Mohammed Wase (medical student) and Dr. Singh describe what it is like to provide health care on the streets. They share their personal experiences working in a street medicine team. They describe the practice of harm reduction and emphasize the importance of respecting autonomy and being adaptable in street medicine. 

Written by Mohamed Wase, MSIV, American University of the Caribbean. Editing by Hector Arreaza, MD. Hosted by Harnek Singh, 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 

Dr. Singh: Welcome to another episode of our podcast, my name is Dr. Harnek Singh, faculty in the Rio Bravo Family Medicine Residency Program. Today we have prepared a great episode about street medicine, a field that has grown a lot during the last decade and continues to grow now. We are joined by a guest who is passionate about this topic. Wase, please introduce yourself.

Wase: Hello everyone, my name is Mohammed, many know me as Wasé, I am a 4th year medical student from the American University of the Caribbean. Today we’re diving into a topic that sits at the intersection of medicine, compassion, and public health — Street Medicine and Harm Reduction. We’re going to step outside with this episode, literally, away from the clinic and hospital, to explore more about what care looks like in the streets. 

Historic background: How did street medicine start?

Wase: The roots of Street Medicine in the United States go back to Dr. Jim Withers in Pittsburgh in the 1990s, who literally began by dressing as a homeless person and providing care on the streets to build trust. His efforts have shaped street medicine to what it is today. It combines primary care, mental health, and social support. 

Dr. Singh: For family physicians, this model aligns perfectly with our holistic approach. We don’t just treat diseases; we treat people in context — their environment, their challenges, their stories. What is the main population seen by a street medicine team?

Wase: This patient population includes those struggling with homelessness, housing insecurity, food insecurity, substance use disorders; with patients being preoccupied on where they will sleep that night or when their next meal comes, they do not have the luxury of prioritizing their health. Street Medicine is a powerful outreach program to bring care to them in order to provide equitable care within our community. 

Dr. Singh: How is street medicine different than caring for patients in the clinic?

Wase: Working on the street means we have to think differently about what healthcare looks like — and that’s whereharm reductioncomes in.

What is Harm Reduction?

Wase: Harm reduction is a public health philosophy that focuses on reducing the negative consequences of high-risk behaviors, rather than demanding complete abstinence.

Dr. Singh: Preventive care is the backbone of family medicine. For example, we keep up with the USPSTF guidelines and make sure our patients are up to date with their screenings. But what does that look like in the street medicine setting? 

Wase: In practice, that might mean:

-needle exchange program: Offering clean syringes to prevent HIV transmission and removing used needles

-distributing naloxone to prevent overdose deaths

-offering fentanyl test-strips to prevent use of substances that are unknowingly laced with fentanyl

Dr. Singh: Also:

-providing condoms to prevent sexually transmitted infections

-providing wound care to prevent further spread of infection

Wase: Yes, the idea is: people are going to engage in risky behaviors whether or not we approve of it, so let’s meet them with compassion, tools, and trust instead of judgment. Harm reduction also applies beyond substance use; think about safer sex education, or even diabetic foot care among people who can’t refrigerate insulin or change shoes daily. It’s all about meeting people where they areandkeeping them alive and engaged in care. 

Planning in Street Medicine: 

Wase: It takes careful disposition planning and aftercare for this population. Instead of the traditional outpatient setting where we can place referrals and expect our patients to follow through with them. On street medicine, for follow up visits it requires arranging transportation, finding a pharmacy close in proximity, educating and counseling on medication adherence and how to make it, and making sure they have some sort of shelter to get by. 

Dr. Singh: Let’s describe a typical street med encounter.

Wase: A typical Street Medicine encounter might look like this: a small team — usually a physician, nurse, social worker, and sometimes a peer advocate — goes out with backpacks of supplies. They might start with wound care, blood pressure checks, or even medication refills. But what’s just as important is the relationship-building. Sometimes, the first visit isn’t about medicine at all — it’s about showing up consistently.

Over time, that trust opens the door for conversations about addiction treatment, mental health, and preventive care. For example, in some California Street Medicine programs, teams are treating chronic conditions like hypertension, diabetes, and hepatitis C, right where patients live with the same evidence-based care we’d give in a clinic. One of my favorite quotes from Street Medicine teams is: “We’re not bringing people to healthcare; we’re bringing healthcare to people.”

Challenges in Street Medicine:

Wase: The populations that you will encounter include many people who will often downplay their own health concerns and prior diagnoses. Unfortunately, this is usually from countless months or years of feeling neglected by our healthcare system. Some may even express distrust in our healthcare system and healthcare providers. Patient will, at times, be apprehensive to receive care or trust you enough to tell their story. 

Dr. Singh: Interviewing patients is a critical aspect of providing equitable care on the streets. It is always important to offer support and medical care, even if the patient denies it, always reassure that your street medicine clinic will be around every week and ready for them when they would like to seek care. 

Wase: Respecting patient autonomy is an utmost concern as well. Another element of interviewing to consider is to invite new ideas and information; instead of lecturing patients about taking medications on time or telling them they need to stop doing drugs—simply asking a patient “would you like to know more about how we can help you stop using opioids?” respects their choice but can also spark new ideas for them to consider. 

Singh: Adaptability is another key component to exceling patient care in street medicine. Like, performing physical exams on park benches or in the back of a minivan. Always doing good with our care but also respecting their autonomy is crucial in building a trust that these patients once lost with our system. 

Wase: Each patient has their own timeline, but we as providers should always assure them that our door is always open for them when they are ready to seek care. 

Conclusion.

Wase: So, to wrap up — Street Medicine and harm reduction remind us that healthcare isn’t just about hospitals and clinics. It’s about relationships, trust, and dignity.

Every patient deserves care, no matter where they sleep at night.

If you’re a resident or student listening, I encourage you to seek out these experiences — volunteer with Street Medicine teams, learn from harm reduction workers, and let it shape how you practice medicine. Thank you for listening to this episode of the Rio Bravo qWeek podcast. I’m Mohammed — and I hope this conversation inspires you to meet patients where they are and walk with them on their journey to health.

Dr. Singh: If you liked this episode, share it with a friend or a colleague. This is Dr. Singh, 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! 

_____________________

References:

1. Doohan, N.C. “Street Medicine: Creating a ‘Classroom Without Walls’ for People Experiencing Homelessness.” PMC – National Library of Medicine, 2019.
2. Hawk, M., et al. “Harm Reduction Principles for Healthcare Settings.” Harm Reduction Journal, vol. 14, no. 1, 2017.
3. Withers, J.S. “Bringing Health Professions Education to Patients on the Streets.” Journal of Ethics, AMA, vol. 23, no. 11, Nov. 2021.
4. “Our Story.” Street Medicine Institute, 2025, www.streetmedicine.org/our-story.
5. “Principles of Harm Reduction.” National Harm Reduction Coalition, 2024, https://harmreduction.org/about-us/principles-of-harm-reduction/.
6. Salisbury-Afshar, Elizabeth, Bryan Gale, and Sarah Mossburg. “Harm Reduction Strategies to Improve Safety for People Who Use Substances.” PSNet, Agency for Healthcare Research & Quality, 30 Oct. 2024.
7. Douglass, A.R. “Exploring the Harm Reduction Paradigm: The Role of Boards in Drug Policy and Practice.” PMC – National Library of Medicine, 2024.
8. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Kara Willbanks (medical student) explains the definition, pathophysiology, and treatment of eczema. Dr. Arreaza adds some input about bleach baths and topical steroids. 

Written by Kara Willbanks, MSIV, American University of the Caribbean. Comments and edits by Hector Arreaza, MD.

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

October is the Eczema Awareness Month!

What Is Atopic Dermatitis? 

Atopic dermatitis, a form of eczema, is a chronic, relapsing inflammatory skin disorder that often begins in childhood but can affect people of all ages. 

Other eczematous dermatoses include seborrheic dermatitis, contact dermatitis, juvenile plantar dermatosis, and stasis dermatitis. 

Atopic dermatitis is one of the most common skin conditions in the developed world, typically affecting up to 20% of children and 5-10% of adults. Patients usually present with severe pruritus (itchiness) and dry, inflamed patches of skin. Common sites include the face and extensor surfaces in infants, and flexural areas — like the elbows and knees — in older children and adults. 

Atopic dermatitis is often associated with other allergic conditions like asthma and allergic rhinitis — what we call the “atopic triad.” These conditions should also be considered when diagnosing someone with atopic dermatitis. 

Pathophysiology

Atopic dermatitis is believed to occur due to a combination of genetic, immune, and environmental factors. A major component is a defective skin barrier, often linked to mutations in the filaggrin gene. This allows irritants, allergens, and microbes to penetrate the skin more easily, triggering inflammation.

Differential Diagnosis

Atopic dermatitis can sometimes mimic other skin conditions, so it’s important to keep a differential in mind: 

-Contact dermatitis – triggered by allergens or irritants; often limited to the area of exposure but also tends to be very itchy. 

-Seborrheic dermatitis – greasy scales, typically on the scalp, eyebrows, and nasolabial folds 

-Psoriasis – well-demarcated plaques with silvery scales; sometimes found in similar areas of the body as eczema. 

-Tinea (fungal infections) – ring-shaped lesions with active, scaly borders -Important to note that treatment of tinea with topical steroids can make the rash much worse. 

-Scabies – intense itching, especially at night, with burrows between fingers. 

Ruling out these conditions helps guide the right treatment and prevent chronic mismanagement. As a recap our main differential diagnosis: contact dermatitis, seborrheic dermatitis, psoriasis, tinea, and scabies.

The treatment cornerstone: Moisturizers 

The most important daily treatment for atopic dermatitis is regular moisturizing. Moisturizers repair the skin barrier, reduce water loss, and protect against irritants. They should be applied at least twice daily, ideally right after bathing while the skin is still damp (within 3 minutes is most ideal). Use greasy ointments or thick creams rather than lotions — think products with ceramides or glycerin (hydrates and protects skin). 

It is best to choose ointments or creams without additives, perfumes or fragrances. Greasier ointments are the preferred vessel; however, patient compliance may be less as they may be unpleasant to some.

Bleach Baths 

For patients with frequent skin infections or severe eczema, dilute bleach baths can be a game-changer. How to do it? Use ¼ to ½ cup of household bleach in a full standard bathtub of water (about 40 gallons) and soak for 10 minutes, twice a week. This helps reduce bacterial colonization — particularly Staphylococcus aureus — which commonly worsens eczema. 

After the bath, pat the skin dry and immediately apply a moisturizer (within 3 minutes). 

Bleach baths are endorsed by the American Academy of Pediatrics and the American Academy of Dermatology as an adjunctive treatment for atopic dermatitis, especially in patients with moderate to severe disease and frequent bacterial infections, but the evidence for their efficacy is mixed, and further well-designed studies are needed.

Medical Treatments

-Topical corticosteroids: When moisturizers alone aren’t enough, we move to anti-inflammatory therapy. Topical corticosteroids are the first-line treatment for flares. Some studies suggest that a short burst of a high-potency topical corticosteroid to rapidly control active disease, followed by a quick taper in potency, is most effective, whereas others use the lowest-potency agent thought to be needed and adjust upward only if this fails. Common steroids used are hydrocortisone (low potency), triamcinolone (medium potency), or betamethasone (high potency). 

-High-potency steroids should never be applied to sensitive skin like the face. With short-term use of lower-potency steroids, there is a low likelihood of skin atrophy but use for more than 6 months is linked with greater levels of skin thinning 

-Wet wrap therapy: Wet wrap therapy improves absorption of topic steroid. Apply a topical steroid, then layer a wet dressing and then a dry dressing over the top of that. This can be beneficial in providing  both relief of symptoms and prevention of itching. In pediatric patients it is called “daddy’s socks therapy” because large socks may be used to cover the arms of kids.

-Topical calcineurin inhibitors — like tacrolimus — are great alternatives for sensitive areas or for maintenance once inflammation is under control. They may burn upon application which can scare patients away from their use.

-PO antihistamines can help with itching, especially at night, but they don’t treat inflammation itself.

-Systemic therapies, like dupilumab (Dupixent®), an IL-4 receptor antagonist, are reserved for moderate to severe cases unresponsive to topical therapy. This is a great time to refer to your local dermatologist for management! Many of the newer treatments are highly effective but can require more frequent monitoring.

Recent Research 

One recent study is the 2024 Cochrane network meta-analysis comparing effectiveness of topical anti-inflammatory treatments for eczema that was recently published in the AFP Journal in July of 2025.

Here are the highlights:

-Over 291 RCTs with ~45,846 participants were included. 

-The analysis ranked potent topical corticosteroids, JAK inhibitors (for example ruxolitinib (Opzelura® 1.5 %), and tacrolimus 0.1 % among the most effective for reducing signs and symptoms of eczema. 

-In contrast, PDE-4 inhibitors [like crisaborole (Eucrisa®) 2 %] were among the least effective in this comparison. 

-Regarding side effects: tacrolimus and crisaborole were more likely to cause burning or stinging at the application site; corticosteroids were less likely in the short term to cause local irritation.

-Long-term outcomes regarding effectiveness or safety of treatments for eczema were not addressed by the review because they are rarely reported.”

-Another insight from this study is considering cost when initiating treatment. Most topical steroids are significantly more cost effective than JAK inhibitors or calcineurin inhibitors so it may be best to start with a cheaper solution in an uninsured patient considering their relative effectiveness. 

Additional Tips & Lifestyle 

-Keep baths and showers short and in lukewarm water.

-Avoid harsh soaps and detergents — use gentle, fragrance-free cleansers.

-Wear soft cotton clothing instead of wool or synthetics.

-Identify and avoid triggers — common ones include stress, sweating, allergens, and certain foods (especially in kids).

-Ice packs can help reduce itching and relieve any burning sensation.

-Keep fingernails short, especially in children, help cause less trauma to the skin from repeated itching. 

Living with eczema 

Many celebrities like Kerry Washington, Jessica Simpson, Kelly Rowland, Brad Pitt and Kristen Bell have spoken out about their lives with eczema. They have shared personal stories about how they were diagnosed, what treatment works for them, and the general impact it has had on their lives and mental health. I feel like it can be so important for celebrities to speak out about their lives with certain conditions because it helps to normalize the condition, raise awareness of the struggles, and encourages more open dialogue.

It is important to remember that for patients living with eczema, the persistent itch-scratch cycle can be very distressing, causing patients to struggle with their sleep and day-to-day activities. Anxiety and depression are common in patients with eczema so as physicians it is vital to monitor for signs of distress. Support groups can be incredibly helpful for patients [National Eczema Association]

If you are interested in providing additional information to your patients or getting this for yourself, you can find more resources on altogethereczema.org or nationaleczema.org. 

Key Takeaways 

Atopic dermatitis is chronic but manageable. Moisturizers are the foundation of treatment. Topical steroids and calcineurin inhibitors control inflammation. Bleach baths help reduce bacterial load and flare severity. Always rule out other skin conditions to ensure appropriate management. Atopic dermatitis can be managed by the primary care physician but in certain cases (cases refractory to standard topical treatment, recurrent infections, etc.), a referral to dermatology can be especially helpful.

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. Coping with eczema. Allergy & Asthma Network. (2025, May 20). https://allergyasthmanetwork.org/what-is-eczema/coping-with-eczema/.
2. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014 Feb;70(2):338-51. doi: 10.1016/j.jaad.2013.10.010. Epub 2013 Nov 27. PMID: 24290431; PMCID: PMC4410183. https://pubmed.ncbi.nlm.nih.gov/24290431/.
3. Yancey, J. R., & Green, S. (2025, July 15). Effectiveness of topical anti-inflammatory drugs for eczema. American Family Physician. https://www.aafp.org/pubs/afp/issues/2025/0700/cochrane-eczema.html.
4. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Luz Perez (MSIV) presents all the available pneumococcal vaccines for adults. Dr. Arreaza guides the discussion about what to do with adults who have previously received pneumococcal vaccines. 

Written by Luz Perez, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.

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

Today we’re answering a clinic classic: Which pneumococcal vaccine should my adult patient get—and when? This is an update of episode 90.

Why pneumococcal vaccines matter?

Pneumococcal vaccines prevent infections caused by the bacteria Streptococcus pneumonia. These bacteria can cause serious infections like pneumonia, meningitis, and bacteremia. In 2017, the CDC reports that there were more than 31,000 cases of pneumococcal infections and 3,500 deaths from invasive pneumococcal disease. 

Children are vaccinated in early childhood, before age 5, with PCV15 or PCV 20, at the age of 2, 4, 6 months and a last dose around 12-15 months. 

Why do we vaccinate adults?

Adults are vaccinated because they’re at higher risk of getting pneumococcal disease or of having worse outcomes if they do. Vaccines are important because they protect these at-risk patients and reduce the spread of infections among communities. 

What are the available vaccines? PCV vs PPSV.

There are two pneumococcal vaccines used in practice: a polysaccharide vaccine (PPSV) and a conjugate vaccine (PCV). Both protect by targeting capsular polysaccharides from pneumococcal serotypes most often responsible for invasive disease. In simple terms, these vaccines target a part of the bacteria “coating” and create antibodies or proteins that protect the body when the strep enters the body. 

PPSV (polysaccharide): PPSV is made from purified pieces of the pneumococcal capsule or coating. The current vaccine PPSV23 (Pneumovax®) covers 23 serotypes (or strains) that were the leading cause of pneumococcal infections in the 1980s. 

PCV (conjugate): Pneumococcal conjugate vaccines (PCVs) take capsular polysaccharides from the bacterium and chemically link them to a carrier protein, which changes and strengthens the immune response. Current PCVs come in four versions: 

PCV13 (Prevnar 13)

PCV15 (Vaxneuvance)

PCV20 (Prevnar 20)

PCV21 (Capvaxive) 

The number indicates the amount of pneumococcal capsule types covered by each vaccine. PCV21 was designed around adult disease patterns and covers many serotypes currently driving invasive disease in adults. However, it does not include serotype 4, but this serotype is covered by the PCV20 and PCV15.

Who should be vaccinated? 

In 2024, the United States Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) updated their recommendations on Pneumococcal vaccinations for adults. Their recommendations are: 

• Everyone 50 years or older
• Adults age 19–49 with risks: chronic lung/liver disease, heart failure, diabetes; CSF leak or cochlear implant; immunocompromised states (e.g., HIV, hematologic malignancy, CKD/nephrotic syndrome); functional/anatomic asplenia.
• Patients with history of prior invasive pneumococcal disease: still vaccinate. 

What vaccine should be given for adults that have never received the Pneumococcal vaccine?

For eligible adults with no prior pneumococcal vaccines, there are three choices:

1. PCV21 once
2. PCV20 once
3. PCV15 now, followed by PPSV23 later, usually 1 year; 8 weeks if immunocompromised, CSF leak, or cochlear implant.

PCV 20 or PCV21 seem more convenient. Once and done. 

• If available, PCV21 is a great one-and-done pick for most adults because it’s tailored to current adult serotypes.
• Serotype 4 caveat: If your patient is at higher risk for serotype 4 disease—think Navajo Nation, or folks in the Western US/Canada with substance use disorders or experiencing homelessness—choose PCV20 (or PCV15 followed by PPSV23 if PCV20 isn’t available).

What if the patient already received a Pneumococcal vaccine in the past?

Plan depends on which vaccine they received and when.

• PPSV23 only: give PCV21 ≥1 year later (or PCV20 if serotype-4 risk or PCV21 unavailable).
• PCV10 or PCV13 only: give PCV21 (or PCV20 if PCV21 unavailable) ≥1 year later. 
• If a PCV is not available, discuss PPSV23 now vs waiting until PCV is available.

If patient receives PPSV23 now will need to return ≥1 year later to receive a PCV vaccine, and no more vaccines are needed after that.

Is it safe to administer the Pneumococcal vaccine with other vaccines?

• Coadministration is fine with other non-pneumococcal vaccines, as long as we use different syringes and sites. Data support same-day administration of PPSV23 + influenza, and PCV20 with influenza or mRNA COVID-19 vaccines.

Some patients are hesitant to receive vaccines, Are there side effects and contraindications to the vaccine?

Local reactions are most common: pain/tenderness; swelling/induration (~20%); redness (~15%). Some people “baby” the arm for a couple of days. These typically resolve in 3–4 days; NSAIDs and warm compresses help.

• Systemic symptoms: fatigue, headache, myalgias/arthralgias, chills; fever ≥38°C is uncommon (<5%). Usually mild and self-limited.
• Contraindications: history of severe allergy (e.g., anaphylaxis) to a pneumococcal vaccine or components.

Bottom line: If a patient is 50+, or younger with specific risks, they likely need one conjugate dose—PCV21 or PCV20—and they’re done. Use PCV15 followed by PPSV23 when needed, and remember the serotype 4 caveat.

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. Musher DM, Rodriguez-Barradas MC. [Pneumococcal Vaccination in adults. UpToDate Inc. Literature review current through September 2025. Topic last updated January 13, 2025. https://www.uptodate.com/contents/pneumococcal-vaccination-in-adults
2. Centers for Disease Control and Prevention. (2025, May 29). Pneumococcal conjugate vaccine (interim) VIS: What you need to know. U.S. Department of Health and Human Services. Retrieved [access date], from https://www.cdc.gov/vaccines/hcp/current-vis/pneumococcal-conjugate.html?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.html
3. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Nathan Bui and Sanjay Reddy describe how to manage opioid use disorder (OUD) by using microinduction and harm reduction, strategies that are reshaping the way we treat opioid use disorder. 

Written by Sanjay Reddy, OMSIV and Nathan Bui, OMSIV. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific.

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

Welcome to episode 203 of Rio Bravo qWeek, your weekly dose of knowledge.

Today, we’re tackling one of the biggest health challenges of our time: opioid use disorder, or OUD. Nearly every community in America has been touched by it: families, friends, even healthcare providers themselves. 

For decades, treatment has been surrounded by barriers, painful withdrawals, stigma, and strict rules that often do more harm than good. Too many people who need help never make it past those walls. But here’s the hopeful part, new approaches are rewriting the story. They are less about rigid rules and more about meeting people where they are. 

Two of the most promising strategies for treatment of OUD are buprenorphine microinduction and harm reduction. Let’s learn why these two connected strategies could change the future of addiction recovery. 

Background information of treatment: The X-waiver (short for DATA 2000 waiver) was a special DEA requirement for prescribing buprenorphine for opioid use disorder. Doctors used to take extra training (8 hours) and apply for it. Then, they could prescribe buprenorphine to a very limited number of patients. 

The X-waiverhelped regulate buprenorphine but also created barriers to access treatment to OUD. It was eliminated in January 2023 and now all clinicians with a standard DEA registration no longer need a waiver to prescribe buprenorphine for OUD. 

Why buprenorphine?

Buprenorphine is one of the safest and most effective medications for opioid use disorder. It has some key attributes that make it both therapeutic and extremely safe: 

1) As a partial agonist at mu-opioid receptors, it binds and provides enough partial stimulation to prevent cravings and withdrawal symptoms without producing strong euphoria associated with full agonists. 

2) Because it has a strong binding affinity compared to full agonists, it easily displaces other opioids that may be occupying the receptor. 

3) As an antagonist at kappa-opioid receptors, it contributes to improved mood and reduced stress-induced cravings. 

4) The “ceiling effect”: increasing the dosage past a certain point does not produce a stronger opioid effect. This ceiling effect reduces the risk of respiratory depression and overdose, making it a safer option than full agonists. 

5) It also had mild analgesic effects, reducing pain. 

6) Long duration of action: The strong binding affinity and slow dissociation from the mu-opioid receptor are responsible for buprenorphine's long half-life of 24–60 hours. This prolonged action allows for once-daily dosing in medication-assisted treatment for OUD. 

Induction vs microinduction:

The problem is, starting it—what’s called “induction”—can be really tough. Patients usually need to stop opioids and go through a period of withdrawal first. 

Drugs like fentanyl, which can cause precipitated withdrawal —a sudden, severe crash may push people back to using opioids. Because buprenorphine binds so tightly to the mu-opioid receptor, it can displace other opioids, such as heroin or methadone. If buprenorphine is taken while a person still has other opioids in their system, it can trigger sudden and severe withdrawal symptoms.

Opioid withdrawal sign sand symptoms:

Opioid withdrawal symptoms are very uncomfortable; patients may even get aggressive during withdrawals. As a provider, once you meet one of these patients you never forget how uncomfortable and nasty they can be. The symptoms are lacrimation or rhinorrhea, piloerection "goose flesh," myalgia, diarrhea, nausea/vomiting, pupillary dilation, photophobia, insomnia, autonomic hyperactivity (tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia), and yawning. 

Think about all the symptoms you run for COWS (Clinical Opiate Withdrawal Scale). It is estimated 85 % of opioid-using patients who inject drugs (PWID) reported opioid withdrawal. Fortunately, even though opioid withdrawal is very uncomfortable, it is not life-threatening (unlike alcohol or benzodiazepine withdrawal, which can be fatal).

Many patients who start the journey treating opioid use disorder experience “bumps in the road” --they avoid treatment or drop out early. 

What is Microinduction? 

Microinduction is a fairly new strategy started in Switzerland around 2016. It is also known as the “Bernese method” (named after the city of Bern, Switzerland). 

With this method, instead of stopping opioids cold turkey, patients start with tiny doses of buprenorphine—fractions of a milligram. These doses gradually increase over several days while the patient continues their regular opioid use. While they begin this titer, they can continue use of the full agonist they were previously using–methadone, fentanyl, or heroin, while the buprenorphine begins to take effect. 

Once the buprenorphine builds up to a therapeutic level, the full agonist is stopped. This method uses buprenorphine’s unique pharmacology to stabilize the brain’s opioid system without triggering those really nasty withdrawal symptoms.

Early studies and case reports suggest this is safe, tolerable, and effective method to do. Microinduction is changing the game, and it has been spreading quickly in North America. 

Instead of forcing patients to stop opioids completely, the dose is slowly increased over the next three to seven days, while the patient keeps using their usual opioids.By the end of that week, the buprenorphine has built up to a therapeutic level and the full agonist is stopped. The difference is really dramatic. Instead of a painful crash into withdrawal, patients describe the process as a gentle step down, or a ramp instead of a cliff. 

It’s a flexible method. It can be done in a hospital, a clinic, or even outpatient with good follow-up. Once a patient and doctor develop a strong relationship built on the principles of patient autonomy and patient-centered care, microinduction can be closely monitored on a monthly basis including televisits. Microinduction has been shown to help more patients stay in treatment. 

The Role of Harm Reduction 

Instead of demanding perfection, harm reduction focuses on best practices providers can implement to reduce risk and keep patients safe. Harm reduction can vary from providing naloxone to reverse overdoses, giving out clean syringes, or offering safer injection education. 

It also means allowing patients to stay in treatment even if they keep using other substances, and tailoring care for groups like adolescents, parents, or people recently released from incarceration. Harm reduction says that instead of demanding perfection, let’s focus on progress. Instead of all-or-nothing, let’s devote resources to keeping people alive and safe. 

As mentioned,an option is providing naloxone kits so overdoses can be reversed in the moment. Also, giving out clean syringes so the risk of HIV or hepatitis infection is reduced while injecting heroin. Another way to reduce harm is teaching safer injection practices so people can protect themselves until they’re ready for that next step in their treatment. 

It also means keeping the doors open, even when patients slip. If someone is still using other substances, they still deserve care. And it means tailoring support for groups who oftentimes get left behind. For people like adolescents, parents balancing childcare, or people coming out of incarceration who are at the highest risk of overdose. 

Harm reduction recognizes that recovery isn’t a straight line. It’s about meeting people where they are and walking with them forward. 

Conclusion:

Microinduction is itself a harm reduction strategy. It lowers barriers by removing the need for painful withdrawal.When paired with a harm reduction culture in clinics, patients are more likely to enter care, stay engaged, and build trust with doctors for continued care. 

Managing opioid use disorder is one of the greatest health challenges of our time. But solutions like buprenorphine microinduction and harm reduction strategies are reshaping treatment—making it safer, more humane, and more accessible. If we embrace these approaches, we can turn barriers into bridges and help more people find recovery. 

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. Bluthenthal, R. N., Simpson, K., Ceasar, R. C., Zhao, J., Wenger, L., & Kral, A. H. (2020). Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs. Drug and Alcohol Dependence, volume 211, 1 June 2020, 107932. https://doi.org/10.1016/j.drugalcdep.2020.107932.
2. De Aquino, J. P., Parida, S., & Sofuoglu, M. (2021). The pharmacology of buprenorphine microinduction for opioid use disorder. Clinical Drug Investigation, 41 (5), 425–436. https://doi.org/10.1007/s40261-021-01032-7. 
3. Taylor, J. L., Johnson, S., Cruz, R., Gray, J. R., Schiff, D., & Bagley, S. M. (2021). Integrating harm reduction into outpatient opioid use disorder treatment settings. Journal of General Internal Medicine, 36 (12), 3810–3819. https://doi.org/10.1007/s11606-021-06904-4.
4. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

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

_____________________

Arr: Welcome to another episode of Rio Bravo qWeek. My name is Hector Arreaza, I’m an associate program director and faculty in the Rio Bravo Family Medicine Residency Program. Today my co-host is Cameron Carlisle, who is a 4th-year medical student finishing his last rotation of med school. Welcome, Cameron, please introduce yourself.

Arreaza: What are we talking about today, Cameron?

Cam: Dr. Arreaza, did you know you’re probably carrying around a chemical in your body that mimics estrogen? In fact, a 2004 CDC study found over 92% of Americans had detectable levels of Bisphenol A (BPA) in their urine. 

Today’s topic is BPA.

BPA is everywhere: receipts, water bottles, canned foods, baby bottles, and even our dental fillings. It’s one of the most ubiquitous endocrine-disrupting chemicals (EDCs), which interferes with the body’s hormone systems. That’s why today’s episode is about making the invisible visible. 

Our goals for today’s podcast:

• Break down what BPA is
• Show how it affects the human body
• Explain how you and your patients can limit exposure
• Empower both clinicians and the public with real, practical information

Arreaza: Thanks for clarifying BPA today. It seems like we always have to learn about a new carcinogen or toxic substance that we are exposed to. I remember when I was a child, Yellow #5 became very concerning for the general public but it is still being used in our foods. So, it’s good you are talking about this. 

Cam: Bisphenol A (BPA) is an industrial chemical used since the 1950s, primarily in polycarbonate plastics and epoxy resins. It makes plastic clear, and is often found in:

• Water bottles
• Canned food linings
• Baby bottles (pre-2012)
• Takeout containers
• Cash register receipts
• Dental sealants

Arreaza: So, I’ve seen the “BPA-free” labels many times, and today I’m glad you are going to shed some light about it.

Cam: What’s alarming is that BPA leaches out of these products, especially when exposed to heat, acidity, or repeated use. A Harvard study found that people who drank from plastic bottles for just one week had a 69% increase in urinary BPA levels (Carwile & Michels, 2009).

Arreaza: That’s a lot of people 69%. Section 3: What happens when BPA gets into our body? How BPA Works in the Body

Cam: BPA is classified as an endocrine disruptor, meaning it can bind to estrogen receptors and mimic or block natural hormone functions.

It affects:

• Reproductive systems (both male and female)
• Neurodevelopment
• Thyroid signaling
• Pancreatic β-cell function
• Metabolism and fat storage

Even low-dose exposure can disrupt cellular function. BPA acts as a xenoestrogen (foreign estrogen) and has been shown to alter DNA methylation, leading to epigenetic changes that persist across generations (Manikkam et al., 2013).

Arreaza: So, BPA can cause epigenetic changes that can be inherited. BPA can persist for generations in your offspring.

Here’s where it gets serious. Let’s go system-by-system:

• Females: Linked to PCOS, infertility, and early puberty (Peretz et al., 2014).
• Males: Reduced sperm count and motility; altered testosterone levels.

• Increased risk of preterm birth, gestational diabetes, and low birth weight (Snijder et al., 2013).
• Studies show BPA crosses the placenta, directly affecting the fetus.

• Associated with ADHD, anxiety, and impaired executive function in children exposed in utero (Mustieles et al., 2015).

• BPA exposure is linked to insulin resistance, obesity, and type 2 diabetes, even at low doses (Lang et al., 2008).

• Animal and human data link BPA to increased risk of breast and prostate cancer via estrogenic mechanisms.

• A 2020 JAMA study found individuals with higher BPA levels had a 49% increased risk of all-cause mortality compared to those with lower levels (Gao et al., 2020).

Arreaza: You are scaring me. I wonder what my BPA level is in my blood. Actually, BPA can be detected in urine. This is the most common approach for population-level biomonitoring, because BPA and its metabolites are mostly excreted in urine. Studies have found that BPA is present in most people, even up to 85–99% in large cohorts. 

Cam: That’s literally everyone. 

Let’s talk about things we use every day:

• Thermal receipts (like from Target or Starbucks): BPA can transfer onto your skin and be absorbed, especially if your hands are wet or lotioned.
• Canned soups: One study showed that eating canned soup daily for five days led to a 1000% increased urinary BPA levels (Carwile et al., 2011).
• Plastic water bottles left in the car on hot days or plastic food trays for microwaving = chemical leaching.
• Baby bottles and pacifiers (pre-2012): primary concern for newborns.

Arreaza: So, Cameron, you were exposed to BPA as a baby.

Cam: Here’s the jaw-dropper: We ingest up to 5 grams of plastic per week, roughly the weight of a credit card (WWF, 2019; University of Newcastle). This includes microplastics like BPA, which enter through food, water, and air.

Arreaza: So, it translates into 40 lbs of plastic in a lifetime, by age 70. What can we do as family physicians?

As family physicians, we are at the frontlines of prevention. Our role includes:

• Anticipatory guidance: during prenatal visits, well-child visits, and chronic disease management
• Screening opportunities: ask about storage habits, microwave use, and receipt handling
• Environmental health counseling: AAFP recommends addressing endocrine disrupting chemicals (EDCs) when relevant to a patient’s concerns.

It’s not just about treating diabetes or obesity. It’s about recognizing that environmental exposure may be a root cause.

Arreaza: Prevention is my favorite topic!

Cam: One helpful clinical practice:

Arreaza: What else can we do to reduce BPA exposure?

Here’s what patients and doctors alike can do today:

• Switch to BPA-free products, but be careful, as replacements like BPS or BPF may also be harmful (Rochester & Bolden, 2015).
• Avoid microwaving or dishwashing plastic containers.
• Use digital receipts.
• Filter tap water using carbon filters, which can reduce microparticle ingestion.
• Choose fresh produce over canned goods when possible.

Also, wash your hands after handling receipts, especially before eating or touching your face.

Arreaza: What is our government doing to protect us?

Regulations are slowly catching up:

• The FDA banned BPA in baby bottles and sippy cups in 2012.
• The European Union has stricter limits, and France banned BPA in all food packaging in 2015.
• California’s Proposition 65 requires BPA warning labels.

Arreaza: Proposition 65, passed by direct voter initiative in 1986, “WARNING: This product contains chemicals known to the State of California to cause cancer and birth defects or other reproductive harm.”

Arreaza: The FDA is planning to phase out petroleum-based food dyes (certified color additives) from the American food supply – marking a significant milestone in the efforts to protect the public. 

Cam: Many products still contain BPA analogs (BPS, BPF), which are not yet well-regulated.

This is where clinician advocacy matters, where we can guide public opinion and support legislative change.

Arreaza: So, millions of pounds of toxic substances are produced by many industries in the US. As physicians, we have to stay informed and update our patients.

Cameron: How can we wrap up this episode?

• BPA is a hormone disruptor hiding in plain sight.
• People are exposed to BPA every day, but small lifestyle changes can dramatically reduce it.
• Family medicine has a role in education, prevention, and advocacy.

Let’s all be part of the solution for our health and future generations. Stanley (tumblers) are not sponsoring this episode, and we did not receive any money from them. 

Arreaza: That’s it for today’s episode of Rio Bravo qWeek. If you enjoyed this episode, share it with a colleague or medical student who may need to know about BPA. I’m Dr. Arreaza, signing off.

Cameron: Hopefully, in the future I will talk to you about more endocrine disrupting chemicals. Thanks 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. Carwile, J. L., & Michels, K. B. (2009). Urinary bisphenol A and obesity: NHANES 2003–2006. Environmental Research, 111(6), 825–830.
2. Carwile, J. L., et al. (2011). Canned soup consumption and urinary bisphenol A: A randomized crossover trial. JAMA, 306(20), 2218–2220.
3. Centers for Disease Control and Prevention (CDC). (2004). Fourth National Report on Human Exposure to Environmental Chemicals.
4. Gao, X., et al. (2020). Urinary bisphenol A and mortality risk. JAMA Network Open, 3(8), e2011620.
5. Lang, I. A., et al. (2008). Association of urinary bisphenol A with medical disorders and laboratory abnormalities in adults. JAMA, 300(11), 1303–1310.
6. Manikkam, M., et al. (2013). Epigenetic transgenerational inheritance of disease. PLOS ONE, 8(1), e55387.
7. Mustieles, V., et al. (2015). Bisphenol A and neurodevelopmental outcomes in children. Environmental Health Perspectives, 123(7), 689–695.
8. Peretz, J., et al. (2014). Bisphenol A and reproductive health. Environmental Health Perspectives, 122(8), 775–786.
9. Rochester, J. R., & Bolden, A. L. (2015). Bisphenol S and F: A systematic review. Environmental Health Perspectives, 123(7), 643–650.
10. Snijder, C. A., et al. (2013). Fetal growth and prenatal exposure to bisphenol A. Environmental Health Perspectives, 121(3), 393–398.
11. World Wildlife Fund (WWF). (2019). No Plastic in Nature: Assessing Plastic Ingestion from Nature to People.
12. University of Newcastle (Australia). (2019). Human Consumption of Microplastics.
13. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Future Dr. Ayyagari describes the different types of acute kidney injury and shares some elements of management for each category. Dr. Arreaza shares some input about statistics and the importance of drinking water during summer.

Written by Tejasvi Ayyagari, MSIV, Ross University School of Medicine. 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:

Dr. Arreaza: Hello everyone, and welcome back to Rio Bravo qWeek — your weekly dose of knowledge. I’m Dr. Arreaza, I am a faculty member and associate program director of the Rio Bravo FM residency program. In Episode 126, we briefly introduced the topic of Acute Kidney Injury (AKI), but today, we’re taking a deep dive into the matter. I have here alongside my cohost, future Dr. Ayyagari, AKA TJ. Please, TJ, introduce yourself.

TJ: Hey everyone, good to be back on the podcast. My name is TJ Ayyagari, and I am currently finishing my last rotation of medical school with Rio Bravo CSV outpatient.  I hope everyone is doing well and staying safe.

Dr. Arreaza: So, TJ prepared this discussion about acute kidney injury, also known as AKI. This is a critical topic for our Kern community, especially during the summer months when the risk of AKI increases. You will face many patients with AKI on the wards, in the clinic, and especially on your future board exam. Hopefully, by the end of this episode, you all will have more information on AKI, but also the three different types: prerenal, intrinsic, and postrenal. 

TJ: Without further ado, let’s get started, Dr. Arreaza.

SECTION 1 – What is AKI?

Dr Arreaza: Let’s start with the definition. Let’s explain what AKI is. 

TJ: Absolutely.  So, an AKI is not just a bump in the patient’s creatinine. According to the Kidney Disease Improving Global Outcomes (KDIGO) definition, an AKI embodies any of the following criteria:

• Increase in serum creatinine by ≥0.3 mg/dL within 48 hours, OR
• Increase in serum creatinine to ≥1.5 times baseline within the prior 7 days, OR
• Urine volume <0.5 mL/kg/h for 6 hours

Dr. Arreaza: The numbers show that AKI is increasing in our hospitals. According to the CDC, the incidence rate of newly diagnosed AKI has increased from 80 per 1,000 patient-years in 2007 to 242 per 1,000 patient-years in 2022. We must be vigilant and diagnose AKI appropriately because time is gold. We need to correct it and prevent further kidney damage, if possible. A critical step in the treatment is determining why the AKI is happening. Let’s start by discussing prerenal AKI. 

SECTION 2 – Prerenal AKI

Dr. Arreaza: Let’s remember our Latin language, “pre” means before, and “renal” means kidney. So, when you say pre-renal, it sounds like you’re referring to an event that happens before the kidneys.

TJ: You’re right.A prerenal AKI is the most common type, and it refers to a problem that occurs before the kidney. The keyword here is perfusion — the kidneys are fine structurally, but they’re not getting enough blood flow.

Common causes:

• Hypovolemia: vomiting, diarrhea, bleeding, and overdiuresis (surreptitious diuretic use).
• Low cardiac output: heart failure, MI (if the heart cannot pump blood effectively across the body, the kidneys suffer)
• Systemic vasodilation: sepsis, cirrhosis (with widespread vasodilation and increased capillary permeability, resulting in more fluids shifting across the vasculature to tissues, which means less is available for the kidneys).

Dr. Arreaza: So, less perfusion means less oxygen, less nutrients and more damage to the kidney.

TJ: However, the good news is that it’s often reversible if you fix the underlying cause quickly. 

Dr. Arreaza: What would we expect to see on lab values?

TJ: As a result of low kidney perfusion, the kidneys do their best to conserve sodium and water, and urea reabsorption is increased in the proximal tubule. Subsequently, BUN rises disproportionately compared to creatinine (BUN: Cr ratio > 20:1).  There is also a lab value called the Fractional excretion of sodium, otherwise known as FeNa, which will appear as <1% suggesting a prerenal AKI because the kidneys are holding onto sodium to preserve volume.

Dr. Arreaza: Let’s talk about correction of prerenal AKI. If there is no perfusion, let’s improve renal perfusion!

TJ: Of course!  The treatment is to restore volume — fluids if hypovolemic, improve cardiac output if heart-related, and treat infection if septic. But remember, in CHF or cirrhosis, fluids can be tricky.

SECTION 3 – Intrinsic AKI

Dr. Arreaza: Excellent explanation, TJ. So, let’s talk about the second type of AKI: intrinsic. Intrinsic AKI means the problem is inside the kidney itself.  If you’re comparing it to simple terms, the plumbing and water pressure are fine (perfusion is normal), the drains are fine (no obstructions), but the kidney’s filter is damaged.

TJ: Major categories:

• Acute tubular necrosis (ATN): Most common intrinsic cause. Usually from ischemia or toxins (like aminoglycosides, IV contrast, ethylene glycol).
• Acute interstitial nephritis (AIN): Often an allergic reaction to drugs.  Here’s a quick little mnemonic with the 6Ps to help remember the most common causes. 

Pee — diuretics like furosemide or thiazides.
Pain-free — NSAIDs.
Penicillin — and other beta-lactam antibiotics.
Proton pump inhibitors — like omeprazole.
rifamPin — and other rifamycin antibiotics.
Cimetidine — yes, the old-school H₂ blocker still shows up on exams.

• Glomerulonephritis: Autoimmune, post-infectious, or vasculitis. You’ll see proteinuria, hematuria, and RBC casts.

Dr. Arreaza: A common cause of AKI is diabetes. Diabetes causes prerenal AKI (dehydration caused by uncontrolled diabetes) and intrinsic from renal parenchymal damage and tubular necrosis. So clinically, what would we expect?

TJ: With Intrinsic AKI, as a result of tubular damage, there is impaired urea reabsorption.  Subsequently, BUN and creatinine both rise more proportionally (BUN: Cr ratio closer to 10 –15:1). 

• With ATN, muddy brown casts can be appreciated in UA
• With AIN, look for fever, rash, and especially eosinophilia, as well as a UA displaying eosinophils or WBC casts.
• With Glomerulonephritis, look for RBC casts and proteinuria on UA, and you may even see edema on physical exam with hypertension.

Dr. Arreaza: Treating intrinsic AKI will depend on etiology. Hydration would not fix the problem in most cases. Let’s mention some treatment options for intrinsic AKI.

TJ: Intrinsic AKI is a bit like fixing a flooded house — you don’t just start bailing water; you find the source of the leak, stop it, and protect what’s left. Whether it’s ATN, AIN, or GN, the playbook is: remove the injury, give the kidney a rest, and treat the underlying cause.

Dr. Arreaza: Sure. We start with supportive care, especially treating hyper or hypotension, maintaining normovolemia, correcting electrolyte imbalances, and using antibiotics in case of infection. 

-We must identify and remove reversible causes, such as discontinuing nephrotoxic agents such as NSAIDs, aminoglycosides, and iodine contrast. -Also, other reversible factors must be corrected such as hypovolemia (IV fluids), hypotension (vasopressors) to prevent further kidney damage.

TJ: -Hemodialysis or renal replacement therapy (RRT) is reserved for severe cases of refractory hyperkalemia, metabolic acidosis, volume overload unresponsive to diuretics, and uremic symptoms (encephalopathy, pericarditis, pleuritis).

Dr. Arreaza: Immunosuppression is required for specific types of glomerulonephritis. For instance, rapidly progressive crescentic glomerulonephritis warrants high-dose glucocorticoids and cyclophosphamide. In ANCA-associated vasculitis, glucocorticoids plus cyclophosphamide or rituximab, and sometimes plasma exchange, are standard.

SECTION 4 – Postrenal AKI

Dr. Arreaza: We spent enough time in intrinsic AKI.  Why don’t we move on to our last topic of AKI, postrenal.

TJ: So, withpostrenal AKI, imagine that urine leaving the kidney encounters a roadblock.  Urine can’t get out, so pressure builds up, damaging the kidney.

Common causes:

• For men, benign prostatic hyperplasia (BPH) is a significant factor (as the prostate grows bigger, it can compress the urethra, leading to urine backflow, which can not only cause AKI, but can also lead to possible UTIs in the process).
• Kidney stones, tumors, strictures, and neurogenic bladder

When doing my urology and nephrology rotations at Kern Medical, I encountered many kidney stones and urethral strictures, and unfortunately, a fair number of patients suffering from RCC that caused not only the AKI but also extreme discomfort.

Dr. Arreaza: It seems like we need some imaging to diagnose postrenal AKI.

TJ: Yes.If you’re concerned about obstruction, a renal U/S can quickly help diagnose an underlying obstruction, or a CT scan for more details.

Lab patterns?

• In the early phase (before tubular injury):
• BUN: Cr ratio >20:1 — looks like prerenal.
• FeNa <1%.
• Urine osmolality >500 mOsm/kg.
• In the later phase (after prolonged obstruction → tubular injury):
• BUN: Cr ratio ~10–15:1 — now looks intrinsic.
• FeNa >2%.
• Urine osmolality ~300 mOsm/kg.

Dr. Arreaza: BUN:Cr ratio and FeNa are not reliable to diagnose postrenal AKI, so we must rely more in imaging and clinical presentation. Let´s talk about the management of postrenal AKI.

TJ: Absolutely!  The main way to treat a post-renal AKI is to relieve the obstruction causing it in the first place, whether it be through surgery, TURP, lithotripsy, etc.

Dr. Arreaza: I think the favorite treatment done by urology to relieve obstruction is a ureteral stent, which, remember, needs to be removed later. Typically, 1-2 weeks is sufficient to treat kidney stones. The risk of encrustation and infection increases significantly after 4–6 weeks, and stents should ideally be exchanged within 3 months to minimize complications. 

SECTION 5 – Closing

Dr. Arreaza: I know you’ve spent a decent amount of time explaining the details of the AKI types with us, TJ, but could you give us a summary?

TJ: Viewers, if there’s anything to take away from this, remember:

• Prerenal: Poor perfusion, fix the flow.
• Intrinsic: Structural damage inside the kidney — think ATN, AIN, GN.
• Postrenal: Obstruction — relieve the blockage.

When you see AKI, think: Before the kidney, in the kidney, or after the kidney? That simple framework can help you move fast and help your patient recover kidney function.

Dr. Arreaza, any advice you want to give to the viewers?

Dr. Arreaza: Yes,weare in the middle of summer, and we treat a large amount of farm workers, construction workers and people who spend time outdoors, in general, remind your patients to drink water. Water is life, especially for the kidneys, there is no substitute. That’s it for today’s episode of Rio Bravo qWeek. If you enjoyed this review, share it with a colleague or medical student who could use a quick AKI refresher. And remember — the kidneys may be small, but they’re mighty… and they hold grudges when you ignore them. I’m Dr. Arreaza, signing off.

TJ: Thank you for tuning in, everyone. Have a nice day!

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. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements. 2012;2:1–13. https://kdigo.org/guidelines/acute-kidney-injury/.
2. Kaur A, Sharma GS, Kumbala DR. Acute kidney injury in diabetic patients: A narrative review. Medicine (Baltimore). 2023 May 26;102(21):e33888. doi: 10.1097/MD.0000000000033888. PMID: 37233407; PMCID: PMC10219694. https://pmc.ncbi.nlm.nih.gov/articles/PMC10219694/
3. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Jesica Mendoza explains the pathophysiology, diagnosis and management of ascites. Dr. Arreaza adds input about early detection and prevention of spontaneous bacterial peritonitis. 

Written by Jesica Mendoza, OMS IV, Western University, College of Osteopathic Medicine of the Pacific. 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.

Welcome to our episode 200! It is an honor to welcome back a wonderful medical student, her name is Jesica, and she has prepared this topic, and she is excited to share this information with us. Jesica presented in June this year an episode about gestational diabetes (episode 193) and today she will talk about ascites. Jesica, please tell us who you are again. 

What is ascites?

Ascites is the buildup of fluid in between the visceral peritoneum and the parietal peritoneum in the abdomen. This is often caused by cirrhosis of the liver due to the increased portal HTN which leads to increased nitrous oxide (NO) and prostaglandins which then causes splanchnic vasodilation and decreased effective arterial volume. The decrease in arterial volume then causes an increase in the renin–angiotensin–aldosterone system (RAAS) and antidiuretic hormone (ADH) from the renal system which leads to sodium and water retention. This then causes a net reabsorption of fluids and ascites.

Evaluation of ascites.
Once someone has been found to have ascites the next step will be a diagnostic paracentesis. This includes removing fluid from the peritoneal cavity in order to determine the SAAG (Serum Ascites Albumin Gradient) score. 

SAAG : (serum albumin) − (albumin level of ascitic fluid). The two values should be measured at the same time.

This score helps determine the cause of the ascites with a score >1.1 g/dL indicating portal hypertension usually due to liver disease such as cirrhosis. A SAAG score of <1.1 g/dL will suggest causes such as tuberculosis, malignancy, pancreatitis, nephrotic syndrome, or inflammatory conditions. 

A paracentesis can be done for diagnostic purposes in a new-onset ascites or if a patient with known ascites has clinical deterioration (such as fever, abdominal pain, hepatic encephalopathy, renal dysfunction, or leukocytosis). In cases of tense or refractory ascites, the paracentesis can be done for both diagnostic and therapeutic purposes. Tell us more about the serum ascites albumin gradient (SAAG).

If the SAAG is greater than 1.1 (portal hypertension) you then use the serum protein levels for further management. For a low serum protein (<2.5) you proceed with an abdominal US with doppler. The ultrasound will tell you whether the liver is cirrhotic and if the hepatic vessels are patent. Once cirrhosis is identified in the patient, the workup for chronic liver disease management can be started. Another cause of low protein is Budd-Chiari syndrome. In this case anticoagulation is used. 

Budd-Chiari syndrome is caused by obstruction of the hepatic venous outflow tract, most commonly the hepatic veins or the intra-/suprahepatic inferior vena cava, in the absence of cardiac or pericardial disease. This causes hepatic congestion, which can present with acute or chronic abdominal pain, hepatomegaly, ascites, and, in some cases, progressive liver dysfunction or portal hypertension; but up to 20% of cases may be asymptomatic. The most frequent underlying cause is a prothrombotic state, particularly cancer (Jes: myeloproliferative neoplasm). That’s why you mention the treatment: anticoagulation.

A SAAG greater than 1.1 with a high serum protein level (>2.5) the cause points towards right sided heart failure or constrictive pericarditis. In both cases a referral to cardiology should be placed for management of the underlying cause of the ascites. Another cause of elevated protein levels is portal or splenic vein thrombosis. If this is the case, the patient is managed with anticoagulation again. 

Treating the underlying cause.

Patients with cirrhosis causing ascites will need treatment for the underlying cause. If that cause is Hepatitis C or Hepatitis B, then starting antiviral therapy is crucial to reduce the liver’s inflammation. Diuresis is also very important to help with decreasing the ascites and in turn all the symptoms of ascites. Usually Furosemide and/or spironolactone can be used. In cases of mild ascites spironolactone is usually first line treatment. If the patient has recurrent ascites, they often are given a combination of spironolactone and loop diuretics like furosemide. 

The recommended ratio of furosemide (Lasix) to spironolactone for the treatment of ascites is 40 mg of furosemide to 100 mg of spironolactone (a 1:2.5 ratio). Recommended max dose: 160 mg furosemide and 400 mg spironolactone daily. Dose adjustments can be made every 72 hours to minimize electrolyte disturbances. 

Once the patient has ascites under control the diuretic dose is adjusted to the lowest effective dose to minimize side effects.

Medications to avoid, sodium and water restriction.

In conjunction with medical management, it is ideal that the patient stops alcohol if the patient has alcohol induced cirrhosis causing the ascites. The patient should also follow a low-sodium diet (less than 2 grams/day) to help prevent the fluid overload that worsens the ascites. Also, something very important is that the patient must avoid use of NSAIDs, b-blockers, and ACE/ARBs. Patients need to be educated on the importance of avoiding NSAIDS especially because these medications can be found over the counter and are readily accessible but very harmful to cirrhotic patients.

Fluid (water) restriction is generally not recommended for patients with liver cirrhosis and ascites unless they have moderate to severe hyponatremia (serum sodium ≤125–126 mEq/L). When indicated, fluid restriction is typically set at 1,000 mL per day for moderate hyponatremia. The fluid management in ascites is focused on sodium restriction.

Refractory ascites. 

Sometimes there are people who have already received diuretics and have tried lifestyle changes, but the ascites continues to recur. In these cases, serial therapeutic paracentesis or trans jugular intra-hepatic portosystemic shunts (TIPS) can be done. 

One special case is when the ascites is caused by a malignancy. In this case fluid will continue to accumulate even with repeat paracentesis. PleurX is another available treatment. PleurX is a thin, flexible silicone catheter and a one-way valve that is inserted into the peritoneal cavity to allow for drainage of the fluid. Usually, the patients are sent home with this catheter and have caregivers who help them drain fluid using vacuum bottles. This is useful in reducing hospitalization in patients. However, it is not recommended in patients with infection, chylous effusions, mediastinal shifts, or hemorrhage risks. If the patient is a good candidate, they can be put on a list for liver transplant. 

Spontaneous bacterial peritonitis. 

A patient with SBP usually presents with systemic inflammatory response syndrome (SIRS) and large volume ascites on abdominal US. SBP is confirmed via paracentesis with >250 PMNS/mL. Fluid should be sent to the lab for culture and then antibiotics should be started. IV 3rd generation cephalosporins are typically used. Fluoroquinolones are also used to prevent the recurrence of SBP.

If you desire to learn more about SBP, listen to our episode 123. By the way, propranolol is a frequently used medication to prevent GI bleeding from esophageal varices in cirrhosis and also to decrease the development of ascites. It should be used in patients who have compensated cirrhosis and must be avoided in patients with refractory ascites, hypotension, renal dysfunction or active infection. 

So, to wrap things up we should remember that once we identify ascites with our physical exam of the patient, we should make sure to obtain a paracentesis as these results will be the main guide for our treatment. The treatment can then range from medical treatment such as spironolactone and/or loop diuretics to TIPS procedures, PleurX or even liver transplant. Always be on the lookout for SBP in patients with ascites and always remember to obtain a culture on the ascitic fluid prior to starting antibiotics. 

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. Ascites, Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/14792-ascites.
2. Huang LL, Xia HH, Zhu SL. Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites. J Clin Transl Hepatol. 2014 Mar;2(1):58-64. doi: 10.14218/JCTH.2013.00010. Epub 2014 Mar 15. PMID: 26357618; PMCID: PMC4521252. https://pmc.ncbi.nlm.nih.gov/articles/PMC4521252/.
3. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Dr. Lopez presents the most important screening tests for young adults. Dr. Arreaza adds some input on screening for depression and anxiety. 

Written by Alejandra Lopez, MD. Edits by Hector Arreaza, MD. Rio Bravo Family Medicine Residency Program. 

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

Dr. Lopez: Screening is testing done to help identify disease in a person or population that typically appears healthy. Our goal as clinicians is to see which children are at increased risk of disease and will merit additional testing. For clinicians, testing should be both easy to perform and interpret. Now let’s talk about prevention in young adults.

Dr. Arreaza: I can see it is important to talk about young adults because that population may be very hesitant to go to the doctor, in general. Tell us more about it.

Dr. Lopez: We all know that early detection and prevention are key, but many young adults skip routine check-ups. Why is that? Sometimes it’s lack of awareness, fear, or just not knowing where to start. That’s why today, we’ll focus on four key screenings that every adolescent and young adult should know about.

The Annual Physical Exam

Dr. Arreaza: I’m excited to talk about it. Many young adults only see a doctor when they’re sick, but screenings help catch issues early, sometimes before symptoms even appear. Tell us about the annual wellness exams and why they matter.

Dr. Lopez: Let’s start with the basics—annual wellness exams. Many young people don’t feel the need to see a doctor if they’re feeling fine. So, these check-ups are important because many serious health conditions start silently, meaning no symptoms at first. 

Dr. Arreaza: What do we look for in an annual exam?

Dr. Lopez: An annual check-up:

· It is important to track growth and development (especially important for adolescents)

It also helps monitor blood pressure, weight, and BMI to help find out who is at risk for elevated or low BP, underweight or overweight/obesity, by analyzing both weight and body mass index.

· Discuss lifestyle habits like diet, exercise, and sleep

· Evaluate whether you are up to date on vaccinations or due for age-appropriate vaccines.

· Address any mental health concerns

It’s also a great opportunity for young people to establish a relationship with a provider they trust. This makes it easier to discuss sensitive topics like sexual health or mental health.

Dr. Arreaza: So, you say that the annual physical exam helps identify all these issues early, and at the same time, you establish a relationship of trust with a doctor who you may need at any time. 

STI Screening

Dr. Arreaza: That brings us to our second key screening: testing for sexually transmitted infections (STIs). There are many STIs. Let’s focus on gonorrhea, chlamydia, syphilis, and HIV. Dr. Lopez, can you breakit  down for us? Who needs STI screening, and why is it so important?

Dr. Lopez: Absolutely. The CDC recommends that ALL sexually active women under age 25 get screened for chlamydia and gonorrhea annually. HIV testing should also be done at least once for all young adults and annually for those at higher risk. Why is this the case? Because Many STIs have no symptoms, but untreated infections can lead to serious complications like infertility or pelvic inflammatory disease (PID) in women. The good news is that these infections are easily treatable if caught early. If caught later in life, then women and men alike are at risk for worse conditions. 

Dr. Arreaza: Let's talk about how do we do it?

Dr. Lopez: STI screening is simple:

· For chlamydia and gonorrhea, it’s usually a urine test or a vaginal/cervical/oral swab.

· For HIV, it’s a quick blood test or even an oral swab.

Many young adults avoid testing because of fear, stigma, or concerns about privacy, but most clinics offer confidential or even anonymous testing. 

Doctors do not share any information regarding the minor or young adult or any patient for that matter. AND if we are requested to share any information with others- then it is our obligation as doctors to ALWAYS ASK THE PATIENT before sharing ANY health information with third parties/other entities

Dr. Arreaza: And that includes parents of minors. Doctors are not allowed to discuss STI test results with parents of minors unless they are authorized by the patient or if the patient is in danger, for example, if this is a result of sexual abuse.

Mental Health Screenings

Dr. Arreaza: Now, let’s talk about something that’s just as important as physical health—mental health. Depression and anxiety are very common in young people, but many don’t seek help. How do doctors screen for depression?

Dr. Lopez: Screening for depression is now a standard part of primary care. The most commonly used tool is the PHQ-9 questionnaire, which asks about:

· Mood changes (sadness, hopelessness)

· Loss of interest in activities

· Sleep disturbances

· Changes in appetite

· Difficulty concentrating

A score on this test can help determine whether someone is at risk of depression and needs further evaluation or support.

Dr. Arreaza: And why should we screen for depression?

Dr. Lopez: Because early treatment makes a huge difference. Depression can affect school, work, relationships, and even physical health. But with therapy, lifestyle changes, and sometimes medication, people can and do recover.

I always tell young adults: Mental health is just as important as physical health. Seeking help is a sign of strength, not weakness.

Dr. Arreaza: This is a USPSTF recommendation GRADE B. We are encouraged to screen adults, including pregnant and postpartum women, as well as older adults.

HPV Screening & Vaccination

Dr. Lopez: Dr. Arreaza, finally, let’s talk about HPV—one of the most preventable causes of cancer. The human papillomavirus (HPV) is the most common STI worldwide, and it’s responsible for almost all cases of cervical cancer, as well as throat, anal, and penile cancers. The good news? The HPV vaccine is over 90% effective at preventing these cancers. 

Dr. Arreaza: In fact, from 2015 to 2018, U.S. women ages 14 to 19 experienced an 88% decrease in HPV-related disease. That’s a direct result of the vaccine's effectiveness.

Dr. Lopez: It’s recommended for:

· All boys and girls, starting at the age of 9. ACIP gave new recommendations for use of a 2-dose schedule for girls and boys who initiate the vaccination series at ages 9-14 years. Three doses remain recommended for persons who start HPV vaccination at ages 15-26 years and for immunocompromised persons.

· Catch-up vaccination is recommended for people up to age 26 (and in some cases, up to 45 with provider recommendation)

Dr. Arreaza: And what about screening for HPV? How do we screen?

Dr. Lopez: Great question, Dr. Arreaza. Pap smears start at age 21, for all women regardless of sexual activity, and are repeated every 3-5 years depending on HPV testing. Many people think Pap smears check for STIs, but they actually look for abnormal cervical cells that could lead to cancer. HPV vaccination plus routine screening means cervical cancer is one of the most preventable cancers today!

Closing Thoughts & Call to Action

Dr. Arreaza: That wraps up today’s discussion on essential health screenings for young adults! Dr. Lopez, any final take-home messages?

Guest: My biggest message is don’t wait until something is wrong to see a doctor. Preventative care is simple, quick, and can save lives.

If you’re between the ages of 13-26, here’s what you should do:

-Get an annual wellness exam

-Get tested for STIs if sexually active

-Check in on your mental health and talk to someone if you need support

-Get the HPV vaccine if you haven’t already and follow up on screening

Taking these small steps today leads to better health for years to come!

Host: That’s fantastic! Dr. Lopez. I hope all our primary care providers can take these easy steps to keep our young community healthy. If you found this episode helpful, share it with a friend, and don’t forget to subscribe to our podcast for more practical health discussions.

Dr. Lopez: Until next time—thanks for chiming in, medical community. Take care and take charge of your health!

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. Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources. U.S. Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm, accessed on June 26, 2025.
2. Recommendation: Anxiety Disorders in Adults: Screening, United States Preventive Services Taskforce, June 20, 2023, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening, accessed on June 26, 2025.
3. Recommendation: Depression and Suicide Risk in Adults: Screening, United States Preventive Services Taskforce, June 20, 2023, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-adults, accessed on June 26, 2025.
4. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Future doctors Redden and Ibrahim discuss with Dr. Arreaza the different causes of fatigue, including physical and mental illnesses. Dr. Arreaza describes the steps to evaluate fatigue. Some common misconceptions are explained, such as vitamin D deficiency and “chronic Lyme disease”. 

Written by Michael Ibrahim, MSIV, and Jordan Redden, MSIV, Ross University School of Medicine. 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.

Dr. Arreaza: Today is a great day to talk about fatigue. It is one of the most common and most complex complaints we see in primary care. It involves physical, mental, and emotional health. So today, we’re walking through a case, breaking down causes, red flags, and how to work it up without ordering the entire lab catalog.

Michael:

Case: This is a 34-year-old female who comes in saying, "I’ve been feeling drained for the past 3 months." She says she’s been sleeping 8 hours a night but still wakes up tired. No recent illnesses, no weight loss, fever, or night sweats. She denies depression or anxiety but does report a lot of work stress and taking care of her two little ones at home. She drinks 2 cups of coffee a day, doesn’t drink alcohol, and doesn’t use drugs. No medications, just a multivitamin. Regular menstrual cycles—but she’s noticed they’ve been heavier recently.

Jordan:

Fatigue is a persistent sense of exhaustion that isn’t relieved by rest. It’s different from sleepiness or muscle weakness.

Classification based on timeline:

    •   Acute fatigue: less than 1 month

    •   Subacute: 1 to 6 months

    •   Chronic: more than 6 months

This patient’s case is subacute—going on 3 months now.

Dr. Arreaza:

And we can think about fatigue in types:

    •   Physical fatigue: like muscle tiredness after activity

    •   Mental fatigue: trouble concentrating or thinking clearly (physical + mental when you are a medical student or resident)

    •    Pathological fatigue: which isn’t proportional to effort and doesn’t get better with rest

And of course, there’s chronic fatigue syndrome, also called myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which is a diagnosis of exclusion after 6 months of disabling fatigue with other symptoms.

Michael:

The differential is massive. So, we can also group it by systems.

Jordan:

Let’s run through the big ones.

Endocrine / Metabolic Causes

    • Hypothyroidism: A classic cause of fatigue. Often associated with cold intolerance, weight gain, dry skin, and constipation. May be subtle and underdiagnosed, especially in women.

    • Diabetes Mellitus: Both hyperglycemia and hypoglycemia can cause fatigue. Look for polyuria, polydipsia, weight loss, or blurry vision in undiagnosed diabetes.

    • Adrenal Insufficiency: Think of this when fatigue is paired with hypotension, weight loss, salt craving, or hyperpigmentation. Can be primary (Addison's) or secondary (e.g., due to long-term steroid use).

Michael: 

Hematologic Causes

    • Anemia (especially iron deficiency): Very common, especially in menstruating women. Look for fatigue with pallor, shortness of breath on exertion, and sometimes pica (craving non-food items). 

    • Vitamin B12 or Folate Deficiency: B12 deficiency may present with fatigue plus neurologic symptoms like numbness, tingling, or gait issues. Folate deficiency tends to present with megaloblastic anemia and fatigue.

    • Anemia of Chronic Disease: Seen in patients with chronic inflammatory conditions like RA, infections, or CKD. Typically mild, normocytic, and improves when the underlying disease is treated.

Michael: 

Psychiatric Causes

    • Depression: A major driver of fatigue, often underreported. May include anhedonia, sleep disturbance, appetite changes, or guilt. Sometimes presents with only somatic complaints.

    • Anxiety Disorders: Mental fatigue, poor sleep quality, and hypervigilance can leave patients feeling constantly drained.

    • Burnout Syndrome: Especially common in caregivers, healthcare workers, and educators. Emotional exhaustion, depersonalization, and reduced personal accomplishment are key features.

Jordan: 

Infectious Causes

    • Epstein-Barr Virus (EBV):

Mononucleosis is a well-known cause of fatigue, sometimes lasting weeks. May also have sore throat, lymphadenopathy, and splenomegaly.

    • HIV:

Consider it in high-risk individuals. Fatigue can be an early sign, along with weight loss, recurrent infections, or night sweats.

    • Hepatitis (B or C):

Can present with chronic fatigue, especially if liver enzymes are elevated. Screen at-risk individuals.

    • Post-viral Syndromes / Long COVID:

Fatigue that lingers for weeks or months after viral infection. Often, it includes brain fog, muscle aches, and post-exertional malaise.

Important: Chronic Lyme disease is a controversial term without a consistent clinical definition and is often used to describe patients with persistent, nonspecific symptoms not supported by objective evidence of Lyme infection. Leading medical organizations reject the term and instead recognize "post-treatment Lyme disease syndrome" (PTLDS) for persistent symptoms following confirmed, treated Lyme disease, emphasizing that prolonged antibiotic therapy is not effective. Research shows no benefit—and potential harm—from extended antibiotic use, and patients with unexplained chronic symptoms should be thoroughly evaluated for other possible diagnoses.

Michael: 

Cardiopulmonary Causes

    •   Congestive Heart Failure (CHF): Fatigue from poor perfusion and low cardiac output. Often comes with dyspnea on exertion, edema, and orthopnea.

    •   Chronic Obstructive Pulmonary Disease (COPD): Look for a smoking history, chronic cough, and fatigue from hypoxia or the work of breathing.

    •   Obstructive Sleep Apnea (OSA): Daytime fatigue despite adequate hours of sleep. Patients may snore, gasp, or report morning headaches. High suspicion in obese or hypertensive patients.

Jordan:

Autoimmune / Inflammatory Causes

    •   Systemic Lupus Erythematosus (SLE): Fatigue is often an early symptom. May also see rash, arthritis, photosensitivity, or renal involvement.

    •   Rheumatoid Arthritis (RA): Fatigue from systemic inflammation. Morning stiffness, joint pain, and elevated inflammatory markers point to RA.

    •   Fibromyalgia: A chronic pain syndrome with widespread tenderness, fatigue, nonrestorative sleep, and sometimes cognitive complaints ("fibro fog").

Cancer / Malignancy

    •   Leukemia, lymphoma, or solid tumors: Fatigue can be the first symptom, often accompanied by weight loss, night sweats, or unexplained fevers. Consider when no other cause is evident.

Michael:

Medications:

Common culprits include:

    ◦   Beta-blockers: Can slow heart rate too much.

    ◦   Antihistamines: Sedating H1 blockers like diphenhydramine.

    ◦   Sedatives or sleep aids: Can cause grogginess and daytime sedation.

    •   Substance Withdrawal: Fatigue can be seen in withdrawal from alcohol, opioids, or stimulants. Caffeine withdrawal, though mild, can also contribute.

Dr. Arreaza:

Whenever we evaluate fatigue, we need to keep an eye out for red flags. These should raise suspicion for something more serious:

    •   Unintentional weight loss

    •   Night sweats

    •   Persistent fever

    •   Neurologic symptoms

    •   Lymphadenopathy

    •   Jaundice

    •   Palpitations or chest pain

This patient doesn’t have these—but that doesn’t mean we stop here.

Dr. Arreaza:

Those are a lot of causes, we can evaluate fatigue following 7 steps:

1. Characterize the fatigue.
2. Look for organic illness.
3. Evaluate medications and substances.
4. Perform psychiatric screening.
5. Ask questions about quantity and quality of sleep.
6. Physical examination.
7. Undertake investigations.

So, students, do we send the whole lab panel?

Michael:

Not necessarily. Labs should be guided by history and physical. But here’s a good initial panel:

    •   CBC: To check for anemia or infection

    • TSH: Screen for hypothyroidism

    • CMP: Look at electrolytes, kidney, and liver function

    • Ferritin and iron studies

    • B12, folate

    • ESR/CRP for inflammation (not specific)

    • HbA1c if diabetes is on the radar

Jordan:

And if needed, consider:

    • HIV, EBV, hepatitis panel

    • ANA, RF

    • Cortisol or ACTH stimulation test

Imaging? Now that’s rare—unless there are specific signs. Like chest X-ray for possible cancer or TB, or sleep study if you suspect OSA.

Dr. Arreaza:

Unaddressed fatigue isn’t just inconvenient. It can impact on quality of life, affect job performance, lead to mood disorders, delay diagnosis of serious illness, increase risk of accidents—especially driving. So, don’t ignore your patients with fatigue!

Jordan:

And some people—like women, caregivers, or shift workers—are especially at risk.

Michael:

The cornerstone of treatment is addressing the underlying cause.

Jordan:

If it’s iron-deficiency anemia—treat it. If it’s depression—get mental health involved. But there’s also: 

Lifestyle Support: Better sleep hygiene, light physical activity, mindfulness or CBT for stress, balanced nutrition—especially iron and protein, limit caffeine and alcohol

Dr. Arreaza:

Sometimes medications help—but rarely. 

And for chronic fatigue syndrome, the current best strategies are graded exercise therapy and CBT, along with managing specific symptoms. 

Beta-alanine has potential to modestly improve muscular endurance and reduce fatigue in 

older adults, but more high-quality research is needed.

SSRI: fluoxetine and sertraline. 

Iron supplements: Even without anemia, but low ferritin [Anecdote about low ferritin patient]

Jordan:

This case reminds us to take fatigue seriously. In her case, it may be multifactorial—work stress, caregiving burden, and possibly iron-deficiency anemia. So, how would we wrap up this conversation, Michael?

Michael:

We don’t need to order everything under the sun. A focused history and exam, targeted labs, and being alert to red flags can guide us.

Jordan:

And don’t forget the basics—sleep, stress, and nutrition. These are just as powerful as any prescription.

Dr. Arreaza:

We hope today’s episode on fatigue has given you a clear framework and some practical tips. If you enjoyed this episode, share it and subscribe for more evidence-based medicine!

Jordan:

Take care—and get some rest~

___________________________

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. DynaMed. (2023). Fatigue in adults. EBSCO Information Services. https://www.dynamed.com (Access requires subscription)
2. Jason, L. A., Sunnquist, M., Brown, A., Newton, J. L., Strand, E. B., & Vernon, S. D. (2015). Chronic fatigue syndrome versus systemic exertion intolerance disease. Fatigue: Biomedicine, Health & Behavior, 3(3), 127–141. https://doi.org/10.1080/21641846.2015.1051291
3. Kroenke, K., & Mangelsdorff, A. D. (1989). Common symptoms in ambulatory care: Incidence, evaluation, therapy, and outcome. The American Journal of Medicine, 86(3), 262–266. https://doi.org/10.1016/0002-9343(89)90293-3
4. National Institute for Health and Care Excellence. (2021). Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: Diagnosis and management (NICE Guideline No. NG206). https://www.nice.org.uk/guidance/ng206
5. UpToDate. (n.d.). Approach to the adult patient with fatigue. Wolters Kluwer. https://www.uptodate.com (Access requires subscription)
6. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 197: Continuous Glucose Monitoring

Written by William Zeng, MSIII, and Chris Kim, MSIII. University of Southern California.

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.

Will: Intro
Today we’re exploring Continuous Glucose Monitoring, or CGM. We’ll break down what CGM is, who benefits, how to access it, options available for our patients, the pros and cons, and a few final reflections on where this technology is heading. Chris, So what is CGM?

Chris:
Continuous glucose monitoring refers to the use of a small wearable sensor placed just under the skin to track glucose levels in real time throughout the day and night. These sensors measure glucose in the interstitial fluid and transmit readings to a receiver or smartphone at regular intervals, allowing for 24/7 glucose trend tracking. 

Will:

CGM has been shown to improve glycemic control, increase “time in range,” and reduce hypoglycemia. Let’s review some evidence.

Chris:

A 2023 meta-analysis published in Diabetes Technology & Therapeutics reported a mean Hemoglobin A1c reduction of 0.43% across multiple trials. 

Will:

In people with Type 1 diabetes, the IMPACT and DIAMOND studies showed sustained improvement in Hemoglobin A1c and hypoglycemia reduction over 6–12 months. CGM use in insulin-treated Type 2 diabetes patients also resulted in significant benefits, including reduced variability and fewer severe glucose excursions. 

Chris:

Clinically and economically, CGMs help prevent long-term complications such as cardiovascular disease, nephropathy, and retinopathy. Chris, What patients specifically benefit the most from CGM?

Will: 
CGMs are most commonly indicated for people with Type 1 diabetes and for those with Type 2 diabetes who are using intensive insulin regimens—typically defined as multiple daily injections or insulin pump therapy. 

Chris:

And what are the qualifications in order to be covered by insurance?

Will:

In the United States, Medicare covers CGM as durable medical equipment for qualifying patients, and coverage requires a prescription, documentation of insulin use, and regular follow-up. Most major private insurers—including Blue Cross, Aetna, UnitedHealthcare, Cigna, and Kaiser—follow similar guidelines. Coverage is generally granted for patients with Type 1 diabetes or insulin-requiring Type 2 diabetes who monitor glucose at least four times daily or use an insulin pump. 

Chris:

Some plans require demonstration of hypoglycemia unawareness or frequent glucose variability. For patients not on insulin, OTC CGMs may be an option, but coverage is typically not provided. That said, new FDA decisions are allowing over-the-counter access to CGMs like Abbott’s FreeStyle Libre and Dexcom’s Stelo, expanding availability for lifestyle or preventive purposes.

Will:

[There are a lot of products on the market. Which are the main products and how are they different?]

Chris:

The three main players in the CGM space are Dexcom, Abbott (FreeStyle Libre), and Senseonics (Eversense), each with unique offerings.

Let’s start with Dexcom. Dexcom G7 is a real-time CGM system approved for both Type 1 and Type 2 diabetes. It combines a sensor and transmitter into one compact wearable patch worn on the abdomen or upper arm for up to 10 days. It updates glucose readings every 5 minutes and connects directly to a smartphone or Apple Watch via Bluetooth. Dexcom also integrates with insulin pumps like Tandem’s t:slim and the Omnipod 5. Data can be shared with providers through Dexcom Clarity, which integrates into electronic medical records (EMRs) like Epic. OTC access is not yet available for DEXCOM G7, but a new non-prescription product called Dexcom Stelo is being rolled out in 2025, targeting non-insulin-using Type 2 patients. Dexcom Stelo will also offer 15-day wear, smartphone integration, and factory calibration. The estimated OTC cost for Dexcom Stelo is expected to be around $99 for a 15-day sensor, or about $198/month.

Will:

$200! Abbott FreeStyle Libre comes in several versions. The Libre 2 offers 14-day wear and requires users to scan the sensor with their smartphone or reader to retrieve a glucose value. It has optional real-time alarms for high and low readings and transmits data to LibreView, which can integrate with most EMRs. Libre 3 is a real-time CGM with 1-minute interval updates, Bluetooth transmission, and a slimmer profile. Libre sensors are widely used in primary care and available OTC for non-insulin users. Libre 2 sensors cost approximately $70–$85 for a 14-day sensor, while Libre 3 is slightly higher, around $85–$100 per sensor—totaling about $140–$200/month out of pocket without insurance.

Chris:

Senseonics Eversense E3 is the only implantable CGM on the market. It involves a minor in-office procedure to insert the sensor under the skin of the upper arm, which lasts up to 180 days (and a newer version, Eversense 365, lasts up to one year). A removable transmitter worn on top of the skin sends data every 5 minutes to a mobile app and vibrates for alerts. It requires 1–2 calibrations per day using a traditional fingerstick meter. It integrates with Eversense DMS software for physician monitoring. The total cost for Eversense depends on the insertion procedure and insurance, but cash pay for the full 6-month system is estimated at $2,400–$3,000, or about $400–$500/month including follow-up visits.

Will:

Additional lower-cost CGMs such as the Medtrum A6 TouchCare are available internationally and in select U.S. pilot programs. These devices offer 14-day wear, smartphone syncing, and daily calibration, but are not yet FDA-approved for wide use and lack full EMR integration.

Chris:

In terms of performance and value, Dexcom G7 offers the most advanced real-time feedback and integration, making it ideal for those on insulin pumps or needing tight control. 

Will:

FreeStyle Libre offers the best affordability and convenience, especially for non-insulin users or those who prefer not to deal with constant alerts. Eversense offers a niche but compelling option for people who want to avoid frequent sensor changes. Chris, [Are there any downsides or risks that patients should be aware of before trying out CGM?]

Chris:

CGMs are generally safe and well-tolerated, but they do have limitations. Dexcom G7 has a known failure mode where sensors sometimes fail prematurely, often before the full 10-day duration. Some users have reported “signal loss” errors or random disconnections, especially when switching between phone models or operating systems. There are occasional reports of inaccurate highs or lows due to compression during sleep or dehydration. Though the G7 is factory-calibrated, abrupt changes in hydration or blood flow can affect its readings.

Will:

FreeStyle Libre systems, particularly Libre 2, require the user to scan the sensor to retrieve data unless alerts are enabled. These devices may be affected by vitamin C (ascorbic acid), which can falsely elevate glucose readings, and they do not currently allow for automated insulin delivery integration. Some Libre 2 users have noted adhesive-related rashes or spontaneous detachment. Libre 3, while more advanced, still may lose Bluetooth connection intermittently, particularly if the phone is out of range or the app is not running in the background.

Chris:

Senseonics Eversense carries procedural risks due to its implantable nature. Minor scarring or infection at the insertion site has been reported. The transmitter must be worn during waking hours to provide alerts, and users report anxiety over losing the transmitter since data logging is interrupted without it. Calibration is still required, which adds to daily tasks. Additionally, the sensor does not communicate with insulin pumps or closed-loop systems.

Will:

All CGMs can cause mild skin irritation from adhesive, particularly in users with sensitive skin. Alert fatigue is another consideration, as frequent low- or high-glucose warnings may cause stress or lead users to silence notifications entirely. Finally, relying solely on CGM without periodic fingerstick confirmation in symptomatic scenarios can be a risk, especially during rapid glucose changes.

Chris:

Conclusion
[***] Continuous glucose monitors have reshaped the way we manage diabetes, offering unprecedented insight into glucose trends, diet responses, and insulin timing. While CGMs are not flawless, the technology continues to evolve. 

Will: 

If your patient is on insulin or struggling with glucose variability, consider whether CGM is right for your patient. For those not using insulin, consider newer OTC options like FreeStyle Libre or Dexcom Stelo, which offer accessible entry points without the need for prescriptions. As AI integration, longer sensor life, and non-invasive monitoring enter the market, CGM will only become more useful.

Dr Arreaza: Personal experience with CGMs. 

I do not have diabetes, but I have a strong family history of diabetes (including father, 2 grandmas, and about 15 uncles, aunts, and cousins.)

I wanted to try it so I could teach my patients about CGM. My first experience was with Freestyle Libre 2: 

Pros: Painless placement, easy to use, scanning with phone was easier than fingersticks.

Cons: Required some assembling to be placed, mild discomfort at night, and nighttime alarms.

Dexcom G7:

Pros: No need for scanning, feels more stable in your arm

Cons: High readings (had to calibrate for a more accurate reading)

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. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.