Rio Bravo qWeek

Episode 62: Onychomycosis (nail fungus). 

Future doctors Gabrielle and Jeanette discuss with Dr Arreaza the diagnosis and treatment of onychomycosis, AKA nail fungus.

By Gabrielle Robinson, MS3, and Jeanette Adereti, MS3
Ross University School of Medicine
Facilitated by 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 onychomycosis?

-Onychomycosis is a fungal infection that resides in the finger and toenails. The nails become discolored, have onycholysis (painless separation of nail bed), splitting of nail bed, thickened. There are various causes of onychomycosis and examples include the following: dermatophytes, yeast, non-dermatophyte molds.

-Onychomycosis occurs in 10% of the general population.

Microbiology:

Dermatophytes such as Tinea rubrum, account for most onychomycosis infections (~60-70%) while candida account for most of yeast causes of onychomycosis. Non-dermatophyte molds include fusarium, aspergillus, acremonium, scytalidium, Scopulariopsis brevicaulis.

The type of organism involved has an association for the type of infection it causes. Yeast infects fingernails preferentially while the dermatophytes prefer to infect toenails.

Diagnostic testing including culture, KOH preparation and PAS staining can help with confirming fungal infection, but culture not required for empiric treatment with oral terbinafine.

Severity of onychomycosis:

-Mild-moderate: ≤50 percent involvement of the nail and sparing the matrix/lunula

-Moderate-severe: involving >50 percent of the nail or involving the matrix or lunula, including further spread throughout nail.

-It’s common to have multiple nails affected at the same time. Toenails and fingernails can both be affected. Remember to check all nails in your patients. Nails can show signs of local but also systemic diseases.

Risk factors:

-Health conditions: Diabetes, immune suppression, venous insufficiency, peripheral artery disease, or even just having slow growth of the nails. This makes sense because there is decreased blood flow to those areas resulting in decreased immune surveillance of that area. Patient s with PAD are at risk for onychomycosis. Nails normally grow slower in male. Hormones play a role in that growth.

-Exposure: smoking, trauma to the nail, sports, wearing sweaty shoes, being barefoot in communal areas such as swimming pools, college showers, jail house showers, and gyms.

-Dermatological diseases: tinea pedis (athletes’ foot), excessively sweaty hands (hyperhidrosis), psoriasis

-Other factors: old age, having family members whom the patient shares a living space with, bunion (hallux valgus).

Effects on mental health

Unfortunately, the infection takes a toll on the patient because the infection is unsightly it results in psychosocial disturbances. The patients may not want to wear sandals, get pedicures, or shower during gym class if they are school age. These types of feelings can cause patients to not want to go to work or do things they enjoy due to feelings of embarrassment.

Management
Treatment of dermatophyte onychomycosis is guided by causative organism, severity, treatment availability, and cost.

Oral agents
-Oral treatment is generally the gold-standard for onychomycosis due to shorter course and greater efficacy compared to topical. 
-Oral terbinafine is the preferred oral agent. Itraconazole can be used in patients not able to tolerate/respond to terbinafine.
-Terbinafine and itraconazole both work by blocking important enzymes in fungal synthesis.
-A randomized double-blind trial showed that terbinafine is more effective outcomes and better long-term cure rates than itraconazole.
-Adult dosing of terbinafine: fingernail onychomycosis =250 mg per day for 6 weeks. Toenail onychomycosis= 250 mg per day for 12 weeks.
-Some side effects of oral terbinafine include headache, dermatitis, GI distress, taste disturbances, and liver enzyme abnormalities. Adverse effects of Itraconazole include headache, GI disturbances, liver enzyme abnormalities.
-In patients receiving continuous therapy, monitoring of transaminase levels is typically performed at baseline and repeated at six weeks if therapy will continue beyond six weeks. A medication interaction check is recommended before starting treatment with oral agents. 
-Mycotic cure rates of 76% for terbinafine, 63% for itraconazole with pulse dosing, 59% for itraconazole with continuous dosing, and 48% for fluconazole, topical cure rate is about 40%.
-Recurrence of infection ranges 10-50% (reinfection or persistent infection). Patients need to wait for up to 1 year to see full effect of treatment. Treatment is highly recommended in patients with diabetes, treatment in other patients is cosmetic.

Compliance
Patient compliance is difficult because while taking oral medications, you cannot drink alcohol, and this becomes a problem due to the length of the treatment.

Topical agents
-Efinaconazole, Amorolfine, Tavaborole, Ciclopirox
-Patients who have contraindications to systemic antifungal therapy, who are at risk for drug-drug interactions with systemic antifungal drugs, or who prefer to avoid systemic treatment can be treated with topical therapy. Similarly, to oral agents, these medications work by blocking important processes in fungal synthesis. These agents come in solutions or nail lacquer. Possible side effects include local skin irritation or ingrown nails.

Alternatives
-Less common therapeutic interventions for onychomycosis include oral antifungal agents other than terbinafine and itraconazole, laser therapy, photodynamic therapy, and surgical nail removal.
-Patients with pain or discomfort from infected nails may benefit from removal of hyperkeratotic nail debris. Application of topical urea under occlusion can help with debridement of the nail and symptom improvement.
-Recurrence after treatment of onychomycosis is common.

Prevention:

Now that we have gone over a lot of material about onychomycosis, we should discuss how we can prevent these types of infections from occurring.  Having good “foot hygiene” can help reduce the of infection and re-infection.

Wash your hands and feet frequently, especially after encountering someone who is infected.  

Clip nails straight across and file afterward making sure to sterilize clippers before and after each use.  Do not share nail clippers with others.

If you have a history of sweaty feet, consider using sweat absorbing socks or wearing “breathable shoes” to prevent sweat from accumulating.

Throw out old shoes or disinfect them using antifungal powders.

Wear sandals in communal shower areas and at the pool.

Pay attention to the cleanliness of your nail salon.

Joke: Do you want to know how a person with toenail fungus feels? Just step into their shoes.

Conclusion: Now we conclude our episode number 62 “Onychomycosis (nail fungus).” Future doctors Robinson and Adereti gave a very good summary about symptoms, diagnosis, and treatment of this common infection. Remember, not all patients need to be treated, but patients with diabetes or other risks are highly encouraged to receive treatment to prevent future complications. 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, Gabrielle Robinson, and Jeanette Adereti. Audio edition: Suraj Amrutia. See you next week!

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References:

Goldstein, Adam O et al, Onychomycosis: Epidemiology, clinical features, and diagnosis, Up to Date, last updated: Apr 30, 2019. https://www.uptodate.com/contents/onychomycosis-epidemiology-clinical-features-and-diagnosis?search=onychomycosis&source=search_result&selectedTitle=2~92&usage_type=default&display_rank=2.

Bai, Jennifer, MD, Consult Corner: Laceration through the nail bed, American Society of Plastic Surgeons, January 1, 2020. https://www.plasticsurgery.org/for-medical-professionals/publications/plastic-surgery-resident/news/consult-corner-laceration-through-the-nail-bed.

Goldstein, Adam O et al, Onychomycosis: Management, Up to Date, last updated: Nov 20, 2020. https://www.uptodate.com/contents/onychomycosis-management?search=onychomycosis&source=search_result&selectedTitle=1~92&usage_type=default&display_rank=1.

Rodgers P, Bassler M. Treating onychomycosis. Am Fam Physician. 2001 Feb 15;63(4):663-72, 677-8. Erratum in: Am Fam Physician 2001 Jun 1;63(11):2129. PMID: 11237081. https://www.aafp.org/afp/2001/0215/p663.html.

Mayo Clinic, Patient and Health Information, Nail Fungus, https://www.mayoclinic.org/diseases-conditions/nail-fungus/symptoms-causes/syc-20353294

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!

Dr Arreaza discusses with Dr Carranza the results of the STEP trials: Semaglutide Treatment Effect in People with obesity, which allowed semaglutide gain FDA approval as a treatment for obesity.

By Hector Arreaza, MD, and Claudia Carranza, 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. 

One of the major challenges of modern medicine is to find an effective treatment for obesity.

Obesity was considered a disease in 1998 by the National Institutes of Health[1].

In 2002, the Internal Revenue Service, AKA the feared IRS, issued a statement to make obesity treatment a deductible medical expense. Who would have known that obesity was tax deductible?

Later, in 2013 obesity was accepted as a complex, chronic disease by the American Medical Association[2]. Many other organizations have made statements in favor or against the definition of obesity as a disease.

We recently announced the exciting news of semaglutide as a new FDA-approved medication for the chronic treatment of obesity. Today we want to give you a very brief summary (brief-ísimo) of the trials that allowed semaglutide to gain that FDA-approval. 

Semaglutide was tested at different levels with the STEP trials. STEP stands for Semaglutide Treatment Effect in People with obesity (STEP). All these trials were done in 68 weeks, all patients received counseling about lifestyle modifications, 70-80% were women, ages averaging 40-50 years old.

STEP 1: Does semaglutide cause weight loss in patients without diabetes?

The focal point of this trial was weight management with semaglutide in patients without diabetes. This was a double-blind trial. There were 1961 participants enrolled. A group was assigned to placebo and another group was assigned to weekly injection of semaglutide. For the semaglutide group, the goal dose of semaglutide was 2.4 mg, starting with 0.25 mg, increasing every 4 weeks: 0.5 -> 1.0 -> 1.7 -> 2.4 (reaching the goal dose in 4 months), 3 out of 4 participants were Caucasians. 

Outcomes: after 68 weeks weight reduction was -16.9% in patients on semaglutide, more than 86% of participants had a weight loss >5%, 69% lost >10% of their weight, and 50% percent lost >15% of their body weight, and about 32% lost >20% of their weight. This may be comparable to bariatric surgery in some patients; however, the weight loss is not as dramatic. Other parameters improved were waist circumference, blood pressure, triglycerides. LDL and total cholesterol were not significantly affected. There was a clinical meaningful change in 40% of patients. 7 out of 100 could not complete trial for GI adverse effects, most commonly nausea, diarrhea, vomiting, constipation. Acute pancreatitis presented in 0.2% of the semaglutide group (all recovered during study) vs 0% in the placebo group[3]. 

STEP 2: Does semaglutide cause weight loss in patients with diabetes? 

The focal point of this study was weight management with semaglutide in type 2 diabetes mellitus. 1210 patients participated in 12 different countries across Europe, North America, South America, the Middle East, South Africa, and Asia. Patients were randomly assigned to semaglutide 2.4 mg weekly, Semaglutide 1 mg weekly, or placebo. 

Weight loss was superior with semaglutide 2.4 mg, -9.6% of body weight with semaglutide vs -3.4% weight loss with placebo. As you can see, weight loss in individuals with diabetes is more difficult. The effect on diabetes control was about the same with semaglutide 1 mg vs 2.4 mg. The 1 mg dose reduced A1C -1.5%, and the reduction was -1.6% with semaglutide 2.4 mg. A1C reduction was about the same regardless of weight loss. 

STEP 3: Does Intensive Behavioral Therapy increases weight loss in patients using semaglutide?

Intensive behavioral therapy was put to the test. 611 participants were enrolled. Each patient in this study received IBT: 30 brief sessions, 19 in the first 24 weeks, monthly thereafter provided by a registered dietitian. Participants had obesity and overweight, lived in 41 states in the US, had >1 related comorbidity, no diabetes. They all were put on a low-calorie diet for 8 weeks and were randomized to receive either semaglutide or placebo. 

Weight loss was accelerated by the low-calorie diet and IBT earlier in the study, but at the end there was only 1% difference between the two groups, 17.6% weight loss with IBT vs 16.9% weight loss without IBT. Further research is needed to determine the potential benefits of including a low-carb diet to semaglutide to increase long term weight loss. 

STEP 4: What happens to weight loss if we stop semaglutide?

The focal point of this study was sustained weight management. Patients were randomized to placebo or semaglutide after 20 weeks, but continued lifestyle modifications

Those who remained in semaglutide, continued to lose weight up to 18% (lost 8% additional weight). The placebo arm gained half of their weight back. If you stop the medication weight is likely to come back. 

Weight loss comparison: Contrave® (bupropion-naltrexone) and Saxenda (liraglutide) ~5% weight loss, Qysimia® (phentermine-topiromate ~9%), semaglutide (Wegovy®) is about 15%. The average weight loss with semaglutide is higher than other meds, including liraglutide, after 1 year of use. Medullary thyroid cancer: Not shown to be increased risk.

Newer medications that act on the GLP-1 receptors are showing increased rates of weight loss.

• IBT is less important in weight management if a highly effective medication is used to curb appetite

•Improved glucose control and CVD risk reduction is achieved when patients have ≥10% weight reduction

•Obesity is a complex chronic disease that requires long-term management

Credit: This summary was inspired by Dr Robert F. Kushner, Professor of Medicine, Northwestern University Feinber School of Medicine.

Conclusion: Now we conclude our episode number 61 “Semaglutide for Obesity”. After listening to this episode, we hope you understand the role of semaglutide in the treatment of obesity. Semaglutide has shown to cause weight loss in patient with and without diabetes, and the benefits go beyond weight reduction to include lower blood pressure and triglycerides, among other health markers. Semaglutide is not for everyone, but it can surely be the answer to many of your patients with obesity. 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 and Claudia Carranza. Audio edition: Suraj Amrutia. See you next week! 

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References:

1. Kyle TK, Dhurandhar EJ, Allison DB. Regarding Obesity as a Disease: Evolving Policies and Their Implications. Endocrinol Metab Clin North Am. 2016;45(3):511-520. doi:10.1016/j.ecl.2016.04.004, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4988332/

1. AMA House of Delegates Adopts Policy to Recognize Obesity as a Disease, Obesity Medicine Association, June 19, 2013, https://obesitymedicine.org/ama-adopts-policy-recognize-obesity-disease/

1. Wildings, John P.H. et al., Once-Weekly Semaglutide in Adults with Overweight or Obesity, N Engl J Med 2021; 384:989-1002, DOI: 10.1056/NEJMoa2032183. https://www.nejm.org/doi/full/10.1056/NEJMoa2032183 (STEP1)

1. Davies, Melanie et. al, Semaglutide 2·4 mg once a week in adults with overweight or obesity, and type 2 diabetes (STEP 2): a randomised, double-blind, double-dummy, placebo-controlled, phase 3 trial, The Lancet, March 02, 2021, DOI: https://doi.org/10.1016/S0140-6736(21)00213-0   (STEP 2)

1. Wadden TA, Bailey TS, Billings LK, Davies M, et. al. Effect of Subcutaneous Semaglutide vs Placebo as an Adjunct to Intensive Behavioral Therapy on Body Weight in Adults With Overweight or Obesity: The STEP 3 Randomized Clinical Trial. JAMA. 2021 Apr 13;325(14):1403-1413. doi: 10.1001/jama.2021.1831. PMID: 33625476; PMCID: PMC7905697. https://jamanetwork.com/journals/jama/article-abstract/2777025 (STEP 3)

1. Rubino D, Abrahamsson N, Davies M, et al. Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity: The STEP 4 Randomized Clinical Trial. JAMA. 2021;325(14):1414–1425. doi:10.1001/jama.2021.3224. https://jamanetwork.com/journals/jama/article-abstract/2777886 (STEP 4)

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 60: Variety of Topics.  

Gabrielle Robinson (MS3) discusses with Dr Arreaza these topics: IsoPSA, 3HP for LTBI, shingles vaccine, and DELC.

Introduction: You will hear a conversation between Gabrielle Robinson, a 3rd year medical student, and Hector Arreaza. They discussed 4 articles about topics that are relevant to current clinical practice in family medicine.

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.

Variety of Topics. 

By Gabrielle Robinson, MS3, Ross University School of Medicine, and Hector Arreaza, MD.  

The IsoPSA test

H: Cleveland Clinic published this article in July 2020[1]. 

G: According to that article, the IsoPSA test is a new clinically relevant screen for prostate cancer. The data suggests that ISoPSA can potentially decrease unnecessary prostate biopsies by 45%. The IsoPSA evaluates changes in the structure of PSA rather than measuring the concentration of PSA.  

G: IsoPSA is meant to be used in patients who are over 50 years old with PSA > 4ng/mL that have not had a previous diagnosis for prostate cancer or are under surveillance.

H: Is PSA a bad screening test?
G: Measuring the concentration of PSA has proven to be a less sensitive screening tool because PSA is specific for tissues and nonspecific for cancer. This means that a high PSA does not necessarily mean cancer is present.  The PSA can be elevated due to a multitude of reasons including but not limited to prostatitis, benign prostatic hyperplasia, etc.  Unfortunately, this has led to the overdiagnosis of low-grade cancers that were in fact benign conditions. However, PSA is an effective tool for monitoring of recurrence of prostate cancer and it reduces the need for treatment of metastatic disease.

H: As a reminder, screening for prostate cancer in asymptomatic individuals by using PSA is a grade D recommendation from the USPSTF. D means “Do not do it!” However, IsoPSA is not included in that recommendation. We’ll see if evidence suggests IsoPSA as an alternative in the future. 

3HP for latent TB infection treatment

H: This information was published by CDC on June 28, 2018. 

G: Previously, the treatment for latent TB included 3–9 months of DAILY Isoniazid (INH) or Rifampin (RIF), either alone or combined.  Now, new data according to CDC recommends that INH-RPT (isoniazid-rifaPENtine) treatment once a week for 12 weeks (AKA 3HP regimen) is adequate in controlling the reactivation of latent TB[2].

H: RifaPEntine is not Rifampin.

G: It is also worth mentioning that this treatment is also approved for patients 2-11 years of age as well as patients who have HIV/AIDS who are currently taking anti-retroviral.

H: Currently, the regimens for LTBI treatment are: 
-Monotherapy with INH for 6-9 months
-Monotherapy with Rifampin daily for 4 months
-Combinations: INH-Rifampin daily for 3 months (3HR therapy), and INH-RifaPENTINE weekly for 3 months (3HP therapy).

Shingles vaccine may reduce risk of stroke

G: Why do we think having shingles increases risk of stroke in the first place? The mechanism is not well understood but there is a strong index of suspicion that the inflammation resulting from the outbreak plays a significant role.  

H: So, you read a study, a chart review published by the American Heart Association, tell us about it.

In this study, patients who received the shingles vaccine (live vaccine) were compared to patient who did NOT receive the vaccine. The results showed that getting the shingles vaccine decreased the risk of stroke by 16%.  The types of strokes that were decreased included hemorrhagic stroke which was decreased by 12% and ischemic stroke that was decreased by 18%.  The age range for which this was most effective is 66 to 79 years of age and is worth mentioning that patients under 80 years of age had a decreased risk in stoke by 20% while the patients over 80 years old were decreased by about 10%[3].

Diagonal Ear Lobe Crease: An Association with CAD

H: Last week we got this information from Dr Cobos, a Kern Medical hematologist. 

G: Diagonal Ear Lobe Crease (DELC) also known as Frank’s sign, is a crease in the ear lobe that is associated with increased risk of coronary artery disease, peripheral vascular disease, and cerebrovascular disease. Although the pathophysiology of this sign is not yet understood, there has been a grading system set in place that is linked to the incidence of cardiovascular events based on length, depth, bilateralism, and inclination according to Stanford Medicine. The classifications are as follows:

Unilateral incomplete – least severe

Unilateral complete

Bilateral complete – Most severe

Other classification (not associated with increased cardiovascular events):

Grade 1 – wrinkling

Grade 2a – Superficial crease (floor of sulcus visible)

Grade 2b – crease greater than 50% across earlobe

Grade 3 – deep cleft across whole earlobe (floor of sulcus not visible)

H: As a curious fact, Steven Spielberg and Mel Gibson have the DELC. 

Conclusion: Now we conclude our episode number 60 “Variety of Topics.” Future Dr Robinson presented a summary of four interesting articles she read. She explained that IsoPSA may be an alternative for screening for prostate cancer in the future, and she reminded us of the weekly treatment of latent tuberculosis infection with INH and rifaPENtine (also known as 3HP treatment for LTBI). There was a decrease in stroke risk in patients who received shingles vaccine, according to a study published by the American Heart Association in 2020, and the Diagonal Ear Lobe Crease sign was mentioned as a possible association with cardiovascular risk. 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 and Gabrielle Robinson. Audio edition: Suraj Amrutia. See you next week!

____________________________

References: 
 

The IsoPSA Test Is Available, and It Could Change the Diagnostic Paradigm for Prostate Cancer, Consult QD, Cleveland Clinic, Jul 7, 2020, https://consultqd.clevelandclinic.org/the-isopsa-test-is-available-and-it-could-change-the-diagnostic-paradigm-for-prostate-cancer/

CDC Releases Updated Recommendations for Treatment of Latent TB Infection, Centers for Disease Control and Prevention, June 28, 2018, https://www.cdc.gov/nchhstp/newsroom/2018/treatment-of-latent-TB-infection.html

Shingles vaccine may also reduce stroke risk, American Heart Association, February 12, 2020, https://newsroom.heart.org/news/shingles-vaccine-may-also-reduce-stroke-risk

Frank's Sign - Diagonal earlobe crease (DELC), Stanford Medicine 25, July 2, 2015, https://stanfordmedicine25.stanford.edu/blog/archive/2015/what-is-the-name-of-this-sign.html

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

Episode 59: What is Keto?  

Discussion about the benefits and risks of the keto diet. Introduction about the CDC Contraceptive app.

Introduction: Contraception App Update (CDC)
By Cecilia Covenas, MD, and Hector Arreaza, MD

Today is July 16, 2021.

What is the CDC Contraception App? 

The CDC has updated their contraception app to assist health care providers in counseling women, men, and couples on the different contraceptive methods. The app is called Contraception. When you open the app, it has three main sections. MEC by Condition, MEC by Method and SPR. 

MEC stands for Medically Eligibility Criteria, it is a guide to choose the safest contraceptive for patients with certain medical conditions. SPR stands for Selected Practice Recommendations. It is a guide for common topics such as initiation of a particular method, or tests needed before starting a contraceptive, or follow up, etc. The last update to the app was this past March, and it includes new features. Now, you can select up to three conditions at once, move from one condition to another easily, and see additional info for a particular condition and method.

How to use it?

There are three main sections: MEC by condition, MEC by method, and SPR. 

The US MEC recommendations are divided into four categories, from 1 through 4.

Category 1 means no restriction to use that contraceptive (it’s good to use, it’s displayed with a dark green background).

Category 2 means the advantages of using the method generally outweighs the risk (OK to use, it’s marked with a light green color).

Category 3 means the risks of the method generally outweighs the advantages (this is not a good choice choose something else, it’s shown with a light red color).

Category 4 means there is an unacceptable health risk for using that method with that specific condition (do not use this contraceptive method! It is shown with a dark red color background).

For example, a 36-year-old female with obesity (BMI 32) and migraines with aura would like to start Combined Hormonal Contraceptives (CHC or the “pill”), will this be safe for her?

Open the app, choose MEC by condition, then select the conditions “Menarche to <40 years for CHC”, then under Headaches, tap on “Migraines with aura,” and under Obesity, choose “BMI >30”. Tap on Continue.

The recommendations for each condition are displayed, and we can move to each condition easily by tapping on the arrows on the top of the page. In this patient, for example, the “pill” (CHC) is category 1 for her age, category 2 for obesity with BMI >30, but it’s category 4 for migraines with aura. You can see more info by tapping on the plus sign in each recommendation. Based on the evidence, this patient is not a good candidate for CHC. So, do not prescribe it!

Let's say the same patients asks about IUD (Mirena®), acronym LNG IUD, is it a good choice? Let’s tap on MEC by Method, then find the IUD and select the same conditions: age, migraine with aura, and obesity. The IUD is category 1, you can prescribe it safely.

To expand your knowledge even more, tap on the SPR icon and select the recommendations on initiation of the IUD. According to the Selected Practice Recommendations (SPR), the IUD can be inserted at any time if it is reasonably certain the patient is not pregnant. You can insert IUD after obtaining consent, and going over the risks, benefits, and alternatives, under proper supervision if you are a resident.

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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What is Keto?   
By Constance Baker, MS3, Valerie Civelli, MD, and Hector Arreaza, MD.  

What is it/history? 

High fat, low carbohydrate diet 

Goal is to have most of your calories come from fat followed by protein with <50g/day coming from carbohydrates. 

There are many different variations of this diet in regards to amounts of fats and proteins used but carbohydrates should be <50g/day.

Most used today for weight loss and the fight against obesity.

Created in 1921 by Dr. Wilder and Dr. Woodyatt at the Mayo Clinic.

The ketogenic diet was first created as a treatment for epilepsy in children. It was the first line treatment until the creation of antiepileptic medication

At this time, it was also used for treatment in diabetic patients.

How does it work? 

The logic behind the ketogenic diet is to put the body in “starvation” mode by limiting carbohydrate intake and increase use of stored fat in the body. This decreased insulin secretion causing the body to use its glycogen stores until depleted. When those are depleted, the body enters gluconeogenesis. A process where the body makes its own glucose out of the precursors lactic acid, glycerol, and amino acids. This process can only be used for a short time, eventually the body will run out precursors and will have to switch metabolic processes one more. This time, the body switches to ketogenesis. During ketogenesis, the body makes ketones bodies for the primary source of energy in the place of glucose. 

So, the whole goal is to keep the carbohydrates intake as low as possible in order to force the body to use ketones as the primary source of energy instead of glucose.

Insulin promotes storage of fat and glucose in the body. Decreasing the utilization of glucose in the body has a negative feedback on insulin secretion. So overall, insulin is decreased in the body which decreases the overall storage of fat and glucose which is beneficial in someone who has excess fat stores.

Benefits 

Weight loss with a decrease in overall body mass 

Proven to help epilepsy in children 

Decreases cardiovascular risk factors 

Helps with a wide array of metabolic diseases

Adverse effects

At the start of a diet, people can have GI upset like nausea, vomiting and constipation. Some people often report bad breath, headaches and sleeping problems.

Someone can have a false positive breathalyzer test due to the ketones that are produced.

Long term compliance is often difficult to achieve due to the strict dietary restrictions and fatigue.

The American College of Cardiology and American Heart Association do not recommend utilizing the ketogenic due to unknown effects on cardiovascular disease. 

Populations 

BMI >25

Most common population that utilizes the ketogenic diet 

Well liked because weight loss happens quick (within months) as opposed to other diets which take longer to show progress 

Works as an appetite suppressant 

The body has to work harder for its fuel, so you burn more calories through metabolism and increases the breakdown of fat in the body.

Diabetes 

Promotes the body to use the excess glucose for fuel instead of turning it into fat in order to decrease glucose levels in the blood. 

Ketones have a negative correlation with glucose released from the liver. Which means increased ketones = less glucose in blood = better glycemic control. In the long run, this will low an individual’s HbA1c as well. 

The effect on glucose control only seems to affect diabetic patients. A study which compared diabetic and non-diabetic fasting glucose level on the ketogenic diet, and it only lowered the diabetic fasting glucose. 

Caution should be taken in an individual who is taking hypoglycemic causing medications to treat their DM. Medication adjustment is most likely needed, and they should consult their physician. 

Epilepsy 

Ketogenic diet has been a treatment for epilepsy since 1920 when the diet was created. 

The use of this treatment decreased as antiepileptic drugs became more popular and effective at treating. 

Studies have shown that ketogenic diet is just as effective as medications.

Today, ketogenic diet is most commonly used in refractory epilepsy where surgery is not an option. 

Athletes 

During exercise, the body uses fatty acids during oxidative metabolism, so the thought is the use of a high fat diet will increase the utilization of oxidative metabolism and aid in endurance of the athlete. 

Most studies have included endurance (aerobic) athletes over any other kind. The studies have shown that fat consumption increased causing improved body composition in athletes. They have not shown to influence athletic performance in males, but in females, one study showed a decrease in athletic performance when compared to their male counterpart. 

In anerobic athletes, they require more protein overall in their diet due to the need to repair/build their muscles. When utilizing a ketogenic diet, fat is the prominent source of nutrition followed by protein. Their glycogen stores are low which promotes the body to have an affinity for the gluconeogenic pathway which can have negative effect on performance. Some studies have shown a decrease in lean body mass and skeletal muscle thickness which could be detrimental to a body builder or power athlete.

For many years, ketogenic diet has been the treatment option for glucose transporter protein 1 (GLUT-1) deficiency and pyruvate dehydrogenase deficiency.

Individuals with kidney disease, liver failure, pancreatitis and fatty acid metabolism disorders should use caution and are contraindicated, and they should consult with their physician before beginning a ketogenic diet because it can worsen their condition.

Conclusion

Research is still limited for the ketogenic diet overall. Long term complications are still widely unknown because of long term compliance is difficult and research studies have been limited thus far. 

It is a widely used diet in today’s world. 

It has showed great promise in helping in the fight against metabolic diseases 

It has been proven to help with epilepsy in children 

There are mixed reviews for how it is beneficial to athletes. It is reliant on what the goal of training is as well as type of training being utilized. 

This diet is not beneficial to everyone and before you decide to begin it, you should consult with your physician. 

Now we conclude our episode number 59 “The Keto Diet.” Is this a fad diet or the tool you were waiting for to help your patients lose weight? You can decide. Keep reading, keep learning, and keep trying.. 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, Cecilia Covenas, Valerie Civelli, and Constance Baker. Audio edition: Suraj Amrutia. See you next week! 

References:

Gershuni VM, Yan SL, Medici V. Nutritional Ketosis for Weight Management and Reversal of Metabolic Syndrome. Curr Nutr Rep. 2018 Sep;7(3):97-106. doi: 10.1007/s13668-018-0235-0. PMID: 30128963; PMCID: PMC6472268. https://pubmed.ncbi.nlm.nih.gov/30128963/

Harvey KL, Holcomb LE, Kolwicz SC Jr. Ketogenic Diets and Exercise Performance. Nutrients. 2019;11(10):2296. Published 2019 Sep 26. doi:10.3390/nu11102296. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6835497/

Masood W, Annamaraju P, Uppaluri KR. Ketogenic Diet. [Updated 2020 Dec 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499830/

Paoli, A., Rubini, A., Volek, J. et al. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr 67, 789–796 (2013). https://doi.org/10.1038/ejcn.2013.116

Ułamek-Kozioł M, Czuczwar SJ, Januszewski S, Pluta R. Ketogenic Diet and Epilepsy. Nutrients. 2019; 11(10):2510. https://doi.org/10.3390/nu11102510

Wheless, J.W. (2008), History of the ketogenic diet. Epilepsy, 49: 3-5. https://doi.org/10.1111/j.1528-1167.2008.01821.x

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 58: Transaminitis.  

Elevated aminotransferases can be caused by intrahepatic and extrahepatic causes, Dr Martinez and Dr Civelli explain the workup of transaminitis, distribution of Chantix was stopped by Pfizer, smoking cessation updates 

Introduction: Smoking Cessation Updates
By Hector Arreaza, MD, Valeri Civelli, and Yosbel Martinez, MD 

On June 25, 2021, Pfizer stopped distribution of some badges of Chantix(r) after high levels of the carcinogen N-nitroso-di-methyl-amine (NDMA) were found in some lots of the pills. “Pfizer told Reuters the distribution pause was ordered out of abundance of caution while further testing is conducted.”

The FDA approved Varenicline in 2006, and there is evidence that Chantix is the most effective anti-smoking medication.

USPSTF Grade A recommendations:

1. All adults should be asked about their tobacco use. Then, if determined to be smokers or tobacco users, advise them to quit, and provide behavioral interventions and FDA-approved medications for cessation. This applies to all adults who are not pregnant and use tobacco.

2. All pregnant patients should be asked about their tobacco use, advised to quit using tobacco, and offer behavioral interventions for cessation. 

USPSTF Grade I (I stands for “I don’t know”):

1. The USPSTF does not endorse or discourages the use of pharmacotherapy for smoking cessation in pregnant patients because there is insufficient evidence.

2. E-cigarettes have insufficient evidence to be recommended as an effective way to stop smoking in adults. 

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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Transaminitis. 
By Yosbel Martinez, MD

Transaminitis is a way to say elevated aminotransferases. When you see “itis” at the end of a word, it normally means “inflammation” in medical terms, and for that reason transaminitis is not etymologically correct, but it’s easy to use and everyone understands what it means.

What are aminotransferases?

Aminotransferases are intracellular enzymes that are a sensitive indicator of liver cell injury (necrosis or inflammation).

-ALT (alanine aminotransferase) is a more specific measure of liver injury

-AST (aspartate aminotransferase) is less specific because it is also found in striate muscle, heart, brain, kidney and Red and white blood cells.

There is a poor correlation between degree of liver cell damage and level of aminotransferases. Low levels of transaminases may be seen even in some instances when the liver is severely and terminally damaged, for example, in cirrhosis.

General approach of transaminitis > 6 months (asymptomatic patient)

Step 1: Initial evaluation for most common liver conditions.

1. Drugs (herbal or recreational drugs) or medications (acetaminophen, INH, amiodarone, statins)

2. Hepatitis A, B, C

3. Alcoholic hepatitis (AST/ALT ratio above 2:1)

4. Fatty Liver AST/ALT < 1 (may perform RUQ ultrasound to confirm diagnosis)

5. Hemochromatosis (iron/TIBC > 45%)

Hereditary hemochromatosis is an autosomal recessive disorder of the metabolism of iron. It is the most common genetic disease in Caucasians. Women have the protective effect of menstruation, which serves as a monthly phlebotomy until they reach menopause, and hemochromatosis may become symptomatic. Men are more prone to iron-overload disease compared with women. 

Hemochromatosis is asymptomatic in early stages. Some common symptoms include arthralgias, low energy, weakness, and erectile dysfunction in men. Later manifestations include arthralgias, osteoporosis, cirrhosis, hepatocellular cancer, cardiomyopathy, dysrhythmia, diabetes mellitus, and hypogonadism. 

Screening with iron levels should be ordered in patients with first-degree relatives with classical hemochromatosis.

Diagnosis requires confirmation of increased serum ferritin levels and transferrin saturation, with or without symptoms. 

Treatment includes regular phlebotomy guided by serial measurements of serum ferritin levels and transferrin saturation. Iron restriction in diet is normally not needed. Screening for hepatocellular carcinoma is reserved for those with hereditary hemochromatosis and cirrhosis.

Statins

Statins are very important in prevention of treatment of cardiovascular disease. They are safe.

“The risk of hepatic injury caused by statins is estimated to be about 1 percent, similar to that of patients taking a placebo.” Patients with transaminitis below three times the upper limit of normal can continue taking statins safely. Nonalcoholic fatty liver disease and stable hepatitis B and C are not contraindications to statin use. Atorvastatin is contraindicated in active liver disease or in patients with unexplained persistent transaminitis.

Step 2: When you have not determined the source of transaminitis

1. Less common liver conditions:

-Autoimmune hepatitis (more common in women, order SPEP, ANA, ASMA)

-Wilson disease (order ceruloplasmin, look for Kayser-Fleischer rings around the iris of eyes)

-Alfa 1- antitrypsin deficiency (presents with severe emphysema, order AA-1 level)

-Other viral hepatitis: D, E, CMV, EBV, HSV, VZV.

2. Non-Hepatic source.

-Muscle disorder (obtain CK, aldolase)

-Thyroid disease (order TSH, FT4)

-Celiac disease or IBD (obtain IgA anti-tissue transglutaminase, Calprotectin, CRP, P-ANCA, or perform MRCP/ERCP if indicated).

-Adrenal insufficiency (8 am cortisol level and plasma ACTH)

-Anorexia nervosa (assess BMI, recommend psychiatric evaluation, obtain electrolytes and ECHO)

Step 3: Final step of evaluation.

Liver biopsy for diagnostic, staging and grading of liver disease.

Now we conclude our episode number 58 “Transaminitis”. Dr Martinez and Dr Civelli explained what to do when we find elevated aminotransferases. Remember you can have intra-hepatic and extra-hepatic causes. If you cannot determine what’s causing transaminitis, you may need to ask for a liver biopsy.  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, Yosbel Martinez, and Valerie Civelli. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Pfizer Halts Distribution of Stop-Smoking Pill Chantix, WebMD, webmd.com, accessed on Jul 6, 2021. https://www.webmd.com/smoking-cessation/news/20210625/chantix-distribution-halted-pfizer.

Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions, United States Preventive Services Taskforce, uspreventiveservicestaskforce.org, accessed on Jul 6, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions

Crownover BK, Covey CJ. Hereditary hemochromatosis. Am Fam Physician. 2013 Feb 1;87(3):183-90. PMID: 23418762. https://www.aafp.org/afp/2013/0201/p183.html

Gillett RC Jr, Norrell A. Considerations for safe use of statins: liver enzyme abnormalities and muscle toxicity. Am Fam Physician. 2011 Mar 15;83(6):711-6. PMID: 21404982. https://www.aafp.org/afp/2011/0315/p711.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!

Hearing loss in the elderly, Dr Yomi explained the fundamentals of hearing loss, we said good-bye to graduating residents and welcomed the class of 2024.

Introduction: New Academic Year
By Hector Arreaza, MD

Today is July 1, 2021.

It’s that time of the year again when we say good-bye to our dear graduating residents, and we welcome a new group of eager PGY1s. 

On June 27, 2021, we had a graduation ceremony filled with emotion, stories, yummy food, and lots of dancing. We gave a well-deserved tie-dye lab coat to Dr Stewart as a sign of our appreciation and love. We say congratulations to our graduates who received their diploma: Monica Kumar, Joseph Gomes, John Ihejirika, Fermin Garmendia, Roberto Velazquez, Terrance McGill, Yodaisy Rodriguez, and Claudia Carranza. They all participated in this podcast, even more than once. I want to especially thanks Claudia who brought so many good ideas and her enthusiasm to this podcast. She promised she will continue to participate in the near future. 

Lisa Manzanares and Amna Fareedy received their diplomas a few months ago, but they were also remembered during this ceremony. 

And now we welcome our new interns [Drum roll]: Cecilia Covenas, Su Hlaing, Amardeep Chetha, Licet Imbert, Timiiye Yomi, Funmilayo Idemudia, Na Sung, and Amelia Martinez. They are officially starting their residency this week as the Class of 2024. I hope you can enjoy your training with us. And these interns are starting on the right foot. You will hear Tiimy present our podcast discussion today.

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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Hearing loss in the elderly. 
By Timiiye Dawn Yomi, MD, and Hector Arreaza, MD

INTRODUCTION:

Hearing loss is the third most common health condition after hypertension and arthritis to affect the elderly population. According to the World Health Organization, about 538 million people are affected by hearing loss worldwide with people between ages 61 to 70 years accounting for about third of this number. 

80% of those older than 85 years have experienced some form of hearing loss and men tend to experience greater hearing loss with earlier onset compared to women. 

Normal conversation uses frequencies of 500 to 3000 Hz at 45 to 60 dB. After age 60 there is a steady decline by one dB annually. Genetic component plays a role in age related hearing loss.

DEFINITION:

A person who is not able to hear at hearing thresholds of 20dB or better in both ears is said to have hearing loss. Hearing loss can be mild moderate or severe and it can be uni- or bilateral. 

Mild: On the average, persons with mild hearing loss hear the most-quiet sounds between hearing thresholds of 25-34dB with their better ear.

Moderate: The most-quiet sounds heard by these persons are between hearing thresholds of 34-49dB with their better ear.

Moderately severe:    These persons hear the most quiet sounds between hearing thresholds of 50-64dB with their better ear.

Severe: The most quiet sounds heard by these persons are between hearing thresholds of 65-79dB with their better ear.

Profound: Persons with profound hearing loss hear the most quiet sounds at thresholds of 80 dB or more.

Some terms we may want to address here are “Hard of hearing” and Deafness. 

A person is said to be hard of hearing when they have hearing loss ranging from mild to severe, but they usually can communicate through spoken language. 

Deaf people on the other hand have profound hearing loss and often communicate with sign language.

TYPES OF HEARING LOSS:

Hearing loss can be broadly divided into 3 types: Conductive, Sensorineural hearing loss, Mixed.

Conductive hearing loss: This involves anything that would limit the amount of external sound entering the inner ear. Common causes include cerumen impaction, perforated tympanic membrane, otitis media effusion, tumors such as glomus tumors, and tympanosclerosis.

Sensorineural hearing loss: This is hearing loss that involves the inner ear, cochlear and or the auditory nerve. Common causes are age-related hearing loss (presbycusis, which is the most common hearing loss in the elderly population) ototoxic medications such as aminoglycosides, autoimmune diseases, trauma, infection, neoplasm, and Meniere’s disease. 

Mixed: A combination of conductive and sensorineural

RISK FACTORS: 

Aging

Race (Caucasians have the highest prevalence of age-related hearing loss)

Genetics

Socioeconomic status

Loud noise exposure

Ototoxins such as aminoglycosides

Vascular diseases

Hypertension

Diabetes

Immunologic disorders

Infections

Smoking

Hormones such as estrogen.

CLINICAL PRESENTATION:

Patients may present with sudden or gradual hearing loss depending on the etiology

Common symptoms: inability to hear or understand speech in a crowded or noisy environment, difficulty with understanding consonants, difficulty having a phone conversation, inability to hear high pitched voices or noises, mumbling or muffling of speech or other sounds, frequently asking others to repeat themselves, speak more slowly, clearly and loudly; needing to turn up the volume of the TV or radio, withdrawal from conversations, avoidance of social settings, tinnitus (TEEN-it-us), disequilibrium which can result in falls.

Sometimes you have to start the conversation when you notice the patient asks you to repeat frequently. Make sure you gently ask a question such as: “How is your hearing?” or “How would you rate your hearing? Excellent, good or bad?” Patients may be on denial, but spouses or family members can help identify the problem.

ASSESSMENT: 

History: The goal is to identify risk factors such as noise exposure and medication use. 

For example, age-related hearing loss in the elderly has a gradual onset as opposed to hearing loss from perforation of the tympanic membrane which is sudden. 

Due to the emotional and functional impact of hearing loss, it is important to ask about mental health issues such as depression, social isolation and poor self esteem when taking a history from patients. 

Hearing loss can also result in cognitive decline, increase hospitalizations and functional disabilities, especially in the elderly. 

An analysis of 605 elderly patients with a large cohort study who had hearing test and cognitive testing done showed an association between hearing loss and decreased executive function, which makes early identification and treatment important.

SCREENING:

The USPSTF found insufficient evidence to demonstrate the benefits and harms of hearing screening. This a Grade I recommendation.

On the other hand, the American Speech Language Hearing Association advises that individuals over 50 years should have complete audiometric testing done every 3 years. 

Experts also recommend asking older patients or their care givers about hearing problems, counselling on treatments available and referrals when appropriate.

TYPES OF SCREENING TESTS:

Whispered test

Single question

Screening version of the hearing handicap inventory for the elderly

Audioscopy

The whispered test and screening question can be easily done in the primary care physician’s office.

MANAGEMENT:

Hearing loss is a life-changing event. It requires adaptation and changes in family members and friends.

The goals of management are to address underlying and contributing causes as well as comorbid conditions. 

This could range from managing comorbidities like hypertension and diabetes to treating underlying causes such as otitis media with antibiotics and steroids, to the use of devices such as hearing aids. 

Proper and effective interventions can greatly improve functional and emotional functions of affected individuals. 

Despite these potential benefits, non-adherence is common. Commonly cited reasons are initial disappointing results with hearing aids, cost, design of devices, social norms, negative stereotypes associated with hearing loss and use of hearing aids, etc., 

The family medicine physician plays a key role in the identification of patient barriers to managing hearing loss, encouraging adherence and patient monitoring.

PREVENTION:

Avoiding risk factors such as loud noise and ototoxic medications can help prevent the onset of hearing loss. Emerging evidence suggests the use of folic acid 800mcg daily and high intake of omega 3 fatty acids to help slow age-related hearing decline, but additional research is needed to help identify potential strategies to prevent the onset and slow progression age related hearing loss. 

Conclusion: Use your clinical judgment in screening, diagnosing, and treating hearing loss.

Now we conclude our episode number 57 “Hearing loss”, Dr Yomi explained on her official first day of residency how to detect hearing loss in elderly patients and how to evaluate and manage this disabling and life-changing condition. We are excited for this new academic year, we foresee a bright future ahead of us. Just like Hans Rosling said, “I’m not an optimist… I’m a very serious possibilist.” 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 and Timiiye Yomi. Audio edition: Suraj Amrutia. See you next week!

REFERENCES:

World Health Organization. (2021, April 1). “Deafness and hearing loss.” Retrieved from                                                                           https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss        

Anne DW. Gretchen MD. Hearing loss in older adults. Am Fam Physician.2012 Jun 15;85(12):1150-6. PMID: 22962895. https://www.aafp.org/afp/2012/0615/p1150.html#afp20120615p1150-t4

Weber PC. Etiology of hearing loss in adults. In: Kunins L, Deschler DG, ed. UpToDate, Waltham, Mass.: UpToDate, 2021.  https://www.uptodate.com/contents/etiology-of-hearing-loss-in-adults#

Heflin MT. Geriatric health maintenance. In: Givens J, Schmader KE, ed. UpToDate, Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com/contents/geriatric-health-maintenance  

Blevins NH. Presbycusis. In: Kunins L, Deschler DG, ed. UpToDate  Waltham, Mass.: UpToDate, 2021.                                                                                https://www.uptodate.com/contents/presbycusis       

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!

Introduction about Wegovy as a new treatment for obesity. Dr Amodio discusses fall prevention in older adults. 

News: Semaglutide for the treatment of obesity
By Hector Arreaza, MD, and Daniela Amodio, MD. 

About 70% of Americans suffer from overweight or obesity. It has been 7 years since a medication was approved by FDA for chronic weight management. 

As a reminder, Saxenda® (liraglutide, daily SQ injection) was approved in 2014 for the treatment of obesity in adults (7 years ago), and remarkably, in December 2020, Saxenda® was also approved for the treatment of obesity in children older than 12 years old (good to know). Saxenda® is a GLP-1 receptor agonist.

On June 4, 2021 (7 years later), Novo Nordisk® did it again and got approval for a new medication for the treatment of obesity (disclaimer, I do not receive any money from Novo Nordisk®)

After extensive trials (drum rolls), Wegovy® (pronounced wee-GOH'-vee) has been approved by the FDA for chronic weight management. The component is semaglutide, yes, you heard me right, this is the same component of Ozempic®, an injected medication FDA-approved for diabetes treatment, and it is the same component in Rybelsus® (pronounced reb-EL-sus), which is the same semaglutide but in oral form. 

-Wegovy® is a synthetic version of a hormone called glucagon-like peptide 1 (GLP-1). GLP is an incretin, and as such, it reduces glucose levels by optimizing the secretion of insulin and decreasing the secretion of glucagon during digestion. 

Wegovy® exerts its action in areas of the brain to curb appetite and increase satiety. 

The use of Wegovy is approved in adults with a BMI above 30 kg/m2, or above 27 kg/m2 who have at least one weight-related condition. As with other medications for obesity, Wegovy is an adjunct therapy which can be added to intensive lifestyle modifications.

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

Page Break

Elderly Falls.   
By Daniela Amodio, MD, and Hector Arreaza, MD

Patients who are older than 65 are normally called “older patients”, but sometimes it’s confusing, older than who? What does it really mean? There are many euphemisms: seniors, older adults, elderly, “prolonged youth”, or old-timers.

“Aging experts… have tried calling people young old (65 to 74), old old (75-84) and oldest old (85+). Age-based categories at this stage of life often aren't helpful because there is so much variability in how people age.” (Tracey Gendron, gerontologist at Virginia Commonwealth University)[2]

Key points: 

1. A fall is one of the most common events that may make older adults lose their independence.

2. Complications from falls are the leading cause of death from injury in adults older than 65 years old.

3. A multifactorial risk assessments should be done in older adults with >2 falls in the past 12 months. 

Interventions that have shown to be effective in reducing falls: 

Medication review

Exercise programs for muscle strengthening and balance training

Vitamin D supplementation in vitamin D deficiency 

Use appropriate footwear 

Home hazardous assessment 

Comment: Deprescribing is an essential activity during your geriatric visits. Avoid unnecessary medications. Use the AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults to determine which medications you should either discontinue or change to minimize risk of falls. Some examples include: benzodiazepines, some antidepressants and dextromethorphan/quinidine. 

Prevalence and morbidity of falls in older adults:

According to CDC, one out of three adults older than 65 years old reports falling in the previous year. The incidence of falls is higher with advanced age, which means one half of individuals older than 80 years old or those living in nursing homes will fall each year. 

Most falls result in soft tissue injury and 5-10% result in fracture or head trauma. Women and nursing facility residents are more prone to non-fatal injury than men. Death rate due to falls is more common in white men older than 85 years old. 

Risk factors: 

Multiple studies indicate that falls are multifactorial. Risk factors include: old age, cognitive impairment, female gender, history of falls, gait/balance problems, low vitamin D, pain, psychotropic medications, Parkinson's disease, stroke and arthritis. 

Physiologic changes expected with aging: With aging visual acuity is affected as well as inability for dark adaptation. Loss of sensitivity in the legs is expected as well as loss of balance. Also, there may be other changes in the CNS that affect postural control, including loss of neurons and dendrites and depletion of neurotransmitters such as dopamine in basal ganglia. There is inability to keep an upright posture due to decline in baroreflex sensitivity, resulting in hypotension.  Elderly patients are prone to dehydration due to decreased body water percentage and decreased renin and aldosterone levels, these factors can lead to orthostatic hypotension and falls.

Prevention: 

The most modifiable risk factor is medication use. Of note, there is no difference in the risk of falling with the use of older antidepressant or antipsychotics compared with the newer SSRIs. Same thing applies with newer nonbenzodiazepine hypnotics to treat insomnia versus using benzodiazepine. So, the risk is the same.

The risk of falls increases with older adults taking more than one psychotropic medication, and among adults taking >3 medications of any type. 

Other medications that affect the risk of falls are antihypertensive medications. Meta-analysis studies have shown an increase of risk in those elderly patients taking medications such as:  digoxin, diuretics, class Ia antiarrhythmics and NSAIDs. As a reminder, class Ia antiarrhythmics are sodium channel blockers. Drugs in this group include quinidine, procainamide, and disopyramide. They cause QT prolongation, that’s why they are used, for example, in patients with short QT syndrome and recurrent ventricular arrhythmias (VA). 

Medications for dementia such as acetylcholinesterase inhibitors, have been associated with increased risk of syncope. Examples on this group: donepezil and memantine for Alzheimer’s disease.

Hypoglycemia is a risk factor for falls, so be cautious if you decide to use medications that cause hypoglycemia, including insulin. What do we do when we see a patient who reports frequent falls? 

Evaluation of the Elderly Patient Who Falls:

The most important point in the history is asking if there has been a previous fall because this is a strong risk factor for future falls. 

For patients presenting with a fall, it is important to include the activity at the time of the fall, the occurrence of prodromal symptoms (lightheadedness, dizziness and imbalance) and the location and time of the fall. Medication history should focus on newly added medication or recent dosage changes as well as the use of medications mentioned before. 

We need to identify potential factors in the environment such as lighting, floor covering, railings, furniture.  

Physical Exam/Screening tests:

The most important part of the physical examination is evaluation of musculoskeletal function that can be accomplished by performing stability tests.  

A useful test that evaluates strength and balance is the Up and Go test: patient stands up from a chair without using their arms to push against the chair, walks across the room (10 feet), turns around, walks back and sits down without using their arms. This test can evaluate muscle weakness, balance problems, gait abnormalities. 

Timed up and go test (TUG): An elderly patient who takes ≥12 seconds to complete this test is at risk for falling. This should be done routinely in geriatric visits. 

POMA test (performance-oriented Mobility assessment) It evaluates balancing gait through a number of items including ability to sit and stand from an armless chair, ability to maintain standing balance when pulled by an examiner and ability to walk normally, and maneuver obstacles. 

Treatment and Prevention:

In 2011 the AGS and BGS updated clinical practice guidelines for prevention of falls in older adults. All older adults in the community at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. The interventions should be tailored to the individual's cognitive ability and language. The interventions considered to be effective are the following:

1. Home environment assessment and intervention should be performed by a healthcare professional in older adults who have fallen or have risk factors for falling. 

2. Discontinue or minimize psychoactive medications. Tapering medication is associated with a decreased rate of falls.

3. A prescribing modification program for PCP that includes medication review checklist, education and feedback from pharmacists. 

4. Manage foot problems: Clinicians should advise their patients to use walking shoes with high contact surface area. In elderly patients with disabling foot pain, falls may be reduced by intervention such as: customized insoles, foot/ankle exercise and falls prevention education. 

The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls (Grade B). The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older (Grade D).

Fall is a common cause of morbidity, disability and mortality. Let’s remember to screen and intervene to prevent falls.

____________________________

Conclusion: Now we conclude our episode number 56, “Elderly Falls.” Dr Amodio gave us a summary of effective strategies to prevent falls in elderly patients. She described how to perform the “Timed-Up-and-go” test, a useful tool to screen for fall risk. She explained that exercise, home safety inspection, and medication reconciliation are useful strategies to prevent falls. 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, Daniela Amodio, and Cecilia Covenas. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

FDA Approves New Drug Treatment for Chronic Weight Management, First Since 2014, FDA (online), June 4, 2021. https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014

Burling Stacey, “If we can't call old people 'old,' what's the right word?” The Philadelphia Inquirer (online), July 20, 2017. https://www.inquirer.com/philly/health/health-news/if-its-rude-to-call-old-people-old-whats-the-right-word-20170723.html

Berry, Sarah D and Douglas P Kiel, Chapter 34: Falls. Geriatrics Review Syllabus, 9th edition. Editors: Barbara Resnick, 2016.

Reuben, David B. Falls Prevention and Falls. Geriatrics At Your Fingertips, 22nd edition. American Geriatrics Society, 2020.

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!

Dr Civelli and Dr Lundquist describe the Bristol Stool Scale. What is the ideal shape of stools? What is normal vs. abnormal stools? Intro about antibody medicine.

Today is June 9, 2021. 

Antibody Medicine. 

Have you ever heard of antibody medicine? Human biologic targets can be linked to a multitude of diseases onset, progression or even prevention. The role of antibody therapy is to identify those targets, conduct industry-grade research trials to validate and then develop highly specific therapies. Some examples are: Dupixent (dupilumab) for asthma, atopic dermatitis, and chronic sinusitis; rituximab for Non-Hodgkin Lymphoma and pemphigus vulgaris, or other “mabs.” These are a few such examples of antibody medications.  

Antibody medicines typically mimic the natural pathways of the body’s immune system. These antibody medicines are derived from living organisms, not from chemical processes like most pills.  And because they are designed so specifically, they are designed to avoid unwanted effects on other cells in the body.  

Antibody medicines have been proven to change lives and have altered the course of the treatment of serious diseases like asthma, cancer, heart disease, rheumatoid arthritis, and severe eczema over the past several decades. I wonder what this means for accessibility and who will this benefit?  I know many of the “mabs” like dupixent are available and there are assistance programs to help with coverage. I love that we are in the era of innovation and discovery! 

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 is sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

What is brown, smells really bad and may attract flies? I will be honest with you, there’s no clever joke. It was exactly what you are thinking.  That is right, it is Poop. Everyone does it. I do, you do. We all do Doo Doo. 

As physicians, we are here to give you the scoop on the poop. Let’s start with a few rhetorical questions: 

1. What is normal stool?
2. How do you describe it? 
3. Do most patients know the difference b/w normal and abnormal? 
4. Is it easy for patients to describe and talk about?

Normal stool has an alkaline pH. Sodium and potassium salts are the primary stool solutes. The sodium plus potassium concentration in stool usually ranges between 130 and 150 mEq/L. Other cations, such as calcium and magnesium, are present at much lower concentrations. The main inorganic stool anions are bicarbonate (approximately 30 mEq/L), chloride (approximately 10 to 20 mEq/L), and a small amount of phosphate and sulfate. Changes from these baselines may lead us to a variety of diagnoses. 

Let’s take this discussion into clinical practice.  Poop is a tough topic for patients according to multiple sources and extracting pertinent patient history is challenging: Because it is embarrassing, because patients are often unaware of what is normal vs. abnormal bowel movements. 

I have asked patients if they have any constipation. They report bowel movements daily only to find out these are small, hard pellet-like stools daily.  Unless you are a bunny, you are constipated if having pellet-like stool.  

The good news is Ken Heaton, MD, from the University of Bristol, developed the Bristol Chart in 1997 to improve our ability to assess patient bowel movements. The Bristol chart categorizes the 5 different types of stool and shows normal versus abnormal.  The Bristol Stool Scale is also known as the Meyer’s Scale and is still used to today as a great tool to help patient describe the shapes and types of stool. Let’s go over this together: 

Type 1 – Separate Hard lumps, like nuts (hard to pass)

Type 2 – Sausage-shaped, but lumpy

Type 3 – Sausage-shaped, but with cracks on surface

Type 4 – Sausage- or snake-like, smooth, and soft

Type 5 – Soft blobs with clear-cut edges (easy to pass)

Type 6 – Fluffy pieces with ragged edges, mushy

Type 7 – Watery, no solid pieces (entirely liquid) 

The ideal stool is generally type 3 or 4, easy to pass, without being too watery. If yours is like type 1 or 2, you're probably constipated. If your is more like types 5, 6, and 7, you probably have diarrhea. The most important thing to look for in your stool: Well first you must look at it.  Some patients have admittedly avoided this step but encourage them to look every time. "Blood should be the first thing to look for in your stool," according toDr. Mark Pimentel, a gastroenterologist atCedars-Sinai. Blood may be dark black or bright red. It may be a marker of colon cancer, Crohn's disease,or colitis. Can you think of any other differentials? 

Would you recognize the difference between human poop vs. dog poop? True story, I have a doctor friend whose son was obsessed with video games. He played for hours, skipped meals, peed in his pants more than once. One day, my friend came home after working a long shift at the hospital to find large human feces on the living room floor. Naturally, she yelled out his full name and asked why he pooped in the living room. His response? It was the dog!

I preface with this story because 1. I will never let my future kids play video games for hours and 2. typically, unless you’re a doctor or in medicine at some level, most people aren’t going around checking each other’s poop. As studies showed by Dr. Pimentel of gastroenterology at Cedars Sinai, "We often don't realize what's normal vs. abnormal.”  So, educate patients on normal stools and encourage them to talk about it.

It is recommended to have a mainly solid, not loose, consistency. "If someone tells me that their stool looks like soup, gravy or mashed potatoes, and it's been like that for a long time, their stool is not normal," says Dr. Pimentel. Generally, a healthy color is brown, but the color can range from a very light brown to an almost greenish brown. Those colors are all perfectly normal and may vary based on diet. 

Black poop is never normal! Black can mean decomposed blood into heme, so this can be serious. However, keep in mind stool could also turn black with intake of iron pills or certain over-the-counter stomach aids, such as Pepto-Bismol. Blood sausage can give you black stools as well. 

As far as smell is concerned, if your poop is "extremely foul," this can be a sign of maldigestion or malabsorption. 3 primary causes of changes to stool color, consistency or smell are irritable bowel syndrome (IBS),celiac diseaseor alactose intolerance. These differentials should be considered. 

Don’t neglect the basics to a healthy gut meaning: Have a balanced diet, plenty of fiber, adequate hydration, "You can't overdrink water to treat constipation.”  EXERCISE is a must! Regular physical activity keeps your stools moving.

Conclusion.

Now we conclude our episode number 55 “The Poop Episode”. Dr Civelli, Dr Lundquist, and Dr Arreaza had a candid conversation about normal stools. The Bristol or Meyer Scale can help you identify more precisely the type of stools your patients are having. 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, Valerie Civelli, and Arianna Lundquist. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

1. Antibody Medicine and Regeneron Technology, Regeneron, https://www.regeneron.com/science/antibodies, accessed on June 2, 2021. 

1. Emmet, Michael, et al, Acid-base and electrolyte abnormalities with diarrhea, Up to Date, last updated: Jul 01, 2020. https://www.uptodate.com/contents/acid-base-and-electrolyte-abnormalities-with-diarrhea?search=normal%20stool&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6.

1. DerSarkissian, Carol, MD, What Kind of Poop Do I Have? WebMD, January 16, 2020, https://www.webmd.com/digestive-disorders/poop-chart-bristol-stool-scale, accessed on June 9, 2021.

1. Healthy Bowel Movements: Why You Should Pay Attention to Your Poop, Jul 08, 2020, Cedars Sinai Staff (California), https://www.cedars-sinai.org/blog/healthy-bowel-movements.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!

A1C is an easy way to diagnose and monitor diabetes, use and limitations of A1C are discussed with Dr Rodriguez. Vaginal metformin is mentioned as an anecdote which has not been proven to work we remembered Memorial Day. 

Introduction: Vaginal Metformin.  
By Hasaney Sin, MD, and Hector Arreaza, MD.

Today is May 31, 2021.  

There’s a saying that I came across on social media that has always spoken to me which I find relevant to our vocation. “The more I learn, the more I find out I don’t know”. So comes the joys (and challenges) of our chosen career. Case in point, have you ever heard of vaginal metformin? Neither have I, until today. 

There was a randomized clinical trial plan in 2013 at Assuit University in Egypt studying the effectiveness of vaginal metformin for the treatment of polycystic ovarian syndrome (PCOS). As primary care providers, we are very aware of the gastrointestinal side effects of metformin when taken PO. This sometimes prevents compliance with metformin. 

The study at Assuit University was to study the effectiveness of metformin when given vaginally in the effectiveness of treating PCOS, while also decreasing the undesirable side effects of metformin when given PO in hopes of also ultimately improving adherence. Unfortunately, the study was planned to be finished in 2014, but no results have been published thus far[1]. Stay tuned in case there is any update.

Arreaza: I had to do a search because I was very curious too. There is at least one occurrence when vaginal metformin was mentioned, at least in English. It was in an online forum where a doctor recommended vaginal metformin for PCOS to a patient. This has not been evaluated or approved by any organization, so I would not recommend it. You know what would be great? Metformin patches! There you have a business idea guys: The Metfo-patch®. 

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. 

Introduction: Memorial Day. 
Written by Valerie Civelli, MD, read by Steven Saito, MD, and Hector Arreaza, MD

What is Memorial Day? Memorial Day is an American holiday at the end of May to honor the men and women who died while serving in the US military. It has great historical meaning to Americans. It originated from the Civil War which claimed more lives than any other conflict in US history. Civil war ended in 1865.   

A fun fact to know, is that Memorial Day, was originally called “Decoration Day”.  It was 3-years after the Civil war ended, May 5, 1868, that “Decoration Day” was declared as a time for the nation to decorate the graves of those lost in war.  Graves were adorned with flowers and their lives celebrated.  

Maj. Gen. John A. Logan then declared that “Decoration Day” should be observed on May 30th. It is believed that this date was chosen because flowers would be in full bloom across the country. 

The “birthplace” of “Memorial Day” was recognized as coming from Waterloo, New York, because Waterloo was the first to use this term to expand honor and recognition of all US fallen soldiers of war from the Civil War and from World War I. 

In 1971, “Memorial Day” was officially declared a national federal holiday: The National Moment of Remembrance encourages all Americans to pause wherever they are at 3:00 p.m. local time on Memorial Day for a minute of silence, to remember and honor those who have died in service to the nation. If you value your freedom wherever you are, this Memorial Day at 3:00 p.m., pause for a minute to recognize all of our military men and women, both past and present who served and continue to serve our country. We honor every soldier who lost his or her life in any war against America. You are the reason for our freedoms.  You gave the ultimate sacrifice, and we do not take this for granted. 

To all military members who have died at war, we appreciate the privileges we have today because of you. We honor the costly price at which it came.  We remember you. We honor you. We sincerely thank you. Happy Memorial Day everyone! 

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A1C.

By Hector Arreaza, MD, and Yodaisy Rodriguez, MD.  
 

Definition. 

Glycated hemoglobin (glycohemoglobin, hemoglobin A1c, or just A1c) is a form of hemoglobin that is chemically linked to a sugar. Glucose spontaneously bind with hemoglobin, when present in the bloodstream of humans.

A1C refers to the percentage of glycosylation of the hemoglobin A1C chain and correlates with the average blood glucose levels over the previous 2-3 months from the slow turnover of red blood cells in the body. A RBC lives 120 days.

History of A1C. 

Huisman and Meyering separated glycohemglobin for the first time in 1958. A1c for monitoring the degree of control of glucose metabolism in diabetic patients was proposed in 1976 by Anthony Cerami, Ronald Koenig and coworkers.

A1C was first included in the ADA guidelines as a diagnostic test for diabetes in 2010. Prior to that random glucose or fasting plasma glucose were used for diagnosis.

For diagnosis of diabetes, A1C testing should be done by a technique certified by the National Glycohemoglobin Standardization Program and consistent with the Diabetes Control and Complications Trial reference assay.

A1C levels. 

A1C <5.7% is considered normal, 5.7-6.4% is prediabetes, >6.5% is diabetes.

Of note, other criteria for diagnosing diabetes: Fasting plasma glucose >126 mg/dL, 2-hour plasma glucose > 200, random glucose >200 plus classic symptoms.

In patients with prediabetes, A1C should be tested yearly.

The American Diabetes Association (ADA) has recommended glycated hemoglobin testing (HbA1c) twice a year for patients with stable glycemia, and quarterly for patients with poor glucose control. Use ADA guidelines to assess targets.

Point-of-care A1C (POC A1C): POC is not recommended for screening or diagnosis but it is good for monitoring.

A1C limitations.

There are some limitations to A1C testing, and an incomplete correlation between A1C level and average glucose level in certain individuals.

Nonglycemic Factors That May Interfere with A1C Measurement

Falsely lower A1C: Acute blood loss, Chronic liver disease, Hemolytic anemias, Patients receiving antiretroviral treatment for human immunodeficiency virus, Pregnancy, Vitamins E and C. Patients being treated for iron, B12 or folate deficiency, EPO, chronic hemolysis (thalassemia).

Lower or elevate A1C: Hemoglobinopathies or hemoglobin variants, Malnutrition

Falsely elevate A1C: Aplastic anemias, Hyperbilirubinemia, Hypertriglyceridemia, Iron deficiency anemias, Renal failure, Splenectomy.

For example, when RBCs have a short life, like in acute bleeding, the A1C is falsely low. On the other hand, when RBCs live longer (history of splenectomy and aplastic anemias) the A1C is falsely elevated. It’s a good idea to do CBC with A1C.

Ethnic groups: Hemoglobinopathies or hemoglobin variants can change A1C levels and may be more prevalent among certain racial and ethnic groups. A1C tends to be higher in some races/ethnic groups: AA, Hispanic-Americans, Asian-Americans.

Other A1C limitations: It gives you an average, patient may be experiencing hypoglycemia alternated with hyperglycemia and result in normal A1C. 

Screening for diabetes.

ADA: Screen for diabetes or prediabetes all asymptomatic adults, according to the ADA, who have overweight or obesity with one or more risk factor (first degree relative with diabetes, high risk race or ethnic group, history of CVD, hypertension, dyslipidemia, PCOS, physical inactivity, severe obesity, acanthosis nigricans), patients with prediabetes (every year), women with GDM (every 3 years), all other patients after 45 years of age. If results are normal, test every 3 years, patients with HIV.

USPSTF: Adults aged 40 to 70 years who are overweight or obese. The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. (Draft: Asymptomatic adults ages 35 to 70 years who are overweight or obese) This is a Grade B recommendation. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. 

The USPSTF recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant women after 24 weeks of gestation. This is a Grade B recommendation.

Grade I recommendation (insufficient evidence): Asymptomatic pregnant women, Before 24 Weeks of Gestation. The USPSTF concludes that the current evidence is insufficient to screen for GDM in asymptomatic pregnant women before 24 weeks of gestation.

A1C Targets.

A1C goals can range from 6.5% to 8%. Target is individualized based on life expectancy, disease duration, presence of complications, CVD risk factors, comorbid conditions and risks for severe hypoglycemia. Sometimes your goal can be independent of A1C, for example, your goal can be to avoid complications. As a fun fact, A1C is not used in veterinary medicine.

Conclusion.
By Hector Arreaza, MD. 

Now we conclude our episode number 54 “A1C”, three characters that may not mean much for most people but for patients with diabetes, it is a very important number to remember. Remember to check the A1C in all your patients with poor control of diabetes every 3 months, or every 6 months in patients with good control. A1C has its limitations but it certainly is the best way to assess your patients’ glycemic control. We started this episode by giving you a random report about vaginal metformin, the study was unfinished, and we also reminded you of the importance of remembering our heroes during Memorial Day. 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, Hasaney Sin, Valerie Civelli, Yodaisy Rodriguez, and Steven Saito. Audio edition: Suraj Amrutia. See you next week!

References:

Vaginal Administration of Metformin in PCOS Patients, U.S. National Library of Medicine, Clinical Trials.Gov, https://clinicaltrials.gov/ct2/show/study/NCT02026869.

Office of Public and Intergovernmental Affairs, U.S. Department of Veteran Affairs,  https://www.va.gov/opa/speceven/memday/history.asp, accessed on May 26, 2021. 

Pippitt K, Li M, Gurgle HE. Diabetes Mellitus: Screening and Diagnosis. Am Fam Physician. 2016 Jan 15;93(2):103-9. Erratum in: Am Fam Physician. 2016 Oct 1;94(7):533. PMID: 26926406. https://www.aafp.org/afp/2016/0115/p103.html.

Standards of Medical Care in Diabetes – 2021, Diabetes Care, January 1, 2021, vol 44 issue supplement 1, https://care.diabetesjournals.org/content/diacare/suppl/2020/12/09/44.Supplement_1.DC1/DC_44_S1_final_copyright_stamped.pdf.

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!

Colorectal cancer screening update, COVID-19 vaccine update, and abnormal uterine bleeding basics.

Today is May 24, 2021.

Colorectal cancer screening update 
Written by Hector Arreaza, MD. 
Participation: Ikenna Nwosu, MD, and Daniela Viamontes, MD.

Today is May 24, 2021.

On august 29, 2020, we were in the midst of a pandemic and we woke up with the sad news about the death of Chadwick Aaron Boseman (also known as Black Panther). An interesting fact: The tweet in which his family announced his death on Twitter became the most-liked tweet in history. But why are we talking about Chadwick’s death? Because he died of colon cancer. I do not know if this recommendation came because of Chadwick, but it’s a good way to open this episode: remembering Black Panther.

We heard the rumors, but now it’s official. On May 18, 2021, the USPSTF released their final recommendation statement about colorectal cancer screening. The age to start screening has been changed from 50 to 45 years old. This is a grade B recommendation. Grade B means that this recommendation has moderate to substantial net benefit, so offer this service to your patients. 

Screening adults between 76 and 85 years old who have been previously screened has a small net benefit (grade C recommendation). So, select patients may be screened for colorectal cancer in this age group (76-85), especially those who have never been screened.

Do you remember this recommendation from medical school for high risk patients? Start screening at age 40 or 10 years before a patient’s direct-relative was diagnosed with colon cancer. This was a recommendation given by the US Multi-Society Task Force (which includes the American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy). This same organization already recommended in 2017 to start screening at age 45 in African American patients, and the American Cancer Society recommended screening all patients at age 45 in 2018. The ACS does not have a guideline to screen high risk patients for colon cancer. Most organizations agreed on not screening after age 85.

Strategies for screening:

High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every year

Dani: Stool DNA-FIT every 1 to 3 years (Cologuard®)  

CT colonography every 5 years 

Flexible sigmoidoscopy every 5 years OR Flexible sigmoidoscopy every 10 years + annual FIT 

Colonoscopy screening every 10 years

Discuss different options with your patients, choose your favorite and do it!
 

Introduction: Update on COVID 19 vaccines  

By Hector Arreaza, MD, and Lillian Petersen, RN.

COVID-19 vaccines now can be co-administered with other vaccines according to the ACIP. COVID-19 vaccines and other vaccines may now be administered without regard to timing. They can be given on the same day or within the 14 days previously recommended between vaccines. 

It is not known if reactogenicity of COVID-19 vaccine is increased with co-administration with other reactogenic vaccines (such as vaccines with live attenuated viruses). 

How do you decide if you want to co-administer a vaccine? 

1. Consider whether the patient is behind or at risk of becoming behind on recommended vaccines.

2. Consider their risk of vaccine-preventable disease.

3. Consider the reactogenicity profile of the vaccines. If multiple vaccines are administered at a single visit, administer each injection in a different injection site, at least one inch apart or in different limbs. 

Current or previous SARS-CoV-2 infection: 

Everyone should be offered COVID-19 vaccination regardless of their history of COVID-19 infection. Viral testing or serologic test is not recommended for the purposes of vaccine decision-making. People with current SARS-CoV-2 infection should be deferred until the person has recovered from the acute illness (if the person had symptoms) and they have met criteria to discontinue isolation. This applies to patients who got the disease before receiving any vaccine or after receiving the first dose. 

A minimum interval between infection and vaccination has not been established, but evidence suggests that the risk of reinfection is low in the months after initial infection but may increase with time due to waning immunity.

People with a history of multisystem inflammatory syndrome in children (MIS-C) or adults (MIS-A):

It is unclear if people with a history of MIS-C or MIS-A are at risk of recurrence of the same dysregulated immune response following reinfection with SARS-CoV-2 or in response to vaccination. People with a history of MIS-C or MIS-A may choose to be vaccinated but they should consider delaying vaccination until they have recovered from their illness and for 90 days after the date of diagnosis. Find more information at the CDC.gov website.

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 Uterine Bleeding. 
By Sherika Adams, MS3, P. Eresha Perera, MS3, and Hector Arreaza, MD. 

Definition. 

AUB is a symptom, not a diagnosis. It is equivalent to say: “This patient’s periods are abnormal.” Anything that falls out of what is considered “normal periods” is classified as abnormal uterine bleeding.

These 4 elements are assessed when determining if a patient has AUB: Regularity, frequency, duration, and volume. 

What is considered normal? Frequency = Every 24-38 days, regularity +/- 2-20 days over 12 months, duration = 4.5 to 8 days, volume = 5-80 mL. 10-30% of women of reproductive age may have AUB.

According to the American College of Obstetricians and Gynecologists (ACOG), abnormal uterine bleeding is characterized by bleeding or spotting following sexual intercourse or menopause, between menstrual cycles, menstrual cycles lasting more than 38 days or shorter than 24 days, heavy bleeding during menstruation, and “irregular” menstrual cycles that have 7-9 days of variation.

Terms no longer used: menorrhagia, metrorrhagia, and dysfunctional uterine bleeding (DUB). 

Not all symptoms reported as “vaginal bleeding” are coming from the vagina. For example, bleeding from anus, urethra, bladder, and perineum should be ruled out before establishing the diagnosis of AUB.

Classification of Abnormal Uterine Bleeding (AUB). 

Abnormal uterine bleeding (AUB) in nonpregnant premenopausal women can be classified by the acronym PALM-COEIN, which was established by the International Federation of Gynecology and Obstetrics (FIGO) in 2011. 

PALM-COEIN: 

Palm: Structural etiologies, Coein: Non-structural etiologies
 

P is for polyps: Polyps are epithelial tumors in the endometrium or cervix and can be identified by hysterosonography or hysteroscopic imaging.
 

A is for adenomyosis: Adenomyosis is endometrial stroma and glands in the myometrium and can be identified by histopathology, and now MRI and transvaginal ultrasound.
 

L is for leiomyomas: Leiomyomas also known as uterine fibroids are benign smooth muscle tumors that are diagnosed by pelvic examination and pelvic imaging such as ultrasound with contrast or MRI.
 

M is for malignancy and hyperplasia: Malignancy and hyperplasia are often abnormal epithelial tissue that is benign or cancerous that can be seen with transcervical endometrial sampling.
 

C is for coagulopathy: Coagulopathy is bleeding disorders such as Von Willebrand disease is identified by laboratory testing.
 

O is ovulatory dysfunctions: Ovulatory dysfunction occurs when there is a variation of more than seven days of the menstrual cycle in the past 12 months and ovulation is dysfunctional. In a woman without ovulation, there is no corpus luteum, and there is no progesterone, so estrogen goes unopposed, causing a buildup of endometrium and irregular bleeding.  
 

E is endometrial causes: Endometrial causes can occur when there is normal ovulation, no other identifiable cause of AUB, and there is heavy menstrual bleeding, which includes intermenstrual bleeding. Primary disorders of endometrial hemostasis are likely due to vasoconstriction disorders, inflammation, or infection. Endometrial dysfunction is poorly understood; there are no reliable diagnostic methods, and it should be considered only after other causes are excluded.
 

I is for iatrogenic cause: Iatrogenic causes include gonadal steroids (estrogen, androgens), anticoagulants, intrauterine devices, antipsychotics, antidepressants, and anti-hypertensives.
 

N is for not otherwise classified: Example of an etiology under not otherwise classified might be AV malformations.

This classification does not include pregnancy.

Postmenopausal bleeding: Abnormal uterine bleeding can also occur in post-menopausal women and is an indication of potentially lethal endometrial cancer. Post-menopausal women should be worked up for cancer when they present with bleeding. However, most common cause of bleeding in this population is atrophy of the vaginal mucosa or endometrium. If younger than 45 patients but history of unopposed estrogen exposure (PCOS, obesity, estrogen therapy) should also undergo endometrial biopsy to rule out possibility of endometrial cancer. 

Management of AUB. 

Management of the AUB can be initiated only after the etiology of the bleeding has been established. Firs of all, rule out pregnancy related bleeding by performing a pregnancy test. Also, rule out other sources of bleeding.

The first question to answer would be: Does this patient need an emergent treatment for her AUB or can she be treated as outpatient? Determine that by checking the history, vitals, orthostatic vitals, physical exam, and labs. 

If patient requires admission, the options for treatment include: uterine tamponade, intravenous estrogen, dilation and curettage, and uterine artery embolization. In case of severe bleeding without hemodynamic instability, patients can be treated initially with oral estrogen, high-dose estrogen-progestin oral contraceptives, oral progestins, or intravenous tranexamic acid.

For chronic AUB, once etiology has been established, the goal is to treat the underlying condition. The goal of treatment is to control the bleeding since AUB can persists until menopause. 

Initial outpatient treatment is usually pharmacological. For those not wanting to conceive soon, consider IUD placement. “Among medical therapies, the 20-mcg-per-day formulation of the levonorgestrel-releasing intrauterine system (Mirena) is most effective for decreasing heavy menstrual bleeding (71% to 95% reduction in blood loss) and performs similarly to hysterectomy when quality-adjusted life years are considered.”[8]

Other long-term medical treatment options include estrogen-progestin oral contraceptives, oral progestins, oral tranexamic acid, NSAIDs (nonsteroidal anti-inflammatory drugs), and depot medroxyprogesterone.

Surgical treatment is often considered for patients on long term medical therapy with no response, or for severe cases of bleeding with recurrent need for emergent treatment.

Some surgical options are endometrial ablation, which performs as well as the levonorgestrel-releasing intrauterine system. Some structural lesions can be resected via hysteroscopy (polyps).

Myomectomy and uterine artery embolization are options for patients with severe AUB who want to preserve fertility. Uterine leiomyomas or adenomyosis can be medically managed with OCPs but can also be treated with surgery as well, depending on the physician-patient discussion of options.

Hysterectomy is the definitive treatment of severe AUB.

Remember, PALM COEIN stands for: Polyps, Adenomyosis, Leiomyomas, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial causes, Iatrogenic cause, Not otherwise classified.

____________________________

Conclusion.
Written by Hector Arreaza, MD

Now we conclude our episode number 53 “Abnormal Uterine Bleeding”. Eresha and Sherika did a great job explaining the Palm-Coein classification, and gave us a good overview of the management of AUB. Remember to start screening for colorectal cancer at age 45 now, what strategy for screening will you use? And for those patients who were hesitant about getting the COVID-19 vaccine with other vaccines, well, the ACIP said we can co-administer it with other vaccines. 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, Daniela Viamontes, Ikenna Nwosu, Lillian Petersen, Sherika Adams, and P. Eresha Perera. Audio edition: Suraj Amrutia. See you next week! 

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References:

Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States, Centers for Disease Control and Prevention, https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html#Coadministration, accessed on May 20, 2021. 

Colorectal Cancer: Screening, Final Recommendation Statement, U.S. Preventive Services Task Force, May 18, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening.

Abnormal Uterine Bleeding FAQ, The American College of Obstetricians and Gynecologists (ACOG), https://www.acog.org/womens-health/faqs/abnormal-uterine-bleeding, accessed on May 17, 2021. 

Fraser, Ian, et al. Abnormal uterine bleeding in reproductive-age women: Terminology and PALM-COEIN etiology classification, Up to Date, last updated: Dec 16, 2019. https://www.uptodate.com/contents/abnormal-uterine-bleeding-in-reproductive-age-women-terminology-and-palm-coein-etiology-classification?search=palm%20coein&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

Goodman Annekathryn, et al, Postmenopausal uterine bleeding, Up to Date, last updated: Feb 02, 2021. https://www.uptodate.com/contents/postmenopausal-uterine-bleeding?search=abnormal%20uterine%20bleeding%20postmenopausal&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Kaunitz, Andre M, Abnormal uterine bleeding: Management in premenopausal patients, Up to Date, last updated: Aug 25, 2020. https://www.uptodate.com/contents/abnormal-uterine-bleeding-management-in-premenopausal-patients?search=abnormal%20uterine%20bleeding%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Wouk N, Helton M. Abnormal Uterine Bleeding in Premenopausal Women. Am Fam Physician. 2019 Apr 1;99(7):435-443. PMID: 30932448. https://pubmed.ncbi.nlm.nih.gov/30932448/

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!