Rio Bravo qWeek

Episode 82: Eczema Basics. 

By Lam Chau, MS3, Ross University School of Medicine; and Brandy Truong, MS4, Ross University School of Medicine. Edited and moderated by Hector Arreaza, MD.

Brandy and Lam discuss the basics of pathophysiology, presentation, and general treatment of eczema.  

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.

Atopic dermatitis (eczema). 

A common skin disorder among children is atopic dermatitis, commonly known as eczema. At least 1 in 10 children have eczema; however, it affects many adults as well. About 31.6 million people, which is 10% in the U.S., have some form of eczema. Some other statistics worth noting are that children born outside of the U.S. have a 50% lower risk of developing eczema. The risk increases after living in the U.S. for 10 years. Also, 80% of individuals with eczema experience the onset at younger than 6 years old, and at least 80% will outgrow it by adolescence or adulthood. 

Pathophysiology.  

Eczema is caused by a disruption of the skin barrier. The outer layer of the skin contains a protein called “filaggrin” which helps form a barrier between the skin and environment. If a person has less of this protein, it’s harder for the skin to retain water and lock in that moisture. Genetics and environment play a role and it often runs in families. People with eczema often have other allergic conditions such as asthma, seasonal allergies, and/or food allergies.

Presentation. 

Eczema rashes can present differently for each person. It can be all over the body or just a few spots and people go through exacerbations or flare ups where the rash worsens and then gets better, which we call remission. 

In babies, eczema tends to start on the scalp and face. You’ll sometimes see red, dry rashes on the cheeks, forehead, and around the mouth. 

For young children, rashes can occur in the elbow creases, on the back of the knees, the neck, and around the eyes. Sometimes the rash will ooze and crust. 

There’s different severities in eczema which helps guide treatment. 

Mild: some mild areas of dry skin, mild itching (with or without small areas of redness), little or no impact on everyday activities, sleep, and psychosocial well-being.

Moderate: moderate areas of dry skin, pruritus becomes more frequent, redness is moderate, moderate impact on everyday activities and psychosocial well-being, and frequently disturbed sleep.

Severe: widespread areas of dry skin, continuous itching, redness, bleeding, oozing, cracking, severe limitation of everyday activities and psychosocial functioning, and loss of sleep each night.

Exacerbating factors. 

Factors that exacerbate eczema include excessive bathing without moisturizing, low humidity environments, stress, overheating, and exposure to solvents and detergents.

Management. 

Explaining in detail the management of eczema would take a long time, but we will give you some of the basic principles of treatment. Patient follow up is key to succeed in the management of eczema. You may need to see these patients every 2-4 weeks in some cases and escalate treatment depending on severity.

Eczema can be very frustrating for parents and patients. The management requires a multi approach including - eliminating factors that exacerbate eczema, restoring the skin barrier, treating infection, hydrating the skin, patient education, and oral medications.

In terms of patient education, a study was done where it showed a 6-week education program that had 2-hour weekly sessions that talked about medical, nutritional, and psychological issues associated with eczema. It resulted in an overall decrease in severity after one year.

Moisturizing cannot be overstressed. It is the mainstay of the treatment. Use as much creams as you can. The best moisturizers have a high content of oil, and they are recommended instead of lotions, which contain a percentage of alcohol. So, use emollients or thick creams liberally.

Emollients should be applied two times daily and after bathing or handwashing. Some common moisturizers that can be found at common drug stores include Lubriderm, Aveeno, Aquaphor, Cetaphil, and CeraVe. 

Keeping the skin hydrated and moisturized will also help with the itching. Itching can be very disrupting in the patients’ lives and it can worsen symptoms if left untreated. Itching can result in lichenification, infection, bleeding, crusting, oozing, and cause permanent scars.  

Topical steroids is another basic treatment for mild to moderate cases of eczema. Steroids can be used intermittently to prevent and treat exacerbations. For prevention, for example, topical steroids can be used two days a week (weekends) for 16 weeks. To treat exacerbations, prescribe twice a day topical steroid for 2-4 weeks. 

When using topical corticosteroids, there should be caution using a high potency on areas like the face and skin folds since those are areas at risk for atrophy. However, a brief use of a higher potency can provide a quick response then patients can be switched to a lower potency.

In the US, topical steroids are classified in 7 groups, going from group 1 “super-high potency” to group 7 “least potent”. As a primary care provider, you can memorize at least one formulation from each category and prescribe it as needed. 

An example of low potency topical steroid would be hydrocortisone 2.5% (least potent, group 7) and triamcinolone 0.1% (Kenalog®), low potency, group 6. 

A high potency topical corticosteroid would be Betamethasone dipropionate 0.05% cream (Diproline®) or mometasone furoate 0.1% cream (Elocon®). Those two creams are in the group 2 or high potency.

There are other treatments we did not talk about, including calcineurin inhibitors, crisaborole, a phosphodiesterase 4 inhibitor (Eucrisa®), antibiotics, and oral medications. We invite you to keep learning about eczema.

As we conclude this episode, we’d like to recommend you take a look at the National Eczema Association website. It contains a lot of helpful information material for patients. Invite your patients to consult that website as well. 

Conclusion: Now we conclude our episode number 82 “Eczema Basics.” Our medical students have become excellent teachers. Today they explained very well the basics of eczema. Remind your patients to moisturize, moisturize and moisturize their skin with emollients. Topical steroids can be used for the treatment and prevention of exacerbations. Other treatments such as antibiotics, medications and even biologicals are not always needed but they may be used depending on severity. 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, Brandy Truong, and Lam Chau. Audio edition: Suraj Amrutia. See you next week! 

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References:

“Eczema Prevalence, Quality of Life and Economic Impact.” National Eczema Association, 8 Sept. 2021, https://nationaleczema.org/research/eczema-facts/. 

Howe, William. Treatment of atopic dermatitis (eczema). Up to Date, last updated: December 08, 2021. https://www.uptodate.com/contents/treatment-of-atopic-dermatitis-eczema?search=eczema&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1 .

Sarah, Stein. “Eczema in Babies and Children.” HealthyChildren.org, American Academy of Pediatrics, 13 Mar. 2020, www.healthychildren.org/English/health-issues/conditions/skin/Pages/Eczema.aspx#:~:text=At%20least%20one%20in%2010,sensitive%20skin%20than%20other%20people.  

Watson, Stephanie. “Eczema Support Group: Local, How to Find, and More.” Healthline, Healthline Media, 27 May 2021, www.healthline.com/health/eczema/eczema-support-group#takeaway.

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 81: The Tongue Talks.  

By Idean Pourshams, MD; Golriz Asefi, MD; and Hector Arreaza, MD.   

Drs Asefi, Pourshams, and Arreaza discuss how to discover local or systemic diseases of the tongue. Includes jokes about tongue.

In Traditional Chinese Medicine (TCM), regions of the tongue reflect information about specific organ systems, for example the tip of the tongue traditionally depicts ailments of the heart while the anterior-lateral sections of the tongue represent the lungs, and the posterior-lateral regions reflect the health of the liver and gallbladder. But, today we will focus on common tongue lesions.

Normal tongue.

The tongue is a muscular organ, highly vascularized and highly innervated. It is normally covered by pink mucosa and has a rough surface caused by the presence of papillae (taste buds). It is vital for chewing and swallowing food and it is essential for speaking. The tongue contains an abundance of blood vessels and is constantly regenerating. The top layer of the tongue is replaced every 2-3 days! A healthy tongue should appear slightly wet, light red or pink with possibly a normal thin white coating. There should not be any fissures, teeth marks or swelling. 

On physical exam, ensure that the patient has full range of motion of the tongue. It is very important to look at a patient's tongue during physical examination to note the shape, size, color and texture of the tongue body and coat. Findings can suggest the state of organ functions and progression of any underlying conditions. 

Today we will describe certain physical findings on tongue examination and discuss what clues could be drawn when diagnosing or treating our patients.

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.

Abnormal tongue. 

What would be your suspicions if a tongue was described as having patches resembling smooth red islands or patches located on the top or side of the tongue, and the patches may actually change location, size and shape? Any ideas on a diagnosis?

This could be a geographic tongue also called benign migratory glossitis which is considered harmless and related to allergic rhinitis and other allergies, but it can also be linked to psoriasis and reactive arthritis. 

What about a tongue that is described as dark and furry or hairy, along with a patient complaining of a metallic taste in their mouth? On physical examination you also note halitosis or bad breath. 

This could be a diagnosis of black hairy tongue or lingua villosa nigra. Any idea on what may cause black hairy tongue? Possible causes include antibiotic use, tobacco use, mouth breathing, poor oral hygiene, radiation therapy, chronic use of bismuth.

Now let’s talk about some vitamin deficiencies that may be represented by changes in the tongue’s appearance. If the patient’s tongue appears purple, and the corners of the mouth display angular stomatitis, it would be wise to suspect a vitamin B2 deficiency. B2: Eyes and mouth. 

B2 is also known as riboflavin. Patients can have painful cracks in the corners of the mouth and on the lips known as angular cheilitis, also scaly patches on the head, and a magenta mouth and tongue. It is seen in patients who do not eat enough meats (vegans), but also in chronic disorders such as chronic diarrhea, liver disease, alcohol use disorder, malabsorption, and chronic use of barbiturates. 

Giving Vitamin B supplements by mouth may solve the problem. Vitamin B intoxication is virtually impossible, so you can supplement vitamin B along with other vitamins by mouth confidently, especially patients who are on hemodialysis or peritoneal dialysis. Foods rich in riboflavin include grains, mushrooms, and dairy products.

Vitamin B2 deficiency is normally not seen just by itself but combined with other vitamin B deficiencies. 

Another presentation of a patient’s tongue may be inflammation of the tongue, or glossitis, that is extremely uncomfortable or painful. Any suspicion on what vitamin may be deficient?

You might suspect vitamin B3 deficiency, also known as… niacin!

While we mentioned angular stomatitis with riboflavin deficiency, that is, cracks on the corners of the mouth; with niacin deficiency, the lips may appear cracked along the surface of the lips themselves. Foods that are rich in niacin include meats and poultry, fish, and nuts.

Let’s remember the condition associated with niacin (B3) deficiency: Pellagra. This is an Italian word that translates to “rough skin.” Although nutritional deficiency may be less frequent now than centuries ago, we still may see pellagra in cases of gastrointestinal disease in which absorption of nutrients is diminished, or in patients with malnourishment, possibly from alcoholism.

In addition to manifestations of the tongue, pellagra can progress to cause a red rash on the cheeks or around the neck, constipation that then leads to diarrhea, nervousness and depression which lead to dementia, and if left untreated patients will die. 

These are the 4 D’s of Pellagra: Dermatitis, Diarrhea, Dementia and Death. 

The next description of a tongue is of a patient with a pale, light-colored tongue. What could be a possible diagnosis?

This patient may have iron deficiency anemia, and along with the changing color, there may be soreness, atrophy of the taste buds as well as angular stomatitis. These patients may also have fatigue and feeling cold especially in the extremities. While ferrous sulfate can be prescribed for anemia it is important to remember its irritating effect on the stomach mucosa and possible gastrointestinal side effects such as constipation. That’s why supplementation by iron-rich foods is preferred if the anemia is not severe. Food sources with heme iron include red meat, fish and poultry. Non-heme sources of iron include spinach and other dark leafy green vegetables, as well as egg yolks. The food with the highest content of iron is… liver. Remember that iron absorption is improved by vitamin C.

Now what if a patient's tongue looks beefy, red, and inflamed with the patient complaining of soreness?

This may be vitamin B12 deficiency also known as cobalamin, which is critical for red blood cell maturation. Without cobalamin, patients develop pernicious anemia with symptoms of fatigue, irritability, confusion, depression, numbness and tingling of the extremities and eventually psychosis. 

Vitamin B12 is found in many foods such as meat, fish, dairy and eggs, and fermented foods including sauerkraut, yogurt, and kimchi. Do you remember what parietal cells within the gastric mucosa release, which is essential for absorption of vitamin B12 from the digestive tract? If you said intrinsic factor you are correct. 

And it is important to remember that the use of antacids can diminish levels of intrinsic factor and contribute to vitamin B12 deficiency, as well as other medications such as PPIs, metformin, colchicine, and aminosalycilic acid (an anti-tuberculosis medication which I’ve never seen prescribed). Interestingly, co-administration of Vitamin B12 with vitamin C may reduce the available amount of Vitamin B12 in your body. So, take vitamin C two or more hours apart from Vitamin B12.

Let’s describe another patient, a child with congenital hypothyroidism. What would you expect to see on examination of the mouth or tongue?

Such patients may have a thick tongue, that may not even properly fit in the space of the mouth, thus protruding from the mouth. The same is true for adults with enlarged tongues as well as other symptoms of hypothyroidism. The medical term for enlarged tongue is macroglossia. This can also be seen in Down’s syndrome. 

Another case can be a patient with thick white patches on the tongue which spread onto the cheeks. These white patches wipe off easily with a gauze.

The obvious suspicion would be oral thrush, or to be more specific pseudomembranous oropharyngeal candidiasis, which is a yeast infection seen in both immunocompetent and immunosuppressed children and adults. We cannot talk about the tongue without mentioning oral candidiasis. It is normally associated with infants and children who are bottle-fed or have used antibiotics or corticosteroids to treat asthma or allergic rhinitis, or patients with HIV/AIDS. Also, adults who use dentures are at increased risk of oral thrush.

The treatment of oral candidiasis must be individualized, based on the severity of the infection and immune status of the patient, but it is normally treated with topical antifungal in immunocompetent patients with mild disease or systemic therapy in severe cases or immunosuppressed patients. 

Also, in cases of white tongue in adults, you should consider leukoplakia also called smoker's keratosis which may or may not be cancerous. Please be vigilant because leukoplakia could be an early sign of cancer.

Leukoplakia is a descriptive clinical term used for a white plaque or lesion on the tongue or oral cavity that cannot be wiped off with a gauze. A biopsy for a definite diagnosis may be needed after a 6-week observation to rule out other causes such as mechanical friction. The differential diagnosis of white lesions on the tongue is extensive, and it includes lichen planus, leukoedema, tobacco chewer’s white lesion, chemical burns, HPV, and squamous cell carcinoma.

Another patient presents with small shallow sores on the inside of the mouth, at the base of the gums, and on the sides or surface of the tongue. What do you think the diagnosis might be here?

This may be a canker sore or aphthous ulcer. The sores can be painful, making it difficult for the patient to eat and talk. Treatments include oral rinses with benzydamine hydrochloride, and pastes such as benzocaine or steroids like triamcinolone can also be used to reduce inflammation.

Finally let's describe a patient who comes in with a trembling tongue. What would be a potential diagnosis in such a patient?

It would be important to rule out a stroke, and immediate medical attention is important. Fasciculations of the tongue may indicate a lower motor neuron injury, which can lead to dysarthria or dysphagia, and new onset of fasciculations may be a sign of ALS or amyotrophic lateral sclerosis. Let’s also include the differential of seizure in that case, but the shaking would not only include the tongue, but also the larynx, pharynx, and face in a rare condition called palatal tremor. 

We did not cover viral infections, strawberry tongue, lichen planus, Plummer-Vinson Syndrome, ankyloglossia, macroglossia, angioedema, and many more but we’ll leave it for part 2.

Conclusion: The tongue talks. The tongue can show signs of disease specific to the tongue but also signs of systemic disease. Let’s remember to check the tongue of our patients. Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. When we find tongue abnormalities, let’s keep in mind viral and fungal infections, vitamin deficiencies, immunodeficiencies, premalignant and malignant lesions.

Now we conclude our episode number 81 “The Tongue Talks.” Drs Asefi, Pourshams, and Arreaza discussed common findings of the tongue. By examining the tongue you can find clues for significant local or systemic diseases. Keep in mind infections, vitamin deficiencies, benign lesions and even cancer. The tongue is more than an organ for speaking, breathing, swallowing and testing. It is a symbol of the way we talk to others: “A tongue has no bones but it's strong enough to break a heart, so be careful with your words.” 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Idean Pourshams, and Golriz Asefi. Audio edition: Suraj Amrutia. See you next week! 

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References:

Anastasi JK, Chang M, Quinn J, Capili B. Tongue Inspection in TCM: Observations in a Study Sample of Patients Living with HIV. Med Acupunct. 2014 Feb 1;26(1):15-22. doi: 10.1089/acu.2013.1011. PMID: 24761186; PMCID: PMC3929461. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3929461/

Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010 Mar 1;81(5):627-34. PMID: 20187599. https://www.aafp.org/afp/2010/0301/p627.html

Geographic tongue - Symptoms and causes - Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/geographic-tongue/symptoms-causes/syc-20354396

Wolff, Klaus; Richard Johnson, and Arturo P. Saavedra. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 7th edition, McGraw Hill Education, 2013, p. 819.

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 80: Oral Meds for COVID-19. 

The US department of human health and services recently launched the COVID19 Therapeutics Locator website to allow providers find locations where they can send prescriptions for Paxlovid and Molnupiravir. Find the COVID19 therapeutics locator online: https://arcg.is/iuuW50

Yasmin and Arti discuss oral medications under emergency use authorization for COVID-19: Paxlovid and Molnupiravir. 

Introduction: Meds for COVID-19.  
By Hector Arreaza, MD.  

For the last 2 years, humanity has faced the challenge to find an effective way to fight COVID-19. This pressing charge has not been free of obstacles. It has been hindered by politics, misinformation, greed, jealousy, and many other not-so positive human traits. For me, living through the pandemic has been somewhat frustrating and shaming. Stupidity, vulgarity, and mediocrity are a few of the attributes that have flourished during the last 2 years all around us. 

But not everything about the pandemic has been negative. Many talented people with good intentions have engaged in serious research and have made tremendous contributions to science and humanity. Vaccines have been developed using cutting-edge technology and their efficacy has been very positive so far. Many medications have been tried to fight COVID-19 since the beginning. Some clinicians have tried to repurpose old medications in their honest desires to fight COVID-19. Examples include ACE inhibitors, statins, azithromycin, hydroxychloroquine, and chloroquine, which have not proven to be effective against this virus so far. 

Ivermectin, for example, has been very controversial since the beginning of the pandemic. Ivermectin is not approved by the FDA for the treatment of COVID-19. Until today, the National Institutes of Health do not have enough data to recommend for or against using ivermectin for COVID-19. “Results from adequately powered, well-designed, and well-conducted clinical trials are needed to provide more specific, evidence-based guidance on the role of ivermectin in the treatment of COVID-19.” Ivermectin is still being used by some clinicians in the United States based on personal experience and opinions.

At this time, remdesivir (brand name Veklury®) is the only medication approved by the FDA to treat COVID-19. IV remdesivir won full FDA approval in October 2020 for hospitalized patients, and its use has been expanded a couple days ago to include use in non-hospitalized high-risk patients. 

The NIH recommends against IL-6 inhibitors, such as tocilizumab or sarilumab, in COVID-19 patients who are not in the ICU. At this moment, there is not enough data for the NIH to make a recommendation for patients who are in the ICU. Baricitinib is an oral medication used to treat rheumatoid arthritis authorized in November 2020 to be used in combination with remdesivir for the treatment of COVID-19 in certain hospitalized children and adults who require supplemental oxygen, mechanical ventilation, or Extracorporeal membrane oxygenation (ECMO). Baricitinib is now authorized to be used without remdesivir against COVID-19 in hospitalized patients. We cannot forget the use of dexamethasone in hospitalized patients requiring oxygen.

Today we want to give you a little taste of two oral medications: Paxlovid® and molnupiravir. You will listen to two brave medical students presenting what they have found about these medications. 

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. 

Paxlovid®.   
By Yasmin Fazli, MS3, Ross University School of Medicine.  

What is it?

Paxlovid® is the first oral treatment for mild-to-moderate coronavirus disease (COVID-19) in patients over 12 years-old to be issued by the FDA. The FDA issued an emergency use authorization (EUA) on December 22, 2021. It is made up of two different medications: nirmatrelvir and ritonavir. Nirmatrelvir is a protease inhibitor while ritonavir helps decrease the breakdown of nirmatrelvir. 

The combination authorized is nirmatrelvir 300 mg plus ritonavir 100 mg. You may remember ritonavir use in combination with other antiretrovirals for the treatment of HIV/AIDS.

At the end of the 2021, Pfizer announced that results from a trial comparing between Paxlovid® versus a placebo revealed that Paxlovid® reduced proportion of mortality and morbidity by 88% compared to placebo after a 5-day course.

When and how to prescribe it?

To use Paxlovid® some criteria must be met by the patient. First, a positive result of COVID-19 viral testing, second, the patient must be at high risk for illness progression to a more severe state, including hospitalization and death; and third, the patient must be 12 years or older. 

Paxlovid® should be started as soon as possible after diagnosis of COVID-19 and within 5 days of symptom onset. It is to be taken by mouth 2 times a day for 5 days straight with or without food. You take 3 pills twice a day. It is not authorized for more than 5 days. 

It is not authorized for the pre-exposure or post-exposure prevention of COVID-19. It’s not meant to be a replacement for the vaccine. 

Side effects?

Possible side effects of Paxlovid® include dysgeusia (altered or impaired sense of taste), diarrhea, increased blood pressure, and myalgia (muscle aches). Nirmatrelvir and ritonavir, which comprise Paxlovid®, also interact with other medications, which may lead to serious or life-threatening adverse reactions. 

It’s contraindicated in patients taking medications that are dependent on CYP3A metabolism for clearance, for example, warfarin, amiodarone, clozapine, midazolam, sildenafil (for pulmonary hypertension), etc. A list of these medications has been reviewed by the FDA and you can find it online. 

Liver problems have occurred in patients receiving ritonavir. Therefore, caution should be exercised when administering Paxlovid® to patients with pre-existing liver diseases, liver enzyme abnormalities, or hepatitis. Furthermore, Paxlovid® is not recommended for patients with severe kidney problems, and if they do use it, the dose should be adjusted.

Because nirmatrelvir is co-administered with ritonavir, there may be a risk of HIV-1 developing resistance to HIV protease inhibitors in individuals with uncontrolled or undiagnosed HIV-1 infection. 

As for pregnancy or lactation, there currently is no data available for it to understand any potential effects on miscarriages, birth defects, or maternal and fetal outcomes. 

Considering all of this, please review your patients’ list of medications and supplements and medical history prior to initiating Paxlovid®.

Concerns?

Due to its limited clinical data availability, other adverse effects that have not been reported may also occur while using Paxlovid® on top of the side effect list we are aware of. Ritonavir is a well-known medication, but nirmatrelvir is brand new. 

Another concern is its limited availability. So even though it has shown positive results, it is not widely available yet, which leads to having to prioritize certain populations such as the unvaccinated patients. This may prove to be a moral and ethical concern. 

Effectiveness?

There is no long-term data on Paxlovid® yet; however, from what we do know, it is proving to be effective more than placebo by almost 90% which shows much promise. It works against current or previous variants of COVID-19. 

EPIC-HR is the randomized, double-blind, 2-arm study done to prove Paxlovid®. It included 2246 patients with laboratory-confirmed SARS-CoV-2 infection, mild to moderate symptoms, and at least one comorbidity with increased risk of developing severe illness from COVID-19. Patients were randomly assigned 1:1 to receive either Paxlovid or placebo orally every 12 hours for 5 days.

Results: Paxlovid significantly reduced the risk of COVID-19-related hospitalization or death from any cause by 89% (within 3 days of symptom onset) compared with placebo. Through day 28, 0.7% (5/697) of patients in the Paxlovid® arm were hospitalized compared with 6.5% (44/682) of those in the placebo arm. The study also showed that nobody died taking Paxlovid® while 12 people died taking placebo. These are promising results and Pfizer will be announcing more information on the effectiveness as time passes by. 

Pricing?

The original pricing was announced to be $530.00; however, it’s been added that it’ll be at no cost to the people in the United States. 

Molnupiravir.   
By Arti Patel, MS3, Ross University School of Medicine.  

1. What is molnupiravir? 

Molnupiravir is an antiviral medication that can be used to treat COVID-19. Molnupiravir is a nucleoside analog that inhibits viral replication. The active drug of molnupiravir (N-hydroxycytidine) tricks the RNA polymerase enzyme into incorporating the drug instead of uridine or cytidine. Nucleobases continue to get added to the RNA chain and eventually the new RNA molecule has accumulated enough errors that the virus cannot replicate further. 

2. When and how to prescribe it? 

Molnupiravir is available for Emergency Use Authorization for “mild to moderate COVID-19 disease in adults with positive results of direct viral testing who are at risk of developing severe COVID-19, including hospitalization or death or those in whom alternative COVID-19 treatment options approved by the FDA are not accessible or clinically appropriate.” 

FDA provided EUA status on December 23, 2021. It should be taken as soon as COVID-19 is diagnosed, and within 5 days of symptom onset. It is not to be used as a method to prevent COVID-19 disease. Not for prophylaxis. 

Benefits of treatment have not been seen after hospitalization, so administration of molnupiravir in patients hospitalized due to COVID-19 is not recommended. Adults above the age of 18 should take 800 mg orally every 12 hours for 5 days, with or without food. Use for longer than 5 days has not been studied. 

3. Side effects? 

Most common adverse effects are diarrhea, nausea, and vomiting. 

4. Concerns? 

Pediatric patients: Molnupiravir may not be used in patients under the age of 18 due to effects on bone and cartilage growth. Studies in rats with repeated doses of molnupiravir showed bone and cartilage toxicity. 

Pregnancy: Fetal toxicity was observed when given to pregnant individuals in animal reproduction studies. Risk of adverse maternal or fetal outcomes or birth defects have not been studied in humans as of now. Use of molnupiravir in pregnant individuals may be considered once the prescribing physician has assessed the potential risks and benefits. Prior to initiating treatment of molnupiravir, if clinically indicated, assess whether a patient is pregnant. If a patient is having irregular menstrual cycles, first day last menstrual period is unknown, or patient is not using an effective method of contraception, a pregnancy test is advised. 

Females of childbearing age are advised to use an effective method of contraception while under treatment of molnupiravir and for 4 days after the final dose. Effects of molnupiravir on sperm are not known, thus effective contraception must be used while under treatment of molnupiravir and for 3 months after the last dose. 

Additionally, breastfeeding is not recommended during treatment and for 4 days after the last dose. 

5. Effectiveness? 

Although molnupiravir is not substitute in patients for whom COVID-19 vaccination and booster are recommended, it can be used for treatment of non-hospitalized patients with COVID-19 who have a high risk of progression to severe disease. 

In, MOVe-OUT, a randomized, double-blind, placebo-controlled clinical trial, almost 7% of about 700 individuals who received molnupiravir were hospitalized compared to almost 10% of 700 individuals who received the placebo. During the follow up period, one person who received molnupiravir died compared to 9 people who received the placebo. The safety and effectiveness of molnupiravir continues to be studied. 

Availability and pricing?

Not available in pharmacies yet, and preliminary pricing for a 5-day course of molnupiravir was about $700.

Conclusion of episode:

Now we conclude our episode number 80 “Oral Meds for COVID-19.” We hope you got enough information about these two medications: Pax-lovid and Mol-nu-pira-vir. Remember that they are authorized (not approved yet) by the FDA for the treatment of COVID-19. They are both oral medications, taken twice a day for 5 days. Their use in pregnant patients is not recommended yet. Paxlovid can be used in patients older than 12 years old, and molnupiravir in patients older than 18 years old. We’ll keep learning together about these medications in the future. 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Arti Patel and Yasmin Fazli. Audio edition: Suraj Amrutia. See you next week! 

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References:

F.D.A. Approves Remdesivir for Patients Not Hospitalized, The New York Times, nytimes.com, January, 21, 2022, https://www.nytimes.com/2022/01/21/world/remdesivir-fda-approval-expanded-covid.html.

“Frequently Asked Questions on the Emergency Use Authorization for Paxlovid for Treatment of COVID-19”, U.S. Food and Drug, December 22, 2021, https://www.fda.gov/media/155052/download. Accessed on Jan 24, 2022.

“Pfizer Receives U.S. FDA Emergency Use Authorization for Novel COVID-19 Oral Antiviral Treatment,” pfizer.com, December 22, 2021. https://www.pfizer.com/news/press-release/press-release-detail/pfizer-receives-us-fda-emergency-use-authorization-novel. 

Ahmad, B., Batool, M., Ain, Q. U., Kim, M. S., & Choi, S. (2021). Exploring the Binding Mechanism of PF-07321332 SARS-CoV-2 Protease Inhibitor through Molecular Dynamics and Binding Free Energy Simulations. International journal of molecular sciences, 22(17), 9124. https://doi.org/10.3390/ijms22179124

Coronavirus (COVID-19) Update: FDA Authorizes Additional Oral Antiviral for Treatment of COVID-19 in Certain Adults, fda.gov, December 23, 2021. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-oral-antiviral-treatment-covid-19-certain. Accessed on January 24, 2022.

Fact Sheet for Healthcare Providers: Emergency Use Authorization for Molnupiravir, fad.gov, December 23, 2021, https://www.fda.gov/media/155054/download, accessed on January 24, 2022. 

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

Intimate Partner Violence.  

Dr Yomi discusses how to screen for intimate partner violence (IPV), she shares statistics, risk factors, and how to prevent it. Introduction about steroid injections and hyperglycemia with Dr Kooner.

Today is January 18, 2022.

Introduction: Intra-Articular Corticosteroid Injections and Hyperglycemia
By Gagan Kooner, MD, Government Medical College of Amritsar, India.

There is a physiologic association between hyperglycemia and corticosteroids. Do intra-articular steroids induce hyperglycemia? According to the Spine Intervention Society’s Patient Safety Committee, the answer is yes. These researchers reviewed studies done on both diabetic and non-diabetic patients.

In non-diabetic patients, transient and self-limited hyperglycemia was reported following peripheral intraarticular injections. The increase in blood glucose was less than 40 mg/dl, and levels returned to near baseline by 24 hours. The hyperglycemia in patients with diabetes is more significant. In patients with well-controlled diabetes (hemoglobin A1C of <7), glucose levels rose to the 300s at 1-2 days after administration. Less significant elevations persisted for up to 5-7 days! This effect was evidenced with injections into different joints, with different preparations such as methylprednisolone and betamethasone. 

The effects of epidural steroid injections vs injections in other joints were compared in patients with and without diabetes. Three consecutive injections were given. On day 1 following the injection, there was a significant increase in post-prandial glucose in all groups. However, on day 7, only patients who had received intra-articular injections, did not return to baseline. The hyperglycemia is likely to happen because the steroid spreads in a larger area when injected in a large joint. Also, a caveat is that the group of patients who received intra-articular steroid injections had a higher proportion of diabetic patients. 

Spine Intervention Society recommendations: 

All patients with diabetes should have a provider to contact if their glucose levels become difficult to control.

The informed consent process should include the potential for hyperglycemia after the procedure. Patients with diabetes should check their glucose consistently for at least two days before the procedure. A rule of thumb is to cancel the procedure if the glucose is above 200 mg/dl.

The number of joints and the total amount of steroid given should be considered. 

If the procedure is only a diagnostic block; only local anesthetic should be used (avoid unnecessary steroids).

After the procedure, patients should monitor their glucose until levels return to baseline and adjust their treatment accordingly.

In conclusion, it appears there is a definite correlation between intra-articular steroid injections and hyperglycemia. Although the risk may be minimal, in my opinion, following these recommendations would ensure we are providing adequate healthcare to our patients, especially those more vulnerable, such as diabetic patients. 

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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Intimate Partner Violence. 
By Timiiye Yomi, MD. Discussion with Hector Arreaza, MD.

INTRODUCTION

The CDC defines domestic violence (also called Intimate Partner Violence or IPV) as physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner (spouse, boyfriend/girlfriend, sexual partner, etc.). According to the National Coalition Against Domestic Violence, it is the willful intimidation, physical assault, battery, sexual assault and/or other abusive behavior perpetrated by one intimate partner against another. 

A FEW THINGS TO NOTE:

The CDC considers IPV a serious public health issue affecting men and women globally. 

It begins at an early age. Research has shown that it is most prevalent among adolescents and young adults and it declines with age. An estimated 8.5 million women and 4 million men in the US who have reported experiencing IPV in their lifetime all say they first experienced it before they turned 18 years of age.

Women are more frequently victims of IPV. Data from the National Intimate Partner Sexual Violence Survey (NISVS) reveals 1:4 women (23%) and 1:7 men (14%) in the US report having experienced severe physical assault from an intimate partner, 16 % of women and 7% of men have experienced sexual violence, and 47% of women and men have gone through some form of psychological aggression like humiliating and controlling behaviors from an intimate partner. However, men are less likely to report it.

Frequency and severity can vary but there is always a consistent effort by one partner to maintain power or control over the other. 

Abusers may often seem harmless and perfect initially but over time, they become increasingly aggressive and controlling towards their partner. [Dead little fly]

IPV can happen in all types of intimate relationship: homosexual or heterosexual.

Many racial/ethnic and sexual minority groups are more disproportionately affected by IPV. Studies have shown that Native American and Alaska Native women experience higher rates of IPV. Also, IPV is more prevalent among same sex couples compared to heterosexual relationships. 

IPV is grossly underreported and underrecognized by healthcare professionals and even when reported, remains under-addressed. 

IPV is preventable. 

RISK FACTORS:

Being a woman

Age: More prevalent among adolescent and young adults

Low income

Low educational attainment

Unemployment/Job loss

Alcohol consumption

Childhood history of exposure to violence (for example, between parents)

Childhood abuse and neglect

Stress and anxiety and other psychiatric illnesses

Antisocial personality traits, history of delinquency

Peer violence (gangs)

Hostile communication methods

Unhealthy cultural and religious beliefs

The health and economic consequences of IPV are very significant. 

Survivors suffer various adverse health outcomes, including physical and mental issues, many of which become chronic. 

Population based surveys suggest 52% women and 17% men who are victims of IPV suffer PTSD. 

Sadly, many victims have also lost their lives to IPV. Over 1,000 homicidal deaths in the US are due to IPV. Apart from harm to victims, healthcare costs and decreased productivity from paid work are significantly increased. It costs the US an estimated $2-8 billion dollars annually to cater to the needs of survivors. 

What role do primary care providers play in minimizing the impact of IPV on both victims and the society?

SCREENING

The USPSTF recommends screening of all female patients of childbearing age for IPV. Women who are positive should receive intervention services. (Grade B recommendation).

There are no recommendations on screening males. 

There are various screening tools developed that have been found to be effective. 

HITS: (Hurt, Insult, Threaten, Scream): Self-reported or physician administered; greater than or equal to 10 points is positive. 

How often does your partner physically hurt you? 

How often does your partner insult or talk down to you? 

How often does your partner threaten you with physical harm? 

How often does your partner scream at you?

Scoring: never = 1 point, rarely = 2 points, sometimes = 3 points, fairly often = 4 points, frequently = 5 points. A score of greater than 10 points is a positive screen.

WAST: (Women Abuse Screening Tool): Self-reported; screening is subjective, physician uses clinical judgement. The questionnaire has 8 questions, you can ask the first 2 and then decide if you want to ask the rest of the questions. There is no minimal score. It is provider dependent.

1. In general, how would you describe your relationship? A lot of tension, Some tension, No tension.

2. Do you and your partner work out arguments with: Great difficulty, Some difficulty, No difficulty.

Research shows that patients are in favor of being asked about IPV by their primary care providers at wellness visits. But even though physicians generally feel their patients should be screened for IPV, only a small amount of them do and this is largely due to physicians not feeling comfortable with asking the questions related to IPV. Below are some tips to help with discussing IPV with patients.

TIPS

Explain the rationale behind asking the questions

Show compassion and avoid being judgmental

Use a more open-ended questions approach as opposed to directly questioning patients about specific abuse as this can make patients uncomfortable

Respect confidentiality (conditional)

Discuss with patients in private

Believe and validate patient experience

Listen respectfully

Provide/refer for proper intervention

Assess high risk of harm on every visit including homicide

Be aware of mandatory reporting/confidentiality laws in your state and inform patients of any limits to patient-doctor confidentiality before you begin any discussions.

Reporting IPV:

Physicians are mandatory reporters. Health care providers are required to make a report if they provide medical services to a patient whom they suspect is suffering from a physical injury due to a firearm or assaultive or abusive conduct.

As physicians, we must be aware that many patients who test positive may not be ready or even willing to leave such abusive relationships. This may be due to factors such as financial and safety concerns, kids in the relationship, and even hope that their partners would change. Even if we do not agree with their decisions, we must.

Respect autonomy and allow patients make their own decisions about situations 

Be supportive; provide access to community services, give info on local shelters and the National domestic violence hotline.

Offer info on safety planning: have copies of keys, information on local shelters, have a bag packed with essentials, copies of personal documents, establish coded words with trusted family and friends, etc. This prepares the victims to leave the situation in the face of immediate harm.

PREVENTION:

The World Health Organization recommends legislative reform and media campaign to increase awareness on IPV.

School-based education programs that deal with dating violence. 

Early intervention services in at risk families: housing programs, strengthen household financial security and work-family support. 

Bystander empowerment and education.

RESOURCES:

National Domestic Violence Hotline 
Call 1-800-799-7233 and TTY 1-800-787-3224.

Love is Respect National Teen Dating Abuse Helpline 
Call 1-866-331-9474 or TTY 1-866-331-8453

Rape, Abuse & Incest National Network’s (RAINN) National Sexual Assault Hotline 
Call 800-656-HOPE (4673) to be connected with a trained staff member from a sexual assault service provider in your area.

Conclusion: Now we conclude our episode number 79 “Intimate Partner Violence.” This is a worldwide problem that affects primarily women but can also affect men. We discussed how to screen women in clinic and what to do in case you detect a positive case. Make sure you provide support and offer referrals as needed to assist patients who are being abused. As physicians, you may be the only person who knows about these abusive relationships, so your intervention is key in preventing, treating, and stopping intimate partner violence in our communities. 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Timiiye Yomi, and Gagan Kooner. Audio edition: Suraj Amrutia. See you next week! 

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References:

Patel, Jaymin; Byron Schenider and Clark Smith, Intra-Articular Corticosteroid Injections and Hyperglycemia, Spine Intervention Society Patient Safety Committee, SpineIntervention.Org, published online on October 4, 2017, https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/FactFinder_2017-10_Hyperglyc.pdf.

California’s Domestic Violence & Mandatory Reporting Law: Requirements for Health Care Practitioners, Futures without Violence, https://www.futureswithoutviolence.org/userfiles/file/HealthCare/mandatory_calif.pdf. Accessed on November 11, 2021.

Dicola D, Spaar E. Intimate Partner Violence. Am Fam Physician. 2016 Oct 15;94(8):646-651. PMID: 27929227. https://www.aafp.org/afp/2016/1015/p646.html

Centers for Disease Control and Prevention. Intimate Partner Violence. Preventing Intimate Partner Violence Across the Lifespan: A Technical Package of Programs, Policies, and Practices, https://www.cdc.gov/violenceprevention/pdf/ipv-technicalpackages.pdf. Accessed on November 11, 2021. 

National Coalition Against Domestic Violence, https://ncadv.org/. Accessed on November 11, 2021.

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 78: Infantile Hemangioma. 

Dr Shelat discusses with Dr Schlaerth and Dr Arreaza the definition, pathophysiology, diagnosis and treatment of infantile hemangioma.

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Infantile Hemangioma. 
By Tejal Shelat, MD (Lady Hardinge Medical College). 
Discussed with Katherine Schlaerth, MD; and Hector Arreaza, MD.  

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.

What is infantile hemangioma?

Infantile hemangioma is vascular overgrowth that leads to tangled blood vessels that appear as a reddish plaque on the skin as early as days to weeks after birth. 

It is the most common benign vascular tumor in infants, with a prevalence of 4-5% in mature neonates and is about 2.5 times more common in female (ratio female:male is 3:1) and Caucasian children. 

Risk factors: 

There are several risk factors, including prematurity, low birth weight less than 1000g, family history of infantile hemangioma, placental anomalies, and eclampsia.

Progression of infantile hemangioma. 

Hemangiomas typically undergo three phases:

First is the proliferation phase that occurs between 0 to 6 months of age, with about 80% growing to their final size by age 3 months. During this time there is growth of a bright red, soft, raised, non-blanching plaque that is visible on the skin. This occurs to due proliferation of rapidly dividing endothelial cells in the blood vessels.

This is followed by a plateau phase.

Next is the involution phase, that occurs after 6 months of age. The lesion/s now turn deep red or violet and spontaneously begin to regress in size.

Pathogenesis. 

Several hypotheses have been described to explain the reason behind the occurrence of hemangiomas. We now know that they occur due to dysregulation in angiogenesis and vasculogenesis. 

The most likely trigger is thought to be hypoxia, which induces transcription of the Vascular Endothelial Growth Factor (VEGF) gene, leading to overexpression of angiogenic factors such as VEGF. This leads to differentiation of endothelial cells, influx of other cells such as mast cells, myeloid cells and also tissue inhibitors of metalloproteinases (TIMPs).

Regression. 

The mast cells produce interferon and transforming growth factor, which, along with the TIMPs that we just talked about all work together to halt the proliferation of endothelial cells. The endothelial cells then become senescent and that leads to passive involution of the hemangioma.

Diagnosis. 

The diagnosis of infantile hemangiomas is clinical. If you are not familiar with how a hemangioma looks, search in your favorite dermatology atlas. 

A hemangioma may be red if it involves the papillary dermis (called superficial strawberry hemangiomas), but they can also be purple, blue, or colorless if they involve the reticular dermis or subcutaneous fat (called deep, cavernous hemangiomas).

Early white discoloration of infantile hemangioma may be an early sign of imminent ulceration.

Additional workup.  

Further investigation is also required in specific situations: 

If there are 5 or more cutaneous lesions, we would need a liver ultrasound to rule out involvement of the liver

For facial or segmental involvement, echocardiogram and MRI of the head are recommended to rule out posterior fossa malformations, hemangioma (usually localized on the face), arterial anomalies, cardiovascular anomalies, eye anomalies, sternal clefting and/or supraumbilical raphe 

PHACE Syndrome: posterior fossa brain malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities. By definition, PHACE is diagnosed when there is at least one hemangioma >5 cm on head/scalp PLUS one major or two minor criteria OR hemangioma of any size on neck, upper trunk and proximal upper extremity plus two major criteria.

Major criteria include arterial anomalies such as anomaly of major cerebral or cervical arteries, retinal vascular anomalies, sternal defect. 

Minor criteria include cerebral artery aneurysm, ventricular septal defect, etc.

Laryngoscopy should be done if there is cervicofacial involvement, i.e., beard distribution

Spinal ultrasound should be performed if the hemangioma is in the lumbosacral region

Management

-Most hemangiomas will not require treatment, and most need observation only. 

-When treatment is needed, treatment is usually medical depending on severity, location, and extension of hemangioma/s, you may decide to go with topical or systemic therapy.

-Topical therapies include beta blockers (propranolol 1% applied TID for 1 year), corticosteroids, and imiquimod, but data on efficacy is limited.

-Systemic therapies: Beta blocker therapy (with propranolol by mouth) is indicated when there is concern for ulceration or scarring in large, facial, segmental and or rapidly growing hemangiomas, for visual impairment in periorbital involvement, high output heart failure in hepatic involvement and airway obstruction in subglottic involvement. The dose of propranolol is 1mg/kg to 3mg/kg in the form of an oral solution, depending on the response to therapy and weight of the child. Initiation of therapy may require hospital admission to watch for side effects to beta blockers.

-Second-line treatments include systemic corticosteroids

-Surgical intervention is rarely needed, and it´s usually avoided because surgical scars may be worse than the resulting lesion after spontaneous regression. 

Prognosis. 

The prognosis is very good for most uncomplicated hemangiomas, with about 50% undergoing complete involution by age 5 years and about 90% by age 9 years. Permanent cutaneous residua are seen for hemangiomas that involute slowly, after 6 years of age and hemangiomas involving the eyelid, nasal tip, ear and lip. Functional impairment or obstruction may occur when the hemangioma is located near natural orifices and/or in the head and neck area. In these cases, surgical intervention may be needed.

Conclusion. 

You may find hemangiomas during routine physical exam of a newborn. It is important to remember the natural progression of uncomplicated hemangiomas. Make sure to educate parents about concerning features and how to determine if treatment is needed. In most cases, when treatment is needed, a dermatology evaluation is needed.

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[Music to end: JERUSALEMA]

Now we conclude our episode number 78 “Infantile Hemangioma.” We learned about the natural progression of most hemangiomas. They grow for up to 3 years, then remain unchanged until around 6 years of age when they gradually regress without treatment. In most cases, monitoring is all what’s needed. However, it’s important to identify the hemangiomas with concerning features that require additional work up or early treatment. Treatment is mainly medical. Surgery is rarely recommended or required. 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Tejal Shelat. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Léauté-Labrèze, C., Harper, J. I., & Hoeger, P. H. (2017). Infantile haemangioma. The Lancet, 390(10089), 85-94.

Kowalska, M., Dębek, W., & Matuszczak, E. (2021). Infantile Hemangiomas: An Update on Pathogenesis and Treatment. Journal of clinical medicine, 10(20), 4631.

Metry D.W. Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications. UpToDate. Accessed December 5, 2021. https://www.uptodate.com/contents/infantile-hemangiomas-epidemiology-pathogenesis-clinical-features-and-complications#H22.

Antaya R.J. Infantile Hemangioma. Medscape. Accessed December 5, 2021. https://emedicine.medscape.com/article/1083849-overview#a1.

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!

Intrahepatic Cholestasis of Pregnancy (ICP).

Amel and Dr Wonderly discuss the signs, symptoms, and management of ICP. A reminder for alcohol use disorder screening.

Introduction: Screening for alcohol use disorder. 
Written by Hector Arreaza, MD. Reviewed by Jacqueline Uy, MD.

Today is December 3, 2021.

Substance misuse occurs in about 20% of patients seen in primary care settings. For example, alcohol-related disorders are present in up to 26% of general clinic patients, “a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes”[1]. The USPSTF recommends screening for unhealthy alcohol use in adults 18 years or older, including pregnant women, and provide those engaged in risky drinking with brief behavioral counseling to reduce alcohol use (this is a Grade B recommendation). This brief introduction is to encourage everyone to screen adults for alcohol use disorder. Let’s start with the basics. 

It is important to know the size of a standard drink so you can counsel your patients appropriately. According to the CDC, a standard drink is equal to 14 grams (0.6 ounces) of pure alcohol. Generally, this amount of pure alcohol is found in:

12 ounces of beer (5% alcohol content).

8 ounces of malt liquor (7% alcohol content).

5 ounces of wine (12% alcohol content).

1.5 ounces or a “shot” of 80-proof (40% alcohol content) distilled spirits or liquor (such as gin, rum, vodka, whiskey).

Moderate alcohol drinking means 2 drinks or less in a day for men and 1 drink or less in a day for women. Binge drinking means drinking enough to bring your blood alcohol concentration (BAC) level to 0.08% or more. This may be different in each patient, as humans metabolize alcohol differently, but usually it corresponds to 5 or more drinks on a single occasion for men or 4 or more drinks on a single occasion for women, generally within about 2 hours[2].

A good approach to screen for alcohol use disorder is by asking: “Do you sometimes drink alcoholic beverages?”, and then the single screening question, “How many times in the past year have you had 5 or more drinks (men) OR 4 or more drinks (women) in a day?”[3] 

The screening is considered positive if the patient answers one or more times a year. If positive, then you may continue your assessment with another tool such as AUDIT. This can be a topic for a whole episode. 

For now, we just want to remind you to screen your patients for alcohol use because the prevalence is very high and we as primary care physicians can make a big difference in the prevention and treatment of alcohol misuse in our communities. 

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. 

Intrahepatic Cholestasis of Pregnancy (ICP). 

Written by Amel Tabet, MS3, American university of the Caribbean. Discussion with Sally Wonderly, MD; and Hector Arreaza, MD.

What is Intrahepatic Cholestasis of Pregnancy and why does it matter?

As its name implies, Intrahepatic Cholestasis of Pregnancy (ICP) is a multifactorial liver dysfunction in some pregnant women that occurs during their either second or third trimester of pregnancy and resolves spontaneously after parturition. It is defined by the presence of pruritus -- previously called pruritus gravidarum or recurrent jaundice of pregnancy-- and abnormally elevated serum bile acid levels and mildly increased hepatic aminotransferase levels, in the absence of diseases that may yield similar laboratory findings and symptoms. Key symptoms are pruritus, high bile acid and high transaminases. 

How common is ICP?

In the US incidence ranges from 0.32 percent to 5.6 percent, depending on the area. The Los Angeles area has a high incidence compared to other areas in the US. The highest rates in Europe are in Scandinavia. 

It is very frequent in Chile (South America). The indigenous people known as Araucanos have the highest incidence worldwide at 27.6 percent.

Pathogenesis

The pathogenesis of ICP remains unclear. It is mainly attributed to changes in various sex steroid levels but more recent research points towards an etiology that relates to various mutations in the many genes involved in the control of the hepatocellular transport systems such as the ABCB4 gene, which encodes multidrug resistance protein 3 (MDR3) linked to progressive familial intrahepatic cholestasis, errors of the ABCB11 gene that encodes for the bile salt export pump, and more recently on FXR/NR1H4 and PXR/NR1I2 genes that encode for proteins that critically regulate bile acid synthesis and transport, and the transcription of ABCB11 in humans and the role of epigenetics influence by means of methylation of these genes. 

Dangers for mother: Beside the discomfort of pruritus, ICP is transient and of little maternal risk generally. The mother may be uncomfortable but it’s not fatal.

Danger to fetus: The elevated bile acids enter the fetal circulation because it crosses the placenta. Bile acids cause major fetal and neonatal complications, such as abnormal intrapartum fetal heart rate and meconium-stained amniotic fluid that can lead to fetal distress and prematurity or intrauterine demise and to neonatal respiratory distress syndrome associated with bile acids entering the lungs.

Who is at risk for ICP?

Multifetal pregnancies.

Genetics: There is also a significant genetic influence that leads to variability of incidence by population. In North America, cholestasis is infrequent with an overall incidence approximating 1 case in 500 to 1000 pregnancies. Whereas its rate is high in indigenous women from Chile and Bolivia and nears 5.6 % among Hispanic women in Los Angeles. In other countries, for example Sweden, China, and Israel, the incidence varies from 0.25 to 1.5 %.

Diet and environment can also have an influence. Research has shown an association of ICP with environmental and dietary factors such as seasonal changes of mineral dietary components and with gut-derived endotoxins subsequent to increased gastrointestinal permeability. This complex nature-nurture interaction suggests that ICP is strongly modulated by epigenetic mechanisms.

Liver disease: Women with preexisting liver disease are at risk. Other risks include in vitro fertilization, cholelithiasis, advanced maternal age, and Hepatitis C and fatty liver disease. 

History of ICP is an important risk, because it also recurs during subsequent pregnancies in 60 to 70 % of patients.

Signs and symptoms:

The main clinical presentation is an often-generalized pruritus in late second or third trimester, that usually starts and predominates on the palms and soles and is worse at night. It could range from mild to intolerable pruritus that may precede laboratory findings by several weeks and evidenced by possible presence of scratch marks and excoriations on physical examination. Jaundice arises in 14 to 25 % of patients and it typically develops 1 to 4 weeks after the onset of itching. Other accompanying symptoms may also occur such as nausea, RUQ pain, steatorrhea, poor appetite and sleep deprivation. Other signs include dark urine, pale stools.

Diagnosis:

To establish a diagnosis, careful history taking, physical examination, and laboratory evaluation are performed. Thus, in the absence of any other liver disease, ICP is diagnosed by the presence of pruritus that is associated with elevated total serum bile acid levels, elevated aminotransferases (seldom exceed 250 U/L), hyperbilirubinemia (4 to 5 mg/dL) and elevated alkaline phosphatase. In severe cases that account for 20%, cholestasis manifests as bile acids levels > 40 micromol/L.

Differential diagnosis include: Preeclamptic liver disease, which is ruled out if blood pressure elevation or proteinuria are absent and cholelithiasis and biliary obstruction are excluded by sonography. Moreover, because of mild transaminitis in case of ICP, acute viral hepatitis is an improbable diagnosis. 

Liver biopsy is generally not needed. Even though not necessary for diagnosis, liver biopsy for research purposes, showed occurrence of changes with presence of cholestasis with bile plugs in the hepatocytes and canaliculi of the centrilobular regions, without inflammation or necrosis. These changes were found to fade after delivery with recurrence in successive pregnancies or with estrogen-containing contraceptives.

Management:

Management focuses mainly on reducing maternal discomfort due to pruritus and prevention of more serious fetal outcomes and reduce the risks of prenatal morbidity and mortality. 

For patients that have persistent clinical findings consistent with ICP without any biochemical evidence of ICP, we only treat with antihistamines and topical emollients such as calamine lotion and we perform a weekly evaluation of maternal total serum bile acid (TSBA) level. 

In symptomatic patients with positive biochemical evidence of ICP we treat with ursodeoxycholic acid (UDCA) 300 mg BID or TID until delivery. UDCA was found in clinical trials to relieve pruritus, lower bile acid and serum enzyme levels, and to reduce preterm birth, fetal distress, respiratory distress syndrome, and neonatal intensive care unit admission. Along with treatment, we continue the weekly evaluation of the TSBA level with a warranted earlier delivery if TSBA ≥100 micromol/L and the related high risk of stillbirth. 

Thus, delivery management is mainly based on the highest TSBA level at any time during pregnancy. 

If TSBA level is <40 micromol/L, delivery is advised at 37 to 38 6/7 weeks (Grade 2C). 

For TSBA within 40-99 micromol/L range, delivery is advised at 36 to 37 weeks (Grade 2C). 

For TSBA ≥100 micromol/L, delivery is recommended at 36 weeks.  

For any patient with worsening liver function tests and relentless symptoms despite treatment, or a prior history of ICP and fetal death before 36 weeks and recurring ICP in the present pregnancy, delivery before 36 weeks is warranted.

Postpartum women with persistent clinical symptoms should undergo liver function and TSBA level check and should be referred to liver specialist if unresolved dysfunction. Check liver function tests and bile acids 6-8 weeks after delivery and investigate other causes if these labs are abnormal.

There is a risk for recurrence in up to 90% of future pregnancies and it can present with hormonal contraceptives as well. 

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Now we conclude our episode number 77 “Intrahepatic Cholestasis of Pregnancy” or ICP. If you have a pregnant patient who complains of severe pruritus, remember to check total serum bile acids and liver function tests. Elevated bile acids in pregnancy should not be taken lightly. Act promptly and wisely. Delivery may be warranted even before 36 weeks in patients with worsening liver function, unrelenting symptoms or prior ICP with fetal death before 36 weeks. 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Amel Tabet, Sally Wonderly, and Jacqueline Uy. Audio edition: Suraj Amrutia. See you next week! 

References:

Sullivan Eleanor and Michael Fleming, A Guide to Substance Abuse Services for Primary Care Clinicians, Treatment Improvement Protocol (TIP) Series, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, www.samhsa.gov,   https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/SMA08-4075_508.pdf

Alcohol Questions and Answers, Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/alcohol/faqs.htm#bingeDrinking, accessed on November 16, 2021.

Helping Patients Who Drink Too Much: A CLINICIAN’S GUIDE, Updated 2005 Edition, National Institutes of Health, www.nih.gov, 

Dermatological Disorders. In: Cunningham F, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, Spong CY. eds. Williams Obstetrics, 25e. McGraw Hill; 2018. Accessed October 11, 2021. https://accessmedicine-mhmedical-com.aucmed.idm.oclc.org/content.aspx?bookid=1918§ionid=141465503

Hashemi N, Ukomado C. Hepatic Complications of Pregnancy. In: Greenberger NJ, Blumberg RS, Burakoff R. eds. CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, 3e. McGraw Hill; 2016. Accessed October 11, 2021. https://accessmedicine-mhmedical-com.aucmed.idm.oclc.org/content.aspx?bookid=1621§ionid=105182308.   

Hepatic, Biliary, and Pancreatic Disorders. In: Cunningham F, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, Spong CY. eds. Williams Obstetrics, 25e. McGraw Hill; 2018. Accessed October 12, 2021. https://accessmedicine-mhmedical-com.aucmed.idm.oclc.org/content.aspx?bookid=1918§ionid=148216133.

Intrahepatic cholestasis of pregnancy. Keith D Lindor, Richard H Lee. UpToDate. Sep 2021. https://www.uptodate.com/contents/intrahepatic-cholestasis-of-pregnancy?search=intrahepatic%20cholestasis%20of%20pregnancy&source=search_result&selectedTitle=1~60&usage_type=default&display_rank=1#references    

Klauser CK, Saltzman DH. Gastrointestinal Disorders in Pregnancy. In: DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 12e. McGraw Hill; 2019. Accessed October 11, 2021. https://accessmedicine-mhmedical-com.aucmed.idm.oclc.org/content.aspx?bookid=2559§ionid=206962251.

Cabrerizo R, Castaño GO, Burgueño AL, Fernández Gianotti T, Gonzalez Lopez Ledesma MM, Flichman D, Pirola CJ, Sookoian S. Promoter DNA methylation of farnesoid X receptor and pregnane X receptor modulates the intrahepatic cholestasis of pregnancy phenotype. PLoS One. 2014 Jan 31;9(1):e87697. doi: 10.1371/journal.pone.0087697. PMID: 24498169; PMCID: PMC3909199. https://pubmed.ncbi.nlm.nih.gov/24498169/

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 76: Eating Disorders. 

The malaria vaccine is announced by Dr Parker, eating disorders such as anorexia and bulimia are briefly discussed by Sophia, Jeffrey and Dr Arreaza. 

Introduction: Introducing the malaria vaccine (RTS,S)
Written by Hector Arreaza, MD; read by Tana Parker, MD.  

Today is November 26, 2021.

Malaria is a devastating disease that continues to kill thousands of people every year around the world. Since the year 2000, there have been 1.5 billion cases of malaria and 7.6 million deaths. In 2019, there were 229 million new cases, and 409,000 deaths, mostly children under 5 years of age.

Effective vaccines for many protozoal diseases are available for animals (for example, the vaccine against toxoplasmosis in sheep, babesiosis in cows, and more.) However, vaccines for protozoal disease in humans had not been widely available … until now. 

The RTS,S is a vaccine against malaria approved by the European Medicines Agency in July 2015 for babies at risk, and it was rolled out in pilot projects in Malawi, Ghana and Kenya in 2019.  In October 2021, the World Health Organization announced the recommendation of this anti-malaria vaccine. The trade name of this vaccine is Mosquirix®. The vaccination is recommended for children in sub-Saharan Africa and other regions with moderate to high transmission of Plasmodium falciparum, which is considered the deadliest parasite in humans.  

The approved vaccine has shown low to moderate efficacy, preventing about 30% of severe malaria after 4 doses in children younger than five years old. Implementation of vaccination is not free from challenges, and it should be executed not as the solution for the disease, but as part of the solution, along with other efforts such as mosquito control, effective health care, and more.

RTS,S is an add-on to continue the fight against malaria worldwide. Hopefully we can lighten the heavy burden of malaria for more than 87 countries that suffer the severe consequences of poor control of this devastating disease. 

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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Eating Disorders. 
Written by Sophia Dhillon, MS3, Jeffrey Nguyen, MS3. Discussion with Hector Arreaza, MD. 

This is not intended to be a comprehensive lecture on eating disorders. This episode is intended to give you basic information, hoping to motivate you keep learning about it. 

Let’s start talking about eating disorders today, specifically anorexia nervosa and bulimia nervosa. 

What is an eating disorder? An eating disorder is a disturbance of eating that interferes with health. As a reminder, health is “a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity.” So, an eating disorder, in a wide context, is any eating pattern that is out of what is considered “normal”, and that variation in feeding causes health problems. But in general, when we talk about eating disorders in medicine, we refer to anorexia nervosa and bulimia nervosa, but it includes also avoidant/restrictive food intake disorder, binge eating disorder, night eating disorder, pica, and rumination disorder. 

ANOREXIA

In general, anorexia is characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure or an irrational fear of weight gain as well as distorted body self-perception. There are 2 main subtypes of anorexia: restricting type vs binge-eating/purging type. Tell us the difference between anorexia restrictive type and binge eating-purging type.

Anorexia, restrictive type is when weight loss is achieved by diet, fasting and/or excessive exercise, meanwhile the binge-eating/purging type entails eating binges followed by self-induced vomiting and/or using laxatives, enemas or diuretics. These patients will have intense fear of gaining weight or becoming fat. They will have a distorted perception of body weight and shape or denial of the medical seriousness of one’s low body weight.

Anorexia nervosa is different than avoidant/restrictive food intake disorder. In anorexia, you have an altered perception of your body (“I’m fat”), but in avoidant/restrictive food intake disorder, your perception of your body weight and shape is not abnormal. “I’m skinny, and I’m OK with that.” This is new information for me. I thought anorexia was present always when a patient refused to eat, whether you liked your body or not.

Why do people develop eating disorders? 

There are so many reasons why people develop eating disorders. First, it can be psychological due to low self-esteem, feelings of inadequacy or failure, feeling of being out of control, response to change (i. e. puberty) or response to stress. Second, it can be due to interpersonal issues like having trouble with family and personal relationships, difficult expressing emotions or feelings, or even history of being teased based on size or weight. Lastly, it is the social and cultural norms that we grow up in. There are cultural pressures that glorify thinness and place value on obtaining the perfect body, narrow definitions of beauty that include women and men of specific body weights and shapes. 

Sometimes there is no reason. Some people just get obsessed with their weight and perceive themselves as “fat”. 

Effect of anorexia on different parts of the body

Since these patients are scared of gaining weight, how does it affect the entire body?

Anorexia can affect multiple systems in our body. Just to name a few symptoms that it can manifest as: amenorrhea, infertility, constipation, dizziness, hypothermia, bradycardia, hypotension, dry skin and even hair loss. Starvation induces protein and fat catabolism that leads to loss of cellular volume and atrophy of the heart, brain, liver, intestines, kidneys, and muscles. 

Cardiac: It can decrease cardiac mass, decrease cardiac chamber volumes, cause myocardial fibrosis and pericardial effusion. These manifestations are reversible if the patient gains weight. Functionally, it can cause bradycardia due to increased parasympathetic activity, hypotension, decreased heart rate variability and QT prolongation on ECG. 

Lungs: shortness of breath due to weakened and wasting of the respiratory muscles, pneumothorax and aspiration pneumonia. 

GI system: it leads to gastroparesis with bloating, constipation, severe pancreatitis and mild transaminitis. 

Hematologic: anemia, leukopenia and thrombocytopenia. 

Skin manifestations include dry/scaly skin, hair loss, acne, hyperpigmentation and acrocyanosis. You can also find lanugo, which is a very thin, light colored hair on the face and body. It is thought that the lanugo is an adaptation from the body to keep it warm. Lanugo is common in patients with anorexia nervosa or other causes of malnourishment. That’s why wearing coats in warm weather can be a silent sign of anorexia. 

Other subtle signs include social withdrawal, fidgeting (to burn calories), and always “eating” in private.  It is important to remember that all these manifestation that Jeffrey mentioned are not present with intermittent fasting because intermittent fasting is an intermittent restriction of food, the nutritional needs are met during the “feasting” periods after “fasting”. Some may argue that intermittent fasting may promote eating disorders, but I believe intermittent fasting is just an effective treatment for obesity.

Treatment plan for anorexia

There are several treatment options for these patients. We can refer them to nutritional rehabilitation where they can supervise meals. We can refer them to psychotherapy, such as cognitive behavioral therapy or motivational interviewing. There is also a drug called Olanzapine for this condition. 

Sometimes, patients may need admission to the hospital. I learned recently that UCLA has an Eating Disorder Program which includes inpatient services. Some centers are very specialized and include family therapy and group therapy. Listeners, you can continue to research about anorexia, it’s is fascinating. The prevalence of anorexia in the US is estimated to be 0.6%[3]. 

BULIMIA

By definition, bulimia nervosa is when a person binge eats and then uses certain behaviors to prevent weight gain. These behaviors may include self-induced vomiting, using laxatives or diuretics, exercising excessively, or fasting and having a restrictive diet. 

Signs and symptoms to look for

A physical examination is key. On physical presentation, these people usually can have overweight or obesity. That’s the main difference with anorexia. Anorexia: skinny people, bulimia: normal weight, overweight or obesity. Regardless of their weight, these patients are malnourished. They may lack some essential nutrients causing serious health consequences. That’s why nutrition cannot be assessed by BMI only. 

Common signs they will present with will include tachycardia, hypotension (systolic blood pressure below 90), dry skin, and hair loss. If the person uses self-induced vomiting to prevent weight gain, they may have erosion of the dental enamel from all the acid that comes up when they vomit. There may also be scarring or calluses on the dorsum side of the hand from all the acid too. Their parotid glands, that are located on the side of the jaws will also be swollen, causing a sign known as chipmunk face of bulimia.

From talking to this person and getting a detailed history, we will learn of the symptoms bulimia nervosa can cause. This will include lethargy and fatigue, irregular menstrual periods in a female, abdominal pain and bloating, and constipation

This disorder really does take a toll on the body. There’s plenty of complications that come with it as well. Let’s try to break it down by system. 

GI system has the most complications: esophageal tears from the vomiting called Mallory-Weiss syndrome, which will present with bloody vomits, a loss of gag reflex, esophageal dysmotility, abdominal pain and bloating, GERD, diarrhea and malabsorption of nutrients, fatty stools known as steatorrhea, colonic dysmotility leading to constipation, irritable bowel syndrome, rectal prolapse, and pancreatitis. 

Cardiac: serious complication is ipeac-induced myopathy, let’s spend a little time on this. Ipecac is a syrup that someone with bulimia nervosa may use to make themselves vomit. If a person uses this syrup frequently or for a long amount of time, there is a component called emetine will accumulate in muscle, including cardiac muscle. If a person uses ipecac chronically, it can be detected in the urine for up to 60 days. This will damage the heart muscles or myocardium and lead to cardiomyopathy. It will present with symptoms such as chest pain, shortness of breath, hypotension, tachycardia or bradycardia, T wave abnormalities on ECG, conduction delays, arrythmias, pericardial effusions, and even congestive heart failure. Cardiomyopathy may be irreversible. 

Renal system: dehydration, hypokalemia, hypochloremia, hyponatremia, and metabolic alkalosis. This could happen in patient who use diuretics as a purging mechanism. 

Endocrine system: Electrolytes and hormones imbalance. The endocrine system primarily impacts the reproductive and skeletal systems. Among 82 women treated for bulimia nervosa, menstrual irregularities were present in 45 percent at pretreatment and in 31 percent at 12-month follow-up. These irregularities may look like spotty or very light menstrual cycles. Cycles may be very erratic or completely absent. 

Skeletal system: osteopenia and osteoporosis are common with bulimia nervosa. Osteopenia means weaker and more brittle bones. Osteoporosis is more serious than osteopenia and can more easily result in fractures.

The diagnosis of bulimia nervosa can usually be made clinically. And after the diagnosis with bulimia nervosa, the first step in helping them is always getting a full lab work up to see what systems to the body have been impacted. 

Treatment options include nutritional counseling, behavioral therapy, and even medications. If a person needs help connecting with someone that can help with this disorder, there are organizations that they can contact which will connect them with proper resources in their area. Organizations include the Academy for Eating Disorders and the National Eating Disorders Association. 

Bulimia nervosa is more prevalent in females than males in all age groups. In the US, adult prevalence is 1.0% and adolescent prevalence is 0.9%, with the median age of onset of 18 years. After comparing different age groups, we have seen the prevalence of bulimia nervosa has increased over time. 

Conclusion: 

Anorexia nervosa and bulimia nervosa are eating disorders that can have consequences on the health of our patients. We should know the difference between these two diseases and know the resources available in our community to assist these patients. The diagnosis may be done clinically, but you will need to order labs or imaging for a full assessment. 

Eating disorders are an example of the direct effect a mental illness can have in the body. In the specific case, anorexia and bulimia cause malnutrition. The treatment of these diseases requires a multidisciplinary team to treat the patient and the family as well.

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Conclusion: Now we conclude our episode number 76 “Eating Disorders.” We started this episode with exciting news about the new malaria vaccine, a step forward on our fight against malaria. Sophia, Jeffrey, and Dr Arreaza presented an interesting overview about anorexia and bulimia. They taught us that if a patient perceives him or herself as “fat”, but they are actually underweight, they may have anorexia. Patients with bulimia tend to have normal or above normal BMI but have periods of binging and purging. Be aware of these conditions while assessing your patients’ nutritional status and treat appropriately or refer as needed. 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Tana Parker, Sophia Dhillon, and Jeffrey Nguyen. Audio edition: Suraj Amrutia. See you next week! 

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References: 

Malaria’s Impact Worldwide, Centers for Disease Control and Prevention, https://www.cdc.gov/malaria/malaria_worldwide/impact.html, accessed on November 15, 2021. 

Constitution of the World Health Organization, Basic Documents, Forty-fifth edition, Supplement, October 2006, accessed on Aug 26, 2021. Accessed on November 15, 2021.  https://www.who.int/governance/eb/who_constitution_en.pdf.

12 Secret Signs of Anorexia, CBS News, August 12, 2010, https://www.cbsnews.com/pictures/12-secret-signs-of-anorexia/3/. 

Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58. doi: 10.1016/j.biopsych.2006.03.040. Epub 2006 Jul 3. Erratum in: Biol Psychiatry. 2012 Jul 15;72(2):164. PMID: 16815322; PMCID: PMC1892232. https://pubmed.ncbi.nlm.nih.gov/16815322/. 

Mitchell, James E, MD; and Christie Zunker, PhD, CPH, CHES, Bulimia nervosa and binge eating disorder in adults: Medical complications and their management, UpToDate, October 2021. https://www.uptodate.com/contents/bulimia-nervosa-and-binge-eating-disorder-in-adults-medical-complications-and-their-management?search=Bulimia%20nervosa%20and%20binge%20eating%20disorder%20in%20adults:%20Medical%20complications%20and%20their%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Yager, Joel, MD, Eating disorders: Overview of epidemiology, clinical features, and diagnosis, UpToDate, October 2021. https://www.uptodate.com/contents/eating-disorders-overview-of-epidemiology-clinical-features-and-diagnosis?search=Eating%20disorders:%20Overview%20of%20epidemiology,%20clinical%20features,%20and%20diagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Yager, Joel, MD, Eating disorders: Overview of prevention and treatment, UpToDate, October 2021. https://www.uptodate.com/contents/eating-disorders-overview-of-prevention-and-treatment?search=Eating%20disorders:%20Overview%20of%20prevention%20and%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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 75: Multisystem Inflammatory Syndrome in Children (MIS-C).  

Dr Schlaerth explains the signs, symptoms, and basic management of MIS-C. Lam explain the role of anti-obesity medications in weight management. 

Introduction: The Role of Drugs in Weight Loss Management    
By Lam Chau, MS3, Ross University School of Medicine   

Today about 70% of adult Americans are overweight or obese. Obesity is associated with increased risk of heart disease, stroke, and diabetes, among many other diseases. Studies have shown losing 5-10% of your body weight can substantially reduce your risk of cardiovascular disease. 

Traditional belief is that weight loss can only be attributed to diet and exercise. While there are certainly elements of truth to that statement, medication is a safe and proven method for weight management that is often overlooked. The fact of the matter is that weight loss is an ongoing field of study with constant new research and innovations. 

In June of this year, a medication named Wegovy was approved for weight loss management by the 

FDA. This drug is indicated for chronic weight management in patients with a BMI of 27 or greater with an accompanying weight-related ailment or in a patient with a BMI of 30 or greater. 

Rachel Batterham, PhD, of the Centre for Obesity Research at University College London, shared: "The findings of this study represent a major breakthrough for improving the health of people with obesity. No other drug has come close to producing this level of weight loss — this really is a game changer.”

Despite breakthroughs like these, the use of medication for weight loss is still relatively low. Dr. Erin Bohula, a cardiologist and assistant professor at Harvard Medical School, believes “there are probably a few reasons for this, including cost, if not covered by insurance, and a perception these agents are not safe in light of the history with weight loss agents.”

A study from 2019 examined the medical records from eight geographically dispersed healthcare organizations. They found that out of 2.2 million patients who were eligible for weight loss medication, only 1.3% filled at least 1 prescription.

Weight loss is a dynamic process with many different variables. While it may not necessarily be for everyone, medication can help tremendously and is an option you should consider if you are interested in weight loss[1,2].

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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Multisystem Inflammatory Syndrome in Children (MIS-C).   
By Katherine Schlaerth, MD, and Hector Arreaza, MD.

History and epidemiology

Most children who get COVID-19 have either no symptoms or very mild symptoms. However, about 18 months ago, a new pediatric complication of COVID-19, possibly postinfectious, was described. 

The eight children who were initially described had a clinical presentation which was similar to either Kawasaki Disease or perhaps toxic shock syndrome, and since these children had signs of a hyperinflammatory state coupled with shock, the new syndrome was named Multisystem Inflammatory Syndrome in Children, or MIS-C for short. By midsummer of 2021, the United States had about two thousand cases and 30 deaths in children under 21. 

Other name for this condition is Pediatric Hyperinflammatory Shock.

Diagnosis

What are the criteria for a diagnosis of Multisystem Inflammatory Syndrome? 

They include:

Age below 21

Fever above 100.4 degrees Fahrenheit or 38 degrees centigrade for 24 hours (a subjective fever for more than 24 hours counts too). 

Laboratory evidence of inflammation which should include at least two of the following tests: elevated CRP, elevated ESR, elevated fibrinogen level, procalcitonin, D-dimer, ferritin, lactic acid dehydrogenase (LDH), interleukin-6, and neutrophil counts, low lymphocyte count and low albumin.

Severe disease necessitating hospitalization with multisystem organs affected. The systems affected include cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, and neurologic (at least three systems need to be involved). 

No creditable other diagnosis.

Other symptoms include:

GI complaints (diarrhea, vomiting, abdominal pain)

Skin rash

Conjunctivitis

Headache

Lethargy

Confusion

Respiratory distress

Sore throat

Myalgias

Swollen hands/feet

Lymphadenopathy

Cardiac signs and symptoms include troponin/BNP elevation and arrhythmia. Findings on ECHO may include depressed LVEF, coronary artery abnormalities, including dilation or aneurysm, mitral regurgitation, and pericardial effusion.

There also must be a positive test for SARS-CoV-2 and this test can be either a reverse transcriptase polymerase chain reaction (RT-PCR), serologic, or antigen testing. Exposure to someone who has had or is suspected of having had COVID-19 within the last 4 weeks also counts. 

Patients with MIS-C may have predominately gastrointestinal symptoms, mucocutaneous findings, and may be hypotensive or “shocky” on presentation. Up to 80% require ICU admission. Thrombocytopenia and /or elevated transaminase levels can also be seen. 

MIS-C vs Kawasaki Disease

The big issue in diagnosing MIS-C is the overlap with Kawasaki’s disease and with toxic shock syndrome. Patients with Kawasaki Disease in their second week of illness often will have thrombosis, not thrombocytopenia. Whereas MIS-C usually affects school age children or adolescents, Kawasaki Disease is more commonly a problem in younger children, who have an average age of 2 years. 

Kawasaki Disease is also more common in Asian children and MIS-C disproportionately seems to affect Black and Hispanic children. 

Obesity seems to be another risk factor for MIS-C. 

Kawasaki’s Disease also has different cardiac manifestations from MIS-C. Coronary artery dilatation is common in Kawasaki’s disease and left ventricular dysfunction in MIS-C, although sometimes coronary artery dilatation and rarely aneurisms can be noted on echocardiogram in putative MIS-C, which is why differentiation from Kawasaki’s Disease is an issue. 

Pathophysiology

The cause of MIS-C is probably postinfectious immune dysregulation. Only a minority of MIS-C patients are identified as having COVID-19 by RT-PCR, but most have positive tests for immunoglobulin G. 

Statistically, there is a lag of 4-6 weeks between peak community cases of COVID-19 and the time at which children present with MIS-C.  

Although research is being done on MIS-C, and theories abound about etiology, there is no clear-cut answer to why some children get MIS-C and the vast majority do not.

In a review of the literature on MIS-C using literature from December 2019 through May 2020, gastrointestinal symptoms such as diarrhea, and abdominal pain were 4-5 times more common than cough and respiratory distress. 

There was a slight preponderance of male patients and mean age was 8 ½ years. ICU admission was common and 2/3 required inotropic support, over ¼ needed respiratory help with extracorporeal membrane oxygenation warranted in 31 children. The death rate was 1.5 % of these very sick children treated in hospital. 

In another smaller study, 80% had mild, but 44% had moderate to severe EKG abnormalities including coronary involvement. The good news was that coronary arteries were normal in all children after a month, and at 4-9 months, only 2-4% had mild heart abnormalities.

Unfortunately, mechanisms of MIS-C as well as universal treatment is still being worked out. Published articles may be delayed due to time constraints in publishing. Other immunologic interventions do not have sufficient data.

Treatment

What about the treatment of children diagnosed with MIS-C?

Usually, a variety of specialists become involved initially. These can include pediatric rheumatology, infectious disease, cardiology, and hematology. If children with MIS-C meet criteria for complete or incomplete Kawasaki disease as well, regardless of COVID-19 testing results, IVIG and aspirin are reasonable. 

Corticosteroid use must be individualized, and if used it may require a taper. 

An echocardiogram can be done initially looking for coronary aneurisms and repeated in a week. 

In severe cases, shock may be a presenting factor needing urgent attention. Generally, the treatments used are decided by the aforementioned consults and may consist of immunomodulating therapy, including possibly IVIG (2g/kg), and/or corticosteroids methylprednisolone (30mg/kg). 

Antivirals

The role of antiviral therapy is unclear and remdesivir should be reserved for children with acute COVID-19. 

COVID-19 vaccination-associated myocarditis

Another entity which needs further evaluation is COVID-19 vaccination-associated myocarditis in adolescents. This problem is more common in young males and may occur after the administration of mRNA based COVID-19 vaccines. The presentation occurs within 2 weeks of COVID-19 vaccination, and clinical presentation can include chest pressure, abnormal biomarkers (elevated troponins), and cardiac imaging findings. It is unknown if subclinical cases occur. 

COVID-19 infection in children, while usually benign, has the potential to become serious, and the association between some mRNA vaccines and the occurrence of myocarditis has yet to be thoroughly studied. We look forward to more and better data to guide the care of children and young adults in these spheres.

The risk of having myocarditis is still higher with the actual COVID-19 than the COVID-19 vaccine. The incidence of myocarditis after BioNtech/Pfizer vaccine was 2.13 cases per 100,000 persons in a large study done in a large health care organization in Israel where more than 2 million people were vaccinated (that represents 0.00213%). Another US study showed that there were 77 cases per million doses of vaccines in young male, in contrast, there were 450 cases of myocarditis per million COVID-19 cases in the same age group.

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Conclusion: Now we conclude our episode number 74 “Multisystem Inflammatory Syndrome in Children.” Dr. Schlaerth explained that MIS-C is a work in progress in terms of pathophysiology, diagnosis, treatment, and prognosis. MIS-C and Kawasaki Disease are very similar, but, for example, GI symptoms, cardiac dysfunction, shock and multisystem dysfunction are more prominent in MIS-C than Kawasaki Disease. Whereas coronary artery aneurysms are more common in Kawasaki disease than MIS-C. 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Katherine Schlaerth, and Lam Chau. Audio edition: Suraj Amrutia. See you next week! 

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References:

FDA Approves New Drug Treatment for Chronic Weight Management, First Since 2014, June 04, 2021, U.S. Food and Drug Administration (FDA), https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014.

Saxon DR, Iwamoto SJ, Mettenbrink CJ, et al. Antiobesity Medication Use in 2.2 Million Adults Across Eight Large Health Care Organizations: 2009-2015. Obesity (Silver Spring). 2019;27(12):1975-1981. doi:10.1002/oby.22581. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868321/. 

Carroll, Linda, Weight-loss pills can help. So why don't more people use them? NBC News Health Care, September 2, 2018.  https://www.nbcnews.com/health/health-care/weight-loss-pills-can-help-so-why-don-t-more-n905211

World Health Organization, WHO recommends groundbreaking malaria vaccine for children at risk, October 6, 2021. https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk

Lee, Min-Sheng et. al, Similarities and Differences Between COVID-19-Related Multisystem Inflammatory Syndrome in Children and Kawasaki Disease, Front. Pediatr., 18 June 2021, https://doi.org/10.3389/fped.2021.640118. 

Gail F. Shust, Vijaya L. Soma, Philip Kahn and Adam J. Ratner, Pediatrics in Review July 2021, 42 (7) 399-401; DOI: https://doi.org/10.1542/pir.2020-004770.

Jain SS, Steele JM, Fonseca B, et al. COVID-19 vaccination-associated myocarditis in adolescents. Pediatrics. 2021; doi:10.1542/peds.2021-053427.  https://pediatrics.aappublications.org/content/pediatrics/early/2021/08/12/peds.2021-053427.full.pdf. 

Wilson, Clare, Myocarditis is more common after covid-19 infection than vaccination,  New Scientist, 4 August 2021, https://www.newscientist.com/article/mg25133462-800-myocarditis-is-more-common-after-covid-19-infection-than-vaccination/#ixzz79JPn2E47.

Son, Mary Beth F, MD, and Kevin Friedman, MD, COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis, Up to Date, September 2021, https://www.uptodate.com/contents/covid-19-multisystem-inflammatory-syndrome-in-children-mis-c-clinical-features-evaluation-and-diagnosis?search=kawasaki%20vs%20misc&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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 74: Breast Cancer Screening. 

Salwa and Veronic discuss who, how, and when to screen for breast cancer. The Pfizer COVID-19 vaccine was authorized for use in children 5-11 years of age.

Introduction: Pediatric COVID-19 Vaccines
By Lam Chau, MS3, Ross University School of Medicine

On November 2nd, 2021, the CDC endorsed a unanimous recommendation to allow the use of the Pfizer COVID-19 vaccine for children ages 5-11 years of age. The White House has secured 28 million pediatric doses of the Pfizer vaccine, enough to cover every child ages 5-11 within the United States without cost. 

The official CDC recommendation is that all children aged 5 and older get vaccinated, regardless of past infection history. The Pfizer vaccine for children is given in two doses, 3 weeks apart.

Individuals older than 12 are given a 30-microgram dose, while pediatric individuals are given a 10-microgram dose. For extra precaution, the pediatric vaccine vials are being shipped with a unique orange cap to clearly distinguish itself from higher dose vaccines. Clinical trials with the lower dose vaccine demonstrated a strong antibody response and a prevention rate of symptomatic COVID-19 of 90%. 

The reported side effects were minimal, and no serious adverse events or myocarditis were reported during the trials. The vaccination of children cannot be understated. The benefits go well beyond just the physiological processes of vaccination. It will foster a safer environment for our children and help improve their emotional and social development. 

While there is still a lot to be done to end the pandemic, this recent announcement is an enormous step in the right direction in returning to normalcy. 

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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Breast Cancer.   
By Salwa Sadiqali, MS3, Ross University Medical School; Veronica Phung, MS3, Ross University School of Medicine; and Hector Arreaza, MD.  

Salwa: Welcome back from Spooky season! Did you see all the flyers and advertisements about Breast cancer awareness last month? 

Veronica: I did! It’s because October was breast cancer awareness month.

Salwa: And spooky season, and of course pumpkin spice season! I got my dose of pumpkin spice this morning. Well, every morning to be exact, Starbucks is my second home. What do you know about breast cancer? 

Veronica: Well...breast cancer is the most commonly diagnosed cancer worldwide. And, fun fact, I know that Angelina Jolie had an increased risk of breast cancer, so she had surgery to remove them.

Arreaza: I remember it being all over the news back in 2013. It caused “The Angelina Effect.” There was an increase in people searching about breast cancer on the internet. Let’s dive into this topic a bit more. What exactly is breast cancer?

Salwa: It’s a process in which normal cells of the breast start growing too quickly, out of control. It can happen in males too, but it’s much rarer.

Veronica: And there are different types of breast cancers that originate from the different types of tissue in the breast. There’s ductal carcinoma, lobular, inflammatory, Paget’s, and phyllodes to name a few. 

Salwa: Not only are there different types of breast cancers, but some can also be hereditary meaning mutated genetic information is passed on from generation to generation.

Arreaza: That’s what happened with Angelina Jolie. She had a BRCA1 gene mutation. 

Veronica: BRCA1 and BRCA2 mutations are the most common causes of hereditary breast cancer. Normally, the BRCA gene helps make proteins that repair damaged DNA. When this gene is mutated, it can’t make those proteins, so damaged DNA stays damaged. But this only makes up 5-10% of all breast cancers.

Salwa: Exactly! Here’s an interesting fact, women of Ashkenazi Jewish heritage are at a much higher risk of developing a BRCA mutation. There are several other genes that are also linked to hereditary breast cancer. But those genes aren’t that common. Non-hereditary breast cancers are much more common - they make up about 85% of breast cancers. 

Arreaza: Ok so you two gave us a lot of good information, but do you know how to screen for breast cancer?

Salwa: When and how often you screen depends on which guidelines your physician is following. Generally, you’ll get a mammogram, basically an X Ray of the breast. 

Veronica: The US Preventative Screening Task Force or USPSTF is a panel of experts that uses medicine-based evidence to make screening and vaccination guidelines. These guidelines are reviewed and updated yearly. For breast cancer, the USPSTF recommends women ages 50-74 have a mammogram every other year. 

Salwa: The American College of Obstetrics and Gynecologists recommends mammograms starting at the age of 40 and repeating the test every year or every other year. While the American Cancer Society recommends annual mammograms from 40 to 54 years of age and then every other year for women 55 years or older. 

Veronica: Dr. Arreaza, you see a lot of patients and I’m sure you’ve referred plenty of them for breast cancer screening. How do you decide which guidelines to follow? 

Arreaza: When you have a patient between 40-50 years old, you have an opportunity to talk about screening, and make a shared decision. 

The USPSTF recommends that women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or an ancestry associated with BRCA1/2 gene mutation be screened with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.

Some instruments use to assess the need for BRCA mutation screening include Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, 7-Question Family History Screening Tool, International Breast Cancer Intervention Study instrument (Tyrer-Cuzick).

Salwa: What about the self-breast exams? I remember those were recommended all the time.

Veronica: That’s a great question! Current research suggests that doing a self-breast exam doesn’t necessarily help detect tumors early – whether cancerous or not. And, sometimes, while doing self-breast exams you may feel a lump that’s actually normal breast tissue and it may cause unnecessary anxiety. That being said, you should always know how your breasts normally look - as in are they symmetrical, how the nipples look, how the skin normally looks. And of course, if you notice any changes or have any concerns, please visit your primary care provider. 

Arreaza: Breast awareness. The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects.

Salwa: As medical students, we have the opportunity to work with different departments in the hospital. I’m currently doing my surgery rotation and Veronica completed hers in September. As part of the rotation, we had the opportunity to work at the Breast Clinic with Dr. Snyder. We saw a lot of patients from CSV because their PCPs were screening them for breast cancer and all those women were able to get the higher level of care they needed. Find available resources in your community for free screening mammograms. For example, Cancer Detection Program/Every Woman Counts by Clinica Sierra Vista.

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Now we conclude our episode number 74 “Breast Cancer Screening.” October was breast cancer awareness month, but it is not too late to remind everyone of the need to screen for breast cancer. Whether you follow the American Cancer Society, the USPSTF or the ACOG guidelines, just do not forget to screen. 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Lam Chau, Salwa Sadiqali, and Veronica Phung. Audio edition: Suraj Amrutia. See you next week! 

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References:

AAFP Signs Off on Pediatric COVID-19 Vaccine Recommendations, American Academy of Family Physicians, November 3, 2021. https://www.aafp.org/news/health-of-the-public/20211103covidvaccchildren.html?%20cid=DM63464&bid=188450701

ACS Breast Cancer Early Detection Recommendations. American Cancer Society. (n.d.). Retrieved October 11, 2021, from https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html.

Basu, N.N., Hodson, J., Chatterjee, S. et al. The Angelina Jolie effect: Contralateral risk-reducing mastectomy trends in patients at increased risk of breast cancer. Sci Rep 11, 2847 (2021). https://doi.org/10.1038/s41598-021-82654-x

Breast cancer information and support. Breastcancer.org. (n.d.). Retrieved October 10, 2021, from https://www.breastcancer.org/.

Breast cancer: Screening. Recommendation: Breast Cancer: Screening | United States Preventive Services Taskforce. (2016, January 11). Retrieved October 10, 2021, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening. 

Practice Bulletin Number 179: Breast Cancer Risk Assessment and Screening in Average-Risk Women. (2017). Obstetrics and gynecology, 130(1), e1–e16. https://doi.org/10.1097/AOG.0000000000002158

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 73: Anticoagulation in Afib. 

When should you start anticoagulation in atrial fibrillation? What medications are appropriate? Virginia Bustamante, Charizza Besmanos and Dr Arreaza discuss this topic.  
By Charizza Besmanos, MS4; Virginia Bustamante, MS4; and Hector Arreaza, MD

Charizza: Hello, welcome to today’s episode of Rio Bravo qWeek Podcast. My name is Charizza Besmanos, a 4th year medical student from American University of the Caribbean and I am joined here today by Virginia Bustamante. 

Virginia: I’m Virginia Bustamante, an incoming 4th year medical student from Ross University. 

Arreaza: And I’ll be here just to make sure that you guys behave during this episode.

Charizza: Before we get started on our discussion, I have a quick patient case to share with you. 

This is a 66-year-old woman who is brought to the ED with sudden onset of severe difficulty speaking and weakness while having breakfast. She has hypertension, hyperlipidemia, severe left atrial enlargement seen on previous ECHO, and is noncompliant with her medications. She is a lifetime nonsmoker and does not drink alcohol. On admission, her blood pressure is 152/90 and pulse is 124/min and irregularly irregular. She is awake and alert but has difficulty finding words while trying to speak. She has severe right lower facial droop and marked weakness and sensory loss in the right arm and mild weakness in right leg. Fingerstick glucose is at 105. ECG shows atrial fibrillation. Acute stroke management is started right away. CT shows occlusion of the left MCA. What management could have prevented this complication? 

Virginia: This patient clearly has multiple risk factors for thromboembolism events but given her irregularly irregular pulse consistent with atrial fibrillation, she would’ve warranted long-term anticoagulation to prevent stroke, which she most likely had. 

Charizza: Exactly. Today’s topic is atrial fibrillation, specifically the use of anticoagulation.

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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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Virginia: Anticoagulation is indicated to decrease the risk of thromboembolic events such as ischemic stroke in patients with atrial fibrillation (A-fib). Not all patients receive anticoagulation. Like most things in medicine, you must decide to start anticoagulation when the benefits of decreasing the risk of stroke outweighs the risk of bleeding. So, for assessing the risk of stroke in A-fib, the American College of Cardiology along with American Heart Association and the Heart Rhythm Society published a guideline in the Journal of the American College of Cardiology in 2014 and was recently updated in 2019[1] detailing in which patients anticoagulation is recommended. 

Charizza: Yes, according to the guideline, “high risk patients” are all patients with valvular A-fib, and those with nonvalvular A-fib with a CHADVASC score of >/= 2 in men or >/= 3 in women, and those with nonvalvular Afib and hypertrophic cardiomyopathy. Those with “medium risk” are patients with nonvalvular Afib with CHAD2VASc score of 1 in men or 2 in women. In these patients, anticoagulation is considered but the risk and benefits are discussed with the patient. Those with “low risk” are patients with CHAD2VASc score of 0 in men or 1 in women and anticoagulation is not routinely recommended in these patients. Can you tell us briefly what CHA2DVASc score is? 

Virginia: CHA2DS2-VASc score is the stroke risk assessment tool of choice by the AHA/ACC/HRS guideline. It is great because it is a mnemonic. Each letter is assignment 1 point except for 2 criteria. C stands for congestive heart failure, H for HTN defined as >140/90, A2 is for or Age>75 which is for 2 points, D for diabetes, S2 is for stroke or TIA and it’s for 2 points, V for vascular disease such as MI, A for age 65-74, S for female sex. 

Charizza: That certainly makes it easy to remember. Not only that, but you can also find CHA2DS2-VASc score of MDCalc to make it even easier.

Virginia: Now that we’ve established which patients should receive anticoagulation, how do we choose which anticoagulant? 

Charizza: For this discussion today, I would like to focus on nonpregnant patients. There really are 2 main anticoagulants, DOACs (or the direct oral anticoagulants) and warfarin. DOACs are the direct thrombin INH (dabigatran) and the direct factor Xa INH (rivaroxaban, apixaban, and edoxaban). DOAC is recommended as first-line in the long-term management of nonvalvular afib as trials have shown DOACs are more successful at reducing risk of thromboembolic events and have a lower risk of bleeding than warfarin and warfarin requires INR monitoring with dose adjustments. Although, in patients with valvular Afib, warfarin is preferred.

Arreaza: All of them are by mouth. 

Virginia: Dosing of DOACs depends on the kidney function, so it is important to obtain the creatinine clearance. For dabigatran, the direct thrombin INH, the recommended dose for patients with CrCl >30 mL/min is 150mg PO twice daily based on the results from the RE-LY trial (2), which evaluated the efficacy and safety of dabigatran with warfarin in patients with Afib. For patients with CrCl of 15-30 mL/min, the recommended dose is 75mg PO BID. Those with CrCl <15 mL/min or on dialysis, dabigatran is not recommended. 

Charizza: For the apixaban (Eliquis®), a direct factor Xa inhibitor, the dosing is 5mg BID for patient with normal renal function. For those with moderate kidney dysfunction such as Cr is >1.5, patient who is > 80years old or body weight <60kg, dosing of apixaban is decrease to 2.5 mg PO BID. There is not enough data for use of apixaban in patients with CrCl <15 or in dialysis. 

Virginia: For another direct factor Xa INH rivaroxaban (Xarelto®), dose is 20 mg once per day for CrCl >50 mL/min, 15 mg once per day for CrCl 15 to 50 mL/min, and for CrCl <15 mL/min do not use rivaroxaban.

Charizza: Essentially, any DOACs is not recommended for severe kidney impairment which is CrCl <15 mL/min or those on dialysis. 

Virginia: Yes, and for those patients where DOAC cannot be used, warfarin can be initiated. 

Charizza: Initiating warfarin for long-term anticoagulation in patient with atrial fibrillation does not necessarily require heparin bridge(4). 

Virginia: Before starting warfarin, a baseline INR is obtained. Usually, the initial dose of warfarin is 5mg PO daily for 3 days (5). And on day 4, INR is check in the morning and adjusting the dose of warfarin depending on the INR. 

Charizza: Warfarin dose is adjusted for a target INR of 2-3(6). Warfarin can be complicated to maintain, however, there are anticoagulation clinic to make sure they compliant with theirs and INR is therapeutic.

Thank you for your attention.

Now we conclude our episode number 73 “Anticoagulation in Afib.” Anticoagulation is an essential part of the management of Afib, mainly to prevent embolic stroke. 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 with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Virginia Bustamante, and Charizza Besmanos. Audio edition: Suraj Amrutia. See you next week! 

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References:

January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., & Yancy, C. W. (2019, January 28). 2019 AHA/ACC/HRS FOCUSED update of the 2014 Aha/acc/hrs guideline for the management of patients with atrial fibrillation: A report of the American College of Cardioloy /American Heart Association Task force on clinical practice guidelines and the heart Rhythm Society. Journal of the American College of Cardiology. https://www.sciencedirect.com/science/article/pii/S0735109719302098?via%3Dihub . 

Bavry, Anthony A., MD, MPH, FACC, Randomized evaluation of long-term anticoagulant therapy RE-LY. American College of Cardiology. (2020, August 25). https://www.acc.org/latest-in-cardiology/clinical-trials/2013/07/19/12/25/rely. 

Warren J Manning, MD; Daniel E Singer, MD; Gregory YH Lip, MD, FRCPE, FESC, FACC. Atrial fibrillation in adults: Use of oral anticoagulants. Up to Date. (n.d.). https://www.uptodate.com/contents/atrial-fibrillation-use-of-oral-anticoagulants?search=atrial+fibrillation&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H416912985 .

Ebell MH. Evidence-based initiation of warfarin (Coumadin). Am Fam Physician. 2005 Feb 15;71(4):763-5. PMID: 15742915. https://www.aafp.org/afp/2005/0215/p763.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!