Rio Bravo qWeek

Steven and Dr. Cha explained the importance of fluoride recommendations to prevent dental decay in kids who live in areas where water fluoride is low.

A: When I moved to Bakersfield, my children were 3 and a 5 years old, we took them to a pediatrician, and they got a prescription for fluoride supplements, that was something I had never seen before, so I was curious, and for many years I wanted to know the fluoride content of my water. Recently, I discovered the page nccd.cdc.gov thanks to the American Family Physician article about the fluorination of water, and I found the content of Bakersfield.  Because in Family Medicine we see patients from the cradle to the tomb and from head to toe, today we will talk about dental health. 

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.

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Fluoride Supplementation in Kids. 
Written by Steve Beebe, MS3, Ross University School of Medicine. Editions by Hector Arreaza, MD; and Gina Cha, MD.

G: Let’s start with the definition of fluoride, What is fluoride?

S: Fluoride is a mineral – a substance that occurs in nature in its well-defined crystalline form. Put another way, fluoride is the negatively charged form of the element fluorine -- one of the elements on the periodic table. Fluoride is considered one of the essential/beneficial trace elements that our body uses for a variety of purposes. Other common trace elements include copper, iodine, iron, and zinc.[1] Where can fluoride be found?

G: Fluoride is commonly found in groundwater. It can also be found in tea, bones, shells, medical supplements, and fluoridated toothpaste. The fluoride takes the place of hydroxyl groups in the tooth matrix thereby making teeth more resistant to acidic substances which reduces dental caries.

A: Why is fluoride a controversial topic?

S: Although fluoride and dental caries/cavities are inversely correlated, it has yet to be shown that fluoride is strictly essential.[2]

A: Also, fluoride is not innocuous, it can be detrimental if taken in excess. Why is the fluorination of water important?

G: Dental caries is the most common chronic disease in children. The National Health & Nutrition Examination Survey showed that over 23% of children between ages 2-5 had dental cavities.[3] Unfortunately, having dental caries is associated with localized pain, tooth loss, impaired growth, impaired weight gain, and poor school performance, and it carries a risk for dental caries in the future as an adult.[4]

A: Some parents think that having caries on your baby teeth does not matter because those teeth are going to fall anyways.

G: The American Academy of Pediatric Dentistry explains that fluorination of the water supply helps balance the risk of getting dental caries with the risk of fluorosis or tooth mottling from excessive fluoride intake.[5] How much fluoride is enough for human consumption?

S: The National Academic Press recommends a maximum of 2.5mg of fluoride each day to avoid fluorosis (mottling of teeth). The NAP recommends 0.1 to 1mg from birth to 1 year of age and 0.5 to 1.5mg from 1-3 years of age as safe and adequate.[6]

The United States Preventive Services Task Force (USPSTF) recommends starting an oral fluoride supplement at 6 months of age in areas where the water supply is deficient in fluoride. S: Topical application of fluoride is seen as safe as early as the eruption of primary teeth.[7] (A: dental varnishing we do in well-child exams). Unfortunately, the USPSTF mentions that there have been no studies done to adequately address the dosage of oral fluoride supplementation in children with poor water fluoridation. Is there such a thing as too much fluoride?

G: Yes. Symptoms are dose-dependent and range from generalized pain, nausea, vomiting, diarrhea, staining of the teeth (fluorosis), renal dysfunction, cardiac dysfunction, coma, and death. When do we start giving fluoride supplements to our patients if needed?

S: The American Dental Association (ADA) recommends cleaning the teeth of children under the age of 2 years old with water and a brush as soon as teeth protrude into the mouth – a grain of rice-sized smear of fluoridated toothpaste can be used. At 3-6 years of age, the ADA recommends children use a pea-sized amount of fluoride toothpaste when brushing with a toothbrush.[8] (A: we have an obsession with comparing staff to food)

G: The American Academy of Pediatric Dentistry (AAPD) recommends a community fluorination level of 0.7 ppm in the water supply. They recommend against supplementing children under 6 months of age. However, they recommend the following daily oral supplementation:

Average:              

6 m-3 years: 0.25 mg.

3-6 years: 0.5.

6-16 y: 0.5 – 1 mg

The dose changes based on how much fluoride you have in your water:

•             0.25 mg of Fluoride in areas with <0.3ppm Fluoride in children aged 6 months to 3 years

•             0.5 mg of Fluoride in areas <0.3ppm Fluoride for children aged 3-6 years

•             0.25mg of Fluoride in areas 0. 3 to 0.6ppm Fluoride for children aged 3-6 years

•             1mg of Fluoride in areas <0.03 ppm Fluoride for children aged 6-16 years

•             0.5 mg of Fluoride in areas 0.3 to 0.6ppm Fluoride for children aged 6-16 years

 [9]

A: In Bakersfield, the fluoride concentration 0.14 mg/L. What does this mean?

This water system has fluoride from natural sources, but at a level below what is recommended for the prevention of tooth decay. So, counsel your patients about the prevention of decay during clinic and prescribe as needed. The U.S. Department of Health and Human Services recommends a level of 0.7 mg/L of fluoride in your drinking water. This is the level that prevents tooth decay and promotes good oral health. For additional information on fluoride in drinking water please visit the CDC Water Fluoridation Page.

G: The American Academy of Family Physicians agrees with these guidelines provided by the AAPD.[10] When should we stop giving fluoride supplements to our patients? 

Oral supplementation does not seem to be recommended past 16 years of age.

A piece of advice from a dentist: “Only brush and floss the teeth you want to keep.”

Conclusion: Now we conclude our episode number 102 “Fluoride supplementation in kids.” Dr. Cha and future doctor Steven explained the importance of dental decay prevention. Fluorination of water varies in different areas of the US. Remember to check the fluoride in your city water, and if it is below 0.7 milligrams per liter, kids in your area may need fluoride supplementation to prevent caries. Adjust the dose accordingly to prescribe the right amount. Visit “My water’s fluoride” website at nccd.cdc.gov for more information. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Gina Cha, and Steve Beebee.

Audio edition: Suraj Amrutia. 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!

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References:

[1] S. Pazirandeh, MD, D. L. Burns, MD, I. J. Griffin, MB ChB. Overview of Dietary Trace Elements. UpToDate. Accessed 5/30/2022.

[2] Subcommittee on the Tenth Edition of the Recommended Dietary Allowances. Recommended Dietary Allowances, 10th Edition. Page #235. Available at: https://www.nap.edu/catalog/1349/recommended-dietary-allowances-10th-edition (Accessed on 5/30/2022).

[3] Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Centers for Disease Control and Prevention; 2019.

[4] Chou R, Pappas M, Dana T, Selph S, Hart E, Schwarz E. Screening and Prevention of Dental Caries in Children Younger Than Five Years of Age: A Systematic Review for the U.S.Preventive Services Task Force. Evidence Synthesis No. 210. Agency for Healthcare Research and Quality; 2021. AHRQ publication No. 21-05279-EF-1.

[5] American Academy of Pediatric Dentistry. Fluoride therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:302-5.

[6] Subcommittee on the Tenth Edition of the Recommended Dietary Allowances. Recommended Dietary Allowances, 10th Edition. Page #238. Available at: https://www.nap.edu/catalog/1349/recommended-dietary-allowances-10th-edition (Accessed on 5/30/2022).

[7] USPSTF. Prevention of Dental Caries in Children Younger than 4 years: Screening and interventions. December 7th, 2021.

[8] American Dental Association. Healthy habits. https://www.mouthhealthy.org/en/babies-and-kids/healthy-habits (Accessed on May 30, 2022).

[9] American Academy of Pediatric Dentistry. Fluoride therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:302-5.

[10] H. Silk, MD, MPH. Fluoride: The Family Physician's Role. https://www.aafp.org/pubs/afp/issues/2015/0801/p174.html. Accessed 5/30/2022.

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!

Episode 101: Fasting Precautions.  
By Danish Khalid, MS4; and Sapna Patel, MS4. Ross University School of Medicine. 
Comments by Valerie Civelli, MD; and Hector Arreaza, MD. 

Fasting is a healthy lifestyle that may impact your health but fasting is not for everyone. Sapna, Danish, Dr. Civelli, and Dr. Arreaza explain some precautions to be taken in certain populations.  

We’ve talked about intermittent fasting, but we need to add a very big caveat: fasting isn’t for everyone. It carries certain risks. Some people who should absolutely not attempt fasting include those severely malnourished or underweight, children under eighteen years of age, pregnant women, and breastfeeding women. And the concern for these individuals involves providing adequate nutrition for normal growth or development. We also have to be cautious in patients with chronic heart problems, renal issues, eating disorders, fragile diabetics, or recently hospitalized patients.

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.

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S: The normal growth spurt in puberty requires a tremendous amount of nutrients. Underfeeding during this period may result in stunted growth, which may be irreversible. 

D: Or in pregnant women, the developing fetus requires adequate nutrients for optimal growth, and nutritional deficiency may cause irreversible harm during this critical period. It’s for this reason many women take specialty formulated pregnancy multivitamins.

S: The same concept applies to breastfeeding mothers. Developing babies receive all their nutrients from the mother. So, if the mom becomes deficient in vitamins and minerals, then the baby may also be deficient. Which again would result in irreversible growth retardation. 

D: Others that should take caution when fasting but don’t necessarily need to avoid it include those who have gout, diabetes, gastroesophageal reflux disease, or are taking medications.  For these individuals, it is wise to seek medical advice from a healthcare professional.

A: Chances are that you may not find a physician who is pro-fast, but after reading about it and trying it myself, I think it is a safe way to lose weight or maintain a healthy weight. 

S: Gout is an inflammatory arthritis caused by excess uric acid in the joints. It can be either due to decreased uric acid excretion through urine or increased production of uric acid through breakdown of nucleic acid. Fasting decreases the elimination of uric acid through urine. Thus, theoretically worsening gout. Now although most patients with a history of gout tolerate fasting without any exacerbation, knowing the potential risk is important. 

D: If you have type 1 or type 2 diabetes, it's essential to be particularly careful while fasting or even just changing dietary patterns. This is especially true if you are taking medications. If you continue to use the same dose of medication but reduce food intake, you run the risk of your blood sugar getting low - a situation called hypoglycemia. Symptoms include shaking, sweating, irritability or nervousness, feeling faint, confusion, delirium, seizures, and if left untreated may even lead to death. What is even more worrisome, these symptoms may appear very rapidly, so understanding your body and the cues it provides is essential. Thus, you must consult with your physician to adjust the doses of diabetic medication before starting any dietary program to avoid having any hypoglycemic episodes as they can be potentially life-threatening. 

A: The risk of hypoglycemia is high in patients with diabetes who are taking medications, but it’s less likely to happen in patients with obesity without diabetes. The body fat (stores) acts as the fuel for your body functions. Patients will not die if they stop eating. 

S: If you have GERD (heartburn) this is oftentimes due to increased pressure on the stomach which forces food and stomach acid back up. This can be made worse during fasting because there is nothing in the stomach to absorb the stomach acid. Sometimes, fasting can improve symptoms because food stimulates the production of stomach acid, so fasting reduces it. 

A: My GERD improves with fasting. 

D: Patients who are taking regular medication for any condition need close follow-up as certain medications are best taken with meals. The most common medications that cause problems during fasting include aspirin, metformin, iron, and magnesium supplements.  

S: Myth: Women shouldn’t fast. One area of specific concern with women is that fasting could affect reproductive hormones, LH and FSH, similar to that seen in anorexia. This can lead to amenorrhea and difficulty conceiving. However, these problems only arise when body fat percentages fall too low. And women with excessively low body fat should not be fasting in the first place. As mentioned earlier, these individuals are severely malnourished and should stop immediately. 

V: Women: 12-13 hrs. fasting, increase to 1 hr. up to 16 hrs. 8hr feeding window. 6-8 wks. for full benefit.

A: Exercise is allowed during fasting. 

Conclusion: Now we conclude episode 101, “Fasting precautions.” Fasting is safe for most patients but be cautious in certain patients such as pregnant women and diabetics. Make sure you take the necessary steps to avoid side effects or complications during fasting. Even without trying, every night you go to bed being a little wiser. Today we thank Sapna Patel, Danish Khalid, Valerie Civelli, and Hector Arreaza. 

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! 

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References:

Fung, Jason, MD; and Jimmy Moore. “The Complete Guide to Fasting.” Victory Belt Publishing. 2016. p179-189;199-209.

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 100: Sexercise. 

Written by Valerie Civelli, MD. Comments by Namdeep Grewal, MD; and Hector Arreaza, MD.

Have you ever wondered if sex is a good workout? Drs. Civelli, Grewal and Arreaza discuss the topic based on evidence offered by science. 

The following episode is not recommended for young children or people who consider sex a sensitive topic. 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.

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Sexercise. 
Written by Valerie Civelli, MD. Comments by Namdeep Grewal, MD; and Hector Arreaza, MD.

A: If I say “bow chika wow wow” what’s the first thing that comes to mind? The Chipmunks movie right?

B: Yes, exactly, I can hear Alvin in his high-pitched voice, [higher tone] “bowchicka wow wow”. For those of you unfamiliar with this movie, don’t feel too left out because even Alvin was hinting to exactly what you’re thinking.

A: Yep, we’re going there today people.  Let’s talk about sex.  Medically speaking of course. 

B: That’s right because 1. If you’re doing it, your risk for heart attacks and strokes are decreased after age 50 and 2. If you’re not doing it, ask you’re doctor, we should be discussing it and why not.

A: Yes, that is the guideline-directed recommendation actually. We’re recognizing more and more the importance of sexual activity in medicine and its impact on overall health, quality of life and even level of risk for mortality. However, given the sensitive nature of sexuality, few studies have been done to better correlate and define exactly what this means for our health specifically. Sex can be an embarrassing topic to discuss by patients, doctors and researchers which has been largely influenced by culture, religion and other societal norms.  Well, today let’s break this proverbial glass. 

B: I agree, let’s talk about sexuality activity and what research do we have.

A: It has been said that Dr. Masters and Dr. Johnson were the earliest pioneers of this type of investigation. They published the first study of its kind in 1966, which examined the physiological responses of sexual activity. This was an 11-year observational study involving 382 females, ages 18 to 78, and 312 male volunteers, 21 to 89 years of age. The study identified a progressive increase in respiratory rates, up to 40 per minute, an increased heart rate 110 to 180 beats/min and an increase in systolic blood pressure by 30 to 80mmhg during sexual activity. 

In 1970, Hellerstein and Friedman identified the mean heart rate at the time of orgasm was 117.4 beats per minute with a range of 90 to 144. This was done in middle-age men, average age 47.5. Interestingly, the 24-hr ekg monitoring also identified a lower peak post coital heart rate, which was usually lower than the heart rates achieved with normal daily activities (around 120.1 beats per minute). 

In 1984, Bohlen et al. did a racier study with 10 couples using ECG, oxygen consumption (measured using a fast-responding polarographic O2 gas analyzer), heart rate and blood pressure monitoring before and during 4 types of sexual activity. This study obtained data during self-stimulation, partner stimulation, man-on-top and woman-on-top coitus.  The men were aged 25 to 43 years of age.  Results showed that self-stimulation increased the heart rate by 37 % from baseline to orgasm compared with a 51 % increase with man-on-top coitus. 

B: So already it was clear in 1966 to 1984 that physical exertion in the bedroom correlates to physiologic responses like increased heart rate, blood pressure, etc.  However, our question of the day is, does sexual activity count as exercise, and to that question we ask why or why not?

A: When I think about exercise, I think about heart rate and blood pressure.  I think about indicators of energy expenditures and/or intensity. And specifically, while I’m working out…I’m talking about at the gym, and I’m running on the treadmill for example, my mental state is, how much longer until I can quit.  Duration and level of intensity while under this physical exertion feels most important. And according to the AHA, this has been heavily studied.  That’s why 150 active intentional minutes of exercise are recommended per week to improve cardiovascular health. Does this translate to sexual activity? 

B: Well before we answer this, let’s first mention the Bruce protocol. Have you ever heard of this? The Bruce protocol is a standard test of cardiovascular health, comprised of multiple stages of exertion on a treadmill, with three minutes spent per stage. Also at each stage, the incline and speed of the treadmill are elevated to increase cardiac work output, which is called METS. Stage 1 of the Bruce protocol is performed at 1.7 miles per hour and a 10% incline. Stage 2 is 2.5 mph and 12%, while Stage 3 goes to 3.4 mph and 14%. If you’re a pilot for example, the FAA expects testing to achieve 85-100% of Maximum Predicted Heart Rate (220 minus your age) for a 9-minute duration.  

With the Bruce protocol in mind, we circle back to our question of the day, does sex count as exercise?

A: In 2007, Palmeri et al. reported that in 19 men and 13 women aged 40-75 years old, the intensity of sexual activity was comparable to stage II of the standard multistage Bruce protocol (moderate intensity) on a treadmill for men and stage I (low intensity) for women. In addition, maximal heart rate and blood pressure during sexual activity was approximately 75 % of that attained during maximum treadmill stress testing of the Bruce protocol. Collectively, based on these above studies, the physiological responses of sexual activity seem to be at a moderate intensity. 

B: Okay, so “you’re saying there’s a chance.” Right, one in a million Lloyd. Another movie reference, if you’ve seen the American classic Dumb and Dumber, you can appreciate it.  The point is, the level of intensity was identified by Palmeri’s research but are we convinced sex may be used as exercise based on studies that were conducted more than a quarter of a century ago? As a studious, thriving resident physician, with a heavy background in research, I turned to Up to date for more data, and recommendations.  I had zero findings. 

Naturally I turned to Men’s Health magazine to see what is out there to the general public:

A: “You’re in bed with your partner and you just finished a vigorous sex session. You’re hot and sweaty, worked past that side cramp you got while thrusting, and are convinced you just burned as many calories as you would at the gym. You figure you can skip the treadmill today since your sex workout—a.k.a sex exercises, a.k.a sexercises—got you plenty of cardio.

Well, we may have bad news: it depends on the type of sex you’re having—specifically, how active you are during it, and how long you’re having it—but unless you’re really going at it for a couple of hours, odds are, it wasn’t that great of a workout.

To better quantify this, couples were evaluated while running on a treadmill for 30 minutes and compared to their sexercise.

The results, which were published in the journal PLOS ONE, concluded that men burn 100 calories during the average sex session, while women burn about 69 calories. The researchers estimated that men burn roughly 4.2 calories per minute during sex, while women burn 3.1 calories.

B: Men may be more physically active during sex which potentially explains why they burn more calories, study author Antony Karelis. But the main reason, Karelis told Time, is that “Men weigh more than women, and because of this, the energy expenditure will be higher in men for the same exercise performed.”

It's also worth knowing that sex sessions in the study lasted an average of 25 minutes That's far longer than average. Times varied in the study, ranging from 10 to 57 minutes. 

A: The longer the session, the more calories burned. 

B: One study in the New England Journal of Medicine found that most sex sessions last six minutes.

A: Here are some tips for burning more calories during sex:

Make some moans and sighs to burn some extra calories.

Change your position to make it more of a workout, especially women. If you're on top, move your hips like a belly dancer. It will feel good while giving you a workout.

Experiment with a position where you squat on top of your partner and then bounce up and down. That's a great way to work out your thighs and rear.

Try being on top rather than on the bottom, because research suggests that requires more energy.

Kiss in unusual positions. Have the guy on his back. Do a push up on top of him. Come down to kiss him and then push back up.

Take off your clothes in ways that burn calories. Draw it out and make it part of your foreplay. Or tease him as you get undressed. Do a seductive dance with a silk scarf, for example.

Give a good massage to get your heart rate up. Ramp things up by going deeper. It's more sensual and works different muscles. Take turns so you can both get the calorie burn and its arousing impact.

B: Harvard source:  During sexual intercourse, a man's heart rate rarely gets above 130 beats a minute, and his systolic blood pressure nearly always stays under 170. All in all, average sexual activity ranks as mild to moderate in terms of exercise intensity. 

A: As for oxygen consumption, it comes in at about 3.5 METS (metabolic equivalents), which is about the same as taking a walk or playing ping pong. Sex burns about five calories a minute; that's four more calories used than watching TV.

B: How do we decide if one is fit enough for sexual activity? For a 50-year-old man, the risk of having a heart attack in any given hour is about one in a million; sex doubles the risk, but it's still just two in a million. For men with heart disease, the risk is 10 times higher — but even for them, the chance of suffering a heart attack during sex is just 20 in a million. In short, if you are able to climb 3 flights of stairs, you are safe to proceed. 

A: Circling back to exercise, keep in mind 4-5 calories burned per minute is still better than zero. Any time spent engaging in any level of physical activity is better than sitting on the couch. 

B: Further, “Having sex for at least 10 minutes contributes to your cardiorespiratory health, increased serotonin levels (the happy hormone), and improved sleep,” Silberstang says. Studies have found that sex can relieve everything from anxiety and depression to high blood pressure. 

A: When men orgasm, their bodies release serotonin, oxytocin, and prolactin, all hormones associated with better moods, relaxation, and lowered stress. Multiple studies have also found links between regular sex and a reduced risk for heart disease and prostate cancer, and a stronger immune system. One reason that sex isn’t classified as a workout is due to its average duration: 3 to 13 minutes,” Silberstang explains. “So, naturally, one of the ways to make sex more of a cardio workout is to increase the time of the act.”

C: The present study indicates that energy expenditure during sexual activity appears to be approximately 85 kcal or 3.6 kcal/min and seems to be performed at a moderate intensity in young healthy men and women. These results suggest that sexual activity may potentially be considered, at times, as a significant exercise. Moreover, both men and women reported that sexual activity was a highly enjoyable and more appreciated than the 30 min exercise session on the treadmill. Therefore, this study could have implications for the planning of intervention programs as part of a healthy lifestyle by health care professionals. 

B: We look forward to future studies that may further show the relationship between psychosocial/qualitative factors and energy expenditures which could explain how these variables could affect overall health and quality of life.

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Now we conclude episode 100, “Sexercise.” If you ever wondered if sexual intercourse was a good workout, today we learned that in general it is not an energy-demanding activity. The average man burns just 24 kilocalories during sex, but with some adjustments you can burn more calories, especially if the activity takes longer. If your patient is not having sex, they do not have to start having it just to exercise, remind everyone to be sexually responsible to prevent the spread of sexually transmitted infections and unintended pregnancies. Even without trying, every night you go to bed being a little wiser.

Today we thank doctors Valerie Civelli, Namdeep Grewal, and Hector Arreaza. 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!

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References:

Frappier, Julie; Isabelle Toupin, Joseph J. Levy, Mylene Aubertin-Leheudre, and Antony D. Karelis. Energy Expenditure during Sexual Activity in Young Healthy Couples, PLOS One, plos.org, Published: October 24, 2013, https://doi.org/10.1371/journal.pone.0079342.

Casazza, Krista, Ph.D., R.D.; Kevin R. Fontaine, Ph.D.; Arne Astrup, M.D., Ph.D.; et al. Myths, Presumptions, and Facts about Obesity, N Engl J Med 2013; 368:446-454 DOI: 10.1056/NEJMsa1208051

Blaha, Michael Joseph, M.D., M.P.H. Is Sex Dangerous If You Have Heart Disease?. Health. Jons Hopkins Medicine, accessed June 20, 2022. https://www.hopkinsmedicine.org/health/wellness-and-prevention/is-sex-dangerous-if-you-have-heart-disease   

Jackson G. Erectile dysfunction and cardiovascular disease. Arab J Urol. 2013;11(3):212-216. doi:10.1016/j.aju.2013.03.003. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4442980/  

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Davey Smith G, Frankel S, Yarnell J (1997) Sex and death: are they related? Findings from the Caerphilly Cohort Study. BMJ 315: 1641-1644. doi:https://doi.org/10.1136/bmj.315.7123.1641. 

Ebrahim S, May M, Ben Shlomo Y, McCarron P, Frankel S et al. (2002) Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study. J Epidemiol Community Health 56: 99-102. doi:https://doi.org/10.1136/jech.56.2.99. 

Laumann EO, Glasser DB, Neves RC, Moreira ED Jr. (2009) A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int J Impot Res 21: 171-178. doi:https://doi.org/10.1038/ijir.2009.7. 

Lindau ST, Gavrilova N (2010) Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ 340: c810. doi:https://doi.org/10.1136/bmj.c810. 

Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA et al. (2007) A study of sexuality and health among older adults in the United States. N Engl J Med 357: 762-774. doi:https://doi.org/10.1056/NEJMoa067423. 

McCall-Hosenfeld JS, Jaramillo SA, Legault C, Freund KM, Cochrane BB et al. (2008) Correlates of sexual satisfaction among sexually active postmenopausal women in the Women's Health Initiative-Observational Study. J Gen Intern Med 23: 2000-2009. doi:https://doi.org/10.1007/s11606-008-0820-9. 

Bartlett RG Jr. (1956) Physiologic responses during coitus. J Appl Physiol 9: 469-472. 

Bohlen JG, Held JP, Sanderson MO, Patterson RP (1984) Heart rate, rate-pressure product, and oxygen uptake during four sexual activities. Arch Intern Med 144: 1745-1748. doi:https://doi.org/10.1001/archinte.144.9.1745.  

Hellerstein HK, Friedman EH (1970) Sexual activity and the postcoronary patient. Arch Intern Med 125: 987-999. doi:https://doi.org/10.1001/archinte.125.6.987.  

Larson JL, McNaughton MW, Kennedy JW, Mansfield LW (1980) Heart rate and blood pressure responses to sexual activity and a stair-climbing test. Heart Lung 9: 1025-1030.  

Masini V, Romei E, Fiorella AT (1980) Dynamic electrocardiogram in normal subjects during sexual activity. G Ital Cardiol 10: 1442-1448. 

Nemec ED, Mansfield L, Kennedy JW (1976) Heart rate and blood pressure responses during sexual activity in normal males. Am Heart J 92: 274-277. doi:https://doi.org/10.1016/S0002-8703(76)80106-8.  

Palmeri ST, Kostis JB, Casazza L, Sleeper LA, Lu M et al. (2007) Heart rate and blood pressure response in adult men and women during exercise and sexual activity. Am J Cardiol 100: 1795-1801. doi:https://doi.org/10.1016/j.amjcard.2007.07.040. 

Casazza K, Fontaine KR, Astrup A, Birch LL, Brown AW et al. (2013) Myths, presumptions, and facts about obesity. N Engl J Med 368: 446-454. doi:https://doi.org/10.1056/NEJMsa1208051. 

Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN et al. (2007) Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 39: 1423-1434. doi:https://doi.org/10.1249/mss.0b013e3180616b27.  

Drenowatz C, Eisenmann JC (2011) Validation of the SenseWear Armband at high intensity exercise. Eur J Appl Physiol 111: 883-887. doi:https://doi.org/10.1007/s00421-010-1695-0.  

Johannsen DL, Calabro MA, Stewart J, Franke W, Rood JC et al. (2010) Accuracy of armband monitors for measuring daily energy expenditure in healthy adults. Med Sci Sports Exerc 42: 2134-2140. doi:https://doi.org/10.1249/MSS.0b013e3181e0b3ff. 

Mackey DC, Manini TM, Schoeller DA, Koster A, Glynn NW et al. (2011) Validation of an armband to measure daily energy expenditure in older adults. J Gerontol A Biol Sci Med Sci 66: 1108-1113.  

Mignault D, St-Onge M, Karelis AD, Allison DB, Rabasa-Lhoret R (2005) Evaluation of the Portable HealthWear Armband: a device to measure total daily energy expenditure in free-living type 2 diabetic individuals. Diabetes Care 28: 225-227. doi:https://doi.org/10.2337/diacare.28.1.225-a.  

Ryan J, Gormley J (2013) An evaluation of energy expenditure estimation by three activity monitors. Eur J Sport Sci: 1-8. 

St-Onge M, Mignault D, Allison DB, Rabasa-Lhoret R (2007) Evaluation of a portable device to measure daily energy expenditure in free-living adults. Am J Clin Nutr 85: 742-749. 

Welk GJ, McClain JJ, Eisenmann JC, Wickel EE (2007) Field validation of the MTI Actigraph and BodyMedia armband monitor using the IDEEA monitor. Obesity (Silver Spring) 15: 918-928. doi:https://doi.org/10.1038/oby.2007.624. 

Wetten AA, Batterham M, Tan SY, Tapsell L (2013) Relative Validity of Three Accelerometer Models for Estimating Energy Expenditure During Light Activity. J Phys Act Health. 

Brazeau AS, Karelis AD, Mignault D, Lacroix MJ, Prud'homme D et al. (2011) Test-retest reliability of a portable monitor to assess energy expenditure. Appl Physiol Nutr Metab 36: 339-343. doi:https://doi.org/10.1139/h11-016. 

Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN et al. (2007) Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation 116: 1081-1093. doi:https://doi.org/10.1161/CIRCULATIONAHA.107.185649. 

Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr. et al. (2011) 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc 43: 1575-1581. doi:https://doi.org/10.1249/MSS.0b013e31821ece12. 
 

Steinke EE, Jaarsma T, Barnason SA, Byrne M, Doherty S et al. (2013) Sexual Counseling for Individuals With Cardiovascular Disease and Their Partners: A Consensus Document From the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP). Circulation. 

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 99: Intermittent Fasting 99. 

By Danish Khalid, MS4; Sapna Patel, MS4; Ross University School of Medicine. Comments by Valerie Civelli, MD; and Hector Arreaza, MD.

Intermittent caloric restriction may seem like a new trend, but Sapna and Danish discussed that actually fasting is practiced in different cultures and it has many health benefits, including weight loss. .  

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.

D: Welcome and thank you for tuning back to our Nutrition series! Today, we want to give a shout out to one of our listeners. She brought up a topic that has recently gained public interest. Intermittent fasting. So, if you’re listening, Hina Asad, this one's for you! Let’s jump in! 

V: 2/3 women are overweight and obese. 1.5 pounds gained/yr on avg age 50-60’s.

S: So like we said earlier, intermittent fasting has recently gained much public interest as a weight loss approach. Or should I say, revitalized itself, as it has been around for years. It describes an eating pattern in which you alternate between periods of eating and fasting (or not eating). The length of each fast can vary in duration.

A: There are feasting and fasting periods, or fed states and fasting states. What is more effective: Intermittent restriction of calories or continuous restriction of calories? 

D: Before we dive in, let’s go back. We know that calorie reduction has been consistently found to produce reduction in body weight and improve overall health. We talked about how to calculate our basal metabolic rate and subtracting calories from our daily caloric intake to result in weight loss. However, this can be difficult to sustain over a long period. Additionally, it requires that you adjust your caloric needs every so often as you lose weight, which can further make it difficult. So how is intermittent fasting different from this?  

S: Well, in contrast to calorie reduction, intermittent fasting focuses on when calories are consumed and the total quantity consumed. Intermittent fasting works through an altered liver metabolism, referred to as the “metabolic switch.” It’s where the body periodically switches from liver-derived glucose to adipose-derived ketones. In doing so, it stimulates an adaptive response including improved glucose regulation, improved insulin sensitivity, and increased stress resistance via conditioning.

V: When you eat is more important than what you eat. Benefits: reducing cancer, Alzheimer's, DM risk, better sleep, less hangry(*find evidence). 

D: What happens when we fast? In our previous podcast we mentioned ketosis, but let's talk about the physiology behind fasting.

Feeding: blood sugar levels rise as we absorb food and insulin levels rise in response to move glucose into the cell. Excess glucose is stored as glycogen in the liver to convert it to fat.

S: Postabsorptive phase (6-24hrs after beginning fasting): Blood glucose and insulin start to drop. To supply energy ,the liver starts to breakdown glycogen, releasing glucose. Glycogen stores last 24-36hrs. 

V: Insulin levels are low, and fat stores are available and improves mental clarity

D: Gluconeogenesis (24hrs - 2 days after beginning fasting): Glycogen stores run out. The liver manufactures new glucose from amino acids called “gluconeogenesis” ( literally “making new glucose)

S: Ketosis (2- 3 days after beginning fasting).

A: Autophagy: “Auto” means self and “phagy” means eat. So the literal meaning of autophagy is “self-eating.”

S: The protein conservation phase (5 days after beginning fasting): High levels of growth hormone maintain muscle mass and lean tissues. The energy for basic metabolism is mostly supplied by fatty acids and ketones. Blood glucose levels are maintained by gluconeogenesis using glycerol. Increased adrenaline levels prevent any decrease in metabolic rate. There is a normal amount of protein turnover, but it is not being used for energy.

V: How long should we fast for? 

D: Fasts can range from 12 hours to three month or more. We can categorize them as short (<24 hours) and long (>24 hours). However, shorter regimens are generally used by those mostly interested in weight loss. The short daily fasting regimens can be divided into the length of fasting - 12 hours fasts, 16 hours fasts, and 20 hours fasts. 

S: Daily 12 hour fasting introduces a period of very low insulin levels during the day with 3 equally spaced meals throughout the day. This prevents the development of insulin resistance, making the 12 hour fast effective against obesity. Although a great preventative strategy, it is not the most effective at reversing weight gain. 

D: Fun Fact: In years past, the 12 hour fasting period was considered a normal eating pattern. This probably explains why prior to the 1970s, there was much less obesity. It wasn’t until the 1970s when the USDAs made dietary changes making a higher-carb and lower-fat diet a staple. That’s when obesity started to rise. 

S: On the other hand, during the 16 hour fasts most people skip the morning meal to account for the extra hours. In this regimen, you have an 8-hour eating window period, this is why it’s also called time-restricted eating. Although you can still eat 3 meals most people tend to stick to 2 meals. The 16 hour fast certainly has more power than the 12 hour fast, but it should be combined with low-carb diets to allow for a slow and steady weight loss. 

A: Feasting periods should not be so liberal, and over time it becomes easier to control hunger. 

V: Feeding hours: healthy fats, proteins, fish, avocados, grass fed butter, unprocessed carbs (especially Low glycemic berries, squash, quinoa, vegetables, Low sugar, low alcohol intake

… eating healthy basically.

D: Fun Fact: A Swedish bodybuilder named Martin Berkha popularized this regimen, which is why you will also hear it being called the LeanGains method. 

V: Skipping breakfast reduces caloric intake by 20-40%, addresses visceral fat.

S: Lastly, the 20-hour fasting regimen, also known as “the Warrior diet.”  Ancient warrior tribes such as Spartans and Romans devised a “warrior diet” in which all meals are eaten in the evening during a 4 hour window. This results in a 20-hour fasting period each day. This diet also emphasizes natural, unprocessed foods and high-intensity interval training.

A: Summary: 12-hour, 16-hour, 20-hour. Dr. Jason Fung also recommends 24-hour fasting. It is basically skipping breakfast every day and skipping lunch 3 times a week. “Hunger is your friend”.

D: Before we move forward, I just want to add that not all fasts are the same. For instance, I’m a Muslim, and there’s a month where we fast for religious purposes, called Ramadan. During this time we fast from sunrise to sunset, or dawn to dusk. In contrast to traditional fasting, this fasting differs in that we don’t eat or drink anything. Even water. Whereas in intermittent fasting it’s different. Now, there have been studies done where they studied individuals during this time to see if there was any weight loss during this period. It was found that people typically lost about 1-2 pounds of weight. However, I do want to clarify this weight loss could be fat loss or muscle loss. 

A: Another group of people who fast are Mormons. They traditionally fast once a month, the first Sunday of every month. It’s a complete abstinence of food and water for 24 hours, skipping 2 meals. Fasting periods are linked to improve your spiritual well-being as well. 

S: Certain Hindu festivals and holy days require devotees to observe fasting as part of their

 worship. 

For example, Navarātrī, the nine-night celebration that occurs yearly. Some people take only water during these nine days, while some eat fruit while some eat one meal a day. 

Hindus will observe fasts of varying strictness depending on individual beliefs or practices. Here are some examples of common fasts observed by Hindus:

not partaking any food or water for a set number of days.

limiting oneself to one specific vegetarian meal during the day.

eating or drinking only certain food types for a set number of days.

Avoiding eating certain food types for a set number of days.’

S: So what can I consume when I fast? Do I have to completely stop eating and drinking for those hours?

D: Only certain fluids can be consumed during fasting periods: water, tea and coffee ( iced or hot) and homemade bone broth. It's important for you to drink water frequently throughout the day. You can enjoy flat, mineral or carbonated water.  

V: While Fasting: ok to have coffee, tea and water. Fasting creates a state of alertness.  

S: What can you add to your water? Limes, lemons, sliced fruit (do not eat the fruit itself), vinegar, Himalayan salt, chia, and ground flaxseeds ( 1 tbsp in 1 cup water). Do not add sweetened powders even if it's sugar-free.

D: You can consume up to 6 cups of caffeinated or decaffeinated coffee on a fasting day. Black coffee is preferred, but you can add up to 1 tbsp of certain fats in your coffee. These include: coconut oil, medium chain triglyceride oil (MCT oil), butter, ghee, heavy whipping cream (35% fat), half and half, whole milk, ground cinnamon for flavor.

V: Ghee butter is clarified butter with no lactose. 

A: You can curve appetite by drinking water, eating grains of salt, and drinking pickle juice (use a straw to avoid dental problems)

S: You can consume unlimited herbal tea during your fasting period.  I know Danish and I both are Tea Connoisseurs. Right Danish? Teas can suppress your appetite, lower your blood sugar levels and are otherwise beneficial (positivi-tea). Bitter melon tea, black tea, cinnamon chai tea and oolong tea, help lower blood sugar levels. Peppermint tea and green tea help suppress appetite. Peppermint is good for GI discomfort such as gas and bloating.

A: Peppermint oil is good for IBS.

D: It's not uncommon to experience some lightheadedness during your first few days of fasting periods. This is often caused by dehydration and decreased levels of electrolytes. An easy remedy is a good homemade broth. Both vegetable and meat or bone broth will work. Things you can include in your broth: any vegetable that grows above the ground, leafy greens, carrots, onions, bitter melon, animal meat and bones (mostly bones, any animal), Himalayan salt, any herbs or spices, ground flaxseeds. Avoid vegetable puree, potatoes, yams, beets or turnips and store bought broths. (Dr. Fung).

A: This is the end of this part on “How to fast”. Some people think fasting includes being hungry the whole day, but the “hungry” feeling goes away after 1 hour, and you learn to recognize the cues from your body about hunger and satiety. 

___________________________________________________________________________

Now we conclude our episode number 99 “Intermittent Fasting 99.” This is not a complete guide to fasting, it’s only a brief overview. Fasting has become a new nutritional trend with proven benefits. Remind your patients that one of the secrets of fasting is “delay, don’t deny”, meaning they can delay eating a few hours and then enjoy what they like the most. Sapna, Danish and Dr. Civelli also reminded us to eat with moderation after breaking our fast to maintain the benefits of fasting. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Sapna Patel, Danish Khalid and Valerie Civelli. Audio edition: Suraj Amrutia. 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!

_____________________

Resources: 

Fung, Jason, MD; and Jimmy Moore. “The Complete Guide to Fasting.” Victory Belt Publishing. 2016. p179-189;199-209.

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 98: Apretude and code blue. 

Apretude is a new injectable medication for HIV pre-exposure prophylaxis (PrEP), Dr. Yomi presents how to use it. Then, Mandeep, Jon, and.  

Introduction: Apretude, a new injectable for HIV PrEP.  
By Timiiye Yomi, MD. Moderated by Jennifer Thoene, MD.  

What is HIV PrEP? Pre-exposure prophylaxis (or PrEP) consists of taking medication when a patient has a high risk of contracting HIV to lower their chances of getting infected. 

Who can take HIV PrEP? Individuals who may benefit from PrEP include but are not limited to: Male who have sex with male (MSM), people with multiple sexual partners with no consistent use of condoms, or people who have been diagnosed with an STD in the past 6 months, IV drug users who share needles, syringes, or other injection equipment.

History of HIV PrEP: In 2012, the first medication for HIV PrEP was approved—Truvada® (tenofovir-emtricitabine). Truvada is a once-daily oral prescription drug. Seven years later, in 2019, the next medication for HIV PrEP was approved— Descovy® (tenofovir alafenamide and emtricitabine). It is also a daily PO medication. But today we want to introduce you to the newest medication for HIV PrEP—Apretude® (cabotegravir). On Dec 20, 2021, FDA approved Apretude (cabotegravir), an extended-release injectable for HIV-1 pre-exposure prophylaxis for at-risk adolescents and adults who weigh at least 35 kg (77 lbs).

Mechanism of action: Apretude is a long-acting integrase inhibitor that works by binding to the HIV integrase active site and blocking the strand transfer step of retroviral DNA integration.

How is it given? 

Comes as a 600-mg (3-mL) injection. Patients receive 2 initiation injections administered 1 month apart, thereafter every 2 months. Patients can start medication immediately or first take the oral formulation for 4 weeks to assess how well they tolerate the medication before beginning the injection.

Trials: The safety and efficacy of Apretude in reducing the risk of contracting HIV-1 were evaluated in two randomized double-blind trials comparing Apretude and Truvada (once-daily oral medication).

Trial 1: Participants who took Apretude had a 69% less risk of contracting HIV compared to Truvada.

Trial 2: Participants who took Apretude had a 90% less risk of contracting HIV compared to Truvada.

Common side effects: Fever, malaise, fatigue, sleep problems, myalgias and arthralgias, headache, rash, red and swollen eyes, edema of face, lips, mouth, tongue; GI discomfort, hepatotoxicity, and depression.

Note: Some drug-resistant HIV variants have been identified in people with undiagnosed HIV prior to beginning Apretude. People who test positive for HIV while on Apretude must transition to a complete HIV treatment regimen as Apretude is not approved for HIV treatment. 

Requirements to receive Apretude: 

-Patient must be HIV-1 negative

-Patient must remain negative to continue receiving Apretude

-Patient must not miss any injections as this increases their risk of contracting the virus 

Apretude does not protect against other sexually transmitted infections. Patients must be sexually responsible and use other forms of protection such as condoms during sexual intercourse.

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.

___________________________

A code blue in clinic.  

By Manpreet Singh, MS3; Jon-Ade Holter, MS3; and Sheinnera Gerongay, MS3. Ross University School of Medicine.

What is a code blue?

Arreaza: Today we will present to you a case to remind you about some principles of cardiopulmonary resuscitation (CPR). The term “code blue” in the United States refers to a situation where a patient is in cardiac arrest, respiratory arrest, unresponsive, or experiencing another medical emergency that requires immediate attention. “Code blue” is commonly used in hospitals and clinics to call a rapid response team to arrive immediately to evaluate the patient. We hope you can benefit from this brief review and feel ready for your next code blue. Of course, you will need more than we provide during these few minutes, but we hope it triggers your curiosity to keep learning or practicing. By the way, “code blue” is not standard for medical emergency in the whole world. For example, in the United Kingdom, they call it “code red”.

Case presentation: Mr. DD 56-year-old man with a past medical history of coronary artery disease, recent MI, DM2, and CHF presents today to our clinic for hospital follow. He had an MI 2 weeks ago. He reports that when he was at home working in the yard, he suddenly had 8/10 retrosternal chest pain, pressure-like, accompanied by shortness of breath and diaphoresis. The pain radiated to the left side of his neck/jaw and down his left shoulder and arm. 

Jon: Nitroglycerin was taken by Mr. DD 3 times without resolution of symptoms. The patient was taken by EMS to Kern Medical ER. In the hospital, there was a 4mm ST elevation on ECG on leads II, III, and aVF. Q waves were also seen in anterior leads V4-V6. Patient was taken to cath lab and stent was placed in the RCA. ECHO showed decreased left ventricle wall motion and dilated left ventricle with an ejection fraction of 28%. Mr. DD was discharged after 5 days in the hospital.

M: He is currently on lisinopril, carvedilol, atorvastatin, aspirin, clopidogrel, metformin, and digoxin. He states he is not compliant with all the medications because he forgets to get refills at times. He has a 35-pack year history of smoking and drinks 3-4 4oz drinks every day after work. He states he has used methamphetamine and cocaine intermittently within the last 6 months.

J: Today, he lets the MA know that he is having some chest pain at night, shortness of breath with minimal activity for the last week, and at times he feels his heart is beating too fast. He has a follow-up appointment with cardiology in 2 weeks. The MA tells you that the patient vitals today are BP:195/105, HR: 108, RR: 28, and O2% 89% on room air. 

M: You are reviewing the patient’s chart when you hear a loud thud coming from the room, you rush into the room and find the patient on the ground. The patient is unresponsive and is not moving. What is your next action? 

A. Try to lift the patient off the ground and back onto the chair or bed 

B. Give the patient nitroglycerin sublingually 

C. Call and wait for the EMS before proceeding 

D. Obtain IV access

E. See if the patient is arousable and check pulse and breathing 

E is the correct answer to this question because before initiating any type of treatment, first, you must assess the patient for alert response and their basic vitals such as their pulse and breathing.

J: We do this because we need to know if the cardiopulmonary systems are intact. When they are not intact, regardless of the level of medical training, we must start CPR protocol. 

M: This patient most likely suffered a tachyarrhythmia, a very common post-MI-complication that causes the highest mortality rates. The most common cause of death are ventricular fibrillation and ventricular tachycardia. 

J: These are the steps we must take in order to start resuscitation of the cardiopulmonary system in any environment before the patient can be taken to a higher level of care. In this situation, Doctor Holter and Doctor Singh will perform 2-patient CPR. This is only an introduction of basic life support and advanced cardiac life support. You will need additional training to get the BLS and ACLS certificates. 

M: First, assure your environment is safe before preceding to render care. You want to be able to give the best uninterrupted care to your patient without becoming a patient yourself. 

Jon: Doctor Holter. Mandeep: Doctor Singh.

J - Doctor Holter: I will reach down and check the patient. “Sir, Sir, are you okay” – I am assessing for reactions from visual or verbal cues given by me. When the patient is unresponsive to verbal and visual cues, I will give a painful stimulus to the patient such as a nail bed pinch or sternal rub. Next, it is necessary to assess the pulse and breathing of the patient. 

Narrator: The reason we check if the patient is alert is to assess the neurologic activity. The lack of response to painful stimuli indicates there is no self-protect response. To assess the carotid pulse, you must palpate the carotid artery by placing the index and middle fingers near the upper neck between the sternomastoid and trachea roughly at the level of the cricoid cartilage. Assess breathing by checking the rise and fall of the chest. Lack of responsiveness, pulse, and breathing indicates that immediate Cardiopulmonary Resuscitation (CPR) needs to be initiated. 

J - Doctor Holter: Please call 911 and get an AED.

M - Doctor Singh: I will call 911 and get an AED.

J- Doctor Holter: I will place the person on their back and start single-person CPR until Doctor Singh comes back. 

Narrator: CPR is performed by placing the patient flat on their back on an even surface. Place the heel of your hand on the center of the person’s chest (on the mid sternum) then place the palm of your other hand on top. Press down 5-6 cm (2-2.5 inches) at a rate of 100-120 beats per minute. Compressions should not be interrupted because they serve as an artificial way of contracting the heart and circulating the blood to maintain blood perfusion. 

For 1 or 2 person CPR on an adult: Give 5 cycles of 30 compressions to 2 breaths.

For 1 person CPR on a child: Give 5 cycles of 30 compressions to 2 breaths.

For 2 person CPR on a child: Give 5 cycles of 15 compressions to 2 breaths.

M - Doctor Singh : Doctor Holter, continue the compressions and I will give rescue breaths and start to place the AED pads on the patient. Let me know if you are tired and we can switch to give high-quality CPR with adequate depth and rate. 

Narrator: The AED comes with a diagram made on the pads to instruct where to place the pads. Once an AED is positioned correctly on the patient’s chest, let it detect if a shockable rhythm is present. Shockable rhythms include ventricular fibrillation and ventricular tachycardia. If there is not a shockable rhythm detected, then continue with CPR until a higher level of care is reached. If a shockable rhythm is detected, the AED will advise the users to step back and verbalize “clear” in order to ensure that everyone is clear of the patient. It will then administer a shock to the patient in the range of 120-200 Joules, based on the device manufacturer’s recommendation.

M - Doctor Singh: Doctor Holter, stay clear of the patient. The AED advises shocking the patient. I will press the button to administer the shock now.

Narrator: After administration of the first shock, ACLS guidelines recommend continuing CPR for 2 minutes without checking for a pulse, as effective cardiac contractility lags behind the restoration of an organized electrical rhythm. After the next 2-minute cycle of CPR, the AED will reanalyze the patient’s rhythm to determine if the rhythm is once again shockable. 

J - Doctor Holter: Doctor Singh , continue high-quality CPR while I initiate ACLS protocol. I will get an IV and start epinephrine. 

M- Doctor Singh: I will continue CPR in the meantime. 

Narrator: ACLS starts with again CPR, AED rhythm reading, and shock administration but with a higher level of care (ACLS). You must obtain IV or IO access. Epinephrine is administered every 3-5 minutes during the cycle in doses of 1 mg at a time. After each dose of epinephrine and CPR for 2 minutes the AED should reassess if the rhythm is shockable, and then continue CPR for another 2 minutes. At this time, it is recommended to use amiodarone or lidocaine. CPR will continue but at this time patient will likely be in the ambulance on the way to the hospital, and EMS will be managing the cycles. The cycles will continue until return of spontaneous circulation is obtained.

J: Myocardial infarction is the most common cause of shock-refractory ventricular fibrillation, along with coronary artery disease. If CPR does not resume spontaneous circulation within 40-50 minutes, there is a decreased chance of recovery. Spontaneous circulation may be achieved in patients with refractory Vfib with coronary revascularization. Therefore, in addition to traditional CPR, venoarterial ECMO (extracorporeal membrane oxygenation) can be used as an adjunct and can result in much better systemic perfusion. Essentially, this is a technique in which blood is drained from the body and circulated outside through an oxygen and heat exchanger and is then reintroduced into the body. This technique can be used if preparing for coronary revascularization. 

M: Vfib is a great risk in the acute phase after MI, up to 72 hours after revascularization, due to the recent ischemia and reperfusion. After the first 72 hours and up to a month following, Vfib remains a risk due to the continued remodeling of the heart. This newly remodeled tissue can cause interruptions in the normal electrical signaling of the heart leading to dissociated contractions and subsequent lack of perfusion through the body, which can quickly lead to death within minutes if not recognized and managed immediately with CPR and defibrillation as described.

J: Clinicians should be aware of their patients who would be more susceptible to serious events such as this and be on top of their training about management. This may not be a common occurrence in clinics, but it is a very serious event and requires a prompt and appropriate response.

Conclusion: Now we conclude our episode number 98 “Apretude and code blue.” Dr. Yomi concisely explained how to use the new injectable medication for HIV Pre-Exposure Prophylaxis (PrEP). Then, Manpreet, Jon, and Sheinnera presented a case that can actually happen in clinic and anywhere. CPR is a life-saving skill that needs to be learned and practiced over and over so we are not taken by surprise. Remember that heart disease continues to be the number 1 killer in the United States. So, make sure you know where your AED is and be ready to use it when needed. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Timiiye Yomi, Jennifer Thoene, Manpreet Singh, Jon-Ade Holter, and Sheinnera Gerongay.

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:

American Heart Association 2022 CPR cheat sheet. American Heart CPR Class, BLS, ACLS Ft. Myers all Lee County. (n.d.). Retrieved June 2, 2022, from https://www.cprblspros.com/cpr-cheat-sheet-2022.

Algorithms. CPR & First Aid, Emergency Cardiovascular Care, American Heart Association, cpr.heart.org. Retrieved June 2, 2022, from https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms.

Bhar-Amato J, Davies W, Agarwal S. Ventricular Arrhythmia after Acute Myocardial Infarction: 'The Perfect Storm'. Arrhythm Electrophysiol Rev. 2017 Aug;6(3):134-139. doi: 10.15420/aer.2017.24.1. PMID: 29018522; PMCID: PMC5610731.

Farkas, J. (2021, November 29). Post-mi complications. EMCrit Project. Retrieved June 2, 2022, from https://emcrit.org/ibcc/post-mi-complications/#ventricular_tachycardia.

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 97: EAT and NEAT. 

Your body burns calories not only if you exercise. Sapna, Danish, and Dr. Arreaza explain the different ways you can burn more calories.

Introduction: Energy in and Energy out
By Hector Arreaza, MD. Read by Suraj Amrutia. 

Our bodies are not machines. The simplistic concepts of energy balance, i.e., “energy in and energy out,” are influenced by a myriad of physiological processes and systems that include neurotransmitters, hormones, genetic and epigenetic factors, and many more. The combination of all these processes is called metabolism. The use of energy varies greatly among humans, that is why we come in many shapes and forms. If we apply the principles of thermodynamics to humans, people who eat the same amount of calories, have the same body weight, and have the same level of physical activity should have the same weight. But that theory has been debunked by multiple studies. That explains, for example, why some people who are naturally “thin” can remain thin regardless of their caloric intake and their physical activity. Today we will explain how our bodies use the energy that goes in, or in other words, how we spend our calories. We hope you enjoy this conversation. 

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.

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EAT and NEAT. 
By Hector Arreaza, MD; Sapna Patel, MS IV; and Danish Khalid, MS IV.  

A: Energy expenditure is the amount of energy people need to carry out their physical functions. Energy expenditure is made up of resting metabolic rate, physical activity, and dietary thermogenesis. The widest variance in energy expenditure among most individuals is physical activity.

S: For individuals with moderate physical inactivity the distribution of energy expenditure is:

~70% resting metabolic rate, ~20% physical activity, ~10% diet-induced thermogenesis.

D: Exercise Activity Thermogenesis (EAT) consists of physical activity that is planned, structured and repetitive done with the purpose of improving our well-being. Some EAT include sports, gym, etc. 

Just like gasoline for motor vehicles, available energy in muscle (ATP) is used for mechanical work, and some energy is released as heat (thermogenesis). The efficiency in converting ATP to mechanical work is ~30%; it means that out of 100 ATPs produced, 30 result in muscle work. 

A: An increase in body temperature triggers the CNS to cool the body via increased dilation of skin smooth muscle blood vessels, increased heart rate, and increased sweat production – all that help facilitate the release of heat during physical exercise. 

S: Non-Exercise Activity Thermogenesis (NEAT) consists of physical activity that is not typically considered exercise (e.g., maintaining posture, standing, walking, stair climbing, fidgeting, cleaning, singing, and other activities of daily living.) Walking can be considered EAT or NEAT.

NEAT often represents the widest variance in total energy expenditure among individuals. NEAT can range between 150-500 kcal/day, which is often greater than bouts of exercise. 

D: NEAT is an example of a behavioral factor to explain the perception that some people are “naturally skinny” and can maintain a healthier body weight compared to others, even with the same caloric intake and same routine “exercise” activity. Increasing your number of steps per day can be achieved by altering daily activity, or by scheduled walking/running. 

S: For example: Parking far away, taking the stairs instead of the elevator, going to your coworker’s office instead of calling.

A: You can monitor your number of steps per day with a pedometer or other tracking device (cell phone). The number of steps recorded by different pedometers can vary.

D: Less than 5,000 steps/day is average for U.S. adults, and it is considered sedentary.

S: 5,000 – 7,5000 steps/day is low active, and 7,500 – 10,000 steps/day is somewhat active.

A: More than 10,000 steps/day is desirable (active). 

10,000 steps per day x 7 days per week x one calorie per 20 steps = 3,500 calories burned per week.

D: On average, 1 calorie is “burned” for every 20 steps, it means 4,000 steps / 20 = 200 calories.

S: Definition of rest days. Rest days are any days that don’t involve heavy lifting and focus on cardio or core exercises. Rest days are an important part of any exercise routine as it gives your body a chance to repair and recover. At least one rest every week. 

D: On the other hand, workout days involve heavy lifting: push, pull, legs, etc. For example, on rest days I do cardio and abs.

Conclusion: Now we conclude our episode number 97 “EAT and NEAT.” Keep in mind the ways your body uses the energy you put in. Energy is used by our resting metabolic rate, our exercise activity thermogenesis (EAT), our non-exercise activity thermogenesis (NEAT), and our food-associated thermogenesis (the energy we burned while we eat). We tend to underestimate the power of NEAT, but parking your car far away, taking the stairs, and increasing your daily steps can make a big difference in your daily energy expenditure. Let’s remember the virtues of physical activity to promote good health. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Sapna Patel, and Danish Khalid. Audio edition: Suraj Amrutia. 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:

Levine JA. Nonexercise activity thermogenesis (NEAT): environment and biology. Am J Physiol Endocrinol Metab. 2004 May;286(5):E675-85. doi: 10.1152/ajpendo.00562.2003. Erratum in: Am J Physiol Endocrinol Metab. 2005 Jan;288(1):E285. PMID: 15102614.

Bays, Harold E. and William McCarthy, Obesity Algorithm® 2021©, Obesity Medicine Association. 

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 96: Tirzepatide. 

By Maria Beuca, MS3, Ross University School of Medicine. Comments by Hector Arreaza, MD. 

Today is May 19, 2022, and we want to talk about a new drug that was recently approved by the FDA on May 13, 2022, for the treatment of type 2 diabetes. 

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.

This drug is known as tirzepatide, also known by the brand name Mounjaro®. It is an injection given once a week that mimics the effects of two hormones: GIP (Glucose-dependent Insulinotropic Polypeptide) and GLP-1 (Glucagon-Like Peptide-1). These two hormones are involved in lowering blood glucose levels after eating by stimulating insulin release, they are “incretin” hormones. 

What is unique about this new drug, tirzepatide, is that it is the first and only approved single molecule that binds and activates BOTH GIP and GLP-1 receptors. Because of this dual incretin action, it has also been referred to as a “twincretin.” It increases first and second-phase insulin secretion AND decreases glucagon levels in a glucose-dependent manner, and this lowers both fasting blood glucose levels and post-meal glucose levels. 

It is also an appetite suppressant, causing significant weight loss in patients with type 2 diabetes. 

Tirzepatide vs semaglutide: Semaglutide (Ozempic®) was approved for the treatment of type 2 Diabetes in December 2017, and then approved for weight loss in June 2021 under the brand name Wegovy®. 

Semaglutide is a GLP-1 receptor agonist, but it does not work on GIP receptors. Due to this dual incretin action of tirzepatide, it has now been shown to be superior at all doses to semaglutide. 

Evidence: There was a 40-week study done in July 30, 2019- February 15, 2021, called “SURPASS-2” where 1879 patients were assigned in a 1:1:1:1 ratio to either semaglutide 1 mg or to the 3 different doses of tirzepatide (5 mg, 10 mg, 15 mg). The patients all had a mean HbA1c of 8.28% at the start of the study. 

By the end of the study, the patients on tirzepatide at the different doses had an A1c of 6.2% for the 5mg dose, 6 % for the 10 mg dose, and 5.9% for the 15 mg dose, whereas the patients on semaglutide had their HbA1c at 6.42%.

On tirzepatide, about 82-86% of patients decreased their HbA1c below 7.0%, compared to 79% of the patients on semaglutide.

Comment: It seems like a race: All GLP-1 RA are competing to reach the lowest A1C and get the lowest weight. What is more amazing is that up until now, an A1c level < 5.7% without a risk of hypoglycemia was not considered attainable with current treatment options, but with tirzepatide, this goal was met. 

Fasting Serum glucose levels prior to treatment: 173. Fasting Serum glucose after treatment with:

Tirzepatide 5 mg: 117.0,     10 mg:  111.3,    15 mg:  109.6. Semaglutide 1 mg: 124.4.

Comment: No hypoglycemia.

Weight loss for patients on Tirzepatide was also greater, patients lost about 4 to 12 lbs more (1.9 to 5.5 kg) than with semaglutide. Weight loss in 40 weeks: Tirzepatide:  5mg: 16 lbs (7.6 kg), 10 mg: 20 lbs (9.3 kg), 15 mg: 24 lbs (11.2 kg). Semaglutide: 12 lbs (5.7 kg).

Other positive effects that many patients experience were: improved lipid profile, blood pressure, liver enzymes, and improved biomarkers of insulin sensitivity.

Another Phase 3 clinical trial of tirzepatide that is currently ongoing is the SURMOUNT-1, which focuses on the weight loss benefits of the drug, and results are expected in 2023. Preliminary data shows that tirzepatide has similar weight loss as bariatric surgery. 

Cost: Tirzepatide (Mounjaro) is a rival for Novo Nordisk’s semaglutide sold as Ozempic and Wegovy. 

Institute for Clinical and Economic Review (ICER) released the final report for tirzepatide cost: $5,500-5,700/year. Semaglutide: Ozempic, Wegovy ~ $16,000/year without insurance. 

Comment: [3 times cheaper]. 4x more expensive in the US, rarely covered by health insurance for weight loss

Administration: 1x week, any time, with or without meals.  Doses: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg. Week 1-Week 4: Start with 2.5 mg injection 1x week. Treatment initiation, not intended for glycemic control. Week 5-Week 8:  Increase to 5.0 mg 1x week. >Week 9: may increase dose another 2.5 mg every 4 weeks as needed for glycemic control. Maximum dose: 15 mg 1x week.

Adverse Reactions: Nausea, diarrhea, decreased appetite, vomiting, constipation, dyspepsia, abdominal pain. 

Drug Interactions:  Delays gastric emptying, can affect absorption of oral medications taken at the same time. Warfarin = monitor more closely.

Contraindications: Type 1 diabetes, pregnancy, personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2: medullary thyroid cancer, parathyroid tumors, and pheochromocytoma). Thyroid c-cell tumors were noticed in rats. Symptoms of thyroid cancer: mass in neck, dysphagia, dyspnea, persistent hoarseness.

Warnings & Precautions:

Pancreatitis: Has been reported in clinical trials. Discontinue if suspected. 

Hypoglycemia: May cause hypoglycemia if used with insulin or insulin secretagogues (sulfonylurea). Reducing dose of these may be necessary.

Hypersensitivity is possible.

Acute Kidney Injury: No dosage adjustment needed, but monitor renal function if patient has renal impairment with severe GI reactions. It may cause nausea, vomiting and diarrheaà dehydrationà acute kidney injury. Can worsen chronic renal disease or renal impairment.

Severe gastrointestinal disease: May cause Gastrointestinal adverse reactions, sometimes severe. Not recommended in patients with severe gastrointestinal disease, may aggravate symptoms, has not been studied.

Acute gallbladder disease: Also has occurred in 0.6% of patients in trials. monitor and follow-up if cholelithiasis is suspected. 

Diabetic retinopathy: Not studied, monitor for complications. Rapid glucose control can cause temporary worsening of diabetic retinopathy, monitor these patients. 

Pregnancy: May cause fetal harm.

Females of Reproductive potential: If using oral contraceptives, switch to non-oral contraceptive or add a barrier method for 4 weeks after starting drug and for 4 weeks after increasing dose.

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Now we conclude our episode number 96 “Tirzepatide.” Maria explained that tirzepatide has a dual effect on both GLP-1 and GIP receptors. The medication has been approved for the treatment of type 2 diabetes, but it has been proven to be very effective for weight loss also, almost comparable to bariatric surgery. Remember the contraindications and side effects of this medication to use it appropriately. The good news with tirzepatide is the cost —almost 3 times lower cost than its main competitor. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza and Maria Beuca.

Audio edition: Suraj Amrutia. 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! 

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References:

Dockrill, Peter. “Experimental Drug Breaks Record for Weight Loss in Latest Clinical Trial Results.” ScienceAlert, 9 May 2022, https://www.sciencealert.com/experimental-drug-breaks-record-for-weight-loss-in-latest-clinical-trial-results.

Frías, Juan P., et al. “Tirzepatide versus Semaglutide Once Weekly in Patients with Type 2 Diabetes: Nejm.” New England Journal of Medicine, 5 Aug. 2021, https://www.nejm.org/doi/full/10.1056/NEJMoa2107519. 

“Label as Approved by FDA. - Pi.lilly.com.” Mounjaro Prescribing Information, Lilly USA, LLC, May 2022, https://pi.lilly.com/us/mounjaro-uspi.pdf. 

Mounjaro. Prescribing Information. Lilly USA, LLC.  May 2022. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi

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 95: Exercise Medicine. 

Exercise can be used as medicine if given at the right dose and frequency. Sapna and Danish explain some principles of exercise medicine. 

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Introduction: Is the monkeypox a hoax?   
By Hector Arreaza, MD.  

Today is May 27, 2022. Before we dig into exercise, I want to share some information about a trending topic.

I remember my lectures on public health in medical school in the late 90s when my teachers taught me about the tremendous accomplishment of humanity in eradicating smallpox. The last natural outbreak of smallpox in the United States occurred in 1949, and the last case of smallpox was recorded in Somalia (Africa) in 1977. Until it was wiped out, smallpox had plagued humanity for at least 3000 years, killing 300 million people in the 20th century alone, but the World Health Organization declared smallpox eradicated in 1980. No cases of natural smallpox have happened ever since, and if you discovered a case of smallpox, I was told by my teachers, you would be awarded one million dollars by the WHO. I did my research online and I could not confirm that information, but I learned that the variola virus (smallpox virus) is kept only in two locations in the planet: the CDC in Atlanta, Georgia, United States and the VECTOR Institute in Koltsovo, Russia.  

Why am I talking about smallpox? Because the monkeypox is a new trending topic in the media. Now as the COVID-19 panorama starts to look somehow comforting, monkeypox is starting to gain more attention in the media. Even the name “monkeypox” sounds terrifying. The CDC issued a health alert on May 20, 2022, about the most recent confirmed case of monkeypox in the United States, but this is not the first case of monkeypox in the US. In 2021 there were two travel-associated cases, and in 2003 there was an outbreak of 47 cases associated with imported small mammals. Cases of monkeypox have been identified in several non-endemic countries since early May 2022; many of the cases have involved men who have sex with men (MSM) without a history of travel to an endemic country. Cases of monkeypox outside of Western and Central Africa are extremely rare, and we hope they continue to be rare. 

Is monkeypox a hoax? Is it real? Only time will tell. For now, let’s be optimistic and hope for a world free of dangerous pandemics. Whether monkeypox will continue to spread or not is still unknown. 

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.

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

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Exercise Medicine. 
By Danish Khalid, MS4, and Sapna Patel, MS4, Ross University School of Medicine

Today is May 12, 2022.

D: Welcome back to our Nutrition Series! Thank you for joining us again! Nutrition is such a big part of medicine, it’s the answer to many chronic diseases and yet it’s the most neglected subject in medicine. Our goal here is to educate not only ourselves but our patients and bring awareness of this discrepancy we’ve created in medicine.

S: If you’re new to this series, I suggest you pause this and listen to the first few episodes as we build upon them each time. In our previous episode, we discussed how the term “diet” brings upon a negative connotation as well as explored various popular meal plans. 

A: Exercise prescription. FITTE (Obesity Medicine Association): Frequency, Intensity, Time, Type, Enjoyment. 

D: As healthcare professionals, time and time again we advise our patients “diet and exercise,” because that’s what we were taught and research has backed for many years. It’s so easily said, yet the words carry such weight. But what does that really mean? Well, that’s what we’re here to explore. At least the latter part, exercise.  

S: extra fries?

D:Or shall I say, “physical activity?” Again, just like the word “diet,” “exercise” has similar negative connotations. Thus, let’s avoid saying “exercise” and resort to words such as “physical activity or workout.” Disclaimer: What we discuss here today is focused directly towards those who are beginners. For those of you who are more experienced, this may benefit as a reminder of the foundations.  

A: Screen your patients. 95% of patients will benefit from exercise, and most do not need a special test. Only 5% of your patients may require additional testing. 

S: So what is the best workout for me, you, or our listeners? Well, as simple as that sounds, it’s not that simple. Especially nowadays, where information is at the tips of our fingers, it is so easy to get confused on how to start. But let’s start by establishing your fitness goals. Do you want to lose fat, gain muscle, or gain muscle while losing fat?  

S: Once you’ve figured that out, then it's all about small steps and achievable goals. Oftentimes, individuals start their journey to healthy living with unrealistic goals, hoping to achieve them within a few weeks or months when in actuality it takes longer. This often leads to falling off or reverting back to their unhealthy habits. But small tricks such as reducing the amount of sedentary behavior can do wonders. With technology ruling over our lives, we’ve adapted to this sedentary lifestyle, became comfortable and left physical activity behind. In fact, the National Center of Health Statistics found that only 26% of men, 19% of women, and 20% of adolescents meet sufficient activity levels. 

D: So the first step: Move more, sit less. And for those with a busy lifestyle, some physical activity is better than none. According to the Physical Activity Guidelines published by the US Department of Health and Human Services, for substantial health benefits, adults should do: 

At least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity aerobic physical activity.

Or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity aerobic physical activity. 

And muscle-strength training of moderate or greater intensity that involved all major muscle groups on 2 or more days a week. 

S: How many of you understood that? What does this all mean? Let's break it down. The amount of time for exercise is self-explanatory, but what does moderate or vigorous intensity aerobic physical activity mean? Putting it in simple terms, aerobic physical activity means “cardio”. The level of intensity varies based on the activity you perform. Moderate-intensity activities include a brisk walk or walking on the treadmill at 2.5 to 4mph, playing double tennis, or raking the yard. Whereas, vigorous or high-intensity activities include jogging, running, carrying heavy groceries or objects upstairs, shoveling snow, or participating in a strenuous fitness class. You may have heard of the terms of: low-intensity steady state (LISS) cardio and high-intensity interval training (HIIT) cardio. 

A: In general, if you’re doing moderate-intensity activity, you can talk but not sing during the activity. Vigorous-intensity activity, you will not be able to say more than a few words without pausing for a breath.

D: So what’s the best cardio routine? LISS or HIIT? Well, there’s a lot of potential options. In terms of the best form of cardio for fat burning, there’s one thing you need to prioritize, that is preventing muscle loss. This enables your physique to dramatically improve as you lose weight. 

S: Ok, give us the evidence.

D: One study claimed that HIIT cardio workouts should be included due to its potential muscle sparing properties. HITT training can be done in a fraction of a time as LISS and is a great cardio workout to burn fat. Furthermore, the study  recommended performing lower body cardio workouts, rating bicycling as the most effective method of HIIT. However, HIIT is very demanding on the body as it may cause potential muscle recovery issues, which is why you should also combine it with a few LISS sessions per week as well. And one of the best methods of LISS include doing the stairmaster at 2.5 speed to 4. Furthermore, those looking for a fat burning effect should aim for an effective heart rate level during cardio. To keep it simple, those performing HIIT should aim to keep the heart rate 140-160 beats per minute and for LISS should aim for 110-130 beats per minute, keeping your heart rate elevated will optimize fat-burning effects from cardio. 

S: When should you perform cardio? What’s the best time? Well, studies have shown that the best time to perform cardio sessions should be when you’re not strength training or right after. It was found that participants who performed cardio before strength training experienced greater muscle loss than those who performed it after, or when not strength training. 

And while we’re on this topic, let’s address a myth regarding cardio: Sweating more does not equal more calories burnt. Each individual has a temperature setpoint for sweating. Once you meet that body temperature limit, you start to sweat as your body’s way of cooling down. For example, those from the midwest or east coast deal with a colder climate. Their setpoint is lower than those on the west coast or where the climate is hotter year-round. Thus, these people sweat more than others and easier.

D: How about those whose goals are to gain muscle? Is it the same or different? Don’t worry we haven’t forgotten about you guys. Although, going on a jog, or run, or riding a bike, is an effective way to help you burn some additional calories, and help you get into that hypocaloric state. It doesn’t allow you to build lean muscle tissue to achieve the desired physique many of us want.  The only way to obtain that is by incorporating strength training into your regular exercise regimen. This is why the guideline, as mentioned earlier, recommends strength training in addition to cardio, notice the “AND”. Yes, I’m talking about hitting the weight on a regular basis. 

S: Show me some more evidence.

D: Multiple studies have compared diet alone versus diet + weight training and diet + weight lifting + cardio after. And every single time, those with weight training wins out, especially if it’s the muscular physique you are looking to build. Now, don’t overlook this subtle difference that all exercises are created equal, because it’s not. Well, what training split should I follow then? Does it matter? The total body split, or push pull legs, or the “bro split”? You see, oftentimes people get confused as to which to choose, and that confusion can lead to no choice at all. Do whichever you like, but just make sure you’re doing this, and here’s the key: progressive overload. Adding more weight to allow more strength to build from workout to workout, or phase to phase. Or increasing metabolic overload or demand by keeping the rest time shorter and getting more work accomplished from workout to workout. Whatever strategy you choose, as long as you are striving to push yourself to a higher level of fitness and strength. That’s going to do the job.  

A: Use PT to assist you to design a good physical activity plan, depending on disability or limitations of movements. 

S: Yup I agree, personally I choose to increase each set by at least 10-15lbs, and rest for 30 secs to 1 mins since my goal is to increase my strength and endurance.  

You know what I’ve noticed, Danish? A lot of women refused to lift weights. They want to get fit and toned, but they don’t want to look “bulky”. So, they skip the weights, and perform hours of cardio, or worse - they avoid exercising all together. A common misconception about heavy weight training, especially among women, is that lifting heavy weight will lead to a bulky looking physique. It’s true that lifting heavy will promote hypertrophy in muscles leading to a size increase. However, the idea that it leads to a “bulky” look is untrue.

The true culprit that leads to bulky physiques is fat accumulation. Excessive body fat is what causes both men and women to look bulky. The most important aspect of someone’s physique is his or her body fat percentage. A good physique nearly always requires a fairly low body fat percentage to achieve. Lifting heavy can help accomplish this.

D: What about the hormones? 

S: Testosterone, or the lack thereof, is one of the main reasons that women won’t get bulky from lifting weights. Testosterone is a natural anabolic steroid, which directly stimulates muscle growth. And, on average, women only have one seventh the amount of testosterone as men. So, as usual, that means women have to work harder. But it also means you don’t really need to worry about bulking up. Heavy weight training has a plethora of benefits that can help develop muscle, shed fat, increase metabolism and ultimately lead to anyone’s desired physique.

D:Another question that gets asked a lot: which workouts will help me lose my belly fat? Should I do a lot more abdominal workouts? Although there’s so much more to this question. The simple answer: None. You cannot specifically target belly fat. Your body has its own way of allocating fat distribution, different areas in men and women. Similarly, when you lose fat, you’ll oftentimes notice different areas losing more fat first. Don’t get discouraged and be patient. As the results will come. One advise, take weekly pictures for comparison. It is said and accepted by many that it takes 4 weeks for you to see your body change, 8 weeks for friends and family to notice, and 12 weeks for the rest of the world. So keep grinding. 

And last but not least, it’s important that we reiterate: physical activity only supports and aids your eating lifestyle. It will not combat a poor eating lifestyle. Proper eating habits are 80% (relative number). So keep your eating habits in check. 

S:Well, that’s all we’ve got for today. If you liked this and found this helpful, feel free to reach out and let us know. It’s always a pleasure to hear from our listeners and motivates us to do more. And before we end this episode, we’d like to know: What do you want to hear about next? What questions do you have? Or something you don’t completely understand? Let us know and we’d be happy to learn with you. Till next time. Take care!

A: Email [email protected] 

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[Music to end: Your Choice]

Now we conclude our episode number 95 “Exercise Medicine.” Sapna and Danish reminded us that the US Department of Health & Human Services recommends 150-300 minutes a week of MODERATE-intensity aerobic exercise AND  muscle-strength training 2 or more days a week. Most of your patients will benefit from exercise, only a minority may have contraindications to exercise, in such cases, make sure you perform a proper evaluation, even a cardiology referral, before sending them to the gym.

This week we thank Hector Arreaza, Danish Khalid, and Sapna Patel. 

Audio edition: Suraj Amrutia. 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! 

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References:

Wilson JM, Marin PJ, Rhea MR, Wilson SM, Loenneke JP, Anderson JC. Concurrent training: a meta-analysis examining interference of aerobic and resistance exercises. J Strength Cond Res. 2012 Aug;26(8):2293-307.

Wisloff, Ulrik; Ellingsen, Oyvind; Kemi, Ole J.High-Intensity Interval Training to Maximize Cardiac Benefits of Exercise Training?, Exercise and Sport Sciences Reviews: July 2009 - Volume 37 - Issue 3 - p 139-146.

Ratamess NA, Kang J, Porfido TM, Ismaili CP, Selamie SN, Williams BD, Kuper JD, Bush JA, Faigenbaum AD. Acute Resistance Exercise Performance Is Negatively Impacted by Prior Aerobic Endurance Exercise. J Strength Cond Res. 2016 Oct;30(10):2667-2681.

Foster C, Farland CV, Guidotti F, Harbin M, Roberts B, Schuette J, Tuuri A, Doberstein ST, Porcari JP. The Effects of High Intensity Interval Training vs Steady State Training on Aerobic and Anaerobic Capacity. J Sports Sci Med. 2015 Nov 24;14(4):747-55.

Michael A. Wewege, Imtiaz Desai, Cameron Honey, Brandon Coorie, Matthew D. Jones, Briana K. Clifford, Hayley B. Leake, Amanda D. Hagstrom. The Effect of Resistance Training in Healthy Adults on Body Fat Percentage, Fat Mass and Visceral Fat: A Systematic Review and Meta-Analysis. Sports Medicine, 2021.

Demco, Sonja. “Why Women Will Not Get Bulky Lifting Weights.” Demcofitness, 21 Oct. 2019, https://www.demcofitness.com/single-post/Why-Women-Will-Not-Get-Bulky-Lifting-Weights.

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 94: Elevated Alk Phos. 

Akhil explains what to do when the alkaline phosphatase is elevated, including labs, imaging and other studies. 

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.

Elevated Alk Phos. 
By Akhil Patel, MS4, American University of the Caribbean. Comments by Hector Arreaza, MD.

Serum alkaline phosphatase: When you find elevated serum alkaline phosphatase, you must consider the two most common sources: the liver and bones. Other sources to consider include the third-trimester placenta, intestine, and kidneys. To determine if the abnormal elevation of alkaline phosphatase has clinical significance, you need to consider if it is a physiological or pathological elevation first. 

Ruling out physiological concerns: Typically, you should rule out physiological causes first as they are fewer and easier to determine via patient history. This can be even quicker to determine but also sometimes bypassed if a patient’s history and labs present with more concerning etiologies of pathological elevation.

Common causes of physiological elevations in alkaline phosphatase include pregnancy, patients with blood type O and B after eating a fatty meal, and younger children. 

Pregnancy: During pregnancy women in their third trimester will have elevated serum alk phos from the placenta. 

Blood type: During digestion, alk phos is released from the intestines in patients of blood type O and B. A postprandial increase can be 1.5 to 2 times the upper limit of normal in these patients, however, there is no clinical significance. 

Children: Younger children tend to have higher alk phos due to increased bone turnover. You can find a reference range chart online for different age groups. It is possible for alk phos to be up to three times higher in infancy and adolescence reflecting the ages with the highest bone growth velocity. 

Fun fact: Alkaline Phosphatase (also known as ALP) is a natural enzyme present in raw milk. Complete pasteurization will inactivate the enzyme in milk, therefore, presence of alkaline phosphatase in milk is an indicator of failed pasteurization. This is because the most heat-stable bacteria found in milk, Mycobacterium paratuberculosis, is destroyed by temperatures lower than those required to denature ALP.

Evaluation of pathological alkaline phosphatase: 

Degree of elevation: Another consideration is the level of alk phos elevation. If alk phos is at least four times the upper limit of normal, then cholestasis is the likely cause with many specific etiologies to consider. If alk phos is not markedly elevated (four times the upper limit) then the cause is likely not as specific and many different etiologies should be considered whether hepatic or non-hepatic.  

Liver source: 

Common symptoms: Jaundice, abdominal pain, ascites, easy bruising, nausea and/or vomiting, choluria, acholia or hypocholia, unexplained weight loss, fatigue, or anasarca.

If alk phos is elevated along with liver function testing and bilirubin, it is easier to determine the liver etiology (hepatitis, cirrhosis). However, if it is an isolated elevation in alkaline phosphatase, then other sources must be considered more carefully. 

A helpful test at this point is to look at is GGT or serum 5’-Nucleotidase for elevation. Typically, these will be elevated with alk phos if it is of liver origin. If they are not increased, you should consider bone-related etiologies.

-If a hepatic cause is determined, a right upper quadrant ultrasound is the best initial test to determine intrahepatic or extrahepatic causes. This imaging will look at the hepatic parenchyma and bile ducts. Biliary dilation on ultrasound suggests an extrahepatic cause while no dilation suggests an intrahepatic cause. 

Liver source with biliary dilation: CBD is considered dilated when >6mm. 

If biliary dilation is present suggesting an extrahepatic cause, ERCP or MRCP is the next best step in visualizing the cause with choledocholithiasis being the most common cause. Other causes to consider: malignant obstruction, primary sclerosing cholangitis strictures, chronic pancreatitis causing strictures, and AIDS cholangiopathy. 

Malignant obstructions can be from the pancreas, gallbladder, ampulla of vater, bile duct, or distant metastasis. If the results of these tests are inconclusive the next best step is to consider a liver biopsy. 

Liver source without biliary dilation: Without biliary dilation on ultrasound, there is a larger pool of etiologies to consider for intrahepatic causes: drug toxicity, primary biliary cirrhosis, primary sclerosing cholangitis, viral hepatitis, cholestasis of pregnancy, and total parenteral nutrition (TPN). 

Tests: Antimitochondrial antibody (AMA) testing is a good place to start at this point which would suggest primary biliary cirrhosis (PBC) and indicate confirmation with a liver biopsy. Other tests to order at this point include hepatitis panel, EBV and CMV, and possibly pregnancy testing. If patient history and these tests are all negative, the next best step to consider is a liver biopsy if alk phos is significantly elevated more than two times the upper limit of normal. 

Summary: GGT, Liver US, Dilated? -> MRCP, ERCP, CT scan of abdomen and pelvis. Non dilated? AMA, Hepatitis panel, EBV, CMV, pregnancy test.

Fun fact: When Alkaline phosphatase is elevated you can order the test called Alkaline Phosphatase isoenzymes. You will get a result with percentages for each isoenzyme: ALPI – intestinal, ALPL – nonspecific, but mainly expressed in liver, bone, and kidney; ALPP – placental, and ALPG – germ cells.

Nonhepatic evaluation:

With an isolated alkaline phosphatase elevation and normal GGT or serum 5’-Nucleotidase, the first thing to consider is bone-related pathologies involving high bone turnover: Healing fractures, osteomalacia, Paget’s disease of bone, osteogenic sarcoma, bone metastasis, hyperparathyroidism, and hyperthyroidism. Patient history, ordering thyroid and parathyroid function testing, imaging with bone scintigraphy are all important in sorting through the differential of bone-related pathologies. 

Other extrahepatic diseases to consider that have shown elevated alkaline phosphatase include myeloid metaplasia, peritonitis, diabetes mellitus, subacute thyroiditis, uncomplicated gastric ulcer, and sepsis. Each of these has its own work up and an elevated alk phos level has little significance clinically.

Paget’s disease of bone: 

Paget disease of bone is a benign disorder that presents with focal areas of increased bone turnover in one or more skeletal sites. 

Mostly affects male older adults, but female patients can also be affected. Commonly affects the bones of the pelvis, spine, skull, and long bones. 

Pain is the most common symptom, and the presentation of the disease may depend on which bones are affected, the extent of involvement, and the presence of complications. 

Paget’s disease of bone may be asymptomatic, incidental elevated serum alkaline phosphatase levels on routine labs or abnormal imaging tests performed for other reasons can point to Paget’s disease of bone. Other common symptoms include deafness, and tight hats. 

Diagnosis is normally done by plain radiography and serum alkaline phosphatase. Radionuclide scans is used to determine the extent of disease. Treatment with nitrogen-containing bisphosphonates (zoledronic acid, risedronate, and alendronate).

Complications of the disease include arthritis, gait changes, hearing loss, nerve compression syndromes, and osteosarcoma. 

Use serum alkaline phosphatase for assessing treatment response. Early diagnosis of Paget disease of bone is key in the management and patients have a better prognosis when treatment is initiated before complications. Consult with a specialist to confirm the diagnosis and start treatment.

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Conclusion: Now we conclude our episode number 94 “Elevated Alk Phos”. Elevated Alk Phos can be normal in some circumstances, mainly in pregnancy and childhood. You can start a workup when the alk phos is persistently elevated 4 times above the upper limit of normal. The most common causes can be grouped as hepatic and non-hepatic, and the bones is the most common non-hepatic source. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, and Akhil Patel. Audio edition: Suraj Amrutia. 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! 

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References:

Williams, J., & Nieuwsma, J. (2016). Screening for depression in adults. In J. A. Melin (Ed.), UpToDate. Retrieved February 1, 2017, from https://www.uptodate.com/contents/screening-for-depression-in-adults.

Lawrence S Friedman, MD (2020). Approach to the patient with abnormal liver biochemical and function tests. Shilpa Grover (Ed.), UpToDate. Retrieved Maye 12, 2022 from https://www.uptodate.com/contents/approach-to-the-patient-with-abnormal-liver-biochemical-and-function-tests. 

Lawrence S Friedman, MD (2020). Enzymatic measures of cholestasis (eg, alkaline phosphatase, 5'-nucleotidase, gamma-glutamyl transpeptidase). Shilpa Grover (Ed.), UpToDate. Retrieved Maye 12, 2022 from https://www.uptodate.com/contents/enzymatic-measures-of-cholestasis-eg-alkaline-phosphatase-5-nucleotidase-gamma-glutamyl-transpeptidase.

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 93: Hyponatremia treatment.    

Catherine and Dr. Saito discuss how to treat hyponatremia in an effective and safe way, especially when the hyponatremia is severe.

Introduction: What is sodium?
By Hector Arreaza, MD. Read by Alyssa Der Mugrdechian, MD; and Gina Cha, MD.  

Sodium is a white metal that does not exist in nature in its free form. In its solid form, it’s so soft that you could cut it like butter with a knife. It is the sixth most common element in the earth’s crust. Even though sodium only makes up to 0.2% of our body weight, it plays a key role in nerve conduction, muscle contraction, and most importantly regulating water balance. 

Today we will be talking about low sodium, known as hyponatremia. We will focus on how to treat hyponatremia and will mention some common causes and symptoms. We hope you can learn something from us today.

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 physician for additional medical advice.

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Hyponatremia treatment.   
By Catherine Nguyen, MS4, Ross University School of Medicine. Comments by Steven Saito, MD; and Hector Arreaza, MD. 

DEFINITION: Serum sodium concentration <135 mEq/L. 

CAUSES:

-Advanced renal impairment > impairment in free water excretion > hypoosmolality of serum

-Diuretics (thiazides first 1-2 weeks)  

-SIADH (Syndrome of inappropriate ADH, I call it the syndrome of EXCESSIVE ADH to help me remember it), caused by common meds.

-Heart failure (low cardiac output) & cirrhosis (arterial vasodilation impairment) > decreased tissue perfusion (baroreceptors in carotid sinus senses reduction in pressure) > stimulus of ADH

-GI fluid loss (diarrhea, vomiting)

-CNS disturbances (stroke, hemorrhage, infections, psychosis, trauma) > increases ADH release

-Malignancies > ectopic production of ADH (small cell carcinoma)

-Drugs > SSRI, carbamazepine, cyclophosphamide 

-Potomania > patient drinks large amounts of beer and decreased intake of foods (solids).

PRESENTATION:

-Asymptomatic

-Nausea & malaise earliest findings (125-130)

-Headache, lethargy, muscle cramps, confusion/AMS, and eventually seizures, coma, and respiratory arrest (115-120)

-Acute hyponatremia encephalopathy may be reversible, but permanent neurologic damage or death can occur.

TREATMENT: 

Clinic: Chronic cases of hyponatremia may require spread-out treatment. Hyponatremia is never normal.

-Mild hyponatremia > concentration of 130 to 134 mEq/L: NO treatment with hypertonic saline. Rather, the initial approach includes general measures that are applicable to all hyponatremic patients (i.e., identify and discontinue drugs that could be contributing to hyponatremia; identify and, if possible, reverse the cause of hyponatremia; and limit further intake of water [e.g., fluid restriction, discontinue hypotonic intravenous infusions].

-Moderate hyponatremia > concentration of 120 to 129 mEq/L 

ASYMPTOMATIC - 50 mL bolus of 3 percent saline (ie, hypertonic saline) to prevent the serum sodium from falling further.

SYMPTOMATIC – (call ICU) 100 mL bolus of 3 percent saline, followed, if symptoms persist, with up to two additional 100 mL doses (to a total dose of 300 mL); each bolus is infused over 10 minutes.

-Severe hyponatremia > concentration of <120 mEq/L (call ICU) 

INITIATE intravenous 3 percent saline beginning at a rate of 15 to 30 mL/hour, administered via a peripheral vein. 

ALTERNATIVE OPTION is to give 1 mL/kg (maximum, 100 mL) boluses of 3 percent saline intravenously every six hours, with dose modification as needed. Some patients may also require desmopressin (dDAVP) to prevent overly rapid correction.

Osmotic demyelination syndrome:

-Brain adaptations that reduce the risk of cerebral edema makes the brain vulnerable to injury if chronic hyponatremia is too rapidly corrected. 

-Large cohort study has shown that correction by less than 5 mEq/L per day was not associated with neurologic complications.

-More common when Na is <120 mEq/L.

-Symptoms include dysarthria, dysphagia, paraparesis or quadriparesis, behavioral disturbances, movement disorders, seizures, lethargy, altered mental status, and even coma.

MONITORING:

-Monitor the patient for symptoms and remeasure the serum sodium concentration hourly to determine the need for additional therapy. 

-Monitoring can be spaced out when the serum sodium has been raised by 4 to 6 mEq/L to every 12 hours until the serum sodium is 130 mEq/L or higher.

-The rate of correction of hyponatremia should be 6 to 12 mEq per L in the first 24 hours and 18 mEq per L or less in 48 hours.

-Fluid restriction — Restriction to 50 to 60 percent of daily fluid requirements. In general, fluid intake should be less than 800 mL/day. 

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Conclusion: Now we conclude our episode number 93 “Hyponatremia treatment.” Remember to correct sodium appropriately, especially in case of severe hyponatremia. Use hypertonic saline in patients with acute hyponatremia with sodium below 129, especially if they are symptomatic. Sodium should be corrected at a rate of 6 to 12 milliequivalents per liter in 24 hours, or less than 18 milliequivalents per liter in 48 hours. If done at a higher rate, there is a risk of causing the osmotic demyelinating syndrome. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Catherine Nguyen, Steven Saito, Alyssa Der Mugrdechian and Gina Cha. Audio edition by Suraj Amrutia. 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! 

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References:

Sterns, Richard H, MD. Overview of the treatment of hyponatremia in adults, UpToDate, June 11, 2021, https://www.uptodate.com/contents/overview-of-the-treatment-of-hyponatremia-in-adults. Accessed on May 11, 2022.

Sterns, Richard H, MD. Manifestations of hyponatremia and hypernatremia in adults, UpToDate, January 10, 2022. https://www.uptodate.com/contents/manifestations-of-hyponatremia-and-hypernatremia-in-adults. Accessed on May 11, 2022. 

Osmotic demyelination syndrome (ODS) and overly rapid correction of hyponatremia, UpToDate, March 14, 2022, https://www.uptodate.com/contents/osmotic-demyelination-syndrome-ods-and-overly-rapid-correction-of-hyponatremia. Accessed on May 11, 2022.

Goh KP. Management of hyponatremia. Am Fam Physician. 2004 May 15;69(10):2387-94. PMID: 15168958.

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!