Episode 181: Cannabinoid Hyperemesis Syndrome

Future Dr. Johnson explains the pathophysiology, assessment, and management of Cannabinoid Hyperemesis syndrome. Dr. Arreaza adds some insights on the topic.  

Written by Tyler Johnson, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. Editing and comments by Hector Arreaza, MD.

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

Definition 

Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic abdominal pain, vomiting, or nausea in older adolescents and adults who have chronic ϲаnոаbis use.

The term “marijuana” is considered racist by some people. In the 1930s, American politicians popularized the term “marijuana” in the U.S. to portray the drug as a “Mexican vice” and to have a justification to persecute Mexican immigrants. 

Epidemiology 

The overall prevalence of cannabinoid hyperemesis syndrome is unknown due to a lack of definitive criteria or diagnostic tests. It occurs in a population that may not disclose substance use. One study conducted in 2015 in a United States urban emergency department not named, found one-third of patients with near-daily cannabis use met criteria for having had CНЅ in the prior six months.

Why are rates of CHS increasing?

Between 2005-2014 hospitalizations cyclic vomiting syndromes increased by 60 %. concurrent cannabis use in hospitalized patients increasing from 2 to 21 percent. 7 years after the commercialization of cannabis in Canada, the Canadian health services found a 13-fold increase in cyclic vomiting syndromes

Potential correlations for the increase in CHS are increased legalization and commercialization of cannabis, higher tetrahydrocannabinol concentrations in cannabis products, and increased recognition of the syndrome.

Legal status of Cannabis in the US

Cannabis is legal in 24 states: Alaska, Arizona, California, Colorado, Connecticut, Delaware, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Jersey, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, Virginia, and Washington. It is also legal in Washington, D.C. Cannabis is approved for medical use in 38 states.

Federal level: 

Cannabis 

is a Schedule I drug, under the Controlled Substance Act (added in 1970) in the group of Hallucinogenic or psychedelic substances. 

Tetra-hydro-cannabinol

 (THC, a “mind-altering substance in cannabis”) is on the same list. However, cannabidiol (CBD, derived from hemp or non-hemp plants) was removed from the Controlled Substances Act in 2018. CBD is FDA-approved (under the name of Epidiolex®) to treat rare seizure disorders. 

CBD is still on the list of controlled substances in some states. I see THC as a problem.

THC increased concentration 

As recreational Cannabis becomes more normalized, innovators look to find new ways to differentiate their product and increasing THC has become a common way to perform this similar to alcohol content in the beer, wine, and liquor industry. 

An article by Yale School of Medicine titled “Marijuana: Rising THC Concentrations in Cannabis Can Pose Health Risks” states, “In 1995, the average THC content in cannabis seized by the Drug Enforcement Administration was about 4%. By 2017, it had risen to 17% and continues to increase. Beyond the plant, a staggering array of other cannabis products with an even higher THC content like dabs, oils, and edibles are readily available—some as high as 90%.”

Recently, cannabis-infused water started to be sold in some grocery stores.

Pathophysiology of CHS

It is not entirely understood. Some suggest multifactorial involving cannabinoid metabolism, exposure dose and tolerance modifying receptor regulation, complex pharmacodynamics at Cannabinoid receptors, and even changes in genetics and cannabinoid variation in plants. 

CB1 receptors are involved in gastric secretion, sensation, motility, inflammation, and lipogenesis. The activation of CB1 and CB2 receptors has been suggested as the possible cause of CHS.

Risk Factors

CHS can occur after acute or acute on chronic use but many report daily 3-5x cannabis use cannabis use over one year and many over at least two years. Median age 24 years. 

Interesting facts

Medical visits for inhaled cannabis are more likely associated with CHS while edibles are more likely for acute psychiatric reactions.

Also, CHS is a paradoxical effect since cannabis and cannabinoid receptor agonists are known antiemetics (as seen in nabilone and dronabinol (synthetic analogs of THC)) and prescribed by some physicians to combat chemotherapy effects.

Clinical Features of CHS

Cyclical pattern with abdominal pain, severe nausea, and vomiting up to 30 episodes daily. Pain is intense and even referred to as “scromiting” due to its intense nature, causing patients to scream and vomit concurrently.

Typically, it presents with 2 or more episodes over a 6-month period with no symptoms in between. It starts within 24 hours of last cannabis use (differentiating from cannabis withdrawal) and occurs at day or night. 

There is a gradual symptom resolution of nausea and vomiting after several days of cannabis cessation. 

Some patients had symptoms 2 days to 2 weeks after cessation. 

Diagnosis of CHS

Clinical diagnosis

Rule out neurological symptoms such as migraine headaches, acute abdomen, motion sickness, and medications, such as recent antibiotics and chemotherapy.

Often the diagnosis is discovered with a thorough history reporting a decrease in symptoms with hot showers/baths.

Management of CHS 

Acute

Rehydrate with Fluids 

Dopamine Antagonists– Droperidol (0.625 or 1.25mg) /Haloperidol (0.05 to 0.1mg/kg with max dose of 5mg initially) favored over typical antiemetics like Zofran or Reglan.

If needed, combine with an antiemetic like metoclopramide IM or ondansetron IV and consider patients’ dehydration status likely requiring US-guided IV.

Topical capsaicin cream 0.025 – 0.1% on the abdomen. 

Long term

97% resolution of symptoms completely in a systematic review of patients who stopped cannabis use.

Reinforce it may take several weeks of abstinence for symptoms to resolve and symptoms can worsen if cannabis is resumed. It is unknown if a reduction in use can prevent recurrence.

Approaches in the clinic

Educate patients on the etiology of their symptoms with complete cessation of cannabis use.

Consider referral to counseling for cannabis use disorder and abstinence support for treatment-seeking cannabis users. 

Approach topics such as changing one's environment, seeking social support, and using self-help techniques to non-treatment-seeking individuals.

Consider referring patients with polysubstance use and significant comorbidities to a supervised withdrawal management setting. 

Conclusion: Cannabis use is increasing with legalization and commercialization across the United States. With increased use, Cannabinoid hyperemesis syndrome incidence increases. Often it can be diagnosed with a thorough history including chronic cannabis consumption and symptomatic relief by showers. Physicians will need to develop counseling approaches to better understand CHS patients and how to approach an often-difficult topic.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

References:

1. Angulo MI. Cannabinoid Hyperemesis Syndrome. JAMA. 2024;332(17):1496. doi:10.1001/jama.2024.9716. Link: https://jamanetwork.com/journals/jama/fullarticle/2824833#:~:text=Cannabinoid%20hyperemesis%20syndrome%20(CHS,last%20less%20than%201%20week.
2. Backman, Isabella, Marijuana: Rising THC Concentrations in Cannabis Can Pose Health Risks, Yale School of Medicine, August 30, 2023. https://medicine.yale.edu/news-article/not-your-grandmothers-marijuana-rising-thc-concentrations-in-cannabis-can-pose-devastating-health-risks/
3. Buchanan, Jennie A and George Sam Wang, Cannabinoid Hyperemesis Syndrome, Up To Date, updated July 17, 2024. https://www.uptodate.com/contents/cannabinoid-hyperemesis-syndrome
4. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 180: Pediatric Hip Pain

Future Dr. Pena-Brockett explains the differential diagnosis in a 14-year-old patient who has a new onset of left hip pain. Dr. Arreaza adds comments and explains toxic synovitis.  

Written by Natalie Pena-Brockett, MSIV, California Health Sciences University. Comments by Hector Arreaza, MD.

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

Having a limping kid can be terrifying. Many questions may cross your mind: Is this a permanent damage? What is going on here? Where is the pain located? Do I need to send this child to the hospital? Today, hopefully, we can help you ease some of your fears. 

Case: This is a 14-year-old boy with no past medical history, no trauma, presents to the family medicine clinic with a complaint of left-sided hip pain. Mom notes that her son has been limping for the last week and complaining of pain in his left hip and knee when he walks. He has never experienced this pain before this week. He does not take any medications. Physical exam: He is afebrile and all of his vitals are within normal limits. On exam, you note that his BMI is at the 90th percentile (overweight), and has an antalgic gait where he is favoring the right side and has tenderness on his left groin. His left foot is turned outward while standing up straight. His left knee has negative findings on specialized tests, but he has restricted movement of the left hip. 

Discussion: This is a common topic that you will see on board exams or limping into your office. Although pediatric hip pain may seem like a benign musculoskeletal concern, taking the time to take a complete history and perform a thorough physical exam is critical to assess the severity of the patient’s concern.

Physical Exam for Pediatric Hip Pain.

1. Observation: Every physical exam begins the moment you first see the patient. This allows you to gauge the patient’s comfort level, the natural stature, length, and positioning of the patient’s extremities, skin changes, gait, and ability to bear weight. 
2. Palpation: In medicine, our hands are one of our greatest tools for evaluating patients, especially those with musculoskeletal concerns. This is the time to palpate the area for any tenderness or gross deformities of the pelvis, hip, knee, or leg. 
3. Special Tests: In the world of MSK, we have all sorts of tests to evaluate the range of movement of our joints and tendons. When specifically evaluating the hip, the most common are the FABER(flexion, abduction, external rotation),test to assess the sacroiliac joint, Ober’s Test to assess the iliotibial band, and Straight Leg Raise to assess for lumbar radiculopathy.

Legg-Calve Perthes Disease

-Legg-Calve Perthes disease is an idiopathic avascular necrosis of the femoral head. 

-It is most commonly observed in patients between the ages of 2-12 years and in a higher ratio of males to females 1. 

-It often manifests as an atraumatic limp with limited movement in abduction and internal rotation. 

-X-ray imaging may demonstrate a widening of the joint space and sclerosis of the femur, and MRI will confirm osteonecrosis of the femoral head. 

-Early diagnosis is key to minimizing the risk of developing osteoarthritis of the hip. 

-The goal of treatment is to maintain the shape of the femoral head and the range of motion of the hip. 

-The first-line treatment includes managing pain with NSAIDs, limiting weight-bearing activity, and physical therapy for range of motion.

-If the disease progresses, bracing and casting can be used to retain the femoral head within the acetabulum to keep the shape and integrity of the femoral head. In more serious cases, a surgical osteotomy may be done to cut and realign the bones. 

Developmental Dysplasia of the Hip (DDH)

-Developmental Dysplasia of the Hip (DDH) is a pediatric condition that results in unilateral or bilateral instability of the hip due to the abnormal development of the acetabulum or femur. 

-This is most commonly seen in newborns, especially those which develop in a breech position. 

-These patients often present with a shortened leg or asymmetric gluteal creases and a Trendelenburg gait when walking. 

-The Trendelenburg gait is an abnormal gait caused by weak hip abductor muscles. The person's trunk shifts over the affected hip during the stance phase of walking and away from it during the swing phase, making it look like the person is missing steps or limping. 

-On physical exam, hip joint laxity can be evaluated with the Ortolani and Barlow maneuvers to apply pressure to the proximal femur to assess dislocatability of the hip joints. These maneuvers would both be considered positive if a “clunk” is felt over the hip as this means that the hip is dislocated with pressure. Due to the patient's age usually being under 6 months old, ultrasound is the most common imaging modality to confirm the diagnosis, otherwise, an X-ray can be used. 

-The treatment in patients under 18 months old, a Pavlik Harness is often used to treat patients to maintain the placement of the hip within the acetabulum. 

-Patients between the ages of 18 months and 9 years old, are most often treated with open or closed reduction of the hip. 

-There is generally less success in reduction treatment of children older than 9 years old as they have likely developed femoral head deformities and are at greater risk of osteonecrosis. 

-Children with DDH should continue to be monitored with regular imaging to evaluate for complications. These patients should also be made aware that they are also at increased risk of requiring a hip replacement, especially if their treatment included a reduction. 2

Slipped Capital Femoral Epiphysis (SCFE)

-Slipped Capital Femoral Epiphysis (SCFE) is one of the most common pediatric hip pathologies in which the capital femoral epiphysis is anterolaterally displaced from the femoral neck. 

-Although slightly more common in males than females between the ages of 10 to 16, the greatest risk factor for an SCFE is childhood obesity 3. 

-Common symptoms include an insidious onset of unilateral hip pain and a change in gait due to the displacement of the hip from the acetabulum. In some instances of chronic SCFE, some patients will experience ipsilateral knee pain due to compensation. 

-A SCFE can be evaluated with an AP radiograph which will demonstrate a widened physis in the early stages or the classic “slipped ice cream cone sign” which is the posterior displacement of the femoral epiphysis. 

-Management of a SCFE includes limiting weight-bearing activities as well as screw fixation by an orthopedic surgeon to stabilize the hip.Patients should consider pinning the contralateral hip due to increased risk of developing a future SCFE. Early diagnosis is critical as untreated SCFE can lead to osteonecrosis.

Osgood-Schlatter

-Osgood-Schlatter is a repetitive-use pediatric condition as a result of traction to the growth plate of the tibial tubercle. 

-This pathology is most common in male children between the ages of 9 to 14 years old 4. 

-Active athletes or children with rapid growth spurts are at greater risk of developing Osgood-Schlatter than non-active children.

-These children often present with an achy knee pain that can lead to a unilateral limping gait.  On physical exam, these patients often have a bony prominence over the tubercle that is tender to palpation with greater tenderness over the patellar tendon. 

-The knee will have full range of motion and stability, but will likely have a warmth and erythema over the knee.  Imaging of the knees can have nonspecific findings and diagnosis is made clinically. 

-For management, it is recommended that children continue their regular activities and rest with NSAIDs for pain management as needed 5. Physical therapy can be prescribed to prevent deconditioning as this can result in recurrence or additional injuries.

Arreaza: It seems like the pain is more localized to the knee, but it can be referred to the hip. If you have tenderness on the tibial tubercle, you got the diagnosis. 

Juvenile Idiopathic Arthritis (JIA)

-Juvenile Idiopathic Arthritis (JIA) is a systemic rheumatologic condition in children that often presents as a polyarticular pain. The onset of disease is often bimodal with peaks between 2 to 5 years old and 10 to 14 years old. 6

-Patients will often complain of minor symmetric joint pain and stiffness until an infection causes an inflammatory reaction that exacerbates the joint pain or can increase joint involvement. Small joints are the most likely to be involved, but hips and knees can also be affected. 

-Lab evaluation will demonstrate inflammation with an elevated ESR, low hemoglobin, and a positive ANA. 

-Disease management starts with NSAIDS for pain control and can escalate to immunosuppressive measures for moderate disease7.

Toxic Synovitis

-Toxic synovitis, also known as transient synovitis, is the leading cause of acute hip pain and limping in children aged 2–12, more commonly affecting boys. 

-This self-limited inflammatory condition, often confused by its name as "toxic," has no relation to a toxic state. It typically arises after an upper respiratory or other viral infection (e.g., rubella or coxsackie virus).

-Children with toxic synovitis may show mild to moderate hip pain, limp, and keep their hip in abduction and external rotation. Movement is usually possible within a limited range, and weight-bearing is often maintained.

-Evaluation: A thorough history and physical exam are key, as laboratory tests like CBC, ESR, and CRP are often normal, mainly used to rule out other conditions like septic arthritis. X-rays typically show no abnormalities, although small changes may appear. Ultrasound can help detect joint effusion and rule out septic arthritis if no effusion is present.

Arreaza: DDX: DDH, SCFE, Osgood Schlatter, and toxic synovitis.

Osteopathic Manipulative Treatment in Pediatric Hip Pathologies

• Sacroiliac Articulatory Technique- this is a technique in which you move the joint into an out of its barrier to reduce restriction and improve movement
• Counterstrain of Tender points (psoas, piriformis, hip adductors)- in this technique we shorten the muscle to decrease tension.  This allows the muscle to increase blood lymphatic flow to reduce nociceptive and proprioceptive activity of the muscle
• Balanced Ligamentous Tension of the Innominate- with this technique, we manipulate the joint in a way that moves the ligaments into neutral position so that there is balance in all planes of motion.  The goal is to again release tension within the muscles and the joint

Clinical Decision Making 

Now that we have covered the most common differential diagnoses for pediatric hip pain, let’s revisit our patient presentation and identify the key characteristics to determine which diagnosis he most likely has.

1. The patient is 14 years old.  This makes DDH and Legg-Calve Perthe less likely, and SCFE more likely.
2. He has been complaining of symptoms for 1 week, which indicates that is not likely a chronic condition. This makes DDH and Osgood-Schlatter less likely.
3. The patient has never experienced joint pain like this before.  This makes JIA, DDH, and Osgood-Schlatter less likely.
4. The patient is overweight. This makes SCFE more likely.
5. The unilateral hip tenderness and no knee pain.      This makes Osgood-Schlatter and JIA less likely.
6. The patient has antalgic gait and limited internal rotation of the foot. This makes Legg-Calve Perthes and SCFE more likely.

Now when we take the epidemiological factors, the history of the present illness, and the physical exam findings into account, this patient’s presentation best aligns with a SCFE. We would order a bilateral AP and Frog-leg views of the hips. If either imaging shows a widened physis or the classic “ice cream cone sign”, this is when we would start the referral process for an orthopedic surgery consultation for internal fixation. As family medicine physicians, we would give instructions for strict non-weight bearing activities and analgesics or anti-inflammatories for pain management.

Keep in mind some of the DDX: Calve Legg-Perthes disease, Developmental Dysplasia of the Hip (DDH), Juvenile Idiopathic Arthritis (JIA), Osgood Schlatter, toxic synovitis, and Slipped Capital Femoral Epiphysis (SCFE). Hopefully, the next time you have a pediatric patient present with a complaint of hip pain, you’ll feel more comfortable evaluating and working up the case.

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This week we thank Hector Arreaza and Natalie Pena-Brockett. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

References:

1. Osteonecrosis of the femoral head / Legg-Calvé-Perthes disease | Time of Care. Accessed October 27, 2024. https://www.timeofcare.com/osteonecrosis-of-the-femoral-head-legg-calve-perthes-disease/
2. Scott EJ, Dolan LA, Weinstein SL. Closed Vs. Open Reduction/Salter Innominate Osteotomy for Developmental Hip Dislocation After Age 18 Months: Comparative Survival at 45-Year Follow-up. J Bone Joint Surg Am. 2020;102(15):1351-1357. doi:10.2106/JBJS.19.01278. https://europepmc.org/article/med/32769602
3. Perry DC, Metcalfe D, Costa ML, Van Staa T. A nationwide cohort study of slipped capital femoral epiphysis. Arch Dis Child. 2017;102(12):1132-1136. doi:10.1136/archdischild-2016-312328. https://pubmed.ncbi.nlm.nih.gov/28663349/
4. Haines M, Pirlo L, Bowles K-A, Williams CM. Describing Frequencies of Lower-Limb Apophyseal Injuries in Children and Adolescents: A Systematic Review. Clin J Sport Med. 2022;32(4):433-439. doi:10.1097/JSM.0000000000000925. https://pubmed.ncbi.nlm.nih.gov/34009802/
5. Wall EJ. Osgood-Schlatter disease: practical treatment for a self-limiting condition. Phys Sportsmed. 1998;26(3):29-34. doi:10.3810/psm.1998.03.802. https://pubmed.ncbi.nlm.nih.gov/20086789/
6. Oberle EJ, Harris JG, Verbsky JW. Polyarticular juvenile idiopathic arthritis - epidemiology and management approaches. Clin Epidemiol. 2014;6:379-393. doi:10.2147/CLEP.S53168. https://pubmed.ncbi.nlm.nih.gov/25368531/
7. Beukelman T, Patkar NM, Saag KG, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken). 2011;63(4):465-482. doi:10.1002/acr.20460. https://pubmed.ncbi.nlm.nih.gov/21452260/
8. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 179: Impact of intermittent fasting Impact on T2DM

Future Dr. Carlisle explains the physiology of fasting and how it can help revert type 2 diabetes. Dr. Arreaza adds details on how to do intermittent fasting. 

Written by Cameron Carlisle, MSIV, Ross University School of Medicine. Comments and edits by Hector Arreaza, MD, FAAFP.

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

What is type 2 Diabetes Mellitus (T2DM)?

-Type 2 Diabetes Mellitus (T2DM) is a metabolic disorder characterized by insulin resistance and impaired glucose regulation. 

-This impaired regulation can lead to hyperglycemia, contributing to complications in a myriad of organs: heart, kidneys, eyes, nerves, etc. (target organs). According to the CDC, more than 38 million Americans have T2DM (about 1/10 people). 

-Multiple mechanisms are believed to contribute to insulin resistance in obese patients with T2DM, such as increased lipid deposition throughout the body and systemic inflammation.

What is Intermittent Fasting (IF)? 

Intermittent fasting (IF) has recently gained popularity as a dietary approach for health benefits, but it has been around for thousands of years. IF is an eating pattern that alternates between eating and fasting (no calories consumed) over a specific period of time. When you are fasting, you are allowed and encouraged to keep drinking water and non-caloric drinks, like coffee, tea, and even homemade bone broth.

-According to the International Food Information Council Foundation (IFIC), 10% of Americans engage in IF daily. 

-According to Mark Mattson, a neuroscientist and IF expert for over 25 years, a mechanism called “metabolic switching” is seen with IF. This is when your body runs out of glucose and starts burning fat (i.e., fatty oxidation). These metabolic changes can help protect your organs and reduce the risk of chronic conditions, like T2DM. 

Common IF methods: 

• Time-restricted eating: Most common method, involves eating within a specific time frame (e.g., the 16:8, 18:6, 12:12 method is also common.  [16:8 means you have 16 hours of fasting and 8 hours of eating.]
• Alternate-day fasting: Alternating between fasting days and normal eating days.  [Find more info in The Complete Guide to Fasting, by Jason Fung, who is a nephrologist, he explains that alternate-day is basically eating every other day, which would give 36 hours of fasting, but if you are a beginner you can try a 24 hours fasting, in short, not eating breakfast any day of the week and having lunch 4 days a week, and dinner every night.]
• 5:2 diet (aka periodic fasting): Maintaining a normal diet for 5 days, with 2 days (usually non-consecutive) of caloric restriction (25% of normal caloric intake; e.g., 500 calorie meal). 

IF is strongly believed to improve metabolic health in individuals with T2DM by reducing insulin resistance via increasing insulin sensitivity, promoting weight loss (patients with obesity and DM… AKA patients with diabesity), and enhancing lipolysis via fat oxidation.

While fasting, the body goes through several phases that affect how energy is metabolized. Between 0 and 4 hours after eating, the body enters a feeding state, using glucose as its main energy source. After fasting for 12-16 hours, the body enters ketosis and starts to use fat for energy. Within 24-36 hours, autophagy begins, a process that recycles damaged cells and allows for cellular repair. This process can have great benefits for people with T2DM, such as improved insulin sensitivity and glucose regulation. 

Pathophysiology of Implementing IF in T2DM. 

-IF is thought to increase insulin sensitivity by decreasing fatty tissue in the body (i.e., visceral adipose tissue), which is correlated to insulin resistance. Insulin resistance is defined as higher than normal circulating insulin levels needed for a glucose lower response, which is thought to be the culprit for the generation of T2DM. It means you need high levels of insulin to keep glucose normal. 

-Obesity is an important risk factor for T2DM. Visceral adipose tissue functions as an organ via the secretion of adipokines (cytokines or cellular messengers produced by adipose tissue): leptin and adiponectin. 

• Leptin: proinflammatory, leading to chronic inflammation. Patients with higher BMI levels and increased insulin resistance were found to have increased leptin levels.

[Leptin is a good hormone at normal levels, but there is leptin resistance] 

• Adiponectin: anti-inflammatory and antidiabetic effects. Higher adiponectin levels result in decreased hepatic gluconeogenesis, enhanced glucose absorption, and enhanced skeletal muscle and hepatic fatty acid oxidation. Levels drop as visceral fat increases. 

-Dr. López-Jaramillo, a Colombian endocrinologist and researcher, and colleagues published a review in 2014 examining the imbalance in the levels of leptin and adiponectin in individuals with metabolic syndrome. This imbalance (increase in leptin and decrease in adiponectin) is linked to obesity and insulin resistance, which has been shown to increase the risk of T2DM. It has been shown that IF has resulted in the reduction of leptin levels and increased levels of adiponectin, which leads to decreased insulin resistance and increased insulin sensitivity. 

-IF allows pancreatic beta-cells to rest by not having to secrete insulin constantly. This allows the beta-cells of the pancreas to improve in function over time. In addition, IF has been shown to lead to noticeable weight loss and loss in body fat, both of which play an important contribution in managing T2DM. Research demonstrates that this weight loss increases insulin sensitivity and decreases the need for insulin therapy, making IF a powerful approach for improving metabolic health. 

AMP-Activated Protein Kinase (AMPK) and Its Role in IF and T2DM 

Recent research has highlighted an important enzyme seen in IF, AMP-activated protein kinase (AMPK), which plays a vital role as an important energy sensor in cells. It is activated when cellular energy levels are low, such as during IF. A 2020 research study in Nature Reviews Endocrinology explains that activation of AMPK aids in suppressing gluconeogenesis and stimulates fatty acid oxidation, leading to optimal energy balance and reduction of visceral adipose tissue accumulation, a major contributor to insulin resistance and T2DM progression. AMPK is upregulated during fasting, which enhances glucose metabolism and reduces insulin resistance. This is imperative in managing T2DM, as it counters the effects of insulin resistance associated with T2DM.

Exercise, which also promotes AMPK activation, complements IF and can promote a synergistic effect in improving insulin sensitivity and promoting fat burning, 

New Research Findings on IF and T2DM 

-The EARLY (Exploration of Treatment of Newly Diagnosed Overweight/Obese Type 2 Diabetes Mellitus) study is a randomized clinical trial published in JAMA Network Open (2024). Findings In this randomized clinical trial study found that a time-restricted eating window significantly improved fasting glucose levels and HbA1c levels in individuals with T2DM. The study examined the effect of a 16-week 5:2 meal replacement (5:2 MR) fasting plan that consisted of five days of normal eating and 2 days, nonconsecutive of restricted diet (500-600 calories). This group was examined alongside a group of patients who took metformin 0.5 g BID and empagliflozin 10 mg QD. The study wanted to investigate the changes in HbA1c in Chinese adults with early T2DM.

-The study was a randomized clinical trial of 405 adults, and a study showed that the 5:2 MR approach led to better glycemic control at 16 weeks compared to the counter treatments with metformin and empagliflozin. The 5:2 MR group had the greatest reduction in HbA1c (-1.9%), followed by metformin (-1.6%), and empagliflozin (-1.5%). The 5:2 MR plan also revealed the greatest weight loss (-9.7 kg), followed by empagliflozin (-5.8 kg), and metformin (-5.5 kg). 

-This research suggests IF, such as 5:2 MR, can be a powerful tool in the management of T2DM and improving metabolic health. This study can potentially open doors for healthcare providers to provide the 5:2 MR approach for individuals as an effective initial lifestyle intervention. However, follow-up studies are needed to assess the effectiveness and durability of the 5:2 MR.

Safety and Risks of IF in T2DM. 

-IF when combined with glucose-lowering medications (e.g., insulin, sulfonylureas, GLP-1 agonists) can increase the risk of hypoglycemia. Also, prolonged fasting can lead to nutrient deficiencies if not planned carefully. Patients should be counseled on maintaining a balanced, nutritious diet during non-fasting days. 

-IF is not suitable for everyone. Children under the age of 18 should not try IF due to needing proper calories for adequate development and proper growth. Also, it is recommended that pregnant or breastfeeding women do not undergo IF. It is advised that people with eating disorders should not try IF. 

-Individuals with certain medical conditions, such as kidney stones or gastroesophageal disease should speak with their doctor before trying IF. Also, patients on insulin or other glucose-lowering medications should adjust their dose and talk with their healthcare providers to prevent hypoglycemia during fasting. It is recommended that each person speak with their doctor to discuss the safety and risks of IF and see if it would benefit the individual before starting IF. 

-Many studies have explored the benefits of IF at the micro level revealing its cellular benefits and on a macro level of the body as a whole. However, more research is needed to confirm the long-term effects of IF on glycemic control and its sustainability as a therapeutic approach for T2DM. 

Conclusion:

-IF shows potential for improving glycemic control, promoting weight loss, and enhancing metabolic health in individuals with T2DM. Despite its benefits, IF may present with risks, such as hypoglycemia, nutrition deficiencies, or dehydration in certain patients. Therefore, it may not be suitable for all individuals. It’s important to monitor patients who engage in IF, especially for patients with T2DM. Patients should follow up with their doctor for individualized IF plans in patients with T2DM. 

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This week we thank Hector Arreaza and Cameron Carlisle. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

References:

1. Albosta, Michael, and Jesse Bakke. “Intermittent Fasting: Is There a Role in the Treatment of Diabetes? A Review of the Literature and Guide for Primary Care Physicians - Clinical Diabetes and Endocrinology.” BioMed Central, BioMed Central, 3 Feb. 2021, doi.org/10.1186/s40842-020-00116-1.
2. Blumberg, Jack, et al. “Intermittent Fasting: Consider the Risks of Disordered Eating for Your Patient - Clinical Diabetes and Endocrinology.” BioMed Central, BioMed Central, 21 Oct. 2023, https://clindiabetesendo.biomedcentral.com/articles/10.1186/s40842-023-00152-7.
3. De Cabo, Rafael, and Mark P. Mattson. “Effects of intermittent fasting on health, aging, and disease.” New England Journal of Medicine, vol. 381, no. 26, 26 Dec. 2019, pp. 2541–2551, https://doi.org/10.1056/nejmra1905136.
4. Guo, Lixin, et al. “A 5:2 intermittent fasting meal replacement diet and glycemic control for adults with diabetes.” JAMA Network Open, vol. 7, no. 6, 21 June 2024, https://doi.org/10.1001/jamanetworkopen.2024.16786.
5. Herz, Daniel, et al. “Efficacy of Fasting in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review.” Nutrients, U.S. National Library of Medicine, 10 Aug. 2023, www.ncbi.nlm.nih.gov/pmc/articles/PMC10459496/. 
6. Herzig, S., & Shaw, R. J. (2018). AMPK: Guardian of metabolism and mitochondrial homeostasis. Nature Reviews Molecular Cell Biology, 19(2), 121-135.
7. Longo, V. D., & Mattson, M. P. (2014). Fasting: Molecular mechanisms and clinical applications. Cell Metabolism, 19(2), 181-192. https://doi.org/10.1016/j.cmet.2013.12.008
8. López-Jaramillo P, Gómez-Arbeláez D, López-López J, et al. The role of leptin/adiponectin ratio in metabolic syndrome and diabetes. Hormone Molecular Biology and Clinical Investigation. 2014;18(1):37–45.
9. Mattson, Mark P., et al. “Impact of intermittent fasting on health and disease processes.” Ageing Research Reviews, vol. 39, Oct. 2017, pp. 46–58, https://doi.org/10.1016/j.arr.2016.10.005. 
10. Patikorn, Chanthawat, et al. “Intermittent fasting and obesity-related health outcomes.” JAMA Network Open, vol. 4, no. 12, 17 Dec. 2021, https://doi.org/10.1001/jamanetworkopen.2021.39558.
11. Sharma, Suresh K, et al. “Effect of Intermittent Fasting on Glycaemic Control in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.” TouchREVIEWS in Endocrinology, U.S. National Library of Medicine, May 2023, www.ncbi.nlm.nih.gov/pmc/articles/PMC10258621/#:~:text=In%20IF%2C%20eating%20habits%20are,the%20risk%20of%20developing%20T2DM.
12. Xiaoyu, Wen, et al. “The effects of different intermittent fasting regimens in people with type 2 diabetes: A network meta-analysis.” Frontiers in Nutrition, vol. 11, 25 Jan. 2024, https://doi.org/10.3389/fnut.2024.1325894. 
13. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 178: Social Media in Medicine

Dr. De Luna and Dr. Song explain the role of social media in medical education and how online journal clubs have become more useful in recent years.  Dr. Arreaza offers insights into our role as educators and sources of truth.

Written by Patrick De Luna, MD. Comments by David Zheng Song, MD, and Hector Arreaza, MD

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

Intro to episode (voiceover): Get ready to listen to a great conversation between three doctors diving into the impact of social media on medicine. It’s no secret that social media shapes our lives—not just as professionals, but also as humans and members of our society. Every second, new information floods our feeds, and with the rise of artificial intelligence, it’s becoming harder to separate fact from fiction. As doctors, we have a crucial role in clearing up confusion and supporting evidence-based practices. You’ll hear insightful tips from Dr. De Luna, Dr. Song, and Dr. Arreaza—but remember, you also have a role in spreading the truth, you must be a reliable source of online truth and correct misinformation quickly. Also, use reliable sources, recommend fact-check websites, including Snopes, and FactCheck.org, and avoid “back-and-forth” arguing about fake news online, because as you keep arguing, fake news will continue to spread.

Social Media in Medicine.

Patrick: Social media has helped both physicians and patients obtain and expand their knowledge of medicine. This role in medical knowledge expansion has been more prevalent since the COVID-19 pandemic, especially in the form of podcasts (like this one), medical content creators, and personalities.  This growing medium has helped physicians to deliver medical knowledge in an efficient, but layman, format which can become a great outreach and educational tool. 

Arreaza: This podcast was created 3 days before the lockdown. It has been an educational tool for those who record and hopefully for those who listen to us.

Patrick: In today’s episode, we will explore a little about how this more accessible approach to medical learning has shaped our medical education landscape. We’ll explore a recent study that shows the breakdown of how social media is used among medical professionals and the concerns that physicians have about medical education through social media. We will discuss how platforms such as X/Twitter have “Journal Club” threads and their implications. Furthermore, will discuss how online personalities have been able to bring medical education discussion to the broader population, and what we can learn from their work. 

David: Who is your favorite medical educator?

Patrick: Dr. Mike (YouTube FM), Dr. Glaucomflecken (ophthalmologist comedian), and HealthyGamerGG (gamer), and yours?

David: Curbsiders (THE internal medicine podcast)

Arreaza: I like Dr. Glaucomflecken as well. He is a comedian but he is becoming a little more political. The AFP podcast is my favorite.

David: We will explore and discuss how we could make quality and accurate medical education content and, hopefully, mitigate concerns about creating future educational content for physicians and patients alike. 

Analysis of Healthcare Professional Social Media Use

Patrick: Social media has traditionally been used to share about your social life (posting pictures of your cat and family vacation), stay up to date on news and what is happening among your peers, as well as (for some select folks) a platform for content creation and a means of a career. Healthcare professionals also participate in social media in the same manner. 

David: Some social media users are called “influencers”. 

Arreaza: The term “influencer” is becoming a somewhat negative term online because many “influencers” are giving a bad reputation to that term, to the point that many prefer to be called “content creator.”

Patrick: In a recent study published in Taylor and Francis’ Medical Education Online, 72.1% of the participants reported use of social media to some degree. Out of the 72%, 11.5% of the surveyed report using social media sites exclusively for professional purposes, 22.8% for strictly personal use, and 65.7% for both. 

David: The most used social media platforms among healthcare workers were Facebook at 70%, YouTube 58%, LinkedIn 52%, Instagram 42%, Twitter (now called X) 27%, TikTok 10%, and Reddit at 5% among those surveyed. Those are 6 different media, which ones do you currently use, Patrick?

Patrick: [Add response]. 20.4% of the surveyed indicated they use clinically focused social media platforms as well. This same survey found that respondents specializing in addiction medicine, family medicine, pediatrics, and psychiatry were more likely to use social media for continued professional development as compared to other specialties. 

David: Social media among the participants was highly used for staying informed with medical news and actively participating in medical discussions online, especially about medical management and treatments. Of note, the data is based on a population that skews more toward physicians and medical professionals who have practiced for more than 15 years. 

Arreaza: Doximity is one of those platforms that I have used in the past, and it contains interesting articles but they have to be read “with a grain of salt,” because they are editorials.

The “New Journal Club” Online

Patrick: Multiple residency programs report using social media as a form of engagement about published journal articles and updates to medical practice. Medical education may benefit from the implementation of social media and similar platforms as a medium for professional development, according to an analysis performed by Medical Education Online. The use of social media among many physicians has changed from content consumption (passive) to active participation in furthering medical education. 

David: This is reflected heavily in how platforms such as X (formerly known as Twitter), have become a forum towards a new form of “Journal Club”.Tweet Threads can now be utilized for further publication discussion in an open online space.  Good examples of this can be found among Twitter feeds from publication sites like the New England Journal of Medicine or #IDJClub (Before their move to Meta’s Threads in November 2023). The Infectious Disease Journal Club, using the handle @IDJClub, published a study in May 2022 highlighting the impact of 20 months of journal club hosting through Twitter.

Patrick: The authors of the study state that it may be harder for physicians outside of academic circles to have opportunities for well-scaffolded discussions and continued maintenance of critical appraisal skills. Due to an explosion of questionable medical literature during to COVID-19 pandemic (AKA fake news), they report a higher need for avenues to keep the practice of critical appraisal, thus we need to expand journal club access outside of academic sites.

Arreaza: From May 19, 2019 – August 7, 2021, the @IDJClub account was followed by almost 9,500 followers from 114 countries and hosted 31 journal club posts and discussions. During the study, they found data that shows a decrease in participation in journal clubs use in residencies, as well as a lack of expert hosts to lead those discussions. 

Patrick: In addition to the increased accessibility, the survey makes a case that online interdisciplinary journal clubs can be an effective tool to update medical professionals and for practicing critical appraisal of the research studies. 75% of respondents believed that they learned more from these #IDJClub discussions than in their traditional journal club forums (if such forums were available to their respective programs). A case is made where it could be reflective of easier access, the make-up of how the publication is presented, and how the overall journal club is run. 

Concerns and Challenges to Avoid

David: As well-intended and useful as these platforms for medical education can be, some authors from AAFP recommend that we be mindful of problems that can occur from misapplied use. 

Patrick: One problem that has been brought to the AAFPs' attention is potential society and licensing board actions. Medical boards, such as our own California Medical Board, can sanction physicians, uphold practice restrictions, or even take away physician licenses due to unprofessional behavior in social media content creation. This is especially worrisome if posting scientifically misleading or untrue claims.

David: One example was an incident here in Bakersfield where 2 physicians used YouTube to post the results of COVID-19 tests at their urgent care during the peak of the pandemic. They misled the public in stating the disease did not have serious ramifications as the CDC stated. Due to the large number of viewers, the physicians were censured by medical societies due to their distribution of biased and unfounded information to the public. 

Patrick: AAFP authors suggest that for medical statements and discussions posted on social media for general patient education, it is recommended to add hyperlinks or direct sources with any online interaction in-so-that it better qualifies accuracy. If it’s unverifiable, it would be best to add written caveats about the information’s non-verifiability or that it is in the process of continued research. 

Patrick: At this time, there is some effort made by social media platforms to help indicate that the post is made by a reputable source. For example, when a licensed medical professional posts on YouTube, there are information panels that appear that will give context to the health content that is viewed. At the time of this episode, YouTube also currently allows channels to apply to be indicated as a licensed medical professional in the channel's posts. The applicants are examined by three different medical societies: the Council of Medical Specialty Societies (CMSS), the National Academy of Medicine (NAM), and the World Health Organization (WHO) to standardize how health education should be shared online. 

David: An example being Dr. Lin of Common Sense Family Doctor, an online medical blog for patients and physician education. In his statement to AAFP, he states that he wanted to post educational content twice a week, however, it required 3 to 4 hours a week to create. This can be time-consuming and distracting from other responsibilities.

Arreaza: Social media can change mind. What other concerns do you think should be considered when physicians try to educate patients in an online environment?

Social Media Platforms to Teach Medicine to the Greater Public 

Patrick: In general, social media platforms can be used to educate the public. One AAFP panel of authors wrote that some key points are important to consider when creating online content that is meant for public use.

1. We must define our goals toward the subset population we are directing the education towards. Is it providing general health education? Is it promoting a practice? Is this used to advocate for a cause?
2. We must consider who our audience is. For example, if our goal is to create a professional message to incite political or societal change towards public health policy, it would be best to utilize platforms that involve policymakers, political leaders, and/or patients that can inform them of what we want to achieve. 
3. Focus on general topics. These can include topics such as viral medical discussion trends on platforms like TikTok (ex. Ozempic), fitness and wellness, nutrition, or topics that you yourself have interest or expertise in. This can lead to the production of original content such as informatic YouTube series’, podcasts such as this one, or discussion threads. AAFP recognizes that this can become a creative outlet for physicians and can reduce burnout.

Conclusion

Patrick: We can see the transformative impact of social media on medical education, and how it’s further evolved since the COVID-19 pandemic. We explored how platforms like Twitter have redefined traditional journal clubs, making scholarly discussions more accessible across global medical communities. Moreover, we examined the role of influential medical content creators in bridging the gap between healthcare professionals and the general public. 

Patrick: While social media presents unprecedented opportunities for disseminating medical knowledge, our discussion also highlighted the challenges, including the need for accuracy in content, navigating professional conduct, and addressing algorithmic biases that can influence online interactions.

Patrick As we conclude, it's evident that social media has revolutionized medical education by fostering broader engagement and democratizing access to knowledge. However, both physicians and content creators must uphold ethical standards and ensure the accuracy of information shared online. By navigating these challenges thoughtfully, we can harness its full potential as a powerful tool for advancing medical education and improving health outcomes in our local communities. 

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This week we thank Hector Arreaza, Patrick De Luna, and David Zeng Song. Audio editing by Adrianne Silva. Intro by Raj Ajudia, MSIII. 

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

Links:

1. Topf, Joel M., Introduction: Social Media and Medical Education Come of Age, Seminars in Nephrology, Volume 40, Issue 3, 247 – 248. https://www.seminarsinnephrology.org/article/S0270-9295(20)30043-7/fulltext
2. Nguyen BM, Lu E, Bhuyan N, Lin K, Sevilla M. Social Media for Doctors: Taking Professional and Patient Engagement to the Next Level. Fam Pract Manag. 2020;27(1):19-14. https://www.aafp.org/pubs/fpm/issues/2020/0100/p19.html
3. Iserson KV, Derse AR, Delpier M. Navigating the Hazards of Social Media. Fam Pract Manag. 2022;29(3):15-20. https://www.aafp.org/pubs/fpm/issues/2022/0500/p15.html
4. Van Ravenswaay L, Parnes A, Nisly SA. Clicks for credit: an analysis of healthcare professionals' social media use and potential for continuing professional development activities. Med Educ Online. 2024 Dec 31;29(1):2316489. doi: 10.1080/10872981.2024.2316489. Epub 2024 Feb 15. PMID: 38359156; PMCID: PMC10877644. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10877644/
5. Doctor Mike, YouTube Channel, https://www.youtube.com/@DoctorMike
6. Dr. Glaucomflecken, YouTube Channel, https://www.youtube.com/@DGlaucomflecken
7. HealthyGamerGG, YouTube Channel, https://www.youtube.com/@HealthyGamerGG
8. Get info on health-related content, Google Support, https://support.google.com/youtube/answer/9795167
9. Apply to be a source in YouTube health features, YouTube Help, https://support.google.com/youtube/answer/12796915
10. Theme Song: Works All The Time by Dominik Schwarzer, License #5924333, PremiumBeat.com.  

Episode 177: Urinary Incontinence in Older Adults

Future Dr. Nguyen explains the evaluation and treatment of older adults with urinary incontinence.  Dr. Arreaza adds insights into the conservative management of urinary incontinence.

Written by Vy Nguyen, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. Editing and comments by Hector Arreaza, MD.

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

Definition of urinary incontinence. 

The International Continence Society (ICS) defines it as any involuntary urine leakage. 

Epidemiology of urinary incontinence. 

Data analysis from the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2018 shows that more than 60% of adult women which is equivalent to around 78,000,000 females living in the United States experience urinary incontinence with 32.4% reporting symptoms monthly. More data analysis shows the strongest association with urinary incontinence include age greater than 70, prior vaginal delivery, and BMI of 40 or greater. 

Despite urinary incontinence commonly affecting the senior population, this medical condition can also affect the quality of life of younger adult females and males. On top of that, urinary incontinence is often underestimated due to the low report level for various reasons and the obtained data might not accurately reflect the true prevalent rate. 

Types and etiology.

Urinary incontinence is divided into 5 categories: stress, urge, mixed, overflow, and functional. 

Stress urinary incontinence has the highest prevalence of 37.5% followed by mixed urinary incontinence at 31.3%, urgency at 22%, and unspecified urinary incontinence at 9.2%. Due to time constraints, we will discuss the most prevalent type which is stress urinary incontinence.

In females, stress urinary incontinence is often due to urethral sphincter hypermobility caused by weakened pelvic floor muscles. It can also be caused by dysfunction of the sphincter muscle that is exacerbated by increased intraabdominal pressure from coughing, sneezing, or physical exertion. This type of incontinence is commonly seen in pregnant women, those who experienced childbirth, and young women active in sports. 

In males, the most common etiology for stress urinary incontinence in males is prostate surgery such as radical prostatectomy which can damage the external urethral sphincter. Another cause is spinal cord injury or disease that can interfere with sphincter function. 

Evaluation. 

Urinary incontinence is first evaluated by a thorough history taking that includes inquiries about the type, severity, burden, and duration of incontinence. The initial evaluation includes a voiding diary that can provide clarity and help distinguish between the different types of incontinence or identify the dominating type in the case of mixed incontinence. 

Examples of voiding diary can be found on the websites of International Urogynecological Association (IUGA). Medical conditions such as COPD and asthma can induce cough; heart failure can cause volume overload; neurological disorders and musculoskeletal conditions can interfere with bladder emptying and urinary retention and thus should also be investigated. It is also helpful to ask about medication and substance use as the adverse effects can directly or indirectly contribute to urinary incontinence. For our female-identifying patients, a gynecological and obstetrical history such as birth history (vaginal versus c-section), current pregnancy as well as low estrogen (menopause) can contribute to reversible urinary incontinence. 

Management. 

There are various treatment modalities for stress urinary incontinence ranging from conservative to more invasive surgical management. 

Conservative treatment: 

-Initial treatment includes pelvic floor strengthening exercises and bladder training with scheduled void. 

-Pelvic floor muscle training (PFMT) is very effective, and it is proven to help achieve cure and improve the quality of life in women with ALL types of urinary incontinence. 

-For stress urinary incontinence, the median cure rate is around 58.8% for women after 12 months and 78.8% for men at 6 months of supervised pelvic floor muscle training (PFMT). 

-Certain behavioral modifications such as fluid intake management (<64 fluid ounces and in smaller portions throughout the day), constipation management, and weight loss can also relieve incontinence. 

-According to an AFP article, Cochrane for Clinicians, patients who have obesity may benefit from weight loss, improving the cure rate and improvement of symptoms in any type of urinary incontinence. SOR: B.

-Conservative management should be implemented for 6 weeks before considering other options. 

-Supplemental modalities can also be introduced in addition to pelvic floor exercises; those include vaginal weighted cones, biofeedback alone or with electrical stimulation. 

-Vaginal cones and electric stimulation are more effective than control at achieving cure or improving symptoms in patients with stress urinary incontinence.

-In the case that initial management does not offer relief, physicians can consider support devices such as pessaries. However, their use is associated with a high incidence of UTIs and doesn’t have long-term efficiency. 

Medications.

-In terms of pharmacologic treatments, several medications are being evaluated such as duloxetine and alpha-adrenergic agonists, but the FDA has yet to approve any medications for stress urinary incontinence. 

Invasive treatment:

-Lastly, patients without sufficient control of their incontinence via initial management or pessaries should be considered for surgical management. 

-Mid-urethral sling procedures have become the standard surgery for stress urinary incontinence due to their minimally invasive approach, rapid recovery, low-risk complications, and high cure rates and thus is the single most investigated procedure with the strongest evidence for its use. Around 53% after 3 years for males who received slings and 84.4% at 12 months for women who received surgical interventions. 

-Trans- or periurethral injections of bulking agents are also commonly used given the low invasive nature and rapid recovery. 

-Other procedures such as intravesical balloons, and electrical stimulation of pelvic floor can offer some benefits though data remains limited. Response rate often varies depending on the type of incontinence and treatment. Multiple modalities should be explored if symptoms persist. 

Conclusion:

-Urinary incontinence affects various physical, mental, and social aspects of our patients’ lives and thus can interfere with work, travel, exercise, and sexual activities. While it is a common presentation in elderly adults, it is imperative to emphasize that it is not part of normal aging. One survey shows almost three out of four women with urinary incontinence hesitate to disclose their symptoms and only 60% of those who tried to address their symptoms receive treatments. 

-Our patients might also see us as their sons, daughters, or even grandchildren and are reluctant to share their symptoms due to embarrassment. As we observe and approach our patients with compassion, we can help these individuals understand that many of these symptoms have reversible causes and can be managed to allow for a better quality of life.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

References:

1. Patel, Ushma J, et al. Updated Prevalence of Urinary Incontinence in Women: 2015–2018 National Population-Based Survey Data. Female Pelvic Medicine & Reconstructive Surgery 28(4):p 181-187, April 2022.https://journals.lww.com/fpmrs/abstract/2022/04000/updated_prevalence_of_urinary_incontinence_in.1.aspx
2. Tran, Linh and Puckett, Yana. Urinary Incontinence. National Library of Medicine. Last updated Aug 8, 2023.https://www.ncbi.nlm.nih.gov/books/NBK559095/
3. Clemens J, et al. Urinary incontinence in males, Up to Date, last updated: Mar 26, 2024. https://www.uptodate.com/contents/urinary-incontinence-in-males. 
4. Lukacz, Emily, et al. Female urinary incontinence: treatment and evaluation, Up to Date, last updated: Apr 2024. https://www.uptodate.com/contents/female-urinary-incontinence-treatment.
5. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 176: Self-sampling for HPV screening

Future Dr. Markarian explains the importance of HPV screening for the prevention of cervical cancer. Dr. Arreaza adds some insight about cervical cancer.

Written by Chantal Markarian, MSIV, American University of the Caribbean. Editing and comments by Hector Arreaza, MD.

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

Insights into Cervical Cancer.

Chantal: Cervical cancer stands as the most prevalent form of cancer in women globally costing the lives of approximately 350,000 women annually. About 4,000 women die of cervical cancer a year in the US. 

Cervical cancer is initially asymptomatic, allowing it to advance to a more severe stage if not detected early. The positive news is that cervical cancer is highly preventable through screening for precancerous lesions or the presence of HPV —the primary culprit behind most cases.

The role of HPV: Human Papilloma Virus, according to the World Health Organization, caused an estimated 620,000 cancer cases in women and 70,000 cancer cases in men.

Cervical cancer is more prevalent in certain regions. In regions with established screening initiatives, the incidence rate and mortality rate of cancer are lower than in resource-limited areas. This highlights that resource-constrained countries continue to bear a burden of this disease. In nations like the United States, access to the HPV vaccine along with routine screenings, like Pap smears and HPV tests has significantly decreased the prevalence of cervical cancer.

Screening recommendations from the US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS).

The U.S Preventive Services Task Force advises that women aged 21 to 29 undergo a Pap test every three years while those aged 30 to 65 should opt for co-testing (Pap and HPV tests) every five years. These examinations are usually conducted in outpatient facilities, where a medical professional collects a sample of cervical cells that are later examined under a microscope.

A normal result states that the sample was adequate for evaluation, in other words, that endocervical/transformation zone components are present, and that the patient is “Negative for intraepithelial lesion or malignancy.” 

ACS recommends cervical cancer screening begin at age 25 for women and people with a cervix. Those aged 25 to 65 should have a primary HPV test every 5 years. (A primary HPV test means the HPV test is done without cytology; follow-up screening can be done with a Papanicolaou (Pap) test if needed.) If primary HPV testing is not available, screening may be done with either a co-test every 5 years, which combines an HPV test with a Papanicolaou (Pap) test, or a Pap test alone every 3 years. 

How is Cervical Cancer Classified?

Two systems categorize lesions: the Cervical Intraepithelial Neoplasia (CIN) scale and the Bethesda system.

• The CIN scale categorizes lesions based on the degree of involvement of the cervical lining ranging from mild (CIN I) to moderate (CIN II) to severe dysplasia (CIN III).
• The Bethesda system emphasizes cytological findings organizing results into categories such as atypical squamous cells, low-grade lesions (LSIL), and high-grade lesions (HSIL).

ASCUS (Atypical Squamous Cells of Undetermined Significance) is the most common abnormality seen in pap smears. It may or may not indicate a problem, you have to make a decision based on the patient. 

Cervical cancer is largely linked to high-risk HPV (hrHPV), mostly HPV 16 and 18, and scientists are investigating tests that identify hrHPV DNA or RNA. These tests may provide a more accurate evaluation of cancer risk compared to traditional cytology. Examples include DNA amplification tests like Cobas test and the Xpert HPV test.

Obstacles to Screening.

Despite the efficacy of cervical cancer screening, many women face many obstacles to testing. In regions with limited resources, fear, embarrassment, lack of awareness, and restricted healthcare access pose challenges to screening.

In Nigeria, a study revealed that women often avoid Pap smears due to a lack of awareness. Similarly, healthcare providers in Ecuador highlighted issues like the absence of screening programs and inadequate health promotion efforts. Women in Peru face obstacles such as long waiting times preferences for female healthcare providers and limited access to health facilities. 

In 2022, 31% of minority women in the US did not undergo Pap smears in the past three years; many of these women were uninsured, unemployed, or low-income. These challenges contribute to higher rates of cervical cancer among women who do not follow recommended screening guidelines.

We must mention the cultural obstacle as well. Some cultures do not allow any kind of pelvic exams before marriage. They put a major emphasis on being a “virgin,” and placing a speculum in the vagina may be considered culturally unacceptable. In those cases, the doctor has to use their best persuasion skills to accomplish the goals of care. For example, they may suggest having the mother in the room during the pap smear, using the smallest speculum possible, or other techniques.

Self-sampling.

In 2020, the World Health Organization (WHO) introduced a global initiative to combat cervical cancer worldwide. The initiative aims to:

• Vaccinate 90% of girls by age 15.
• Screen 70% of women by age 35.
• Treat 90% of women with lesions and invasive cancer by 2030.

To achieve these goals, self-sampling for HPV testing has been introduced as a viable option for cervical cancer screening. 

Self-sampling for HPV testing is seen as an alternative for cervical cancer screening that addresses barriers associated with traditional methods. This approach enables women to take samples themselves using swabs or brushes removing the necessity for a pelvic examination. The option to mail in samples and receive results within two weeks enhances the convenience, privacy, and accessibility of the process giving individuals control over their health.

While self-sampling for hrHPV detection is not currently standard practice in the United States, it has been successfully implemented in countries across Europe, Africa, and South America. Pilot studies are ongoing in nations like Canada and New Zealand to assess its effectiveness offering promise for its impact.

In May 2024, the Food and Drug Administration (FDA) approved primary HPV self-collection for cervical cancer screening in a health-care setting. That means, the patient still has to go to a clinic to self-collect her sample. 

How Effective is HPV Self-Sampling?

Research supports the accuracy of HPV self-sampling. A study conducted by Polman et al., which involved a randomized controlled trial, demonstrated that HPV tests on self-collected samples were just as precise as those done on samples collected by clinicians in detecting high-grade lesions (CIN II and CIN III). Similarly, a meta-analysis conducted by Arbyn et al. showed no difference in sensitivity or specificity between self-sampled and clinician-sampled tests for detecting CIN grade II or higher.

These results indicate that self-sampling could be an adequate screening method for cervical cancer. This reassurance may motivate women to partake in screenings knowing they have a convenient and effective option. Ok, let’s say a patient has collected her sample or the sample was collected by a clinician, what is next?

Management of Cervical Cancer Screening Results.

The process of managing cervical cancer screening results involves evaluating a patient’s immediate and five-year risk of developing cervical abnormalities (CIN 3+) following guidelines from the American Society for Colposcopy and Cervical Pathology (ASCCP).

The ASCCP app is the best investment you can make in primary care. It is only $9.99, but it can save you a lot of time in clinic. Estimating risk is a process that considers factors such as current HPV test results, past screening outcomes, the patients' age, and whether they’ve had a hysterectomy or not. 

When Risk is Elevated, Prompt Action.

If a patient’s immediate risk of developing CIN 3 exceeds 4%, expedited treatment is typically recommended. This treatment may entail one of several procedures aimed at removing abnormal cervical tissue.

• Loop Electrosurgical Excision Procedure (LEEP): A common method that removes tissue using an electric wire loop. 
• Cold Knife Conization: In this procedure, a scalpel removes a cone-shaped section of the cervix.
• Laser Cone Biopsy: This technique involves removing a cone-shaped section of tissue using a laser.

Alternatively, healthcare providers may opt for treatment methods such, as cryotherapy, thermos-ablation, and laser ablation to eliminate abnormal tissue.

And those procedures are typically out of the scope of family medicine, but many family doctors may perform them with the proper training and experience.

When the risk is deemed low, Surveillance.

Patients with a risk of CIN 3 below 4% are typically advised to undergo surveillance with HPV testing every 1-5 years. If HPV testing is not available cytology alone (Pap test) is considered acceptable.

Special considerations for women.

For women under 25, a cautious approach is taken. If a low-grade lesion (LSIL) is identified through cytology, it is recommended to repeat the test annually for two years. If two consecutive tests show normal results the patient can resume screening intervals based on age. However, if a high-grade lesion (HSIL) is detected, a colposcopy and biopsy are recommended. It should be noted that expedited treatment is generally not advised for this age group since many high-grade lesions may resolve spontaneously.

For women over 25, the presence of low-grade lesions or persistent high-risk HPV often leads to recommendations for colposcopy and cervical biopsy.

When a cervical biopsy shows adenocarcinoma in situ it is suggested to perform an excisional procedure to rule out invasive cancer. The next steps depend on the margins of the excised tissue; If the margins show positive results (indicating abnormal tissue remains) further excision is necessary to ensure clear margins. This may be followed by a hysterectomy due to the risk of residual disease. 

For individuals who have been treated for high-grade lesions there is still a risk of developing cervical cancer. Therefore, long-term surveillance is essential. Women over 25 should undergo HPV testing six months after treatment, then annually until three consecutive negative tests are obtained. Subsequently testing every three years is advised for 25 years. As for women under 25, cervical cytology should be done six months post-treatment. Then at six-month intervals until three consecutive negative results are achieved. Once they reach 25 years old, they should switch to HPV testing.

As summary, HPV is the most common cause of cervical cancer, and screening must be implemented no matter what your zip code is because adequate screening can lead to a lower mortality. Remember that self-collection is an alternative for your patients, and it is FDA-approved if it is done in a healthcare setting. The ASCCP guidelines are very useful but difficult to memorize, so you can invest in the ASCCP phone app to provide accurate care for your patients. Thanks!

References: 

1. World Health Organization. HPV and Cervical Cancer Fact Sheet. 2024. Available online: https://www.who.int/en/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer (accessed on 10 August 2024).

2. Arbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. 2020;8(2):e191-e203.

3. Serrano B, Ibáñez R, Robles C, Peremiquel-Trillas P, de Sanjosé S, Bruni L. Worldwide use of HPV self-sampling for cervical cancer screening. Preventive Medicine. 2022;154:106900.

4. Gupta S, Palmer C, Bik EM, et al. Self-sampling for human papillomavirus testing: increased cervical cancer screening participation and incorporation in international screening programs. Front Public Health. 2018;6:345033.

5. Ubah C, Nwaneri AC, Anarado AN, Iheanacho PN, Odikpo LC. Perceived barriers to cervical cancer screening uptake among women of an urban community in South-eastern Nigeria. Asian Pac J Cancer Prev. 2022;23(6):1959-1965.

6. Vega Crespo, B., Neira, V.A., Ortíz Segarra, J. et al.Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals. BMC Public Health 22, 2144 (2022). https://doi.org/10.1186/s12889-022-14601-y

7.Olaza-Maguiña AF, De la Cruz-Ramirez YM. Barriers to the non-acceptance of cervical cancer screenings (Pap smear test) in women of childbearing age in a rural area of Peru. Ecancermedicalscience. 2019;13:901.

8. Sharma M, Batra K, Johansen C, Raich S. Explaining correlates of cervical cancer screening among minority women in the United States. Pharmacy. 2022 Feb 15;10(1):30.

9. Polman NJ, Ebisch RMF, Heideman DAM, et al. Performance of human papillomavirus testing on self-collected versus clinician-collected samples for the detection of cervical intraepithelial neoplasia of grade 2 or worse: a randomised, paired screen-positive, non-inferiority trial. The Lancet Oncology. 2019;20(2):229-238.

10. Costa S, Verberckmoes B, Castle PE, Arbyn M. Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening. British Journal of Cancer. 2023 Mar 23;128(5):805-13.
11. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2020;24(2):102-131.

12. Straughn, Jr, J Michael, and Catheryn Yashar. “Management of Early-Stage Cervical Cancer.” Www.uptodate.com, 2 Aug. 2024, https://www.uptodate.com/contents/management-of-early-stage-cervical-cancer. Accessed 13 Aug. 2024.

13. AMBOSS GmbH.Cervical cancer screening. https://amboss.com/. Accessed August 18, 2024.

14. Royalty-free music used for this episode: Lofi-Chilly by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 175: Alcohol Use Disorder Basics   

Future Dr. Sangha explains the clinical presentation, diagnosis, and fundamentals of the treatment of alcohol use disorder (AUD). Dr. Arreaza offers insights about the human aspect of the treatment of AUD.    

Written by Darshpreet Sangha, MS4, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.

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

What is Alcohol Use Disorder?

AUD is characterized as the inability to stop or control alcohol use despite adverse physical, social and occupational consequences. 

According to DSM-5, it is a pattern of alcohol use that, over 12 months, results in at least two of the following symptoms, indicating clinically substantial impairment or distress: 

1. Alcohol is frequently used in higher quantities or for longer periods than planned.
2. There is a persistent desire or unsuccessful attempt to reduce or manage alcohol use.
3. Activities that are required to get alcohol, consume alcohol, or recuperate from its effects take up a lot of time.
4. A strong need or desire to consume alcohol—a craving.
5. A pattern of drinking alcohol that prevents one from carrying out important responsibilities at work, school, or home.
6. Sustained alcohol consumption despite ongoing or recurring interpersonal or social issues brought on by or made worse by alcohol's effects.
7. Alcohol usage results in the reduction or cessation of important social, professional, or leisure activities.
8. Frequent consumption of alcohol under risky physical circumstances.
9. Continuing to drink even when one is aware of a chronic or recurrent health or psychological issue that may have been brought on by or made worse by alcohol
10. Tolerance: requiring significantly higher alcohol intake to produce the same intended effect. 
11. Withdrawal: Characterized by the typical withdrawal symptoms or a noticing relief after taking alcohol or a closely related substance, such as benzodiazepine.

How can we determine the severity of AUD? 

• Mild: 2–3 symptoms
• Moderate: 4–5 symptoms
• Severe: >/= 6 symptoms

Who is at risk for AUD?

Note: Ancestry offers a DNA analysis to find out about your heritage. You can also send that DNA to a third party to learn about your risks for diseases and conditions (for example, Prometheus.) Anyone can find out about their risk for alcoholism by doing a DNA test. 

The risk factors for AUD are: 

• Male gender
• Ages 18-29
• Native American and White ethnicities
• Having Significant disability
• Having other substance use disorder
• Mood disorder (MDD, Bipolar)
• Personality disorder (borderline, antisocial personality)

What is heavy drinking?

According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), heavy alcohol use is characterized as: 

• Males who drink > 4 drinks daily or > 14 drinks per week 
• Females who drink > 3 drinks on any given day or > 7 drinks per week

Pathophysiology of AUD.

The pathogenesis of AUD is not well understood, but factors that may play a role are genetics, environmental influences, personality traits, and cognitive functioning. Also, genetic factors may decrease the risk of AUD, i.e., the flushing reaction, seen in individuals who are homozygous for the gene that encodes for aldehyde dehydrogenase, which breaks down acetaldehyde. 

Who should be screened?

A person with AUD may not be easy to diagnose in a simple office visit, but some clues may point you in that direction. First of all, patients with AUD may present to you during their sober state, that´s why ALL adults (including pregnant patients) must be screened for AUD in primary care )Grade B recommendation). The frequency has not been determined but as a general rule, at least in Clinica Sierra Vista, we screen once a year. The USPSTF has concluded that there is insufficient evidence to recommend screening adolescents between 12-17 years old. 

What are the clinical manifestations of AUD?

Some symptoms may be subtle, including sleep disturbance, GERD, HTN, but some may be obvious, such as signs of advanced liver disease (ascites, jaundice, bleeding disorders, etc.)

If you draw routine labs, you may find abnormal LFTs (AST:ALT ratio >2:1), macrocytic anemia (MCV >100 fL), and elevated Gamma-glutamyl transferase (GGT). All these findings are highly suggestive of AUD. 

Patients with AUD may present in either an intoxication or withdrawal state. 

Signs and symptoms of acute intoxication may include “slurred speech, nystagmus, disinhibited behavior, incoordination, unsteady gait, hypotension, tachycardia, memory impairment, stupor, or coma.” 

Signs and symptoms of withdrawal range from tremulousness to hallucinations, seizures, and death. They are seen between 4 and 72 hours after the last drink, peaking at 48 hours, and can last up to 5 days. Alcohol withdrawal is one of the few fatal withdrawal syndromes that we know in medicine, and the symptoms can be assessed using a CIWA assessment. 

Treatment of AUD.

There are factors to consider before starting treatment: 

• Evaluating the severity of AUD 
• Establishing clear treatment goals is associated with better treatment outcomes
• Assessing readiness to change: It can be done by motivational interviewing and using the stages of change model, which are, Pre-contemplation, contemplation, preparation, action, maintenance, and relapse.
• Discussing treatment of withdrawal.

Treatment may be done as outpatient or it may require hospitalization. Dr. Beare sent an email with this information: “The approach to treating patients with AUD can be broken into two parts - the first is withdrawal management and the second is the long-term maintenance part. You MUST have a good plan for withdrawal treatment as it can be fatal if it's not addressed properly.” 

“Patients with any history of seizures due to withdrawal or a history of delirium tremens need inpatient management. If their withdrawal symptoms are typically mild (agitation, tremors, sleeplessness, anxiety) then outpatient management may be appropriate, typically with a long-acting benzodiazepine such as Librium or Ativan.”

According to Dr. Beare, “the human aspect isa key element in treating alcohol use disorder. These patients arrive with tremendous amounts of suffering, shame, guilt, and fear. The relationship between the patient and provider needs to be built with compassion and understanding that this disease is horrible from the patient's perspective and using an algorithmic and calculated approach can cause significant harm to the rapport-building process, leading to lower success rates.”

Treatment requires a lot of motivation and willpower. Hopefully, we can use some tools to assist our patients to be successful.

-For mild disorder, Psychosocial interventions like motivational interviewing and mutual help groups like AA meetings may be enough to help our patient quit drinking.

-For moderate or severe disorder: 

1st line treatment is Meditation and structured, evidence-based psychosocial interventions (CBT, 12-step facilitation); which leads to better outcomes

• For patients who lack motivation, motivational interviewing can be a useful initial intervention
• For motivated patients: medical management, combined behavioral intervention, or a combination of both can be utilized
• For patients with limited cognitive abilities, 12-step facilitation, or contingency management can be helpful 
• For patients who have an involved partner: Behavioral couples therapy can be utilized

Medications for AUD.

The first-line pharmacological treatment is Naltrexone. It is given as a daily single dose and can be started while the patient is still actively drinking. There is a monthly dose of long-acting injectable naltrexone as well. Naltrexone is contraindicated in individuals taking opioids, and patients with acute hepatitis or hepatic failure. Alternative 1st line treatment is Acamprosate which can be used in people with contraindications to Naltrexone.

AUD is a chronic problem and requires a close follow-up to evaluate response to treatment and complications. Medications need to be used along with psychotherapy and support, and medications may need to be changed or adjusted depending on the patient. It is an individualized therapy that requires full engagement of the doctor, the patient, and their families or social support. 

In conclusion, I would just like to add that, be compassionate because AUD is not a choice. AUD is a chronic problem like diabetes and HTN and may require a long road to recovery. Treatment includes psychotherapy, medications, and regular follow-up.

Thank you for listening!

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

References:

1. Risky drinking and alcohol use disorder: Epidemiology, clinical features, adverse consequences, screening, and assessment, https://www.uptodate.com/contents/risky-drinking-and-alcohol-use-disorder-epidemiology-clinical-features-adverse-consequences-screening-and-assessment, accessed on August 18, 2024.
2. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry, Accessed on August 18, 2024.
3. Alcohol use disorder: Treatment overview, https://www.uptodate.com/contents/alcohol-use-disorder-treatment-overview, assessed on August 18, 2024. 
4. Royalty-free music used for this episode, Grande Hip-Hop by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 174: GERD in Adults

Common and atypical symptoms are presented. Pathophysiology, diagnosis, and management are discussed. H. pylori's role is discussed during this episode. 

Written by Jacquelyn Garcia MS4 Ross University School of Medicine. Comments by Hector Arreaza, MD.

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

Definitions: 

Gastroesophageal reflux (GER): occasional backflow of stomach acid into the esophagus. It's a common physiological process that happens to many people, especially after meals. Occurs less than twice a week. Associated with mild and temporary symptoms such as heartburn or regurgitation. 

Gastroesophageal reflux disease (GERD): a chronic and more severe form of GER. It occurs when acid reflux happens frequently, typically more than twice a week, and/or causes esophageal injury/complications. 

-Non-erosive reflux disease (NERD)= GER without evidence of esophageal injury on endoscopy. 

-Erosive reflux disease (ERD)= GER with evidence of esophageal injury on endoscopy.

AFP Journal, January 2024: “Nonerosive GERD does not increase the likelihood of esophageal cancer. However, erosive GERD is associated with a doubled, but still low, risk of developing cancer, with the likelihood increasing over time.”

Pathophysiology:

The main pathophysiology behind GERD is lower esophageal sphincter (LES) dysfunction which can occur due to the following:

-LES Pressure: The LES is a muscular ring at the junction of the esophagus and stomach. It normally maintains a high-pressure zone to prevent reflux. In GERD, the intragastric pressure is higher than the pressure created by the LES. The tone of the LES can be reduced by caffeine, nitroglycerin, and scleroderma. 

-Transient LES Relaxations (TLESRs): These are normal relaxations of the LES that occur independently of swallowing. In GERD, these relaxations are more frequent or prolonged, allowing acid to reflux into the esophagus.

-Anatomic abnormalities: A hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity. This disrupts the normal anatomy of the gastroesophageal junction, reducing the pressure barrier and promoting reflux.

Epidemiology: 

It affects 10-20% of adults in Western cultures and less than 5% in Asia. Prevalence in the US ranges from 18.1% to 27.8% with a slightly higher rate in men. 

Risk factors: 

-Obesity, pregnancy, scleroderma, hiatal hernia; smoking, caffeine, alcohol, stress, fatty/fried/spicy foods. Spicy foods can be a challenge in some cultures (e.g. Mexican and Indian.) Sometimes, patients may ask for “something” to stop GERD but all they may need is dietary modification. 

-Medications: 

-aspirin, ibuprofen, clindamycin, tetracycline, bisphosphonates (irritate the esophagus and cause heartburn pain similar to GERD) 

-anticholinergics, TCA’s, CCB’s, ACEi, statins, benzodiazepines, theophylline, opioids, progesterone (increase acid reflux and worsen GERD)

Clinical features: 

Typical symptoms: 

-heartburn (burning retrosternal pain) 

-regurgitation (acidic stomach contents)

Atypical symptoms: 

-chest pain (can mimic angina pectoris, squeezing/burning substernal, radiates to back/neck/jaw/arm) 

-water brash (hypersalivation)

-globus sensation (lump in throat)

-nausea 

-belching

-bloating 

Alarm features in GERD: 

-dysphagia

-odynophagia (pain with swallowing)

-new onset of dyspepsia in ≥60yo 

-weight loss

-GI bleeding

-vomiting

-anemia 

Diagnosis: 

-There is no gold standard test 

-Patient with typical symptoms: diagnosis can be based on clinical symptoms alone 

-Patient with atypical symptoms: these symptoms can be seen in GERD but are not sufficient for diagnosis of GERD in the absence of typical symptoms. Need to rule out other disorders before associating the symptoms with GERD. (ex: chest pain r/o other causes such as MI with ECG) 

-Patient with alarm features: refer to GI for upper GI endoscopy. 

Complications: 

-Esophagitis: Erosive reflux disease (ERD) = GER with evidence of esophageal distal injury on endoscopy; in untreated GERD 30% have esophagitis. 

-Iron deficiency anemia: due to mucosal ulcerations -> chronic bleeding.

-Esophageal stricture: narrowing near GE junction, solid food dysphagia.

-Barrett Esophagus: intestinal metaplasia of esophagus due to chronic GERD (stratified squamous epithelium replaced by columnar epithelium)

-Risk factors: GERD for 5-10 years, >50yo, males, obesity, Caucasian, Tobacco use, family history 

                -Predisposes to esophageal adenocarcinoma 

Role of H. pylori.

Sometimes we tend to think that H. pylori is the cause of GERD. “H. pylori infection appears to protect the esophagus from gastroesophageal reflux disease, Barrett's esophagus, dysplasia in Barrett's esophagus, and esophageal adenocarcinoma, perhaps by causing chronic gastritis that interferes with acid production.”

It is unclear whether long-term use of PPIs heightens the risk of atrophic gastritis in patients with H. pylori. Consequently, routine screening for H. pylori infection and empiric eradication of H. pylori are NOT advised for patients with GERD. However, if H. pylori is diagnosed in the setting of GERD, eradication of H. pylori has been associated with an improvement of symptoms in patients with antral-predominant gastritis. 

Treatment: 

Two categories: 

Mild/intermittent symptoms (<2 times per week) 

“Step up approach”

1. Lifestyle modifications (weight loss, elevation of head of bed if have nighttime symptoms, diet modification/elimination of triggers) and low dose histamine 2 receptor antagonists or H2RA (famotidine, nizatidine, cimetidine) PRN for 4 weeks; antacids if symptoms <1/week 

2. Symptoms persistà standard dose H2RA BID for 2 weeks 

3. Symptoms persistà low dose PPI (omeprazole, pantoprazole, esomeprazole) qd for 4-8 weeks 

4. Symptoms persistà standard dose PPI qd for 4-8 weeks 

5. Symptoms persistà refractory GERD tx

Arreaza: What if the symptoms improve? 

-Symptoms improved on PPIà taper and discontinue PPI if asymptomatic for 8 weeks (do not do if have erosive esophagitis or Barrett’s) 

-Symptoms improved on H2RA à continue as PRN + lifestyle modifications 

Arreaza: What if symptoms come back?

-Recurrent symptoms ≥3months of discontinuing meds: resume previous therapy for 8 weeks

-Recurrent symptoms within 3 months of discontinuing meds: upper GI endoscopy and long-term maintenance therapy 

Jacquelyn:

Severe/frequent symptoms (≥2 times per week), ERD, Barrett’s esophagus 

“Step down approach”

1. Lifestyle modifications AND standard dose PPI qd for 4-8 weeks.

2. Symptoms persistà refractory GERD tx 

Refractory GERD tx:

1. Discuss with pt med compliance and usage

2. Symptoms persistà different PPI for 8 weeks or PPI BID for 8 weeks 

3. Symptoms persistà upper GI endoscopy

Alarm features: upper GI endoscopy. 

The Choosing Wisely campaign recommends that you discuss stopping PPI every year with your patient because PPIs are not free of harms.

PPI adverse effects: associated with increased risk of C. diff according to FDA safety announcement in 2012. Even without recent antibiotic use. So, patients may have to switch to another alternative due to this adverse effect of PPIs. 

-others: GI upset (nausea, diarrhea, and abdominal pain), decreased iron, B12, calcium, and magnesium absorption (FDA 2010 advises possible increased risk of fractures in elderly).

PPIs were a breakthrough medication in 1989, before that time, people got surgery for gastritis, but over time PPIs became popular, but they can be a double-edged sword, it is excellent for symptom control at the expense of potential short- and long-term side effects. 

-Other treatment options if there is no improvement with medical management, if a large hiatal hernia is present, or if complications occur despite medical therapy, surgical treatment is recommended. 

Conclusion: GERD is very common in our clinics/hospitals. It is important to recognize classic symptoms and differentiate symptoms from mild to severe. We need to start treatment and refer to GI promptly. Primary care is in a special position in evaluating these patients so we can avoid them developing potential complications like cancer. 

______________________

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

References:

1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastroesophageal reflux disease: a systematic review. Gut. 2014;63(6):871–880. doi: 10.1136/gutjnl-2012-304269  https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/definition-facts
2. Fass, Ronnie, et al. Approach to refractory gastroesophageal reflux disease in adults, Up to Date, last updated: May 14, 2024. https://www.uptodate.com/contents/approach-to-refractory-gastroesophageal-reflux-disease-in-adults. 
3. Kahrilas, Peter, et al. Medical management of gastroesophageal reflux disease in adults, Up to Date, last updated: Sep 19, 2022. https://www.uptodate.com/contents/medical-management-of-gastroesophageal-reflux-disease-in-adults.
4. Kahrilas, Peter, et al. Clinical manifestations and diagnosis of gastroesophageal reflux in adults, Up to Date, last updated Jul 15, 2022. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-gastroesophageal-reflux-in-adults.
5. Kahrilas, Peter, et all. Pathophysiology of gastroesophageal reflux disease, Up to Date, last updated: May 22, 2024. https://www.uptodate.com/contents/pathophysiology-of-gastroesophageal-reflux-disease.
6. Schwaitzberg, Steven D, Surgical treatment of gastroesophageal reflux in adults, Up to Date, last updated: Sep 27, 2023. https://www-uptodate-com/contents/surgical-treatment-of-gastroesophageal-reflux-in-adults. 
7. Shaqran TM, Ismaeel MM, Alnuaman AA, et al. Epidemiology, Causes, and Management of Gastro-esophageal Reflux Disease: A Systematic Review. Cureus. 2023;15(10):e47420. Published 2023 Oct 21. doi:10.7759/cureus.47420. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10658748/
8. Spechler, Stuart J, et al. Barrett's esophagus: Epidemiology, clinical manifestations, and diagnosis, Up to Date, last updated: Apr 30, 2024. https://www.uptodate.com/contents/barretts-esophagus-epidemiology-clinical-manifestations-and-diagnosis.
9. Shaughnessy AF. No Increased Risk of Esophageal Cancer With Nonerosive Gastroesophageal Reflux. Am Fam Physician. 2024;109(1):. https://pubmed.ncbi.nlm.nih.gov/38227884/
10. U.S. Food and Drug Administration. (2012). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs).  https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-clostridium-difficile-associated-diarrhea-can-be-associated-stomach. 
11. Wolf, Michael M et al. Proton pump inhibitors: Overview of use and adverse effects in the treatment of acid related disorders, Up to Date, last updated: May 31, 2024. https://www.uptodate.com/contents/proton-pump-inhibitors-overview-of-use-and-adverse-effects-in-the-treatment-of-acid-related-disorders.
12. Royalty-free music used for this episode: Milkshake by Gushito, downloaded on July 20, 2023, from https://www.videvo.net

Episode 173: Acute Osteomyelitis

Future Dr. Tran explains the pathophysiology of osteomyelitis and describes the presentation, diagnosis and management of acute osteomyelitis. Dr. Arreaza provides information about    

Written by Di Tran, MSIII, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.

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

What is osteomyelitis?

Osteomyelitis, in simple terms, is an infectious disease that affects both bone and bone marrow and is either acute or chronic.  According to archaeological findings of animal fossils with a bone infection, osteomyelitis was more than likely to be known as a “disease for old individuals”.Our ancestors over the years have used various vocabulary terms to describe this disease until a French surgeon, Dr. Nelaton, came up with the term “Osteomyelitis” in 1844. 

This is the beauty of medical terms, Latin sounds complicated for some people, but if you break up the term, it makes sense: Osteo = bone, myelo = marrow, itis = inflammation. So, inflammation of the bone marrow.

Traditionally, osteomyelitis develops from 3 different sources:

1. First category is the “hematOgenous” spread of the infection within the bloodstream, as in bacteremia. It is more frequent in children and long bones are usually affected. [Arreaza: it means that the infection started somewhere else but it got “planted” in the bones]
2. Second route is “direct inoculation” of bacteria from the contiguous site of infection “without vascular insufficiency”, or trauma, which may occur secondary to fractures or surgery in adults.  In elderly patients, the infection may be related to decubitus ulcers and joint replacements.
3. And the third route is the “contiguous” infection “with vascular insufficiency”, most seen in a patient with a diabetic foot infection.

Patients with vascular insufficiency often have compromised blood supply to the lower extremities, and poor circulation impairs healing. In these situations, infection often occurs in small bones of the feet with minimal to no pain due to neuropathy.They can have ulcers, as well as paronychia, cellulitis, or puncture wounds.

Thus, the importance of treating onychomycosis in diabetes because the fungus does not cause a lot of problems by itself, but it can cause breaks in the nails that can be a port of entry for bacteria to cause severe infections. Neuropathy is an important risk factor because of the loss of protective sensation. Frequently, patients may step on a foreign object and not feel it until there is swelling, purulent discharge, and redness, and they come to you because it “does not look good.”

Acute osteomyelitis often takes place within 2 weeks of onset of the disease, and the main histopathological findings are microorganisms, congested blood vessels, and polymorphonuclear leukocytes, or neutrophilic infiltrates.

What are the bugs that cause osteomyelitis?

Pathogens in osteomyelitis are heavily depended on the patient’s age.  Staph. aureus is the most common culprit of acute hematogenous osteomyelitis in children and adults.  Then comes Group A Strep., Strep. pneumoniae, Pseudomonas, Kingella, and methicillin-resistant Staph. aureus.  In newborns, we have Group B Streptococcal. 

Less common pathogens are associated with certain clinical presentations, including Aspergillus, Mycobacterium tuberculosis, and Candida in the immunocompromised.Salmonella species can be found in patients with sickle cell disease, Bartonella species in patients with HIV infection, and Pasteurella or Eikenella species from human or animal bites.

It is important to gather a complete medical history of the patient, such as disorders that may put them at risk of osteomyelitis, such as diabetes, malnutrition, smoking, peripheral or coronary artery disease, immune deficiencies, IV drug use, prosthetic joints, cancer, and even sickle cell anemia. Those pieces of information can guide your assessment and plan.

What is the presentation of osteomyelitis?

Acute osteomyelitis may present symptoms over a few days from onset of infection but usually is within a 2-week window period.  Adults will develop local symptoms of erythema, swelling, warmth, and dull pain at the site of infection with or without systemic symptoms of fever or chills.Children will also be present with lethargy or irritability in addition to the symptoms already mentioned.

It may be challenging to diagnose osteomyelitis at the early stages of infection, but you must have a high level of suspicion in patients with high risks. A thorough physical examination sometimes will show other significant findings of soft tissue infection, bony tenderness, joint effusion, decreased ROM, and even exposed bone. 

Diagnosis.

As a rule of thumb, the gold standard for the diagnosis of osteomyelitis is bone biopsy with histopathology findings and tissue culture. There is leukocytosis, but then WBC counts can be normal even in the setting of acute osteomyelitis.Inflammatory markers (CRP, ESR) are often elevated although both have very low specificity. 

Blood cultures should always be obtained whenever osteomyelitis is suspected.  A bone biopsy should also be performed for definitive diagnosis, and specimens should undergo both aerobic and anaerobic cultures.  In cases of osteomyelitis from diabetic foot infection, do the “probe to bone” test. What we do is we use a sterile steel probe to detect bone which is helpful for osteomyelitis confirmation.

Something that we can’t miss out on is radiographic imaging, which is quite important for the evaluation of osteomyelitis.  Several modalities are useful and can be used for the work-up plan; plain radiographs often are the very first step in the assessment due to their feasibility, low cost, and safety.  Others are bone scintigraphy, CT-scan, and MRI.  In fact, the MRI is widely used and provides better information for early detection of osteomyelitis than other imaging modalities.  It can detect necrotic bone, sinus tracts, and even abscesses. We look for soft tissue swelling, cortical bone loss, active bone resorption and remodeling, and periosteal reaction.  Oftentimes, plain radiography and MRI are used in combination. 

Treatment:

Treatment of osteomyelitis actually is a teamwork effort among various medical professionals, including the primary care provider, the radiologist, the vascular, the pharmacist, the podiatrist, an infectious disease specialist, orthopedic surgeons, and the wound care team.

Something to take into consideration, if the patient is hemodynamically stable it is highly recommended to delay empirical antibiotic treatment 48-72 hours until a bone biopsy is obtained.  The reason is that with percutaneous biopsy ideally done before the initiation of antibiotic treatment, “the microbiological yield will be higher”.We’ll have a better idea of what particular bugs are causing the problem and guide the treatment appropriately. 

The choice of antibiotic therapy is strongly determined by susceptibilities results.  The antibiotic given will be narrowed down only for the targeted susceptible organisms.  In the absence of such information, or when a hospitalized patient presents with an increased risk for MRSA infection, empiric antibiotic coverage is then administered while awaiting culture results. 

It should be broad-spectrum antibiotics and include coverage for MRSA, broad gram-negative and anaerobic bacteria.  For example, vancomycin plus piperacillin-tazobactam, or with broad-spectrum cephalosporin plus clindamycin.  Treatment will typically be given for 4 to 6 weeks.

The duration between 4-6 weeks is important for complete healing, but a small study with a small sample showed that an even shorter duration of 3 weeks may be effective, but more research is needed. 

In certain situations, surgery is necessary to preserve viable tissue and prevent recurrent infection, especially when there are deep abscesses, necrosis, or gangrene, amputation or debridement is deemed appropriate. 

If the infected bone is completely removed, patients may need a shorter course of antibiotics, even a few days only. Amputation can be very distressing, especially when we need to remove large pieces of infected bone, for example, a below-the-knee amputation. We need to be sensitive to the patient’s feelings and make a shared decision about the best treatment for them.

In patients with diabetes, additional care must be taken seriously, patient education about the need for compliance with treatment recommendations, with careful wound care, and good glycemic control are all beneficial for the healing and recovery process. 

Because this is a very common problem in the clinic and at the hospital, we must keep our eyes wide open and carefully assess patients with suspected osteomyelitis to detect it promptly and start appropriate treatment. Adequate and timely treatment is linked to fewer complications and better outcomes.

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Conclusion: Now we conclude episode number 173, “Acute Osteomyelitis.” Future Dr. Tran explained the pathophysiology, diagnosis, and management of osteomyelitis. A bone biopsy is the ideal method of diagnosis. Delaying antibiotic treatment a few days until you get a biopsy is allowed if the patient is stable, but if the patient is unstable, antibiotics must be started promptly. Dr. Arreaza mentioned the implications of amputation and that we must discuss this treatment empathically with our patients. 

This week we thank Hector Arreaza and Di Tran. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

1. Bury DC, Rogers TS, Dickman MM. Osteomyelitis: Diagnosis and Treatment. Am Fam Physician. 2021 Oct 1;104(4):395-402. PMID: 34652112.
2. Cunha BA. Osteomyelitis in elderly patients. Clin Infect Dis. 2002 Aug 1;35(3):287-93. doi: 10.1086/341417. Epub 2002 Jul 11. PMID: 12115094.
3. Fritz JM, McDonald JR. Osteomyelitis: approach to diagnosis and treatment. Phys Sportsmed. 2008 Dec;36(1):nihpa116823. doi: 10.3810/psm.2008.12.11. PMID: 19652694; PMCID: PMC2696389.
4. Hatzenbuehler J, Pulling TJ. Diagnosis and management of osteomyelitis. Am Fam Physician. 2011 Nov 1;84(9):1027-33. PMID: 22046943.
5. Hofstee MI, Muthukrishnan G, Atkins GJ, Riool M, Thompson K, Morgenstern M, Stoddart MJ, Richards RG, Zaat SAJ, Moriarty TF. Current Concepts of Osteomyelitis: From Pathologic Mechanisms to Advanced Research Methods. Am J Pathol. 2020 Jun;190(6):1151-1163. doi: 10.1016/j.ajpath.2020.02.007. Epub 2020 Mar 16. PMID: 32194053.
6. Momodu II, Savaliya V. Osteomyelitis. [Updated 2023 May 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532250/
7. Royalty-free music used for this episode: Trap Chiller by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net
    

Episode 172: NAFLD and Obesity

Future Dr. Nguyen explains the pathophysiology of non-alcoholic fatty liver disease and how it relates to obesity. Dr. Arreaza gives information about screening and diagnosis of NAFLD. 

Written by Ryan Nguyen, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.

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

Introduction/Pathophysiology
Nonalcoholic fatty liver disease (NAFLD) refers to the buildup of excess fat in liver cells, occurring without the influence of alcohol or drugs. Nonalcoholic steatohepatitis (NASH) represents a more severe form of NAFLD, characterized by inflammation and liver cell injury due to fat accumulation. If left untreated, NASH can progress to liver fibrosis or cirrhosis. Typically, NAFLD/NASH is diagnosed after other liver conditions are ruled out, making it a diagnosis of exclusion.

NAFLD -> NASH -> Cirrhosis -> Liver failure. Another term for NAFLD is metabolic dysfunction-associated steatotic liver disease. 

Fatty liver disease is identified when more than 5% of liver weight consists of fat, whereas, NASH is diagnosed when this fat accumulation is accompanied by inflammation and liver cell injury, sometimes leading to fibrosis. Understanding these distinctions is crucial in recognizing and managing the spectrum of liver conditions associated with obesity and metabolic syndrome.

BMI serves as a tool to gauge body fat levels: individuals are categorized as normal weight if their BMI falls between 18.5 and 24.9, overweight if it ranges from 25 to 29.9. Class I obesity is diagnosed with a BMI of 30 to 34.9, class II obesity between 35 and 39.9, and class III obesity when BMI exceeds 40.

Obesity puts you at risk of NAFLD, but you can also see NAFLD in non-obese patients, but the prevalence is very low, about 5%. What did you learn about the demographics of NAFLD?

NAFLD is most widespread in regions like South Asia, the Middle East, Mexico, Central and South America, with prevalence rates exceeding 30%. In the United States, prevalence varies with approximately 23-27%, notably higher among Asians at 30%, followed by Hispanic individuals at 21%, White individuals at 12.5%, and Black individuals at 11.6%. 

Across all racial groups, obesity plays a significant role, affecting more than two-thirds of individuals diagnosed with NAFLD. Understanding these demographics underscores the global impact of obesity on NAFLD prevalence.

Diagnosis: Screening/Labs/Imaging/Tools

The American Association for the Study of Liver Diseases does not recommend screening for NAFLD, but if it is discovered an appropriate workup is warranted. 

AST/ALT Ratio

Liver health can be assessed by a series of tests aimed at assessing fat accumulation, inflammation, and fibrosis. Initial screening often includes laboratory tests such as measuring the ratio between aspartate transaminase (AST) and alanine transaminase (ALT), where a ratio less than 1 may suggest possible NAFLD, although it is not diagnostic on its own. Normally, AST is slightly more elevated than ALT. So, if the AST/ALT ratio is lower, then means that ALT is higher than AST. 

FibroSure®.

Additionally, you can measure indirect markers of fibrosis with tests such as FibroSure or FibroTest blood tests that combine several biomarkers including age, sex, gamma-glutamyl-transferase (GGT), total bilirubin, alpha-2-macroglobulin, apolipoprotein A1, haptoglobin, and ALT to provide insights into liver health.

Some people may be more familiar with FibroSure before Hepatitis C treatment. You can get a fibrosis score (F0-F4), and it is considered significant fibrosis if the score is > or equal to F2. Imaging plays a crucial role in diagnosing NAFLD without the need for invasive procedures like liver biopsy. Vibration-controlled transient elastography (Fibroscan) uses ultrasound to measure liver stiffness, indicating potential fibrosis and inflammation. While noninvasive and portable, it focuses solely on liver ultrasound and may not be universally accessible. MRI with proton density fat fraction (MRI-PDFF) offers a comprehensive assessment of liver fat content, commonly used in clinical and research settings for NAFLD and NASH evaluation.

For evaluating hepatic fibrosis in patients with suspected NAFLD, tools like the Fibrosis-4 Index (FIB-4) incorporate age, AST, ALT, and platelet count to estimate the likelihood of liver disease progression. These screening methods collectively aid in diagnosing and monitoring NAFLD, particularly in individuals at risk due to factors like prediabetes, type 2 diabetes, obesity, and abnormal liver enzyme ratios. 

With the FIB-4 you can get a faster answer than FibroSure because you only need 4 elements: Age, platelet count, AST and ALT. Cirrhosis is less likely if FIB-4 is <1.45, it is considered intermediate if it is between 1.45 and ≤3.25, and cirrhosis is more likely with a score >3.25. Understanding these diagnostic approaches is essential for early detection and management of NAFLD in clinical practice.

Some researchers are invested in diagnosis and treating NAFLD while others recommend against labeling patients with NAFLD. A 2018 Lancet article concluded that the risks of over-diagnosing and overtreating NAFLD exceed the benefits of screening or periodic imaging because of “the low hepatic mortality, high false-positive rate of ultrasonography, selection bias of current studies, and lack of viable treatment.” However, patients who suffer from metabolic syndrome should be counseled about dietary modification and physical activity regardless of their liver condition. 

NAFLD and obesity

Fatty liver disease is often caused by multiple insults towards either genetically or environmentally predisposed individuals. Family history of NAFLD and having specific genetic variants are important risk factors for NAFLD. Those with prior health conditions can have increased susceptibility to NAFLD including T2DM leading to insulin resistance, metabolic syndrome, sleep apnea, hepatitis C, and cardiovascular or chronic kidney disease. 

A sedentary lifestyle and unhealthy nutrition (especially high intake of processed carbohydrates) cause an increase in free fatty acids leading to hepatic fat deposition → ballooning of hepatocytes → leading to hepatocyte injury/death → inflammation with fibroblast recruitment → end result of fibrosis/cirrhosis. Just a quick reminder, NAFLD is defined as fatty liver with >5% hepatic fat and NASH is defined as fatty liver with >5% hepatic fat with inflammation, hepatocyte injury, with or without fibrosis that we can determine through imaging. 

A leading concern for the development of NAFLD is the consumption of high fructose corn syrup.  High fructose corn syrup (HFCS), commonly found in candy, processed sweets, soda, fruit juices, and other processed foods, is linked to non-alcoholic fatty liver disease (NAFLD). Unlike natural whole fruits, which contain fiber and are generally healthier due to their slower absorption, HFCS lacks fiber and is quickly absorbed, leading to rapid transport to the liver. This process contributes to NAFLD by increasing the hepatic synthesis of lipids and interfering with insulin signaling. To avoid HFCS, individuals are encouraged to consume whole fruits rather than fruit juices and adopt diets rich in whole grains, lean meats, plant-based proteins, fruits, and vegetables, such as the Mediterranean or DASH diets, which are less likely to promote NAFLD, especially in those with healthy body weight.

NAFLD treatment.

Avoiding alcohol seems very obvious, but we need to mention it. Avoiding heavy alcohol consumption is recommended and complete abstinence is suggested.

Weight loss is crucial; even a modest reduction of 3–5% in body weight can alleviate hepatic steatosis, with greater improvements typically seen with 7–10% weight loss, particularly beneficial for addressing histopathological features of NASH, such as fibrosis. We must focus on tailored medical nutrition therapy and regular physical activity. 

A strategic meal plan is essential, emphasizing achieving a healthy body weight while limiting trans fats and ultra-processed carbohydrates. Options like the Mediterranean diet, which balances lean proteins and restricts processed carbohydrates have shown promise. 

Dynamic aerobic and resistance exercises play a significant role in managing NAFLD. They help maintain a healthy weight and enhance peripheral insulin sensitivity, reduce circulating free fatty acids and glucose levels, and boost intrahepatic fatty acid oxidation while curbing fatty acid synthesis. These benefits contribute to mitigating liver damage associated with NAFLD, offering therapeutic advantages beyond mere weight reduction.

Exercise may not be a great tool for weight loss, but it is a great tool for weight maintenance, liver health, and overall health as well. “Most patients with NAFLD die from vascular causes, but NAFLD puts patients at increased risk of cardiovascular death”. 

Medications for NAFLD.

Regarding pharmacotherapy, while no medications are currently FDA-approved specifically for NAFLD treatment, some options show promise in clinical settings. Vitamin E supplementation at 800 IU (international units) daily has demonstrated biochemical and histological improvements in NASH cases without diabetes or cirrhosis, though long-term use may elevate prostate cancer risks. It is important to make a shared decision with the patient before starting Vitamin E supplementation. 

Medications like pioglitazone can reduce liver fat and improve NASH, even as they may increase body weight. But our favorite, GLP-1 receptor agonists, such as liraglutide and semaglutide, also show potential in reducing liver fat and improving NASH symptoms, and this is an emerging therapeutic option for managing this condition.

If you decide to treat, then you should monitor as part of the treatment. An aminotransferase check is recommended 6 months after starting a weight loss program. If levels do not improve or do not return to normal after 5-7% of weight loss, another cause of elevated transaminases needs to be investigated.

You also need to monitor fibrosis in patients with >F2. If fibrosis has been proven by liver biopsy, you can order FibroSure every 3-4 years. 

Having a fatty liver may be a red flag that your patient has a metabolic problem. If you discover it, start interventions that would benefit not only the liver but the whole metabolic profile of your patient. The Obesity Medicine Association (OMA) issued a Clinical Practice Statement (CPS) regarding NAFLD and obesity stating that patients with obesity are at increased risk for NAFLD and NASH. It recommends that clinicians strive to understand the etiology, diagnosis, and optimal treatment of NAFLD with a goal to prevent NASH in their patients.

Regular exercise, even walking 30 minutes a day can show many benefits in curbing fatty accumulation in the liver. Having a proper diet with avoidance of high fructose corn syrup can overall help in reducing NAFLD/NASH. 

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Conclusion: Now we conclude episode number 172, “NAFLD and Obesity.” Future Dr. Nguyen explained that NAFLD and obesity are closely related and NAFLD can lead to NASH and cirrhosis in some patients. Dr. Arreaza explained that screening may not be recommended by some medical societies, but others are in favor of screening and treating this disease. However, most people agree that NAFLD is a sign of metabolic disease and a good reason to talk about healthy eating and physical activity with our patients. There are no FDA-approved medications to treat NAFLD, but some evidence suggests that Vitamin E can improve it and GLP-1 receptor agonists are a promising option. 

This week we thank Hector Arreaza and Ryan Nguyen. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

1. Karjoo S, Auriemma A, Fraker T, Edward H. Nonalcoholic fatty liver disease and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022. https://doi.org/10.1016/j.obpill.2022.100027.
2. Curry M, Afdhal N. Noninvasive assessment of hepatic fibrosis: Overview of serologic tests and imaging examinations.  https://www.uptodate.com/contents/noninvasive-assessment-of-hepatic-fibrosis-overview-of-serologic-tests-and-imaging-examinations
3. Royalty-free music used for this episode: Cool Groove (Alt-Mix) by Videvo, downloaded on Nov 06, 2023, from https://www.videvo.net