Rio Bravo qWeek

Episode 92: Paleo vs Keto vs Mediterranean. 

Sapna and Danish explain the main differences between three meal plans: Paleo, Keto, and Mediterranean. Intro about fad diets.

Introduction: Fad diets.  
By Hector Arreaza, MD.  

It is estimated that 2/3 of Americans are overweight or have obesity (73% of men and 63% of women), but only 19% of people claim to “be on a diet”, and 77% of people are trying to “eat healthier”[1]. It seems like many of us are on the weight-loss wagon together, hoping for a cure for this disease.

These days it is commonplace to hear about fad diets. Fad diets are short-lived eating patterns that make unrealistic claims about weight loss and improving health, with little to no effort on your part. “The Super-Duper diet will make you lose 100 pounds, eliminate your cellulite, erase stretch marks, remove your wrinkles, and give you extra energy to fly to the moon and back, buy the super-duper diet now!” We surely have a lot of products that make senseless promises, claim many victims, and leave people with empty pockets.   

Today is May 6, 2022. Sapna and Danish will enlighten us again with more nutrition discussions. When you go around your grocery store, have you wondered what “keto-friendly” really means? We hope after today, you get a better idea about it. Today we are presenting a brief discussion to compare three common dietary approaches for weight loss: Keto, Paleo, and Mediterranean. I’m sure you have heard some things about these diets, but we want to add to your fund of knowledge. Whether they are fad diets or not, we’ll let you decide. Enjoy it!  

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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Paleo vs Keto vs Mediterranean. 
Prepared by Sapna Patel, MS4, and Danish Khalid, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.

Welcome back to our Nutrition series!

D: In our previous episode, we talked about calorie balance and macronutrients. The basics of nutrition. So, if you haven’t already listened to that, pause this, and go listen to that first. As we will only continue to build on that knowledge. Now, let’s begin…

S: Whether your goals are to lose fat or gain muscle. Nowadays, we’ve got so many ways to achieve our nutritional goals. It can be difficult and overwhelming to know which one is best for you. So today,  we will talk about some of the main “diets'' that are well known to all.

Comment: People hate the word “Diet”, should we call them meal plans or Nutrition plans?

S: The Paleo meal plan. The Ketogenic meal plan. The Mediterranean meal plan. And as we go through each of them, we will compare them and discuss which fit certain nutritional goals.

Comment: These meal plans are very trendy right now, some people call them fad diets, but only time can tell if these diets really work long term or not.  

D: Let’s start with the Paleo meal plan. What is it? Also known as the Paleolithic diet, Caveman diet, or Stone-Age diet, this meal plan revisits the way humans ate almost 2.5 million years ago—The hunter-gatherer lifestyle. Overall, the meal plan is high in protein, moderate in fat (mainly unsaturated fats), low-moderate in carbohydrates (restricting high-glycemic carbohydrates), high in fiber, and low in sodium and refined sugars. It includes mainly lean meats, fish, fruits, vegetables, nuts, and seeds.

Comment: It is low in carbs because carbs were so rare and uncommon in nature before agriculture was introduced to humanity. Animals (including humans) had to wait until the season when the fruit was ripe to enjoy something sweet.

S: So, what are some of the benefits of the Paleo meal plan? Well, studies have shown that the paleo meal plan produces greater short-term benefits, including

-          Greater weight loss

-          Reduced waist circumference

-          Decreased blood pressure

-          Increased insulin sensitivity

-          Improved cholesterol

D: You must be wondering, what’s the catch? Aside from the diminishing long-term effects. Although the meal plan focuses on many essential food groups, it also omits others such as whole grains, dairy, and legumes. This could lead to suboptimal intake of important nutrients. Additionally, the restrictive nature of the meal plan may also make it difficult for people to adhere to such a meal plan in the long run. With these confounding facts, there hasn’t been a strong link that the paleo meal plan improves cardiovascular risk or metabolic disease.

S: Basically, for those looking for a cleaner meal plan, the paleo meal plan is geared towards eliminating high-fat and processed foods that have little nutritional value and too many calories. Moving on to the Ketogenic Meal plan.

D: What is the Ketogenic Meal plan? Basically, the ketogenic meal plan is a high fat, moderate protein, and low carb lifestyle. It’s about creating ketones. For example, beta-hydroxybutyrate, acetoacetate, and acetone. Ketones are basically a fourth macronutrient. Although we don’t find it in our day-to-day food, it’s what our body creates.

So why do we need ketones, and why does our body create them in the first place? Our body uses carbohydrates, more specifically glucose, as the major source of energy for its daily needs. So, imagine, when we are in periods of starvation and deprive ourselves of carbohydrates. The body would resort to breaking down protein to create glucose for our demanding body in a process called gluconeogenesis. That seems illogical, right? Why would our body break down muscle?  That is where ketones come in. While our body is trying to keep up with demands, our liver is working on creating another source of energy. A process called ketogenesis, where ketones are made through fat, more specifically medium-chain fatty acids, to fuel our body.

S: So, what’s so great about the Ketogenic Meal plan? Well, for starters, during ketogenesis due to low blood glucose feedback, the stimulus for insulin secretion becomes low, which sharply reduces the stimulus for fat and glucose storage. Additionally, people will initially experience rapid weight loss up to 10 lbs. in the first 2 weeks or less. Although the first few pounds may be water weight loss due to the diuretic effect of this meal plan, eventually you obtain fat loss.

In this meal plan, lean body muscle is largely spared. So those who are overweight individuals with metabolic syndrome, insulin resistance, and type II diabetes mellitus, are more likely to see improvements in clinical markers for disease risk. Additionally, reducing weight, mainly truncal obesity, may help improve blood pressure, blood glucose regulation, triglyceride levels, and HDL cholesterol.

D: That sounds awesome! What do I have to eat? Well, the dietary macronutrients are divided into approximately 55-60% fats, 30-35% protein, and 5-10% carbohydrates. Specifically, no more than 50 grams of carbohydrates.

Comment: The difference between ketosis and ketoacidosis is a frequent question done by patients and medical providers. The main difference is that in ketosis your glucose level is normal or low and your pH is still physiologic, but in ketoacidosis, the pH is lower than 7.35 and glucose is above 250 mg/dL. So, when a person is in ketosis, you will not see the, for example, Kussmaul’s breathing pattern, but in ketoacidosis, you will see that breathing pattern. If you want more info about the keto meal plan, you can listen to our episode 59, done by a great medical student Constance.  

S: Finally, the Mediterranean meal plan.

The hallmark of this meal plan is simple…minimally processed foods. The main characteristic of a Mediterranean meal plan includes a low-moderate protein intake (very low consumption of red meat, moderate consumption of fish and shellfish), moderate-high fat (rich in unsaturated fats, lower in saturated fats), and moderate to high carbohydrates (legumes, unrefined grains). A very different take from the previous two meal plans.

D: What is the hype all about? Why year after year does the Mediterranean meal plan come out on top? Well, the reason why it’s one of the better options is because of the style of eating. It encourages vegetables and good fats (limiting bad fats) and discriminates against added sugar. No preservation, no packaging, no processing. This style of eating plays a big role in preventing heat disease, and reducing risk factors such as obesity, diabetes, high cholesterol, or high blood pressure.

S: In fact, numerous studies have shown that the Med meal plan promotes weight loss and prevents heart attacks and helps with type 2 diabetes by improving levels of hemoglobin A1c, blood sugar levels, and decreasing insulin resistance. No wonder why out of all these meal plans, it’s the only one that meets the AHA dietary recommendations.

D: In a meta-analysis of randomized trials including the large PREDIMED trial, a Mediterranean meal plan reduced the risk of stroke compared with a low-fat diet (HR 0.60, 95% CI 0.45 to 0.80) but did not reduce the incidence of cardiovascular or overall mortality. By contrast, in observational studies, a Mediterranean meal plan was associated with lower overall mortality and cardiovascular mortality.

Following a Mediterranean meal plan may lead to a reduction in total cholesterol. For example, in a 2011 meta-analysis of six randomized trials comparing the Mediterranean approach with a low-fat diet in 2650 individuals with overweight or obesity, a Mediterranean meal plan led to a greater reduction in total cholesterol (-7.4 mg/dL, 95% CI -10.3 to -4.4) but a nonsignificant reduction in LDL cholesterol (-3.3 mg/dL, 95% CI -7.3 to +0.6 mg/dL [5]. A Mediterranean meal plan may also decrease LDL oxidation.

S: Additionally, in observational studies, a Mediterranean meal plan was also associated with a decreased incidence of Parkinson disease, Alzheimer disease, and cancers, including colorectal, prostate, aerodigestive, oropharyngeal, and breast cancers. 

Comment: I am excited to try the Mediterranean meal plan when I visit Spain this coming summer. It will be my first time in Valencia. 

Keep in mind, with any meal plan, it will work differently for everyone. Just because it worked for an individual doesn’t mean it’ll work for you. And vice versa. Besides, everyone has different goals we want to achieve, like all of us here.

What do you call someone who can't stick with a meal plan?  A deserter.

Protein

Fat

Carbohydrate

High

Low-Moderate

Moderate

Moderate-High

Moderate-High

Conclusion: Now we conclude our episode number 92 “Paleo vs Keto vs Mediterranean.” The take-home messages are: Paleo is a style of eating that encourages unprocessed foods, mainly lean meats, fruits and vegetables in their natural state; Keto consists of eating less than 50 carbs a day and encourages high-fat foods; and the Mediterranean plan promotes good quality fats from vegetable sources, moderate protein and low to moderate carbs. These meal plans have a main goal in common: help your patients lose weight, improve their overall health, and decrease mortality. Even without trying, every night you go to bed being a little wiser.

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

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:

Weight Loss Industry Analysis 2020, Cost & Trends, franchisehelp.com, https://www.franchisehelp.com/industry-reports/weight-loss-industry-analysis-2020-cost-trends/. Accessed on May 2, 2022. 

Masood W, Annamaraju P, Uppaluri KR. Ketogenic Diet. [Updated 2021 Nov 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.

Taylor B, Rachel M, Adrien B, et al. The Paleo Diet For Health Professionals. In: University of California, Davis - Nutrition. 2018.

Miguel A. Martínez-González, Alfredo Gea and Miguel Ruiz-Canela, originally published on 28 Feb 2019, https://doi.org/10.1161/CIRCRESAHA.118.313348. Circulation Research. 2019;124:779–798.

Gerber, M., & Hoffman, R. (2015). The Mediterranean diet: Health, science and society. British Journal of Nutrition, 113(S2), S4-S10. doi:10.1017/S0007114514003912. 

Colditz, Graham A. “ Healthy Diet in Adults.” UpToDate, 11 Dec 2019, https://www.uptodate.com/contents/healthy-diet-in-adults.

Fitó M, Guxens M, Corella D, Sáez G, Estruch R, de la Torre R, Francés F, Cabezas C, López-Sabater MDC, Marrugat J, García-Arellano A, Arós F, Ruiz-Gutierrez V, Ros E, Salas-Salvadó J, Fiol M, Solá R, Covas MI; PREDIMED Study Investigators. Effect of a traditional Mediterranean diet on lipoprotein oxidation: a randomized controlled trial. Arch Intern Med. 2007 Jun 11;167(11):1195-1203. doi: 10.1001/archinte.167.11.1195. PMID: 17563030.

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 91: Nutrition Introduction. 

Sapna Patel and Danish Khalid present the basics of macronutrients and the definition of basic energy expenditure (BEE), they explain basic concepts on macronutrients. 

Introduction: Unable to control the epidemic of obesity 
By Hector Arreaza, MD.  

Today is April 27, 2022. In this episode, we will cover the very basics of classic nutrition. As we know, obesity is reaching epidemic proportions in the United States. Regardless of all the advances in science, we have not been able to control one of the most detrimental diseases in our communities. 

Obesity is among the most difficult to treat chronic diseases. There are countless recommendations about what to eat and not to eat, best workouts, miraculous shakes, magical weight-loss supplements, innovative devices, promising programs, novel medications, and the latest surgeries, however, we still have millions of patients who are suffering every day the consequences of undiagnosed and untreated obesity. We are hoping this is the first of multiple episodes addressing the problem of obesity, we hope you enjoy it.  

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 provider for additional medical advice.

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Nutrition Introduction. 
By Sapna Patel, MS4, and Danish Ross University School of Medicine. Comments by Hector Arreaza, MD. 

Obesity is a disease when the patient has excessive body fat resulting in “sick fat disease” with metabolic consequences or “fat mass disease.” Excessive body fat is caused by genetic or developmental errors, infections, hypothalamic injury, adverse reactions to medications, nutritional /energy imbalance, and/or adverse environmental factors. Let us talk about one of the pillars of the treatment of obesity.

S: Hi, my name is Sapna Patel. I am a 4th-year medical student. I am passionate about fitness and cooking. I have been active all my life doing soccer, taekwondo, kickboxing, and weightlifting. I am joined here today with Danish. 

D: Hi, my name is Danish. I am also a fourth-year medical student. I have a background in mixed martial arts, boxing, and karate. And just like Sapna, I too am passionate about fitness, and nutrition. 

S: Today we are here to talk about nutrition. One of the most neglected subjects in medicine, yet the most important subjects. As we speak, we are sitting in Kern County, which has the highest obesity rate in the whole state of California with more than 60% of the population considered overweight. Poor nutrition is the leading cause of people being overweight and obese, and in turn, obesity leads to various other medical conditions. 

It is important to educate ourselves on nutrition, not only as medical professionals but as someone who lives in the most obese country. And it is as simple as knowing how to balance calories and macronutrients. 

D: To maintain a healthy weight and lifestyle over time, it is important that we maintain caloric balance. Oftentimes we tend to overeat, tipping us into a caloric surplus. This leads us to being overweight and obese which are the most important factors associated with poor health outcomes. It is associated with premature mortality as well as increased incidence of cardiovascular disease, diabetes, hypertension, cancer, and other important conditions. Calculating total energy expenditure for recommended daily caloric intake is based on age, sex, weight, and activity level.

Basal Energy Expenditure (BEE) (male/female): 66.5 + (13.5/9.5 x weight (kg)) + (5/2 x height (cm)) - (7/5 x age).

S: Another easier way to know your basal energy expenditure, is to use the table made by the USDA guideline which has an average estimate energy expenditure per day based on age, sex, activity level. Or a lot of bodybuilders use a rough calculation for basal energy expenditure which is: 

Formula = BW (lbs) x 14-16 (where 14=moderately active, and 16=very active) 

For example, one of my goals is to increase muscle mass. And based on the calculations, my BEE is 1458 kcal/day with my current activity level. Thus, if I wanted to gain muscle without gaining fat, I would have to keep to this number. Whereas, Danish I know you have a different goal

D: Yes so, one of my goals is to achieve fat loss. For me, my basal energy expenditure is 2400 kcal/day with my current activity level. However, this number is to maintain my current weight. If I need to lose weight, I will have to subtract calories from my daily balance. Typically, I would subtract 500 kcal/day, as this allows for a fat loss of 1 pound per week or 3500 kcal/week. 

Many should aim for 0.5 pounds to 2 pounds per week, but nothing more than 2 pounds as this could lead to undesirable appearances such as excess skin. If you are looking to gain weight, it is the same concept, however the opposite. You add calories instead. Of course, it is not as simple as just over-eating. That is where macronutrients come in, it is important to balance your proteins, fats, and carbohydrates. 

S: On that note, let us talk about macronutrients. Macronutrients are the chemical compounds consumed in the largest quantities and provide bulk energy. The three primary macronutrients include proteins, carbohydrates, and fats. Let us start with protein. 

D: Protein should make up 10- 35% of total caloric intake, as recommended by the United States Dietary Guidelines. Or consume 0.8-1.2 grams of your body weight in pounds. 

Common sources of dietary protein include whole foods such as fish, eggs, lean meat, vegetables (specifically peas, lentils, soybeans), and protein powders such as casein, whey, and soy. 

S: So, for me being a vegetarian, I must only rely on eggs, vegetables, and milk proteins.

In terms of milk protein, there are two different types, rapidly versus slowly digested. Rapidly digested milk proteins are what we see termed whey or soy protein. Whereas slowly digested milk proteins are termed casein.

Whey hydrolysate and soy are digested and absorbed quickly, only 90 mins after you consume whey. It delivers essential amino acids, branched-chain amino acids, and leucine, making it the perfect end to your workouts, as it will kickstart the muscle repair and rebuilding process. 

Casein protein provides your body with a slow, steady release of amino acids, and stay elevated in your blood for 4-5hrs after you consume it. making it ideal before fasting situations, such as sleep. The peptides found in casein work similarly to ACE-I (angiotensin converting enzyme inhibitors) and lower blood pressure and reduce the formation of blood clots.  It also contains several bioactive peptides that are beneficial to your digestive system.

D: Let's move on to fats. Fat should make up 20- 35% of total caloric intake, as recommended by the United States Dietary Guidelines. The type of fat consumed is more important than the amount of total fat. There are technically 4 types of fats: saturated, trans, mono- and polyunsaturated fats. 

Saturated and trans fats contribute to coronary heart disease, while mono/polyunsaturated fats are protective. The major sources of saturated fats include butter, ghee, ice creams, sausages, bacon, and cheese with the list going on.  

The major sources of trans fats include margarine and partially hydrogenated vegetable fats. Guidelines recommend limiting consumption of saturated and trans-fat to under 10% of calories per day. The major sources of mono/polyunsaturated fats include omega-3, fish oil, avocados, nuts, and seeds. Furthermore, some evidence shows that long-term consumption of fish oil and n-3 fatty acids reduces the risk of cardiovascular disease. So, the next time you are out shopping, keep an eye on those fats. 

S: Last but not least, carbohydrates. As recommended by US Dietary Guidelines, carbs should make up 45-65% of total caloric intake. Here quantity and type of carbohydrate matter because they can have different effects on postprandial (after meal) glucose levels, termed glycemic index. Studies have shown that diets with a high glycemic index (foods that increase your blood sugar levels substantially) have been associated with developing type 2 diabetes mellitus and coronary heart disease. 

One important way of achieving a healthy diet is to replace carbohydrates having a high glycemic index (e.g., white rice, pancakes) with a low glycemic index (e.g., fruits, vegetables).  Additionally, adding sugars should be limited and comprise no more than 10% of total calories consumed. These added sugars often come from sweetened beverages and almost all processed foods. They should be substituted with naturally occurring sugars in fruits or milk. 

S: As you can see, nutrition is not as simple as just eating the right things. It includes knowing your caloric balance and having the appropriate number of macronutrients. However, it does not just stop there. There is no “whey” we can fit all this information into just one podcast so stay tuned as we continue to further discuss nutrition. 

D: Before we leave, just a few tips. With any goal, diet is 80% of the work whereas exercise is 20%. If your diet is not healthy, it will not matter how much you work out. And lastly, keep consistent and be disciplined. Good day to you all. 

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Conclusion: Now we conclude our episode number 91 “Nutrition Intro.” Sapna and Danish briefly explained the macronutrients needed to maintain our metabolic needs. They presented the concept of basic energy expenditure (or BEE). If you have not memorized that formula yet, don’t worry, it can be easily found online, or calculated by your electronic medical record system. Consider using BEE to help your patients know the number of calories they need to carry out fundamental body functions such as breathing, blood circulation, body temperature, etc. You can recommend your patients subtract about 500 calories from their daily BEE to lose weight. However, Dr. Arreaza also warned that the “calories in-calories out” system may be more challenging than we think because our bodies are very complex. We’ll let you decide what works best for your patients. 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:

Colditz, Graham A. “Healthy Diet in Adults.” UpToDate, 11 Dec. 2019, https://www.uptodate.com/contents/healthy-diet-in-adults

Walle, Gavin Van De. “What's the Difference between Casein and Whey Protein?” Healthline, Healthline Media, 30 Aug. 2018, https://www.healthline.com/nutrition/casein-vs-whey#benefits. 

Tang JE, Moore DR, Kujbida GW, Tarnopolsky MA, Phillips SM. Ingestion of whey hydrolysate, casein, or soy protein isolate: effects on mixed muscle protein synthesis at rest and following resistance exercise in young men. J Appl Physiol (1985). 2009 Sep;107(3):987-92. doi: 10.1152/japplphysiol.00076.2009. Epub 2009 Jul 9. PMID: 19589961.

Dietary Guidelines for Americans, 2020-2025. U.S. Department of Agriculture, USDA, https://www.dietaryguidelines.gov/.

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 90: Vaccines and Acne. 

Updates on pneumococcal and COVID-19 vaccines. Sarah explains the treatment of acne.

New Pneumococcal Vaccine Recommendations. 
Written by Harkiran Bhattal, MS4, Ross University School of Medicine; Timiiye Yomi, MD; and Hector Arreaza, MD.

During the recording, we used brand names because they are easier to use. We are not sponsored by the manufacturers of these vaccines. 

Terminology of pneumococcal vaccines: 

PCV13: Prevnar13®

PPSV23: Pneumovax23®

PCV15: Vaxneuvance® 

PCV20: Prevnar20®

Tips about pneumococcal vaccines:

-Prevnar13 is no longer used in adults. 

-Pneumovax23 is still being used in adults.

-The two newer members of the pneumococcal vaccines are: Prevnar20® (PCV20) and Vaxneuvance® (PCV15).

The following groups of patients are all adults 19-64 with underlying conditions OR >65 years old.

Group A: Unknown or no prior doses of Prevnar13 or Pneumovax 23

Option 1: Prevnar20 given as a single dose

Option 2: Vaxneuvance followed by a dose of Pneumovax23 at least a year later (Consider >8 weeks in patients >19 at the highest risk)

Group B: Previously received Pneumovax 23

Give Prevnar20 or Vaxneuvance (at least 1 year since the last Pneumovax 23)

Group C: Previously Received Prevnar13

Give Pneumovax23 or Prevnar20 (if Pneumovax 23 is not available) >1 year since last dose of Prevnar13

Group D: Previously completed series of Prevnar13 and Pneumovax23 in any order

No additional doses are needed.

Scenario 1: 68 yo M who has not previously received PCV or whose previous vaccination history is unknown (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by a dose of Pneumovax23.

Scenario 2: 25 yo F with HIV not previously received PCV or whose vaccination history is unknown (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by

a dose of Pneumovax 23 given 8 weeks later. This patient is in the highest risk group.

Scenario 3: 50 yo M with chronic alcoholism who has not received any vaccine or unknown status (Group A). This patient should receive: 1 dose of Prevnar20 and be done, or Vaxneuvance followed by Pneumovax 23 one year later.

Scenario 4: 43 yo M with previous Pneumovax 23 only (Group B). This patient should receive either: a single dose of Prevnar20 or Vaxneuvance and be done with either vaccine. Give either vaccine at least 1 year after Pneumovax 23.

Scenario 5: 25 yo F with CSF leak and previously received Prevnar13 (Group C). This patient should 

receive Pneumovax23 or Prevnar 20 (if Pneumovax 23 is unavailable) at least one year after her las Pneumovax dose.

Scenario 6: 35 yo M who previously completed Prevnar13 and Pneumovax in any order because he has a cochlear implant (Group D). This patient should NOT receive any additional dose.

Research and Monitoring

CDC and ACIP will continue to assess the safety of Vaxneuvance and Prevnar20 vaccines (the new kids on the block), monitor the impact of the implementation of new recommendations, and assess post-implementation effectiveness and recommendations as appropriate.

Examples of risk factors to consider administration of pneumococcal vaccines: Chronic renal failure, HIV infection, alcoholism, cigarette smoking, chronic heart, liver, and lung disease. For a complete list of conditions, visit CDC.gov.

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A second booster shot of COVID-19 vaccines. 
By Hector Arreaza, MD.

On March 29 and 30, 2022, CDC announced that a second booster dose of any mRNA COVID-19 vaccine may be given to certain individuals who are at risk of severe outcomes from COVID-19(1). 

Individuals who may choose to receive a second booster are: 

1. People older than 12 years of age who have a moderate to severe immunocompromising condition. Remember, use Pfizer for older than 12 yo, and Moderna for older than 18 yo.

2. People older than 50 years of age who are NOT moderately or severely immunocompromised.

3. People 18-49 years of age who are NOT immunocompromised but received the J&J COVID-19 vaccine as both the primary and booster dose. 

When can you receive the second booster shot? At least 4 months after the first booster dose.

Who is considered up to date? A person is considered up to date when he/she has received all recommended doses in their primary vaccine series, and a booster dose when eligible. A second booster dose is not required to be considered up to date at this time.

Underlying medical conditions associated with higher risk for severe COVID-19 include: Cancer, obesity, cerebrovascular disease, diabetes mellitus, HIV, obesity, COPD, smokers, and chronic liver disease.

Comment: Remember to give the second booster to your patients. 

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Acne Treatment.  
By Sarah Park, MS3, University of California Los Angeles. Discussed with Hector Arreaza, MD.  

Definition: Acne vulgaris is a common inflammatory disorder of the pilosebaceous unit, which includes the hair follicle and sebaceous gland. It is characterized by chronic or recurrent development of papules, pustules, or nodules commonly on the face, chest, or upper back.(1,2) Acne affects nearly 50 million people in the U.S. per year and can cause significant psychological distress in those who are affected. It primarily begins at puberty when the production of androgens and/or sensitivity of androgen receptors increase, thereby commonly affecting adolescents and young adults.(2) 

Pathophysiology: The pathophysiology of acne involves four main processes: 1) sebum overproduction, 2) hyperkeratinization of the follicle, 3) bacterial colonization by Cutibacterium acnes, and 4) inflammation.(2,3) It can be classified as mild, moderate, or severe based on the extent and types of lesions.3

Treatment: Treatment is selected based on the severity of the condition, patient preference, and tolerability. Acne treatment often requires long-term, consistent use of one or more medications.(3) The main objective of treatment is to decrease sebum production, get rid of extra keratin, treat infection and decrease inflammation. You can warn your patients that their skin may feel dryer and more scaly than usual, but that’s part of the treatment. 

For mild and exclusively comedonal acne, topical retinoids like tretinoin are the treatment of choice(4), but topical retinoids can be used in any level of severity for maintenance. Examples: Adapelene, tazarotene, and tretinoin, 

For mild inflammatory papulopustular acne or mild mixed comedonal and papulopustular acne, topical retinoids may be used in combination with antimicrobial therapy (either combined with benzoyl peroxide or combined with benzoyl peroxide plus clindamycin or erythromycin). If patients cannot tolerate a topical retinoid, alternatives include salicylic acid and azelaic acid. Of note, oral or topical antibiotics should only be used in combination with benzoyl peroxide and retinoids for a maximum of 12 weeks. 

If unresponsive to these topical therapies, namely retinoids, benzoyl peroxide, and/or clindamycin, alternative therapies may be initiated. These include topical dapsone, minocycline, and clascosterone.

Topical dapsone is an effective treatment for both inflammatory papulopustular and comedonal acne lesions. 

Topical minocycline is an alternative topical antibiotic used for specifically moderate to severe acne. 

And last but not least is topical clascosterone, a relatively new topical (specifically an androgen receptor inhibitor) approved by the FDA in 2020.(4)

Treatment for moderate to severe acne: For moderate to severe acne vulgaris, management is systemic therapy. This includes oral antibiotics or hormonal therapies, often used in conjunction with topical therapy, or monotherapy with oral isotretinoin. 

1. Oral antibiotics for acne vulgaris include doxycycline, minocycline, and sarecycline. Treatment should be limited to three to four months.(5)

2. For female patients, hormonal therapy with oral contraceptives and/or spironolactone is also an option. A meta-analysis comparing oral contraceptive therapy and oral antibiotic therapy suggests similar efficacy for the treatment of acne. OCP treatment is often the first-line choice for hormonal therapy, especially for patients who desire the added benefit of contraception. Spironolactone is often used for patients who have contraindications to OCP therapy or prefer to avoid OCPs. Both methods work to inhibit acne by reducing the effects of androgen on the pilosebaceous unit.5

3. For severe, extensive, nodular acne vulgaris, oral isotretinoin is the drug of choice. It is given as a monotherapy and is often used when all other treatment modalities fail.  Oral isotretinoin is the only medication that can permanently affect the natural course of acne by affecting all four factors in acne pathogenesis. Isotretinoin is most notably known for its teratogenic adverse effects and so is contraindicated in pregnant women and pregnancy must be avoided during therapy by using two forms of birth control.(5)

Comment about isotretinoin use: Although prescribing isotretinoin (brand name Accutane®) is within the scope of family medicine, many providers choose not to prescribe it because of lack of training, monitoring hassles, fear of side effects, especially due to concerns with teratogenicity. Isotretinoin is an effective treatment for a condition that can not only disfigure and scar the face but can also cause significant psychosocial dysfunction. Dr. Van Durme recommended when you prescribe isotretinoin, you should have a regular schedule of monthly laboratory tests (including pregnancy test), then office visit, and then prescription, in that order. This schedule will improve the likelihood that side effects are managed promptly and medication is taken appropriately(7). If you would like more information about prescribing isotretinoin, visit https://ipledgeprogram.com.

Conclusion: Use topical retinoids alone for mild cases of acne; topical retinoids combined with benzoyl peroxide or topical clindamycin or erythromycin for moderate cases; and topical retinoids combined with benzoyl peroxide and oral antibiotics in severe cases. Remember that isotretinoin is an oral treatment reserved for severe inflammatory papules and pustules with nodules. Treating acne effectively can certainly improve the quality of life of your patients. 

Now we conclude Episode 90 “Vaccines and Acne”. We gave you an update on pneumococcal and COVID-19 vaccines. Prevnar 20 seems to be the new star in the show. PCV15 is also useful but it needs to be followed by a shot of Pneumovax 23. Regarding COVID-19 vaccines, a second shot may be given to patients older than 12 who are immunocompromised or patients older than 50 who are NOT immunocompromised. Then we finished with a discussion about acne and we learned that topical is usually enough for mild cases, but oral therapy may be needed in moderate to severe cases of acne. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. Send us your feedback by email to [email protected], or in our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Timiiye Yomi, Amardeep Chetha and Sarah Park. Audio edition: Suraj Amrutia. See you next week! 

References:

Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep 2022;71:109–117. DOI: http://dx.doi.org/10.15585/mmwr.mm7104a1

2. Pneumococcal Vaccination Timing for Adults, CDC. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf, accessed on March 30, 2022.

Interim Clinical Considerations for Use of COVID-19 Vaccines, Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html#considerations-covid19-vax-booster, accessed April 5, 2022. 

Thiboutot, Diane, MD; and Andrea L Zaenglein, MD. Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/pathogenesis-clinical-manifestations-and-diagnosis-of-acne-vulgaris

Leung AK, Barankin B, Lam JM, Leong KF, Hon KL. Dermatology: how to manage acne vulgaris. Drugs Context. 2021 Oct 11;10:2021-8-6. doi: 10.7573/dic.2021-8-6. PMID: 34691199; PMCID: PMC8510514.

Oge' LK, Broussard A, Marshall MD. Acne Vulgaris: Diagnosis and Treatment. Am Fam Physician. 2019 Oct 15;100(8):475-484. PMID: 31613567.

Graber, Emmy, MD, MBA. Acne vulgaris: Overview of management, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/acne-vulgaris-overview-of-management

Harris C. Clascoterone (Winlevi) for the Treatment of Acne. Am Fam Physician. 2021 Jul 1;104(1):93-94. PMID: 34264597.

Acne vulgaris: Management of moderate to severe acne, UpToDate. Accessed on April 1, 2022. https://www.uptodate.com/contents/acne-vulgaris-management-of-moderate-to-severe-acne

Van Durme DJ. Family physicians and accutane. Am Fam Physician. 2000 Oct 15;62(8):1772, 1774, 1777. PMID: 11057835. https://www.aafp.org/afp/2000/1015/p1772.html

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 89: Gonorrhea Basics. 

Written by Robert Besancenez.  

Robert, Dr. Schlaerth, and Dr. Arreaza discuss the basics of gonorrhea, including presentation, treatment, and even a potential gonococcal vaccine.

Introduction: Gonorrhea is commonly known as “the clap” or “the drip”. This ancient disease, described as “the perilous infirmity of burning” in a book called The History of Prostitution, has been treated with many remedies throughout history, including mercury, sulfur, silver, multiple plants, and even gold. Today we will discuss the clinical features, diagnosis, and current therapy of gonorrhea. By the way, did you know that gonorrhea in Spanish is used as an insult in Colombia? Well, now you know it. 

Definition: Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae (common name gonococcus), which is a gram-negative, intracellular, aerobic, diplococci. This disease leads to genitourinary tract infections such as urethritis, cervicitis, pelvic inflammatory disease (PID), and epididymitis. 

This is Rio Bravo qWeek, 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. 

___________________________

Gonorrhea. 
Written by Robert Besancenez, MS4, Ross University School of Medicine. Moderated and edited by Hector Arreaza, MD. Discussion participation by Katherine Schlaerth, MD.

Epidemiology: The disease primarily affects individuals between 15–24 years of age (half of the STI patients in the US). CDC estimates that approximately 1.6 million new gonococcal infections occurred in 2018. Incidence rates are highest among African Americans, American Indians, and Hispanic populations.

Transmission is sexual (oral, genital, or anal) or perinatal (causing gonococcal conjunctivitis in neonates). 

Risk factors include unsafe sexual behaviors (lack of barrier protection, multiple partners, men who have sex with men (MSM), and asplenia, complement deficiencies. Individuals with low socioeconomic status are at the highest risk: poor access to medical treatment and screening, poor education, substance use, and sex work.

Presentation: 

The incubation period is ~ 2–7 days, and sometimes patients do not develop any symptoms.

Urogenital infection: Gonorrhea is commonly asymptomatic, especially in women, which increases the chance of further spreading and complications. 

When symptoms are present, typical symptoms include purulent vaginal or urethral discharge (purulent, yellow-green, possibly blood-tinged). Discharge is less common in female patients. Urinary symptoms include dysuria, urinary frequency, and urgency. 

Male: - Typical presentation is urethritis. 

- Penile shaft edema without other signs of inflammation.

- Epididymitis: unilateral scrotal fullness sensation, scrotal swelling, redness, tenderness, relief of pain with elevation of scrotum —Prehn Sign— and positive cremasteric reflex.

- Robert: Prostatitis: fever, chills, general malaise, pelvic or perineal pain, cloudy urine, prostate tenderness (examine prostate gently).

Female: - Cervicitis: Friable cervix and discharge (purulent, yellow, malodorous), 

- PID: pelvic or lower abdominal pain, dyspareunia, fever, cervical discharge, cervical motion tenderness but also uterine or adnexal tenderness, abnormal intermenstrual bleeding. PID can be subclinical and diagnosed retroactively when tubal occlusion is discovered as part of a workup for infertility. PID can cause Fitz-Hugh-Curtis syndrome (perihepatitis with RUQ pain).

- Bartholinitis presents with introitus pain, edema, and discharge from the labia. 

- Vulvovaginitis may occur but is rare (due to the tissue preference of gonococci)

Extragenital infection: 

Proctitis: Rectal purulent discharge, possible anorectal bleeding and pain, rectal mucosa inflammation, or rectal abscess (less common).

Pharyngitis: sore throat, pharyngeal exudate, cervical lymphadenitis. 

Disseminated gonococcal infection (DGI): Triad of arthritis, pustular skin lesions, and tenosynovitis. 

As mentioned in Episode 46, on December 23, 2020, the California Department of Public Health (CDPH) sent a “Dear Colleague” letter to warn the medical community about the increased cases of DGI in California and Michigan. Increased cases may be caused by decreased STD testing and treatment because of the COVID-19 pandemic, and not necessarily because of a more virulent strain of gonorrhea. Later, treatment of gonorrhea was updated because of resistance.  

Epidemiology: ∼ 2% of cases. Most common in individuals younger than 40 years old, the female to male ratio is 4:1. A history of recent symptomatic genital infection is uncommon. Asymptomatic infections increase the risk of dissemination due to delayed diagnosis and treatment.

Clinical features: Two distinct clinical presentations are possible. 

Arthritis-dermatitis syndrome:

Polyarthralgias: migratory, asymmetric arthritis that may become purulent.

Tenosynovitis: simultaneous inflammation of several tendons (e.g. fingers, toes, wrist, ankle).

Dermatitis: vesicular, pustular, or maculopapular lesions, possibly with a necrotic or hemorrhagic center.  Most commonly distributed on the trunk, extremities (sometimes involving the palms and soles). Typically, < 10 lesions with a transient course (subside in 3–4 days). Additional manifestations: fever and chills (especially in the acute phase).

Purulent gonococcal arthritis: Abrupt inflammation in up to 4 joints (commonly knees, ankles, and wrists). No skin manifestations, rarely tenosynovitis. Genitourinary manifestations in only 25% of affected individuals. Not to be confused with reactive arthritis. 

Health care providers living in California: Order Nucleic acid amplification test (NAAT) and culture specimens from urogenital, extragenital mucosal sites (e.g., pharyngeal and rectal), and from disseminated sites (e.g., skin, synovial fluid, blood, and cerebrospinal fluid) before initiating empiric antimicrobial treatment for patients with suspected DGI. Report within 24 hours of diagnosis to the California Department of Public Health.

Complications of DGI: sepsis with endocarditis, meningitis, osteomyelitis, or pneumonia.

Diagnosis of gonorrhea: The test of choice is Nucleic acid amplification testing (NAAT) of first-catch urine or swabs of urethra, endocervix and pharynx, and synovial fluid in disseminated infection. 

Other possible tests: gram stains and bacterial cultures (Thayer-Martin agar, useful for antibiotic resistance, results may take 48 hours, sensitivity is lower than NAAT.)

Synovial fluid analysis: Appearance of fluid can be clear or cloudy (purulent), high Leukocyte count (up to 50,000 cells/mm3): especially segmented neutrophils, gram stain positive in < 25% of cases.

Treatment: Ceftriaxone and doxycycline for uncomplicated cases, but may require different approaches in case of allergies or intolerance to these antibiotics, or in severe cases. 

Uncomplicated gonorrhea (affecting cervix, urethra, rectum, pharynx)

First-line treatment: single-dose ceftriaxone 500 mg IM (1 G for patients >150 Kg) PLUS doxycycline 100 mg PO twice a day for 7 days If a chlamydial infection has not been excluded.

During pregnancy: Ceftriaxone PLUS single-dose azithromycin 1 gram PO(doxy is contraindicated – teratogen)

Complicated gonorrhea (salpingitis, adnexitis, PID/ epididymitis, orchitis)

Single-dose ceftriaxone IM PLUS doxycycline PO for 10–14 days  (women may require additional administration of Metronidazole PO for 14 days). 

DGI

Ceftriaxone IV every 24 hours for 7 days 

In case Chlamydia infection has not been ruled out: PLUS doxycycline PO twice a day for 7 days

Drainage of purulent joint(s)

Sequelae: Without treatment, a prolonged infection may lead to complications, such as hymenal and tubal synechiae that lead to infertility in women.

Prevention:

-Screening for gonorrhea (USPSTF recommendations, September 2021, Grade B): Annual NAAT screening of gonorrhea AND chlamydia for sexually active women ≤ 24 years (including pregnant persons) or > 25 years with risk factors (e.g. new or multiple sex partners, sex partner with an STI, etc.). Evaluate for other STIs if positive (e.g. chlamydia, syphilis, and HIV). 

There is insufficient evidence to recommend for or against screening gonorrhea in asymptomatic males (Grade I).

In all patients: Evaluate and treat the patient's sexual partners from the past 60 days. Provide expedited partner therapy if the timely evaluation of sexual partners is not feasible. Single-dose cefixime PO (if chlamydia has been excluded in the patient) OR Single-dose cefixime PO PLUS doxycycline PO for 7 days. Sexual partners must be treated simultaneously to avoid reinfections.

A possible gonococcal vaccine: A gonococcal vaccine is theoretically possible, let’s remember that the meningococcal vaccine exists. Meningococcus is closely related to gonococcus. A study published in 2017 showed that MeNZB® (a vaccine used in New Zealand until 2011 to fight against a meningitis epidemic) provided partial protection against gonorrhea. Food for thought for you guys. 

Conclusion: Let’s remember to screen asymptomatic women for gonorrhea, identify symptomatic patients and start treatment promptly, and prevent serious complications, and more importantly, let’s promote safe sex practices to prevent this disease.

Now we conclude our episode number 89 “Gonorrhea Basics”. Gonorrhea affects mainly the urogenital area, but it can spread to the pharynx, rectum, skin, and even joints. When you see septic arthritis in patients with high risk for gonorrhea, suspect disseminated gonococcal infection and start treatment promptly. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Robert Besancenez, and Katherine Schlaerth. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Seña, Arlene C, MD, MPH; and Myron S Cohen, MD.  Treatment of uncomplicated Neisseria gonorrhoeae infections, UpToDate, updated on Jan 27, 2022. Accessed on April 5, 2022. https://www.uptodate.com/contents/treatment-of-uncomplicated-neisseria-gonorrhoeae-infections

Ghanem, Khalil G, MD, PhD. Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents, UpToDate, updated on Sep 17, 2021, accessed on April 5, 2022. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-neisseria-gonorrhoeae-infection-in-adults-and-adolescents

Klausner, Jeffrey D, MD, MPH. Disseminated gonococcal infection, UpToDate, updated on March 3, 2022. Accessed on April 5, 2022. https://www.uptodate.com/contents/disseminated-gonococcal-infection

Petousis-Harris H, Paynter J, Morgan J, et al. Effectiveness of a group B OMV meningococcal vaccine on gonorrhea in New Zealand – a case control study. Abstract presented at: 20th International Pathogenic Neisseria Conference. Manchester, UK; 2016. 

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 88: EVALI. 

Nugdeep and Jeffrey present E-cigarette and Vaping Associated Lung Injury (EVALI), including symptoms, diagnosis, and treatment. Introduction includes a word of advice for matching and not matching students in 2022. 

Introduction: The Match 2022 is over.  
By Hector Arreaza, MD. Read by Valeri Civelli, MD. 

Another Match season is behind us. It’s time to celebrate and prepare for a new stage of your career. As an interesting fact, the American Association of Family Physicians announced that in 2022 the highest number of family medicine residents matched.

Positions for family medicine residencies have been steadily growing for the last 13 years in a row. There are 756 family medicine categorical and combined residency programs, that’s 15 more programs than in 2021. 

Also, in 2022, osteopathic medical schools had the historic highest number of students matching into family medicine, to be exact 1,496 DO seniors matched to family medicine this year, that’s 58 more students than 2021.

During this season, the number of U.S. medical grads matching into family medicine “did not increase despite a larger number of positions available.”[1]

If you did not match this year, the Match can also be a time of reflection and goal setting as you prepare with optimism for the next season. To increase your chances to match next year, Dr. Margarita Loeza advised in an AMA article[2] to stay in touch with your medical school, find a job in a clinical setting, take Step 3, and try a new approach during next season. For example, you may consider applying to a higher number of programs or even more than one specialty. 

Residency training is the primary way to get licensed to see patients, but there are hundreds of alternative ways to pursue your passion for medicine. Do not give up on your goals. “Never give up on something that you can’t go a day without thinking about.” ―Winston Churchill.

This is Rio Bravo qWeek, 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. 

Page Break

EVALI.

By Nugdeep Singh, MS4; and Jeffrey Nguyen, MS4. Ross University School of Medicine. Participated in the discussion: Hector Arreaza, MD.

N: Good afternoon listeners. My name is Nugdeep Singh, and I am a fourth-year medical student. 

J: Hello, and I’m Jeffrey Nguyen, also a fourth-year medical student. Thank you for having us today Dr. Arreaza. 

N: Today we will be talking about E-cigarette and vape-associated lung injury (EVALI), also known as vaping-associated pulmonary injury (VAPI). But, before we get into the medical pathology of E-cigarettes and vapes, why don’t we give a little background on them.

Arreaza: EVALI and VAPI sound like another Indian holiday or an Italian dessert, but EVALI and VAPI are certainly no joke. 

J: Sure, let’s get started. So, E-cigarettes are battery-operated devices that heat liquids containing nicotine to produce an aerosol that the user inhales. Long-term health effects and whether they help an individual quit smoking has been controversial, as there has not been much research on it. 

These E-cigarettes have raised public health concerns on smoking prevalence and their potential use by children. In 2019, over 5 million children and adolescents were using 3-cigarettes. This represented an increase in e-cigarette use by high school students from 12% in 2017 to 28% in 2019. In fact, Massachusetts legislation bans the sale of all flavored tobacco products starting in June 2020. Nicotine is the main ingredient in the liquid, however, there are other constituents that are carcinogenic potential. Nugdeep, can you go over some of these ingredients? 

N: Yea, let’s start with nicotine. The level of nicotine varies between 0 to 36mg/mL, though it can be higher in some. Nicotine salt is another variant that can provide a different sensation in a user’s throat. Next is propylene glycol, which are humectants, and they are the main component of most E-cigarette liquids. 

Arreaza: When you mentioned proPYlene glycol, I immediately thought of “PEG”. PolyEthylene Glycol, does it ring a bell? Yes, it’s a common laxative, but besides that it’s used in the mRNA COVID-19 vaccines. Having allergy to PEG is one of the few contraindications of the COVID-19 vaccine. But you are not talking about PEG, you are talking about propylene glycol, which is a lightly sweet substance used in e-cigarettes, which can cause chemical conjunctivitis or respiratory irritation.  The consequences of chronic inhalation of propylene glycol are still unknown.

N: Finally, there are flavorings and there are about 7000 flavors available. Some examples include candy, fruits, sodas, and alcohol flavors. 

J: Can I add something real quick? 

N: Yea, of course. 

J: Although these flavorings do add taste to the experience, it attracts E-cigarettes in the youths, especially those who do not already smoke. So, kids, don’t start smoking these just because of the different flavors. Sorry for interrupting you, you can continue. 

N: It’s all good. To continue where I left off, metals such as tin, lead, nickel, chromium, and arsenic have also been found in these liquids. In addition to these, people can also use aerosolized THC or cannabinoid oils with these E-cigarettes. 

J: Wow, there are so many ingredients found in these liquids that the public is not aware of. Now that we know a little more about E-cigarettes, let’s talk about how they affect the lungs. 

N: Yea, let’s get to it. E-cigarette and Vape Associated Lung Injury was first recognized in the summer of 2019 and to date, there are more than 2800 cases that have been reported to CDC as of February 2020. Among those, 68 deaths have been recorded.  Approximately 66% are male users and nearly 80% are under the age of 35. Unfortunately, 22% of the patients have underlying asthma. 

J: Currently, we still don’t fully understand how E-cigarettes affect the lungs. Reported cases have hypothesized that lung diseases are associated with acute eosinophilic pneumonia, diffuse alveolar hemorrhage, acute and subacute hypersensitivity pneumonitis, respiratory bronchiolitis-associated pneumonitis, and interstitial lung disease, suggesting that more than one mechanism of injury may be involved. It is important to understand that there is no evidence of an infectious etiology. 

N: One interesting fact is that when they took fluid samples from the lungs (called bronchoalveolar lavage) from patients with lung injury from E-cigarettes, they noticed that the sample contained THC and/or Vitamin E acetate. Of course, other additives were included, however, these two were in the majority of fluid samples. In fact, the product Juul® was recently found to have a strong association with EVALI. 

Arreaza: JUUL was a commercial success, compared to Uber and Airbnb, but it has been involved in a lot of controversies around the world. 

J: Vitamin E acetate? But isn’t that found in many other products that we use on a daily basis? 

N: Definitely, Vitamin E is found in many foods including vegetable oils, cereals, meats, fruits, and vegetables. It is also available as dietary supplements and is in cosmetic products such as skin creams. There are no known harms when Vitamin E acetate is ingested or applied to the skin, however, research suggests that it interferes with normal lung functions. 

J: Interesting, who knew something as simple as Vitamin E can cause harm to the lungs when used differently. To continue, let’s talk about symptoms that patients present with. Respiratory symptoms include shortness of breath, cough, chest pain, pleuritic chest pain, and hemoptysis. Patients may have subjective fever and chills. GI symptoms include abdominal pain, nausea, vomiting, and diarrhea. Vital signs can be remarkable for tachycardia, tachypnea, and hypoxemia that may progress to respiratory failure. Nugdeep, are there any criteria to meet the diagnosis of E-cigarette and Vape Associated Lung Injury? 

N: Before I talk about how to make the diagnosis, I want to mention that CDC recommends obtaining detailed information on the type of vaping device used, type of substance used, frequency of vaping, and where these devices were obtained. To answer your question, in order to make the diagnosis, you need:

Use of e-cigarettes in the past 90 days.

Chest x-ray or CT chest showing lung opacities without any signs of lung infection.

Negative influenza PCR, respiratory viral panel, and other respiratory infections like urine antigen test for legionella. (COMMENT: COVID-19?)

Once the diagnosis has been made, what are the treatment options? 

J: Since this is a new and upcoming problem, there are no known treatments to date. The most important thing is to rule out infectious processes, such as community-acquired pneumonia. However, patients diagnosed with EVALI can be started on antibiotics empirically to cover pathogens of community-acquired pneumonia. Systemic glucocorticoids have been used; however, the efficacy has not been formally studied. The decision to initiate systemic glucocorticoids is challenging due to various presentations, but it has been suggested to initiate systemic glucocorticoids for patients who meet the criteria for EVALI and have progressively worsening symptoms and hypoxemia. So, what does supportive care entail?

N: 95% of patients with this diagnosis will require hospitalization for supportive care, such as supplemental oxygen with a target pulse oxygen saturation of 88-92%. If hypoxemia worsens, management follows that for acute respiratory distress syndrome. In order to discharge a patient, it is important to ensure vital signs, oxygen saturation and exercise tolerance are stable for 24-48 hours prior to discharge. Jeffrey, to conclude this podcast, can you talk about the prognosis of EVALI? 

J: Sure. When comparing fatal vs nonfatal cases of EVALI, the proportion of fatal cases was higher among patients over the age of 35 and those with a history of asthma, cardiac or mental health conditions. Case reports among adolescents suggest residual lung dysfunction, like short-term diffusion abnormalities. However, it remains unclear whether abnormalities persist in the long term. We would need to wait while they do more research about this condition. 

Arreaza: E-cigarette use is increasing, and we need to be aware of the signs and symptoms of E-cigarette and vape-associated lung injury (EVALI) to start treatment appropriately. Remember to include e-cigarettes and vaping when you ask questions about smoking. 

____________________________

Now we conclude our episode number 87 “EVALI.” EVALI stands for E-cigarette and vape-associated lung injury. The medical community has been increasingly concerned about the safety and health consequences of e-cigarettes and vaping. When you encounter a patient with respiratory complaints, remember to ask about any form of tobacco use, including e-cigarettes and vaping. If you suspect a patient has EVALI, confirm the diagnosis with a chest x-ray or CT scan and rule out any infectious etiology. Consider hospital admission if symptoms are severe, for example, if the patient has shortness of breath or requires oxygen. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at [email protected]. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Valerie Civelli, Nugdeep Singh, and Jeffrey Nguyen. Audio edition: Suraj Amrutia. See you next week! 

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References:

Mitchell, David, Family Medicine Welcomes Largest Class of Residents Ever, American Association of Family Physicians, aafp.org, March 18, 2022, https://www.aafp.org/news/education-professional-development/2022-match-day.html.

Smith, Timothy M., What if you don’t match? 3 things you should do, American Medical Association (ama-assn.org), https://www.ama-assn.org/residents-students/match/what-if-you-don-t-match-3-things-you-should-do.

Kaplan, Sheila, Andrew Jacobs, and Choe Sang-Hun, The World Pushes Back Against E-Cigarettes and Juul, The New York Times, nytimes.com, March 30, 2020 https://www.nytimes.com/2020/03/30/health/vaping-juul-international.html.

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 87: Latent TB Infection.  

By Mariana Gomez, MD (Romulo Gallegos University School of Medicine, Carillion Clinic Infectious Disease), and Hector Arreaza, MD (Romulo Gallegos University School of Medicine, Rio Bravo Family Medicine Residency Program). 

Dr. Gomez explains how to screen for and treat Latent TB infection. 

Today is March 18, 2022.

Dr. Mariana Gomez graduated from medical school at the Romulo Gallegos University in Venezuela. She completed her residency in Internal Medicine in St Barnabas Hospital, which is affiliated with the Albert Einstein School of Medicine, Bronx, New York. She then completed a fellowship in Infectious Diseases at Carilion Clinic, which is affiliated with Virginia Tech School of Medicine. She currently works in Virginia, United States. 

This is Rio Bravo qWeek, 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. 

Some questions discussed during this episode:

Who should be screened for latent TB infection? 

A CDC questionnaire can determine the risk for latent TB infection. Some patients who may be screened are those who resided for 1 month in a country with high TB prevalence, those who are currently immunosuppressed or planning immunosuppression in the near future (50 mg of prednisone or equivalent a day for 1 month), and those who had close contact with patients with TB infection (Latent Tuberculosis Infection: A Guide for Primary Health Care Providers (cdc.gov)). 

The USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk.

Screening Tests: Currently, there are two types of screening tests for LTBI in the United States: the tuberculin skin test (TST, also known as PPD) and the Interferon Gamma Release Assay (IGRA, brand names QuantiFERON®-TB and T-SPOT®.TB). 

The TST requires intradermal placement of purified protein derivative and interpretation of response 48 to 72 hours later. The induration is measured in millimeters. The induration is the palpable, raised, hardened area or swelling, not the erythema.

IGRA requires a single venous blood sample, and the result is obtained in 1-2 days. Two types of IGRAs are currently approved by the US Food and Drug Administration: T-SPOT.TB (Oxford Immunotec Global) and QuantiFERON-TB Gold In-Tube (Qiagen). 

The CDC recommends screening with either test (TST or IGRA) but not both. 

IGRAs is preferred for patients who received a BCG vaccine (bacille Calmette–Guérin) or if they are unlikely to return for TST interpretation.

Why should we screen for LTBI?

How can we decide between Questionnaire only vs PPD vs QuantiFERON Gold?

What is the next step in assessing asymptomatic individuals with positive PPD?

A useful resource is the online TST/IGRA Interpreter (tstin3d.com). 

You can calculate the risk of latent TB infection and the risk of INH-induced hepatitis.

How can we decide to treat LTBI?

What are the recommended regimens? 

CDC recommends three preferred regimens. These are chosen for effectiveness, safety, and high treatment completion rates. These regimens are rifamycin-based. They are:

INH+rifapentine for 3 months: once-weekly isoniazid plus rifapentine for adults and children older than age 2, regardless of HIV status.

Rifampin for 4 months: daily rifampin.

INH+rifampin for 3 months: daily isoniazid plus rifampin.

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Now we conclude our episode number 86 “Latent TB Infection.” Dr. Gomez taught us how to screen and treat latent TB infections. Remember to screen only those who are at risk of TB infection. Once you get a positive screen test, select the patients who will receive treatment of LTBI to prevent reactivation of TB infection. You have at least 4 regimens to treat LTBI. The regimens that include rifamycin are recommended by the CDC. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza and Mariana Gomez. Audio edition: Suraj Amrutia. See you next week! 

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References:

Latent Tuberculosis Infection: Screening, September 06, 2016,  United States Preventive Services Taskforce, uspreventiveservicestaskforce.org. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening.

Lewinsohn, David M., et al, Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clinical Infectious Diseases, 2017;64(2):e1–e33, Infection Diseases Society of America, https://www.idsociety.org/globalassets/idsa/practice-guidelines/official-american-thoracic-society.infectious-diseases-society-of-america.centers-for-disease-control-and-prevention-clinical-practice-guidelines-diagnosis-of-tuberculosis-in-adults-and-children.pdf.  

Sterling TR, Njie G, Zenner D, et al. Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recomm Rep 2020;69(No. RR-1):1–11. DOI: http://dx.doi.org/10.15585/mmwr.rr6901a1.

The Online TST/IGRA Interpreter, McGill University and McGill University Health Center Montreal Quebec, Canada, http://tstin3d.com/. 

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 86: Abdominal Pain Case. 

Spikevax® is the brand name of the Moderna COVID-19, and it received full FDA approval in January 2022. Hepatitis B vaccine is now universally recommended to all adults between 19-59 years of age, or older than 60 with risk factors. Deidra Sieck presents a case of abdominal pain in pregnancy and differential diagnosis are discussed.  

Introduction: Spikevax ® and Hepatitis B universal vaccination.  
Written by Hector Arreaza, MD. Participation by Cecilia Covenas, MD.

Spikevax®. This is the brand name given to the mRNA COVID-19 vaccine manufactured by Moderna. It was given full FDA approval for the prevention of COVID-19 in adults 18 years and older. This is the second vaccine approved by the FDA for the prevention of COVID-19 (the first vaccine was Comirnaty®, formerly known as Pfizer Vaccine.) 

The primary series of Spikevax for immunocompetent adults is comprised of 2 doses, 4 weeks apart. Immunocompromised patients receive a 3rd dose as part of the primary series, one month after the second dose. A booster shot of Spikevax is given at least 5 months after completing the primary series. Spikevax was also authorized for use as a “mix and match” single booster dose following completion of primary vaccination with a different COVID-19 vaccine. It means that recipients of the Pfizer and J&J vaccines who are 18 years and older may receive a single booster dose of Spikevax. The full FDA approval was granted to Spikevax on January 31, 2022.

Did you know that Hepatitis B has killed 40 times more unvaccinated healthcare workers than HIV?  Yes, that’s right. Hepatitis B is 50 to 100 times more infectious than HIV. It is transmitted by percutaneous or mucosal exposure to infected blood or other bodily fluids. As a reminder, immunizations against many diseases have been required for health care workers for decades, and hepatitis B is one of those required vaccines. That’s not new, what’s new is the new recommendation about universal Hep B vaccination. 

In November 2021, the ACIP (Advisory Committee on Immunization Practices from CDC) recommended universal adult Hepatitis B vaccination. After reviewing clinical evidence, the ACIP has unanimously voted to recommend the Hep B vaccine for all adults ages 19-59. Patients who should receive hep B vaccines are: all adults between 19 and 59 years of age, and adults older than 60 with risk factors for hepatitis B infection. However, adults older than 60 without risk factors may also receive hep B vaccines. 

Vaccinating against Hep B is done to decrease new infections, prevent transmission, and reduce health disparities. HHS has called for the elimination of viral hepatitis as a public health threat by 2030. There are some reasons to recommend universal Hep B vaccination for adults: many infected patients did not have any risk factors for infection and still got infected; almost 85% of adults in the U.S. fall into a higher-risk group, including patients with diabetes and kidney disease; hepatitis B cases in the U.S. rose by 11% between 2014 and 2018 despite having highly effective vaccines; Hep B is one of the primary causes of liver cancer, one of the deadliest cancers; universal vaccination of newborns started in 1991 in the U.S., so, many adults are not immune to Hep B, but now they can be vaccinated without the many restrictions imposed in the past.

Remember, Spikevax is the new name for the Moderna vaccine; and you can start vaccinating all adults between 19 and 59 years of age against hep B, regardless of risk factors.

This is Rio Bravo qWeek, 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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Abdominal Pain Case.  

By Deidra Sieck, MS4, Ross University School of Medicine. Hosted by Hector Arreaza, MD.  

Abdominal pain in pregnancy is quite common and has a wide differential. I want to begin with a case and then highlight a few of the “do-not-miss” diagnoses when a patient comes with the chief complaint of abdominal pain during her pregnancy. 

Case presentation: 23-year-old G2P1 at 32 weeks of gestation complains of 12 hours of right lower quadrant abdominal pain, anorexia, and nausea with vomiting. She denies vaginal bleeding or leakage of fluid from the vagina. Denies diarrhea or eating stale foods. No medical history and has been in good health. Denies dysuria and has had no previous surgeries. Her vital signs include a blood pressure of 100/70 mm Hg, heart rate of 105 beats per minute, and temperature of 101.5 F. On abdominal examination, bowel sounds are hypoactive. The abdomen is tender in the right lower quadrant to right flank with significant involuntary guarding. The cervix is closed. The fetal heart tones are in the range of 160 BMP (modified vignette from case files obstetrics and gynecology 5th ed.)

What are some of the differentials that come to mind? 

The 6 differentials that should come to mind that are do not miss diagnoses include:  

Placental abruption

Appendicitis 

Cholecystitis 

Ectopic Pregnancy 

Hemorrhagic cyst 

Ovarian Torsion

I want to discuss each of these diagnoses and then devise a plan for the patient in this case. 

Placental abruption

This is the most common cause of third trimester bleeding and is an obstetric emergency. It occurs during the second and third trimesters and is described as a midline persistent suprapubic pain. The pain is also accompanied by vaginal bleeding as well as an abnormal fetal heart rate tracing.  Mothers at risk have had a previous abruption, hypertension during the pregnancy, cocaine use, smoking, or preterm premature rupture of the membranes, or trauma as the most common cause of the abruption. This diagnosis is made clinically. The ultrasound is an unreliable modality to see the abruption. If the mother is stable and it is not a complete abruption, the mother usually delivers the baby very quickly vaginally. However, if the abruption is complete, the fetal heart tracing is category III, or the mother is hemodynamically unstable, it is best to deliver by c-section. 

Appendicitis. 

Appendicitis can occur any trimester during pregnancy and has been found to occur in 0.1-1.4/1000 pregnancies. 

The typical nonpregnant patient with appendicitis will come with complaints of right lower quadrant pain that may radiate to the right upper quadrant. This is usually associated with other complaints of nausea, vomiting, anorexia, or fever. [Anorexia: 80% sensitive, The sign of the hamburger] 

However, this diagnosis may be missed later in pregnancy because of an atypical presentation. As the gravid uterus grows, it can displace the appendix upward and lateral toward the flank. This leads to a presentation that appears to be more consistent with pyelonephritis, leading to a missed diagnosis. Because of the delay in diagnosis pregnant women are 2-3 times more likely to have a ruptured appendix, and the resulting peritonitis increases the likelihood of morbidity and mortality for the patient.  

If appendicitis progresses to appendiceal rupture, there is a 30% chance of spontaneous abortion of the fetus. These patients need an ultrasound to make the diagnosis since they cannot have a CT scan in pregnancy despite a CT scan being the preferred modality in nonpregnant patients. The ultrasound should show a non-compressible, blind-ended tubular structure in the right lower quadrant with a maximal diameter greater than 6mm.

After the ultrasound confirms the diagnosis, these patients should be taken immediately for an appendectomy. However, the decreased resolution of imaging seen with ultrasound can also lead to delays in these patients receiving the appendectomy.

Cholecystitis. 

Cholecystitis is more common in pregnancy, with occurrence in 1/1600 pregnancies. This can occur anytime in pregnancy after the first trimester. Pregnant women are especially high risk of cholecystitis since they are female and fertile. The other two “f’s” that are commonly listed as risk factors for cholecystitis include forty, and obesity. [the F word is banned in this podcast]. 

Pathophysiology: The increased progesterone and estrogen increase bile lithogenicity. Progesterone also decreases gallbladder contractility. This increase in gallbladder volume and decreased contractility lead to an increase in “biliary sludge” in the gallbladder. The biliary sludge acts as a precursor to gallstones and obstruction of the cystic duct or the common bile duct. The patient with cholecystitis typically comes with complaints of pain in the right upper quadrant which can be associated with nausea, vomiting, anorexia, and fever. This is the same presentation as a patient in pregnancy. 

The complication of missing this diagnosis includes secondary infection with enteric flora such as: E. coli, Klebsiella, and Enterococcus faecalis.  Fetal loss is seen in 3-20% of pregnancies complicated by cholecystitis. 

The diagnosis is made with a careful history as well as an ultrasound showing gallstones with dilation and thickening of the gallbladder and gallbladder wall. 

Treatment should be started with bowel rest, IV hydration, correction of electrolytes, analgesics. They should be given antibiotics if no improvement after 12-24 hours or are experiencing systemic symptoms. If the medical management does not work, these patients should have a cholecystectomy.  

The cholecystectomy will most likely be laparoscopic due to the gravid uterus making it difficult to perform an open approach. If in the third trimester and the patient is stable, the surgeon may opt to wait until after delivery to remove the gallbladder.

Ectopic pregnancy. 

This is the leading cause of maternal mortality in the first and second trimesters. It usually presents during the first trimester as pelvic or abdominal pain that is usually unilateral. The patient could also complain of nausea, vomiting, syncope, or vaginal spotting. The diagnosis is made using a serum hCG that meets the threshold and transvaginal ultrasound. 

The treatment can be surgical or medical. If the pregnancy is early, methotrexate can be used. 

However, the hCG needs to be trended and followed to zero. A D&C can also be used to treat ectopic pregnancy. Surgery is the first treatment in a patient that is hemodynamically unstable. This diagnosis is not likely in our patient.

Ruptured corpus luteum or ruptured hemorrhagic cyst. 

The corpus luteum cyst is part of a normal endocrine function or a result of prolonged progesterone. In pregnancy, the corpus luteum produces progesterone until 7-10 weeks’ gestation until the placenta can produce steroids including hCG and progesterone to maintain the pregnancy. However, intrafollicular bleeding can occur because of the thin-walled capillaries that invade the granulosa cells from the theca interna. If there is excessive hemorrhage, the cyst can enlarge and rupture. 

The patients presenting with this complaint present with unilateral cramping and lower abdominal pain 1-2 weeks before the rupture. If the corpus luteum becomes hemorrhagic, a hemoperitoneum can develop. These women should undergo an ultrasound, which will show free intraperitoneal fluid. This could also include some fluid around the ovary. The confirmatory method for diagnosis is laparoscopy. 

Culdocentesis is a procedure that checks for abnormal fluid in the space just behind the vagina. This area is called the cul-de-sac. During a culdocentesis, a long thin needle is inserted through the vaginal wall just below the uterus and a sample is taken of the fluid within the abdominal cavity.

Once the bleeding is controlled, there is no further treatment needed. However, if the patient requires a cystectomy due to continued bleeding and the pregnancy is less than 10 weeks, she will need exogenous progesterone because of the loss of the corpus luteum. 

Ovarian Torsion. 

Pregnancy is a risk factor for ovarian torsion, especially around 14 weeks and after delivery. Torsion is most likely between 10-17 weeks, and more likely to happen in masses 6-8 cm in diameter. Pregnant and nonpregnant patients have the same presentation, suprapubic or lower quadrant pain, nausea, and vomiting, up to 20% can have a fever.

Plan for the patient in the case:

1. Ultrasound: Showed a non-compressible, blind-ended tubular structure in the right lower quadrant with a maximal diameter of 7mm.

2. Appendectomy: Take the patient to the OR.

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Now we conclude our episode number 86 “Abdominal Pain Case.” We started by giving you an update on Spikevax®, formerly known as “the Moderna vaccine”. This is the newest COVID-19 vaccine fully approved by the FDA for patients 18 years and older. Also, Hepatitis B vaccination is now recommended universally to all adults 19-59 regardless of risk factors. Then, Deidra presented a case of a patient who was pregnant and had abdominal pain. Surprisingly, her diagnosis was appendicitis. This is a good reminder that pregnant and nonpregnant patients can get appendicitis. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Cecilia Covenas, and Deidra Sieck. Audio edition: Suraj Amrutia. See you next week! 

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References:

Coronavirus (COVID-19) Update: FDA Takes Key Action by Approving Second COVID-19 Vaccine, US Food and Drug Administration, January 31, 2022. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/spikevax-and-moderna-covid-19-vaccine.

ACIP fully recommends Spikevax, as CDC expands wastewater surveillance, University of Minnesota, Center for Infectious Disease Research and Policy (CIDRAP), February 04, 2022. https://www.cidrap.umn.edu/news-perspective/2022/02/acip-fully-recommends-spikevax-cdc-expands-wastewater-surveillance. 

ACIP recommends universal hepatitis B vaccination for adults aged 19 to 59 years, Healio.com, https://www.healio.com/news/infectious-disease/20211103/acip-recommends-universal-hepatitis-b-vaccination-for-adults-aged-19-to-59-years.

Landmark vote by CDC’s Advisory Committee on Immunization Practices (ACIP) to recommend universal hepatitis B vaccination, Hepatitis B Foundation, November 4, 2021. https://www.hepb.org/news-and-events/news-2/the-cdcs-advisory-committee-on-immunization-practices-acip-voted-to-recommend-universal-hepatitis-b-vaccination/

Ananth, Cande Vanessa V, and Wendy L Kinzler. “Placental Abruption: Pathophysiology, Clinical Features, Diagnosis, and Consequences.” Edited by Charles J Lockwood, and Vanessa A Barss,  22 Feb. 2021, https://www.uptodate.com/contents/placental-abruption-pathophysiology-clinical-features-diagnosis-and-consequences. 

Brooks, David C. Edited by Stanley W Ashley et al., Gallstone Disease in Pregnancy, 26 July 2021, https://www.uptodate.com/contents/gallstone-diseases-in-pregnancy.  

H., De Cherney Alan, et al. “Chapter 25: Surgical Disorders In Pregnancy.” Current Diagnosis and Treatment: Obstetrics and Gynecology, McGraw Hill Medical Publishing Division, 2019. 

“Obstetrics and Gynecology.” Case Files: Obstetrics and Gynecology 5th Edition, by Eugene C. Toy et al., McGraw-Hill Medical, 2016, pp. 135–144. 

Rebarber, Andrei, et al. “Acute Appendicitis in Pregnancy.” Edited by Martin Weiser et al., Up To Date , 17 Sept. 2021, https://www.uptodate.com/contents/acute-appendicitis-in-pregnancy. 

Runowicz, Carolyn D, and Molly Brewer. “Adnexal Mass in Pregnancy.” Edited by Barbara Goff and Alana Chakrabarti, UpToDate, 10 Feb. 2022, https://www.uptodate.com/contents/adnexal-mass-in-pregnancy. 

Tulandi, Togas. “Ectopic Pregnancy: Clinical Manifestations and Diagnosis.” Edited by Deborah Levine et al., UpToDate, 18 Jan. 2022, https://www.uptodate.com/contents/ectopic-pregnancy-clinical-manifestations-and-diagnosis.

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 85: Detecting Dementia and Evusheld®. 

Parneeta Singh explained a new blood test to predict Alzheimer’s disease and an artificial-intelligence cognitive test for early detection of dementia. Dr Saito and Dr Arreaza present Evusheld, a monoclonal antibody for pre-exposure prophylaxis against COVID-19.  

Today is March 4, 2022. Today marks the 2-year anniversary of our podcast. We have been bringing you relevant clinical information for 2 years, almost every week. We hope you have found this podcast useful. If you have learned at least one thing from us, our goal has been reached. This podcast started as an experiment and it has become an enriching experience for students, residents, faculty, and all of you who listen to us throughout the world. We look forward to many more years of education, updates, and fun! Thanks for listening.

Introduction: Innovative ways to detect dementia: Alzosure Predict® and CognICA® 
By Parneeta Singh, MD, Ross University School of Medicine; comments by Hector Arreaza, MD.   

Alzheimer’s disease (AD) is a neurocognitive disorder that is the most common cause of dementia. More than 6 million Americans aged 65 and older have the late-onset subtype while many more between ages 30 and 60s have the early-onset subtype although the latter is very rare. 

One of the first signs of AD is memory issues. A decline in other aspects of thinking, impaired judgment or reasoning, visual/spatial problems can also indicate early stages of AD. Mild cognitive impairment (MCI) can also be considered an early sign of AD. However, not everyone with MCI will develop the disease. As the disease progresses, people with AD have trouble performing daily activities such as cooking, driving, managing their finances while some have personality changes as well. 

According to the Alzheimer’s Association, two abnormal structures called plaques (deposits of a protein fragment called beta-amyloid that builds up between neurons) and tangles (twisted fibers of another protein called tau that builds up inside neurons) are most probably responsible for the damaging effects seen in AD. Patients with AD develop plaques and tangles initially in parts of the brain involved in memory, such as the entorhinal cortex and hippocampus, before affecting other parts of the brain such as the cerebral cortex which is responsible for reasoning, social behavior, and language. 

Today, AD is at the forefront of biomedical research with earlier diagnoses and interventions improving drastically. New research conducted by Diadem (a diagnostic company that focuses on AD research) exhibited that a novel blood test called Alzosure Predict® identifies a variant of the protein p53 which seems to predict AD’s progression up to 6 years before a clinical diagnosis is made. 

This blood test measures a derivative of p53 (U-p53AZ) which is implicated in AD pathogenesis. Blood samples from patients aged 60 years and older who had different levels of cognitive function were analyzed which showed that the test predicted a decline from MCI to AD at the end of 6 years. The test can also classify a patient’s cognition stage. The positive predictive value (PPV) and negative predictive value (NPV) were at 90%. Knowing which patients will progress to AD allows them to try treatments earlier on the disease when therapies are most likely to be more effective. 

Additionally, using the test could speed up the approval of prospective drug treatments and allow those patients with a likelihood of developing AD to enroll in clinical studies. Patients can also be monitored during a study instead of relying on costly PET scans and painful lumbar punctures. These findings were presented at the 14th Clinical Trials on Alzheimer's Disease (CTAD) conference in November 2021.

Another way to detect dementia early on is by an artificial intelligence cognitive assessment called Cognetivity's Integrated Cognitive Assessment (CognICA®) which has been cleared by the US Food and Drug Administration in October 2021. It is a 5-minute computerized cognitive assessment that is completed using an iPad. It has numerous advantages over traditional pen and paper-based cognitive tests such as avoidance of cultural or educational bias, absence of learning effect upon repeat testing, its high sensitivity to detect early-stage cognitive impairment, and since it is computer-based, it can be self-administered and performed remotely. 

In conclusion, reliable, simple, cost-effective measures of cognition are critical for providing quality care whether it is in the field of family medicine, neurology, or geriatrics. According to Percy Griffin, Ph.D., MSc, director of scientific engagement at the Alzheimer's Association, the ability of such technologies to detect dementia before significant loss of brain cells “would be game-changing” for individuals, their families, and the healthcare system at large. 

This is Rio Bravo qWeek, 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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Evusheld. 

Written by Brandy Truong, MS4, Ross University School of Medicine. Edited by Hector Arreaza, MD. Collaboration: Steven Saito, MD.

This monoclonal antibody is for pre-exposure prophylaxis (PrEP) of COVID-19, which means it is given prior to exposure to the virus. Evusheld is not a replacement for COVID-19 vaccines, and everyone eligible to receive one of the safe and effective COVID-19 vaccines should do so.

It is meant to give protection to those who are unable to mount an adequate immune response against COVID 19 after vaccination. It was given an emergency authorization use by FDA on December 8, 2021. EVUSHELD is tixagevimab co-packaged with cilgavimab, two long-acting antibodies. This medication may be effective for pre-exposure prevention up to six months.

It was designed to be given to the immunocompromised population and for anyone who cannot receive the vaccine, as long as the patient is older than 12 years and more than 88 pounds.  (We totally make the cut). If your patient has a health condition that won’t allow their immune system to develop a strong enough response to the COVID-19 vaccine, for example, they are immunocompromised because of cancer, they can receive Evusheld. 

If they are taking medications that prevent a strong enough response to the COVID-19 vaccine, for example, chemotherapy or transplant anti-rejection medications, they can receive Evusheld.

If they are unable to get the vaccine due to anaphylaxis to all of the COVID-19 vaccines or their ingredients, they can receive Evusheld.

Monoclonal antibodies are lab-made proteins that mimic the immune system’s way of fighting off infections. The two antibodies in Evusheld are long-acting and are made to specifically fight off against SARS-CoV-2. Evusheld is administered by two injections immediately given one after another.

In a recent study done looking at how effective Evusheld was, it showed a 77% reduced risk of developing COVID-19 compared to individuals who received placebo. This study was a randomized, double-blind, placebo-controlled trial in adults older than 59 years old or with a prespecified chronic medical condition or at increased risk for COVID-19 and for other reasons didn’t receive the vaccine and have no prior history of COVID-19. 

Some side effects of the medication include hypersensitivity reactions, bleeding at injection site, headache, fatigue, and cough. 

If you would like to provide this monoclonal antibody Evusheld to your patients, as well as other treatments such as Paxlovid, Molnupiravir, sotrovimab, and bebtelovimab, consult the COVID-19 Therapeutics Locator provided by the office of the Assistant Secretary for Preparedness & Response. You can do a Google search for HHS COVID-19 Therapeutics locator or you can find the link in the notes of this episode. [https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com/]

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Now we conclude our episode number 85 “Detecting Dementia and Evusheld” You listened to Dr Singh present some new promising ways to recognize Alzheimer’s disease early and detect those who are at risk of progression. We are all hoping for a simple way to diagnose Alzheimer’s, and in the near future, we may have a blood test that can help us diagnose this devastating disease. Also, you heard about Evusheld, the new monoclonal antibody given Emergency Use Authorization by FDA for pre-exposure prophylaxis for COVID-19. Consult the Therapeutics Locator to see the availability in your area. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Parneeta Singh, Brandy Truong, and Steven Saito. Audio edition: Suraj Amrutia. See you next week! 

References:

Alzheimer’s Association: What is Alzheimer’s Disease? https://www.alz.org/alzheimers-dementia/what-is-alzheimers, accessed on 30 December 2021. 

National Institute of Aging: What is Alzheimer’s Disease? https://www.nia.nih.gov/health/what-alzheimers-disease, accessed on December 30, 2021. 

New Blood Test May Detect Preclinical Alzheimer's Years in Advance, https://www.medscape.com/viewarticle/963509?uac=242448MJ&faf=1&sso=true&impID=3825884&src=WNL_trdalrt_211126_MSCPEDIT#vp_1, accessed on 30 December, 2021.

FDA Clears 5-Minute Test for Early Dementia, https://www.medscape.com/viewarticle/961277?uac=242448MJ&faf=1&sso=true&impID=3729166&src=wnl_newsalrt_211020_MSCPEDIT, accessed on 30 December, 2021.

Cognetivity Neurosciences, https://cognetivity.com/cognica/, accessed on December 30, 2021. 

Evusheld Antibody Treatment for COVID-19 High-risk Groups, South Carolina Department of Health and Environmental Control, December 8, 2021, https://scdhec.gov/covid19/monoclonal-antibodies/evusheld-antibody-treatment-covid-19-high-risk-groups.

HHS Therapeutics Locator, office of the Assistant Secretary for Preparedness & Response,  https://covid-19-therapeutics-locator-dhhs.hub.arcgis.com/

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!

Intro about race in algorithms. Self-reported case of anosmia by Dr. Arreaza. Some common smells in medicine are discussed with Dr Grewal, for example, halitosis, bromhidrosis, and fetor hepaticus. Parosmia is also mentioned as a sequela after COVID-19 infection. 

Intro: Race in clinical algorithms.  
By Brandy Truong, MS4, Ross University School of Medicine.

The year 2020 was not only the beginning of the pandemic but also a time when our country finally took the time to learn more about systemic racism. Many members in the medical community have been fighting racism in medicine for years and unfortunately have often gone unheard. However, in the past few years, people decided to start listening. 

The New England Journal of Medicine published an article in 2020 looking at different algorithms that have a race component and how that can be harmful to patients and perpetuates systemic racism. Let’s take a dive into some of those clinical algorithms. 

Something that has gained a large movement, is getting rid of a test that helps determine kidney function based on race. This test is called estimated glomerular filtration rate, or what we call eGFR which considers a person’s age, gender, race, and levels of creatinine. When it comes to the race category, it considers if someone is African American or not. Therefore, there are different normal eGFR values for African American and then all others. 

The test was based on an assumption that Black people have higher muscle mass on average which led to higher kidney function. This becomes problematic because assuming all Black people have higher kidney function can delay a patient’s referral to a specialist or getting a transplant. This leads to higher rates of end-stage kidney disease and death due to kidney failure compared to the overall population. 

Many physicians and medical students at top universities have pushed their administration to get rid of the eGFR values based on race. Some hospitals like Mass General no longer use eGFR based on race. The National Kidney Foundation and American Society of Nephrology are still evaluating if they recommend the current algorithms. 

When it comes to looking at heart failure risk, the American Heart Association recommends a Heart Failure Risk Score that predicts the risk of death in patients admitted to the hospital. When a patient identifies as not Black, their score increases by 3 points which puts Black patients at lower risk due to a lower score. This score helps us decide on referrals to cardiology and general care. This becomes problematic because Black patients may not receive the care they need if assumed they are lower risk. 

This was shown when a study done in 2019 showed that Black and Latinx patients that presented to an emergency department in Boston with heart failure were less likely than White patients to be admitted to the cardiology unit.

Another algorithm that puts Black patients at lower risk is the STONE score which predicts the likelihood of kidney stones in patients who present in the ER with flank pain. The score increases by 3 points for patients who don’t identify as Black, which once again puts Black patients at lower risk due to a lower score. 

Black maternal mortality is drastically much higher compared to White women. Something that can contribute to it is an algorithm called Vaginal Birth after Cesarean which predicts the risk in a trial of labor for someone who had a prior cesarean section. This algorithm predicts a lower level of success for mothers identified as Black or Hispanic. 

It’s also important to note that the study used to create the algorithm found that variables like marital status and insurance type also correlated with the success of vaginal birth after cesarean, but those factors weren’t included in the algorithm. 

The benefits of having a vaginal delivery include lower rates of surgical complications, faster recovery time, and fewer complications in future pregnancies. Nonwhite women have higher rates of c-section than white women which decreases the chances of nonwhite women from having the benefits of vaginal delivery.

We have to ask ourselves, why continue to use algorithms based on race? A lot of these algorithms were based and created on flawed assumptions. And while geneticists want physicians to take race seriously, studies showed there is more variation within the same racial groups than between different ones. And racial differences that are found, it was most likely due to the effects of racism such as the experience of being Black in America. It’s harmful because these algorithms guide clinical decisions which may direct more attention or resources to White patients than patients of color, which is harmful and increases health disparities. 

This segment touches only the surface of algorithms using race to determine clinical outcomes and how that is flawed. There are also many other factors rooted in systemic racism in why these algorithms considered race in the first place, why we continue to use them, and the disparities in healthcare and clinical outcomes. 

As we end this segment, I want to take the time to thank the folks fighting racism in medicine as it’s not an easy task. As people continue to bring awareness, we need to listen, acknowledge, and make changes accordingly so that all patients can have the care they need and deserve.

This is Rio Bravo qWeek, 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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Smells in medicine.  
By Hector Arreaza, MD. Discussed with Namdeep Grewal, MD.

Some of my happiest memories are linked to smells, I’m sure specific smells bring back memories to you. In my case, the smell of wet dirt on a rainy day accompanied by the aroma of boiling hot chocolate are some of the smells that remind me of my childhood. From my teen and youth years, I remember some of the trendy colognes among young people: Calvin Klein One, Paco Rabanne, and Hugo Boss are some of those smells that have a little space in my limbic system. 

Olfaction is one of the special senses that we take for granted until we lose it. The term anosmia became more popular after March 2020 because anosmia is one of the symptoms of infection by coronavirus. I got COVID-19 recently and experienced anosmia for the first time in my life. I had a feeling of emptiness in my life. I felt incomplete. I will not deny it was pleasant to drive by a particularly stinky road by my house without gagging or covering my nose, but I was missing the smell of foods and other pleasant smells in my life. 

While I was experiencing anosmia I was not working, but I thought about the effect of my anosmia on my work as a physician. What smells could I miss if I did not recover my olfaction? I also reflected on the smells that I have experienced as a doctor. Some smells have helped me guide a diagnosis or start an investigation. Today, I want to discuss the olfactory system as a diagnostic tool in medicine.

Nowadays, clinicians rely less on their olfactory systems to make a diagnosis, but smells can certainly be helpful in some cases. I was blessed with a very sensitive sense of smell, but honestly, I have a hard time tolerating farts, B.O., bad breath, and other unpleasant smells. 

Halitosis: Also known as “bad breath” can be an indication of poor oral hygiene causing dental decay and gingivitis. Halitosis can be a deal-breaker in a relationship, but it can also be a sign of infections such as tonsillitis, lower respiratory infections (viral or bacterial), Vincent's angina (acute necrotizing ulcerative gingivitis), gastroesophageal reflux, Helicobacter pylori infection, and Zenker's diverticulum (which is a pouch or diverticulum that forms in the upper esophagus causing dysphagia, and food and saliva may get stuck in the pouch and decompose over time, no wonder it may cause a smell, remember the mnemonics for your test “Zenker” = “Stenker”). In patients with foul, feculent breath who are acutely ill you will need to rule out intestinal obstruction or diverticulitis.

An ammonia-like smell can be detected in patients with chronic or acute uremia. If the ammonia is accumulated in the blood to a level that makes it perceptible to your nose, you may be in front of a severe case of renal disease, so refer the patient promptly for 

Bromhidrosis (body odor): Body odor is the perceived unpleasant smell that results from bacteria metabolism of fatty acid by bacteria that normally live on the skin. The apocrine glands are located on the axilla, anogenital area, and breasts. These glands develop around puberty and their function is the secretion of pheromones. Sweat is normally odorless, but the bacteria degrade the sweat, oils, and proteins into substances that produce a strong smell. Body odor is normal. Excessive body odor that interferes with social life and self-esteem is considered bromhidrosis. What is considered “excessive” can vary from one patient to another. The treatment of localized bromhidrosis (mostly axilla) is focused on decreasing the amount of sweat by applying antiperspirants and improving hygiene. Recalcitrant cases of bromhidrosis may be related to infections such as intertrigo and erythrasma and require the use of topical or systemic antibiotics, and severe cases may even require a dermatology evaluation. 

Alcohol breath: I’m very familiar with this smell after many years of encounters with intoxicated people, not only patients but friends, uncles, cousins, etc. The smell of alcohol in exhaled air is used to determine blood alcohol content (BAC) by using a machine called a breathalyzer. All states, including California, consider a BAC above 0.08% as the standard to be legally intoxicated while driving. A caveat about BAC by breathalyzer is that patients following a ketogenic diet may have a falsely elevated BAC. So, make sure to inform the officer about your eating habits to avoid getting an unfair DUI sentence. A BAC level above 0.04% is applied to drivers of commercial vehicles, including moving trucks and rental cars, and a BAC above 0.01% for drivers under the age of 21. Most states have a zero-tolerance for underage drinkers and drivers, and harder penalties for those who have exceptionally high BACs. Alcohol intoxication is more than just a smell, you need to have many other signs and symptoms for diagnosis. If you feel your nose and your judgment are inaccurate, you can confirm by measuring a direct alcohol level in the blood, especially when you are in the hospital and need an exact diagnosis. 

Anaerobic infection smell: Anaerobic bacteria cause wound infections that are characteristically foul-smelling. You can find free gas in tissues, abscesses, and pungent discharge. After smelling infected wounds several times, your nose may be able to recognize the typical foul-smelling odor of anaerobic bacteria. But not all bacteria have an unpleasant smell, according to medical literature, I cannot attest to it, pseudomonas smell like grapes or tortillas, streptococcus smells like butterscotch, and proteus smells like burned chocolate or cocoa.

Diabetic Ketoacidosis (DKA): Patients with DKA may have a fruity smell. Acetone and ethyl acetate are elevated in DKA, and they have a scent similar to nail polish remover. If your patient smells like a beauty salon and is breathing fast and deeply (Kussmaul breathing), there is no time to spare, start immediate treatment of DKA. Remember that DKA can be the initial presentation of diabetes in some patients, particularly young patients, and it is fatal if left untreated.

Fetor hepaticus breath: The description of this smell is somewhat confusing. Some people describe it as a combination of rotten eggs and garlic, others describe it as a smell like clover, or Sulphur with a hint of fecal matter, it is also known as the “breath of death”. The components responsible for this smell are “thiols” that enter the systemic circulation through a portosystemic shunt caused by portal hypertension in liver disease. The thiols reach the lungs and from there they are exhaled giving the chronic liver patient the fetor hepaticus breath. Some people also describe it as a “musty” odor. 

Musty smell: You can think of musty as a synonym of moldy. Musty is likely a variant of the word “moisty,” or “moist.” Musty means having an odor (or flavor) suggestive of mold, such as old buildings or stale food, or like sweaters left in an attic for a long time. Mousy means that it smells like a “mouse”. It can be challenging to know what a mouse smells like. If you want to experience a “mousy” odor, walk into a pet store on a summer day and you may be able to recall the smell when you examine a patient. Why are we talking about musty/mousy odor? Because it can be clinically relevant if you find it in a child’s breath, urine or skin, as this can mean accumulation of phenylalanine in the body, known as phenylketonuria. Detecting a “musty” odor during a physical exam may be less common now because phenylketonuria is included in the newborn screening program in the United States and many other countries. Remember that keyword for your exams, “musty” odor means phenylketonuria.

We have discussed different smells in medicine: halitosis, ammonia, body odor, alcohol breath, anaerobic infection, DKA, fetor hepaticus, and musty smell. We did not cover all smells in medicine, but this is a good starting point for you to keep learning about smells in medicine. 

As for anosmia and COVID-19, let’s remember that most people recover their sense of smell within a few days or weeks, but some patients have reported a long-term abnormal sense of smell, either anosmia or parosmia.

Parosmia is an altered perception of odors that causes normally pleasant smells to be perceived as foul or disgusting. For example, smelling coffee can feel like smelling rotten food. Many patients have reported this symptom after recovery from COVID-19. Parosmia may last 3-6 months, and resolution is normally spontaneous.The cause of parosmia is still uncertain, but it is thought to be a result of direct inflammation of nervous tissue in the olfactory system. As we know, COVID-19 is a multisystemic infection that involves not only the respiratory system but also the nervous system, GI tract, cardiovascular system, and other organs that we are still discovering. There is not a specific treatment for parosmia, but some believe in “smell therapy” which consists of smelling strong scents such as ammonia, eucalyptus, citrus, and perfumes to re-train the brain on the normal process of smelling. 

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Conclusion: Now we conclude our episode number 84 “Smells in medicine.” What is a memorable smell you have? Some smells are characteristic findings of certain diseases. For example, a “musty” odor is a keyword for phenylketonuria. Your nose can point you in the right direction to a diagnosis. If you are among the 1 in 10,000 people with congenital anosmia, don’t worry, there are other ways to sense your surroundings, you can still be an excellent clinician without a sense of smell. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Namdeep Grewal, and Brandy Truong. Audio edition: Suraj Amrutia. See you next week! 

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References:

1. Gaffney, Theresa, et al. “A Yearslong Push to Remove Racist Bias from Kidney Testing Gains New Ground.” STAT, 16 July 2020, www.statnews.com/2020/07/17/egfr-race-kidney-test/. 

1. Vyas, Darshali A., et al. “Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms.” New England Journal of Medicine, vol. 383, no. 9, 2020, pp. 874–882., doi:10.1056/nejmms2004740. 

1. Miller, Jami L., Bromhidrosis, UpToDate, last updated: Oct 18, 2021, https://www.uptodate.com/contents/bromhidrosis?csi=b679769a-2e96-4c17-bac5-ad299491751d&source=contentShare.

1. California Driver Handbook, Alcohol and Drugs, California DMV, English 2020,  https://www.dmv.ca.gov/portal/handbook/california-driver-handbook/alcohol-and-drugs/

1. Parosmia After COVID-19: What Is It and How Long Will It Last? Office of Public Affairs, University of Utah Health, September 3, 2021, https://healthcare.utah.edu/healthfeed/postings/2021/09/parosmia.php.

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 83: Solitary Rectal Ulcer. 

Dr Singh explains how we can diagnose and treat solitary rectal ulcer syndrome (SURS) and Brandy gave an introduction regarding Elvis Presley’s death.  

Introduction: Did Elvis Die Pooping?
By Brandy Truong, MS4, Ross University School of Medicine. 

A pop culture trivia fact I always found interesting was that Elvis Presley may have died from trying to have a bowel movement. There are different statements on the cause of death ranging from cardiac arrest, drug overdose, anaphylactic shock, and straining to have a bowel movement. But we’re not here to figure out which one is accurate or debate all that. Elvis was found in the bathroom on the floor and many people described it as if he was on the toilet and then fell forward. If he died from pooping, how does that even happen? We’re going to explore that a little.

When we strain to have a bowel movement, it’s called the Valsalva maneuver. This maneuver is divided into 4 stages. 

Phase 1 is when one first starts straining or bears down. This causes an increase in chest pressure and blood being forced out from the large veins. This is reflected in a rise in blood pressure and a decrease in heart rate. In phase 2, there is reduced venous return to the heart because the blood was forced out of the large veins. Because there is less return to the heart, the heart doesn’t pump out as much as it normally would which leads to a fall in blood pressure. The body senses this fall in blood pressure and will compensate by increasing the heart rate significantly. Phase 3 is when one stops bearing down which results in a release of chest pressure. This causes a fall in blood pressure which causes the heart rate to increase as a reflex. In phase 4, the decreased venous return seen in phase 2 is now restored, which causes an increase in blood pressure. The heart rate then decreases as a reflex response. Both blood pressure and heart rate will return to normal. This entire process occurs over a span of a little over 10 seconds.

Elvis was known to have a drug addiction and later some doctors found that he had hypertrophic cardiomyopathy which is a condition in which the heart is unable to pump blood well. He abused a variety of pain medications including opioids. Opioids often cause constipation; therefore, if Elvis was constipated and straining, the Valsalva maneuver compounded by heart disease and other unhealthy lifestyles he had would have caused his cardiac arrest. 

Intense straining during the process of defecation can result in subarachnoid hemorrhage in people with congenital berry aneurysms, for example. If you end up googling to find out how Elvis died, let us know what you think and if you think he died from pooping. 

This is Rio Bravo qWeek, 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. 

Solitary Rectal Ulcer Syndrome.  
By Parneeta Singh, MD, Ross University School of Medicine. Discussed with Hector Arreaza, MD.

Solitary Rectal Ulcer Syndrome (SRUS) is a benign, rare, underdiagnosed disorder that can mimic and be incorrectly diagnosed as inflammatory bowel disease (IBD) or rectal cancer. The exact prevalence is unknown but in general, it is reported as an annual prevalence of one in 100,000 people. It mostly occurs in the third decade in men and fourth decade in women, with men and women being equally affected. However, cases have been identified in the pediatric and geriatric populations as well. SRUS is a misnomer because although some patients may present with a solitary ulcer, many present with multiple ulcers that may also involve the sigmoid colon. 

Presentation. 

Rectal bleeding (with the amount varying from a little fresh blood to severe hemorrhage that may require blood transfusions), mucus discharge, excessive straining, abdominal and perineal pain, constipation, or diarrhea, feeling of incomplete defecation, tenesmus, and rarely rectal prolapse are clinical symptoms associated with SRUS. Presentation may resemble intestinal parasites such as Entamoeba histolytica (amebiasis) and Enterobius vermicularis (pinworm).

The underlying etiology is unknown, but a number of mechanisms have been suggested including ischemic injury from the pressure of impacted fecal matter and local trauma due to repetitive self-digitation, although the latter remains unproven. 

Ulcers usually occur in the mid-rectum which cannot be reached by self-digitation. Additionally, it has been proposed that the perineum’s descent along with the abnormal contraction of the puborectalis muscle during defecation results in trauma or a prolapsed rectum with mucosal prolapse being the most common underlying pathogenesis in SRUS. 

Diagnosis. 

The diagnosis of SRUS is based on clinical features and proctosigmoidoscopy findings, with histological examination and biopsies being the key to the diagnosis. Imaging studies including defecating proctography, dynamic MRI and anorectal functional studies also aid in the diagnosis with the latter showing that 25% to 82% of SRUS patients have dyssynergia with paradoxical anal contraction. A thorough evaluation is important in ruling out IBD, ischemic colitis, and malignancy.

Histology evaluation of biopsy establishes the diagnosis of solitary rectal ulcer syndrome. Findings include fibromuscular obliteration of the lamina propria. This obliteration causes hypertrophy and disorganization of the muscularis mucosa and regenerative changes. There is an abnormal crypt organization. In cases were polypoid lesions are prevalent, the mucosa has a villiform configuration, and in some cases, the glands may be trapped in the submucosa, which is called colitis cystica profunda.

Treatments.

Various treatment options are available for SRUS with the treatment choice depending on symptom severity and the presence of rectal prolapse. 

The initial steps, especially in asymptomatic patients, include patient education and behavioral modifications which include a high-fiber diet, straining discontinuation, and a discussion of psychosocial factors. 

Biofeedback is the next step in those who fail to respond to conservative measures. Biofeedback seems to help by altering efferent autonomic pathways to the gut that reduces straining with defecation by correcting abnormal pelvic-floor behavior. 

Topical treatments used include corticosteroids, salicylate, sulfasalazine, mesalazine, sucralfate suppositories and topical fibrin sealant. 

Unfortunately, surgery is necessary in almost one-third of adults with associated rectal prolapse who do not respond to the above treatment options. Surgical treatments include ulcer excision, treatment of internal or overt rectal prolapse, and de-functioning colostomy. Open rectopexy and mucosal resection have shown a success rate of 42% to 100%. 

In conclusion, SRUS is an uncommon disease that can mimic IBD and rectal cancer. Thus, a thorough and complete patient history and work-up is required to accurately diagnose SRUS, following which patient education, reassurance that the lesion is benign and a conservative, stepwise individualized approach is important in the management of this syndrome.

Conclusion: Now we conclude our episode number 83 “Solitary Rectal Ulcer.” Rectal bleeding, constipation, diarrhea, abdominal pain… yes, it sounds like Chron’s syndrome, but your list of differentials may be very long. You may want to add to that list Single Rectal Ulcer Syndrome. The treatment goes beyond medications for inflammation and includes pelvic floor training. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Brandy Truong, and Parneeta Singh. Audio edition: Suraj Amrutia. See you next week! 

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References:

“Elvis Presley.” Wikipedia, Wikimedia Foundation, 21 Jan. 2022, https://en.wikipedia.org/wiki/Elvis_Presley#Cause_of_death. 

Markel, Dr. Howard. “Elvis' Addiction Was The Perfect Prescription for an Early Death.” PBS, Public Broadcasting Service, 16 Aug. 2018, https://www.pbs.org/newshour/health/elvis-addiction-was-the-perfect-prescription-for-an-early-death.  

Srivastav, Shival. “Valsalva Maneuver.” StatPearls [Internet]., U.S. National Library of Medicine, 28 July 2021, www.ncbi.nlm.nih.gov/books/NBK537248/. 

Zipes, Douglas. “Valsalva Maneuver.” Valsalva Maneuver - an Overview, ScienceDirect Topics, www.sciencedirect.com/topics/neuroscience/valsalva-maneuver . 

Qing-Chao Zhu, Rong-Rong Shen, Huan-Long, Yu Wang. Solitary rectal ulcer syndrome: Clinical features, pathophysiology, diagnosis, and treatment strategies. World J Gastroenterology. 2014 Jan 21; 20(3): 738–744. doi: 10.3748/wjg.v20.i3.738. PMID: 24574747; PMCID: PMC3921483. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921483/

Young Min Choi, Hyun Joo Song, Min Jung Kim, Weon Young Chang, Bong Soo Kim, Chang Lim Hyun. Solitary Rectal Ulcer Syndrome Mimicking Rectal Cancer. The Ewha Medical Journal. 2016 Jan 29; 39(1): 28-31. doi: https://doi.org/10.12771/emj.2016.39.1.28. Department of Internal Medicine, Surgery, Radiology and Pathology, Jeju National University School of Medicine, Jeju, Korea. https://synapse.koreamed.org/articles/1058669

Sachin B Ingle, Yogesh G Patle, Hemant G Murdeshwar, Chitra R Hinge Ingle. An unusual case of solitary rectal ulcer syndrome mimicking inflammatory bowel disease and malignancy. Arab J Gastroenterol. 2012 Jun 13(2):102. doi: 10.1016/j.ajg.2012.02.004. Epub 2012 Apr 11. Department of Pathology. PMID: 22980604. https://pubmed.ncbi.nlm.nih.gov/22980604/

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!