose corticosteroids, or have an immunodeficiency. It is authorized for a single booster shot 6 months after completing primary series. The booster shot of Moderna should be half dose. People who may receive a booster shot are those who are older than 65 years of age OR 18-64 years of age at high risk of severe COVID-19 or with frequent occupational exposure.Johnson & Johnson (Janssen): No brand name yet. Authorized as a single dose vaccine. Authorized for a single booster shot 2 months after the first dose. Mix and Match Approval: The FDA authorized on October 20, 2021, heterologous booster dose for currently approved or authorized COVID-19 vaccines. You can give a booster shot with a different vaccine than the one you received primarily. For example, a patient who received J&J vaccine may receive a booster shot with Pfizer or Moderna 2 months later. Another example, a patient received primary series of Pfizer vaccine, may receive a booster shot with Moderna, Pfizer or J&J 6 months after completing primary series. Booster shots are authorized, again, for patients who are 65 years and older, 18-64 years of age at high-risk for severe COVID-19 or with frequent occupational exposure.The vaccination of children 5-11 years old is still under discussion, more updates coming soon.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Depression in Adolescents. By Virginia Bustamante, MS4; Charizza Besmanos, MS4; and Hector Arreaza, MD. Vicky: We will talk about adolescence and depression today. I was reading a piece on the Impact of COVID-19 Pandemic on Adolescent Mental Health on Psychiatry Advisor by Tori Rodriguez. She is a licensed professional counselor with a master’s in arts in counseling psychology. This article really got me thinking, how prevalent is depression in adolescents? Even before COVID-19. I read the article and I wasn't even aware of the numbers. So, I decided to do some research on the topic. Charizza: When you brought up the topic for discussion, I asked myself how much do I even know? I found that the CDC reported that “more than 1 in 3 high school students had experienced persistent feelings of sadness or hopelessness in 2019.” This was a 40% increase since 2009. It also said that, “in 2019 about 1 in 6 youth reported making a suicide plan in in the past year. That was a 44% increase since 2009.” 44% increase! That is almost unbelievable. Now I’m asking myself what is causing such a drastic increase.Vicky: When I read Rodriguez’s piece it really got me thinking. What is or are there even known causes linked to this huge increase?Charizza: Are adolescents more open to talk about mental illness? Or are there other factors affecting their mental illness? For example, increasing social media presence or other home/ social pressures. Vicky: Actually, that may be partially why. The U.S. News and

Episode 71: Metabolic Syndrome. Dr Yomi defines metabolic syndrome and describes the basic principles of management. Nathan gives updates about aspirin use in primary prevention of cardiovascular disease.Introduction: Aspirin Update. By Nathan Heathcoat, MS3, Ross University School of Medicine. Arreaza (comment): This week I was checking the list of the top 10 countries where we have the highest number of listeners, and I’m happy to see the Kingdom of Spain as the number 2 country with the most listeners. Out top 1 country is the United States, we also have listeners in Canada, Mexico, the Netherlands, Brazil, Ireland, Australia, South Africa, Mexico, and England. I send my greetings to you wherever you are. I hope you all enjoy today’s episode, from wherever you are, and please send us an email to [email protected] if you have any feedback. We would like to hear from you. Hello, my name is Nathan Heathcoat I am a 3rd year medical student at Ross University School of Medicine. I will be giving a quick update on aspirin. Aspirin has been examined quite a bit by the USPSTF recently. In episode 68, Doctors Arreaza and Civelli discussed the continued recommendations for the use of aspirin for the prevention of preeclampsia in high-risk patients. Now as of October 12, 2021, The USPSTF has been working on draft changes on how we utilize aspirin for the prevention of cardiovascular disease (CVD) events. The previous guideline from 2016 gave aspirin use as CVD event prophylaxis a grade B (as in Bravo) recommendation in patients aged 50-59 who’s 10-year ASCVD risk was 10% or greater. Additionally, for those patients aged 60-69 with a 10-year risk of 10% or more, aspirin use is said to be an individual based approach and received a grade C recommendation. (1) Now with these new draft recommendations, those patients aged 40-59, aspirin only adds marginal benefit. Its recommendation has been tentatively changed to grade C and its use should be an individual based approach. Most notably, for those patients aged 60-69, the USPSTF is suggesting that aspirin confers no net benefit for primary prevention of CVD, and they changed its recommendation to grade D as in delta. (2) So going forward keep in mind that these practice guidelines are under draft review and the official recommendation should be finalized mid to late November 2021. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Metabolic Syndrome. By Timiiye Dawn Yomi, MD; and Hector Arreaza, MD. INTRODUCTION Obesity, especially abdominal obesity, is associated with an increase in insulin resistance which causes abnormal glucose and fatty acid utilization in peripheral muscles, among other consequences. Obesity can often result in type 2 diabetes. The hyperinsulinemia and hyperglycemia resulting from insulin resistance can result in vascular endothelial dysfunction, abnormal lipid profile, hypertension, and vascular inflammation and together, can increase the risk for developing ASCVD. A constellation of metabolic risk factors for type 2 diabetes and cardiovascular disease is what constitutes metabolic syndrome or insulin resistance syndrome.What is a syndrome? It is a group of symptoms that are present together, or a condition characterized by a set of associated symptoms.DEFINITIONThe National cholesterol education program ATP III updated its definition of metabolic syndrome in 2005 and defined it as the presence of any 3 of the following 5 traits. Abdominal obesity: waist circumference ≥ 102cm (40in) in men and 88 cm (35in) in females Serum triglycerides ≥150 mg/dl (1.7 mmol/L) or drug treatment for elevated triglycerides.Serum high density lipoprotein (HDL) cholesterol Blood pressure ≥ 130/85 mmHg or drug treatment for elevated blood pressure.Fasting plasma glucose 100mg/dl or drug treatment for elevated blood glucose.The International Diabetes Federation: 2009 – same criteria, except waist circumference has specific cut off points based on ethnicity and OGTT. Increased waist circumference with ethnic-specific cut off points (Look for table 2 in this handbook).Serum triglycerides ≥150 mg/dl (1.7 mmol/L) or drug treatment for elevated triglycerides.Serum high density lipoprotein cholesterol Systolic blood pressure ≥ 130, diastolic blood pressure ≥85 or treatment for hypertension.Fasting plasma glucose 100mg/dl (5.6 mmol/l) or previously diagnosed type 2 diabetes or oral glucose tolerance test which is recommended for patients with an elevated fasting plasma glucose.As a side note, metabolic syndrome cannot be diagnosed in children Risk factorsWeight is the most important risk factor: Increased body weight is a major risk factor in developing metabolic syndrome. In the National Health and Nutrition Examination Su

Episode 70: HIV Prevention. Prevention is key in controlling HIV-AIDS. Listen to ways to prevent HIV, mainly by using condoms, PrEP and PEP.Introduction: HIV and AIDSBy Robert Dunn, MS3.Introduction: The Human Immunodeficiency Virus (HIV) is a retrovirus that is primarily transmitted via sex, needles or from mother to fetus. Once infected, the virus increases in its copies and decreases the individual’s CD4+ cell count, thus leading to an immunocompromised state known as Acquired Immune Deficiency Syndrome (AIDS). Once with AIDS, the patient is susceptible to opportunistic infections. Prevention from AIDS includes several options. Condoms for safe sex practices are the least invasive and most readily accessible option for all patients. Pre-exposure prophylaxis (PrEP) is also an option for men who have sex with men (MSM) and transgender women. If the patient is also exposed to HIV, post-exposure prophylaxis (PEP) may also be an option to prevent infection but must be administer ideally 1-2 hours after exposure but no later than 72 hours after. Today we will briefly discuss how to prevent HIV infection.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.___________________________HIV Series IV: HIV Prevention. By Robert Dunn, MS3.Participation by Huda Quanungo, MS3; Bahar Hamidi, MS3; and Hector Arreaza, MD. HIV PreventionIntroductionThe Human Immunodeficiency Virus (HIV) is a retrovirus that is primarily transmitted via sex, needles or from mother to fetus. Once infected, the virus increases in its copies and decreases the individual’s CD4+ cell count, thus leading to an immunocompromised state known as Acquired Immune Deficiency Syndrome (AIDS). Once with AIDS, the patient is susceptible to opportunistic infections. Prevention from AIDS includes several options. Condoms for safe sex practices are the least invasive and most readily accessible option for all patients. Pre-exposure prophylaxis (PrEP) is also an option for men who have sex with men (MSM) and transgender women. If the patient is also exposed to HIV, post-exposure prophylaxis (PEP) may also be an option to prevent infection, but it must be administered ideally 1-2 hours after exposure but no later than 72 hours after. We will concentrate in prevention during this episode. What is HIV?The Human Immunodeficiency Virus (HIV) is a retrovirus. When the virus gains access to our body via cuts on the skin or mucosa:The virus injects its 10kb sized RNA genome into our cells. The RNA is transcribed to DNA via viral reverse transcriptase and is incorporated into our cellular DNA genome. This causes our cells to become a virus producer. Viral proteins translated in the cell are transported to the edge of the cell and can bud off into new viruses without lysing the cell. Acute HIV symptoms. Some potential early symptoms of HIV can include fever, chills, rash, night sweats, muscle aches, sore throat, fatigue, lymphadenopathy, and mouth ulcers. The most common acute symptom is NO SYMPTOM. Many people do not feel sick with the acute infection of HIV. Some people can live years with HIV in “clinical latency” without knowing they are infected, but they can still be contagious during this time. As viral load (the amount of virus copies you have in your blood stream) increases, the CD4+ cells that contribute to our adaptive immunity continues to fall. That’s why the best test during this period is not going to be HIV antibody but you should test for antigens. Specifically, the 4th Generation HIV test, which tests for both antibody and p24 antigens.Chronic symptoms. Once patients begin to present with opportunistic infections (i.e. Pneumocystis pneumonia – PCP), or have a CD4 count below 200, the patient is considered to have Acquired Immune Deficiency Syndrome (AIDS) and makes them susceptible to more serious infections. Without treatment, patients with AIDS typically survive about 3 years. Epidemiology of HIVHIV incidence: In 2019, there were 34,800 new HIV infections in the United States. This is an 8% decline from 2015. Amongst age groups: Age 25-34 had the highest rate of incidence (30.1 per 100,000)Age 35-44 had the second highest rate (16.5 per 100,000)Age 45-54 remained stableAge 13-24 had decreasing rates of incidence Amongst ethnic groups: Black/African-American groups has the highest rate of incidence (42.1 per 100,000)Hispanic/Latino had the second highest rate (21.7 per 100,000)Person of multiple races had the third highest (18.4 per 100,000) Amongst sex: Males had the highest rate of incidence (21 per 100,000)Females had the lowest rate of incidence (4.5 per 100,000) HIV Prevalence:In 2019, 1.2 million people (Ages 13 and older) in the US have HIV and 13% of them do not even know it. In 2020, there were an estimated 1.5 million people worldwide

Episode 69: Asymptomatic Bacteriuria. When do you screen for and treat asymptomatic bacteriuria? Find out what the IDSA recommends during this episode. PARTNER studies demonstrated that HIV transmission is minimal with condom-less sex if viral load is undetectable.Introduction: Urine. Urine is a straw-colored, pale yellow, or colorless liquid, which is a by-product of metabolism. It is normally sterile when excreted under normal conditions, but it can also have bacteria even in the absence of infection. When you have bacteriuria with no symptoms, it is called asymptomatic bacteriuria or ASB. Today you will hear Dr Covenas, Dr Civelli and Dr Lundquist discussing when to screen and treat asymptomatic bacteriuria.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. [Music continues and fades…]_____________________________Asymptomatic bacteriuria (update by the IDSA)Written by Hector Arreaza, MD. Participation by Cecilia Covenas, MD; Valeri Civelli, MD; and Ariana Lundquist, MD.Case: 19-year-old female who came to clinic to review lab results with you. She is coming from another clinic and brings her results on paper. Routine labs were done 1 week ago. Her complete blood count is normal, TSH (thyroid stimulating hormone) is normal, hemoglobin A1C of 5.3, and a urine culture showing >100,000 CFU of E. coli. Patient denies dysuria, polyuria, or any urinary symptoms. She has a negative pregnancy test in clinic today. What are you going to do with this significant bacteriuria?This is an Asymptomatic Bacteriuria (ASB). The first question you may ask is “why did she get a urine culture in the first place?” The Infectious Disease Society of America (IDSA) published in its journal “Clinical Infectious Disease” an update in the management of ASB. It is a 28-page long document with answers to 14 questions regarding ASB screening and management in different patient populations.Recommended ASB screening and treatment: IDSA concluded that the only two groups of patients who benefit from screening and treatment of asymptomatic bacteriuria are: Pregnant women and patients who undergo traumatic urologic interventions that result in mucosal bleeding.Pregnant women: Recommend one urine culture at one of the initial visits early in pregnancy. There is insufficient evidence to recommend for or against repeat screening during the pregnancy for a woman with an initial negative screening culture or following treatment of an initial episode of ASB. Treatment: IDSA suggests 4–7 days of antimicrobial treatment rather than a shorter duration, the optimal duration of treatment will vary depending on the antimicrobial given; the shortest effective course should be used. Patients who will undergo endoscopic urologic procedures associated with mucosal trauma: Screening for ASB and treating prior to surgery is RECOMMENDED. The goal is to avoid serious post-operative complication of sepsis. IDSA suggests a urine culture prior to the procedure and targeted antimicrobial therapy prescribed rather than empiric therapy. If bacteriuria is detected, a short course (1 or 2 doses) rather than more prolonged antimicrobial therapy is recommended, and antibiotic should be initiated 30–60 minutes before the procedure.Against ASB screening and treatment: IDSA suggests no screening for or treating ASB in these patients:Pediatric patientsHealthy nonpregnant womenCommunity-dwelling persons who are functionally impairedOlder persons residing in long-term care facilitiesPatients with diabetesPatients who had a renal transplant over 1 month ago (insufficient evidence for less than 1 month ago)Patients with nonrenal solid organ transplantIndividuals with impaired voiding following spinal cord injury (consider atypical symptoms of UTI when deciding treatment vs nontreatment of bacteriuria in these patients)Short-term indwelling urethral catheter (Patients with long-term indwelling catheters (>30 days)Patients undergoing elective nonurologic surgeryPatients planning to undergo surgery for an artificial urine sphincter or penile prosthesis implantation (these patients should receive standard preop antibiotics before surgery)Patients living with implanted urologic devicesInsufficient evidence to recommend for or against ASB screening and treatment: Evidence is insufficient to recommend ASB screening and treatment in patients with high-risk neutropenia (absolute neutrophil count 7 days duration after chemotherapy). These patients should be treated with prophylactic antibiotics and start antibiotics promptly in there is fever. For low-risk neutropenic patients (neutrophils >100, Special populations: In older patients with cognitive impairment with bacteriuria and confusion WITHOUT urinary symptoms or other signs of infection, such as fever or hemodynamic instabi

Episode 68: Prevention - Aspirin, STIs, and Diabetes. Updates on aspirin use for preeclampsia prevention, updated STIs screening guidelines, and new age to start screening for diabetes. Introduction: COVID-19 Booster Shots. Every week there is a lot of information to cover about COVID-19. I’m sure you are aware of some of this information, but here you have it again for historical purposes. Pfizer and BioNtech announced on September 20, 2021, that their COVID-19 vaccine is protective in pediatric patients between 5 and 11 years of age. Let’s remember that this vaccine is being used for patients older than 12, but so far none of the vaccines have been authorized for younger patients. A submission to FDA has been sent, but no approval has been given yet.Recently, we mentioned to you that a booster shot for the mRNA COVID-19 vaccines were likely to be authorized by the FDA around September 20. Indeed, an authorization for a booster was given on September 22, 2021. This authorization was given to the Pfizer/BioNtech vaccine only, and it can be given at least 6 months after the completion of the primary series.The patients who are authorized to receive the booster shot are: Patients who are 65 years of age and older; patients between 18 and 64 years of age at high risk of severe COVID-19; and individuals 18 through 64 years of age with frequent occupational exposure to COVID-19.The Moderna vaccine has not been authorized for a booster shot.Let’s remember that both Pfizer and Moderna have been authorized for a third dose in patients who are immunocompromised. The third dose can be given 4 weeks after completing he initial 2 doses of these vaccines. Patient who may receive a third dose are those who are receiving active cancer treatment, recipients of an organ transplant, or have a moderate or severe immunodeficiency. Stay tuned for more updates in the future.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Page BreakPrevention - Aspirin, STIs and DiabetesBy Hector Arreaza, MD, and Valerie Civelli, MDThe USPSTF has been very active lately. They have released several recommendations in the last few months. Aspirin and preeclampsia: On September 28, 2021, the USPSTF released their recommendation about the use of aspirin to prevent preeclampsia in pregnant persons at high risk. This recommendation is consistent with the previous recommendation given in 2014. New evidence has reinforced that aspirin is effective at reducing risk of perinatal mortality when used properly.The recommendation states: “The USPSTF recommends the use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia.” This is a grade B recommendation. A grade B recommendation means the net benefit of this preventive intervention is moderate to substantial.Who is at risk for preeclampsia? You can classify the risk as High, Moderate, and Low.High: Preeclampsia during previous pregnancies (especially if you had an adverse outcome), multifetal gestation, chronic hypertension, type 1 or 2 diabetes before pregnancy, kidney disease, autoimmune disease, or a combination of multiple moderate-risk factors. Recommend aspirin if a woman has 1 or more of those high-risk factors. Moderate: Nulliparity, obesity, history of preeclampsia in mother or sister, black persons, low income, age 35 years or older, personal history factors (e.g. low birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval, and in vitro conception. Recommend aspirin if patient has 2 or more of these moderate risk factors. You may recommend aspirin even to women with 1 of these risk factors. Low: Do not recommend aspirin to pregnant women who have low risk for preeclampsia. A patient is considered low risk if she had a previous uncomplicated term delivery and has none of the risk factors mentioned above.As a side note, given the current movement for diversity, equality and inclusion, the article also states that “black persons have higher rates of preeclampsia and are at increased risk for serious complications due to various societal and health inequities,” not due to biological propensities.When do you stop aspirin in pregnancy?The decision to continue aspirin in the presence of obstetric bleeding (or bleeding risk) should be considered on a case-by-case basis. You can decide to stop at 36 weeks or continue until delivery based on your clinical judgement or local protocol.Bottom-line: Recommend low-dose aspirin to pregnant women who are at increased risk for preeclampsia after 12 weeks of gestation.Chlamydia and gonorrhea screening: On September 14, 2021, the USPSTF recommended screening women younger than 24 years old who are sexually active for BOTH chlam

Episode 67: Covid, Food, and HIV. Medical students discuss the relationship between high cholesterol and COVID-19, the effect of food order in postprandial glucose and insulin, and HIV history. Moderated by Hector Arreaza, MD. During this episode you will listen to three medical students discussing some topics that they found interesting during their family medicine rotation. All the credit goes to them because they read these topics and provided a very good summary. I hope you enjoy it.____________________High Cholesterol and COVID-19By Milan Hinesman, MS3, Ross University School of MedicineGiven the current state of the world, there’s been a lot more attention to COVID-19 presentation, risks, and treatment. One study conducted by Dr. Kun Zhang and collaborators shows that there may be a relationship between higher total cholesterol levels and ApoB levels to increased risk of COVID-19 infection[1]. Dr. Zhang used a mendelian randomization from the UK Biobank data to test for lipid effects on COVID susceptibility and severity. The study performed analysis of data from the host genetics initiative consisting of more than 14,000 cases and more than one million controls showing a potential positive causal effect between high total cholesterol and ApoB and COVID susceptibility. A mendelian randomization is a process of taking genes which functions are already known and measuring their response to exposure to a disease in observational studies[2]. In short, high cholesterol and high ApoB are linked to COVID-19 infection.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. __________________________Impact of food order on glucose after meals. By Yvette Singh, MS3, American University of the CaribbeanIn the management of diabetes, health care providers usually assess glycemic control with fasting plasma glucose and pre-prandial glucose measurements, as well as by measuring Hemoglobin A1c. Therapeutic goals for Hemoglobin A1c and pre-prandial glucose levels have been established based on the results of controlled clinical trials. Unfortunately, many patients with diabetes fail to achieve their glycemic goals. Elevated glucose after eating may be the cause of poor glycemic control leading to vascular complications. Postprandial hyperglycemia is one of the earliest abnormalities of glucose homeostasis associated with type 2 diabetes. This is one of the important therapeutic targets for glycemic control. Current studies show that the amount and timing of carbs in the diet primarily influence blood glucose levels. Other studies also show that eating whey protein before meals, as well as changing the macronutrients in meals, reduces postprandial glucose levels; however, these studies did not have patients with type 2 diabetes. The main author of this study was Alpana P. Shukla and many other collaborators. The title is Food Order Has a Significant Impact on Postprandial Glucose and Insulin Levels, published by the American Diabetes Association on Diabetes Care in July 2015.This study was performed to analyze the order of food consumption with vegetables, protein and carbohydrates and its effects on postprandial glucose in overweight/obese patients with type 2 diabetes being treated with metformin. Subjects were studied for 1 week. They were given a meal with the same number of calories, after fasting for 12 hours: 55g protein, 68g carbs, and 16g fat. They were asked to eat carbs first, then to eat vegetables and protein fifteen minutes later. This order was reversed during the second week. Their postprandial glucose and insulin levels were measured at 30/60/120 mins after meals. The statistical studies showed an average post prandial glucose decrease by more than 25% when protein was consumed first. As well as the average post prandial insulin levels decreased by more than 40%. These results demonstrated that the timing of carbs during a meal has a significant impact on glucose and insulin levels comparable to some pharmacological agents. Reduced insulin excretion with this meal pattern may also improve insulin sensitivity. This may help patients with type 2 diabetes control their HbA1c, and possibly help reverse early diabetes. Educating patients about this approach is not controlling how much they are eating or restricting their diet so patients will likely comply with this recommendation. Eat your protein first!The potential problems of this study are that it was a small sample size (11 patients), limited food types, and insulin was measured only up to 120 minutes after meals. Further studies are needed to demonstrate the full effectiveness of this recommendation.___________________HIV Series Part I: HIV HistoryBy Robert Dunn, MS3, Ross University School of Medicine This is an HIV series for the Rio Bravo qWee

Episode 66: Meth Abuse. By Ikenna Nwosu, MD, and Hector Arreaza, MD. Discussion about screening, epidemiology, clinical presentation, diagnosis, and treatment of meth abuse. Association between intranasal corticosteroids and lower risk of COVID-19 complications is mentioned.Introduction: Intranasal corticosteroids associated with better outcomes in COVID-19By Bahar Hamidi, MS3, American University of the Caribbean When I first heard of the news of a pandemic occurring, I never thought it would last more than a couple weeks. Of course, as a medical student the first thing I wanted to know was what bug is causing all this commotion in the news. When I discovered “Coronavirus” my first reaction was a chuckle and blurting out “no way.” Why did I respond this way you may ask? As a student when we studied that coronavirus would cause nothing more than a regular cold, thus a mere pesky virus causing a whole pandemic seemed odd to me at the time. Little did I know almost two years later we are still talking about it! “Don’t touch your face before washing your hands.” These are the words that run through my mind anywhere I am nowadays. Why? Well, SARS-CoV-2 spike (S) protein is why. This protein engages ACE2 (angiotensin-converting enzyme 2) as the entry receptor. This virus’s receptor is found to be highly expressed in our nasal mucosa. How much of this ACE2 we have interestingly can correlate with your age; lower in children compared with adults. Other things that can affect a person’s susceptibility is the level of eosinophils in your body. High absolute eosinophil count showed to have a lower hospitalization risk in a group of individuals with asthma and COVID, but we must keep in mind that the study can be confounded by the use of inhaled corticosteroids (iCS). This was taken into account during a study.The study was done by Ronald Strauss and collaborators, it’s titled, Intranasal Corticosteroids Are Associated with Better Outcomes in Coronavirus Disease 2019, and it was published on The Journal of Allergy and Clinical Immunology: In Practice, September 2021.So how may inhaled corticosteroids prevent significant illness from COVID? The answer is lower expression of ACE2 and its cellular serine protease TMPRSS2. Theoretically, it makes sense because the less entry gates the virus has the less sick someone may possibly get. Therefore, the study hypothesizes that by suppressing receptor expression, intranasal corticosteroid use is protective against complicated outcomes like hospitalizations, admission to ICU and mortality.Interestingly in addition, two types of corticosteroids [ciclesonide (Alvesco®) and mometasone (Asmanex® for asthma and Nasonex for allergic rhinitis)] were discovered to suppress replication of coronavirus. This overall study has pertinent findings for the treatment of this everlasting pandemic and proves there is yet much left to discover and continue to research.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Meth Abuse. By Ikenna Nwosu, MD, and Hector Arreaza, MD IntroductionDrug use is a growing problem with serious consequences to individuals, families, and whole nations. Today we will discuss one of the most common drugs abused by our patients: Methamphetamine. Definition Methamphetamine (street name chalk, crank, crystal, glass, ice, meth) is a stimulant commonly abused in many parts of the United States. It is a psychostimulant that causes the release and blocks the reuptake of monoamine neurotransmitters, including dopamine, norepinephrine, and serotonin. Methamphetamine is most often smoked or snorted and is less commonly injected or ingested orally. Arreaza: Phentermine (appetite suppressant) is not meth. Phentermine is less potent because it acts mostly on norepinephrine, very little on dopamine, and minimally on serotonin. Epidemiology Amphetamine-type stimulants, which include methamphetamine, are the fastest rising drug of abuse worldwide. An estimated 2.1% of the United States population have been reported to have tried methamphetamine at some time in their lives with its rate of use found to be similar among men and women. Data indicates that methamphetamine is a significant public health problem. Mortality has increased by about 40 percent from 2015 to 2016 and drug overdose deaths involving methamphetamine have tripled since 2011. Arreaza: The mortality is high but also the morbidity. I can imagine how costly it is for health systems to take care of the complications of meth use, from dental work to cardiovascular disease, i.e., heart failure. It is a serious problem in Bakersfield, California. As an interesting fact, meth is the most common drug identified in urine drug screenings, then follows marijuana, cocaine, heroin, and fentanyl.

Episode 65: Delta Variant. Harendra and Dr Arreaza present current evidence regarding the delta variant of SARS-CoV-2 (COVID-19), effectiveness of vaccines, and more. Introduction: Booster shots for the COVID-19 vaccine. The Department of Health and Human Services (HHS) announced in a statement dated August 18, 2021, that “a booster shot will be needed to maximize vaccine-induced protection and prolong its durability.”This fall people may start getting their booster shots of mRNA vaccines (i.e. Pfizer and Moderna) as long as 8 months have passed since their second dose of the vaccine. The estimated date to start giving booster shots is the week of September 20, 2021.It is anticipated that patients who received the J&J vaccine will also need a booster shot, but more data is needed to make it official. So, stay tuned for updates.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.___________________________Delta Variant – The Science By Harendra Ipalawatte, MS4, and Hector Arreaza, MD. A growing concern and much of the recent talk about COVID 19 has been revolving around the emerging delta variant as well as other noted virus around the world different from the alpha strain. Much like the influenza virus and swine flu, SARS-CoV-2 seems to be changing and adapting in its current form.On July 27, 2021, the CDC recommended to urgently increase COVID-19 vaccination and reinforced the need to wear a mask in public indoor places in areas of high risk for transmission, even for fully vaccinated people. Concerns about DeltaCDC issued this new guidance due to several concerning developments and newly emerging data signals.There is a reversal in the downward trajectory of cases. CDC has seen a rapid and alarming rise in the COVID case and hospitalization rates around the country. In late June 2021, the 7-day moving average of reported cases was around 12,000. In contrast, on July 27, the 7-day moving average of cases reached over 60,000. This case rate looked more like the rate of cases we had seen before the vaccine was widely available. New data shows the delta variant is more infectious even in vaccinated individuals. Data was taken from CDC and unpublished surveillance data that will be posted soon. Delta causes more infections and spreads faster than early forms of SARS-CoV-2. Delta has shown to be more than 2x as contagious as previous variants. The delta variant might cause more severe illness than previous strains in unvaccinated persons. In two different studies from Canada and Scotland, patients infected with the delta variant were more likely to be hospitalized than patients infected with alpha or the original virus strains. Delta is currently the predominant strain of the virus in the United States. Unvaccinated people are considered the greatest concern Breakthrough infections (i.e., infections in patients who are fully vaccinated) happen less often than infections in unvaccinated people, all symptomatic patients infected with the delta variant can transmit it to others. CDC is studying the data on whether fully vaccinated people with asymptomatic breakthrough infections can transmit the infection. However, the greatest risk of transmission is among unvaccinated people who are much more likely to contract and transmit the virus. Fully vaccinated people with delta breakthrough infections can spread the virus to others. However, vaccinated people appear to be infectious for a shorter period. Previous variants typically produced less viral load in the body of infected fully vaccinated people, but the delta variant produces the same high amount of viral load in both unvaccinated and fully vaccinated people. Effectivity of vaccines against delta In one recent study, infection rates in India were analyzed which showed the BNT162b2 (Pfizer-BioNtech) and ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vaccines were effective against the delta variant. Data on all symptomatic sequenced cases of Covid-19 in England were used to estimate the proportion of cases with either variant according to the patients’ vaccination status. The effectiveness after one dose of vaccine (BNT162b2 or ChAdOx1 nCoV-19) was notably lower among persons with the delta variant than among those with the alpha variant. The results were similar for both vaccines. With the Pfizer vaccine, the effectiveness of two doses was 93.7% among persons with the alpha variant and 88.0% among those with the delta variant. With the ChAdOx1 nCoV-19 vaccine, the effectiveness of two doses was 74.5% among persons with the alpha variant and 67.0% among those with the delta variant. Only modest differences in vaccine effectiveness were noted with the delta variant as compared with the alpha variant after the receipt of two vaccine doses. Absolute differences in vacc

Episode 64: H. pylori. Dr Lorenzo explains testing, diagnosis, and treatments for H. pylori, a bacterium that can cause peptic ulcer disease and other complications.By Anabell Lorenzo, MD, and Hector Arreaza, MD. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Today we are going to discuss a topic that may be very basic for many of our listeners, but it is important to check our knowledge foundation to keep building on it. Helicobacter pylori was discovered in 1982 by Barry Marshall and Robin Warren from Australia. They received the Nobel prize in 2005 for their discovery of “the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease”. 1. What is H. pylori?It’s a gram-negative bacteria found in the stomach causing infection and GI symptoms such as dyspepsia. It is a chronic infection and it’s usually acquired in childhood. Incidence and prevalence of H. pylori infection are generally higher in people born outside of North America than among people born here. About 50% of humans are infected by H. pylori in the world. The infection can be life-long and cause no symptoms. The infection can cause peptic ulcers too. 2. When do you test for H. pylori and treat it?Test these patients for H. pylori: -All patients with active peptic ulcer disease (PUD).-Patients with history of PUD (unless previous cure of H. pylori infection has been documented).-Patients diagnosed with low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma.-Patients with a history of endoscopic resection of early gastric cancer (EGC).In a few words, test patients with PUD and stomach malignancies. Controversial indications include:- Consider non-endoscopic test (stool or breath) in patients with unexplained dyspepsia who are younger than 60 years old without red flags.- Patients with typical symptoms of gastroesophageal reflux disease (GERD) who do not have a history of PUD do not need to be tested for H. pylori infection. However, for those who are tested and found to be infected, treatment should be offered, but to the patient that the effects of treatment of H. pylori on GERD symptoms are unpredictable. This means that eradication of H. pylori may or may not affect GERD symptoms. -Patients taking long-term, low-dose aspirin (to reduce the risk of ulcer bleeding)-Prior to initiation of chronic treatment with NSAIDs-Patients with unexplained iron deficiency anemia despite an appropriate evaluation 3. What are the testing options for H. pylori?-In patients is having an EGD, they can be tested with gastric biopsy histology and biopsy urease (best options). Endoscopy biopsy is the best diagnostic test for H. pylori. -In patients who do not require EGD, NONINVASIVE TESTING like STOOL ANTIGEN ASSAY and UREA BREATH TEST are a great option-Before performing the test, it is important to stop PPIs (proton pump inhibitors) for 2-4 weeks and Bismuth/antibiotics use within 4 weeks to avoid false negative results. 4. What ar ethe recommended first-line treatments for H. pylori?Triple therapy: Clarithromycin triple therapy is the recommended option. This treatment includes PPI, clarithromycin, and amoxicillin OR metronidazole for 14 days. This is the recommended in areas where clarithromycin resistance is less than 15%, and in patients with no exposure to macrolides. The two antibiotics and PPI twice a day are given for 2 weeks, and the PPI is continued once daily for one month. PPI may be omeprazole, pantoprazole, or others. Quadruple therapy: Bismuth quadruple therapy consisting of a PPI, bismuth, tetracycline, and a nitro imidazole for 10–14 days is another treatment option. Bismuth quadruple therapy is particularly attractive in patients with any previous macrolide exposure or who are allergic to penicillin. 5. Should we test for H. pylori eradication?Confirmation of eradication should be performed in all patients treated for H. pylori because of increasing antibiotic resistance. There is not a lot of information about antibiotic resistance in the US. The test should be done 4 weeks after completing treatment. 6. What is refractory H. pylori infection? Refractory H. pylori infection is defined by a persistent positive H. pylori test (no serologic), at least 4 weeks after 1 or more full course(s) of a recommended first-line therapy, and when the patient has been off any medications, such as proton-pump inhibitors (PPIs), that may impact the test sensitivity. Refractory H. pylori infection should be differentiated from recurrent infection. A recurrent infection happens when a no serologic test was negative after treatment, then becomes positive again. 7. What tests can be done to evaluate H. pylori antibiotic resistance?We can test for resistance with culture or molecular testing, but these tests are curren

Episode 63: Tumor Markers Basics. George and Harendra discuss with Dr Arreaza the role of tumor markers in the diagnosis and monitoring of different types of cancer. Introduction: Recent News about COVID-19Written by Hector Arreaza, MD. Participation: George Karaghossian, MS3, and Harendra Ipalawatte, MS3.Before we talk about our topic today, there are three news worth sharing about COVID-19.First, we are all aware of the increased number of patients affected by COVID-19 and increased mortality. Most of the patients who are severely ill or those who require admission are unvaccinated. The cases of breakthrough infections (infections in patients who are fully vaccinated) continues to be rare.Second, CDC has officially recommended COVID-19 vaccination in pregnant women (August 11, 2021)[1]. All people 12 years of age and older is recommended to get vaccinated against COVID-19, including pregnant women. There were 2,500 women who received the mRNA vaccine against COVID-19, and there was not an increased risk for miscarriage. Vaccinated pregnant women (or persons) had a miscarriage rate of 13% (similar to the miscarriage average in general population, which is 11-16%).Third, FDA gave an emergency use authorization for a third dose of mRNA vaccines (Pfizer and Moderna) for certain immunocompromised patients (August 12, 2021)[2]. The third dose of the vaccine (it has to be the same vaccine you received) has to be given at least 28 days apart from your last dose. Patients who may receive a third dose include: Patients who are undergoing active treatment for solid tumor and hematologic malignancies, recipients of solid-organ transplant and taking immunosuppressive therapy, moderate or severe primary immunodeficiency (e.g. DiGeorge syndrome, Wiskott-Aldrich syndrome), patients with advanced or untreated HIV infection, patient who are taking high-dose corticosteroids (i.e. >20 mg prednisone or equivalent per day) and other immunosuppressive medications. If in doubt, consult our oncologists and rheumatologists.Let’s switch gear and introduce the topic for today. Given the high mortality and morbidity of cancer, in general, early detection of cancer is one of the most important goals in primary care. Today George and I will discuss the usefulness, pitfalls and will mention some of the most common tumor makers.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. Tumor Markers Basics. By George Karaghossian, MS3, Ross University School of Medicine; Harendra Ipalawatte, MS3, Ross University School of Medicine; and Hector Arreaza, MD. Introduction:Do you remember how we came up with the idea for this topic? We had a patient with an intraabdominal malignancy which appeared to be from the GI tract vs an adnexal mass. We order tumor markers to assist in the diagnosis of the origin of this malignancy. Definition: Tumor markers are usually proteins or other substances that are produced by cancer cells or non-cancerous cells. Circulating biomarkers and tissue biomarkers are the two types of tumor markers we utilize to track the course of the tumor’s growth. Circulating tumor markers are found in bodily fluids such as blood, urine, and stool. Tissue markers are typically found on the actual cancer cells. These markers can help in the assessment of certain cancers. The downside of tumor markers is that they are not always reliable, and they may not be detected in the early stages of cancer[2]. Characteristics of a good screening test: A good screening test must be capable of detecting a high proportion of disease when patients are asymptomatic, tests should be safe, not excessively expensive, lead to improved health outcomes, be widely available, and interventions after a positive test should also be available. Can tumor markers be used for cancer screening?Tumor markers should not be used as a primary tool for cancer screening because they lack sensitivity and specificity. The most definitive tool for diagnosis of cancer therefore is biopsy, thus tumor markers cannot be used to diagnose cancer. Tumor markers can be done in blood, in urine, and in tissue (biopsy). An example of tumor markers in biopsies are estrogen receptor (ER) and progesterone receptor (PR). What are tumor markers good for?Tumor markers may be good indicators of response to cancer therapy. When cancer patients are undergoing therapy for treatment of their cancer, we usually track tumor markers to see if there is downward trend over the course of therapy indicating that the therapy is working. Tumor markers are also a good tool to monitor early relapse of certain malignancies. After treatment, tumor markers may be measured to see if the cancer is returning after treatment. Some tumor markers also assist in deciding which treatment is best. For example, th

Episode 62: Onychomycosis (nail fungus). Future doctors Gabrielle and Jeanette discuss with Dr Arreaza the diagnosis and treatment of onychomycosis, AKA nail fungus.By Gabrielle Robinson, MS3, and Jeanette Adereti, MS3Ross University School of MedicineFacilitated by Hector Arreaza, MDThis is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.What is onychomycosis?-Onychomycosis is a fungal infection that resides in the finger and toenails. The nails become discolored, have onycholysis (painless separation of nail bed), splitting of nail bed, thickened. There are various causes of onychomycosis and examples include the following: dermatophytes, yeast, non-dermatophyte molds.-Onychomycosis occurs in 10% of the general population. Microbiology:Dermatophytes such as Tinea rubrum, account for most onychomycosis infections (~60-70%) while candida account for most of yeast causes of onychomycosis. Non-dermatophyte molds include fusarium, aspergillus, acremonium, scytalidium, Scopulariopsis brevicaulis. The type of organism involved has an association for the type of infection it causes. Yeast infects fingernails preferentially while the dermatophytes prefer to infect toenails. Diagnostic testing including culture, KOH preparation and PAS staining can help with confirming fungal infection, but culture not required for empiric treatment with oral terbinafine. Severity of onychomycosis:-Mild-moderate: ≤50 percent involvement of the nail and sparing the matrix/lunula-Moderate-severe: involving >50 percent of the nail or involving the matrix or lunula, including further spread throughout nail.-It’s common to have multiple nails affected at the same time. Toenails and fingernails can both be affected. Remember to check all nails in your patients. Nails can show signs of local but also systemic diseases. Risk factors:-Health conditions: Diabetes, immune suppression, venous insufficiency, peripheral artery disease, or even just having slow growth of the nails. This makes sense because there is decreased blood flow to those areas resulting in decreased immune surveillance of that area. Patient s with PAD are at risk for onychomycosis. Nails normally grow slower in male. Hormones play a role in that growth.-Exposure: smoking, trauma to the nail, sports, wearing sweaty shoes, being barefoot in communal areas such as swimming pools, college showers, jail house showers, and gyms.-Dermatological diseases: tinea pedis (athletes’ foot), excessively sweaty hands (hyperhidrosis), psoriasis-Other factors: old age, having family members whom the patient shares a living space with, bunion (hallux valgus). Effects on mental healthUnfortunately, the infection takes a toll on the patient because the infection is unsightly it results in psychosocial disturbances. The patients may not want to wear sandals, get pedicures, or shower during gym class if they are school age. These types of feelings can cause patients to not want to go to work or do things they enjoy due to feelings of embarrassment. ManagementTreatment of dermatophyte onychomycosis is guided by causative organism, severity, treatment availability, and cost.Oral agents-Oral treatment is generally the gold-standard for onychomycosis due to shorter course and greater efficacy compared to topical. -Oral terbinafine is the preferred oral agent. Itraconazole can be used in patients not able to tolerate/respond to terbinafine.-Terbinafine and itraconazole both work by blocking important enzymes in fungal synthesis.-A randomized double-blind trial showed that terbinafine is more effective outcomes and better long-term cure rates than itraconazole.-Adult dosing of terbinafine: fingernail onychomycosis =250 mg per day for 6 weeks. Toenail onychomycosis= 250 mg per day for 12 weeks.-Some side effects of oral terbinafine include headache, dermatitis, GI distress, taste disturbances, and liver enzyme abnormalities. Adverse effects of Itraconazole include headache, GI disturbances, liver enzyme abnormalities.-In patients receiving continuous therapy, monitoring of transaminase levels is typically performed at baseline and repeated at six weeks if therapy will continue beyond six weeks. A medication interaction check is recommended before starting treatment with oral agents. -Mycotic cure rates of 76% for terbinafine, 63% for itraconazole with pulse dosing, 59% for itraconazole with continuous dosing, and 48% for fluconazole, topical cure rate is about 40%.-Recurrence of infection ranges 10-50% (reinfection or persistent infection). Patients need to wait for up to 1 year to see full effect of treatment. Treatment is highly recommended in patients with diabetes, treatment in other patients is cosmetic.CompliancePatient compliance is difficult because while taking oral medications, you cannot

Episode 61: Semaglutide for Obesity. Dr Arreaza discusses with Dr Carranza the results of the STEP trials: Semaglutide Treatment Effect in People with obesity, which allowed semaglutide gain FDA approval as a treatment for obesity.By Hector Arreaza, MD, and Claudia Carranza, MDThis is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. One of the major challenges of modern medicine is to find an effective treatment for obesity.Obesity was considered a disease in 1998 by the National Institutes of Health[1].In 2002, the Internal Revenue Service, AKA the feared IRS, issued a statement to make obesity treatment a deductible medical expense. Who would have known that obesity was tax deductible?Later, in 2013 obesity was accepted as a complex, chronic disease by the American Medical Association[2]. Many other organizations have made statements in favor or against the definition of obesity as a disease.We recently announced the exciting news of semaglutide as a new FDA-approved medication for the chronic treatment of obesity. Today we want to give you a very brief summary (brief-ísimo) of the trials that allowed semaglutide to gain that FDA-approval. Semaglutide was tested at different levels with the STEP trials. STEP stands for Semaglutide Treatment Effect in People with obesity (STEP). All these trials were done in 68 weeks, all patients received counseling about lifestyle modifications, 70-80% were women, ages averaging 40-50 years old.STEP 1: Does semaglutide cause weight loss in patients without diabetes?The focal point of this trial was weight management with semaglutide in patients without diabetes. This was a double-blind trial. There were 1961 participants enrolled. A group was assigned to placebo and another group was assigned to weekly injection of semaglutide. For the semaglutide group, the goal dose of semaglutide was 2.4 mg, starting with 0.25 mg, increasing every 4 weeks: 0.5 -> 1.0 -> 1.7 -> 2.4 (reaching the goal dose in 4 months), 3 out of 4 participants were Caucasians. Outcomes: after 68 weeks weight reduction was -16.9% in patients on semaglutide, more than 86% of participants had a weight loss >5%, 69% lost >10% of their weight, and 50% percent lost >15% of their body weight, and about 32% lost >20% of their weight. This may be comparable to bariatric surgery in some patients; however, the weight loss is not as dramatic. Other parameters improved were waist circumference, blood pressure, triglycerides. LDL and total cholesterol were not significantly affected. There was a clinical meaningful change in 40% of patients. 7 out of 100 could not complete trial for GI adverse effects, most commonly nausea, diarrhea, vomiting, constipation. Acute pancreatitis presented in 0.2% of the semaglutide group (all recovered during study) vs 0% in the placebo group[3]. STEP 2: Does semaglutide cause weight loss in patients with diabetes? The focal point of this study was weight management with semaglutide in type 2 diabetes mellitus. 1210 patients participated in 12 different countries across Europe, North America, South America, the Middle East, South Africa, and Asia. Patients were randomly assigned to semaglutide 2.4 mg weekly, Semaglutide 1 mg weekly, or placebo. Weight loss was superior with semaglutide 2.4 mg, -9.6% of body weight with semaglutide vs -3.4% weight loss with placebo. As you can see, weight loss in individuals with diabetes is more difficult. The effect on diabetes control was about the same with semaglutide 1 mg vs 2.4 mg. The 1 mg dose reduced A1C -1.5%, and the reduction was -1.6% with semaglutide 2.4 mg. A1C reduction was about the same regardless of weight loss. STEP 3: Does Intensive Behavioral Therapy increases weight loss in patients using semaglutide?Intensive behavioral therapy was put to the test. 611 participants were enrolled. Each patient in this study received IBT: 30 brief sessions, 19 in the first 24 weeks, monthly thereafter provided by a registered dietitian. Participants had obesity and overweight, lived in 41 states in the US, had >1 related comorbidity, no diabetes. They all were put on a low-calorie diet for 8 weeks and were randomized to receive either semaglutide or placebo. Weight loss was accelerated by the low-calorie diet and IBT earlier in the study, but at the end there was only 1% difference between the two groups, 17.6% weight loss with IBT vs 16.9% weight loss without IBT. Further research is needed to determine the potential benefits of including a low-carb diet to semaglutide to increase long term weight loss. STEP 4: What happens to weight loss if we stop semaglutide?The focal point of this study was sustained weight management. Patients were randomized to placebo or semaglutide after 20 weeks, but continued lifestyle modificationsThose who remained

Episode 60: Variety of Topics. Gabrielle Robinson (MS3) discusses with Dr Arreaza these topics: IsoPSA, 3HP for LTBI, shingles vaccine, and DELC.Introduction: You will hear a conversation between Gabrielle Robinson, a 3rd year medical student, and Hector Arreaza. They discussed 4 articles about topics that are relevant to current clinical practice in family medicine.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.Variety of Topics. By Gabrielle Robinson, MS3, Ross University School of Medicine, and Hector Arreaza, MD. The IsoPSA testH: Cleveland Clinic published this article in July 2020[1]. G: According to that article, the IsoPSA test is a new clinically relevant screen for prostate cancer. The data suggests that ISoPSA can potentially decrease unnecessary prostate biopsies by 45%. The IsoPSA evaluates changes in the structure of PSA rather than measuring the concentration of PSA. G: IsoPSA is meant to be used in patients who are over 50 years old with PSA > 4ng/mL that have not had a previous diagnosis for prostate cancer or are under surveillance.H: Is PSA a bad screening test?G: Measuring the concentration of PSA has proven to be a less sensitive screening tool because PSA is specific for tissues and nonspecific for cancer. This means that a high PSA does not necessarily mean cancer is present. The PSA can be elevated due to a multitude of reasons including but not limited to prostatitis, benign prostatic hyperplasia, etc. Unfortunately, this has led to the overdiagnosis of low-grade cancers that were in fact benign conditions. However, PSA is an effective tool for monitoring of recurrence of prostate cancer and it reduces the need for treatment of metastatic disease.H: As a reminder, screening for prostate cancer in asymptomatic individuals by using PSA is a grade D recommendation from the USPSTF. D means “Do not do it!” However, IsoPSA is not included in that recommendation. We’ll see if evidence suggests IsoPSA as an alternative in the future. 3HP for latent TB infection treatmentH: This information was published by CDC on June 28, 2018. G: Previously, the treatment for latent TB included 3–9 months of DAILY Isoniazid (INH) or Rifampin (RIF), either alone or combined. Now, new data according to CDC recommends that INH-RPT (isoniazid-rifaPENtine) treatment once a week for 12 weeks (AKA 3HP regimen) is adequate in controlling the reactivation of latent TB[2].H: RifaPEntine is not Rifampin.G: It is also worth mentioning that this treatment is also approved for patients 2-11 years of age as well as patients who have HIV/AIDS who are currently taking anti-retroviral.H: Currently, the regimens for LTBI treatment are: -Monotherapy with INH for 6-9 months-Monotherapy with Rifampin daily for 4 months-Combinations: INH-Rifampin daily for 3 months (3HR therapy), and INH-RifaPENTINE weekly for 3 months (3HP therapy). Shingles vaccine may reduce risk of strokeG: Why do we think having shingles increases risk of stroke in the first place? The mechanism is not well understood but there is a strong index of suspicion that the inflammation resulting from the outbreak plays a significant role. H: So, you read a study, a chart review published by the American Heart Association, tell us about it.In this study, patients who received the shingles vaccine (live vaccine) were compared to patient who did NOT receive the vaccine. The results showed that getting the shingles vaccine decreased the risk of stroke by 16%. The types of strokes that were decreased included hemorrhagic stroke which was decreased by 12% and ischemic stroke that was decreased by 18%. The age range for which this was most effective is 66 to 79 years of age and is worth mentioning that patients under 80 years of age had a decreased risk in stoke by 20% while the patients over 80 years old were decreased by about 10%[3]. Diagonal Ear Lobe Crease: An Association with CADH: Last week we got this information from Dr Cobos, a Kern Medical hematologist. G: Diagonal Ear Lobe Crease (DELC) also known as Frank’s sign, is a crease in the ear lobe that is associated with increased risk of coronary artery disease, peripheral vascular disease, and cerebrovascular disease. Although the pathophysiology of this sign is not yet understood, there has been a grading system set in place that is linked to the incidence of cardiovascular events based on length, depth, bilateralism, and inclination according to Stanford Medicine. The classifications are as follows:Unilateral incomplete – least severeUnilateral completeBilateral complete – Most severe Other classification (not associated with increased cardiovascular events):Grade 1 – wrinklingGrade 2a – Superficial crease (floor of sulcus visible)Grade 2b – crease greater than 50% across earlobeGrade 3 – deep clef

Episode 59: What is Keto? Discussion about the benefits and risks of the keto diet. Introduction about the CDC Contraceptive app.Introduction: Contraception App Update (CDC)By Cecilia Covenas, MD, and Hector Arreaza, MDToday is July 16, 2021. What is the CDC Contraception App? The CDC has updated their contraception app to assist health care providers in counseling women, men, and couples on the different contraceptive methods. The app is called Contraception. When you open the app, it has three main sections. MEC by Condition, MEC by Method and SPR. MEC stands for Medically Eligibility Criteria, it is a guide to choose the safest contraceptive for patients with certain medical conditions. SPR stands for Selected Practice Recommendations. It is a guide for common topics such as initiation of a particular method, or tests needed before starting a contraceptive, or follow up, etc. The last update to the app was this past March, and it includes new features. Now, you can select up to three conditions at once, move from one condition to another easily, and see additional info for a particular condition and method. How to use it?There are three main sections: MEC by condition, MEC by method, and SPR. The US MEC recommendations are divided into four categories, from 1 through 4.Category 1 means no restriction to use that contraceptive (it’s good to use, it’s displayed with a dark green background).Category 2 means the advantages of using the method generally outweighs the risk (OK to use, it’s marked with a light green color).Category 3 means the risks of the method generally outweighs the advantages (this is not a good choice choose something else, it’s shown with a light red color).Category 4 means there is an unacceptable health risk for using that method with that specific condition (do not use this contraceptive method! It is shown with a dark red color background). For example, a 36-year-old female with obesity (BMI 32) and migraines with aura would like to start Combined Hormonal Contraceptives (CHC or the “pill”), will this be safe for her? Open the app, choose MEC by condition, then select the conditions “Menarche to 30”. Tap on Continue. The recommendations for each condition are displayed, and we can move to each condition easily by tapping on the arrows on the top of the page. In this patient, for example, the “pill” (CHC) is category 1 for her age, category 2 for obesity with BMI >30, but it’s category 4 for migraines with aura. You can see more info by tapping on the plus sign in each recommendation. Based on the evidence, this patient is not a good candidate for CHC. So, do not prescribe it! Let's say the same patients asks about IUD (Mirena®), acronym LNG IUD, is it a good choice? Let’s tap on MEC by Method, then find the IUD and select the same conditions: age, migraine with aura, and obesity. The IUD is category 1, you can prescribe it safely. To expand your knowledge even more, tap on the SPR icon and select the recommendations on initiation of the IUD. According to the Selected Practice Recommendations (SPR), the IUD can be inserted at any time if it is reasonably certain the patient is not pregnant. You can insert IUD after obtaining consent, and going over the risks, benefits, and alternatives, under proper supervision if you are a resident. 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 Keto? By Constance Baker, MS3, Valerie Civelli, MD, and Hector Arreaza, MD. What is it/history? High fat, low carbohydrate diet Goal is to have most of your calories come from fat followed by protein with There are many different variations of this diet in regards to amounts of fats and proteins used but carbohydrates should be Most used today for weight loss and the fight against obesity.Created in 1921 by Dr. Wilder and Dr. Woodyatt at the Mayo Clinic.The ketogenic diet was first created as a treatment for epilepsy in children. It was the first line treatment until the creation of antiepileptic medicationAt this time, it was also used for treatment in diabetic patients. How does it work? The logic behind the ketogenic diet is to put the body in “starvation” mode by limiting carbohydrate intake and increase use of stored fat in the body. This decreased insulin secretion causing the body to use its glycogen stores until depleted. When those are depleted, the body enters gluconeogenesis. A process where the body makes its own glucose out of the precursors lactic acid, glycerol, and amino acids. This process can only be used for a short time, eventually the body will run out precursors and will have to switch metabolic processes one more. This time, the body switches to ketogenesis. During ketogenesis, the body makes ketones bodies for the primary source of energy

Episode 58: Transaminitis. Elevated aminotransferases can be caused by intrahepatic and extrahepatic causes, Dr Martinez and Dr Civelli explain the workup of transaminitis, distribution of Chantix was stopped by Pfizer, smoking cessation updates Introduction: Smoking Cessation UpdatesBy Hector Arreaza, MD, Valeri Civelli, and Yosbel Martinez, MD On June 25, 2021, Pfizer stopped distribution of some badges of Chantix(r) after high levels of the carcinogen N-nitroso-di-methyl-amine (NDMA) were found in some lots of the pills. “Pfizer told Reuters the distribution pause was ordered out of abundance of caution while further testing is conducted.”The FDA approved Varenicline in 2006, and there is evidence that Chantix is the most effective anti-smoking medication.USPSTF Grade A recommendations:1. All adults should be asked about their tobacco use. Then, if determined to be smokers or tobacco users, advise them to quit, and provide behavioral interventions and FDA-approved medications for cessation. This applies to all adults who are not pregnant and use tobacco.2. All pregnant patients should be asked about their tobacco use, advised to quit using tobacco, and offer behavioral interventions for cessation. USPSTF Grade I (I stands for “I don’t know”):1. The USPSTF does not endorse or discourages the use of pharmacotherapy for smoking cessation in pregnant patients because there is insufficient evidence.2. E-cigarettes have insufficient evidence to be recommended as an effective way to stop smoking in adults. 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. ___________________________Transaminitis. By Yosbel Martinez, MD Transaminitis is a way to say elevated aminotransferases. When you see “itis” at the end of a word, it normally means “inflammation” in medical terms, and for that reason transaminitis is not etymologically correct, but it’s easy to use and everyone understands what it means. What are aminotransferases?Aminotransferases are intracellular enzymes that are a sensitive indicator of liver cell injury (necrosis or inflammation).-ALT (alanine aminotransferase) is a more specific measure of liver injury-AST (aspartate aminotransferase) is less specific because it is also found in striate muscle, heart, brain, kidney and Red and white blood cells. There is a poor correlation between degree of liver cell damage and level of aminotransferases. Low levels of transaminases may be seen even in some instances when the liver is severely and terminally damaged, for example, in cirrhosis. General approach of transaminitis > 6 months (asymptomatic patient) Step 1: Initial evaluation for most common liver conditions.1. Drugs (herbal or recreational drugs) or medications (acetaminophen, INH, amiodarone, statins)2. Hepatitis A, B, C3. Alcoholic hepatitis (AST/ALT ratio above 2:1)4. Fatty Liver AST/ALT 5. Hemochromatosis (iron/TIBC > 45%) Hereditary hemochromatosis is an autosomal recessive disorder of the metabolism of iron. It is the most common genetic disease in Caucasians. Women have the protective effect of menstruation, which serves as a monthly phlebotomy until they reach menopause, and hemochromatosis may become symptomatic. Men are more prone to iron-overload disease compared with women. Hemochromatosis is asymptomatic in early stages. Some common symptoms include arthralgias, low energy, weakness, and erectile dysfunction in men. Later manifestations include arthralgias, osteoporosis, cirrhosis, hepatocellular cancer, cardiomyopathy, dysrhythmia, diabetes mellitus, and hypogonadism. Screening with iron levels should be ordered in patients with first-degree relatives with classical hemochromatosis. Diagnosis requires confirmation of increased serum ferritin levels and transferrin saturation, with or without symptoms. Treatment includes regular phlebotomy guided by serial measurements of serum ferritin levels and transferrin saturation. Iron restriction in diet is normally not needed. Screening for hepatocellular carcinoma is reserved for those with hereditary hemochromatosis and cirrhosis. StatinsStatins are very important in prevention of treatment of cardiovascular disease. They are safe.“The risk of hepatic injury caused by statins is estimated to be about 1 percent, similar to that of patients taking a placebo.” Patients with transaminitis below three times the upper limit of normal can continue taking statins safely. Nonalcoholic fatty liver disease and stable hepatitis B and C are not contraindications to statin use. Atorvastatin is contraindicated in active liver disease or in patients with unexplained persistent transaminitis. Step 2: When you have not determined the source of transaminitis1. Less common liver conditions:-Autoimmune hepatitis (more common in women, order SPEP, ANA, ASMA)-Wi

Hearing loss in the elderly, Dr Yomi explained the fundamentals of hearing loss, we said good-bye to graduating residents and welcomed the class of 2024.Introduction: New Academic YearBy Hector Arreaza, MDToday is July 1, 2021.It’s that time of the year again when we say good-bye to our dear graduating residents, and we welcome a new group of eager PGY1s. On June 27, 2021, we had a graduation ceremony filled with emotion, stories, yummy food, and lots of dancing. We gave a well-deserved tie-dye lab coat to Dr Stewart as a sign of our appreciation and love. We say congratulations to our graduates who received their diploma: Monica Kumar, Joseph Gomes, John Ihejirika, Fermin Garmendia, Roberto Velazquez, Terrance McGill, Yodaisy Rodriguez, and Claudia Carranza. They all participated in this podcast, even more than once. I want to especially thanks Claudia who brought so many good ideas and her enthusiasm to this podcast. She promised she will continue to participate in the near future. Lisa Manzanares and Amna Fareedy received their diplomas a few months ago, but they were also remembered during this ceremony. And now we welcome our new interns [Drum roll]: Cecilia Covenas, Su Hlaing, Amardeep Chetha, Licet Imbert, Timiiye Yomi, Funmilayo Idemudia, Na Sung, and Amelia Martinez. They are officially starting their residency this week as the Class of 2024. I hope you can enjoy your training with us. And these interns are starting on the right foot. You will hear Tiimy present our podcast discussion today.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.___________________________Hearing loss in the elderly. By Timiiye Dawn Yomi, MD, and Hector Arreaza, MD INTRODUCTION:Hearing loss is the third most common health condition after hypertension and arthritis to affect the elderly population. According to the World Health Organization, about 538 million people are affected by hearing loss worldwide with people between ages 61 to 70 years accounting for about third of this number. 80% of those older than 85 years have experienced some form of hearing loss and men tend to experience greater hearing loss with earlier onset compared to women. Normal conversation uses frequencies of 500 to 3000 Hz at 45 to 60 dB. After age 60 there is a steady decline by one dB annually. Genetic component plays a role in age related hearing loss.DEFINITION:A person who is not able to hear at hearing thresholds of 20dB or better in both ears is said to have hearing loss. Hearing loss can be mild moderate or severe and it can be uni- or bilateral. Mild: On the average, persons with mild hearing loss hear the most-quiet sounds between hearing thresholds of 25-34dB with their better ear.Moderate: The most-quiet sounds heard by these persons are between hearing thresholds of 34-49dB with their better ear.Moderately severe: These persons hear the most quiet sounds between hearing thresholds of 50-64dB with their better ear.Severe: The most quiet sounds heard by these persons are between hearing thresholds of 65-79dB with their better ear.Profound: Persons with profound hearing loss hear the most quiet sounds at thresholds of 80 dB or more.Some terms we may want to address here are “Hard of hearing” and Deafness. A person is said to be hard of hearing when they have hearing loss ranging from mild to severe, but they usually can communicate through spoken language. Deaf people on the other hand have profound hearing loss and often communicate with sign language.TYPES OF HEARING LOSS:Hearing loss can be broadly divided into 3 types: Conductive, Sensorineural hearing loss, Mixed.Conductive hearing loss: This involves anything that would limit the amount of external sound entering the inner ear. Common causes include cerumen impaction, perforated tympanic membrane, otitis media effusion, tumors such as glomus tumors, and tympanosclerosis.Sensorineural hearing loss: This is hearing loss that involves the inner ear, cochlear and or the auditory nerve. Common causes are age-related hearing loss (presbycusis, which is the most common hearing loss in the elderly population) ototoxic medications such as aminoglycosides, autoimmune diseases, trauma, infection, neoplasm, and Meniere’s disease. Mixed: A combination of conductive and sensorineuralRISK FACTORS: AgingRace (Caucasians have the highest prevalence of age-related hearing loss)GeneticsSocioeconomic statusLoud noise exposureOtotoxins such as aminoglycosidesVascular diseasesHypertensionDiabetesImmunologic disordersInfectionsSmokingHormones such as estrogen. CLINICAL PRESENTATION:Patients may present with sudden or gradual hearing loss depending on the etiologyCommon symptoms: inability to hear or understand speech in a crowded or noisy environment, difficulty with understanding consonants, d

Introduction about Wegovy as a new treatment for obesity. Dr Amodio discusses fall prevention in older adults. News: Semaglutide for the treatment of obesityBy Hector Arreaza, MD, and Daniela Amodio, MD. About 70% of Americans suffer from overweight or obesity. It has been 7 years since a medication was approved by FDA for chronic weight management. As a reminder, Saxenda® (liraglutide, daily SQ injection) was approved in 2014 for the treatment of obesity in adults (7 years ago), and remarkably, in December 2020, Saxenda® was also approved for the treatment of obesity in children older than 12 years old (good to know). Saxenda® is a GLP-1 receptor agonist.On June 4, 2021 (7 years later), Novo Nordisk® did it again and got approval for a new medication for the treatment of obesity (disclaimer, I do not receive any money from Novo Nordisk®)After extensive trials (drum rolls), Wegovy® (pronounced wee-GOH'-vee) has been approved by the FDA for chronic weight management. The component is semaglutide, yes, you heard me right, this is the same component of Ozempic®, an injected medication FDA-approved for diabetes treatment, and it is the same component in Rybelsus® (pronounced reb-EL-sus), which is the same semaglutide but in oral form. -Wegovy® is a synthetic version of a hormone called glucagon-like peptide 1 (GLP-1). GLP is an incretin, and as such, it reduces glucose levels by optimizing the secretion of insulin and decreasing the secretion of glucagon during digestion. Wegovy® exerts its action in areas of the brain to curb appetite and increase satiety. The use of Wegovy is approved in adults with a BMI above 30 kg/m2, or above 27 kg/m2 who have at least one weight-related condition. As with other medications for obesity, Wegovy is an adjunct therapy which can be added to intensive lifestyle modifications.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 BreakElderly Falls. By Daniela Amodio, MD, and Hector Arreaza, MD Patients who are older than 65 are normally called “older patients”, but sometimes it’s confusing, older than who? What does it really mean? There are many euphemisms: seniors, older adults, elderly, “prolonged youth”, or old-timers.“Aging experts… have tried calling people young old (65 to 74), old old (75-84) and oldest old (85+). Age-based categories at this stage of life often aren't helpful because there is so much variability in how people age.” (Tracey Gendron, gerontologist at Virginia Commonwealth University)[2]Key points: 1. A fall is one of the most common events that may make older adults lose their independence.2. Complications from falls are the leading cause of death from injury in adults older than 65 years old.3. A multifactorial risk assessments should be done in older adults with >2 falls in the past 12 months. Interventions that have shown to be effective in reducing falls: Medication reviewExercise programs for muscle strengthening and balance trainingVitamin D supplementation in vitamin D deficiency Use appropriate footwear Home hazardous assessment Comment: Deprescribing is an essential activity during your geriatric visits. Avoid unnecessary medications. Use the AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults to determine which medications you should either discontinue or change to minimize risk of falls. Some examples include: benzodiazepines, some antidepressants and dextromethorphan/quinidine. Prevalence and morbidity of falls in older adults:According to CDC, one out of three adults older than 65 years old reports falling in the previous year. The incidence of falls is higher with advanced age, which means one half of individuals older than 80 years old or those living in nursing homes will fall each year. Most falls result in soft tissue injury and 5-10% result in fracture or head trauma. Women and nursing facility residents are more prone to non-fatal injury than men. Death rate due to falls is more common in white men older than 85 years old. Risk factors: Multiple studies indicate that falls are multifactorial. Risk factors include: old age, cognitive impairment, female gender, history of falls, gait/balance problems, low vitamin D, pain, psychotropic medications, Parkinson's disease, stroke and arthritis. Physiologic changes expected with aging: With aging visual acuity is affected as well as inability for dark adaptation. Loss of sensitivity in the legs is expected as well as loss of balance. Also, there may be other changes in the CNS that affect postural control, including loss of neurons and dendrites and depletion of neurotransmitters such as dopamine in basal ganglia. There is inability to keep an upright posture due to decline in baroreflex sensitivity, resulting in hypotension. Elderly patients are prone

Episode 55: The Poop Episode. Dr Civelli and Dr Lundquist describe the Bristol Stool Scale. What is the ideal shape of stools? What is normal vs. abnormal stools? Intro about antibody medicine.Today is June 9, 2021. Antibody Medicine. Have you ever heard of antibody medicine? Human biologic targets can be linked to a multitude of diseases onset, progression or even prevention. The role of antibody therapy is to identify those targets, conduct industry-grade research trials to validate and then develop highly specific therapies. Some examples are: Dupixent (dupilumab) for asthma, atopic dermatitis, and chronic sinusitis; rituximab for Non-Hodgkin Lymphoma and pemphigus vulgaris, or other “mabs.” These are a few such examples of antibody medications. Antibody medicines typically mimic the natural pathways of the body’s immune system. These antibody medicines are derived from living organisms, not from chemical processes like most pills. And because they are designed so specifically, they are designed to avoid unwanted effects on other cells in the body. Antibody medicines have been proven to change lives and have altered the course of the treatment of serious diseases like asthma, cancer, heart disease, rheumatoid arthritis, and severe eczema over the past several decades. I wonder what this means for accessibility and who will this benefit? I know many of the “mabs” like dupixent are available and there are assistance programs to help with coverage. I love that we are in the era of innovation and discovery! 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 is sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. The Poop Episode. By Valerie Civelli, MD, and Arianna Lundquist, MD. What is brown, smells really bad and may attract flies? I will be honest with you, there’s no clever joke. It was exactly what you are thinking. That is right, it is Poop. Everyone does it. I do, you do. We all do Doo Doo. As physicians, we are here to give you the scoop on the poop. Let’s start with a few rhetorical questions: What is normal stool?How do you describe it? Do most patients know the difference b/w normal and abnormal? Is it easy for patients to describe and talk about?Normal stool has an alkaline pH. Sodium and potassium salts are the primary stool solutes. The sodium plus potassium concentration in stool usually ranges between 130 and 150 mEq/L. Other cations, such as calcium and magnesium, are present at much lower concentrations. The main inorganic stool anions are bicarbonate (approximately 30 mEq/L), chloride (approximately 10 to 20 mEq/L), and a small amount of phosphate and sulfate. Changes from these baselines may lead us to a variety of diagnoses. Let’s take this discussion into clinical practice. Poop is a tough topic for patients according to multiple sources and extracting pertinent patient history is challenging: Because it is embarrassing, because patients are often unaware of what is normal vs. abnormal bowel movements. I have asked patients if they have any constipation. They report bowel movements daily only to find out these are small, hard pellet-like stools daily. Unless you are a bunny, you are constipated if having pellet-like stool. The good news is Ken Heaton, MD, from the University of Bristol, developed the Bristol Chart in 1997 to improve our ability to assess patient bowel movements. The Bristol chart categorizes the 5 different types of stool and shows normal versus abnormal. The Bristol Stool Scale is also known as the Meyer’s Scale and is still used to today as a great tool to help patient describe the shapes and types of stool. Let’s go over this together: Type 1 – Separate Hard lumps, like nuts (hard to pass)Type 2 – Sausage-shaped, but lumpyType 3 – Sausage-shaped, but with cracks on surfaceType 4 – Sausage- or snake-like, smooth, and softType 5 – Soft blobs with clear-cut edges (easy to pass)Type 6 – Fluffy pieces with ragged edges, mushyType 7 – Watery, no solid pieces (entirely liquid) The ideal stool is generally type 3 or 4, easy to pass, without being too watery. If yours is like type 1 or 2, you're probably constipated. If your is more like types 5, 6, and 7, you probably have diarrhea. The most important thing to look for in your stool: Well first you must look at it. Some patients have admittedly avoided this step but encourage them to look every time. "Blood should be the first thing to look for in your stool," according toDr. Mark Pimentel, a gastroenterologist atCedars-Sinai. Blood may be dark black or bright red. It may be a marker of colon cancer, Crohn's disease,or colitis. Can you think of any other differentials? Would you recognize the difference between human poop vs. dog poop? True story, I have a doctor friend whose son was obsessed with video games. He played for hours, skipped meals, peed in his pants more

A1C is an easy way to diagnose and monitor diabetes, use and limitations of A1C are discussed with Dr Rodriguez. Vaginal metformin is mentioned as an anecdote which has not been proven to work we remembered Memorial Day. Introduction: Vaginal Metformin. By Hasaney Sin, MD, and Hector Arreaza, MD.Today is May 31, 2021. There’s a saying that I came across on social media that has always spoken to me which I find relevant to our vocation. “The more I learn, the more I find out I don’t know”. So comes the joys (and challenges) of our chosen career. Case in point, have you ever heard of vaginal metformin? Neither have I, until today. There was a randomized clinical trial plan in 2013 at Assuit University in Egypt studying the effectiveness of vaginal metformin for the treatment of polycystic ovarian syndrome (PCOS). As primary care providers, we are very aware of the gastrointestinal side effects of metformin when taken PO. This sometimes prevents compliance with metformin. The study at Assuit University was to study the effectiveness of metformin when given vaginally in the effectiveness of treating PCOS, while also decreasing the undesirable side effects of metformin when given PO in hopes of also ultimately improving adherence. Unfortunately, the study was planned to be finished in 2014, but no results have been published thus far[1]. Stay tuned in case there is any update.Arreaza: I had to do a search because I was very curious too. There is at least one occurrence when vaginal metformin was mentioned, at least in English. It was in an online forum where a doctor recommended vaginal metformin for PCOS to a patient. This has not been evaluated or approved by any organization, so I would not recommend it. You know what would be great? Metformin patches! There you have a business idea guys: The Metfo-patch®. 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. Introduction: Memorial Day. Written by Valerie Civelli, MD, read by Steven Saito, MD, and Hector Arreaza, MDWhat is Memorial Day? Memorial Day is an American holiday at the end of May to honor the men and women who died while serving in the US military. It has great historical meaning to Americans. It originated from the Civil War which claimed more lives than any other conflict in US history. Civil war ended in 1865. A fun fact to know, is that Memorial Day, was originally called “Decoration Day”. It was 3-years after the Civil war ended, May 5, 1868, that “Decoration Day” was declared as a time for the nation to decorate the graves of those lost in war. Graves were adorned with flowers and their lives celebrated. Maj. Gen. John A. Logan then declared that “Decoration Day” should be observed on May 30th. It is believed that this date was chosen because flowers would be in full bloom across the country. The “birthplace” of “Memorial Day” was recognized as coming from Waterloo, New York, because Waterloo was the first to use this term to expand honor and recognition of all US fallen soldiers of war from the Civil War and from World War I. In 1971, “Memorial Day” was officially declared a national federal holiday: The National Moment of Remembrance encourages all Americans to pause wherever they are at 3:00 p.m. local time on Memorial Day for a minute of silence, to remember and honor those who have died in service to the nation. If you value your freedom wherever you are, this Memorial Day at 3:00 p.m., pause for a minute to recognize all of our military men and women, both past and present who served and continue to serve our country. We honor every soldier who lost his or her life in any war against America. You are the reason for our freedoms. You gave the ultimate sacrifice, and we do not take this for granted. To all military members who have died at war, we appreciate the privileges we have today because of you. We honor the costly price at which it came. We remember you. We honor you. We sincerely thank you. Happy Memorial Day everyone! ___________________________A1C.By Hector Arreaza, MD, and Yodaisy Rodriguez, MD. Definition. Glycated hemoglobin (glycohemoglobin, hemoglobin A1c, or just A1c) is a form of hemoglobin that is chemically linked to a sugar. Glucose spontaneously bind with hemoglobin, when present in the bloodstream of humans.A1C refers to the percentage of glycosylation of the hemoglobin A1C chain and correlates with the average blood glucose levels over the previous 2-3 months from the slow turnover of red blood cells in the body. A RBC lives 120 days.History of A1C. Huisman and Meyering separated glycohemglobin for the first time in 1958. A1c for monitoring the degree of control of glucose metabolism in diabetic patients was proposed in 1976 by Anthony Cerami, Ronald Koenig and coworkers.A1C was first included in the ADA guide

Colorectal cancer screening update, COVID-19 vaccine update, and abnormal uterine bleeding basics.Today is May 24, 2021.Colorectal cancer screening update Written by Hector Arreaza, MD. Participation: Ikenna Nwosu, MD, and Daniela Viamontes, MD.Today is May 24, 2021.On august 29, 2020, we were in the midst of a pandemic and we woke up with the sad news about the death of Chadwick Aaron Boseman (also known as Black Panther). An interesting fact: The tweet in which his family announced his death on Twitter became the most-liked tweet in history. But why are we talking about Chadwick’s death? Because he died of colon cancer. I do not know if this recommendation came because of Chadwick, but it’s a good way to open this episode: remembering Black Panther.We heard the rumors, but now it’s official. On May 18, 2021, the USPSTF released their final recommendation statement about colorectal cancer screening. The age to start screening has been changed from 50 to 45 years old. This is a grade B recommendation. Grade B means that this recommendation has moderate to substantial net benefit, so offer this service to your patients. Screening adults between 76 and 85 years old who have been previously screened has a small net benefit (grade C recommendation). So, select patients may be screened for colorectal cancer in this age group (76-85), especially those who have never been screened.Do you remember this recommendation from medical school for high risk patients? Start screening at age 40 or 10 years before a patient’s direct-relative was diagnosed with colon cancer. This was a recommendation given by the US Multi-Society Task Force (which includes the American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy). This same organization already recommended in 2017 to start screening at age 45 in African American patients, and the American Cancer Society recommended screening all patients at age 45 in 2018. The ACS does not have a guideline to screen high risk patients for colon cancer. Most organizations agreed on not screening after age 85.Strategies for screening:High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every yearDani: Stool DNA-FIT every 1 to 3 years (Cologuard®) CT colonography every 5 years Flexible sigmoidoscopy every 5 years OR Flexible sigmoidoscopy every 10 years + annual FIT Colonoscopy screening every 10 yearsDiscuss different options with your patients, choose your favorite and do it! Introduction: Update on COVID 19 vaccines By Hector Arreaza, MD, and Lillian Petersen, RN. COVID-19 vaccines now can be co-administered with other vaccines according to the ACIP. COVID-19 vaccines and other vaccines may now be administered without regard to timing. They can be given on the same day or within the 14 days previously recommended between vaccines. It is not known if reactogenicity of COVID-19 vaccine is increased with co-administration with other reactogenic vaccines (such as vaccines with live attenuated viruses). How do you decide if you want to co-administer a vaccine? 1. Consider whether the patient is behind or at risk of becoming behind on recommended vaccines.2. Consider their risk of vaccine-preventable disease.3. Consider the reactogenicity profile of the vaccines. If multiple vaccines are administered at a single visit, administer each injection in a different injection site, at least one inch apart or in different limbs. Current or previous SARS-CoV-2 infection: Everyone should be offered COVID-19 vaccination regardless of their history of COVID-19 infection. Viral testing or serologic test is not recommended for the purposes of vaccine decision-making. People with current SARS-CoV-2 infection should be deferred until the person has recovered from the acute illness (if the person had symptoms) and they have met criteria to discontinue isolation. This applies to patients who got the disease before receiving any vaccine or after receiving the first dose. A minimum interval between infection and vaccination has not been established, but evidence suggests that the risk of reinfection is low in the months after initial infection but may increase with time due to waning immunity. People with a history of multisystem inflammatory syndrome in children (MIS-C) or adults (MIS-A):It is unclear if people with a history of MIS-C or MIS-A are at risk of recurrence of the same dysregulated immune response following reinfection with SARS-CoV-2 or in response to vaccination. People with a history of MIS-C or MIS-A may choose to be vaccinated but they should consider delaying vaccination until they have recovered from their illness and for 90 days after the date of diagnosis. Find more information at the CDC.gov website. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with

Vitamin D deficiency screening recommendations by USPSTF and other organizations is discussed. CDC announces “no masks required” for vaccinated people. Question of the month about fever and cough answered.Introduction: Mask use no longer required for vaccinated peopleBy Hector Arreaza, MDToday is May 17, 2021.Did you receive your COVID-19 vaccine? If you did, we have good news for you, well, this may not be news for you anymore by the time you listen to this episode.The CDC director, Rochelle Walensky, announced a few minutes ago that vaccinated people no longer need to wear masks indoors or outdoors and no longer need to keep social distance[1]. A person is considered fully vaccinated 2 weeks after one dose of J&J vaccine or two weeks after second dose of Moderna or Pfizer vaccines.Fully vaccinated people are required to wear masks in airplanes, trains, buses, other public transportation, health-care settings, and where required by local authorities or businesses. These mask and social distancing guidelines may change in the future because we have seen the behavior of the coronavirus is unpredictable. These guidelines are dynamic. This announcement came one day after CDC endorsed administration of the Pfizer vaccine to persons between 12 and 15 years old. We do not know if this is the beginning of the end, but for sure we are starting to see a light at the end of the tunnel. As of today, about 117 million Americans are fully vaccinated (35% of the population). The effectivity of vaccination has been remarkable. The rate of breakthrough infections (it means infection after full vaccination) is rare, and severity of disease is mild after vaccination. For the record, the federal government has set a goal of vaccinating 70% of Americans by July 4th, 2021. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.Question of the Month: Fever and CoughWritten by Hector Arreaza, MDThis is a 69-year-old male patient, who comes to clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke tobacco. He takes benazepril 10 mg daily. His immunizations are not up to date. Physical exam: Tachycardia of 110 bpm and fever of 101.5 F (38.6 C). He has bibasilar crackles, White count is elevated 13.5, and chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?First, we want to announce the winner. I am the winner [applause].The top 3 differential diagnosis are: 1. Community acquired pneumonia, viral or bacterial (no surprises there, the symptoms are typical of CAP); 2. COVID-19 pneumonia (the rapid COVID-19 test was NEGATIVE, but the confirmatory test is pending, this patient may have COVID-19 until proven otherwise); and 3. My third DDX is pulmonary coccidio-idomycosis (also known as Valley Fever in California, or simply cocci). If you are not familiar with the diseases in the Central Valley of California, you may think this is a very unusual differential, but for us is not that uncommon. One day we will talk more about that disease.Acute management:The first decision you must make is where to treat this patient. Will you treat him at home or in the hospital? If sent to the hospital, can he be treated on the floor or requires ICU admission?You have to determine is the patient is experiencing septic shock or respiratory failure. If septic shock and respiratory failure are not likely, and CURB-65 score is zero, then no hospital admission is needed. This patient meets SIRS criteria (systemic inflammatory response syndrome): temperature >38 C, HR > 90, and WBC >12,000. BP was not provided so it is not possible to determine if he has septic shock (BP Respiratory failure is suspected when pulse ox is below 92% on room air. That information is not provided in this case. Assuming Pulse ox is below 92% on room air, then you use an objective way to determine severity of pneumonia or guide your management. There are not enough elements to calculate the CURB-65 score: Confusion, BUN >20 mg/dL (>7 mmol/L), Respiratory rate ≥30 breaths/minute, Blood pressure (systolic Based on my assessment, this patient meets admission criteria. Let’s assume patient’s blood pressure is below 90/60.The priority is to start fluid resuscitation, Normal saline or LR 30 mL per kilo, in the first 3 hours, mean arterial pressure 60 mmHg to 70 mmHg and urine output >0.5 ml/kg/hour, lactic acid trending down. IF response is poor, consider ICU transfer.Collect blood culture x2 before IV antibiotics. IV antibiotics: Ceftriaxone and Azithromycin IV.Order labs CBC, CMP, D-dimer level, Lactate, procalcitonin, COVID-19 PCR, rapid influenza testin

Progeria is a rare disease that causes premature aging in childhood; the FODMAP diet is explained as a treatment for IBS; J&J vaccine restarted; Question of the month: Fever and Cough.Introduction: Low FODMAP Diet and J&J COVID Vaccine is back. By P. Eresha Perera, MS3, and Sherika Adams, MS3.Today is May 10, 2021.Irritable Bowel Syndrome. Patients with IBS frequently have other conditions such as anxiety, depression, somatization, fibromyalgia, chronic fatigue syndrome, GERD, dyspepsia, non-cardiac chest pain, chronic pain, and other mental illness. A common triad we see in the clinic is: Anxiety + Fibromyalgia + IBS. Treating these conditions is hard, and even more so when they are combined. Let’s focus for now on IBS treatment. Recently we had a patient with IBS who had a laparoscopic cholecystectomy and of course was complaining of abdominal pain and constipation. We mentioned the low FODMAP diet as part of the treatment. The low FODMAP diet has been proven for the treatment of irritable bowel syndrome (IBS) and or small intestinal bacterial overgrowth (SIBO). It has decreased symptoms in 86% of people. FODMAP is an acronym that stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. This diet attempts to restrict these short-chain carbs that are poorly absorbed by the small intestine, resulting in cramping, constipation, diarrhea, bloating, and gas or flatulence.You can recommend your patients to follow 3 steps: Step 1: Eliminate foods that are high on FODMAP, Step 2. Determine which foods cause symptoms by reintroducing eliminated foods slowly, and Step 3. After identification of the FODMAP foods that cause symptoms, remove them completely from the patient’s diet. Dr. Hazel Galon Veloso, John Hopkins's gastroenterologist, recommends doing step 1 for 2-6 weeks and step 2 reintroducing a high FODMAP food back into diet every 3 days. Example of HIGH FODMAP foods: Dairy-based milk, yogurt, ice cream, wheat products (cereal, bread, and crackers), beans, lentils, vegetables like artichokes, asparagus, onions, and garlic, and fruits such as apples, cherries, pears, and peaches. Example of LOW FODMAP foods: Eggs, meat, cheese such as Brie, cheddar, and feta; almond milk, rice, quinoa, oats, potatoes, tomatoes, cucumbers, zucchini, grapes, oranges, and strawberries.If available, Fodmap should be initiated with the advice of a nutritionist that can help with the transition, prevent over-restriction and nutritional replete diet. Consider this diet as an initial treatment for your patients with IBS.Vaccination with J&J COVID 19 Vaccination has been restarted.On a different note, On April 23, 2021, the CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended to restart vaccination with the Janssen/Jonson & Jonson COVID-19 vaccine after a pause on April 13, 2021[2]. After giving the J&J vaccine to almost 8 million patients, 15 cases of Thrombosis with Thrombocytopenia Syndrome (TTS) were reported and three of them died. The recommendation was given after a risk-benefit analysis that determined that the benefits of the vaccine outweigh the risks. The risk of TTS in women age 18-49 still exists, but it is considered very low when compared to all the risks carried by COVID 19 itself. Under the emergency use authorization, the Jonson & Jonson vaccine is considered highly effective and safe. In comparison, the AstraZeneca vaccine has had several more cases of TTS, Moderna has had only 3 but with normal platelets, and Pfizer has had zero cases of TTS[3]. 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.___________________________Question of the Month: Fever and CoughWritten by Hector Arreaza, MDWhat are your top 3 differential diagnosis and acute management for a 69-year-old man with new onset of fever, cough, leukocytosis and a right lower lobe consolidation? Important: Rapid COVID-19 test is negative.____________________________Progeria. With Salwa Sadiq-Ali, MS3, Veronica Phung, MS3; and Hector Arreaza, MD. “The Curious Case of Benjamin Button” is an American movie released in 2008, directed by David Fincher, starring Brad Pitt. Let’s see how we can connect this movie to today’s topic.What is Hutchinson Gilford Syndrome better known as Progeria?V. Phung: That’s a great question! Progeria is an extremely rare disease. It’s progressive and causes children to age very quickly within the first few years of their life. The disease is not evident at birth. S. Sadiq-Ali: Exactly! Usually, kids will start developing symptoms within their first year of life with the first symptom being failure to thrive. Other common features include a disproportionately large head for their face, narrow nasal ridge and tip, small mouth, retro and micrognathia, little to no subQ fat with

Jaime Perales, PhD, presents statistics, screening tools and useful resources for primary care providers for Alzheimer’s disease. The KIDs list is presented. Question of the month: Fever and Cough.Introduction: KIDs List and Cognitive Impairment in the ElderlyBy Hector Arreaza, MDToday is May 3, 2021. In family medicine, we believe in caring for patients “from the cradle to the grave.” During this introduction, we want to inform first of the KIDs list[1] and then some updates on cognitive impairment screening in older adults[2].First, KIDs stand for Key Potentially Inappropriate Drugs in Pediatrics. It is a list of medications that are potentially inappropriate in children. It contains 67 drugs with their risks, recommendations, strength of recommendation and quality of evidence. Common meds include anti-infectives, antipsychotics, dopamine antagonists and GI agents. 85% of these meds require a prescription, and are taken by mouth, or used by parenteral route or even for external use. For example: Mineral oil, oral, carries the risk of lipid pneumonitis, recommended to avoid in patients younger than 1 year old, this recommendation is strong with low quality of evidence. For all the “abuelas” (Spanish for grandmothers) out there, listen to this: Camphor carries a risk of seizures, the recommendation is “use with caution in children.” However, the recommendation is weak and quality of evidence is low, but the concern is enough to include it on the list, in other words, use “vi-vah-pore-oo” with caution in children. I recommend you look up the KIDs list and use your clinical judgment to incorporate it into your practice. From childhood, now we go to the elderly. On February 25, 2020, the USPSTF posted their final recommendation statement regarding screening for cognitive impairment in older adults. This is a Grade I recommendation (Insufficient Evidence). It means that more research is needed to recommend for or against it. This is the same recommendation given in 2014. An article published in JAMA on the same date, Feb 25, 2020, reports that screening instruments can adequately detect cognitive impairment, however there is no evidence that this screening improves patient or caregiver outcomes or causes harm. It is still uncertain if early detection of cognitive impairment is important to provide interventions for patients or caregivers with significant clinical benefits.Jaime Perales, PhD, will present some statistics on Alzheimer’s disease, he will explain some useful tools to screen for cognitive impairment and address the issue of Alzheimer’s disease at the primary care level. 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. Question of the Month: Fever and CoughWritten by Hector Arreaza, MD, read by Claudia Carranza, MD, and Valerie Civelli, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke tobacco, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. He has no surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition? Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to [email protected] and the best answer will win a prize!____________________________Screening for Alzheimer’s. With Jaime Perales Puchalt, PhD, and Hector Arreaza, MD Jaime Perales Puchalt is an Assistant Professor in the Department of Neurology. His main areas of interest include dementia among minorities and populations of Latin American origin in the Americas. He currently spearheads the Latino Alzheimer's education efforts at the University of Kansas Alzheimer’s Disease Center (KU ADC) and the Latino Cohort in which he recruits and conducts clinical dementia assessments of English and Spanish speaking Latinos. He has al

Episode 49: Dementia in Primary Care. Dr Ryan Townley explains what to do when a patient reports “memory problems”, including labs, imaging, and more. Question of the month: Fever and Cough.Introduction: DementiaBy Hector Arreaza, MDToday is April 26, 2021.Dementia is an umbrella term that includes many conditions that have in common a cognitive decline affecting ADLs. It is an acquired condition that presents after the brain is fully developed. As our population ages, the topic of dementia has become more pertinent. Recently we had an introduction about the link between poor sleep and dementia, episode 42. The next two episodes will be about dementia.Today we would like to discuss further this relevant topic. We talked with Dr Ryan Townley, who is an assistant professor in the Department of Neurology at the University of Kansas Medical Center, and the director of the Cognitive and Behavioral Neurology Fellowship. We will discuss dementia screening, how to evaluate our patients who report “memory problems”, including additional testing and imaging, when to send to a neurologist or neuropsychologist, and some things we can do for prevention of dementia. This episode is not intended to be a comprehensive lecture about dementia, but it may motivate you to keep learning about this topic. I hope you enjoy it.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. Question of the MonthWritten by Hector Arreaza, MD, read by Terrance McGill, MDThis is a 69-yo male patient, with controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke tobacco, but smokes recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to [email protected] and the best answer will win a prize!____________________________Dementia in Primary Care. With Ryan Townley, MD, and Hector Arreaza, MD.Ryan Townley, M.D., is an assistant professor in the Department of Neurology at the University of Kansas Medical Center and is the director of the Cognitive and Behavioral Neurology Fellowship. He is also the Alzheimer's Clinical Trials Consortium Associate Director and Primary Investigator at the University of Kansas Alzheimer's Disease Center. Dr. Townley is certified by the American Board of Psychiatry and Neurology. He joined the KU Medical Center faculty in August 2019. Prior to medical school, he earned a bachelor of science in neurobiology from the University of Kansas. He graduated from the University of Kansas School of Medicine, where he earned the 2013 Dewey K. Ziegler Award for Excellence in Neurology presented by the KU Department of Neurology and was honored with the American Academy of Neurology's Outstanding Neurology Medical Student Award. He then completed his neurology residency, an internal medicine internship, and a two-year cognitive behavioral fellowship at the Mayo Clinic School of Graduate Medical Education. He is the author of many publications and has presented more than two dozen lectures and posters nationally and around the world. His clinical and research interests include atypical Alzheimer's diseases, normal pressure hydrocephalus, frontotemporal lobar degeneration and dementia with Lewy bodies. He also has interests in patient, resident and medical student education, and preventative health against neurodegenerative disease.Questions discussed during this episode:What to do when someone complains of "memory problems" in primary care?When should a primary care doctor refer a patient to Neurology for evaluation of dementia?Dementia vs Normal aging. What are the types of dementia?When should a primary care doctor start medications for Alzheimer's disease? First-line pharmacolo

Episode 48: Acute Low Back Pain. Stephanie and Veronica explain common causes of acute low back pain, including lumbar strain, disc herniation, and spondylosis; spontaneous human combustion; question of the month about pneumonia. Introduction: Spontaneous Human CombustionBy Hector Arreaza, MDToday is April 19, 2021. I’ve been trying to keep this podcast very academic and clinically relevant, with a touch of humor but very professional. I hope after this intro, you do not stop listening to us. Recently I was playing a trivia game at a friend’s house. The question was: How many spontaneous human combustion cases have been published in medical journals between 1600 and 1900? What would be your answer? I did not know the answer, but it woke up my curiosity.I did what’s expected of a normal PCP, exactly, I looked it up in Up-to-Date. The only reference to “spontaneous combustion”, I found was on the article about long-term supplemental oxygen therapy (LTOT). “Facial and upper airway burns are an infrequent complication of LTOT, but can be severe and potentially life-threatening. The main cause of burns is exposure to open flames while wearing supplemental oxygen. However, spontaneous combustion may occur with exposure to a spark source rather than an open flame. Certain factors may contribute to the risk of combustion in the absence of open flames, such as facial hair and use of hair products containing oils or alcohol.” This “spontaneous combustion” does not match the definition given the non-medical community.Spontaneous human combustion, also known as preternatural combustion, refers to a rare episode where the complete body, or significant parts of it, are reduced to ashes with no apparent source of ignition. Other items around the body of the victim are intact, making people believe that the fire originated from inside the body. This phenomenon has been described in fictional movies, documentaries, books, novels, and even medical journals. In 1984, Nickell and Fischer[3] investigated cases from the last 3 centuries. They concluded that in those cases of presumed “spontaneous human combustion” possible sources of ignition were ignored on the reports. A common characteristic among victims of spontaneous combustion was intoxication with alcohol or other substances.More recently, the American Burn Association looked into this topic and published in 2012[2] an article titled “Spontaneous Human Combustion in the Light of the 21st Century”. They state that a literature search retrieved 12 case reports between 2000 and 2012. They concluded that the so-call “spontaneous human combustion” is a reality, however, it is not exactly how people think it is. People are not just sitting around and get consumed alive in flames. The term “fat wick burns” was suggested to provide a more exact definition. The article explains that the burn victim must die for the body fat to start melting, then a break in the skin allows melted fat to impregnate clothes and produce a wick effect that allows fire to be on for a long time causing a complete carbonization of tissues. In case you are curious, the number of spontaneous human combustion cases published in medical journals between 1600 and 1900 is ninety-six (96). Citation needed.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. __________________________Question of the Month: Cough and FeverWritten by Hector Arreaza, MD, read by Jacqueline Uy, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?Send us your answer before May 7, 2021, to rbresidency@clinicasierravis

Episode 47: Hearing Carotid Lung. Dr Civelli explains the updates on screening for lung cancer, hearing loss and carotid artery stenosis; Kafiya explains the use of bupropion and naltrexone in methamphetamine abuse, question of the month pneumonia.Introduction: Methamphetamine useBy Kafiya Arte, MS4, and Ariana Lundquist, MD.Today is April 12, 2021.Bakersfield, California, has a methamphetamine (meth) epidemic currently ravaging this area. We as health care workers believe we can spot somebody addicted to meth from a mile away by their characteristic “older-than-stated-age” appearance and obvious “meth mouth”. However, the actual scope of the epidemic is much larger. It’s not just people who are experiencing homelessness that are addicted to, and dying from, meth. I saw while volunteering at a needle exchange at Weill Park, people getting out of nice-looking cars wearing clean, pressed clothes with sharps containers full of used needles ready to exchange. One man even had a teacup poodle in tow. It’s clear that meth can affect anybody. Between May 10 and June 10, 2014, 31.8% of randomly selected patients in the ED of Kern Medical admitted to having used methamphetamine at least once in their life. It’s not just the individual who addicted to meth who is affected. 36.1% of children removed from their home by child protective services in Kern County during the month of May 2014 were cases that involved methamphetamine[1]. Meth accounted for nearly 75% of all drugs seized by the Bakersfield Police Department[2]. Statewide, meth kills more Californians than any single opioid alone[3]. Amphetamine overdose deaths have increased 212% from 777 in 2012 to 2,427 in 2018 in California. In 2020, Kern County had more than double the rate of deaths related to overdose of psychostimulants, of which meth was the dominant drug, compared to the state of California (20.48/100k residents versus 8.21/100k residents, respectively)[3]. This devastating problem, unfortunately, does not have a currently FDA-approved drug to treat it. A promising study called Accelerated Development of Additive Treatment for Methamphetamine Disorder (ADAPT-2), assessed the efficacy of combined bupropion and naltrexone for the treatment of meth use disorder. Bupropion decreases the dysphoria of meth withdrawal that drives continued use; while naltrexone decreases cravings, therefore preventing relapse, as it does with alcohol use disorder. A total of 403 participants with nearly daily meth use were included in the two-stage randomized, double blind trial conducted at 8 different sites from May 23, 2017 to July 25, 2019. The efficacy of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg) was evaluated, as compared to placebo. The results of the study showed a 13.6% response rate in the naltrexone-bupropion group and only 2.5% response with placebo. A response was defined as at least three meth negative urine samples out of four samples obtained at the end of each of the two stages. The trial concluded that although the response rate among participants that received naltrexone and bupropion was low, it was higher than that among participants who received placebo. Although the ADAPT-2 trial did not provide any recommendations that can be adapted to clinical practice, it serves as a starting point for further research of the additive or synergistic effects of bupropion and naltrexone in the treatment of meth use disorder. Hopefully, it will also serve as a catalyst for more pioneering research regarding the legitimization of meth use disorder as a treatable disease with major medical, psychiatric, socioeconomic and legal consequences. Clinicians should stay up to date with research regarding meth use disorder such as ADAPT-2, as it is our duty to understand the health crises that affect our patients on a daily basis, and the tools we can use to treat them.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. ________________________________Question of the MonthWritten by Hector Arreaza, MD, read by Jennifer Thoene, MDThis is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5

Hepatic encephalopathy basics, disseminated gonococcal infections, polyarthralgia question winner, jokes.Today is March 29, 2021.On December 23, 2020, the California Department of Public Health (CDPH) sent a “Dear Colleague” letter because of the increasing reports of disseminated gonococcal infections (DGI). Today, we want to share with you parts of that letter. CDPH is working with local health departments to investigate these cases of DGI, where some patients have experienced homelessness or using illicit drugs, particularly methamphetamine. The CDC noted a similar increase in cases in Michigan in late 2019.What is DGI? DGI is an uncommon but severe complication of untreated gonorrhea. DGI occurs when the sexually transmitted pathogen Neisseria gonorrhoeae invades the bloodstream and spreads to distant sites in the body, leading to clinical manifestations such as septic arthritis, polyarthralgia, tenosynovitis, petechial/pustular skin lesions, bacteremia, or, on rare occasions, endocarditis or meningitis. Patients have initially presented with joint pain attributed to another cause, which was only later determined to be due to DGI. Why is DGI increasing? 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. What do we need to do as medical providers?Screen: Reinstate routine screening recommendations for STDs in females Suspect: For patients reporting joint pain, obtain a social history that includes a sexual and drug use history, and housing status. Suspect DGI in patients with joint pain and treat them according to the CDC STD Treatment Guidelines. Remember that most cases of uncomplicated gonococcal infections are now treated with a single dose of Ceftriaxone 500 mg IM PLUS doxycycline for 7 days. DGI, however, needs IV meds and longer duration of treatment.Test: Order Nucleic acid amplification test (NAAT) and culture specimens from urogenital, extragenital mucosal sites (e.g., pharyngeal and rectal), and from disseminated sites (e.g., skin, synovial fluid, blood, and cerebrospinal fluid) before initiating empiric antimicrobial treatment for patients with suspected DGI. Hospitalization and consultation with ID is recommended for initial therapy. Test all isolates from DGI cases for antibiotic susceptibility, and send all isolates from DGI cases to the local public health laboratory. Report: all suspected and confirmed cases of DGI to public health within 24 hours of identification. Instruct patients to refer their sex partners for evaluation, testing, and presumptive treatment for gonorrhea. 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. Hepatic EncephalopathyGuest: Stephanie Rubio, MS3What is it?Hepatic encephalopathy is a reversible decline in brain function in patients with advanced liver failure and/or portosystemic shunting and may present with ascites. The liver cannot effectively remove ammonia and other toxins from the blood causing a buildup in the bloodstream. Bacteria in the gut can also increase these toxins leading to a rapid progression of signs and symptoms of hepatic encephalopathy. How is the presentation?A wide spectrum of neurological and/or psychiatric abnormalities may be seen, including but not limited to sleep disturbance, mood changes, and euphoria. Motor symptoms include asterixis, dyspraxia, and bizarre behavior. A Subtle form of hepatic encephalopathy known as minimal hepatic encephalopathy presents in 80% of patients with cirrhosis. Neurocognitive signs require higher clinical suspicion because the deficits tend to be mild in presentation. Symptoms to look for while evaluating a patient with cirrhosis: Working memory discrepancies (for example, trying to remember a phone number and write it down, and being unable to recall the number within seconds)Learning impairment (for example, inability to learn new concepts or skills, new recipe)Inhibition control (for example, being unable to avoid eating cake when you are dieting) A brief mini mental status assessment will help guide toward a proper diagnosis. Severity of manifestations is graded due to the importance of differentiating between overt hepatic encephalopathy and covert minimal hepatic encephalopathy for clinical studies.Minimal is graded as abnormal results on psychometric or neurophysiological testing without clinical manifestations vs. Grade I-IV beginning with changes in behavior, mild confusion, slurred speech, or disordered sleep; progressing to coma and unresponsiveness to pain. Who is at risk?Some of the most common causes of liver failure or cirrhosis are patients with severe alcohol abuse, nonalcoholic steatohepatitis (NASH), or hepatitis. It affects 30-45% of patients with liver

Episode 45: Osteoporosis Update. Dr Linares (endocrinologist) explains the basics of screening and treatment of osteoporosis, referring frequently to the updated guidelines of osteoporosis by AACE and ACE (2020). A new group of residents is introduced. Congratulations to our new group of residents: Amelia Martinez Lopez, Amardeep Singh Chetha, Cecilia Selena Covenas, Funmilayo Helen Idemudia, Licet Imbert Matos, Su Myat Hlaing, Timiiye Dawn Yomi, and Young Na Sung. This group of residents will start in July 2021 and will graduate in July 2024. We hope you enjoy your time with us.Today is March 22, 2021.Implanted pacemakers and defibrillators are equipped with a switch that responds to magnetic forces to stop them when needed. Magnetic interference between these cardiac implantable electronic devices (CIEDs) and mobile devices have been investigated for years. It has been established that magnetic fields stronger than 10 gauss can deactivate these cardiac devices, causing pacemakers to give asynchronous pacing and ICDs to stop tachyarrhythmia detection.The Heart Rhythm Society journal, published in October 2009 (that was 11 years ago), an association between portable headphones and significant electromagnetic interference (EMI) in patients with implantable cardioverter-defibrillators (ICD) and pacemakers (PM). 100 patients with implanted devices were tested with different portable headphones. Headphones effectively deactivated implanted devices when held less than 2 cm from skin on the left side of chest. There was not interference when headphones were placed farther than 3 cm. In this study, normal functioning of the devices was restored in 29 out of 30 cases when the headphones were removed from the patient’s chest. The recommendation from that study was to recommend patients to keep their portable headphones at least 3 cm away from their implanted device.More recently, in January 2021, the same journal posted the effect of iPhone 12 on ICDs deactivation. iPhone 12 and MagSafe technology, which allows faster wireless charging, contain strong magnets. iPhone 12 successfully deactivated a Medtronic Inc. ICD when tested by a group of investigators in a patient[2]. The official Apple Support website posted on February 25, 2021, “To avoid any potential interactions with these devices, keep your iPhone and MagSafe accessories a safe distance away from your device (more than 6 inches / 15 cm apart or more than 12 inches / 30 cm apart if wirelessly charging)”[3]. Other devices such as fitness tracker wristbands, and even e-cigarettes have been involved in deactivation of ICDs.Bottom line: Make sure your patient discusses with you or their cardiologist before buying wearable or mobile technology that may interfere with their implanted cardiovascular devices.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. “The secret of getting ahead is getting started” —Mark Twain.Osteoporosis UpdateDuring this conversation, we discussed some parts of the guidelines from the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE)[2], updated in 2020. This is not a complete analysis of those guidelines. For a comprehensive explanation of the guidelines, visit the AACE or ACE websites. The recommendations from these organizations may be different than the ones given by the American Academy of Family Physicians (AAFP) or the United States Preventive Services Taskforce (USPSTF), which are organizations we are more familiar with as family physicians.The questions analyzed during this conversation includes:When would you consider a DEXA scan to screen a woman younger than 65 for osteoporosis? What to do when the report says Osteopenia (T score -1.0 to -2.5)? Let’s mention the recommended dose of Vitamin D and Calcium. What is the FRAX score? What is an easy work up we can do to rule out a secondary cause of osteoporosis before sending patient to you? The new guidelines divide patients in two categories: “High risk/no risk of fractures” and “VERY High risk/prior fractures”, What’s the difference in management between those two categories? (alendronate in high risk vs abaloparatide in very high risk). How can you tell the patient has a good response after 1 year of treatment (Dexa scan, bone turnover markers)? What is a drug holiday? ___________________________Now we conclude our episode number 45 “Osteoporosis Update”. Dr Linares explained what the FRAX score is and mentioned the different options we have for treatment of osteoporosis. DEXA scan continues to be the gold standard for screening, diagnosis and monitoring of osteoporosis. We will announce the winner of the question of the month about polyarthralgia next week, and we wish our new group of residents a great start in J

Episode 44: Diabetic Retinopathy. Dr Carranza explains the effect of diabetes on the retina, domestic abuse among female doctors, jokes.Today is March 15, 2021.Domestic Abuse among Female DoctorsThere are topics which are very sensitive, but we need to talk about them.Such is the case of domestic abuse among doctors. Do you know what is the most important risk factor to be a victim of domestic abuse? Yes, being female, and doctors are not an exception. Recently, in February 2021, the British Journal of General Practice (BJGP) posted an article addressing this topic. The aim of the article was to understand the experience of female doctors as victims of domestic abuse, the barriers they faced to find help, and the impact that domestic abuse had on their work. The study was limited to doctor mothers because the author had access to this group and she was a member of the online forum and a single doctor herself. 114 doctors expressed interest in the study but a total of 21 participants were interviewed. The criteria to be included in the study were being a single mother working as a doctor and having previously left an abusive relationship. Each interview lasted between 44 and 113 minutes and were conducted from August 2019 and March 2020. The interviews were recorded. The principal author of the study can be seen and heard in an interview on the BJGP’s podcast. The doctors felt that stress of domestic abuse affected their quality of work but were unable to participate in seeking help because of the social stigma. One of the barriers for seeking help included lack of confidentiality when the other partner was a doctor as well. One of the participants expressed that the social services did not treat her with respect when the abuser was a doctor himself. Also, the participants expressed embarrassment and shame because of their status as a doctor as she stated that doctors “should know better.” Another negative connotation going through domestic abuse as a doctor is that the particular individual “is not capable of taking care of the patients if she cannot take care of her personal life.” The barriers to find help included “owning up” to domestic abuse, not seeking help from social services and work hours. The doctors feel socially and professionally isolated because they are not able to talk about abuse and fear the consequences of reporting. One of the most helpful thing for victims of domestic abuse was an online social group. The author added that domestic abuse training should be taught in medical school as doctors can be victims as well.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. Question of the Month: Polyarthralgiaby Valerie Civelli (written by Claudia Carranza) This is match week! congrats to everyone, and we hope you matched to your dream residency. This is the question of the month. This is the last week you have to answer this question. We have received very interesting answers but we are hoping to receive yours. A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling very fatigued. You note on her chart that she was diagnosed with COVID-19 six weeks ago that did not require hospitalization. She denies any relevant past medical history. She denies trauma, bleeding, headaches, chest pain, SOB, or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation to bilateral wrist and ankle. No signs of inflammation on joints are noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical ankle and wrist pain with fatigue for 1 month. What workup would you order? Clue: Listen carefully to the history of the patient. Send us your answer to [email protected] before March 22, 2021. The winner will receive a prize.Diabetic Retinopathy A lot of us send out referrals for diabetic retinopathy screenings every day. Now we all learned about this topic in med school but it is important to do an overview as to what diabetic retinopathy entails. These will help us, providers, to be able to explain it to your patients better and also for all listeners to have a better understanding of a much-unwanted complication of diabetes. Basics on Diabetes. So for all of our listeners I wanted to do a quick review on diabetes. A lot of us have heard about “high sugars” and diabetes but what is it really? It is a disease in which carbohydrates are not processed correctly in our body leading to an increase of glucose in our blood. Insulin is made in the pancreas a

Episode 43: Testicular Cancer. Testicular cancer screening and diagnosis (basics), chlorthalidone vs hydrochlorothiazide, and jokes.Today is March 8, 2021. For many years, we have heard about the superiority of chlorthalidone over hydrochlorothiazide to control hypertension, but in clinical practice, hydrochlorothiazide is prescribed more often as the initial therapy for most patients with hypertension as compared to chlorthalidone. As a matter of fact, the Microsoft Word automatic corrector detects hydrochlorothiazide as a correct word, but flags chlorthalidone as misspelled. Also, we know how to abbreviate hydrochlorothiazide (HCTZ), but did you know that chlorthalidone has an abbreviation as CTD?We have been neglecting chlorthalidone regardless its apparent effectivity. In January 2006, the American Heart Association published on its journal Hypertension, a comparison between chlorthalidone and hydrochlorothiazide to control hyperension[1]. A randomized, single-blinded, 8-week active treatment, crossover study compared 12.5mg/day chlorthalidone (force-titrated to 25 mg/day at week 4) and HCTZ 25mg/day (force-titrated to 50mg/day at week 4) in untreated hypertensive patients. 24-hour BP monitoring was assessed at baseline and week 8 plus standard office BP readings every 2 weeks. 30 patients completed the active treatment period. At week 8 there was a greater reduction in baseline systolic blood pressure with chlorthalidone 25mg vs HCTZ 50mg. The effectiveness of chlorthalidone was evidenced by ambulatory blood pressure measurement (ABPM) although this difference was not apparent with office BP measurements. It was a short duration study with a small sample size.More recently, in January 2021, the Journal of Hypertension, which is the official journal of the International Society of Hypertension and the European Society of Hypertension[2], published on PDF a more comprehensive review of these long-time rivals. According to the short version of this article, there is no difference in the short-term net clinical benefit between CTD and HCTZ, BUT long-term available data suggests that CTD is better at reducing major adverse cardiovascular events (MACE) over HCTZ. Stay tuned for the final version of this study.Way to go chlorthalidone!______________________________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 BreakQuestion of the Month: Polyarthralgiaby Claudia Carranza A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain is worse with movement and responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling more fatigued than usual this past month. You note on her chart that she was diagnosed with COVID-19 approximately 6 weeks ago for which she did not need to be hospitalized. She denies history of diabetes, thyroid disease, lupus, rheumatoid arthritis, trauma, or anemia. She denies fecal, urinary, or vaginal bleeding, no headaches, chest pain, SOB or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation at bilateral wrist and ankles. No signs of inflammation on joints is noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical POLYARTHRALGIA and fatigue for 1 month, and what workup would you order (if any)? Clue: Listen carefully to the history of the patient. Send us your answer to [email protected] before March 22, 2021. The winner will receive a prize.“I am not my body. My body is nothing without me.” Tom Stoppard____________________________Testicular Cancer Testicular cancer is the most common solid tumor among males 15 to 34 years of age, with an estimated 8,850 new cases and 410 deaths in the past years. The good news is that with effective treatment, the overall five-year survival rate is 97%[3]. Risk factors. Cryptorchidism: The relative risk of developing testicular cancer ranges from 2.9 to 6.3; the risk is increased in both testes, although the risk is much higher in the ipsilateral testis (6.3 vs. 1.7). Among these patients, the risk of cancer increases when orchiopexy is delayed until after puberty or never performed compared with early orchiopexy. Even after early orchiopexy, the risk of testicular cancer remains elevated compared with the general population. Personal or family history of testicular cancer: Patients with a personal history of testicular cancer have a 12-times greater risk of developing a contralateral testicular cancer than the general population. However, the greatest risk is in the first five years after diagnosis. Patients with a father or brothe

Episode 42: Baker’s Cyst.What is a Baker’s cyst and how to treat it? Alzheimer’s disease may be linked to sleeping pills, polyarthalgia question. Today is March 1, 2021.Arreaza: Spring season is here! A renewal of life and a renewal of hope in the future, and for some, a renewal of allergies. But we will not talk about allergies in our intro today, we will talk about dementia.Civelli: Research is increasingly showing that poor sleep correlates to dementia[1]. In 2019, an article was published by the Alzheimer’s Association International Conference (AAIC) which highlighted several links between sleep medication, sleep disorders and dementia, while also showing us what we still don’t know. Arreaza: Investigators at Utah State University (go Aggies! – my wife told me to say that) found interesting sex-related differences: For Men who reported using sleep medication for sleep issues, there was a 3-fold risk of developing Alzheimer’s disease than men who did not use sleep medications. Women however had different results. For Women who did NOT report having any sleep disturbance but still used sleep meds, the risk of Alzheimer’s disease was nearly 4x’s greater. However, in Women who DID self-report sleep disturbances at baseline, but also took sleeping pills, there was actually a 33% reduction in risk for Alzheimer’s disease. Civelli: Another study by investigators at University of California, San Francisco (UCSF) did not echo these findings. They found no sex-related differences, and they adjusted for a variety of genetic and lifestyle confounders. In this UCSF research, frequent sleep meds and later dementia were strongly correlated – but only in Caucasian adults. The specific sleep medications were not identified however, some meds such as benzos, antihistamines, antidepressants, or others were included. Arreaza: At the University of East Anglia in Norwich, England, in 2018 it was found that long-term exposure to anticholinergic drugs, some antidepressants and antihistamines were specifically associated with a higher risk of dementia, while use of benzodiazepines were not.Civelli: Meanwhile in pursuit of physical proof: 337 brains from the U.K. brain bank were examined. 17% and 21% had known benzodiazepines and anticholinergic chronic exposures. Slight signals in neuronal loss in the nucleus basalis of Meynert were identified. Whether benzodiazepine exposure relates to dementia remains controversial.Arreaza: Suvorexant (Belsomra), the only orexin receptor antagonist that regulates wakefulness, is being tested in Alzheimer’s disease. This targeted therapy decreases sleep fragmentation and increases total sleep time. It may be the future. We will see.Civelli: Lastly, although not a magic bullet, trazodone, has been shown to increase total sleep time in patients with Alzheimer’s disease without affecting next-day cognitive performance, and even slowing down cognitive decline in patients who complained of sleep disturbance. According to Dr. Karageorgiou of UCSF “You’re not going to see long-term cognitive benefits if it’s not improving your sleep, So, whether trazodone improves sleep or not in a patient after a few months can be an early indicator for the clinician to continue using it or suspend it”. More prospective research is needed. Arreaza: The bottom line is: Dementias are associated with serious circadian rhythm disturbances. Physicians are encouraged to focus on improving sleep to help patients with, or at risk for, dementia by consolidating their sleep rhythms. So, what will you do to help your patients sleep better today? 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.________________________Question of the Month: Polyarthralgiaby Ikenna Nwosu A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain is worse with movement and responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling more fatigued than usual this past month. You note on her chart that she was diagnosed with COVID-19 approximately 6 weeks ago for which she did not need to be hospitalized. She denies history of diabetes, thyroid disease, lupus, rheumatoid arthritis, trauma, or anemia. She denies fecal, urinary, or vaginal bleeding, no headaches, no chest pain, no SOB or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation at bilateral wrist and ankles. No signs of inflammation on joints are noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical POLYARTHRALGIA and fatigue for 1 month, and what workup would you order (if any)? Clue: Lis

Episode 41: Otitis Media.Diagnosis and treatment of acute otitis media in children, when to avoid antibiotics, use of short course of antibiotics, question of the week about polyarthralgia and fatigue.Today is February 22, 2021. Question of the Month by Claudia Carranza A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain is worse with movement and responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling more fatigued than usual this past month. You note on her chart that she was diagnosed with COVID-19 approximately 6 weeks ago for which she did not need to be hospitalized. She denies history of diabetes, thyroid disease, lupus, rheumatoid arthritis, trauma, or anemia. She denies fecal, urinary, or vaginal bleeding, no headaches, no chest pain, no SOB or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation at bilateral wrist and ankles. No signs of inflammation on joints is noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical POLYARTHRALGIA- and fatigue for 1 month, and what workup would you order (if any)? Send us your answer to [email protected] before March 22, 2021. The winner will be announced and will receive a prize.Introduction to episode:This week we announced 3 new chief residents. Dr Manny Tu will replace Dr Lisa Manzanares, a big supporter of this podcast and chief for more than 1 year, who graduated last week as didactics chief. Dr McGill and Dr Gomes will continue to be chiefs until they hand over the baton to Dr Gina Cha and Dr Alejandro Gonzalez-Perez. Congrats, dear residents! (or should we say sorry?)When you treat an infection, you need to know the recommended duration of treatment. Normally, the more severe an infection is, the longer the duration of treatment. In many instances, shorter courses of antibiotics can have similar efficacy to longer courses[1], and treating for shorter periods may also reduce the development of resistance and infections by C. difficile. Some infections in which this applies are, for example, community-acquired pneumonia (CAP), where treatment can be shortened to 3-5 days instead of 7-10 days; nosocomial pneumonia which can be treated for 7 days instead of 10-15 days; pyelonephritis, 5-7 days instead of 10-14 days; intra-abdominal infection (after source control) for 4 days instead of 10 days; COPD exacerbation, less than 5 days instead of more than 7 days; bacterial sinusitis, 5 days instead of 10; uncomplicated cellulitis, 5-6 days instead of 10 days. Of course, you must use your clinical judgement when deciding to use a shorter course of antibiotic treatment.As a reminder, FDA has also warned about the relationship between fluoroquinolones and an increased risk of aortic dissection. On their website, it states that “Health care professionals should avoid prescribing fluoroquinolones to patients who have an aortic aneurysm or are at risk for an aortic aneurysm, such as patients with peripheral atherosclerotic vascular diseases, hypertension, certain genetic conditions such as Marfan syndrome and Ehlers-Danlos syndrome, and elderly patients”. They also say you “may prescribe fluoroquinolones to these patients only when no other treatment options are available”[2]. Other safety concerns reported by FDA about fluoroquinolones include: significant decrease in blood sugar and certain mental health side effects, disabling side effects of the tendons, muscles, joints, nerves, and central nervous system, restriction in use for certain uncomplicated infections, peripheral neuropathy, and tendinitis and tendon rupture. Therefore, think about this warning before prescribing fluoroquinolones[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. ____________________________Acute Otitis Media.Dr Katherine Schlaerth is a native of Pennsylvania. She graduated from Manhattan College and received her medical degree from the State University of New York, Buffalo. Dr. Schlaerth completed her pediatrics residency at Children’s Hospital LA and an Infectious disease fellowship at LAC-USC Medical Center. She is board certified in pediatrics, pediatric infectious diseases, family medicine and has a Certificate of Added Qualifications in Geriatrics. Dr. Schlaerth was an associate professor at Loma Linda and is an associate professor emeritus at USC. She has a special interest in research and has published in addiction medicine, child development and other areas.Some topics discussed during this episode included definition of otitis media; risk factors such

Episode 40: Emotional Support Animals.Service Animals vs Emotional Support Animals, meet Ronica and Fred, HTN medications at night, jokes about being 40. Today is February 15, 2021.We hope you had a beautiful Valentine’s Day. Today I’d like to share some information that may be not so new anymore, but for some people it may be new. It’s about hypertension chronotherapy. An article published in AAFP News in November 2019 explains that taking hypertension medication at bedtime improves cardiovascular risk. This was a large prospective study that compared taking meds at bedtime vs taking meds in the morning. It was called The Hygia Chronotherapy Trial. It was originally published in October 2019 in the European Heart Journal. The study was conducted in Spain (ole!), and involved almost 20,000 patients with hypertension who were divided into two groups: One group took all their hypertension medications at bedtime, and another group took all their hypertension medications in the morning. In the next 6 years, 1,752 participants experienced cardiovascular-related death, myocardial infarction, coronary revascularization, heart failure or stroke. And the good news is that the bedtime medication group showed an improved blood pressure control and lower risk than the morning medication group. Taking BP medications at bedtime dropped the death rate by 45%. Incidence of myocardial infarction, stroke and heart failure were all significantly reduced. Taking thiazides at bedtime may be challenging, on the bright side, the study also found that moving only one medication to bedtime is still beneficial. 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. Emotional Support AnimalsArreaza: Our guest does not need introduction because you have listened to her voice in several episodes, especially in our recent episode about menopause. Welcome, Valerie Civelli, it’s a pleasure to have you here. Random question, what is the farthest place you have visited? What will be talking about today?Civelli: Emotional Support Animals (ESA). Many people with disabilities use a service animal in order to fully participate in everyday life. Dogs can be trained to perform many important tasks to assist people with disabilities, such as providing stability for a person who has difficulty walking, picking up items for a person who uses a wheelchair, preventing a child with autism from wandering away, or alerting a person who has hearing loss when someone is approaching from behind.Arreaza: So, is it like a service animal? Civelli: Service animals and emotional support animals are not the same, so be sure to note the different. According to the APA, American Psychology Association: Species: Any animal can be an emotional support animal. Under federal law, only dogs and miniature horses can be service animals[2]. Such is the case of Abrea Hensley who has flown from Nebraska to Chicago with her miniature mare, Flirty in August 2019. Arreaza: There was revival on the topic again. A story went viral in February 2020, one year ago, as Ronica Froese flew from Michigan to Ontario (California) with her service animal who is a miniature horse named Freckle Butt Fred, or Fred for short. They traveled together in first class. The picture went viral online, and it created positive and negative comments among travelers and internauts. Miniature horses were approved as service animals in 2011 by the ADA (Americans with Disability Act).Civelli: Purpose: An emotional support animal assists through its presence alone. A service animal is specially trained to perform tasks for someone with a disability. Training: An emotional support animal requires no training; all that's needed is a letter from a mental health professional explaining its therapeutic value. Service animals must undergo individualized training. Arreaza: Animals for sure generate a reaction in humans whenever they enter a room. Tell us about the legal protections. "An animal's eyes have the power to speak a great language." ― Martin Buber. "An animal's eyes have the power to speak a great language." ― Martin BuberCivelli: While the Americans with Disabilities Act (ADA) protects service animals, it does not cover emotional support animals. Emotional support animals are covered only under the Air Carrier Access Act and Fair Housing Act. Keep in mind, the criteria of mental or emotional disability is defined in the DSM 5, by the Americans with Disability Act (ADA), the Fair Housing Act, the Rehabilitation Act of 1973 (section 504), as well as the Air Carrier Access Act (49 U.S.C. 41705 and 14 C.F.R. 382).Arreaza: Where can service animals go?Civelli: A service animal can go anywhere its owner goes. While owners of emotional support animals may get away with bringing them into places where pets

Episode 40: Erectile Dysfunction Basics. Erectile dysfunction fundamentals, allergy to penicillin label removal, jokesToday is February 5, 2021. Question of the month: Diabetes managementThis is a reminder of our question for this month. Please answer before Feb 15, 2021. The best answer will receive a prize. Question: What is the first treatment approach for type 2 DM? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random BG of 210.Send your answer to [email protected]. Don’t miss this chance to win.Penicillin Allergy Study: How many times have you heard a patient say that they are allergic to penicillin? Exactly, a lot! Skin allergy testing continues to be the best test to diagnose penicillin allergy. All patients who have a negative penicillin allergy skin test should be challenged with penicillin in a medical setting for 1-2 hours to ensure that immediate reaction does not occur. Many patients labeled as “allergic to penicillin” may not be truly allergic. We recognize that true penicillin allergy exists, and allergic reactions range from mild rash to life-threatening anaphylaxis, but many patients needing penicillin may not get it because of a wrong diagnosis of penicillin allergy. Up to 15% of the US population are labeled as “allergic to penicillin”. The American Journal of Respiratory and Critical Care Medicine published in February 2020 a way to remove low-risk penicillin allergy labels in an ICU. The investigators created a risk-stratification tool after evaluating 318 patients in an allergy clinic. Low risk indicators include urticaria to penicillin >5 years ago, a self-limited rash, GI symptoms only, a remote childhood history, a family history only, avoidance from fear of allergy only, a known tolerance to penicillin since the reported reaction, or non-allergic symptoms. Using that tool, 216 patients admitted to the MICU labeled as “allergic to penicillin” were evaluated. 68 patients qualified as “low risk.” 54 patients agreed to be challenged with a single oral dose of 250 mg amoxicillin and observed for 1 hour. None of the challenged patients had any immediate or delayed reaction. Their penicillin allergy label was removed. Later, 41 of the 54 challenged patients received multiple doses of either penicillin’s (17 patients) or cephalosporins (24 patients) without any reaction. This tool has not been validated to be used in an outpatient setting yet, but it sets the foundation for further investigation in this matter.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. ____________________________Erectile Dysfunction. Arreaza: Today our guest is Dr. John Ihejirika. Ihejirika: My name is Dr. John Ihejirika. I am one of the third/Final-year residents at the Rio Bravo Family Medicine residency program, here in Bakersfield, California. I am glad to be back on the podcast and thanks for having me again.Arreaza: What topic are you discussing today?Today I will be talking about Erectile dysfunction.Arreaza: What is Erectile dysfunction?Ihejirika: Erectile dysfunction [ED] can be defined as the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. It is very common, affecting at least 12 million men in the United States. The condition can be caused by vascular, neurologic, psychological, medications and hormonal factors. Arreaza: What are common conditions associated with ED?Ihejirika: Common conditions related to ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment. Performance anxiety and relationship issues are common psychological causes. Medications and substance use can also cause or exacerbate EDMedications: Antidepressants are a common cause especially the SSRI and SNRI drugs. Substances: Tobacco, alcohol, and illicit drugs can cause ED. Marijuana use may cause ED, although further study is needed.Arreaza: Is ED related to any other risks?Ihejirika: Cardiovascular risk: ED is associated with an increased risk of cardiovascular disease, particularly in men with metabolic syndrome. Initial treatment: Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions. Arreaza: Let’s talk about the “blue pill.”Ihejirika: Oral phosphodiesterase-5 inhibitors are the first-line treatments for ED. Second-line treatments include alprostadil and vacuum devices. Arreaza: Vaccum: No medication interaction.Ihejirika: Surgically implanted penile prostheses are an option when other treatments have been ineffective. Counseling is recommended for men with psychogenic ED.Arreaza: However, most cases have an organic cause. How is E

Episode 38: Menopause Tips. Asthma treatment update, menopause tips, MMR associated fever and seizures.Today is January 25, 2021.Updates on asthma: As you know asthma is a significant burden for our healthcare system, and for the most part it is not preventable nor curable, but advances in management have changed many patient’s lives over the last 40 years. On our episode 27, we mentioned the updated practice guidelines by the Global Initiative of Asthma (GINA). Today we will give you the updated recommendations by the National Asthma Education and Prevention Program (NAEPP) posted on December 3, 2020. It contains recommendations for the treatment of asthma in children, adolescents, and adults[1]. This is an update from the NAEPP 2007 guidelines and are slightly different than GINA regarding step 1 and step 2 management.-Step 1 (intermittent asthma): NAEPP did not make any changes from 2007. They continue to recommend short-acting β2-agonists [SABAs] for rescue therapy. Remember that GINA recommends against use of SABA as a sole therapy for step 1. -Step 2 (mild persistent asthma): Either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA. -Step 3 and step 4 (moderate persistent asthma): formoterol combined with an inhaled corticosteroid in a single inhaler (also known as single maintenance and reliever therapy – SMART) is recommended as the preferred therapy. For step 3 a LOW-dose ICS-formoterol therapy is recommended, and for step 4 a MEDIUM-dose ICS-formoterol therapy is recommended for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. -Step 5 (severe persistent), adding a long-acting muscarinic antagonist (LAMA) is recommended in patients whose asthma is not controlled by ICS-formoterol therapy. -Fractional exhaled nitric oxide testing (FeNO) is recommended to ASSIST in diagnosis and monitoring of symptoms, but is should not be used ALONE for the diagnosis and monitoring of asthma, and do NOT use in younger than 5 yo patients. Another recommendation is to control allergens in patients with relevant sensitivity. This may not sound so new, but there are several strategies for allergen mitigation, for example, use of impermeable pillow and mattress covers only as part of a multicomponent allergen mitigation intervention. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort. If you are still confused about these 2020 NAEPP guidelines updates, I recommend you go online and review them, it is easier to read them than listening to them. Find the link in our posted script.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. ____________________________Menopause Tipsby Valerie, That's me, Dr. Civelli w/ a C!and your friendly medical student neighbor Patrick De LunaTIP #1: Hot Flashes. Hot flashes, aka vasomotor symptoms occur in 70% of women in menopause. Hot flashes can last 1-5 minutes; can be characterized by perspiration, flushing, chills, clamminess, anxiety, and on occasion, heart palpitations; and can cause sleep disturbances. Hot flashes are the most common indication for hormone replacement therapy (HRT). Contraindications for HRT include undiagnosed vaginal bleeding, a history of breast cancer, VTE, or Severe liver disease.Dr Wonderly, how do you treat hot flashes? [Listen to her answer in Episode 38]TIP #2: Hormonal replacement therapy for hot flashes.Estrogen or estrogen/progesterone combo is the most effective therapy for menopausal hot flashes. It’s FDA-approved and has a grade A research according to AAFP and ACOG. Topical methods are preferable as they have fewer adverse effects. But how do you choose? There’s Estrogen? Or estrogen/Progesterone combo? And what is the cancer risk? Remember if using hormones: Dose, duration and risk factors are key! Combined estrogen/progestogen therapy is recommended over estrogen alone, but still increases the risk of breast cancer after three to five years of use. There is no evidence that using low-dose local estrogen increases the risk of breast cancer recurrence. Combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene may also be used, especially when the patient still has a uterus. The decision to start HRT or to continue for more than three to five years should be made after reviewing all risks, benefits, and symptoms with each patient. Dr Wonderly, when do you decide to continue HRT for longer than 3-5 years? [

Episode 37: Honey in Medicine. Smoking cessation update. Honey in medicine. Uses, precautions, honey-related terms. Macroglossia and presbycusis are defined. Jokes about honey. Today is January 15, 2021. The American Thoracic Society approved a clinical practice guideline regarding pharmacologic treatment of tobacco dependence in adults. This guideline was published in May 2020 in the American Journal of Respiratory and Clinical Care Medicine. Seven recommendations about initial medications used in smoking cessation were given, five are STRONG recommendations and two are CONDITIONAL recommendations.Let’s start with the STRONG recommendations for tobacco-dependent adults in whom treatment is being initiated:Varenicline over a nicotine patch is recommended. Remarks: Be prepared to counsel your patients about the relative safety and efficacy of varenicline compared with a nicotine patch.Varenicline over bupropion is recommended.In patients who are not ready to quit smoking, treatment with varenicline rather than waiting until patients are ready to stop tobacco use is recommended.In patients with comorbid psychiatric conditions, including substance-use disorder, depression, anxiety, schizophrenia, and/or bipolar disorder, varenicline over a nicotine patch is recommended.For tobacco-dependent adults for whom treatment is being initiated with a controller, extended-duration (>12 weeks) over standard-duration (6–12 weeks) therapy is recommended. A controller is a medication with a delayed onset of effect that reduces the frequency and intensity of smoking (i.e. varenicline), whereas a reliever is a medication with acute effect to reduce cravings (i.e. nicotine gum). CONDITIONAL recommendations:Varenicline plus a nicotine patch over varenicline alone is suggested (conditional recommendation, low certainty in the estimated effects).Varenicline over electronic cigarettes is recommended. Remarks: serious adverse effects of e-cigarettes have been reported. The recommendation will be reevaluated if these reports continue. Quotes about honey: You catch more flies with honey than with vinegar.No bees, no honey; no work, no money.Honey is sweet but bees sting.Be like the honey bee, anything it eats is clean, anything it drops is sweet, and the branch it sits upon does not break (Iman Ali, Pakistani actress)When you go in search of honey you must expect to be stung by bees (Joseph Joubert, French moralist)Life is the flower for which love is the honey (Victor Hugo, French poet)______________________________Claudia: Today we have a special episode to honor those with a sweet tooth. We will talk about the ultimate nature candy: honey. Yes, we will talk anything related to honey in medicine.But... what is honey? It is a sticky, sweet, clear yellowish-brown fluid made by bees. How? you might wonder; well they collect nectar in their honey stomach or what they call the “crop” and as you might be guessing they create honey by vomiting this digested nectar. Hector: Let’s start with honeycomb lung. Claudia: Honeycomb lung — This is something many medical students and residents might hear for the first time and think huh? Unfortunately hearing a patient has honeycomb lungs is not at all “sweet news.” Honeycomb lung is indicative of end-stage pulmonary fibrosis, and many disorders such as Idiopathic Pulmonary Fibrosis, sarcoidosis, hypersensitivity pneumonia, and eosinophilic granuloma can progress to end-stage fibrosis, but cannot be detected by pathologists at this stage of the disease. For that reason, biopsy of extensive honeycomb lung is not helpful and should be avoided.This Honey-comb appearance of lungs in CT scan has been found to be common in COVID-19.Hector: Yes, honeycombing fibrosis seems to follow ground-glass opacities(1) in COVID 19 patients. Honeycombing are small cystic spaces with irregular thickened walls made out of fibrous tissue. A friend told me this bold statement: “A CT scan is more sensitive than PCR to detect COVID-19”. That puzzled me, and I had to look it up. The American College of Radiology issued a statement saying that “viral testing remains the only specific method of diagnosis. Confirmation with the viral test is required, even if radiologic findings are suggestive of COVID-19 on CXR or CT. CT is reserved for hospitalized, symptomatic patients with specific clinical indications for CT.”(2) Do not use CT for COVID-19 diagnosis.Claudia: Next term is Honeymoon cystitis — Now why would you ruin a honeymoon which is supposed to be fun with the not so fun word cystitis.? Well because this uncomfortable infection is common in sexually active women and it makes sense that it can occur more often in newly-weds during a much-anticipated vacation. Hector: Recurrent urinary tract infections are a common problem in sexually active women. Anatomy is to blame of this problem. Sexual intercourse may cause local irritation of the urethral meatus and lead to cystitis ("honeymoon cystitis"). Claudia: Honey-colored cr

Episode 36: Birth Control and HTN. Gonorrhea treatment update. Use of birth control in hypertension. Explanation of allodynia and hyperalgesia. Tips on contraceptives. Jokes.HAPPY NEW YEARS EVERYONE! Welcome to our first episode of 2021. We are full of hope and optimism for this new year, even though this year is looking just the same so far.Outdated treatment for gonorrhea: Ceftriaxone 250 mg IM and azithromycin 1 gram PO.Updated treatment of gonorrhea: On December 18, 2020, the CDC recommended a new treatment of uncomplicated urogenital, rectal, or pharyngeal gonorrhea with a single IM dose of 500 mg of ceftriaxone (instead of 250 mg). For patients who weigh more than 150 kg (300 lbs), the single intramuscular dose is 1 gram. If chlamydial infection has not been excluded, doxycycline 100 mg orally twice a day for 7 days is recommended (instead of azithromycin). However, azithromycin, 1 g PO single dose, is still recommended in pregnancy.Allergy to cephalosporins: In patients with cephalosporin allergy, a single 240 mg IM dose of gentamicin PLUS a single 2 GRAMS oral dose of azithromycin is an option.Expedited Partner Therapy – EPT: When permitted by state law, the partner may be treated with a single 800 mg oral dose of cefixime, and ADD oral doxycycline 100 mg twice daily for 7 days if chlamydia infection has not been excluded.Test of cure: A TOC is not needed for patients with uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, a test-of-cure is recommended for pharyngeal gonorrhea, 7–14 days after initial treatment. Retest: ALL persons treated for gonorrhea should be retested 3 months after treatment. If retesting at 3 months is not possible, we should retest within 12 months after initial treatment.Summary: treat urogenital, rectal, and pharyngeal gonorrhea with single IM dose of 500 mg of Ceftriaxone PLUS doxycycline 100 mg BID for 7 days. 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. ____________________________Interview to Dr Tammela by Dr Arreaza (unscripted)Highlights of the interview:What measurement is essential before starting combined oral contraceptives? The answer is blood pressure measurement.Dr Tammela is the chief of women’s health in Clinica Sierra Vista. She is a practicing OB/Gyn specialist. Some topics discussed during the interview includes: Why is blood pressure measurement essential before starting combined hormonal contraception?Contraindications to combined hormonal contraceptionThree scenarios and recommend what type of contraception should be used: Patient younger than 35, healthy, well-controlled hypertensionPatient older than 35, well-controlled HTN, or patient of any age with BP 140-160/90-100 mm HgPatient of any age with blood pressure >160/100Continued blood pressure monitoring after initiation of combined hormonal contraceptionWhen to stop CHCTIPS by Valerie Civelli, MD and Patrick De Luna, MS3Which OCP to choose?Tip #1:In general, higher estrogen in birth control pills (35mcg) means better cycle control but worse estrogen-related side effects: such as nausea or breast tenderness. Lower dose estrogen birth control, (typically 20 µg) are better for those experiencing estrogen related side effects and must be taken at the same time every day. Remember: the lower the dose of Estrogen means the higher risk of breakthrough ovulation and breakthrough bleeding. LoLo® is a great option!Dr. Karen Tammela, OBGYN, when asked about her OCP preference for patients, she states, “I pretty much always use monophasic pills. They seem in general to provide improved cycle control. I think most OB/GYN‘s agree...”Tip #2:For patients who c/o bloating, weight gain, hirsutism and acne, think about Yaz®, and its higher dose sister Yasmin®: Drosperinone + Ethinyl Estradiol. Yaz or Yasmin have a special type of progesterone, Drospirinone, which makes it unique. Tip #3:Yaz and Yasmin: Let’s talk about insurance coverage (Family Pact and Kern Health) 12-month Supply may be provided twice in one year. For a 3rd dispense of 12-month supply, TAR is required for prior authorization. If you see this med was not covered, it’s likely the patient has been prescribed two-12/month supplies OCPs already. Submit a TAR in this case for coverage.Tip #4:Yaz or Yasmin are special because it is not just a low androgen option (which is what you look for in a pill for patients in need of acne control), but it is actually an ANTI-androgen, so it is THE BEST OPTION for acne. It also is the best option to reduce pill related weight gain, as the progesterone element (drospironone) acts as a diuretic. Did you know Drosperinone has antiandrogenic properties equivalent to 25mg of spironolactone? Tip #5:Menstrual headaches? Think Mircette®. Mi

Episode 35: Palliative Care and Hospice. COVID-19 vaccines and USPSTF recommendations. Palliative care and hospice briefly explained by Dr Tu. Pyogenic granuloma is defined. Feliz Navidad, and jokes. Hepatitis B screening in adolescents and adultsFirst, on December 15, 2020, the USPSTF recommended to offer screening for Hepatitis B virus infection to all adolescents and adults at increased risk for infection, regardless of their immunization status[1]. Some examples of patients at increased risk are:Those coming from countries with HepB prevalence above 2% (for example, most countries in Africa and Southeast Asia, South Korea, Italy, Colombia, Ecuador, and Peru, among others). Also, US-born children if they did not receive the HepB vaccine as infants AND their parents come from countries with a prevalence above 8% (check the list online).Other groups include: IV drug users, MSM, HIV, even household contacts of persons known to have POSITIVE HepB surface antigen. Remember to order the right test for screening: HepB surface antigen. As a reminder, Hep B screening in pregnant women at the first prenatal visit is a USPSTF “A” recommendation. Screening for high blood pressure in children and adolescentsOn November 10, 2020, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents. This is a Grade I recommendation[2]. When screening, clinicians should consider risk factors, such as obesity, family history of hypertension, and ethnicities such as African-American or Hispanic. The grade I recommendation means that more research is needed. Maybe you guys can use that as a research idea.Announcement of Coronavirus VaccinesOn December 11, 2020, the FDA granted an Emergency Use Authorization for tozinameran or the BNT162b2 vaccine, manufactured by Pfizer-BioNtech, becoming the first coronavirus vaccine approved in the USA. A week later, on December 18, 2020, the mRNA-1273 vaccine, manufactured by Moderna, was also approved for emergency use. The two vaccines are being administered as we speak to front-line health care providers across the nation. The two vaccines have an efficacy above 90%, and consist of two doses: 3 weeks apart for Pfizer, and 4 weeks apart for Moderna. They seem to reduce the risk of severe COVID-19.Reported side effects include: injection site pain, fatigue, headache, muscle pain, and joint pain. Some people may experience fever. Side effects are more common after the second dose; younger adults, who have more robust immune systems, reported more side effects than older adults. Staggering vaccinations among staff is recommended.The vaccines have not been tested in children or pregnant women yet. The American College of Obstetricians and Gynecologists (ACOG), recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on ACIP-recommended priority groups. ACOG recommends that pregnant individuals should be free to make their own decision in conjunction with their clinical care team. Efforts across the globe are being made to find a vaccine and medications to treat COVID-19. Sputnik V was a vaccine created in Russia and being distributed in allied countries; the Soberana 1 and Soberana 2 were created in Cuba and are under investigation; and in October, a “molecule” called DR-10 was announced in Venezuela that reportedly neutralizes 100% of SARs-CoV-2. There is so much to say about this topic, and the conversation may go beyond just science, but we invite you to follow the news from trustworthy sources as they continue to evolve. 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 is sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.“You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.”Dame Cicely Mary SaundersEnd-of life care may be challenging but also very rewarding. You get to take care of people during this critical time or their lives. Some people think it’s the end of a life, some people see it as a period of your existence, a passage to a “better life” or whatever your belief is about it. As doctor, we consider seriously the principle of sanctity of life vs quality of life. Today, we have Dr Tu, who previously talked about wound care, and now he comes with a new topic to discuss. Welcome again Dr Tu.1. Question #1: Who are you? Presently I am a second-year family medicine resident. And I recently finished my palliative care-hospice elective 2 weeks ago with Dr. Warren Wisnoff. And I had a wonderful and full of learning experience during this rotation. And I really want to share some of those experiences with you. 2. Question #3: What did you learn this

Bonus Episode: Our History. Listen to some of the founders of the program as they share memories, dreams, anecdotes and vision for the Rio Bravo Family Residency Program. End of Season 1. The sun rises over the San Joaquin Valley, California, today is November 6, 2020.The 2021 Match season is in full development. We have reviewed many applications and interviews will begin this coming week. We wish good luck to all candidates. May you find a residency that meets your expectations and provides you the training you want.Today we present a bonus episode to remember our program history. How did this residency program start? Who helped with the foundation of the program? What improvements are expected in the future? We will answer those and other questions in this bonus episode, and you will hear from some of the founders of the program.Stay tuned.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.“The only thing necessary for the triumph of evil is for good men to do nothing.” – Edmund BurkeCongratulations to the winner of the presidential elections in the United States of America. Good men need to be actively engaged in improving our society, otherwise evil will prevail and chaos, suffering and misery will spread. I think our residency program is an example of good things that have been done by good people. We will listen to an interview done by Dr Manzanares, our current chief resident, with Mr Schilling, former CEO of Clinica Sierra Vista and founder of the program. Sandra Lopez, our first residency coordinator, will also share her thoughts. And we will also hear from two graduates of our first class, Dr Cindy Her and Fernando Palacios. Dr Stewart will close the episode sharing her vision for the future. Foundation of the Rio Bravo Family Medicine Residency Program The first class started on June 23, 2014. The first residents were: Hector Arreaza, Josue Balart, Rafael Chiquillo, Cindy Her, Fernando Palacios, and Adan Romero. Program Director: Carol Stewart; Program Coordinator: Sandra Lopez. Faculty: Irene Sunday and Ryan Cabatbat. The program was housed in the Greenfield Community Health Center until March 6, 2015, when the East Niles Community Health Center was officially opened to the public. The program increased the number of residents in each class from 6 to 8 every year in 2019. Statistics: Graduates as of November 2020: 21, with 2 residents graduating by the end of January 2021, for a total of 23 residents. Stayed in the Central Valley: 14. Underserved areas: 19. Stayed in Bakersfield: 11. Stayed with Clinica Sierra Vista: 12.Our mission: To Seek, Teach and Serve​Educate and train high quality family medicine residents in multicultural, rural and underserved settings.Support a family medicine-centered education service and research in Kern County.Facilitate the development and sustenance of a regional service-education network for family physicians and allied health professionals.Serve in a general capacity to facilitate, research and organize innovative approaches to health care in family and community medicine.​Our GoalsExcellence in medical education.Facilitate selection of practice sites in the Central San Joaquin Valley.Provide ongoing support in practice through continuing medical education efforts, research activities and program educational activities.Develop and implement the health team concept in the health care delivery system for this region.Respect for resident’s well-being.Instruct residents in longitudinal care of their patients with an understanding of the impact of psychosocial factors on their health and wellbeing.Teach residents the principles of health maintenance, disease prevention, health education and community-oriented primary care, in addition to caring for a broad range of acute and chronic problems encompassing the fields of pediatrics, adult medicine, and OB/GYN.Highest quality patient care.Sustain learning environments that foster academic excellence, inspire the highest standards of professionalism, and ensue the delivery of safe, high-quality care to patients.Serve in a general capacity to facilitate, research and organize innovate approaches to health care in family and community medicine.Needs met by the residency program: Patients seen: Each resident sees a minimum of 1650 patients in clinic and 1040 patients in hospital before graduation. That’s 2,690 patients per resident. If we have 23 graduates = 61,870 patients seen in by our graduates, and that does not include the patients seen by all other residents who are in the program.Our service areaThe population we serve has a variety of acute and chronic conditions. Unique to this area is Valley Fever. Residents who are interested in infectious Disease may find a variety of acute and chronic infections, including HIV, STIs, hepa

Episode 33: The Flu. Saba and Dr Arreaza gave us a brief review on the flu shot. Influenza vaccination starts at 6 months of age. Vaccinate everyone including pregnant women. Pectoriloquy is basically being able to understand the voice of a patient with a stethoscope placed on their chest. We learned the Spanish word gripe (gree-pay) which means cold and flu in Spanish. The sun rises over the San Joaquin Valley, California, today in October 30, 2020.Halloween is just around the corner! Today we will talk about vaccines because the new influenza season just started. If you have not realized it yet, this podcast is a strong defender of vaccines. So today we bring you what you need to know about the feared flu shot.Some fun facts about cold and flu symptoms. A cough can travel as fast as 50 mph and expel almost 3,000 droplets in just one go. Sneezes can travel up to 100 mph and create about 100,000 droplets. Yikes![1] During a pandemic, coughing or sneezing in public may even be more embarrassing than farting. Did you know that the average adult produces about 1.5 quarts of mucus a day, that’s 48 ounces! and we swallow most of it. As a reference, a Big Gulp has about 30 ounces. The amount of mucus can double or triple during infections. That’s a lot to swallow!This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse and you say that you are neutral, the mouse will not appreciate your neutrality.” — Desmond Tutu.This is not a podcast about politics, but with elections coming soon, we remind everyone to vote for the candidate who represents their values and beliefs. The two big contenders, Donald Trump and Joe Biden, have their own opinions and two different visions of what they want to do in the following 4 years in America. So, go and vote! You can decide who is the oppressor and who is the oppressed, based on your own judgement.Here we have Saba Ali, a fourth-year medical student who will talk about influenza vaccine.Timing of vaccineSaba: Remember to start influenza vaccination at 6 months of age. Any patient who has not received any influenza vaccine before age 8 should receive 2 doses 1 month apart. Vaccination is most effective if received by the end of October, although a vaccine administered in December or later is likely still beneficial. Intranasal vaccineArreaza: And for those who are scared of needles, we have good news: The “intranasal vaccine” or live attenuated influenza vaccine (LAIV4) is approved for use in healthy non-pregnant individuals, 2 years through 49 years of age. Saba: Don’t use LAIV4 in younger than 2 years or older than 50 years, pregnant women, patients with severe allergies to previous flu vaccines, patients younger than 18 receiving aspirin or salicylate-containing medications, immunosuppressed patients, caregiver of immunosuppressed patients, children younger than 5-year-old with asthma, people on antiviral medications, patients with active communication between the CSF and oropharynx, nasal pharynx, nose, or ear, or any other cranial CSF leak, and patients with cochlear implants, asplenia or persistent complement component deficiencies.Types of vaccinesArreaza: CDC recommends using any age-appropriate influenza vaccine: 1. inactivated influenza vaccine [IIV], 2. recombinant influenza vaccine [RIV], or 3. live attenuated influenza vaccine (LAIV). No preference is expressed for any influenza vaccine over another. Egg AllergySaba: A common question we have from patients is “I have egg allergy; can I still get the flu shot?”Arreaza: The answer is: The influenza vaccine contains potential allergic components that may cause an anaphylactic reaction. One such allergen is egg proteins. Currently, all vaccines except for (Flublok (RIV4) quadrivalent for ≥18yo, and Flucelvax (IIV4) quadrivalent for ≥4yo) may contain trace amounts of egg proteins such as ovalbumin. Healthcare providers should be aware that allergic reactions, although rare, can occur at any time, even in the absence of a history of previous allergic reactions to vaccines. Therefore, providers giving the vaccination should have a plan for emergencies and be trained in cardiopulmonary resuscitation. Saba: The following are recommendations for patients with a history of egg allergies:Patients with only urticaria after exposure to egg should receive an influenza vaccine appropriate for their age and health status. Patients that report having more severe reactions to egg and required epinephrine or other emergency intervention can also get any vaccine appropriate for age and health status. If a vaccine other than CCIIV4 or RIV4 is given, it should be given in an inpatient or outpatient setting supervision

Episode 32: VertigoThe sun rises over the San Joaquin Valley, California, today is October 20, 2020.It’s time to talk about vaccines again. The ACIP (Advisory Committee on Immunization Practices) posted new recommendations for meningococcal vaccinations on September 25, 2020. There are two kinds of meningococcal vaccines in the US: 1. Meningococcal conjugate or MenACWY vaccines (Menactra®, Menveo®, and MenQuadfi®)2. Serogroup B meningococcal or MenB vaccines (Bexsero® and Trumenba®). Let’s discuss how they are given.MenACWY: Menactra (MenACWY-D), Menveo (MenACWY-CRW), and MenQuadfi (MenACWY-TT) MenACWY routine: The meningococcal conjugate vaccine should be given to ALL PATIENTS at 11 to 12 years old, with a booster dose at age 16. Remember, it’s a two-dose series, the booster dose at age 16 is important to provide protection during the ages of highest risk of infection. So, that was easy. The hardest part is for patients younger than 10 years old because only patients who are at risk receive routine meningococcal conjugate vaccines before age 11. MenACWY in special groups: This vaccine is given to patients older than 2 months old only if they are at increased risk for meningitis (i.e., persistent complement component deficiencies; persons receiving a complement inhibitor such as eculizumab [Soliris] or ravulizumab [Ultomiris]); persons who have anatomic or functional asplenia; persons with HIV infection; microbiologists routinely exposed to Neisseria meningitidis; persons at increased risk in an outbreak; persons who travel to or live in hyperendemic or epidemic areas; unvaccinated or incompletely vaccinated first-year college students living in residence halls; and military recruits.) I invite you to consult ACIP recommendations regarding vaccination in special groups. MenB: Trumenba (MenB-FHbp), Bexsero (MenB-4C) MenB shared decision: MenB vaccination is not routinely recommended for all adolescents. It may be given to adolescents and young adults (16 through 23 years old, preferred age is 16-18 years old) on the basis of shared clinical decision. Those who decide to receive MenB vaccine, receive two doses 1-6 months apart depending on the brand name you use. MenB vaccines are not recommended before age 10 in any case. Adults older than 24 and older don’t need MenB unless they are at increased risk.MenB in special groups:Patients with certain medical conditions (persons with persistent complement component deficiencies; receiving a complement inhibitor; with anatomic or functional asplenia; microbiologists exposed to isolates of N. meningitidis; and persons at risk in outbreaks) should receive MenB vaccine. These recommendations will be included in the updated 2021 immunization schedules, and the AAFP will review changes to the schedules once they are available (1).This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.____________________________“A man is who he thinks about all day long” –Waldo Emerson.If you think you are not good enough, you may not reach your goals. So, think positive about yourself all day long, and you will become that person you think you are and will reach your goals.Hi, this is Dr Carranza, I’m a PGY3, and today I will interview a special guest.Question Number 1: Who are you? Hello, I’m Jagdeep Sandhu. I’m a 4th year medical student from Ross University, currently doing a sub-internship in family medicine. I’m originally from Seattle, Washington. I have an Indian ancestry, so I enjoy meditating and cooking Indian dishes.Question number 2: What did you learn this week? Lightheadedness vs VertigoThis week we learned about dizziness and its differentials. It is important to differentiate dizziness vs lightheaded because a lot of patients will say they are dizzy when they are truly lightheaded. To be honest dizziness (at least for me) is one of the toughest complaints to get from a patient as it is hard to pinpoint its etiology.Important questions to ask the patient are:Do you feel like you’re going to pass out? Do you experience a sense of darkness in front of your eyes? (points to syncope)Is the room spinning? Are you having nausea or vomiting? Ringing in your ears? (points to vertigo) Peripheral VertigoPeripheral refers to vertigo originated from the ear structures, whereas central from the brainstem. Differentials of peripheral vertigo include:Benign paroxysmal positional vertigo: Transient episodes of vertigo caused by stimulation of vestibular sense organs, this is most commonly due to calcium debris within the posterior semicircular canal, known as canalithiasis. It affects middle-age and older patients; and twice as many women than men. Classically, patients describe a brief spinning sensation brought on when turning in bed or tilting the head backward to look up. The dizziness is quite brie

The sun rises over the San Joaquin Valley, California, today is October 9, 2020. About one year ago, the American Thoracic Society and Infectious Diseases Society of America issued an official clinical practice guideline regarding the diagnosis and treatment of adults with community acquired pneumonia (CAP). There you can find the answer to 16 common questions about CAP in adults. For example, question 8 refers to the antibiotics recommended for empiric treatment of CAP in adults as outpatients. For healthy outpatient adults without comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) or risk factors for antibiotic resistant pathogens (prior respiratory isolation of MRSA or Pseudomonas, or recent hospitalization AND receipt of parenteral antibiotics in the last 90 d), It is recommended monotherapy with amoxicillin or doxycycline or a macrolide.For outpatient adults with comorbidities, the antibiotics recommended (without specific order) are 1. Combination of amoxicillin/clavulanate or cephalosporin (such as Cefuroxime) PLUS Macrolide (such as azithromycin) or doxycycline or2. Monotherapy with respiratory fluoroquinolone (such as levofloxacin).CAP with no comorbidities in adult: Monotherapy with amoxicillin, doxy or a macrolide. CAP with comorbidities: Combined Augmentin or cephalosporin PLUS a macrolide or doxycycline. It’s a tongue twister, may it’s better if you take a look at the official recommendation.This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “Courage isn’t having the strength to go on – it is going on when you don’t have strength. – Napoleon Bonaparte.Dr. Arreaza: Courage means to keep going even when you don’t have strength. Feeling discouraged is not uncommon during residency. You may feel inadequate at times, you may feel like “you don’t know enough,” but don’t worry, it is not easy, but the extra work is worth it. Get the courage to keep going. Dr. Patel: Hi listeners, I’d like to introduce myself, name is Ravi Patel, I’m a non-practicing MD who recently moved to Bakersfield and just met Dr. Arreaza, and his quote resonates with me because my journey to practicing medicine has been quite long and I definitely feel the importance in not giving up in the face of discouragement. Dr. Arreaza: Can you tell us a little bit of your background on working with pain management and opioids?Dr. Patel: I have several years of experience working in pain management and primary care with the Vegas metro population, huge indigent population which faces unique challenges especially in regards to opiate therapy. I’m here to discuss with Dr. Arreaza issues involving opiate usage, when it is appropriate, when it is not appropriate, and the importance of limiting usage, and in what cases long term usage is appropriate.Dr. Arreaza: That’s going to be our first topic – opiate therapy. When is it appropriate? How do you screen patients for therapy?Dr. Patel: It’s important to follow CDC guidelines, great place to begin, in screening patients it is inevitable due to the nature of opiates, to have drug-seeking patients. I like to begin with CDC guidelines. It’s important to stay under 90 MMEs per day, just in terms of efficacy and of course legal reasons, and most importantly patient safety. I like to follow the rule of 3 and 7, meaning acute patients, acute care in acute care settings, more so ED settings rather than urgent care, where 3-day courses of opiates are more suitable. Of course, there are other reasons as well, such as peri-surgical pain, 1-2 weeks may be appropriate, and then going case by case basis for chronic opiate therapy. Dr. Arreaza: Acute pain is an indication for opiates, like a fracture, so do you say 2 weeks would be enough?Dr. Patel: Every patient is different, look at it on case by case basis. More so than the number of days it’s the MMEs and the strength of the medication being prescribed. We want to start with longer acting medications; short-term, short acting medications tend to produce that feeling of euphoria, that instant rush that has a psychological addiction factor. I have seen many patients that go in for something as simple as a fracture and come out with an addiction to opiates. It can happen very quickly, in less than a week, in a matter of few days, opiate addiction takes place.Dr. Arreaza: So, we can start an addiction by just prescribing one week of opiates.Dr. Patel: Correct.Dr. Arreaza: Well the symptoms you mentioned, the patients who get this energy bust or euphoria, those are the patients who are more at risk of being addicted, and of course there is a genetic and biological component to it as well. I can tell you by experience that my patients usually say they feel sleepy; it has a sedative effect. Those are usually

Episode 30: Street Medicine BasicsThe sun rises over the San Joaquin Valley, California, today is October 2nd, 2020.I have two sneaky children who are always trying to hide during the week to play video games. Well, I read an article that gave some relief to my worried mind about the benefits of videogames. The article was published in 2007, titled “The Impact of Video Games on Training Surgeons in the 21st Century”. The study consisted in having 33 participants (residents and attendings) to answer a questionnaire, go through a training called Top Gun, and play over-the-counter video games. Then the doctors were evaluated in their performance during laparoscopic procedures. The results showed that video game play correlated with 37% fewer errors and 27% faster completion. Conclusion, video game experience skill correlates with laparoscopic surgical skills. Who would have thought that video games may be a practical teaching tool to train surgeons[1]. “Dementia is one of the greatest challenges in healthcare,” said Andrea Pfifer, CEO of AC Immune, a company developing several treatments for Alzheimer’s Disease. There is a new case of dementia every 3 seconds in the world, currently 50 million people live with dementia, and we still don’t have an effective treatment or cure. The main theory of the pathophysiology of Alzheimer’s is the accumulation of beta amyloid in the brain, but anti-beta amyloid therapies have fallen short in clinical trials, making some researchers reconsider this hypothesis[2]. Some underrated targets may include inflammation and vascular factors. But the tau protein, a key element in the formation of neurofibrillary tangles in the brain, is experiencing a starring moment. Semorinemab is the first anti-tau therapy to enter a phase 2 study. Alzhemier’s disease as a multifactorial condition, may need a combination of treatments with anti-beta amyloid and anti-tau medications, among other therapies. We will continue to hope for a cure as the research continues to evolve in the following years. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “I am only one, but still I am one. I cannot do everything, but still I can do something, and because I cannot do everything I will not refuse to do something that I can do.”– Edward Everett Hale (frequently attributed to Helen Keller)You are only one, but you can do something for someone. This quote is very appropriate for our episode today, and you’ll see later why. This quote reminds me of the story of the starfish thrower[3], and I have to admit that I had an impulsive purchase a few minutes ago, because that story connected me to my youth, and I want to read it again, so I just bought the book in Amazon. The story is about a man who throws sea stars back to the sea to prevent their death. Even though there are thousands of stars, that man decides to change the destiny of one star at the time. We may be only one, and we may save only one star, but for that star you make a difference. I recommend you read that story. It’s inspiring. Talking about inspiring, I had a conversation with Dr Beare about street medicine, I hope you enjoy it.Arreaza: We have Dr. Beare with us – He’s famous around here, loved my residents and staff, thank you for your time, Dr. Beare, Chief Resident Rio Bravo Class of 2019.Beare: Thank you for the invite and kind introduction, I am Matthew Beare, Medical Director of Special Populations at CSV, development and implementation of special programs for homeless, migrant farm workers, and patients who suffer from substance use disorder. Street medicine program, branch of our homeless help, has been in place for one year. It opened in October 2019. Arreaza: Ok so you are doing street medicine, and addiction medicine, and primary care.Beare: Yes, and often there is overlap between the two.Definition of street medicineArreaza: What is street medicine?Beare: From a medical standpoint, street medicine is basic medicine; more of a philosophical approach, and I guess there’s a practical difference as well, but what we are trying to do is provide high level primary care to our homeless, chronically-unsheltered patients, to meet them where they are, as opposed to have them meet in clinic.Our philosophy of street medicine is “ go to the people,” so once a week, every Thursday, we pack up our medical supplies and a small team of us go directly into a variety of homeless encampments here in Kern County, in Bakersfield, and we provide care on site, so that can be everything from preventative care to acute treatment of different illnesses including procedures such as I&D of abscesses, joint injections, we can provide on-site prescription medications, and we can also start the process of starting lab work, sending prescription information to various pharmac

Episode 29: OSA with Clau.Obstructive sleep apnea (OSA) can be confused with ADHD in pediatric patients. Dr Carranza explains how to work up and treat OSA in kids. Listen to several adventitious breath sounds as explained by Xeng, and learn what Dormir means. Cruel joke about thalidomide. Contest: Define mittleschmerz.The sun rises over the San Joaquin Valley, California, today is September 25, 2020.As allopathic doctors, medications are our most potent tools to fight and prevent diseases. Today, we want to remind everyone about substance abuse and give you an update on a procoagulant agent. Substance abuse is a growing problem. Due to increased stress, anxiety, depression, and unemployment, drug abuse is on the rise during the current pandemic[1]. Some medications may not be considered a “drug of abuse” when prescribed alone, but they can be combined with other medications to cause a potentially addictive effect. Such is the case of promethazine[2,3], which is usually combined with codeine, dextromethorphan and expectorants for cough. Promethazine is also used as an antiemetic, for procedural sedation, and for allergic reactions. Promethazine-containing products are abused for their sedative effects. Specifically, when promethazine is combined with opioids, it potentiates euphoria, alleviates withdrawal symptoms and relieves opioid-induced nausea. So, be aware of drugs that can potentially be misused or abused, even when they are not scheduled. Other examples include quetiapine, baclofen, gabapentin, fluoxetine, and more. Examples of OTC medications that can also be misused are diphenhydramine and loperamide.Now, let’s talk briefly about tranexamic acid. You may remember this medication as a treatment for menorrhagia, and to control bleeding in general. UptoDate stated in December 2019 that this medication is now recommended in patients with moderate Traumatic Brain Injury (TBI) presenting within 3 hours of the event[4]. Interestingly, tranexamic acid is a potent neurotoxin with a mortality rate of 50%, but ONLY when given accidentally via intraspinal route. Remember, it’s safe IV and oral, but NOT intraspinal. Survivors of intraspinal injection often experience seizures, permanent neurological injury, ventricular fibrillation, and paraplegia. Container mix-ups were involved in 3 recent cases[5]. So, this is why checking medication labels is critical._____________________________This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “A life without a cause is a life without effect.” ― Paulo CoelhoThink about your purpose in life, what motivates you? Where do you want to be? Start now to direct your life to get you where you want to be. Claudia Carranza is here with us today, a Wednesday after didactics to discuss another topicWho are you? My name is Claudia Carranza; you might recognize my voice from the “Espanish word of the week”, I am a PGY3 resident in our Rio Bravo Family Medicine residency program. I am married to an internal medicine resident, we have 2 dogs and they keep us really busy going to the dog park, long walks and jogging. What did you learn this week? This week I learned about obstructive sleep apnea (OSA). I actually had a patient recently with obstructive sleep apnea which persisted despite prior tonsillectomy. I also learned that obstructive sleep apnea in children can present with symptoms similar to ADHD. I thought, I definitely need to read more about management and I would like to focus mostly on pediatrics. A lot of patients ask me: what is obstructive sleep apnea? And I would tell them in my own words that “it’s a condition in which something blocks your upper airway and it makes you sometimes snore and wake up multiple times at night because you are unable to breath”. A fancier definition is “a complete or partial upper airway obstruction which can result in gas exchange abnormalities”. This doesn’t sound very pleasant and patients won’t necessarily come to you complaining that they are waking up at night. Instead, it can be presented to you as different complaints such as snoring, daytime sleepiness with car rides or at school, nocturnal enuresis, and in particular in children it can manifest as inattention, learning problems, hyperactivity, impulsivity, rebelliousness and even aggression. But wait; these last few symptoms sound a lot like attention deficit hyperactivity disorder or ADHD. So here where SCREENING becomes very important, and usually you will ask your patient or their parent: does your child snore? More often than not the parents will know; sometimes I have even had a patient’s brother or sister in the room who says: “yes he/she snores!” Another part of your yearly check-ups will be looking at the oropharynx and you will see whether the patient has enlarged tonsils. Remember: not

Episode 28: AnisocoriaThe sun rises over the San Joaquin Valley, California, today is September 18, 2020.Welcome to our “student-only” episode. Out of all the social determinants of health, the USPSTF recommends screening for intimate partner violence and for child maltreatment[1]. Today, we would like to dedicate a few minutes to intimate partner violence (IPV) in women. Screening for IPV is a USPSTF grade B recommendation, which means you should offer this service to your patients. Women of reproductive age should be screened for IPV and receive ongoing support services, if screening is positive. There are several tools you can use to screen. For example, HARK (Humiliation, Afraid, Rape, Kick); HITS (Hurt, Insult, Threaten, Scream); and WAST (Woman Abuse Screening Tool)[2].Briefly, the WAST has two questions, which can be followed by 6 additional questions (just like when you do PHQ2 and PHQ9). The first two questions are:1. In general, how would you describe your relationship? (No tension, Some tension, A lot of tension)2. Do you and your partner work out arguments with... (No difficulty, Some difficulty, Great difficulty?). It is POSITIVE if patient answers "a lot of tension" and "great difficulty", then you can continue with the rest of the questions which is part 2, until completing 8 questions in total. The screen is positive based on your clinical judgement, no positive score threshold is established. In California, health practitioners are required to report to law enforcement if they provide medical services to a patient with a physical injury due to firearm, or assaultive/abusive conduct within two working days[3]. Make sure you review your local regulations about mandatory reporting in your area. ___________________________This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.” ― William Arthur Ward.Did you know the word doctor comes from the Latin root docere which means teacher? I was very surprised by that etymology. So, as doctors, we are teachers. What kind of teacher do you want to be as a doctor? A teacher who tells, explains, or demonstrates? It takes a lot of practice and effort, I bet, but your patients will thank you if you become a teacher who inspires them. Today, you will listen to our medical students. This is the first episode that is 100% made by medical students. Today our doctor students become our teachers. First, let’s listen to Li Liang, then Hugh and Meredith. Anisocoria: Unequal PupilsAs a continuation on the theme of anisocoria, we will wrap up. Hopefully with something wise, but more than anything the point of this is just to stir your mind and say, “Yeah…the cobwebs are lifting.” Yes, Halloween is coming. Is it the eye? Or is it the brain? Or is it in the blood vessel? It has been said by multiple somebodies some time ago, “the eyes are the windows into the soul” or rather into the hidden chambers of what’s inside the big watermelon we have atop of our gravity defying bodies.I learn best by stories and people, so if you’ll indulge me. Think of a musician, a rather famous rock star who The Rolling Stones called “The Greatest Rock Star ever.” Maybe this clip might help. https://youtu.be/J-_30HA7rec.That was just David Bowie. I never knew this but conveniently he will highlight our topic for both anisocoria and heterochromia. As a quick reminder, heterochromia is asymmetric iris coloration, when hereditary, is a phenotypic expression of 2 different iris variegation. When someone young presents with heterochromia it can be associated with congenital syndromes, but in the case of David Bowie[4], it was acquired from injury. This also clues us into his story about anisocoria, which he was not born with. In fact, it was over a love for a girl when he was an invincible teenager. Turns out most love stories have a villain, and his happened to be his best friend at the time, who also loved the same girl. What’s two teenage boys filled with testosterone to do about this? Dueling in a “fight of passion,” Bowie was sucker punched in his left eye, added a fingernail scratch, and even after surgery and prompt care, he “wears the badge of love on his eye.” His abnormal pupil is the big pupil! So, it isn’t the small one as you may think. What is anisocoria? Unequal pupil size, specifically by at least 0.4mm. The difficulty is determining what caused it. Therefore, the goal in primary care is to quickly identify the emergent/urgent causes from the ones that have time to do further workup. Anisocoria doesn’t really sound benign when educating a patient about this. But in fact, physiologic anisocoria happens often. Some people may even have anisocoria daily. Prevalence is in the range of

Episode 27: POCUS The sun rises over the San Joaquin Valley, California, today is September 11, 2020. Today we honor those who lost their lives during the deadliest terrorist attacks in the history of the world, which happened in 2001. Today, nineteen years later, there are many tears to wipe off, hearts to comfort, and many unanswered questions. Our fight against evil is still unfolding, especially during this time of pandemic. Humans will continue their search for happiness and hopefully good will prevail.How is the air quality where you live today? In Bakersfield, this week our air quality has been worsening, and asthma exacerbations will likely be on the rise. Recently, the American Family Physician journal published a practice guideline update issued by the Global Initiative for Asthma (GINA). GINA now recommends against using short-acting beta2 agonist (SABA) as sole therapy for patients with mild intermittent asthma (Step 1). A low-dose inhaled corticosteroid (ICS) and formoterol combination used as needed is the preferred treatment in adults and adolescents in the Step 1 group. If ICS/formoterol is not affordable, then a low dose ICS and SABA as needed is recommended, basically it is recommended to avoid prescribing SABA alone[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. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “To cure sometimes, to relieve often, to comfort always,” Dr. Edward TrudeauAs doctors, we always want to heal our patients. I think that’s the reason all of us went to medical school. However, we have to recognize our limitations, and the limitations of modern medicine, even with all the advances of our era. Some patients may not be cured, and that can be devastating for some physicians, but even when we cannot cure, we can often offer relief, and always provide comfort. What a great teaching for us!Today we have Dr Verna Marquez. She is a faculty in our program who is always involved in new and exciting projects. Today, she will talk about POCUS. Dr Marquez, please introduce yourself.What is POCUS? Why is it important?POCUS stands for Point of Care Ultrasound. It is a goal-directed, bedside ultrasound examination performed by a healthcare provider to answer a specific question or to guide performance of an invasive procedure. History: In 1940s Diagnostic ultrasounds was first developed and used in medicine, but POCUS has been integrated into diverse areas of clinical practice since the early 1990s. Impact in primary care: Many professional societies and national organizations nowadays have recognized the potent impact of POCUS and have endorsed its routine use in clinical practice. POCUS improves clinical outcomes, reduces failure rates during procedures, rapidly narrows differential diagnosis, shortens time to definitive treatment, lower costs, and reduces the use of ionizing radiation of CT imaging. It is especially empowering and critical for front line providers in rural, underserved, or resource-constrained environments where advance imaging and specialists are in scarce supply. Family physicians are often the providers in these key clinical contexts. Because Family medicine physicians have a strong background in obstetric ultrasound, family physicians are well positioned to learn other applications of POCUS. When can we use POCUS?POCUS can be used to assess most body systems. Generally, the rule is to “rule in” or “rule out” a specific condition or answer a “yes or no” question. Clinical applications:As a FM physician, we perform it mostly for diagnostics –and the most commonly performed ones are evaluation of GB, liver, kidneys, bladder, gravid and non-gravid uterus, joints, LE veins, breast, soft tissues, scrotal and since our program just started the curriculum, heart and lungs are other applications we can do as well. POCUS can narrow down our differential diagnosis based on the presenting signs and symptoms. It will guide additional investigations, especially in urgent or emergent situations.We can also use POCUS for Procedural guidance – it has been shown to reduce complications and improve success rates of invasive bedside procedures.We are also utilizing it for Screening such AAA. Screening with US is potentially advantageous because it is non- invasive and avoids ionizing radiation. Others are for Monitoring and resuscitation commonly performed in the hospital setting like in the ED and ICU. Example include monitoring for volume status on patients with CHF or dehydration so scanning for IVC distention and collapsibility, monitoring LV contraction in responses to inotrope initiation, and monitoring for resolution or worsening of pneumothorax or pneumonia on lung US.Bedside US can direct emergent interventions by rapidly detecting tension PT, cardiac tamponade and massive PE with acute RVF. What are important considera

Episode 26: Eye KnowThe sun rises over the San Joaquin Valley California. Today is September 4, 2020.It should be not surprise to us that evidence shows the use of marijuana during pregnancy affects the development of the nervous system of the fetus. More than 500,000 live births were analyzed retrospectively from the Canadian birth registry and it showed incidence of autism spectrum disorder (ASD) was higher in children born from mothers who used marijuana during pregnancy compared with non-exposed children (4 versus 2.4 diagnoses per 1000 person-years). Incidence of intellectual disability and learning disorders was also higher in marijuana-exposed children. So, remember to counsel your pregnant patients to avoid marijuana[1].Do you think that patients with obesity have a higher prevalence of musculoskeletal pain? You think? And what’s a common prescription for chronic pain? Yes, you guessed it, it’s opioids. So, you think obesity and opioids are linked? Articles published in the American Journal of Preventive Medicine (AJPM) [2] and Journal of American Medical Association (JAMA)[3] showed a clear link between obesity and opioid use. Patients who are overweight have 24% incidence of long term opioid use, while the incidence in patients with severe obesity was 158%. Again, incidence is 24% in overweight vs 158% in severe obesity. That’s crazy, the most common chronic pain associated with obesity and opioid use was back pain and joint pain. Now you know it, two of the most popular epidemics, obesity and opioids, go hand in hand. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.“Success is not final; failure is not fatal: It is the courage to continuethat counts.” –Winston S. ChurchillSuccess is such a complex term! Success for you may be different than success for me. Success is not final, just as failure is not fatal. Our life has ups and downs and that’s what makes it interesting. I’d like to thank all our listeners for their support in our mission to educate, and sometimes to entertain you. It has not been easy to produce this podcast. Thanks to all the brave residents who have overcome their fears to record in front of a microphone. This week we have reached some milestones. We had our download number 1,000, and today the last resident of the 2019-2020 group is participating in the main part of the podcast. I was planning to end this season, but I’m happy to inform that some people offered to record more, so we may have an additional episode, before closing this season. I’m planning to change our format after hearing some suggestions from our residents.I’m pleased to present to you Dr Garmendia today. He is here to share some of his wisdom with us. Dr Garmendia, we are closing this season of the podcast with you. So you are the cherry on the cake, no pressure. So, let’s relax and have fun. Question number 1: Who are you? My name is Fermin Garmendia, I am a third-year resident of the Rio Bravo Family Medicine Residency Program. I was born and raised in Cuba where I went to medical school. I came to the US in 2010 and, after several years and some sacrifice, my dream came true. For me, being a family medicine doctor is a privilege. It is diverse and challenging. I have some hobbies, I like watch movies, eat in a good restaurant, passing time with friends but what I enjoys the most it is travel by car, so far yet a short family, my wife, our dog and me. We like to explore and be in several places and California is the opportunity, it is beautiful. I still have a big list of places to visit. Question number 2: What did you learn this week? This week I saw a patient with a subconjunctival hemorrhage. I can picture the face of some colleagues... it is nothing weird or maybe not the most interesting topic, but for some patients (and even for many doctors) this could be frightening. Patients get desperate when they realized the problem, and often those who see someone with subconjunctival hemorrhage may think this is caused by physical trauma. It is common, I have seen many patients with subconjunctival hemorrhages and almost always the treatment is reassuring him or her that it will gradually resolve on its own in few weeks, no need for any treatment, except for some artificial tears for symptomatic relief. We should explain our patients why this event could have happened. This is the interesting topic that I would like to talk about.Subconjunctival hemorrhage Patients are generally asymptomatic. Typically, the patient is unaware of the problem until they look in the mirror or someone else lets them know.A red, bloody eye can look scary, but it is usually harmless and often heal on its own.Causes of subconjunctival hemorrhageThe eye’s conjunctiva contains a lot of tiny blood vessels that can break easily. Rupture of capi

Episode 25: Autism [Music to start: Grieg’s Morning Mood (https://www.youtube.com/watch?v=-rh8gMvzPw0) The sun rises over the San Joaquin Valley, California, today is August 28, 2020. The Journal of the American Board of Family Medicine recently published the characteristics of primary care physicians (PCPs) associated with prescribing potentially inappropriate medication (PIM) for elderly patients. Medicare data from more than 100,000 PCPs was analyzed. The sample included specialists in family medicine, internal medicine, geriatrics and general practice. PCPs more likely to prescribe PIMs were on average older, male, DO, practicing in the South, and have a smaller Medicare patient panel. The study also found that PIM rates have been decreasing over time (1). So, don’t forget to review your Beers Criteria (2) when prescribing meds to your elderly patients. Cancer and VTE normally means low molecular weight heparin, LMWH aka Lovenox®, right? But direct oral anticoagulants (DOACs) are being used more frequently in patients with acute venous thromboembolism (VTE) and active cancer. Studies comparing their safety and efficacy with LMWH are limited. In a recent, randomized trial of 1170 patients with cancer and VTE, the DOAC apixaban resulted in similar rates of recurrent VTE when compared with the LMWH dalteparin (Fragmin®) (5.6 versus 7.9 percent) without any impact on major bleeding events. Apixaban is now considered a suitable alternative to LMWH for treatment of VTE in patients with active cancer (3). So, good point for Eliquis®. [Music mixes with country Chris Haugen - Cattleshire - Country & Folk https://www.youtube.com/watch?v=WiYqHkH4Tnc&list=PLYo1YtVKirP-LAZ3AjpIiJNW9KIe1MJLw&index=7]Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] ____________________________[MUSIC]“By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.” –Confucius Spanish refrains don’t make sense, but here I have one to see if it makes sense: “Nobody learns on someone else’s brain”. It means, you learn better by experience. Dear residents, how do you want to learn wisdom? By reflection, by imitation or by experience? Question number 1: Who are you? This is Steven Saito. I am a former Navy doctor, having spent 6.5 years in the service primarily working out of a branch clinic having taken on a variety of additional duties including prior department head and senior medical officer. I am also a recent graduate from RBFM and have come back as faculty Tag line: I’m here to give you your weekly suppository of information. Relax and let it in. Question number 2: What did you learn this week? What I actually encountered was a need for follow up from podcast #9 vaccine hesitancy. There were follow on questions for autisms and what we can be doing as primary care providers. I’m going to start with some basics of autism. Diagnostic Criteria The current DSM criteria states that a child must have persistent deficits in 3 areas of social communication/interaction and at least 2 of 4 types of restricted/repetitive behaviors. It’s important to understand these criteria as not every child who has difficulty with eye contact falls on the spectrum. A: Areas of social communication and interactionDeficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.Deficits in developing, maintaining, and understand relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.B: Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosync

Episode 24: Alcohol in Clinic[Music to start: Grieg’s Morning Mood (https://www.youtube.com/watch?v=-rh8gMvzPw0) The sun rises over the San Joaquin Valley, California, today is August 21, 2020. Fresh from the oven! The USPSTF issued the following recommendation on August 18, 2020: All sexually active adolescents and adults at increased risk should receive behavioral counseling to prevent Sexually Transmitted Infections (STIs).Counseling results in a moderate net benefit in prevention of STIs, a Grade B recommendation, which means the benefit is moderate to substantial, so offer this service to your patients.Some examples of patients who can benefit from counseling are those who have a current STI, do not use condoms, have multiple partners, belong to a sexual and gender minority, HIV patients, IV drug users, persons in correctional facilities, and others.Offering counseling in person for 30 minutes or less in a single session may be effective, but the strongest effect was found in group counseling for more than 120 minutes, delivered in several sessions. Other options include referring patients for counseling services or inform them about media-based interventions. Of note, there are about 20 million new STIs every year in the US (1). [Music mixes with country Chris Haugen - Cattleshire - Country & Folk https://www.youtube.com/watch?v=WiYqHkH4Tnc&list=PLYo1YtVKirP-LAZ3AjpIiJNW9KIe1MJLw&index=7]Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] ____________________________[MUSIC][Quote]“The illiterate of the 21st century will not be those who cannot read and write but those who cannot learn, unlearn, and relearn” –Alvin Toffler.Sometimes there are things we need to unlearn. We see that frequently in Medicine. New guidelines, recommendations, tests, and treatments are updated regularly. We need to make sure we never stop learning, unlearning and relearning; and residency is just part of the beginning of a life-long commitment to learn. Today we have a dynamic intern. She started just one month ago her residency. I’m happy to welcome Ariana Lundquist today. Question number 1: Who are you?Hi, my name is Ariana and I am a first-year resident at Rio Bravo Family Medicine Residency. I am a California girl through and through from Orange County, California.I grew up surfing every weekend with my dad who also is a family physician.Early on I knew I wanted to be a doctor because I really loved being at my father's private practice. My mom had her private practice at my father's clinic, and so every day after school she would pick my sister and I up and take us to clinic. We would run around and interact with every patient. We truly grew up in the clinic and I cherish those memories as an adult. I went to Canyon high school where I did water polo and swim. For undergrad, I went to Cal State Long Beach where I majored in cell molecular biology with a minor in general chemistry and surfing. I then went to the beautiful island of Dominica to attend medical school at Ross University. My last 2 years of medical school were spent in Bakersfield. As someone who loves the heat and sweet hospitality, Bakersfield was really fit for me. I truly am excited to learn and grow as a physician here in Bakersfield with the Rio Bravo family medicine team. For fun, I still try to surf whenever I get a chance, free dive, scuba dive, karaoke, and spend time with my family. Question number 2: What did you learn this week?This week I was working on my quality improvement project with my co-resident Dr. Civelli on alcohol withdrawals in a hospital setting. During the research, I was wondering about how you would treat alcohol withdrawals in a clinic setting. We encounter a lot of patients who, when they are willing to open up about it, admit to having alcohol dependency. It is never a simple subject to talk about with patients because most people either feel that they have their alcoholism under control or that they are ashamed by the amount that they drink. Once the patient is honest with you about the amount they drink and you realize that they are above the recommended daily intake, that is when you start to assess their willingness to quit. That alone is another subject for a pod cast in the future, but if someone is willing to quit you have to consider if that patient is somebody who might have withdrawal symptoms. Timing of alcohol withdrawal syndromesSyndrome Clinical findings Onset after last drink Minor withdrawalTremulousness, mild anxiety, headache, diaphor