Rio Bravo qWeek

Episode 111: Pregnancy FAQ  

Dr. Urso answers commonly asked questions during pregnancy.  

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

Written by Carmen Urso, MD. Edited by Hector Arreaza, MD.

Pregnancy is one of the most exciting moments of a woman’s life, but at the same time, it could be a little scary because whatever the mother does may affect the baby. This is why it is so important to make sure about general recommendations during pregnancy. The information I present here is evidence-based. 

1. Should I take prenatal vitamins?

The goal of prenatal supplements is to provide the vitamins and minerals needed to promote normal fetal development. Some studies have shown that in high-income countries where the food is vitamin-fortified, and typically people are well-nourished, vitamin supplementation has not proved to improve maternal and neonatal outcomes. However, a Cochrane review of randomized trials in low- and middle-income countries with vitamin and mineral diet deficiency found that supplementation reduces the risk of low birth weight and small for gestational age. Because you don’t always know the nutritional status of a patient, it is advised to use a standard prenatal vitamin. 

What are the most important vitamins in the prenatal period? 

The 2 most important elements are folic acid and iron, which can be found in regular prenatal vitamins. The American College of Obstetrics and Gynecology (ACOG) recommends multivitamins with: 

-Folic acid: 400mcg to 800mcg daily to reduce the risk of neural tube defects. It is recommended to start before pregnancy until the end of the first trimester (12 weeks). Patients with a history of fetal neural tubal defect should take 4000 mcg (4mg) daily. The USPSTF recommends (Grade A, 2017) to supplement with folic acid for all women of childbearing before pregnancy. Supplementation should start at least one month before pregnancy, according to CDC. 

-Iron: 30 mg/day to prevent maternal anemia. The formulation should contain 15-30 mg/dl. Most prenatal contain about 30 mg, which is considered a “low” dose, and 65 mg of elemental iron is equivalent to 325 mg of ferrous sulfate, which is a common supplement given to patients in our clinics. So, patients could take one tablet of 325 mg of ferrous sulfate daily and have enough for their pregnancy, or take it every other day if they are intolerant to iron]

-Vitamin D: Vitamin D deficiency is associated with preterm birth and preeclampsia. 200-600 international units are recommended. ACOG does not recommend screening for vitamin D deficiency before or during pregnancy. The USPSTF concluded there is insufficient evidence to recommend for or against Vitamin D deficiency screening in asymptomatic adults. This is a Grade I recommendation.

-Calcium: Supplements should contain 1000 mg/dL. Most multivitamins have 200-300mg; the rest of the daily calcium should come from dietary sources. Foods rich in calcium include dairy products such as milk, yogurt, cheese, soybeans, seeds, beans, lentils, and dark-green leafy vegetables like kale, spinach, and collard greens. Another source of vitamin D is sun exposure. We do not recommend sun exposure as a source of vitamin D, but there are benefits to sun exposure for other reasons, for example, mood.

2. Should I be eating for 2 while I am pregnant?

It is a misconception. Pregnant women do not have to eat for 2. Caloric intake will depend on the number of fetuses (single or multiple), the trimester, and the pre-pregnancy weight. During the first trimester, no extra daily calories are needed. In the second trimester, a pregnant person will need 340 extra calories/day, and in the third, 450 extra calories/day for a total of 2200 to 2900 kcal/day. 

The weight gain will be based on pre-pregnancy BMI (body mass index). For example, a patient who is overweight (BMI 20-29) should gain 15-25 lbs. in the whole pregnancy, but a patient with obesity (BMI above 30) should gain 11-20 lbs. only. These are the recommendations by the National Academy of Medicine.

Interestingly, if you are underweight before pregnancy, you can gain 30-40 pounds.

National Academy of Medicine Recommendations for Weight Gain in Pregnancy:

Pre-pregnancy BMI Category (kg/m2)                  Recommended Weight Gain (lbs.) 

Underweight (less than 18.5)                                                       28–40 

Normal weight (18.5-24.9)                                                              25-30

Overweight (25.0-29.9)                                                                    15-25

Obese (30 or greater)                                                                         11-20

3. Can I drink alcohol?

There is not a safe level of alcohol during pregnancy. Alcohol can cause life-long birth defects. Even little amounts can cause problems to the baby, such as coordination, behavior, attention, and learning disability. Heavy drinking can cause fetal alcohol syndrome, characterized by developmental delay, short stature, abnormal facial features, small head size, vision impairments, and hearing difficulty. It is recommended to avoid alcohol at all costs during pregnancy. 

4. Can I drink coffee? 

Caffeine increases catecholamine levels in the maternal blood, and it crosses the placenta. Caffeine was thought to increase the risk of spontaneous miscarriage, but recent studies showed that moderate caffeine intake was not related to miscarriage or preterm birth. 

ACOG states that low to moderate intake, less than 200mg (6 oz per day), does not appear to be associated with adverse effects. The amount of caffeine varies in different foods. For example, 8 oz of brewed coffee has approximately 137mg of caffeine. Also, we must remember that caffeine is in other drinks like soda and tea.

Content of caffeine in different drinks: 

-Instant Coffee 76mg 

-Tea, Brewed 48mg; Instant 26-36mg

-Caffeinated soft drink (12 oz) 37mg

-Hot cocoa (12oz) 8-12mg

-Chocolate milk (8oz) 5-8mg

-Dark chocolate (1.45 oz) 30mg 

-Milk chocolate (1.55oz) 11mg 

-Semi-sweet chocolate (1/4 cup) 26-28mg 

-Chocolate syrup (tbsp) 3 mg

-Coffee ice cream or frozen yogurt 2mg 

5. Can I eat fish?

Fish is an excellent source of omega 3, which is associated with improved neurodevelopment in children, decreased risk of preterm birth, and reduced allergy and atopic disease. Fish also contains mercury which can cause fetal neurologic damage. All fish contain mercury, but some have more than others. This is why it is so important to know what fish has more mercury content.

ACOG recommends 2 to 3 servings per week. Pregnant women can have fish high in omega 3 and low in mercury. 

Some examples of fish that are high in omega 3 and low in mercury are anchovies, Atlantic herring, Atlantic mackerel, mussels, oysters, farmed and wild salmon, sardines, snapper, and trout. Seafood that is low in mercury and low in omega 3 includes shrimp, pollock, tilapia, cod, and catfish. Fish high in mercury include king mackerel, marlin, orange roughy, shark, swordfish, tilefish, and tuna bigeye. 

6. Can I eat sushi?

Raw fish can carry bacteria or parasites. Therefore, it is recommended not to have raw fish, but you can have cooked options like tempura sushi. For example, all ingredients are cooked in the California roll except the cucumber and avocado.

7. Can I exercise?

Yes. If you do not have any complications (healthy pregnancy), it is recommended that you have moderate-intensity aerobic exercise for 30 minutes, 5-7 days a week. Moderate exercise means you can carry on a normal conversation during exercise. For example, brisk walking, gardening, and dancing. 

The benefits of exercising during pregnancy go beyond maintaining a good weight. Exercise also decreases muscle discomfort (back pain, pelvic pain), makes the pelvic floor strong, and decreases the risk of urinary incontinence. 

Avoid exercises with a higher risk of injuries, such as skiing, horseback riding, scuba diving, hot yoga o hot Pilates (for the risk of overheating), and skydiving. 

8. Hot tubs and swimming

Hot tubs are not recommended during pregnancy, especially in the first trimester, because higher body temperature has been associated with neural tube defects and miscarriage. Swimming does not appear to have any teratogenic effect because pools are typically cooler than body temperature. 

9. Can I dye my hair? 

There is limited data on the safety of cosmetics. Because it is a topical product, systemic absorption is supposed to be low unless the skin is compromised. However, it is recommended to avoid ammonia-based products. Plant-based hair dyes are probably safe. Also, using these products in a well-ventilated area is recommended to avoid allergies. 

10.  Is it safe to have sex during pregnancy?

Sex is safe if you do not have any complications such as placenta previa, vaginal bleeding, cervical incompetence, preterm labor, risk of preterm labor, or leaking of amniotic fluid. Sex does not increase the risk of complications during pregnancy, but like in the general population, there is a risk of sexually transmitted diseases during pregnancy. During pregnancy, the vaginal circulation is increased, and the cervix is more sensitive, so may have scant vaginal bleeding during intercourse but if the bleeding is heavy, patients should be evaluated.

Conclusion: Now we conclude our episode number 111 “Pregnancy FAQ.” Dr. Urso explained that pregnancy is one of the most exciting moments in a woman’s life. Special care is needed to make sure both mother and baby are healthy and safe during this special time. Appropriate vitamin supplementation, a nutritious diet, adequate exercise, and avoiding alcohol are key elements of prenatal care. We were reminded that sex is generally safe in uncomplicated pregnancies. This week we thank Hector Arreaza, Carmen Urso, Gagan Kooner, and Arianna Lundquist. Audio by Adrianne Silva.

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

_____________________

References:

1. Fox, N.S. “Do and Don’ts in pregnancy, truths and myths”. Obstetrics & Gynecology, vol 131, issue 4, 2018, pp.713–21. DOI:10.1097/AOG.0000000000002517. https://journals.lww.com/greenjournal/Fulltext/2018/04000/Dos_and_Don_ts_in_Pregnancy__Truths_and_Myths.16.aspx. Accessed 7 July. 2022.
2. Advice about eating fish. For those who might become or are pregnant or breastfeeding and children ages 1- 11 years. https://www.fda.gov/food/consumers/advice-about-eating-fish. Accessed 1 August 2022.
3. Garner C.D. Nutrition in pregnancy: Dietary requirements and supplements. Up to Date, last updated April 14, 2022. https://www.uptodate.com/contents/nutrition-in-pregnancy-dietary-requirements-and-supplements. Accessed 4 August 2022.
4. Lockwood, C.J. Prenatal care: Patient education, health promotion, and safety of commonly used drugs. Up to Date, last updated August 16, 2022.https://www.uptodate.com/contents/prenatal-care-patient-education-health-promotion-and-safety-of-commonly-used-drugs. Accessed 1 August 2022.
5. Goetzl, L.M. Folic acid supplementation in pregnancy. Up to Date, Last Updated Jun 16, 2022. https://www.uptodate.com/contents/folic-acid-supplementation-in-pregnancy. Accessed 2 August 2022.
6. Haider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev. 2017 Apr 13;4(4):CD004905. doi: 10.1002/14651858.CD004905.pub5. Update in: Cochrane Database Syst Rev. 2019 Mar 14;3:CD004905. PMID: 28407219; PMCID: PMC6478115. https://pubmed.ncbi.nlm.nih.gov/28407219/. Accessed 2 August 2022.
7. “Moderate Caffeine Consumption During Pregnancy”, The American College of Obstetrics and Gynecologists (ACOG). Committee Opinion, Number 462, August 2010. (Reaffirmed 2020). https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2010/08/moderate-caffeine-consumption-during-pregnancy. Accessed 1 August 2022.
8. Royalty-free music used for this episode: Good Vibes Alt Mix by Videvo, downloaded on May 06, 2022 from https://www.videvo.net/royalty-free-music-track/good-vibes-alt-mix/1017292/

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

Episode 110: Pulse Ox in Dark-skinned People.  

Learn about the most recent findings in pulse oximeters in dark-skinned people. Bahar and Arianna explain the new recommendations by FDA regarding this topic.  

Written by Bahar Hamidi, MS4; and Arianna Crediford, MS4. American University of the Caribbean (AUC). Comments by Hector Arreaza, MD.    

________________

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

_________________

Bahar: When I first saw this news breakout on CNN I was stunned! A cohort study just published (7/11/22) in JAMA called “Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit” revealed that Asian, Black, and Hispanic patients received less supplemental oxygen than White patients, because of the differences in pulse oximeter performance, which may contribute to known race and ethnicity–based disparities in care. I cannot believe this discovery has not been given the attention it deserves earlier. I believe maybe COVID had a lot to do with it; as checking the pulse ox deciphered the patients’ treatment plan. Let’s think about it for a moment, how important is the pulse ox accuracy?

Arianna: Well, we know that insufficient administration of supplemental oxygen can make changes in the initiation and management of noninvasive verse invasive mechanical ventilation. The study mentions some other important points like pulse oximeter performance disparities playing a role in decision-making regarding fluid management, specialty service consultation, and even intensive care unit (ICU) admission.  

Bahar: It states, “artificially high SpO2 readings in the emergency department could also affect the perceived need for cardiology service admission for heart failure management, possibly explaining the finding that Black and Hispanic patients were less likely than White patients to be admitted to a cardiology service.”

Arianna: So how you may ask the study really put this to the test? The large cohort study had 3,069 patients in the intensive care unit, so what they did was they took the average hemoglobin oxygen saturation for each patient and tracked how much supplemental oxygen was given to the patients and lo and behold, the data revealed that Asian, Black, and Hispanic patients had a higher adjusted time-weighted average pulse oximetry reading and were administered significantly less supplemental oxygen compared with White patients even with adjusting for potential confounders.

Bahar: And what is the solution you may ask? Well, the FDA issued a new draft guidance that recommends companies making medical products submit a “race and ethnicity diversity plan” to the agency early in their development of products, and that a plan should include enrolling diverse groups of people into their clinical trials as of April 2022. As a reminder, it's been a year since CDC declared racism a public health threat.  

Arianna: Rutendo Jakachira is a Ph.D. student in Brown University's Department of Physics. She is studying racial disparities in pulse oximetry. She stated that COVID-19 likely helped uncover the suspected pulse oximeter limitations in dark-skinned people. Kimani Toussaint is a professor and senior associate dean in the School of Engineering at Brown University. Jakachira, Toussaint, and their colleagues from Engineering at Brown University are developing non-invasive methods to make pulse oximeters more accurate in blood oxygen readings for people with dark skin tones.

Bahar: Toussaint stated that they are “trying to mitigate the skin tone issues by doing something interesting with the light, but it’s a significant challenge and this really highlights the need to have diversity and inclusion.”  

Pulse oximeters work by sending beams of light through the fingertips to measure blood oxygen levels, they are actually measuring how much oxygen has been absorbed by hemoglobin. Melanin is the brown pigment that gives color to our skin, hair, and eyes. It turns out that both hemoglobin and melanin absorb light at similar wavelengths and it can be challenging to separate their contributions to the detected level of oxygen.  

Arianna: Toussaint explains that melanin will overlap with the absorption properties of the hemoglobin in your blood, which can lead to inaccurate pulse oximeter readings because people have different amounts of melanin.

Bahar: Jakachira and Toussaint are trying to cancel out the effect of melanin on how pulse oximeters measure blood oxygen levels. The result of this work would be a contribution that can be applied to other similar-based technologies that measure levels of substances through the skin, but they could not share additional details of their proceedings as the research team is currently completing a patent application. Now what is also shocking is that there have actually been prior studies that have shown differences of several percentage points in SpO2 for a given hemoglobin oxygen saturation between Black and White patients, but in the past, the clinical significance of these findings was discounted and downplayed.  

Arianna: I think this study and discovery urges further studies in different regions and not just at one institution or geographic location. The article encourages further exploration of specific factors within a racial and ethnic group that could put some patients at particularly high risk of oxygenation disparities, including skin tone, degree of desaturation, exposure to specific oxygen delivery devices, comorbidities, and other sociodemographic factors.  

Bahar: Some other studies they hope will be performed are:

-Differences in oxygen supplementation in patients receiving invasive or noninvasive positive pressure ventilation and a potential association of vasopressors and inotropes AND Clinical decisions other than oxygen delivery that may be affected by pulse oximeter performance discrepancies.

Arianna: So we can definitely say that some groundwork has been done but further research is needed to confirm these findings and explore other clinical factors associated with treatment disparities.

Bahar: It is great to stay in the loop and know what health care providers should look out for, I hope this podcast will raise awareness of the matter and hopefully we come up with a more accurate Pulse Ox prototype that will be fit for all ethnicities and skin tones.

____________________________

Conclusion: Now we conclude episode number 110 “Pulse Ox in Dark-skinned People.” Today we learned that pulse oximeters are being adjusted to become more accurate in different shades of skin. We are working together to make medicine a better science for all. “Not everything that is faced can be changed, but nothing can be changed until it is faced,” said James Baldwin. This week we thank Hector Arreaza, Bahar Hamidi, Arianna Crediford, Valeri Civelli, and Ariana Lundquist. Audio by Adrianne Silva.

Even without trying, every night, you go to bed being a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!  

_____________________

References:

1. Gottlieb ER, Ziegler J, Morley K, Rush B, Celi LA. Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit. JAMA Intern Med. Published online July 11, 2022. doi:10.1001/jamainternmed.2022.2587. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2794196
2. Howard, Jacqueline, Scientists are searching for solutions after studies show pulse oximeters don't work as well for people of color, CNN Health, Published on July 11, 2022. https://www.cnn.com/2022/07/11/health/pulse-oximeters-dark-skin-study/index.html
3. Royalty-free music used for this episode: Good Vibes Alt Mix by Videvo, downloaded on May 06, 2022 from https://www.videvo.net/royalty-free-music-track/good-vibes-alt-mix/1017292/

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!

Manpreet and Jon-Ade explain how to diagnose renal cell carcinoma. Introduction about age and kidney transplant by Dr. Arreaza and Dr. Yomi. 

[Due to technical difficulties this episode was not posted as scheduled, so it had to be reposted on 9/9/2022] 

Introduction: Too old for a new kidney?
By Hector Arreaza, MD. Discussed with  Timiiye Yomi, MD.

Today we will be talking about the kidneys, those precious bean-shaped organs that detoxify your blood 24/7. Amazingly, we can live normal lives with one kidney, but when the kidney function is not good enough to meet the body’s demands, patients need to start kidney replacement therapy. Modern medicine has made a lot of advances with dialysis, but the perfection of a kidney has not been outperformed by any machine yet. That’s why kidney transplant is the hope for many of our patients with end-stage kidney disease.

The need for a kidney transplant is growing, likely due to increasing chronic diseases such as diabetes and hypertension, and also because of an increase in elderly population. About 22% of patients on the kidney transplant waiting list are over age 65. 

A cut-off age to receive kidney transplant has not been established across the globe. Different countries use different criteria for the maximum age for transplant. The American Society of Transplantation’s guidelines states “There should be no absolute upper age limit for excluding patients whose overall health and life situation suggest that transplantation will be beneficial.” So, if your patient is older than 65 and needs a kidney, they may qualify for a transplant, and age should not be an absolute contraindication to receive it. Actually, older patients may have lower risk of rejection due to a theoretically weaker immune system. A live donor is likely to be a better option for elderly patients. 

A condition that would make your elderly patient a poor candidate for kidney transplant would be frailty. Common contraindications to kidney transplant include active infections or malignancy, uncontrolled mental illness, ongoing addiction to substances, reversible kidney failure, and documented active and ongoing treatment nonadherence.

So, remember to take these factors into consideration when deciding if you need to refer your elderly patients for a kidney transplant, there is no such thing as being too old for a new kidney if your patient meets all the criteria for a transplant.

This is Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice.

By Manpreet Singh, MS3, Ross University School of Medicine, and Jon-Ade Holter, MS3 Ross University School of Medicine. Moderated by Hector Arreaza, MD.

Definition:

Renal cell carcinoma is a primary neoplasm arising form the renal cortex. 80-85 percent of renal tumors are renal cell carcinomas followed closely by transitional cell renal cancer and Wilms tumor. 

Epidemiology: 

In 2022, 79,000 new cases of kidney cancer were diagnosed with almost 14,000 mortalities. 

There is a 2:1 male to female ratio and the average age is 64 and normally 65-74. African Americans and American Indians have a higher prevalence rate compared to other racial groups. The lifetime risk for developing kidney cancer in men is about 1 in 46 (2.02%) and 1 in 80 (1.03%) in women. 

Risk Factors associated with RCC: 

Anything that causes assault to the kidneys and affects its function would cause increased demand, injury, and inflammation. This assault can lead to cell derangement and lead to cancer. The risk factors that have been associated with RCC are smoking, obesity, HTN, family history of kidney cancer, Trichloroethylene (a metal degreaser used in large manufacturing factories), acetaminophen, and patients with advanced kidney disease needing dialysis.

Patients with syndromes that cause multiple types of tumors: 

• VHL (von Hippel-Lindau) deficiency, a tumor suppressor, gives rise to clear cell renal cell carcinoma. Familial inheritance of VHL deficiency is mostly found in patients that have RCC at a very young age, before 40 y/o. Other tumors can be found in the eye, brain, spinal cord, pancreas, and pheochromocytomas.
• Hereditary leiomyoma-renal cell carcinoma due to FH gene mutations causing women who have leiomyomas to have a higher risk of developing papillary RCC.
• Birt-Hogg-Dube (BHD) syndrome mutation in FLCN gene who develop various skin and renal tumors.
• Cowden syndrome is a mutation in the PTEN gene giving rise to cancers associated with breast, thyroid , and kidney cancers.
• Tuberous sclerosis causes benign tumors of the skin, brain, lungs, eyes, kidneys, and heart. Although kidney tumors are most often benign, occasionally they can be clear cell RCC.

Screening For RCC:

Screening is unnecessary because of the low prevalence of this cancer in the general population, though certain groups require annual repeat imaging via US, CT, or MRI. 

• Inherited conditions that are associated with RCC such as VHL syndrome or Tuberous Sclerosis
• ESRD patients who have been on dialysis for 3-5 years
• Family history of RCC
• Prior kidney irradiation

Clinical Picture: 

Most patients with RCC are asymptomatic until cancer grows large enough to cause disruption of local organs, such as the kidney, bladder, or renal vein, and dysregulates other organs via metastasis. Therefore, it’s important to look at other signs and symptoms caused by RCC. 

The patient most likely will be an older male who presents with the classic triad of: 

• Flank pain: caused by rapid expansion and stretching of the renal capsule.
• Hematuria: occurs from the invasion of the neoplasm into the collecting duct.
• Palpable abdominal mass: mass tends to be homogenous and mobile with respirations.

Though this presents only in 9% of patients during the presentation, having physical symptoms is a sign of advanced disease and 25% of patients with these signs tend to have distant metastasis. 

• Anemia: normally associated with anemia of chronic disease. It precedes the disease by at least 8 months to 1 year.

• Males can develop varicoceles because of decreased emptying due to neoplasm obstruction. Patients normally develop varicoceles on the left due to the spermatic vein emptying in the higher resistance left renal vein, which causes backup of the blood in the pemphigus plexus. Though a right-sided varicocele should raise a higher suspicion of obstruction due to the spermatic vein draining directly into the IVC which is lower in resistance. A right-sided varicocele is seen in approximately 11 percent of patients.

The paraneoplastic syndrome can also arise from RCC

• Epo: Erythrocytosis with symptoms of weakness, fatigue, headache, and joint pain.
• PTHrP: PTH-related peptide acts like PTH which gives rise to hypercalcemia with the prevalent symptoms of arthritis, osteolytic lesions, confusions, tetany, ventricular tachycardia, shortened QTc, and nausea and vomiting.
• Renin: overproduction from the juxtaglomerular cells can cause disarrangement of the RAAS system causing hypertension.
• Others also like ACTH and beta-HCG.

Other disorders present include hepatic dysfunction, cachexia, secondary amyloidosis, and thrombocytosis.

Workup 

If a patient comes in with painless hematuria, then the first test should be abdominal CT or abdominal ultrasound. A CT is more sensitive than the US but it can quickly indicate if the abdominal mass felt can be a cyst or a solid tumor. 

US of kidneys should show if it’s a simple cyst:

-The cyst is round and sharply demarcated with smooth walls

- It’s anechoic – appears solid black

-There is a strong posterior wall echo

-Use the Bosniak classification to classify mass 

Bosniak I: benign simple cyst with thin wall less than equal to 2mm, no septa or calcifications. No future workup is needed.

Bosniak II: benign cyst, <1mm septa with thin calcification, high attenuation due to contents other than simple water in cyst. No further workup needed.

Bosniak IIF: Minimally complex cyst with multiple hairline thin septa with thickened walls, calcification present, and high attenuation lesions >3 cm diameter, requires f/u with US/CT/MRI at 6 months, 12 months, and annually for the next 5 years. Chance of malignancy: 5%. 

Bosniak III: indeterminate cystic mass with thick, irregular or smooth walls. This requires nephrectomy or radiofrequency ablation. Chance of malignancy: 55% 

Bosniak IV: Clearly a malignancy its grade III with enhancing soft tissue components that its independent from the wall or septum. Requires total or partial nephrectomy. Chance of malignancy 100%. 

CT of the kidneys for a neoplasm should show:

-Thickened irregular walls or septa 

-Enhancement after contrast injection are suggestive of malignancy

-CT can also help detect invasion in local tissue areas such as renal vein and perinephric organs 

MRI is used if the patient cannot use contrast or kidney function is poor. MRI can also evaluate the growth of the cancer.

Other imaging studies:Other imaging studies that may be useful for assessing for distant metastases include bone scan, CT of the chest, magnetic resonance imaging (MRI), and positron emission tomography (PET)/CT.

Treatment and staging 

Nephrectomy, partial or total, will be used as the initial tissue collection for pathology. If the patient is not a surgical candidate, you can also obtain a percutaneous biopsy. The nephrectomy is preferred because first, it serves as a definitive treatment option, but also it allows for definitive staging of the cancer with tumor and nodal staging. Regardless of the size, any solid mass may indicate malignancy and point towards RCC, requiring resection. 

TNM staging

Stage I: Tumor is 7cm across or smaller and only in the kidney with no lymph nodes or distant mets. T1N0M0

Stage IIa: Tumor size is larger than 7cm but still in the kidney but no invasion of lymph node or mets. T2N0M0

Stage IIb: Tumor is growing into the renal vein or IVC, but not into neighboring organs such as adrenals or Gerota’s fascia and still lacks lymph node invasion and mets. T3N0M0. 

Stage III: Tumor can be any size but has not invaded outside structures such as adrenals, though nearby lymph node invasion is present but not distant. There is no distant mets. T3N1M0.

Stage IV:  The main tumor is beyond the Gerota’s fascia and may grow into the adrenal gland . It may or may not spread to the lymph nodes or may not have distant mets. Stage IV also consists of any cancer that has any number of distant mets. T4

Adjuvant therapy can be done with immune therapy.

Conclusion: Now we conclude our episode number 105 “Renal cell carcinoma.” This type of cancer may be asymptomatic until it is large enough to cause symptoms. Keep it on your list of differentials on patients with hematuria, flank pain, weight loss, and abnormal imaging. Keep in mind the features of simple kidney cysts vs complex cysts when assessing kidney ultrasounds. Your patient will be grateful for an early diagnosis of RCC and a prompt treatment. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Timiiye Yomi, Manpreet Singh, Jon-Ade Holter. 

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! 

Bibliography:

1. Is There a Cut Off Age for Kidney Transplant?, Mayo Clinic Connect, Jul 18, 2017, https://connect.mayoclinic.org/blog/transplant/newsfeed-post/is-there-a-cut-off-age-for-kidney-transplant/

1. Atkins, Michael. “Clinical Manifestations, Evaluation, and Staging of Renal Cell Carcinoma.” UpToDate, January 21. https://www.uptodate.com/contents/clinical-manifestations-evaluation-and-staging-of-renal-cell-carcinoma

1. American Cancer Society. “Key Statistics About Kidney Cancer”. Cancer.Org, 2022, https://www.cancer.org/cancer/kidney-cancer/about/key-statistics.html.

1. Escudier B, Porta C, Schmidinger M, Rioux-Leclercq N, Bex A, Khoo V, Grünwald V, Gillessen S, Horwich A; ESMO Guidelines Committee. Electronic address: [email protected]. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Ann Oncol. 2019 May 1;30(5):706-720. doi: 10.1093/annonc/mdz056. PMID: 30788497. https://pubmed.ncbi.nlm.nih.gov/30788497/.

1. Gaillard, F., Bell, D. Bosniak classification system of renal cystic masses. Reference article, Radiopaedia.org. (accessed on 20 May 2022) https://doi.org/10.53347/rID-1006.

1. Kopel J, Sharma P, Warriach I, Swarup S. Polycythemia with Renal Cell Carcinoma and Normal Erythropoietin Level. Case Rep Urol. 2019 Dec 11;2019:3792514. doi: 10.1155/2019/3792514. PMID: 31934488; PMCID: PMC6942735. https://pubmed.ncbi.nlm.nih.gov/31934488/.

1. Leslie SW, Sajjad H, Siref LE. Varicocele. [Updated 2022 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448113/.

1. Maguire, Claire. “Understanding Endoscopic Ultrasound and Fine Needle Aspiration.” Educational Dimension, Educational Dimensions, 1 Jan. 2007, educationaldimensions.com/eLearn/aspirationandbiopsy/eusterm.php.

1. Maller, V., Hagir, M. Renal cell carcinoma (TNM staging). Reference article, Radiopaedia.org. (accessed on 20 May 2022) https://doi.org/10.53347/rID-4699.

1. Palapattu GS, Kristo B, Rajfer J. Paraneoplastic syndromes in urologic malignancy: the many faces of renal cell carcinoma. Rev Urol. 2002 Fall;4(4):163-70. PMID: 16985675; PMCID: PMC1475999. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1475999/.

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

Episode 109: Shingles vaccine before 50

Prabhjot and Dr. Arreaza discuss the indications and contraindications of the zoster recombinant vaccine (Shingrix®). Shingrix is now FDA-approved to be used in people younger than 50 years old. Magic mushroom as a therapy for alcohol use disorder.

_________________

Introduction: “Magic mushroom” as a potential treatment for alcohol addiction

By Hector Arreaza, MD.  

Addiction is one of the biggest challenges in medicine. Patients with addictions are at risk of adverse events or even death from overdose but also are at risk of withdrawal when trying to quit. As medical providers, our goal is to assist our patients to stop using substances that may be toxic and cause detrimental effects on their health in the short and long term. It is not easy to help patients overcome the discomfort, cravings, and even life-threatening symptoms that result from withdrawal.  

Out of the many addictions, alcohol use disorder is one of the most destructive addictions, and the harms from it go beyond the personal effects, as it affects families, communities, and the whole nation. It is a serious public health issue. It is estimated that 15 million people (12 and older) in the US have alcohol use disorder, and about 140,000 people die every year from alcohol-related causes.  

Many patients would like to stop drinking, but the withdrawal symptoms may be more than just discomfort and may become unbearable and even fatal. Today I want to share the news published on August 24, 2022, on JAMA and many news outlets regarding the potential use of Psylocibin as an adjunct therapy to quit drinking alcohol.  

This was a double-blind randomized clinical trial that compared Psilocybin with diphenhydramine. Psilocybin is also known as “magic mushroom”. Participants were offered 12 weeks of psychotherapy and were randomly assigned to receive psilocybin vs. diphenhydramine during 2-day-long medication sessions at weeks 4 and 8. There were 93 participants. The percentage of heavy drinking days during a 32-week period after the first dose of medication was 9.7% for the psilocybin group and 23.6% for the diphenhydramine group. So, patients in the Psylocibin group had decreased heavy drinking, and the mean alcohol consumption was also lower. Blinding was an issue during the study because many participants could guess which medication they were receiving. Some participants described “flying over landscapes, seeing [their] late father and merging telepathically with historical figures.”  

The bottom line of the study is that administration of Psilocybin in combination with psychotherapy produced a significant reduction in the percentage of heavy drinking days over and above those produced by active placebo and psychotherapy. These are exciting news for those who are trying to quit alcohol, and it provides a foundation for additional research on psilocybin-assisted treatment for AUD.

_____________________

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

________________________________________________________________________________________________________________

Shingrix before 50. 

By Prabhjot Kaur, MS4, Ross University School of Medicine.    

1. What is Shingrix?

It’s a recombinant zoster vaccine to protect against Herpes Zoster (Shingles) in adults over 50 years old.  

2. What is Herpes Zoster?

Prabhjot: It’s a viral infection that is caused by the Varicella-Zoster virus, which also causes chickenpox. Chickenpox, also called varicella, can happen in children and adults. After a person is infected with chickenpox, the virus remains dormant in the dorsal root ganglia, which are the clusters of neurons along the spinal column. As the person grows older, or his or her immunity decreases due to conditions such as an infection, malignancy, or pregnancy, the dormant virus becomes reactivated.  

Prabhjot: When the virus reactivates in adults, it presents with a painful, blistering, itchy rash over the specific dermatomes. The rash mostly occurs on the torso, face, or upper extremities, and it is usually only on one side of the body.  

Arreaza: A common belief in the Latino culture (since our audience sees a lot of patients of Latino descent) is that if the rash crosses the midline of your body and it makes a circle around your chest, you will die. If you, as a doctor, get that question from a patient, the answer is: herpes zoster normally affects the root ganglia on one side of the body. If your patient has bilateral herpes zoster, you must rule out immunodeficiency.  

The rash may be preceded or followed by pain, burning, numbing, or tingling of the skin. Some patients might even have fevers, chills, fatigue, and photosensitivity. One of the most common complications of shingles is postherpetic neuralgia, which is a long-lasting pain after the blisters and rash have resolved.  

3. What is the role of the vaccine?

Prabhjot: Shingrix® can reduce the risk of shingles and its complications, such as postherpetic neuralgia. Shingrix is recommended for everyone over 50, even if they have already had shingles, received Zostavax® (discontinued in 2019), or received the varicella vaccine.  

Arreaza: Good point. Let´s talk a little bit about varicella in adults. Patients who have received the varicella vaccine as a child can still receive Shingrix. Let’s remember the chickenpox vaccine (varicella vaccine) became available in the United States in 1995. Normally, a serology test for varicella is not required for people to receive the varicella vaccine as adults, except in certain patients who are planning immunosuppression in the near future. In such cases, if varicella immunity is not reactive, they should be vaccinated against varicella (live attenuated virus) if the immunosuppression can be delayed.  

Prabhjot: What if the patient is already immunosuppressed?

Arreaza: If the patient is already immunosuppressed, the decision is not simple. The varicella vaccine is contraindicated, but some clinicians may recommend Shingrix for the potential protection against primary varicella. Post-exposure prophylaxis with antiviral therapy or immunoglobulin in case of exposure is possible.    

4. How is Shingrix given?

Prabhjot: Shingrix is given in 2 doses, and each dose is given 2-6 months apart. Its immunity stays strong for at least 7 years. Like most vaccines, the most common side effects of the Shingrix vaccine are redness, tenderness, swelling, and discomfort at the vaccine site. Shingrix is deemed to be safe for most people over 50 but not given to pregnant women, people with active shingles, and or with a severe allergy to the vaccine.  

Arreaza: Shingrix is generally avoided in patients with a known history of Guillain-Barré syndrome (GBS) due to a probable association between Shingrix and GBS. This association was not seen with Zostavax, so in case of history of GBS, Zostavax is an option.

5. Effectiveness

Prabhjot: As for its effectiveness, according to the CDC, Shingrix is 97% effective in preventing shingles in adults 50 to 69 and 91% in adults older than 70. If one is immunosuppressed and has a weakened immune system, the vaccine was effective, ranging between 69%-91% in preventing shingles.

6. New update:

Prabhjot: New updates have been made to expand the vaccination of the population under 50 as well. On July 23, 2021, the FDA approved the vaccination for adults over the age of 18 who are at an increased risk or will be in the future due to immunodeficiency or immunosuppression. Such immunodeficiency could be secondary to a disease, malignancy, or therapy such as chemotherapy. Just like the prior recommendation, it is recommended for these individuals to receive two doses of Shingrix for the prevention of shingles and its complications. However, the interval between the two doses can be shortened from the recommended 2-6 months to 1-2 months if the person will be going through intense immunosuppression in the upcoming months. This shortened interval will prevent vaccination during an intense immunosuppressed state. The second dose must not be given before one month.  

7. When to get vaccinated?

Prabhjot: Ideally, one should get vaccinated before starting immunosuppressing therapy; if this cannot be possible, then one should aim for vaccination when their immune response is likely to be the strongest. For example, if it’s an immunity-changing disease such as malignancy, the vaccine would be ideal in the beginning stages, and if a person will receive chemotherapy, it would be ideal to vaccinate before starting chemo.  

8. Few recommendations from CDC:

For Hematopoietic cell transplant:  

Administer Shingrix at least 3-12 months after transplantation. It is important to consider the vaccine is recommended 2 months before the prophylactic antiviral therapy is discontinued. Since the prophylactic antiviral therapy is also protecting against shingles, the vaccine is preferred to be injected while the antiviral therapy is going on.  

Arreaza: For allogeneic HCT (when donor is another person), Shingrix should be given a little bit later, 6-12 months after transplant, prior to discontinuation of antiviral therapy. Acyclovir, famciclovir, and valacyclovir will not neutralize the effectiveness of Shingrix because the vaccine is not a live virus vaccine.

For cancers:

It is ideal to administer Shingrix before chemo, immunosuppressive medications, radiation, or splenectomy. If that is not possible for some reason, administer the vaccine when the patient is stable and not acutely suppressed. For patients on long-term immunosuppressive therapies, administer the vaccine when the immune response is most likely the strongest or right before starting the next cycle of therapy.  

For patients with HIV:

Prabhjot: Shingrix is recommended for patients with HIV due to the high risk of shingles. Immune response to the vaccine may be improved while the patient is on antiretroviral treatment.  

Bottom line: Shingrix is now recommended not only for those over 50 years old but also for those who are 18 and older and are immunosuppressed or will be on immunosuppressive therapy. This new change will benefit those who are receiving treatment and those who are awaiting treatment. Keep in mind to use the vaccine to prevent shingles and its complications.  

____________________

Conclusion: Now we conclude our episode number 109, “Shingles vaccine before 50.” We are used to giving Shingrix to patients older than 50, but we were reminded today that it is also indicated in patients older than 18 who are or will be immunosuppressed. Shingrix should be given in 2 doses 2-6 months apart. Your patients may not notice it, but by giving this vaccine, you are PREVENTING a painful rash that can have long-term effects. This week we thank Jennifer Thoene, Hector Arreaza, Prabhjot Kaur, and Arianna Lundquist. Audio edition by Adrianne Silva.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

________________________________________________________________________________________________________________

References:

• Bogenschutz MP, Ross S, Bhatt S, et al. Percentage of Heavy Drinking Days Following Psilocybin-Assisted Psychotherapy vs Placebo in the Treatment of Adult Patients With Alcohol Use Disorder: A Randomized Clinical Trial. JAMA Psychiatry. Published online August 24, 2022. doi:10.1001/jamapsychiatry.2022.2096. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2795625.
• Osborne, Margaret. Psychedelic ‘Magic Mushroom’ Ingredient Could Help Treat Alcohol Addiction, Smart News, Smithsonian Magazine, https://www.smithsonianmag.com/smart-news/psychedelic-magic-mushroom-ingredient-could-help-treat-alcohol-addiction-180980658/
• “Shingles Vaccination.” Centers for Disease Control and Prevention, page last reviewed: 24 May 2022, https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html.
• “Clinical Considerations for Use of Recombinant Zoster Vaccine (RZV, Shingrix) in Immunocompromised Adults Aged ≥19 Years.” CDC.gov, 20 Jan. 2022.  https://www.cdc.gov/shingles/vaccination/immunocompromised-adults.html.
• “Shingles.” Mayo Clinic, 17 Sept. 2021, https://www.mayoclinic.org/diseases-conditions/shingles/symptoms-causes/syc-20353054.
• Royalty-free music used for this episode: Salsa Trap by Caslo, downloaded on July, 20, 2022 from https://freemusicarchive.org/music/caslo/caslo-vol-1/salsa-trap/. Space Orbit by Scott Holmes, downloaded on July 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/.

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!

Medications that cause weight gain are also called weight positive medications. Sapna, Danish, and Dr. Arreaza mention some of those medications in this episode. 

Introduction: Some meds cause weight gain
By Hector Arreaza, MD.

You will see patients who keep gaining weight regardless of their sincere efforts to eat better and exercise. Some people experience serious difficulties to lose weight. If you want to know how frustrating it can be, imagine your doctor telling you to add one more inch to your height when you are 35 years old. For some people, losing weight is just as hard. One important step you can take to help your patients lose weight is performing a detailed medication reconciliation. Review the medication list, and you may find some meds that are proven to cause weight gain. Today we will discuss some of those medications, but it takes practice to learn all of them. I hope this episode is helpful for you. 

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

___________________________

Weight Gain Meds. 
By Sapna Patel, MS4, and Danish Khalid, MS4. Ross University School of Medicine. Comments by Hector Arreaza, MD.

S: Medications associated with weight gain: See Table 1.1 for medications associated with weight gain and alternatives. 

Antipsychotic agents:

A: Ziprasidone is an antipsychotic medicine that causes the least amount of weight gain.

Antidepressants:

1. There are many antidepressants which are associated with weight gain, including the tricyclics, monoamine oxidase inhibitors (MAOIs), and some of the selective serotonin reuptake inhibitors (SSRIs). 
2. Tricyclic antidepressants, in particular amitriptyline, clomipramine, doxepin, and imipramine, are associated with significant weight gain.
3. Selective serotonin reuptake inhibitors, paroxetine exhibited the greatest weight gain in its class. Whereas fluoxetine exhibited little to no weight gain and remains weight neutral in the class. 
4. Amongst the monoamine oxidase inhibitors, phenelzine had the greatest weight gain. 

Antiepileptics/Antiseizure: 

1. Amongst the antiepileptic drugs used to treat seizures, neuropathic pain, or other psychiatric conditions,  valproate, carbamazepine, and gabapentin are associated with weight gain. Gabapentin is virtually used by all our diabetic patients. 

Antihypertensive agents: Beta Blockers

1. Beta receptors, specifically beta-2 receptors, stimulate the release of insulin. Thus, patients on beta blockers may experience weight gain as a side effect. There are two beta blockers that cause the least amount of weight gain: Carvedilol (Coreg) and nebivolol (Bystolic).

Hypoglycemic medications: 

1. Although intended to regulate blood sugar levels, several anti-diabetic medications are associated with weight gain, specifically sulfonylureas, Actos, and insulin. 
2. As mentioned earlier, metformin as well as GLP-1 agonists are associated with weight loss. Metformin can be considered weight neutral. 

Steroids: 

1. Steroid hormones such as corticosteroids or progestational steroids are associated with weight gain. Steroids may increase levels of cortisol, one of the end pathways in steroidogenesis. Cortisol, also known as the stress hormone, functions by increasing insulin resistance, and decreasing glucose utilization, thus causing weight gain. 

Antihistamine Medications: 

1. Diphenhydramine (Benadryl): commonly used for allergies…or how my mom used it, puts you to sleep right before a flight. However, a side effect of using this medication includes weight gain.
2. Cyproheptadine: an antihistamine, used for antidote to serotonin syndrome and migraines, has an appetite stimulant effect causing weight gain. It can be used off-label as an appetite stimulant in children who do not gain weight.

Fun Fact: Although it is a common belief that combined oral contraceptives cause weight gain, data suggest that significant weight gain is not a common side effect of combined oral contraceptives.

A good practice: Medication reconciliation: Weight positive, weight neutral, or weight negative. 

Weight positive: Deprescribe or change for another medication if possible. Weight neutral and weight negative: Keep them. Don’t be afraid to prescribe anti-obesity meds. We should learn about them, become familiar with side effects, contraindications, dosing, and more, and prescribe them appropriately as part of a weight loss program. Also, don’t forget that these medications are used in conjunction with a proper diet. 

Category

Drug Class

Weight Gain

Alternatives

Psychiatric agents

Bupropion, nefazodone, fluoxetine (short term), sertraline (<1 year)

Neurologic agents

Endocrinologic agents

Cardiologic agents

General

Table 1.1: Medications associated with weight gain and alternatives.4

____________________________

Conclusion: Now we conclude our episode number 107 “Weight Gain Meds.” Sapna and Danish did an excellent job in this episode. Performing a good medication reconciliation is a key element in a weight loss visit. Some patients cannot stop taking medications that cause weight gain, also called weight-positive medications. I recommend you be cautious when discontinuing any medication. If you are not the prescriber, consult with the prescriber to discuss the possibility to lower the dose, finding an alternative medication, or determining if the medication can be discontinued. If none of those options are feasible, you may consider starting metformin if not contraindicated, I hope you learned something new today. 

This week we thank Hector Arreaza, Sapna Patel, Danish Khalid, Valerie Civelli, and Arianna Lundquist. Audio edition by Adrianne Silva.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

References:

References: 

1. Perreault, L., Apovian, C. (2021). Obesity in adults: Overview of management. Pi-Sunyer,  F.X., Seres, D., & Kunins, L. (Eds.) UpToDate.  Available from: https://www.uptodate.com/contents/obesity-in-adults-overview-of-management.

1. Perreault, L. (2022). Obesity in adults: Drug therapy. Pi-Sunyer,  F.X., & Kunins, L. (Eds.) UpToDate. Available from: https://www.uptodate.com/contents/obesity-in-adults-drug-therapy.

1. Dungan, K., DeSantis, A. (2022) Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus. Nathan, D.M., & Mulder, J.E. (Eds.) UpToDate. Available from: https://www.uptodate.com/contents/glucagon-like-peptide-1-based-therapies-for-the-treatment-of-type-2-diabetes-mellitus

1. Perreault, L., Bessesen, D. (2022). Obesity in adults: Etiologies and risk factors. Pi-Sunyer,  F.X., & Kunins, L. (Eds.) UpToDate. Available from: https://www.uptodate.com/contents/obesity-in-adults-etiologies-and-risk-factors

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!

Anti-obesity medications are FDA-approved drugs to support your patient’s efforts to lose weight. It is important for primary care providers to learn about these medications to continue fighting against obesity in our communities.

Introduction: Obesity is a chronic disease.
By Hector Arreaza, MD. 

Obesity has all the characteristics of a chronic disease. Let’s use our imagination and think about a patient with hypertension, for example. Let’s imagine you are the doctor or Mr. Lee. He is 45 years old and his blood pressure has been persistently high, around 150/100, even after lifestyle modifications. You decide to start chlorthalidone 25 mg and Mr. Lee takes chlorthalidone every day. Four weeks later you see Mr. Lee again and you review his labs with him. He has normal renal function and normal electrolytes. His blood pressure is now 119/75. He is feeling great and reports no side effects to chlorthalidone. Would you stop the medication at this time? Think about it. The most obvious answer is NO, you will not stop chlorthalidone. Today you will listen to a discussion about anti-obesity medications, common indications, contraindications, cautions, and more. We will learn that obesity requires chronic treatment with medications just like any other chronic disease. I hope you enjoy it.

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

___________________________

Weight Loss Meds. 
By Sapna Patel, MS4; and Danish Khalid, MS$. Ross University School of Medicine. Moderated by Hector Arreaza, MD.

S: Hello and welcome back to our nutrition series! If you haven't already listened to our previous episodes, pause this and make sure to give them a listen. We have talked about physical activity, meal plans, and intermittent fasting. Today we are going to talk about the clinical management of obesity, specifically the pharmacotherapy that is used. We will divide these drugs into drugs that reduce food intake primarily acting on the CNS, drugs that reduce fat absorption and medications that are associated with weight gain.

D: Can anyone who is considered obese take medications to help them lose weight? Pharmacotherapy should be considered if the patient will be taking the medication in conjunction with the overall weight management program, including changes in eating habits, increased physical activity, and realistic expectations of the medication therapy. Adjuvant pharmacologic treatments should be considered for patients with a BMI >30 kg/m2 or with BMI >27 kg/m2 who have concomitant obesity related diseases.

A: You are going to find doctors who are pretty much against anti-obesity drugs, but that’s not my case. 

S: Drugs that reduce food intake primarily acting on the CNS: 

1. Let's start with Phentermine and other sympathomimetic drugs

A: Phentermine has been in the market over 60 years and it is well tolerated by most patients. It is effective, expect 5-8 lbs weight loss a month when taken with dietary changes and increased physical activity. The weight loss happens mostly the first 3-6 months when you take anti-obesity medications.

1. S: One of the longest clinical trials of the drugs in this group lasted 36 weeks and compared placebo treatment to treatment with continuous phentermine and intermittent phentermine. Both the continuous and intermittent phentermine therapy produced more weight loss than placebo.

1. D: Other options are Phentermine and topiramate ER which is known as  “Qsymia”. 
2. These drugs combine a catecholamine releaser and anticonvulsant respectively.  Topiramate is currently approved by the USFDA as an anticonvulsant for treatment of epilepsy and for prophylaxis of migraine headaches. Weight loss was seen as an unintentional side effect during clinical trials for epilepsy.
3. The mechanism responsible for this is thought to be mediated through the modulation of GABA receptors, inhibition of carbonic anhydrase and antagonism of glutamate to reduce food intake 
4. The common adverse effects include cognitive impairment, paresthesia, and increased risk for kidney stones. Topiramate is also a teratogenic drug, so patients need to be in a good birth control to take it. It causes cleft palate in the fetus.
5. The 2 phase-III trials called EQUIP and CONQUER, both 1 year randomized  placebo-controlled double-blinded clinical trials, 3 different strengths of a once-a day formulation were tested: full strength dose (15 mg of phentermine and 92 mg of topiramate ER), mid-dose (7.5mg of phentermine and 92 mg topiramate ER) and low dose (3.75mg of phentermine and 23 mg of topiramate ER). Subjects  randomized to the full strength dose in EQUIP and CONQUER trials lost an average of 10.9% and 9.8% body weight in 1 year compared to 1.6% and 1.2% loss for placebo subjects respectively. Significant improvement in fasting glucose, insulin, Hemoglobin A1C and lipid profile were seen.
6. Due to the dose dependent side effects of the medications an initial dose of 3.75/23 mg is prescribed daily for the first 14 days then increased to 7.5/23mg daily. These patients should be re-evaluated after 3 months. If 3% weight loss is not achieved by that time, either discontinue or escalate the dose to 15/92mg for 12 weeks.

S: Drugs that reduce fat absorption:

1. Orlistat. What is orlistat? Well it's a selective inhibitor of pancreatic lipase that reduces the intestinal digestion of fat. The mean weight loss when compared to a placebo was 2.51kg at 6 months and 2.75kg at 12 months.

A: It is one of the few anti-obesity medications approved to be used in children 12 years and older.

D: GLP-1 Receptor Agonist (-glutide): 

1. Semaglutide and Liraglutide - Only two that have been approved for treatment of obesity. 
2. A 20-week randomized trial, comparing Liraglutide, placebo, and orlistat, showed that patients assigned to liraglutide lost significantly more weight than those assigned to both. When compared to placebo, those on liraglutide lost a mean weight loss of 2.8 kg. Whereas compared to orlistat lost an average of 5.8kg, however this was on the higher doses of liraglutide. 
3. A 56-weeks trial, comparing liraglutide with placebo, showed a mean weight loss was significantly greater in the liraglutide group (8.0 kg vs 2.6 kg). Furthermore, those who initially lost weight with diet and exercise, a greater proportion of those taking liraglutide maintained the weight loss.  
4. Similarly, clinical trials favored semaglutide, with a weight loss greater in the semaglutide group versus placebo. 
5. For both, weight loss occurred in patients with and without diabetes.

Note: Semaglutide: once a week. Helps induce weight loss. Liraglutide: daily. 

A: We dedicated a whole episode on Semaglutide and another whole episode on Tirzepatide. Tirzepatide (dual agonist: GLP-1 and GIP) seems promising for weight loss and it is likely to be approved soon for obesity treatment. So, when do we discontinue anti-obesity medications? We can ask the same question for other chronic diseases: When do we stop medication for hypertension or diabetes? When we have a patient is unable to keep their weight off, we can’t see him/her as someone who has lost their motivation to keep their weight off. Really what’s happened is that their hormones have changed in a way that is promoting weight gain and it’s very hard to lose weight. We should be at the patient’s side to fight it off.

Conclusion: Now we conclude our episode number 106 “Weight Loss Meds.” Phentermine is the most widely used anti-obesity medication. It is a stimulant, and it is a safe and effective medication for most patients who are fighting obesity. Make sure you learn the contraindication, side effects, and precautions when you prescribe it. Also, learn about other meds that are very effective, including GLP-1 receptor agonists, and your patients will thank you. This week we thank Hector Arreaza, Danish Khalid, and Sapna Patel. Audio by Sheila Toro.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! 

_____________________

References: 

1. Perreault, L., Apovian, C. (2021). Obesity in adults: Overview of management. Pi-Sunyer,  F.X., Seres, D., & Kunins, L. (Eds.) Uptodate. Available from: https://www-uptodate-com.rossuniversity.idm.oclc.org/contents/obesity-in-adults-overview-of-management?search=weight%20loss%20medications&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

1. Perreault, L. (2022). Obesity in adults: Drug therapy. Pi-Sunyer,  F.X., & Kunins, L. (Eds.) Uptodate. Available from: https://www-uptodate-com.rossuniversity.idm.oclc.org/contents/obesity-in-adults-drug-therapy?search=weight%20loss%20medications&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

1. Dungan, K., DeSantis, A. (2022) Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus. Nathan, D.M., & Mulder, J.E. (Eds.) Uptodate. Available from: https://www-uptodate-com.rossuniversity.idm.oclc.org/contents/glucagon-like-peptide-1-based-therapies-for-the-treatment-of-type-2-diabetes-mellitus?search=glp%201%20receptor%20agonists&source=search_result&selectedTitle=2~97&usage_type=default&display_rank=1

1. Perreault, L., Bessesen, D. (2022). Obesity in adults: Etiologies and risk factors. Pi-Sunyer,  F.X., & Kunins, L. (Eds.) Uptodate. Available from: https://www-uptodate-com.rossuniversity.idm.oclc.org/contents/obesity-in-adults-etiologies-and-risk-factors?search=medication%20associated%20with%20weight%20gain§ionRank=1&usage_type=default&anchor=H1612312650&source=machineLearning&selectedTitle=1~150&display_rank=1#H1612312650.

1. Royalty-free music used for this episode: Salsa Trap by Caslo, downloaded on July, 20, 2022 from https://freemusicarchive.org/music/caslo/caslo-vol-1/salsa-trap/. Space Orbit by Scott Holmes, downloaded on July, 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/. 

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!

Monkeypox is a rare disease caused by the monkeypox virus that belongs to the orthopoxvirus (smallpox) family. Nabhan, Dr. Schlaerth, and Dr. Arreaza discuss the basics of what is known about this disease. 

Introduction: Monkeypox 
By Hector Arreaza, MD. 

As of June 29, 2022, there are 5,115 confirmed cases of monkeypox in the world. The country with the most cases is the United Kingdom with >1,000 cases. In the United States, there are 351 confirmed cases, distributed in 28 states, and the state with the highest number of cases is California with 80 cases. Today we will briefly discuss the history, epidemiology, transmission, and management of monkeypox. By the way, by the time you listen to this episode, this disease may have a different name, as the World Health Organization is planning to rename it to minimize stigma and racism. 

Monkeypox is still rare, but because of the current outbreak, we need to include it in our list of differentials when we see rashes. Symptoms of monkeypox can include fever, chills, headache, myalgias, lymphadenopathies, and general malaise. The rash resembles pimples or blisters that appear on the face, inside the mouth, and on other parts of the body, like the hands, feet, chest, genitals, or anus. The rash goes through different stages before healing completely. The illness typically lasts 2-4 weeks. Monkeypox spreads by direct or indirect contact with rash, respiratory secretions, and vertical transmission from mother to fetus. Sometimes, people get a rash first, followed by other symptoms. Others only experience a rash. Currently, there is not a formal treatment for the disease. The information will continue to evolve in the future. 

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

___________________________

By Nabhan Kamal, MS3, American University of the Caribbean School of Medicine. Comments by Katherine Schlaerth. Moderated by Hector Arreaza, MD.

Background.

Monkeypox is a viral zoonotic infection that results in a rash similar to smallpox. It is estimated that humans have been infected by the monkeypox virus for centuries in sub-Saharan Africa. Monkeypox is an orthopoxvirus that was first isolated in the decade of 1950s from a colony of sick monkeys. The variola virus and the vaccinia virus are in the same genus as the monkeypox virus. Variola is the smallpox virus, and vaccinia is the virus in the smallpox vaccine. The virion that has been seen in cells infected with the monkeypox virus looks exactly the same as the virions of variola or vaccinia viruses. It has a characteristic brick-like appearance. 

The two strains of monkeypox identified in different regions of Africa are Central Africa and Western Africa. It seems like the strain of Western Africa is less virulent and lacks a number of genes present in the Central African strain.

Transition to talking about Epidemiology

Why is understanding the epidemiology of monkeypox important? I think it’s important to touch on the epidemiology of the virus because it will help healthcare providers better understand the disease and have a more productive discussion with their patients about this illness if they, unfortunately, happen to fall victim to it. 

Epidemiology

In the 70s, the first time monkeypox was identified as a cause of disease in humans. It happened in the Democratic Republic of the Congo (formerly the Republic of Zaire). After that, only 59 cases of human monkeypox were identified in the decade between 1970 and 1980, with a mortality rate of 17%. All of these cases occurred in the rain forests of Western and Central Africa. These cases occurred in people exposed to rodents, squirrels, and monkeys. An important fact to note is that despite the virus being called “monkeypox”, monkeys and humans are incidental hosts; the reservoir remains unknown but is likely to be rodents. Despite the current common belief that this is the first outbreak of monkeypox in the US, the actual first outbreak of monkeypox in the Western Hemisphere occurred in the United States in 2003. 

Transition to talking about Transmission

Is the monkeypox virus extremely virulent and transmissible just like SARS COV-2? All people born after 1972 have not been vaccinated against smallpox. Routine vaccination of the American public against smallpox stopped in 1972 after smallpox was eradicated in the United States. The virus can spread between animals and humans, just like COVID-19 is believed to be.

Transmission

Animal-to-human transmission – A person gets infected by monkeypox by contact with body fluids coming from an infected animal or through a bite. Monkeypox infection has been found in many types of animals in Africa, including rope squirrels, tree squirrels, Gambian poached rats, dormice, and different species of monkeys.

Human-to-human transmission – In general, humans get infected from other humans through large respiratory droplets, which are produced during cough or sneezing. Also, a person can get infected by close contact with infectious skin lesions and particles or from sexual contact with skin lesions.

Currently, transmission from person-to-person is very low. An outbreak of monkeypox was reported in May 2022 in non-endemic countries with over 90 confirmed cases. Non-endemic countries are all countries outside of Central and Western Africa. However, in this new outbreak, it appears that close contact with infectious skin lesions during sexual contact may be the most likely mode of transmission based on the majority of initial cases in Europe being recorded amongst men who have sex with men. 

As of this recording on June 8, 2022, there are a total of 1088 cases in 29 countries. The UK leads the world with 302 confirmed cases while the US only has 34 confirmed cases. 

Incubation period

The classic incubation period of monkeypox virus infection is usually from 6 to 13 days but can range from 5 to 21 days. Important to note, however, is that persons with a history of an animal bite or scratch may have a shorter incubation period than those with tactile exposures (9 versus 13 days, respectively). So, the infection shows up earlier in people who get an animal bite or scratch.

Management 

Most patients with monkeypox will have mild disease and recover without medical intervention. For patients who are symptomatic, most of them will not require hospitalization. Unlike chickenpox, the vesicular rash caused by monkeypox occurs all at once rather than new lesions appearing as old ones start to crust over and heal.

Antivirals: In some rare cases, antiviral medications can be used for patients that become severely ill as a result of being immunocompromised from HIV, various cancers, organ transplant recipients, etc. The antiviral drug of choice is Tecovirimat. It’s a potent inhibitor of an orthopoxvirus protein required for dissemination within an infected host. This medication protects nonhuman primates from lethal monkeypox virus infections and is also likely to be efficacious against infection in humans. It’s interesting that these medications have been approved for smallpox treatment. 

In patients that have severe disease, dual therapy with Tecovirimat and Cidofovir is recommended. It has in vitro activity against monkeypox and has been shown to be effective against lethal monkeypox in animal models. However, there isn’t any clinical data regarding Cidofovir’s efficacy against monkeypox infection in humans specifically, and it also has significant side effects including nephrotoxicity.

In June 2021, brincidofovir was approved for use in the US for the treatment of smallpox. Brincidofovir is an analog of cidofovir (meaning that it is almost the same with some small tweaks) that can be given orally. Given how new it is, however, its clinical availability is uncertain at this time.

____________________________

Conclusion: Now we conclude our episode number 104 “What is Monkeypox.” Monkeypox is a developing story and we have presented information that may become obsolete in the future. For now, remember to rule out monkeypox in your patients who are highly suspicious to have it, for example, patients with STI-related rashes or with a viral illness followed by a papular rash. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Katherine Schlaerth, Nabhan Kamal, and Lillian Petersen.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

1. Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/poxvirus/monkeypox/, accessed on June 30, 2022. 

1. Muller, Madison, WHO Will Rename Monkeypox Virus to Minimize Stigma and Racism, TIME, June 14, 2022.

1. Isaacs, Stuart, MD, Monkeypox, UpToDate, https://www.uptodate.com/contents/monkeypox, accessed on Jun 06, 2022.

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!

Salwa, Pat, and Dr. Arreaza explain how to care for patients who identify themselves as LGBTQ+. Answered questions include, what screenings are needed? Any special needs? 

Introduction: LGBTQ+ Information.  
By Hector Arreaza, MD. 

Recently the media has been flooded with information about LGBTQ+. If you wonder what LGBTQ+ means, it means lesbian, gay, bisexual, transgender, queer or questioning, and the “+” sign acknowledges other orientations such as asexual, intersex, and more. June was designated as “pride month”. I think we have received more information within the last year than in the previous century. Many people consider this an overrepresentation of the calculated 3.5% to 8% of the population who identify themselves as LGBTQ+, many others consider this a revolution to promote equality in our society by reaffirming gay rights, while others consider this a part of an agenda to destroy the “American way of living” or even the US Armed Forces. 

You can come to your own conclusion about the origin and validity of this movement, but as medical providers, especially as family medicine providers, we must be prepared to care for any patient we encounter, including members of the LGBTQ+ community, and treat them with the same respect and compassion as any other patient. This episode was done to increase your awareness of this topic and motivate you to keep learning about it. By the way, there are now specific fellowships you can take to become more specialized on this topic, and you can find more information on the American Medical Association website.[3] 

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

___________________________

By Salwa Sadiq-Ali, MS IV Ross University School of Medicine, and Pattamestrige Perera, MS IV, American University of the Caribbean. Comments by Hector Arreaza, MD.

Salwa: So, I was browsing the internet as we all do these days and I came across a short film, The Clinic, by a Canada-based organization, the Get REAL movement. Have you heard about this Dr. Arreaza? 

Arreaza: No, I haven’t, but this sounds interesting. What was the film about? 

Salwa: Essentially, it’s about LGBTQ+ patients and how healthcare is not inclusive. The film shows two patients with the same concern, one of which is from the LGBTQ+ community. It goes on to show how they are treated differently by the physician. 

Arreaza: That’s not how it should be. Unfortunately, healthcare disparity is very real, especially in minority groups like the LGBTQ+. One study found that 3.5% of Americans identify as lesbian, gay, or bisexual and 0.3% identify as transgender. They also found that these individuals are more likely to get poor care because of stigma and lack of awareness. 

Salwa: Exactly! And since June is PRIDE month, I thought this would be a great topic! Especially because we as students or healthcare providers don’t learn too much about this in school or training. 

Arreaza: I think that’s a great idea. I’ve heard a lot about PRIDE celebrations and the memorials that are held. How about we start with what exactly is PRIDE?

Pat: PRIDE is a celebration, a movement. It’s celebrated to commemorate the 1969 Stonewall Riots or Uprising. The riots began after the police raided a gay club in New York City leading to almost a week of violent clashes. This event marked the beginning of the gay rights movement as we know it today. 

Arreaza: And today PRIDE is celebrated with parades and many hold memorials for members of the community who were victims of hate crimes. By the way, you can listen to our episode 14, “Gender Diversity”, to learn about the definitions of gender, sexual orientation, and more.

Pat: As you said earlier, LGBTQ+ individuals are part of a minority group and face discrimination. 

Arreaza: Let’s talk about the health care gaps the “community” faces. Tell us more. 

Salwa: Yes absolutely! Let’s get into it! Did you know that LGBTQ+ youth are at a higher risk for substance abuse, STDs, cancers, cardiovascular disease, obesity, bullying, isolation, rejection, anxiety, depression, and suicide in comparison to the general population? 

Arreaza: The AAFP says suicide rates are 4 times higher among LGBTQ+ and even higher among trans youth compared to heterosexual youths. Also, members of the community, specifically men who have sex with men, are at a much higher risk of being affected by HIV/AIDS.

Pat: In fact, family physicians, and all primary care providers, are key to providing care for the LGBTQ+ community and the special needs of the community including gender-affirming care. 

Arreaza: So, what should primary care providers do?

Salwa: That’s a great question! First, let’s go back to the basics. Bedside manners are key. Being open and welcoming will open the door for you to find relevant health information. Having open conversations and being empathetic and mindful will help you build that patient-doctor relationship you want to have with your patients. I’ll share a story from when I was rotating in surgery. I had a transgender patient in the clinic, male to female. That’s what is called a transgender woman. When I was reviewing the chart, I couldn’t tell what pronouns the patient used. The first thing I did when I got into the room was to ask, “What pronouns would you like me to use?”. Even though she was wearing a mask I could tell that her face lit up just by looking at her eyes, and she said, “Thank you, that was very kind of you to ask.” Small things like this can really make a difference. 

Arreaza: And that’s becoming a routine question when our medical assistants encounter a patient for the first time. Their preferred pronoun is listed next to the patient’s name. What about the other health issues for LGBTQ+ patients? What should we do for that?

Salwa: For the other concerns – depression, anxiety, suicide, and more – follow the current guidelines for cisgender patients (cisgender patients are those who identify themselves with their gender assigned at birth). The AAFP and USPSTF have screening guidelines in place that can be utilized to help determine what someone may need further management for. 

Pat: The PHQ9 – a screening questionnaire for depression – will help you determine if you need to start treatment for depression or refer to behavioral health. There’s a similar questionnaire for anxiety – the GAD 7. 

Salwa: When I was doing my psychiatry rotation, I had a transgender male patient who didn’t have a support system. His family had essentially rejected him, and he was so isolated that he became depressed and suicidal. So, I’d say ask your patients about bullying, their support system, ask them about their friends. Maybe even talk to their parents if the patient is a minor, if they consent you to do so, or refer to family therapy. 

Pat: And of course, there is STD testing, HPV vaccination, obesity and related comorbidity screening, PAP smears for anyone with a cervix, maybe even consider an anal PAP smear when appropriate.

Arreaza: Beverly Hills rotation: A gynecologist for men.

People at increased risk of anal cancer:
-Men who have sex with men
-Iatrogenic immunosuppression (e.g., solid organ transplant recipients, long-term oral corticosteroids)
-Women with a history of cervical, vulvar, or vaginal SIL (also termed intraepithelial neoplasia) or cancer
-Women with a history of cervical HPV 16 infection
-Individuals with a history of anogenital warts

Pat: Depression is important to detect on time given the higher rate of suicide in this population, aside from following current guidelines, are there any unique health-related questions we should ask our LGBTQ+ patients? I hope you guys said yes! two common health topics are gender-affirming care and complications related to chest binding. Dr. Arreaza, have you had any patient encounters for gender-affirming care?

Arreaza: Yes actually. I’ve had a few patients who requested gender-affirming care. It requires a multi-disciplinary care team. You must consider hormone replacement, mental health, and surgeries. At the primary care level, you are there as the patient’s support system to help them navigate through everything and provide them with all the information. Hormone replacement is generally done by an endocrinologist or by a primary care provider who has been trained to do it. Of course, when appropriate, we will refer the patients to surgeons for certain procedures. 

Salwa: Exactly! Individuals who, from my understanding, are transgender or non-binary, as in they identify as males but tend to have female sexual characteristics such as breasts, may do something called chest binding. It involves compressing the breast tissue with a wrap to have a more masculine gender expression. Usually, individuals will use commercial binders, elastic bandages, duct tape, or plastic wrap. When you have a patient who practices chest binding, it’s important to address safe practices. They commonly develop dermatological conditions like acne, scarring, fungal infections. But they can also develop other complications like chronic pain, restrictive respiration, rib fractures, syncope, lightheadedness, and heartburn. 

Pat: A study showed that 88.9% of participants experienced a negative side effect of binding, but only 15% sought care. Cleveland Clinic suggests that individuals use a commercial, breathable binder or a sports bra. It’s also important to stay hydrated, have at least one day a week when a binder is not used, and avoid using a binder while sleeping. Most importantly, if you experienced any side effects, to get help from a doctor. 

Arreaza: Asylum seekers due to sexual orientation is possible. People in different parts of the world suffer persecution due to their sexual orientation. LGBTQ+ individuals are target for “killings, sexual and gender-based violence, physical attacks, torture, arbitrary detention, accusations of immoral or aberrant behavior, denial of the rights to assembly, expression and information, and discrimination in employment, health, and education in all regions around the world.

Pat: So, I think we covered most of it. Do you two think we mentioned the important parts?

Salwa: On that note, we want to end this podcast with a small message to LGBTQ+ individuals

listening in. We want you to know that you are not alone and that you matter.

And if you’re listening right now and know someone who is LGBTQ+, check in on them and let

them know how much they mean to you.

Pat: We encourage you to go to your PCP and talk to them about your concerns and how you’re doing. And we encourage all PCPs, all healthcare providers even, to implement these principles when encountering their LGBTQ+ patients.

Arreaza: If you do not feel comfortable caring for LGBTQ+ patients, you can refer them to a provider with the knowledge and skills to care for them.

Available Resources:

• The Center for Sexuality and Gender Diversity in Kern County
• PFLAG Bakersfield Chapter
• Bakersfield LGBTQ+
• The Trevor Project (have crisis counselors available to help)
• National Suicide Hotline (1-800-273-8255)
• National LGBTQ Taskforce
• SAGE - Services and Advocacy for LGBTQ+ Elders
• Transgender Law Center

____________________________

Conclusion: Now we conclude our episode number 103 “Caring for LGBTQ+ Patients.” Remember to screen your patients for conditions related to their gender assigned at birth but take into consideration the effects of hormones in those who have changed their gender. While caring for LGBTQ+ patients, remember to apply the same ethical principles you apply to the rest of your patients: beneficence, non-maleficence, autonomy, and justice. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Salwa Sadiq-Ali, and Pat Perera.

Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

1. Powell, Lauren. We Are Here: LGBTQ+ Adult Population in United States Reaches At Least 20 Million, According to Human Rights Campaign Foundation Report, December 9, 2021, Human Rights Campaign, hrc.org, https://www.hrc.org/press-releases/we-are-here-lgbtq-adult-population-in-united-states-reaches-at-least-20-million-according-to-human-rights-campaign-foundation-report, accessed on June 30, 2022. 

1. How Many People are Lesbian, Gay, Bisexual, and Transgender? UCLA School of Law Williams Institute, April 2011, https://williamsinstitute.law.ucla.edu/publications/how-many-people-lgbt/

1. National LGBTQ+ Fellowship Program, American Medical Association Foundation, https://amafoundation.org/programs/lgbtq-fellowship/

1. Guidelines on International Protection No. 9, United Nations High Commission for Refugees, unhcr.org, published on October 23, 2012, online at: https://www.unhcr.org/509136ca9.pdf, accessed on June 30, 2022. 

1. The Clinic, short film. The Get Real Movement, thegetrealmovement.com, https://www.thegetrealmovement.com/theclinicfilm. Accessed on June 30, 2022. 

1. June is LGBT Pride Month, Youth.Gov, https://youth.gov/feature-article/june-lgbt-pride-month, accessed on June 30, 2022.

1. Stonewall Riots, The History Channel, history.com, https://www.history.com/topics/gay-rights/the-stonewall-riots, Accessed on June 30, 2022. 

1. Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus. 2017 Apr 20;9(4):e1184. doi: 10.7759/cureus.1184. PMID: 28638747; PMCID: PMC5478215. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478215/

1. Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning (LGBTQ+) Health, American Academy of Family Physicians, accessed on June 30, 2022. https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/equality/BKG-LGBTQ+Health.pdf.

1. Creating a welcoming clinical environment for lesbian, gay, bisexual, and transgender (LGBT) patients, rainbowwelcome.org, https://www.rainbowwelcome.org/uploads/pdfs/Creating%20a%20Welcome%20Clinical%20Environment%20for%20LGBT%20Patients.pdf

1. Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study. Cult Health Sex. 2017 Jan;19(1):64-75. doi: 10.1080/13691058.2016.1191675. Epub 2016 Jun 14. PMID: 27300085. https://pubmed.ncbi.nlm.nih.gov/27300085/

1. Moffa, Jamie. Chest Binding: A Physician’s Guide, Pride in Practice, April 6, 2019. https://www.prideinpractice.org/articles/chest-binding-physician-guide/

1. Cleveland Clinic Health Essentials, How to Bind Your Chest Safely, July 26, 2021, https://health.clevelandclinic.org/safe-chest-binding/

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!