Episode 224: Community Health Workers

Dr. Arreaza: Today we will discuss a topic that, frankly, every single person listening, whether you're a medical student, a resident, a nurse, a family doctor, or any primary care provider, needs to really understand. We're talking about community health workers (CHWs). We are joined by our stellar medical student; you may be familiar with her voice from previous episodes about insomnia. Moira, welcome, please introduce yourself. 

Moira: I want to be upfront about why Community Health Workers matter to you specifically. If you've ever felt frustrated that your patient with uncontrolled diabetes keeps missing appointments because they can't get a ride, or that your heart failure patient was readmitted because nobody checked whether they could afford their medications, then you already understand the problem that CHWs are designed to solve.

Dr. Arreaza: We're going to give you the definition of a CHW, the evidence behind their effectiveness, how they fit into your care team, the return on investment, and practical steps for integrating them into your practice. We have pulled information from a lot of peer-reviewed sources, and we want to share them with you. So, Moira, let's start with the basics. What exactly is a community health worker?

Moira: Great question, and it's one that even literature struggles with, because there are so many titles for this role. Community Health Worker is an umbrella term that encompasses more than 20 different titles including outreach workers, promotores or promotoras de salud, community health representatives, lay health workers, peer educators, patient navigators, and many more. The American Public Health Association defines CHWs as frontline public health workers who are trusted members of or have an unusually close understanding of the communities they serve.

Arreaza: And that trust is so important in health care. CHWs are not physicians. They are not nurses. They do not diagnose or prescribe. But they are like a bridge connecting the medical environment, social services, and the community to reduce gaps in healthcare delivery. 

Moira: Exactly. In the United States, the role was formally recognized in the 2010 Patient Protection and Affordable Care Act, which includes several sections highlighting the key roles CHWs play in achieving important goals of healthcare.

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References: 

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! 

Episode 223: Oncogenic Viruses

Introduction

Mehr: Hi everyone, welcome back to the Rio Bravo qweek podcast. Back by popular demand is Me, Mehr Boparai a third-year medical student at COMP-NW. Here with me is Jeremy Pan from COMP who is also a third-year medical student. How are you doing Jeremy?

Jeremy: I’m doing great Mehr.Thanks for the kind intro; we had a fun time this morning doing street medicine and had some practice giving Toradol injections and wound dressings. So excited to be back for another podcast episode this afternoon!

Mehr: This week, we are moving away from bacteria and antibiotics and diving deeper into cancer-causing viruses.

Jeremy: Yes, and if you are interested at all in public health, this is one of those areas where medicine overlaps with public health in a really tangible way. I think one of the most underappreciated aspects of this topic is that we have vaccines that can prevent many of these cancers. If you told someone 50 years ago we’d be vaccinating against cancer, they probably wouldn’t believe you! It’s amazing to see how far medicine has come.

How viruses cause cancer:

Jeremy: Before jumping into specific viruses, I always think having a mechanism-based framework makes everything stick better.

Mehr: Right, because they don’t all cause cancer the same way. Medicine can never be easy huh?

Jeremy: Yea…this career really is just a lifetime of discovery. So just to start, in broad terms, we can think of three main buckets of how viruses can cause cancer:

Mehr: 

Jeremy:

Mehr: And NK cells step in when cells decide to stop expressing MHC I, which abnormal cells like to hide to avoid being caught. So just to reiterate, there are two layers to dissect here: if a cell looks suspicious with an abnormal MHC, CD8 T-cells kill them. If the abnormal cell decides to hide its MHC, then the NK cell will kill it instead.

Jeremy: So, for the final big picture, we can think of oncogenic viruses as either disabling tumor suppression, causing chronic damage over time through inflammation, and weakening the immune system’s ability to catch cancer in time before it develops.

HPV

Mehr: Let’s start with one of the most common viruses afflicting our population – Human Papilloma Virus otherwise known as HPV. 

Jeremy: Right, this notorious virus is probably the most clinically impactful oncogenic virus. The key players HPV utilizes are proteins E6 and E7.

Mehr: Right! E6 binds to and inhibits p53, which normally acts to induce cell cycle arrest, and E7 inhibits Rb, which normally acts as a tumor suppressor gene that inhibits the G1 to S phase transition in a normal cell cycle.

Jeremy: So essentially, we are losing both apoptosis and losing cell cycle control at the same time. What is interesting about HPV is that persistent infection, not just exposure to the virus, is what drives cancer risk. 

Mehr: Exactly, most HPV infections clear on their own, but the ones that persist are the problem. Clinically, many end up being asymptomatic. However, for high-risk infections, we can see genital warts that can itch, feel tender, or cause abnormal vaginal bleeding and discharge. Patients are sometimes not able to have a vaginal delivery because of the warts that are present along their genital tract. We can also see warts on the hands and fingers or plantar surface of our feet.

Jeremy: Another interesting point is that we are also seeing a shift where there are more cases of oropharyngeal cancers in younger, non-smoking patients. This is why if we see an abnormal neck lymph node or persistent sore throat after swallowing in a young patient, HPV should definitely be on the differential. 

Mehr: Screening is very important as well! We typically discover high-risk HPV infections through routine Pap smears and other HPV specific tests through DNA PCR and RNA tests. We also encourage vaccination for effective prevention of both genital warts and high-risk HPV-related cancers. There was also a study in Scotland where there were zero cases of HPV in adults who received the vaccine between 12-13 years of age! Which is crazy! 

EBV

HBV & HCV

Mehr: Now let’s shift to viruses that affect the liver, Hepatitis B virus and Hepatitis C virus.

Jeremy: Both are strongly associated with hepatocellular carcinoma, but they actually get there in slightlydifferent ways.

Mehr: Right. Hepatitis B is a DNA virus that can integrate directly into the host genome, which can disrupttumor suppressor genes and promote oncogenesis.

Jeremy: Whereas Hepatitis C is an RNA virus, so it doesn’t integrate into the host genome. Instead, it causes chronic inflammation Over time, that leads to repeated cycles of hepatocyte injury and regeneration, along withoxidative stress from reactive oxygen species, which increases the risk of DNA mutations.

Mehr: One really important clinical pearl is that Hep B can actually cause hepatocellular carcinoma evenwithout cirrhosis. Whereas with Hep C, the pathway is usually chronic inflammation → fibrosis → cirrhosis → dysplasia→ cancer. 

Jeremy: So, screening becomes really important for both of these viruses. For high-risk patients—like those with chronic hepatitis or cirrhosis—we typically dosurveillance with liver ultrasound every 6 months, sometimes with alpha-fetoprotein levels to see if it is elevated.

Mehr: From a prevention standpoint, the Hep B vaccine is a huge win. It significantly reduces the risk ofhepatocellular carcinoma. For Hep C, we don’t have a vaccine, but direct-acting antivirals can actually cure the infection andreduce long-term cancer risk, which is why we screen between ages 18-79 

nowadays. Global Hep B and C account for 65% of all HCC cases! So, it makes sense that primary care itself is increasing the treatment of Hep C cases as well since it is easier to prescribe and that you want to be treated ASAP. 

Jeremy: Yea, the ability to treat Hep C is so beneficial to population health. Now let’s say you have a patient who develops hepatocellular carcinoma, options can include surgicalresection, liver transplantation, local therapies, or systemic treatments depending on stage. 

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:

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! 

Arreaza: Welcome back tothe Rio Bravo qWeek Podcast! My name is Dr. Hector Arreaza, I am a family physician and faculty member in the Rio Bravo Family Medicine Residency Program. Today I am joined by two excellent medical students who will introduce themselves now, welcome, guys!

Mehr: Thank you for the introduction! My name is Mehr Boparai, third year medical student at WesternU COMP-NW.

Jeremy: And my name is Jeremy Pan, also a third-year medical student at WesternU COMP Pomona and we will be discussing a very prevalent topic today in the clinical world that is arguably becoming one of the biggest threats to modern medicine: antibiotic resistance.

Mehr: That’s right! Imagine this scenario: a routine infection, something we’ve treated easily for decades, suddenly becomes life-threatening because the drugs we always thought we could rely on just don’t work anymore. You likely ran into this problem just last week with one of your patients! That’s not science fiction. That’s happening every day in hospitals across the world.

Dr. Arreaza: I agree, antibiotic resistance must be taken seriously. I increased my awareness in 2023, when I attended a medical research conference in Carmel(which is a popular conference that takes place in that beautiful town). I heard Dr. David Gilbert, a famous and accomplished ID doctor who helped develop the Sanford Guide to Antimicrobial Therapy, he warned everyone about antibiotic resistance as one of the biggest threats for humanity, the other two were a nuclear bomb and an epidemic.

Jeremy: Woah, comparing antibiotic resistance to a nuclear bomb is absolutely crazy, but likely very real!! Well today, we’re going to be focusing on five of the most common infections or “bugs” you’ll see in a hospital setting. We’ll talk about what typically causes them, what antibiotics we used to rely on, and what happens when resistance decides to enter the picture.

Mehr: If you are a medical student (or resident), you understand that dreaded feeling when an attending asks “what antibiotics should we start?” But don’t worry, in this episode, we hope to address the decision-making process in a simple framework.

What is Antibiotic Resistance?

Dr. Arreaza:

 Before we jump into specific common infections and pathogens, let’s cover our basics. Antibiotic resistance occurs when bacteria evolve to survive drugs designed to kill them. This can happen through genetic mutations or by getting resistance genes from other bacteria. Why does this matter?

Jeremy: It matters because antibiotics play a huge role in modern medicine. Without them, surgeries, chemotherapy, organ transplants—even childbirth—become significantly more dangerous.

Mehr: According to the CDC, in the U.S. alone, antibiotic-resistant infections affect over 2.8 million people each year and cause more than 35,000 deaths! So, when we talk about resistance, we’re not just talking about inconvenience for treatments. We’re talking about a fundamental threat to healthcare.

Staph aureus

Dr. Arreaza: So, if you have a patient who comes in with a skin infection or is maybe showing signs of pneumonia or bacteremia, what is one of the most common bugs that you should think about?

Jeremy: Staph aureus! Typically to treat methicillin-sensitive strains (MSSA), we would utilize antibiotics like nafcillin, oxacillin, or cefazolin. But there is one strain in particular that is worrisome, Mehr?

Mehr: yeap, that would have to be MRSA, one of the most well-known resistant organisms. MRSA is resistant to all beta-lactam antibiotics, which means we can say goodbye to all penicillin and most cephalosporins.

Dr. Arreaza: And what is the first antibiotic that comes to mind if we see MRSA on a culture in the hospital?

Mehr: Vancomycin! Alternative treatments include linezolid and daptomycin depending on the type of infection. But what is the problem that we are starting to see?

Jeremy: You guessed it, cases of resistance to vancomycin are starting to appear—VRSA. These cases are still uncommon today, but these findings show a worrying trend, that we will eventually start running out of reliable options.

Dr. Arreaza: Fortunately, VRSA infections are extremely rare, with only 14-16 documented cases in the United States. As of 2019, 52 VRSA strains have been identified in the United States, India, Iran, Pakistan, Brazil, and Portugal. Let’s keep an eye on VRSA in the future. 

E. coli

Dr. Arreaza: Alright, so let’s say you have a patient with dysuria, urinary frequency, maybe even a catheter in place. What’s the most common bug you’re thinking of?

Mehr: That one’s a classic, we are thinking E. coli.

Jeremy: Exactly. E. coli is the leading cause of urinary tract infections, especially in both community and hospital settings.

Dr. Arreaza: So Jeremy, what are we using for uncomplicated UTIs?

Jeremy: We usually think of trimethoprim-sulfamethoxazole, nitrofurantoin, or sometimes fosfomycin. And in more complicated cases, we might consider fluoroquinolones like ciprofloxacin.

Mehr: But here’s where things get tricky. Resistance to TMP-SMX and fluoroquinolones has been increasing significantly. In some areas, resistance rates are over 20–30%, which really changes your empiric choices.

Conclusion:

Dr. Arreaza: So we’ve talked about five major organisms today: Staph aureus, E. coli, Klebsiella, Pseudomonas, and C. diff. What’s the overarching takeaway of the discussion?

Jeremy: The main takeway is that antibiotic resistance is already here, and it’s affecting some of the most common infections we see in clinical practice on a day-to-day basis.

Mehr: And as students and future physicians, it’s important to not just memorize antibiotics, but understand why we’re choosing them.

Dr. Arreaza: Exactly. Always think: What organism am I targeting? What are the local resistance patterns? And can I narrow therapy once I have cultures?

Jeremy: And maybe most importantly—don’t overuse antibiotics, especially in cases when they’re not needed.

Mehr: Because the more we use them, the faster we lose them.

Dr. Arreaza: I’d like to share the story I listed to in a RadioLab episode about Dr Steffanie A. Strathdee, one of the most influential ID doctors in the world and Co-Director at the Center for Innovative Phage Applications and Therapeutics (IPATH). She shared that her husband got infected by Acinetobacter baumannii, an opportunistic infection that can cause severe infection. After trying many antibiotics, he was treated with “phages”, “bacteriophages”. So, that’s part of “thinking out of the box”.

Jeremy: Thank you all for tuning in to the Rio Bravo qWeek podcast series and thank you Dr. Arreaza for having Mehr and me on the podcast today!

Stay informed, stay curious—and we’ll see you next time

Mehr: Guys! I had so much fun! We hope this episode helped simplify antibiotic selection for the most common infections and bugs seen in a hospital setting and gave you a framework you can for initial treatments and cases of antibiotic resistance. Thanks for hanging out with us! 

Dr. Arreaza: And remember, antibiotics are one of the most powerful tools we have in medicine. Let’s use them wisely. This is Dr. Arreaza, signing off. 

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References:

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! 

ARREAZA: Today we will expand on other treatments for insomnia in adults.

MOIRA: Yes, we spent some time explaining the assessment of insomnia and the first-line treatment, Cognitive Behavioral Therapy for Insomnia (CBT-I). We also mentioned sleep hygiene. You can listen to episode 220 if you want to learn more about that. Medication should be considered a secondary option. The American College of Physicians (ACP) recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add medication in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful. 

In general, pharmacotherapy is associated with risks of dependence, tolerance, and poorer quality sleep, whereas evidence-based psychotherapies, like CBT-I, result in better long-term outcomes, no drug dependence or polypharmacy risk, and potential cost savings.

ARREAZA: Yes, we will start this episode by talking about medications. If you practice primary care, I’m 100% sure that a patient has asked you for “sleeping pills” in clinic. Moira, I know our listeners want to hear about meds. What can you tell about meds to treat insomnia?

Moira:We can really split pharmacotherapy for sleep into two categories, OTC, and prescription. And many folks reach for OTC sleep aids before talking to a clinician. When we say OTC sleep aids, we’re mostly talking about sedating antihistamines, like diphenhydramine and doxylamine, which are common in products marketed for occasional sleep difficulties. Melatonin is often marketed as a supplement rather than a drug, but it’s also widely used OTC in many places, though regulations and quality vary by country.

ARREAZA: Exactly. Several studies describe widespread use of these agents among adults and especially older adults, who may face sleep problems related to comorbidities and polypharmacy. Many older adults use OTC sleep aids, often without consulting a healthcare professional or reading labels carefully.

Moira: And there’s evidence that a substantial share of OTC sleep products contains diphenhydramine or doxylamine—first-gen antihistamines that carry anticholinergic burden, which is particularly relevant for older adults. Melatonin’s story is similarly mixed for efficacy. It can modestly affect sleep onset and duration in some populations, especially older adults or circadian rhythm–related sleep problems, but the overall clinical impact is small. What about on the prescription side?

DR. ARREAZA: “Z-drugs” are nonbenzodiazepine sedative-hypnotics that enhance the effects of GABA (neurotransmitter). For example, Zolpidem, Zaleplon, eszopiclone. The risks of benzodiazepine use are significant.Benzodiazepine use is associated with increased fall risk across all age groups, and older adults are the highest risk group. That’s something we should mention to patients who are requesting a “sleeping pill”, “you may sleep a little better, but you may fall.” A meta-analysis of randomized trials in adults over 60 found that benzodiazepines (vs placebo) caused: 2.6× more psychomotor problems (like falls and car accidents), 3.8× more daytime sleepiness, 4.8× more cognitive impairment. Also, benzodiazepine use is associated with a 34% increased risk of hip fractures (RR 1.34) in older adults.

MOIRA: Very significant. Benzodiazepine use is only recommended for four weeks or less due to unproven long-term efficacy and the risk of tolerance, dependence, and misuse. Psychological and physical dependence on benzodiazepines can develop within a few weeks of regular or repeated use. Long-term use is associated with multiple consequences, including dependence, and even increased risk of opioid use. 

Dr ARREAZA: And the withdrawal symptoms are very uncomfortable for benzo dependent patients who try to stop benzos on their own.

MOIRA: And with the Z-drugs you were mentioning, the FDA has required that all Z-drugs carry a Boxed Warning highlighting the risk of complex sleep behaviors such as sleepwalking and sleep-driving, which can result in serious injuries including death. Medications such as benzodiazepines and antidepressants should be avoided for the treatment of insomnia in older adults whenever possible.

DR ARREAZA: There are other prescription options too. Let’s talk about low-dose doxepin has shown to have one of the best balances between efficacy and tolerability. When I hear “doxepin” the word “old” comes to my mind. And, yes, it was approved in 1969, it is a tricyclic antidepressant used to treat depression, anxiety, and insomnia. The recommended dose for insomnia is between 3-6 mg. It is not free of side effects, but lower doses seem to be better tolerated. Complex behaviors associated with doxepin: Doxepin may cause out of bed while not being fully awake and do an activity that you do not know you are doing. The next morning, you may not remember that you did anything during the night. You have a higher chance of doing these activities if you drink alcohol or take other medicines that make you sleepy with this medicine. Reported activities include: "sleep-driving", cooking and eating food, talking on the phone, having sex, or sleepwalking.

Moira: Another group of medications is dual orexin receptor antagonists (DORAs) such as lemborexant are considered medications with good balance of efficacy and tolerability.

No single medication is considered the "best" for all patients. Let’s remember that optimal medication depends on patient age, comorbidities, safety considerations, and the type of insomnia (sleep onset vs. maintenance.)

MOIRA: Older adults deserve special attention. Although insomnia is not a normal part of the aging process, we do see its prevalence increases with age. CBT-I is effective in older adults and is associated with minimal side effects. We can’t talk about sleep meds and older adults without mentioning BEERS criteria, which is a guideline which aims to reduce adverse drug events and polypharmacy by highlighting drugs with risks outweighing benefits, urging safer alternative. In sleep medicine and insomnia management for older adults, Beers Criteria explicitly flag sedating antihistamines (e.g., diphenhydramine, doxylamine) as potentially inappropriate for elderly patients due to anticholinergic burden and adverse effects such as delirium, cognitive impairment, sedation, and falls risk.

MOIRA: Yes! So again, I want to highlight that the first line treatment should always be CBT-I, but when this isn't working or isn't an option, then think about adding pharmacotherapy.

We should really be sharing that OTC options should only be for occasional sleep trouble, not chronic insomnia. Also, be mindful of age-related risks. And consider melatonin with caveats, melatonin may be an option with generally small sleep-onset effects but again, short-term use and quality matters.

To close, OTC sleep aids fill a real need for short-term relief, but they’re not a substitute for diagnosis and evidence-based treatment of insomnia, especially in older adults where safety is a particular concern. And our prescription options like benzos, z drugs, antidepressants, aren’t much better.

DR. ARREAZA: Primum non nocere (“first, do no harm”) is a chief consideration in insomnia management. Sleep is foundational to health, and I hope this helps our colleagues feel more confident in addressing it.If you found this helpful, share it with a friend or colleague and rate us wherever you listen to us. This is Dr. Arreaza, signing off.

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:

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! 

Episode 220: Approach of Insomnia in Adults    

ARREAZA: Today we are going to talk about how to approach sleep issues in adults — from the initial assessment all the way through treatment. And I think what is going to surprise a lot of our listeners is the changes in management in recent years, especially what is recommended as first-line therapy. So, let's jump right in.

MOIRA: Sleep is one of those topics that touches every specialty, but Primary Care in particular, so I'm excited to dig into this.

ARREAZA: Let's start with the big picture–statistics. How common are sleep problems in adults?

MOIRA: Incredibly common. Chronic insomnia affects roughly 10% of the general population, and that number has only grown in recent years . During the COVID-19 pandemic, for instance, prevalence rates of insomnia symptoms were reported globally at 20 to 45% (wow). And, importantly, those sleep problems did not simply resolve once infection rates dropped, insomnia symptoms and fatigue have continued even as mood improves in people recovering from COVID-19 infection. 

ARREAZA: Incredible that we are in 2026 and still talking about COVID-19. And we clinicians need to understand that insomnia isn't just an annoyance. It has long-term consequences. Also, financially, insomnia causes direct and indirect costs of up to $100 billion each year.

MOIRA: Exactly. Insomnia is both a risk factor for, and a symptom of, several psychiatric disorders, and it is a predictor of death by suicide, making it an important target for intervention. It's highly comorbid with medical and psychiatric disorders and is associated with significantly increased healthcare utilization and costs. People with insomnia also perform more poorly on complex cognitive tasks. So, we're talking about a condition that affects cognition, mental health, physical health, and quality of life.

ARREAZA: And yet, it still gets overlooked in many clinical encounters. Let’s be honest, dealing with insomnia is not easy on patients… and doctors!

MOIRA: That's the paradox. Primary care practitioners are often poorly informed about sleep disorders, which remain underdiagnosed and sub-optimally managed. In one Italian epidemiological survey, insomnia was reported by 64% of over 3,000 patients interviewed under general practitioners, with 20% reporting both nighttime and daytime symptoms. So, the patients are there, we're just not always asking the right questions or knowing what to do when they tell us about their sleep.

ARREAZA: Great. Let's talk about assessment. In my experience, we need a full encounter to address sleeping issues. Patients tend to mention insomnia as you start walking out of the room. Let’s say a patient tells us, "Doctor, I can't sleep," how de we approach this?

MOIRA: The first step is a comprehensive sleep and health history. Clinical assessment should describe the sleep disturbance and elicit etiological and exacerbating factors. You want to understand the nature of the complaint; is it difficulty to fall asleep, difficulty staying asleep, early morning awakening, or some combination? How long has it been going on? What's the impact on daytime functioning?

ARREAZA: That’s why I think it should be addressed in a full encounter, if possible, because understanding the full extent of the problem requires time. We need to think about contributing factors too.

MOIRA: Absolutely. Factors such as medications, medical disorders, and psychiatric disorders can all increase the risk for insomnia. You need to screen for comorbid conditions, depression, anxiety, PTSD, and chronic pain. Insomnia is actually both a risk factor for and a symptom of several psychiatric disorders. You also want to rule out other primary sleep disorders. Comorbid insomnia and sleep apnea, for example, is highly prevalent and debilitating. If someone has both insomnia and obstructive sleep apnea, treating only one without addressing the other may lead to suboptimal outcomes.

ARREAZA: Now that you mention comorbid conditions, let’s mention nocturia. I feel like it’s very common with my older patients.

MOIRA: Great point. Nocturia (waking from sleep at night to void) and chronic insomnia frequently co-exist in older adults, contributing synergistically to sleep disturbance. Treatments typically target either nocturia or insomnia rather than simultaneously addressing the shared mechanisms for these disorders. There's emerging work on integrated cognitive-behavioral treatment programs that address both conditions simultaneously, which is a promising direction. But at minimum, you should be asking about it, because if nocturia is driving the awakenings, you need to address that as part of the treatment plan.

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References:

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! 

Shivam: My name is Shivam Patel and I’m currently a 3rd year medical student from Western university and today we will be discussing Chronic Pain After Cancer with an emphasis on Improving functionality in cancer survivors and how it overlaps with musculoskeletal dysfunction. We will also talk about the management of pain in outpatient settings as well as the role acute rehab units can play in recovery.

Arreaza: Before getting into specific considerations, let’s start with a framework most clinicians are familiar with, standard, guideline-based management of upper extremity pain.

Typical approach of a patient with shoulder or upper extremity pain

Shivam: The standard approach for any patient coming in with a musculoskeletal issue is stepwise and conservative first. Initial management includes activity modification, NSAIDs or acetaminophen for pain control, and early referral to physical therapy depending on severity and duration. If symptoms persist, we escalate. That may include imaging—usually starting with X-ray, then MRI if indicated, and consideration of corticosteroid injections, particularly for conditions like subacromial impingement or adhesive capsulitis which are commonly seen especially following breast cancer treatment.

Arreaza: Most guidelines emphasize avoiding early imaging unless there are red flags like trauma, neurologic deficits, or suspicion for malignancy or infection. The reason behind this recommendation is that if you image the population of people older than 50 years old, about 40% of people show rotator cuff tears or damage. 

Shivam: When I First heard about this statistic as a medical student, I was shocked and it opened my eyes to the potential downsides of overimaging. We also emphasize maintaining mobility. For example, in adhesive capsulitis, early range-of-motion exercises are key, not immobilization.

Arreaza: Exactly. “Motion is lotion” (Dr. Uy’s mantra).

Shivam: And pharmacologically, we’re moving toward a multimodal approach. NSAIDs are first line when tolerated. Topical agents like diclofenac can be useful. Neuropathic agents like gabapentin or duloxetine are only considered if there’s a neuropathic component.

Arreaza: And a key element is that opioids are not first-line for chronic musculoskeletal pain.

Shivam: Yes, that’s a key point. Current guidelines recommend minimizing opioid use, reserving them for severe, refractory cases, and even then, for short durations with clear treatment goals.

Arreaza: Now, let’s transition this framework into cancer survivors. 

Shivam: The challenge is that many of these patients present with similar complaints. In the upper extremities, for example, they present with shoulder pain, weakness, stiffness, but the underlying causes are more complex.

Particularly in cancer survivors, upper extremity pain is often multifactorial. You still have mechanical issues but layered on top are treatment-related effects such as surgical disruption of anatomy, radiation-induced fibrosis, chemotherapy-induced neuropathy, and generalized deconditioning.

Arreaza: Let’s take an example: THIs a 55-year-old female, s/p left mastectomy and chemoradiation, completed her cancer treatment 1 year ago and now she is presenting with shoulder pain. So, how do we approach this patient?

Shivam: This was a specific case I had the pleasure of familiarizing myself with however it is important to acknowledge just how many patients in America share similar experiences due to the incidence of breast cancer. If we approach this as a typical rotator cuff issue, we might miss key contributors that have been seen in cancer survivors like pectoralis tightness from radiation, scapular dyskinesis from surgery, or even early lymphedema.

Arreaza: Right, and that changes management. Because if you don’t address those underlying contributors, standard treatments may only provide partial or temporary relief.

Shivam: Exactly. And this is where we start to see the limitations of a purely symptom-based approach. Let’s zoom out again. There are nearly 19 million cancer survivors in the U.S., and that number is increasing due to rapidly improving cancer treatment options. With that, we’re seeing more long-term sequelae—especially involving the musculoskeletal system.

Arreaza: Some symptoms in cancer survivors are reduced mobility, persistent fatigue, weakness, and impaired return to activities of daily living. And this may lead to chronic pain and reduced quality of life. 

Shivam: As a side note, we can also acknowledge the impact of mental and psychological aspects on patients who have cancer or any other chronic condition. If they are depressed or less motivated to be active, participate in therapy, the deconditioning effect can be exacerbated in these patients. 

Arreaza: Great point, and also, this is a population that is often under-referred to rehabilitation services. We hope we can increase awareness today.

Shivam: Yes, some sources state that only around 30% of those that qualify for acute rehab are referred to it. Which is surprising, because rehabilitation directly addresses many of these issues that cancer patients experience—strength deficits, mobility limitations, and functional decline.

Arreaza: Let’s talk about pathophysiology for a moment. Why do these patients develop chronic pain?

Shivam: A major factor is deconditioning. During cancer treatment, patients often reduce their activity levels significantly. That leads to loss of muscle mass, decreased endurance, and altered biomechanics.

Arreaza: I see, sarcopenia plays a role in the development of pain in these patients. 

Shivam: And once pain develops, it further limits activity, reinforcing that cycle—pain → inactivity → deconditioning → more pain. On top of that, structural changes, often caused by fibrosis from radiation, reduce tissue elasticity, limit range of motion, and contribute to stiffness and pain.

Arreaza: And neuropathic pain from chemotherapy adds another layer—burning, tingling, or hypersensitivity—which requires a different treatment approach. So, given this complexity, how should we as clinicians adjust our assessment of pain in these patients?

Shivam: I think it’s very important to start with a thorough history to ensure we don’t miss any past history of chronic conditions or intensive treatment for prior medical diagnoses. First, we need to broaden the differential. Don’t assume it’s a single pathology. Second, incorporate function into our assessment. Ask the patient: What can you do? What can’t you do?  Additionally, I think it’s very important to ask what your patient’s goals are for themselves and what they would like to accomplish. 

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References:

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! 

Episode 218: Statin Therapy Fundamentals

What are statins?

Zohal: Statins are medications that lower cholesterol by inhibiting the enzyme HMG-CoA reductase, which prevents cholesterol synthesis in the liver. By doing so, statins decrease low-density lipoprotein cholesterol (LDL-C). 

Why should we lower LDL?

Zohal: There are four main lipoproteins that transport fats in blood, including chylomicrons, VLDL, LDL, and HDL. This is where we get our “bad cholesterol” vs. “good cholesterol”. Of these, LDL is most associated with an increased risk in cardiovascular disease, while a higher HDL is associated with lower risk. Thus, reducing LDL subsequently reduces the risk of cardiovascular disease. 

Arreaza: The lowest LDL I’ve seen was 25, and the highest HDL was 60. HDL doesn’t really have a strict upper limit, but most people fall between 40 and 60. Extremely high HDL—above 100—may not always be protective and can sometimes signal underlying issues.

Zohal: My HDL is 70! Statins are used for both primary prevention, meaning preventing cardiovascular disease before it occurs, and secondary prevention, meaning preventing disease progression in patients who already have cardiovascular disease.

History of statins.

Zohal: In the early 1900’s, researchers were studying the association between cholesterol and atherosclerosis, and at that time, they primarily used animal subjects. These studies were initially not taken seriously, because most believed cardiovascular disease in humans were simply due to aging and was not preventable. 

It wasn’t until the middle of the century when researchers began observing that increased levels of LDL and decreased HDL was correlated with an increased rate of heart attacks. This finding prompted interest in determining the pathway of cholesterol synthesis in the human body. 

Statins were first discovered in the 1970s when researchers identified compounds that inhibit a critical step in cholesterol synthesis. The first statin approved for clinical use was Lovastatin in 1987.

Since then, multiple statins have been developed, including Atorvastatin, Rosuvastatin, Simvastatin, and Pravastatin. Further clinical trials in the 1990s and 2000s showed that statins significantly reduce myocardial infarction, stroke, and cardiovascular mortality.

Why do Statins Matter in Primary Prevention

Zohal: Cardiovascular disease is the most common cause of death worldwide. As previously mentioned, elevated LDL cholesterol contributes to the development of atherosclerotic plaques within arteries, which can lead to heart attack and stroke. By lowering LDL cholesterol and stabilizing plaque formation, statins implemented in a timely manner significantly reduce the risk of atherosclerotic cardiovascular disease.

Arreaza: One of the things I love most about primary care is prevention. You’re working upstream, often quietly, humbly, helping people avoid disease before it starts. And the truth is—you rarely see the full impact of your actions. You don’t get a notification that says, “this patient didn’t have a heart attack because of you.” But every time you help someone control their blood pressure, quit smoking, improve their diet, or stay consistent with their medications, you’re shifting their tracks. You’re reducing risk in ways that may never be fully visible. That’s the paradox and the beauty of it: in primary care, your highest victories are often events that never happen. 

Who Should Receive Statins for Primary Prevention?

Zohal: Recommendations slightly differ depending on who you ask. We look to the U.S. Preventive Services Task Force, the American College of Cardiology, and the American Heart Association for their recommendations regarding statins for primary prevention.

USPSTF on statins.

The U.S. Preventive Services Task Force (or USPSTF for short) is an organization that works to improve the health of people nationwide by making evidence-based recommendations on effective ways to prevent disease & prolong life. They recommend statins for the primary prevention of cardiovascular disease in:

Their recommendations are graded A, B, C, D, and I, depending on the strength of evidence and this is a Grade B recommendation.

Arreaza: So, you have to meet all the criteria to receive a statin, according to USPSTF: 40-75, one CV risk factor and a high 10-y ASCVD score, by the way, the ASCVD risk calculator was introduced in 2013 by AHA/ACC. It is available online for free and many EHRs have integrated this tool into their software. For example, if you use EPIC, you can type .ascvd and get a score automatically. What about patients with a cardiovascular risk less than 10%?

Zohal: For patients with a 7.5–10% risk, some may offer statin therapy on a case-by-case basis as this is a Grade C recommendation. But I’ll get more into this later.

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:

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! 

Episode 217: Testicular Cancer

Dr. Arreaza: Welcome to Rio Bravo qWeek Podcast. Today we are discussing testicular cancer, a topic that may not appear frequently in primary care but is extremely important to recognize early. We are joined by Brandon Noorvash and Dr. Ebenezer Dadzie. Please introduce yourselves.

Brandon: Thank you, Dr. Arreaza. My name is Brandon Noorvash. I am a third-year medical student at Western University of Health Sciences with a strong interest in urology.

Ebenezer: Thank you for having us. My name is Dr. Ebenezer Dadzie, and I am a PGY-1 resident in the Clinica Sierra Vista Family Medicine Residency Program.

Dr. Arreaza: Testicular cancer represents about 1-2% of cancers in men, but it is the most common cancer in men between the ages of 15 and 40. The good news is that it is also one of the most curable cancers in medicine, especially when detected early. Let’s start with a quick question for our listeners. If a 25-year-old man presents with a painless lump in his testicle, what diagnosis should immediately come to your mind?

Ebenezer: Testicular cancer should always be high on the differential. While benign conditions can cause scrotal swelling, a painless testicular mass should be considered cancer until proven otherwise.

Dr. Arreaza: I agree. Especially if we perform a physical exam and find that the mass is attached to the testicle. Why is this such an important diagnosis for primary care physicians to recognize, what do you think, Brandon?

Brandon: Testicular cancer typically affects young, otherwise healthy men, and early detection dramatically improves outcomes. Patients may delay seeking care because the lump is painless or because they feel embarrassed discussing symptoms. However, when diagnosed early, the 5-year survival rate exceeds 95%, and in localized disease it approaches 99%.

Dr. Arreaza: Exactly, the survival is incredible and it gets even better with early detection. How common is testicular cancer?

Ebenezer: In the United States, approximately 10,000 new cases are diagnosed each year, with around 500 deaths annually. The relatively low mortality reflects how effective current treatments are, especially chemotherapy for germ cell tumors.

Dr. Arreaza: Let’s talk about risk factors. What should clinicians know about risk factors for testicular cancer? Who is at risk?

Brandon: The most important risk factor is cryptorchidism, or undescended testicle. Men with a history of cryptorchidism have about a 4-to-8-fold increased risk of developing testicular cancer.

Ebenezer: Other risk factors include family history, personal history of testicular cancer, infertility, testicular atrophy, and certain genetic conditions such as Klinefelter syndrome. However, many patients who develop testicular cancer have no clear risk factors.

Dr. Arreaza: Brandon, you recently saw a patient with testicular cancer during your rotation. Can you briefly tell us about that case? Protected health information is not being revealed, so patient confidentiality is being respected during this discussion.

Dr. Arreaza: I think we all were pleasantly surprised to know that lung metastasis did not place the patient in a higher risk category. On the other hand, nonpulmonary visceral metastases (such as liver, bone, or brain) define poor-risk disease in nonseminoma and intermediate-risk disease in seminoma. 

Dr. Arreaza: And of course, if the patient presents with sudden severe pain, we should always think about testicular torsion, which is a surgical emergency. What should clinicians focus on during the physical exam?

Ebenezer: Testicular tumors typically feel firm, irregular, non-tender, and located within the testicle itself.

Brandon: A helpful exam pearl is transillumination. Fluid-filled structures like hydroceles will transilluminate, whereas solid tumors do not.

Dr. Arreaza: I have to admit I’ve never done a transillumination in a scrotum before. 

Brandon/Ebenezer: I’ve done it. I had to clean my pen light afterwards.

Arreaza: Once you suspect testicular cancer, what is the next step in evaluation?

Ebenezer: The first diagnostic test is a scrotal ultrasound. Ultrasound is highly sensitive and can determine whether the mass is intratesticular, which is highly suspicious for malignancy.

Dr. Arreaza: US and tumor markers. Let’s talk a bit more about tumor markers. Why are they useful in testicular cancer?

Brandon: Tumor markers help with diagnosis, staging, and monitoring response to treatment.

Ebenezer: Alpha-fetoprotein, or AFP, is typically elevated in non-seminomatous germ cell tumors, particularly yolk sac tumors. An important point is that pure seminomas do not produce AFP.

Brandon: Beta-hCG can be elevated in both seminomas and non-seminomatous tumors, although the levels are often higher in the non-seminomatous types.

Ebenezer: LDH is less specific but can reflect tumor burden and disease activity, so it’s useful for monitoring progression or response to treatment.

Dr. Arreaza: So, tumor markers are not only diagnostic tools, but they also help guide staging and follow-up care. That’s an important board question. Why don’t we perform a biopsy in a testicular mass? 

Ebenezer: Testicular masses suspicious of cancer are not biopsied because biopsy can disrupt lymphatic drainage and potentially spread tumor cells. Instead, the standard treatment is radical inguinal orchiectomy, which both removes the tumor and establishes the diagnosis.

Dr. Arreaza: Brandon, can you briefly explain the two main categories of testicular cancer?

Brandon: Let’s start with the germ cell tumors. They are broadly divided into seminomas and non-seminomatous germ cell tumors (NSGCT). Seminomas tend to grow more slowly and are highly sensitive to radiation therapy.

Ebenezer: Non-seminomatous tumors include embryonal carcinoma, yolk sac tumor, choriocarcinoma, and teratoma. These tumors tend to be more aggressive but are still highly responsive to treatment.

Dr. Arreaza: How are patients staged once the diagnosis is made?

Ebenezer: Staging typically includes a CT scan of the chest, abdomen, and pelvis to evaluate for metastasis, especially to the retroperitoneal lymph nodes, which are the most common site of spread.

Dr. Arreaza: And how is testicular cancer managed?

Brandon: The initial step is almost always radical inguinal orchiectomy. Depending on staging and tumor type, treatment may include active surveillance, chemotherapy, radiation therapy, or retroperitoneal lymph node dissection.

Ebenezer: One reason outcomes are so favorable is that germ cell tumors respond extremely well to cisplatin-based chemotherapy.

Dr. Arreaza: Let’s talk about prognosis.

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:

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! 

Episode 216: Fibromyalgia Overview

Reitta Wyllie and Tejasvi Ayaggari (medical students) discuss with Dr. Arreaza the presentation, diagnosis and management of fibromyalgia, a commonly unrecognized disease that may impact patient’s quality of life if left untreated.  

Written by Reitta Nash, MSIV, American University of the Caribbean. Additional commentary provided by Dr. Tejasvi Ayyagari.  Edits and comments by Hector Arreaza, MD.

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

Introduction

Fibromyalgia is a chronic pain condition that affects millions of people worldwide, yet it remains one of the most misunderstood disorders in medicine. Patients often experience widespread pain, fatigue, sleep disturbances, cognitive difficulties, and a host of other symptoms that significantly impact daily functioning and quality of life. 

TJ: It’s common, but I feel it is mostly misunderstood and sometimes goes undiagnosed.

Reitta: Yes, despite its prevalence, fibromyalgia has historically been met with skepticism, delayed diagnosis, and stigma. Today, we’ll break down what fibromyalgia is, what we know about its underlying mechanisms, how it’s diagnosed, and how it’s managed using evidence-based approaches.

What is fibromyalgia?

Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal pain, accompanied by symptoms such as fatigue, non-restorative sleep, cognitive dysfunction often referred to as “fibro/brain fog,” and mood disturbances.

TJ: Unlike inflammatory or autoimmune diseases, fibromyalgia does not cause structural damage to joints or muscles, nor does it produce objective findings on imaging or routine laboratory testing. Instead, it is considered a centralized pain disorder, meaning pain processing within the central nervous system is altered.

Arreaza: Many years ago, I had a patient who had fibromyalgia in Germany. He shared how hard it was for him to get diagnosed and treated because many countries fail to recognize fibromyalgia as a disease. However, Germany is not one of them. The German Association of the Medical Scientific Societies (AWMF) has established specific diagnostic criteria for fibromyalgia syndrome (FMS). Also, the World Health Organization recognizes fibromyalgia as a chronic condition, and it is included in the International Classification of Diseases 10th edition (ICD-10).

Reitta: The American College of Rheumatology (ACR) recognizes fibromyalgia as a distinct clinical diagnosis, affecting approximately 2–4% of the population, with a higher prevalence in women, though it can affect individuals of any sex or age.

Historical Perspective

Fibromyalgia was once referred to by terms such as fibrositis, a name that implied inflammation of connective tissue. However, as research failed to demonstrate inflammatory changes, the terminology evolved.

In 1990, the American College of Rheumatology introduced the first formal diagnostic criteria, which focused heavily on tender point examination. Over time, these criteria were revised as understanding of the condition improved. Modern diagnostic criteria no longer rely on tender points and instead emphasize symptom severity and widespread pain distribution, reflecting a more patient-centered and clinically practical approach.

What causes fibromyalgia?

The exact cause of fibromyalgia is not fully understood, but current evidence supports a multifactorial, neurobiological model.

The American Academy of Family Physicians identifies a spectrum of chronic overlapping pain conditions that frequently coexist with fibromyalgia, including IBS, TMJ pain, vulvodynia, Chronic fatigue syndrome, interstitial cystitis, endometriosis, chronic tension headaches, migraine, and chronic low back pain. These functional somatic conditions may represent a single disorder manifesting as pain in different body regions at different times over the life span.

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References:

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! 

Abishak and Zat (medical students) explain the cardiotoxic effect of methamphetamine and the diagnosis and treatment of heart failure with reduced ejection fraction (HFrEF). Dr. Arreaza adds insight into the reversibility of meth-associated HFrEF.  

Written by Abishak Govindarajan, MSIV and Zat Akbar Shaw. American University of the Caribbean. Edits and comments by Hector Arreaza, MD.

Welcome

Dr. Arreaza: Welcome to Rio Bravo qWeek. My name is Hector Arreaza, family physician, faculty and associate program director of the Clinica Sierra Vista/Rio Bravo Family Medicine Residency Program. Today we will explore heart failure with reduced ejection fraction, a high-yield and clinically relevant topic in medicine. We will discuss the role of methamphetamine use in the development of HFrEF. This is a pressing issue because about 0.8% of the population 12 and older in the US reported using methamphetamine within the past 12 months in 2024 (National Survey on Drug Use and Health, NSDUH), that’s about ≈2.4 million people!We are joined by two aspiring physicians who will help explore this topic. By the way, we will refer to methamphetamine in this episode as “meth”. [Abishak and Akbar introduce themselves]

Abishak: [Introduce yourself]

The role of meth in HFrEF

Diagnosis

Abishak: Yes, diagnosis requires both symptoms consistent with heart failure and objective evidence of reduced ejection fraction. Echocardiography is the primary diagnostic tool. We also measure BNP. In certain cases, cardiac MRI is used to evaluate myocardial fibrosis and exclude infiltrative or inflammatory etiologies. Coronary angiography may be performed if ischemic disease is suspected.
Guideline-Directed Medical Therapy

Akbar: There are four core pillars in GDMT.

Beta Blocker Considerations

Dr. Arreaza: Yes, the key factor is complete abstinence, plus standard heart failure treatment. If the damage is mostly functional and inflammatory, recovery is possible. If there is extensive fibrosis (scar)

Akbar: Absolutely. Not all meth-associated cardiomyopathy behaves the same way. The extent of fibrosis determines recovery potential. Cardiac MRI with late gadolinium enhancement can help us estimate scar burden. Patients with minimal fibrosis often have better improvement with abstinence and medical therapy.

Dr. Arreaza: So, MRI can actually help us determine the prognosis.

Abishak: Yes, very much so. If MRI shows extensive fibrosis, the likelihood of full EF recovery is lower. That information helps us counsel patients more accurately.

Akbar: Another key issue is right ventricular involvement. Methamphetamine can affect both ventricles. When the right ventricle fails, patients may develop severe peripheral edema, ascites, and hepatic congestion. Right ventricular dysfunction also worsens prognosis significantly.

Dr. Arreaza: And pulmonary hypertension can also worsen the whole picture. 

Akbar: That’s correct. Meth is associated with pulmonary arterial hypertension independently of left-sided heart failure. In some patients, you may see a combined picture of both pulmonary vascular disease and right ventricular dysfunction. That can make management more complicated because pulmonary pressures may remain elevated even after EF improves.

Dr. Arreaza: Tells us about the role of BNP in monitoring these patients. 

Abishak: Serial BNP levels can help track response to therapy. Additionally, troponin may be elevated at times in meth users due to myocardial injury. Monitoring renal function is critical because many heart failure medications affect kidney function and potassium levels.

Akbar:Other lifestyle modifications include sodium restriction, regular follow-ups, vaccination, and avoidance of other cardiotoxic substances such as alcohol or cocaine. Sleep disorders, especially OSA, should be evaluated because untreated OSA worsens heart failure outcomes.

Dr. Arreaza: WhatIs there any role for wearable devices or remote monitoring?

Abishak: Yes, increasingly so. Remote weight monitoring, blood pressure tracking, and symptom reporting can reduce hospitalization. In select patients, implantable hemodynamic monitors may help detect rising filling pressures before symptoms occur.

Dr. Arreaza: It was a great discussion. Thank you, Abishak and Akbar for bringing all that valuable information to us. Let’s wrap it up. 

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!