Rio Bravo qWeek

Vitamin D deficiency screening recommendations by USPSTF and other organizations is discussed. CDC announces “no masks required” for vaccinated people. Question of the month about fever and cough answered.

Introduction: Mask use no longer required for vaccinated people
By Hector Arreaza, MD

Today is May 17, 2021.

Did you receive your COVID-19 vaccine? If you did, we have good news for you, well, this may not be news for you anymore by the time you listen to this episode.

The CDC director, Rochelle Walensky, announced a few minutes ago that vaccinated people no longer need to wear masks indoors or outdoors and no longer need to keep social distance[1]. A person is considered fully vaccinated 2 weeks after one dose of J&J vaccine or two weeks after second dose of Moderna or Pfizer vaccines.

Fully vaccinated people are required to wear masks in airplanes, trains, buses, other public transportation, health-care settings, and where required by local authorities or businesses. These mask and social distancing guidelines may change in the future because we have seen the behavior of the coronavirus is unpredictable. These guidelines are dynamic.   

This announcement came one day after CDC endorsed administration of the Pfizer vaccine to persons between 12 and 15 years old. We do not know if this is the beginning of the end, but for sure we are starting to see a light at the end of the tunnel. 

As of today, about 117 million Americans are fully vaccinated (35% of the population). The effectivity of vaccination has been remarkable. The rate of breakthrough infections (it means infection after full vaccination) is rare, and severity of disease is mild after vaccination. For the record, the federal government has set a goal of vaccinating 70% of Americans by July 4th, 2021. 

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.

Question of the Month: Fever and Cough
Written by Hector Arreaza, MD

This is a 69-year-old male patient, who comes to clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. 

He does NOT smoke tobacco. He takes benazepril 10 mg daily. His immunizations are not up to date. Physical exam: Tachycardia of 110 bpm and fever of 101.5 F (38.6 C). He has bibasilar crackles, White count is elevated 13.5, and chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. 

What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?

First, we want to announce the winner. I am the winner [applause].

The top 3 differential diagnosis are: 1. Community acquired pneumonia, viral or bacterial (no surprises there, the symptoms are typical of CAP); 2. COVID-19 pneumonia (the rapid COVID-19 test was NEGATIVE, but the confirmatory test is pending, this patient may have COVID-19 until proven otherwise); and 3. My third DDX is pulmonary coccidio-idomycosis (also known as Valley Fever in California, or simply cocci). If you are not familiar with the diseases in the Central Valley of California, you may think this is a very unusual differential, but for us is not that uncommon. One day we will talk more about that disease.

Acute management:

The first decision you must make is where to treat this patient. Will you treat him at home or in the hospital? If sent to the hospital, can he be treated on the floor or requires ICU admission?

You have to determine is the patient is experiencing septic shock or respiratory failure. If septic shock and respiratory failure are not likely, and CURB-65 score is zero, then no hospital admission is needed. 

This patient meets SIRS criteria (systemic inflammatory response syndrome): temperature >38 C, HR > 90, and WBC >12,000. BP was not provided so it is not possible to determine if he has septic shock (BP <90/60).

Respiratory failure is suspected when pulse ox is below 92% on room air. That information is not provided in this case. Assuming Pulse ox is below 92% on room air, then you use an objective way to determine severity of pneumonia or guide your management. 

There are not enough elements to calculate the CURB-65 score: Confusion, BUN >20 mg/dL (>7 mmol/L), Respiratory rate ≥30 breaths/minute, Blood pressure (systolic <90 mmHg or diastolic <60 mmHg), Age ≥65 years. Further labs would be needed to determine the severity of this pneumonia. A CURB 65 above 2 points warrants hospital admission. CURB 3-5 may require ICU admission.

Based on my assessment, this patient meets admission criteria. Let’s assume patient’s blood pressure is below 90/60.

The priority is to start fluid resuscitation, Normal saline or LR 30 mL per kilo, in the first 3 hours, mean arterial pressure 60 mmHg to 70 mmHg and urine output >0.5 ml/kg/hour, lactic acid trending down. IF response is poor, consider ICU transfer.

Collect blood culture x2 before IV antibiotics. 

IV antibiotics: Ceftriaxone and Azithromycin IV.

Order labs CBC, CMP, D-dimer level, Lactate, procalcitonin, COVID-19 PCR, rapid influenza testing, urinary antigen testing (eg, pneumococcus, legionella), sputum culture: sputum of good quality, quantitative culture of protected brush or bronchoalveolar lavage; ABG to assess for respiratory failure, especially if patient’s pulse ox is low. In the Central Valley: Order Coccidio-iodomycosis (cocci) titers. Starting empiric fluconazole is an option when you have a high suspicion for pulmonary cocci. 

Procalcitonin: Measure on admission and 1-2 days later. If <0.25 this may indicate a viral pneumonia but antibiotics still recommended based on your clinical judgment. If you suspect bacterial CAP, you can decide to discontinue antibiotics once the procalcitonin is below 0.25 or decreasing more than 80% from peak level.

Lactic acid: Use to guide fluid resuscitation. 

Follow your patient closely until you can tell objectively he is improving.

Vitamin D Check. 
With Yodaisy Rodriguez, MD, and Hector Arreaza, MD

What is Vitamin D?

Vitamin D is a fat-soluble vitamin that has an important function in calcium and bone metabolism. It stimulates absorption of calcium by the intestines, it inhibits excretion of calcium and phosphates by the kidneys, and it increases bone resorption. It also participates in many other cellular functions outside the skeletal system.

Metabolism: There are two kinds of exogenous vitamin D: Vitamin D3 is called cholecalciferol, Vitamin D2 is called ergocalciferol. The major source of natural vitamin D in our bodies is the skin. UV B light turns 7-de-hydro-cholesterol into Vitamin D3 (cholecalciferol) in the skin. Dietary sources of vitamin D can be Vitamin D2 or D3. Only a few foods contain vitamin D naturally. Fatty fish is the main food with vitamin D.

After Vitamin D gets activated by UV light, it gets activated in the liver and results in 25-hydroxyvitamin D, which is the most abundant circulating vitamin D in our bodies. After activation in the liver, 25-hydroxy-vitamin D is then metabolized by the kidney, resulting in 1,25-di-hydroxy-vitamin D, which is the most active form of vitamin D (also short-lived). 

Skin: 7-dehydrocholesterol -> UV Light -> Cholecalciferol (D3) -> LIVER -> 25-hydroxyvitamin-D -> KIDNEY -> 1,25 dihydroxyvitamin D (most active form of vitamin D)

Diet/Supplement: Vitamin D2 and D3 -> LIVER -> 25-hydroxyvitamin-D -> KIDNEY -> 1,25 dihydroxyvitamin D (most active form of vitamin D)

Screening for Vitamin D Deficiency in Adults.

Screening means to run tests before there is clinical evidence of a disease. 

41% of the adult US population has Vitamin D levels below 20, classified as subclinical Vitamin D deficiency, which may contribute to osteoporosis and traumatic fractures in older adults. Clinical vitamin D deficiency (hypocalcemia, hypophosphatemia and rickets and Osteomalacia) is uncommon in the US. 

The goal of screening for vitamin D deficiency would be to identify and treat it before any symptoms are present.

The best marker for detection of deficiency. 

Total 25 hydroxyvitamin D level is currently considered the best marker of vitamin D status. This is the result of the activation by the liver. However, precise measurement of levels is difficult because Vitamin D requirements may vary by individual, by testing method, and between laboratories.

According to the National Academy of Medicine: 97.5% of the population will have their vitamin D at a serum level of 20 ng/mL (49.9 nmol/L) and risk for deficiency. Bone health concerns start at levels less than 12 to 20 ng/mL (29.9- 49.9 nmol/L).

The 2014 National Health and Nutrition Examination Survey found that: 5% of the population 1 year or older had very low 25-hydroxyvitamin D (25[OH]D) levels <12 ng/mL, 18% had levels between 12 and 19 ng/mL.

Risk factors for low vitamin D levels. 

-Low dietary vitamin D intake.

-Little or no UV B light exposure (eg, because of winter season, high latitude, or sun avoidance – office jobs)

-Older age 

-Obesity: people with obesity have a 1.3- to 2-fold increased risk for low vitamin D level

-Patients taking medications that accelerate the metabolism of vitamin D (such as phenytoin)

-Hospitalized or institutionalized patients

-Patients with increased skin pigmentation

-Osteoporosis

-Malabsorption, including inflammatory bowel disease and celiac disease

Interesting fact: Prevalence of low vitamin D is 2 to 10 times higher in black persons than in non-Hispanic white persons.

Recommendations for screening for vitamin D deficiency. 

USPSTF: 2021 – All adults: Grade I (insufficient evidence) for screening for vitamin D deficiency in asymptomatic, community-dwelling, non-pregnant adults. 

USPSTF: 2018 – Elderly patients: Grade D (do not give) Vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older who are community-dwelling without evidence of osteoporosis or vitamin D deficiency.

USPSTF: 2018 – Postmenopausal women: Grade D (do not give) daily vitamin D (400 IU or less) and calcium (1000 mg or less) for the primary prevention of fractures in community-dwelling, postmenopausal women without osteoporotic fractures, increased risk for falls, or a diagnosis of osteoporosis or vitamin D deficiency. Grade I (Insufficient evidence) to recommend daily supplementation with more than 400 IU of vitamin D and more than 1000 mg of calcium to prevent fractures in community-dwelling, postmenopausal women.

USPSTF: 2018 – Men and premenopausal women: Grade I (insufficient evidence) for vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in community-dwelling, asymptomatic men and premenopausal women. 

Dr. Arreaza: Treatment and Interventions.

In general, patients with serum 25(OH)D levels <12 ng/mL are at risk for developing osteomalacia. 

Work up: In patients with Vitamin D <12, measure serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone (PTH), electrolytes, blood urea nitrogen (BUN), creatinine, and tissue transglutaminase antibodies (to assess for celiac disease). Radiographs in case of bone pain. 

PTH should be high in low vitamin D. You can use PTH as an indirect indicator of appropriate level of Vitamin D when it normalizes after adequate repletion. Fracture prevention is accomplished when Vitamin D level is between 28-40 ng/mL (70 to 99 nmol/L).

Yodaisy: Prevention and optimal intake: 

The Institute of Medicine (IOM) in 2010 posted the Recommended Dietary Allowance (RDA) of vitamin D for children 1 to 18 years, pregnant women, and nonpregnant adults younger than age 70 years is 600 international units, and 800 international units for patients older than 70 years. To re

Arreaza: The American Geriatrics Society (AGS) and the National Osteoporosis Foundation (NOF) recommend a slightly higher dose of vitamin D supplementation (at least 1000 international units [25 micrograms], and 800 to 1000 international units daily, respectively) to older adults (≥65 years) to reduce the risk of fractures and falls. Note we are citing different organizations. 

Yodaisy: When a real vitamin D deficiency is diagnosed, it is usually treated with oral vitamin D prescriptions. It can be vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol). Toxicity is rare, which is characterized by marked hypercalcemia, hyperphosphatemia and hypercalciuria. Toxicity is rare (typically >150 ng/mL), and PO vitamin D supplementation has not been associated with serious harms. 

Vitamin D and COVID-19.

There is growing interest as a facilitator of innate immune response during COVID-19 infection. Vitamin D supplementation may be needed to meet recommended intake or treat deficiency, however, exceeding the upper level intake is not recommended. No evidence in reducing the risk of severity, length of hospital stay, or mortality. 

Summary.

USPSTF - Do not give: 

1. Vitamin D to elderly patients to prevent falls. 

2. Vitamin D (<400) and calcium (<1000) to asymptomatic postmenopausal women to prevent fractures.

USPSTF - Insufficient evidence to recommend for or against: 

1. Screening for Vitamin D deficiency in adults.

2. Supplementation with Vitamin D (>400) and calcium (>1000) in asymptomatic postmenopausal women to prevent fractures.

3. Supplementation with Vitamin D and calcium, alone or combined, for the primary prevention of fractures in asymptomatic men and premenopausal women.   

Vitamin D deficiency screening recommendations by other organizations: 

-Against screening: The American Society for Clinical Pathology (ASCP). 

-Insufficient: The American Academy of Family Physicians. 

-Screen in individuals at risk: The Endocrine Society and the American Association of Clinical Endocrinologists.

Prevention of deficiency: Recommended Dietary Allowance: Vitamin D 600 international units until age 70, then 800 units a day. Other organizations (American Geriatrics Society and the National Osteoporosis Foundation) recommend a higher RDA of 800 to 1000 for persons older than 65 who are at risk for vitamin D deficiency.

Now we conclude our episode number 52 “Vitamin D Checks”. Dr Rodriguez explained that the USPSTF gave a grade I recommendation for Vitamin D deficiency screening in asymptomatic adults. Grade I means “insufficient” evidence. The endocrinologists recommend screening those who are at risk for vitamin D deficiency. According to the USPSTF, Vitamin D supplementation in older adults do not prevent falls and do not prevent fractures in postmenopausal women without deficiency or osteoporosis. Make sure you stay up-to-date with any changes in the future. And congratulations to Dr Arreaza for answering the Question of the month. Stay tuned for another question in the future. Even without trying, every night you go to bed being a little wiser.

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

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References:

CDC says fully vaccinated Americans no longer need masks indoors or outdoors in most cases, The Washington Post, May 13, 2021.  https://www.washingtonpost.com/health/2021/05/13/cdc-says-fully-vaccinated-americans-no-longer-need-masks-indoors-or-outdoors-most-cases/

U.S. Preventive Services Task Force. Screening for Vitamin D Deficiency in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(14):1436–1442. doi:10.1001/jama.2021.3069. https://jamanetwork.com/journals/jama/fullarticle/2778487. 

Dawson-Hughes, Bess, MD. Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment. Up to Date, last updated: May 03, 2021. Accessed on May 5, 2021. https://www.uptodate.com/contents/vitamin-d-deficiency-in-adults-definition-clinical-manifestations-and-treatment?search=vitamin%20d&source=search_result&selectedTitle=2~146&usage_type=default&display_rank=1

LeClair BM, Si C, Solomon J. Vitamin D Supplementation and All-Cause Mortality. Am Fam Physician. 2020 Jul 1;102(1): Online. PMID: 32603077. https://www.aafp.org/afp/2020/0701/od1.html#:~:text=In%20summary%2C%20high%2Dquality%20evidence,%3D%20274%20for%201.2%20years).

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!

Progeria is a rare disease that causes premature aging in childhood; the FODMAP diet is explained as a treatment for IBS; J&J vaccine restarted; Question of the month: Fever and Cough.

Introduction: Low FODMAP Diet and J&J COVID Vaccine is back.  
By P. Eresha Perera, MS3, and Sherika Adams, MS3.

Today is May 10, 2021.

Irritable Bowel Syndrome. 

Patients with IBS frequently have other conditions such as anxiety, depression, somatization, fibromyalgia, chronic fatigue syndrome, GERD, dyspepsia, non-cardiac chest pain, chronic pain, and other mental illness. A common triad we see in the clinic is: Anxiety + Fibromyalgia + IBS. Treating these conditions is hard, and even more so when they are combined. 

Let’s focus for now on IBS treatment. Recently we had a patient with IBS who had a laparoscopic cholecystectomy and of course was complaining of abdominal pain and constipation. We mentioned the low FODMAP diet as part of the treatment. The low FODMAP diet has been proven for the treatment of irritable bowel syndrome (IBS) and or small intestinal bacterial overgrowth (SIBO). It has decreased symptoms in 86% of people. 

FODMAP is an acronym that stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. This diet attempts to restrict these short-chain carbs that are poorly absorbed by the small intestine, resulting in cramping, constipation, diarrhea, bloating, and gas or flatulence.

You can recommend your patients to follow 3 steps: Step 1: Eliminate foods that are high on FODMAP, Step 2. Determine which foods cause symptoms by reintroducing eliminated foods slowly, and Step 3. After identification of the FODMAP foods that cause symptoms, remove them completely from the patient’s diet. Dr. Hazel Galon Veloso, John Hopkins's gastroenterologist, recommends doing step 1 for 2-6 weeks and step 2 reintroducing a high FODMAP food back into diet every 3 days. 

Example of HIGH FODMAP foods: Dairy-based milk, yogurt, ice cream, wheat products (cereal, bread, and crackers), beans, lentils, vegetables like artichokes, asparagus, onions, and garlic, and fruits such as apples, cherries, pears, and peaches. 

Example of LOW FODMAP foods: Eggs, meat, cheese such as Brie, cheddar, and feta; almond milk, rice, quinoa, oats, potatoes, tomatoes, cucumbers, zucchini, grapes, oranges, and strawberries.

If available, Fodmap should be initiated with the advice of a nutritionist that can help with the transition, prevent over-restriction and nutritional replete diet. Consider this diet as an initial treatment for your patients with IBS.

Vaccination with J&J COVID 19 Vaccination has been restarted.

On a different note, On April 23, 2021, the CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended to restart vaccination with the Janssen/Jonson & Jonson COVID-19 vaccine after a pause on April 13, 2021[2]. 

After giving the J&J vaccine to almost 8 million patients, 15 cases of Thrombosis with Thrombocytopenia Syndrome (TTS) were reported and three of them died. The recommendation was given after a risk-benefit analysis that determined that the benefits of the vaccine outweigh the risks. The risk of TTS in women age 18-49 still exists, but it is considered very low when compared to all the risks carried by COVID 19 itself. Under the emergency use authorization, the Jonson & Jonson vaccine is considered highly effective and safe. In comparison, the AstraZeneca vaccine has had several more cases of TTS, Moderna has had only 3 but with normal platelets, and Pfizer has had zero cases of TTS[3].  

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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Question of the Month: Fever and Cough
Written by Hector Arreaza, MD

What are your top 3 differential diagnosis and acute management for a 69-year-old man with new onset of fever, cough, leukocytosis and a right lower lobe consolidation? Important: Rapid COVID-19 test is negative.

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Progeria. 
With Salwa Sadiq-Ali, MS3, Veronica Phung, MS3; and Hector Arreaza, MD.  
 

“The Curious Case of Benjamin Button” is an American movie released in 2008, directed by David Fincher, starring Brad Pitt. Let’s see how we can connect this movie to today’s topic.

What is Hutchinson Gilford Syndrome better known as Progeria?

V. Phung: That’s a great question! Progeria is an extremely rare disease. It’s progressive and causes children to age very quickly within the first few years of their life. The disease is not evident at birth. 

S. Sadiq-Ali: Exactly! Usually, kids will start developing symptoms within their first year of life with the first symptom being failure to thrive. Other common features include a disproportionately large head for their face, narrow nasal ridge and tip, small mouth, retro and micrognathia, little to no subQ fat with small outpouchings, delayed eruption of primary teeth, progressive joint contractures, and essentially all geriatric conditions like alopecia, osteoarthritis, and hearing loss. One interesting tidbit though is that their motor and mental development is normal! 

H. Arreaza: A child getting old quickly, that’s so interesting. What’s the pathophysiology of this condition?

V. Phung: So, it’s due to a genetic mutation - a single nucleotide polymorphism - in the LMNA gene known as lamin A. This gene codes for the lamin A protein which holds the cell’s nucleus together. A mutation causes your body to make a much smaller protein called progerin. Progerin is not stable so it doesn’t hold the cell’s nucleus together properly. This instability is thought to be the cause of premature aging. 

S. Sadiq-Ali: That’s right Veronica! There are two common mutations – the classic form and the non-classic form. The difference between the two forms is where in the gene the mutation occurs. 

H. Arreaza: So, if I suspect my patient has progeria, I should do a genetic test for the LMNA gene mutation. How common is progeria?

S. Sadiq-Ali: About 1 in every 4 to 8 million births is affected by progeria. Unlike many other conditions, there aren’t any predisposing factors - such as gender, location, or ethnicity. It’s completely random! Right now, about 179 children across 53 different countries have been diagnosed with progeria. 18 of those cases are here in the US. One family in India, has had 5 children with progeria. Another interesting fact is that there have been only 2 known cases of a completely healthy person carrying the mutated gene!  

V. Phung: Since they’re aging so rapidly and prematurely, their life expectancy is about 14.5 years. However, the oldest believed survivor - Tiffany from Ohio – has lived up to the age of 43! 

H. Arreaza: And she is still alive, as far as I know. What can be done in terms of management to ensure these children and adults can live their best, most comfortable life? 

S. Sadiq-Ali: There’s no cure so you’d want to manage any symptoms and make sure the child is getting proper nutrition. Generally, the recommendation is to have small frequent meals, maintain good hydration, do routine PT and exercises, use shoe pads since they don’t have much body fat to provide cushioning, use plenty of sunscreen, prescribe anticoagulation as needed for geriatric conditions like CAD/CVD, and manage any fractures or dislocations that may occur. It requires a multidisciplinary care team.

H. Arreaza: So, you mentioned Tiffany Wedekind, the person with progeria who has lived the longest. Now, I want to mention Sam Berns, maybe the most famous person with progeria. “Life According to Sam” is an HBO documentary directed by Sean Fine and Andrea Nix Fine. It was presented in January 2013 at the Sundance Film Festival (I love Park City, Utah). The documentary explains the impact of progeria on the lives of Sam Berns and his parents, Dr. Leslie Gordon and Dr. Scott Berns. You can also see or listen to the Ted Talk given by Sam Berns (google it or go to the link in our script).

S. Sadiq-Ali: These kids are aging so quickly they have geriatric conditions; do they die from natural causes or from heart disease and stroke? 

V. Phung: That’s a great question. Unfortunately, yes. Death is commonly due to complications from atherosclerosis, cardiac disease, and cerebrovascular disease - like a heart attack or stroke. 

S. Sadiq-Ali: “The Curious Case of Benjamin Button” is usually thought to be an example of progeria, but it’s actually the opposite: A child born as an adult who dies as a baby.

H. Arreaza: That was really educational. Progeria, a rare disease that you should know about, in case someone asks you. Remember, “family doctors know everything”.  Even without trying every night you go to bed being a little wiser.

Conclusion
By Hector Arreaza, MD

Now we conclude our episode number 51 “Progeria”, a rare disease that requires care by a multidisciplinary team. You may not encounter a patient with progeria in your life, but if you do, now you know the fundamentals of that syndrome. We started this episode talking about the FODMAP diet. Consider this diet as part of the initial treatment of IBS. Don’t forget to send your answer (one more week to do it). What are your top 3 differential diagnosis and the acute management of a 69-year-old male with new onset of fever, cough, leukocytosis, right lower lobe consolidation and negative rapid COVID 19 test. Remember, 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, Sherika Adams, Eresha Perera, Salwa Sadiq-Ali, and Veronica Phung. Audio edition: Suraj Amrutia. See you next week!

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References:

Veloso, H. G. (n.d.). FODMAP Diet: What You Need to Know. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/fodmap-diet-what-you-need-to-know. 

ACIP Updates Recommendations on Johnson & Johnson Vaccine, American Association of Family Physicians, aafp.org. https://www.aafp.org//news/health-of-the-public/20210429acipjjvac.html

Meara, Killian, CDC’s ACIP Votes to Reaffirm Recommendation of Johnson & Johnson COVID-19 Vaccine, April 23, 2021, ContagionLive.com. https://www.contagionlive.com/view/cdc-s-acip-votes-to-reaffirm-recommendation-of-johnson-johnson-covid-19-vaccine

Progeria, National Center for Advancing Translational Sciences, National Institutes of Health, https://rarediseases.info.nih.gov/diseases/7467/progeria, accessed on May 6, 2021.

Sinha JK, Ghosh S, Raghunath M. Progeria: a rare genetic premature ageing disorder. Indian J Med Res. 2014;139(5):667-674. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140030/

Gordon LB, Brown WT, Collins FS. Hutchinson-Gilford Progeria Syndrome. 2003 Dec 12 [Updated 2019 Jan 17]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1121/. 

The Progeria Research Foundation, https://www.progeriaresearch.org/, accessed on May 6, 2021.

Family battles with rare progeria disease, Deccan Herald, New Delhi, November 9, 2009, https://www.deccanherald.com/content/34971/family-battles-rare-progeria-disease.html

Sam Berns, TEDx MidAtlantic 2013, My philosophy for a happy life. Available at: https://www.ted.com/talks/sam_berns_my_philosophy_for_a_happy_life?language=en, accessed on May 6, 2021.

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

Jaime Perales, PhD, presents statistics, screening tools and useful resources for primary care providers for Alzheimer’s disease. The KIDs list is presented. Question of the month: Fever and Cough.

Introduction: KIDs List and Cognitive Impairment in the Elderly
By Hector Arreaza, MD

Today is May 3, 2021.  

In family medicine, we believe in caring for patients “from the cradle to the grave.” During this introduction, we want to inform first of the KIDs list[1] and then some updates on cognitive impairment screening in older adults[2].

First, KIDs stand for Key Potentially Inappropriate Drugs in Pediatrics. It is a list of medications that are potentially inappropriate in children. It contains 67 drugs with their risks, recommendations, strength of recommendation and quality of evidence. Common meds include anti-infectives, antipsychotics, dopamine antagonists and GI agents. 85% of these meds require a prescription, and are taken by mouth, or used by parenteral route or even for external use. 

For example: Mineral oil, oral, carries the risk of lipid pneumonitis, recommended to avoid in patients younger than 1 year old, this recommendation is strong with low quality of evidence. For all the “abuelas” (Spanish for grandmothers) out there, listen to this: Camphor carries a risk of seizures, the recommendation is “use with caution in children.” However, the recommendation is weak and quality of evidence is low, but the concern is enough to include it on the list, in other words, use “vi-vah-pore-oo” with caution in children. I recommend you look up the KIDs list and use your clinical judgment to incorporate it into your practice. 

From childhood, now we go to the elderly. On February 25, 2020, the USPSTF posted their final recommendation statement regarding screening for cognitive impairment in older adults. This is a Grade I recommendation (Insufficient Evidence). It means that more research is needed to recommend for or against it. This is the same recommendation given in 2014. 

An article published in JAMA on the same date, Feb 25, 2020, reports that screening instruments can adequately detect cognitive impairment, however there is no evidence that this screening improves patient or caregiver outcomes or causes harm. It is still uncertain if early detection of cognitive impairment is important to provide interventions for patients or caregivers with significant clinical benefits.

Jaime Perales, PhD, will present some statistics on Alzheimer’s disease, he will explain some useful tools to screen for cognitive impairment and address the issue of Alzheimer’s disease at the primary care level. 

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. 

Question of the Month: Fever and Cough
Written by Hector Arreaza, MD, read by Claudia Carranza, MD, and Valerie Civelli, MD

This is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. 

He does NOT smoke tobacco, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. He has no surgical history. He retired as an accountant 5 years ago. 

Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. 

What are your top 3 differential diagnoses and what is the acute management of this patient’s condition? Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?

Send us your answer before May 7, 2021, to [email protected] and the best answer will win a prize!

____________________________

Screening for Alzheimer’s. 

With Jaime Perales Puchalt, PhD, and Hector Arreaza, MD

Jaime Perales Puchalt is an Assistant Professor in the Department of Neurology. His main areas of interest include dementia among minorities and populations of Latin American origin in the Americas. 

He currently spearheads the Latino Alzheimer's education efforts at the University of Kansas Alzheimer’s Disease Center (KU ADC) and the Latino Cohort in which he recruits and conducts clinical dementia assessments of English and Spanish speaking Latinos. He has also led the integration of the Spanish National Alzheimer's Coordinating Center Unified Data Set 3.0 into REDCap. Together with Dr. Vidoni, Dr. Perales developed Envejecimiento Digno, a curriculum to increase Alzheimer's disease awareness among individual Latino community with different literacy levels.  

Dr. Perales completed his MS in Psychology at the University of València, and his MPH in Public Health and PhD in Biomedicine at the University Pompeu Fabra, Barcelona. He started his research career at the University of València, where he collaborated in several stress-related projects among breast cancer patients, Latin American immigrants and caregivers of schizophrenia patients. Dr. Perales co-managed a four-year European Commission-funded multi-country study on healthy aging (COURAGE in Europe) at the Parc Sanitari Sant Joan de Déu. He also spent one year as a visiting researcher at the Institute of Public Health, University of Cambridge conducting dementia-related epidemiological research and collaborating in successful aging literature reviews. At Juntos: Center for Advancing Latino Health (KU), he contributed to the cultural and linguistic adaptation of several smoking cessation interventions for Latinos[3].

Questions discussed during this episode: 

Incidence and prevalence of dementia in the US: under-diagnosis, death risk, caregiver, 

Recommendations on screening for dementia by national organizations: American Academy of Neurology, examining models of dementia care (page 22), USPSTF, grade I, no evidence, screening early improves outcomes; ARDAD

Best evidence-based tools for screening for dementia: MMSE, MoCA (better for MCI), AD8, MiniCog. 

Useful resources for primary care providers: Alzheimer’s Association: Unidos Podemos (soap opera), NIH Caring for a person with Alzheimer’s Disease, Course: USDHHS,  

Any other information you would like to provide us: The course, Jul 23, 2021, and Sep 3, 2021.

Conclusion.

Now we conclude our episode number 50 “Screening for Alzheimer’s Disease”. You heard from our experts the importance of assessing and treating your patients with Alzheimer’s Disease. We hope you can find all the resources mentioned during our interview with Jaime Perales, make sure you check our episode notes to find the links or just Google them, they are readily available online. Do not forget to send us your answer to the question of the month: What are your top 3 differential diagnosis and acute management of a 69-year-old male with new onset of fever, cough, shortness of breath, and right lower lobe consolidation. 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, Ariana Lundquist, Jaime Perales, Claudia Carranza, and Valerie Civelli. Audio edition: Suraj Amrutia. See you next week!

References and resources mentioned during this episode:

Meyers RS, Hellinga RC, Hoff DS. The KIDs List: Medications That Are Potentially Inappropriate in Children. Am Fam Physician. 2021 Mar 15;103(6):330. PMID: 33719376. https://www.aafp.org/afp/2021/0315/p330.html

Cognitive Impairment in Older Adults: Screening, February 25, 2020. U.S. Preventive Services Task Force.  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening

Patnode CD, Perdue LA, Rossom RC, et al. Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2020;323(8):764–785. doi:10.1001/jama.2019.22258.  https://jamanetwork.com/journals/jama/article-abstract/2761650

KU Medical Center, The Univeristy of Kansas, Core Faculty, https://www.kumc.edu/ku-adc/core-faculty/jaime-perales-puchalt-phd.html

2021 Alzheimer’s Disease Facts and Figures, Special Report on Race, Ethnicity and Alzheimer's in America, published by the Alzheimer’s Association, Chicago, Illinois, USA.  https://www.alz.org/media/documents/alzheimers-facts-and-figures.pdf

Examining Models of Dementia Care: Final Report, U.S. Department of Health & Human Services, September 1, 2016, https://aspe.hhs.gov/pdf-report/examining-models-dementia-care-final-report

¡Unidos Podemos! (Fotonovela, Spanish), Alzheimer’s Association, http://www.alz.org/espanol/downloads/Novella_spanish_081213.pdf

Together We Can! (Picture Novel, English), Alzheimer’s Association, http://www.alz.org/espanol/downloads/Novella_english_081213.pdf

Alzheimer’s Disease, Caring for a Person with Alzheimer's Disease: Your Easy-to-Use Guide, U.S. Department of Health & Human Services, National Institute on Aging, https://order.nia.nih.gov/sites/default/files/2019-03/Caring_for_a_person_with_AD_508_0.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!

Episode 49: Dementia in Primary Care. 

Dr Ryan Townley explains what to do when a patient reports “memory problems”, including labs, imaging, and more. Question of the month: Fever and Cough.

Introduction: Dementia
By Hector Arreaza, MD

Today is April 26, 2021.

Dementia is an umbrella term that includes many conditions that have in common a cognitive decline affecting ADLs. It is an acquired condition that presents after the brain is fully developed. As our population ages, the topic of dementia has become more pertinent. 

Recently we had an introduction about the link between poor sleep and dementia, episode 42. The next two episodes will be about dementia.

Today we would like to discuss further this relevant topic. We talked with Dr Ryan Townley, who is an assistant professor in the Department of Neurology at the University of Kansas Medical Center, and the director of the Cognitive and Behavioral Neurology Fellowship. 

We will discuss dementia screening, how to evaluate our patients who report “memory problems”, including additional testing and imaging, when to send to a neurologist or neuropsychologist, and some things we can do for prevention of dementia. This episode is not intended to be a comprehensive lecture about dementia, but it may motivate you to keep learning about this topic. I hope you enjoy it.

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. 

Question of the Month
Written by Hector Arreaza, MD, read by Terrance McGill, MD

This is a 69-yo male patient, with controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke tobacco, but smokes recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. 

What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?

Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?

Send us your answer before May 7, 2021, to [email protected] and the best answer will win a prize!

____________________________

Dementia in Primary Care. 
With Ryan Townley, MD, and Hector Arreaza, MD.

Ryan Townley, M.D., is an assistant professor in the Department of Neurology at the University of Kansas Medical Center and is the director of the Cognitive and Behavioral Neurology Fellowship. He is also the Alzheimer's Clinical Trials Consortium Associate Director and Primary Investigator at the University of Kansas Alzheimer's Disease Center. Dr. Townley is certified by the American Board of Psychiatry and Neurology. He joined the KU Medical Center faculty in August 2019. 

Prior to medical school, he earned a bachelor of science in neurobiology from the University of Kansas. He graduated from the University of Kansas School of Medicine, where he earned the 2013 Dewey K. Ziegler Award for Excellence in Neurology presented by the KU Department of Neurology and was honored with the American Academy of Neurology's Outstanding Neurology Medical Student Award. He then completed his neurology residency, an internal medicine internship, and a two-year cognitive behavioral fellowship at the Mayo Clinic School of Graduate Medical Education. 

He is the author of many publications and has presented more than two dozen lectures and posters nationally and around the world. His clinical and research interests include atypical Alzheimer's diseases, normal pressure hydrocephalus, frontotemporal lobar degeneration and dementia with Lewy bodies. He also has interests in patient, resident and medical student education, and preventative health against neurodegenerative disease.

Questions discussed during this episode:

What to do when someone complains of "memory problems" in primary care?

When should a primary care doctor refer a patient to Neurology for evaluation of dementia?

Dementia vs Normal aging. 

What are the types of dementia?

When should a primary care doctor start medications for Alzheimer's disease? 

First-line pharmacologic treatment of Alzheimer's disease. 

Prevention of Alzheimer's disease: 

Resources mentioned in this episode:

AD8 Dementia Screening Interview: It is a tool given to an informant (ideally) or to the patient. It can be self-administered or administered by someone in clinic or by phone.

AD8 in English: https://www.alz.org/media/Documents/ad8-dementia-screening.pdf

AD8 in Spanish: https://championsforhealth.org/wp-content/uploads/2017/01/AD8-Screening-Spanish.pdf

Mini-Cog: It is a 3-minute instrument that can increase detection of cognitive impairment in older adults. It can be used effectively after brief training in both healthcare and community settings. It consists of two components, a 3-item recall test for memory and a simply scored clock drawing test. It does not substitute for a complete diagnostic workup.

Mini-Cog in English: http://mini-cog.com/wp-content/uploads/2018/03/Standardized-English-Mini-Cog-1-19-16-EN_v1-low-1.pdf

Mini-Cog in Spanish: http://mini-cog.com/wp-content/uploads/2018/03/SPANISH-Mini-Cog.pdf

Montreal Cognitive Assessment (MoCA): Dementia screening tool, no longer free, it requires training and certification. Available in several languages: https://www.mocatest.org/

Saint Louis University Mental Status Examination (SLUMS): Screening tool for dementia, training advised and available for free, available in Epic.

Training video: https://www.youtube.com/watch?v=z4ctoWU-qzw

SLUMS in English: https://health.mo.gov/seniors/hcbs/hcbsmanual/pdf/4.00appendix8slumsform.pdf

SLUMS in Spanish: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/spanish-pr.pdf

Short Test of Mental Status, The University of Oklahoma Health Science Center, https://www.ouhsc.edu/age/Brief_Cog_Screen/documents/STMS.pdf

Dementia prevention, intervention, and care: 2020 report of the Lancet Commission, The Lancet, Vol 396, Issue 10248, P413-446, AUGUST 08, 2020. https://www.thelancet.com/article/S0140-6736(20)30367-6/fulltext

Dementia Update Course: July 23, 2021, and September 3, 2021. Register at: https://www.eeds.com/portal_live_events.aspx?ConferenceID=634196

____________________________

Conclusion.

Now we conclude our episode number 49 “Dementia in Primary Care”, Dr Ryan Townley explained different tools we have to assess patients with “memory problems” and explained some interesting concepts in the assessment of cognitive impairment. Talking about dementia, don’t forget to answer our question of the month. Send us your top 3 differential diagnosis and acute management of a 69-year-old male with fever, cough, tachycardia, and right lower lobe consolidation. Send your answer before May 7, 2021, and win a prize! 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, Ryan Townley, Ariana Lundquist, and Terrance McGill. Audio edition: Suraj Amrutia. See you next week! 

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 48: Acute Low Back Pain. 

Stephanie and Veronica explain common causes of acute low back pain, including lumbar strain, disc herniation, and spondylosis; spontaneous human combustion; question of the month about pneumonia. 

Introduction: Spontaneous Human Combustion
By Hector Arreaza, MD

Today is April 19, 2021.  

I’ve been trying to keep this podcast very academic and clinically relevant, with a touch of humor but very professional. I hope after this intro, you do not stop listening to us. 

Recently I was playing a trivia game at a friend’s house. The question was: How many spontaneous human combustion cases have been published in medical journals between 1600 and 1900? What would be your answer? I did not know the answer, but it woke up my curiosity.

I did what’s expected of a normal PCP, exactly, I looked it up in Up-to-Date. The only reference to “spontaneous combustion”, I found was on the article about long-term supplemental oxygen therapy (LTOT). “Facial and upper airway burns are an infrequent complication of LTOT, but can be severe and potentially life-threatening. The main cause of burns is exposure to open flames while wearing supplemental oxygen. However, spontaneous combustion may occur with exposure to a spark source rather than an open flame. Certain factors may contribute to the risk of combustion in the absence of open flames, such as facial hair and use of hair products containing oils or alcohol.” This “spontaneous combustion” does not match the definition given the non-medical community.

Spontaneous human combustion, also known as preternatural combustion, refers to a rare episode where the complete body, or significant parts of it, are reduced to ashes with no apparent source of ignition. Other items around the body of the victim are intact, making people believe that the fire originated from inside the body. This phenomenon has been described in fictional movies, documentaries, books, novels, and even medical journals. 

In 1984, Nickell and Fischer[3] investigated cases from the last 3 centuries. They concluded that in those cases of presumed “spontaneous human combustion” possible sources of ignition were ignored on the reports. A common characteristic among victims of spontaneous combustion was intoxication with alcohol or other substances.

More recently, the American Burn Association looked into this topic and published in 2012[2] an article titled “Spontaneous Human Combustion in the Light of the 21st Century”. They state that a literature search retrieved 12 case reports between 2000 and 2012. They concluded that the so-call “spontaneous human combustion” is a reality, however, it is not exactly how people think it is. People are not just sitting around and get consumed alive in flames. The term “fat wick burns” was suggested to provide a more exact definition. The article explains that the burn victim must die for the body fat to start melting, then a break in the skin allows melted fat to impregnate clothes and produce a wick effect that allows fire to be on for a long time causing a complete carbonization of tissues. 

In case you are curious, the number of spontaneous human combustion cases published in medical journals between 1600 and 1900 is ninety-six (96). Citation needed.

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. 

__________________________

Question of the Month: Cough and Fever
Written by Hector Arreaza, MD, read by Jacqueline Uy, MD

This is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. 

What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?

Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?

Send us your answer before May 7, 2021, to [email protected] and the best answer will win a prize!

____________________________

Acute Low Back Pain. 

By Stephanie Rubio, MS3, and Veronica Phung, MS3.

Acute low back pain definition and statistics. 

Eighty percent (80%) of Americans will experience back pain at some point in their lifetime.  Low back pain is the 5th most common reason for all doctor visits in the US. Most cases of low back pain are acute and 90% resolve within 1 month. Recurrence rate for back pain is high at 35% to 75%. 

Acute back pain is defined as pain in the lumbar area for less than 3 months. The sources of low back pain are extensive. We would like to discuss some of the more common causes and important considerations when a patient presents with acute low back pain. 

With such an extensive differential for acute low back pain, we want to briefly discuss three common causes: lumbar strain, disc herniation, and degenerative arthritis of the spine; AND three causes that require special attention: cauda equina, malignancy, and prostatitis.  

Lumbar strain

Lumbar strain is the most common cause of acute low back pain in adults. Presentation can be acute or sub-acute after an injury or strenuous activity such as moving heavy furniture. Paraspinal muscles are typically the source of pain and can be unilateral or bilateral with or without radiation down the leg. Pain increases after immobility and specific movements depending on strain location. Patient will have a negative straight leg test. 

Treatment: Patient education is key for treatment. It includes explaining that acute back pain is often benign in nature and reassurance. Advise your patients to stay active; to avoid twisting and bending, particularly when lifting; and to return to normal activities as soon as possible. 

NSAIDs or muscle relaxants will help the pain process. Muscle relaxants combined with NSAIDs may have additive benefit for reducing pain. “Moderate evidence suggests that no one NSAID is superior, and switching to a different NSAID may be considered if the first is ineffective.” In clinic: Ibuprofen and Naproxen are our “go-to” medications. Acetaminophen is also an option. 

“Moderate-quality evidence supports that non-benzodiazepine muscle relaxants (such as cyclobenzaprine, tizanidine, and metaxalone) are beneficial in the treatment of acute low back pain in the first seven to 14 days with effects for up to 28 days. However, muscle relaxants do not affect disability status. Make sure you warn your patient about drowsiness, dizziness, and nausea. Diazepam and Soma (carisoprodol) have the potential for abuse, so use them cautiously and for a short period only. 

We also have to mention the controversial opioids. Due to the opioid epidemic, prescribe opioids only for patients with severe acute low back pain for a short period; however, there is little evidence of benefit when compared to NSAIDs. 

Epidural steroid injections are not so beneficial for isolated acute low back pain, they may be helpful for radicular pain that does not respond to two to six weeks of noninvasive treatment. Transforaminal injections appear to have more favorable short- and long-term benefit than traditional interlaminar injections. Ok, we are done with lumbar strain.

Disc herniation
Disc herniation may also be acute or subacute with a variety of pathologies involving the displacement of disc material into the spinal cord or nerve roots. 

Presentation: Sudden injury could precipitate pain such as a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg and it is made worse when hips are flexed such as sitting. 

Radicular pain in the dermatome of the compressed nerve root is common. Herniation at L5-S1 is the most common location, and it would present as a loss of sensation on the dorsolateral thigh, lower leg, and dorsal foot. 

Patients can also have motor deficits on the lateral side of the foot which can cause a problem in tilting the sole of the foot away from the midline or difficulty toe walking. Use neurologic deficits to determine the location of herniation.

Radicular pain and radiculopathy are not the same. Radicular pain is a single symptom (pain) that follows the distribution of a nerve root. Radiculopathy is a group of symptoms including, paresthesia, hypoesthesia, motor dysfunction and pain. Symptoms may be the result of compression of more than one nerve root.

(Source: Physio-pedia.com, https://www.physio-pedia.com/Lumbar_Radiculopathy)  

Treatment: Please tell patients to keep moving as much as possible. Bed rest is not helpful and may prolong the pain process. NSAIDs should be used to decrease inflammation. Neurosurgery consultation may be needed for large herniation, especially if there is spinal canal compression, causing severe or progressive motor deficit. 

Use of steroids may be beneficial, but the available evidence suggests limited or no benefit. I’ve seen prednisone prescribed by neurosurgeons frequently when surgery is being delayed. If used, prednisone (60 to 80 mg daily) for five to seven days for patients who do not respond well to analgesics and activity modification. This is followed by a rapid taper to discontinuation over the following 7 to 14 days.

Degenerative arthritis
Spondylosis is more common in patients with advanced age. Osteophyte impingement of a nerve root can cause radicular symptoms following the nerve’s dermatome distribution as well. 

Presentation: Onset tends to be more insidious and posture dependent. For example, extension of the lumbar spine, like standing or walking upright causes pain. Symptoms are related to posture, patient may mention leaning on the shopping cart alleviates the pain.

Neurogenic claudication is typical of spinal stenosis: pain, numbness, tingling, cramping, weakness of the lower back and extremities; which are exacerbated by walking or exertion, worse walking downhill, not worsened by biking. Neurogenic claudication is not to be confused with vascular intermittent claudication, which is pain, cramping, and tightness on the lower extremities relieved by rest, NOT relieved by walking flexed with a shopping cart. 

Treatment: Conservative physical therapy is an appropriate treatment. Cycling exercises can be recommended to keep your patients moving because hip flexed activities do not induce pain. 

Consider a pain management clinic referral for treatment of foraminal stenosis with steroid injections. From personal experience, I can tell you, those shots really work! However, the response is not 100% effective in all patients. You do not send patients to pain management just because they are requesting chronic opioids. You send them for real treatment of pain with procedures. 

Cauda equina syndrome: This condition should always be considered due to the seriousness of the consequences. Symptoms may present as saddle anesthesia, loss of anal sphincter tone, and major motor weakness. Decompression should be performed within 72 hours to avoid permanent damage. Clinical suspicion is low if patient denies problems with bowel or bladder control. The most common symptom is actually neurogenic bladder, evidenced by acute urinary retention or incontinence.  

Malignancy: Cancer is a serious cause of back pain. Your patient may complain of a dull, throbbing pain that progresses slowly and increases with recumbency or cough. Non-radiating pain is worse at night. More common in patients over 50 and history of cancer in the past.

Genital organs: 

Prostatitis can cause referred low back pain. Expect to find evidence of infection in the history. So, a prostate exam and a genital exam may be needed in older males with acute or chronic low back pain. 

Females may also have referred low back pain in the setting of pelvic inflammatory disease and endometriosis. So, a pelvic exam may be needed, based on your clinical judgment.   

Overview of Acute Low Back Pain:  

Patients with acute LBP without any red flags such as: infections, fever, or weight loss should start conservative therapy for up to 6 weeks with NSAIDS and/or muscle relaxants. Localized cold therapy for direct injury first to constrict blood vessels, reduce swelling, decrease inflammation and potentiate a numbing effect. Then heat therapy can be used after inflammation has subsided. 

Reevaluate in 1-3 weeks, if significant pain or neurologic complications persist or if there is no improvement in pain. If there is spinal pathology detected, then surgical evaluation is needed. 

Advise patients to stay active. Physical therapy may prevent recurrence. Studies showed that early physical therapy, after primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. However, it is still unclear which patients with LBP should get referred to physical therapy.

Depending on severity of pain and presentation of the patient, diagnostic studies such as MRI and labs can be ordered if findings are suggestive of serious pathology, such as bilateral radicular signs, urinary retention, saddle anesthesia or suspicion of a high-risk mechanism (cancer, hematoma, abscess), presence of fever, night sweats, nocturnal pain, older patients, and more.

For prevention, remember proper lifting techniques should be used when moving heavy objects. Bend at the knees with a straight back and use the leg muscles to lift instead of bending at the waist to prevent injury. 

Maintaining a healthy weight is important for back health.

Back-strengthening and stretching exercises at least 2 days a week help prevent back pain. exercise by using the proper equipment and techniques. Remember motion is lotion. Encourage patients to keep moving even as patients progress in age. Because you know you’re getting old when your back goes out more than you do.

____________________________

Conclusion: Now we conclude our episode number 48 “Acute Low Back Pain”. Veronica and Stephanie did a great job explaining three common causes: Lumbar strain, disc herniation, and spondylosis. Be aware of signs of cauda equine syndrome, malignancy and prostate in men and pelvic organs in women. Initial imaging and labs are not needed in most patients, but make sure to order an MRI and labs depending on the presence of red flags. 

Don’t forget to send us your answer to the question of the month: What are your top 3 differential diagnoses and explain the acute management of a 69-year-old male with fever, cough, tachycardia, right lower lobe consolidation, and negative COVID-19 test.

Remember, 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, Stephanie Garcia, Veronica Phung, and Jacqueline Uy. Audio edition: Suraj Amrutia. See you next week! 

References:

Tiep, Brian L, MD; Rick Carter, PhD, MBA; Long-term supplemental oxygen therapy, Up-to-Date, Last updated: May 08, 2019. https://www.uptodate.com/contents/long-term-supplemental-oxygen-therapy. Accessed on March 25, 2021. 

Virve Koljonen, MD, PhD, Nicolas Kluger, MD, Spontaneous Human Combustion in the Light of the 21st Century, Journal of Burn Care & Research, Volume 33, Issue 3, May-June 2012, Pages e102–e108, https://doi.org/10.1097/BCR.0b013e318239c5d7

Nickell, Joe; Fischer, John F. (March 1984). "Spontaneous Human Combustion". The Fire and Arson Investigator. 34 (3).

Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012 Feb 15;85(4):343-50. PMID: 22335313. https://www.aafp.org/afp/2012/0215/p343.html.

Lumbar Radiculopathy, Physiopedia, https://www.physio-pedia.com/Lumbar_Radiculopathy, accessed on April 9, 2021. 

Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine (Phila Pa 1976). 2012 Dec 1;37(25):2114-21. doi: 10.1097/BRS.0b013e31825d32f5. PMID: 22614792. https://pubmed.ncbi.nlm.nih.gov/22614792/  

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 47: Hearing Carotid Lung.  

Dr Civelli explains the updates on screening for lung cancer, hearing loss and carotid artery stenosis; Kafiya explains the use of bupropion and naltrexone in methamphetamine abuse, question of the month pneumonia.

Introduction: Methamphetamine use
By Kafiya Arte, MS4, and Ariana Lundquist, MD.

Today is April 12, 2021.

Bakersfield, California, has a methamphetamine (meth) epidemic currently ravaging this area. We as health care workers believe we can spot somebody addicted to meth from a mile away by their characteristic “older-than-stated-age” appearance and obvious “meth mouth”. However, the actual scope of the epidemic is much larger. It’s not just people who are experiencing homelessness that are addicted to, and dying from, meth.  I saw while volunteering at a needle exchange at Weill Park, people getting out of nice-looking cars wearing clean, pressed clothes with sharps containers full of used needles ready to exchange. One man even had a teacup poodle in tow. It’s clear that meth can affect anybody.  

Between May 10 and June 10, 2014, 31.8% of randomly selected patients in the ED of Kern Medical admitted to having used methamphetamine at least once in their life. It’s not just the individual who addicted to meth who is affected. 36.1% of children removed from their home by child protective services in Kern County during the month of May 2014 were cases that involved methamphetamine[1]. 

Meth accounted for nearly 75% of all drugs seized by the Bakersfield Police Department[2]. Statewide, meth kills more Californians than any single opioid alone[3]. Amphetamine overdose deaths have increased 212% from 777 in 2012 to 2,427 in 2018 in California. In 2020, Kern County had more than double the rate of deaths related to overdose of psychostimulants, of which meth was the dominant drug, compared to the state of California (20.48/100k residents versus 8.21/100k residents, respectively)[3]. This devastating problem, unfortunately, does not have a currently FDA-approved drug to treat it. 

A promising study called Accelerated Development of Additive Treatment for Methamphetamine Disorder (ADAPT-2), assessed the efficacy of combined bupropion and naltrexone for the treatment of meth use disorder. Bupropion decreases the dysphoria of meth withdrawal that drives continued use; while naltrexone decreases cravings, therefore preventing relapse, as it does with alcohol use disorder.  

A total of 403 participants with nearly daily meth use were included in the two-stage randomized, double blind trial conducted at 8 different sites from May 23, 2017 to July 25, 2019. The efficacy of extended-release injectable naltrexone (380 mg every 3 weeks) combined with once-daily oral extended-release bupropion (450 mg) was evaluated, as compared to placebo.  

The results of the study showed a 13.6% response rate in the naltrexone-bupropion group and only 2.5% response with placebo. A response was defined as at least three meth negative urine samples out of four samples obtained at the end of each of the two stages.  

The trial concluded that although the response rate among participants that received naltrexone and bupropion was low, it was higher than that among participants who received placebo. Although the ADAPT-2 trial did not provide any recommendations that can be adapted to clinical practice, it serves as a starting point for further research of the additive or synergistic effects of bupropion and naltrexone in the treatment of meth use disorder.  

Hopefully, it will also serve as a catalyst for more pioneering research regarding the legitimization of meth use disorder as a treatable disease with major medical, psychiatric, socioeconomic and legal consequences. Clinicians should stay up to date with research regarding meth use disorder such as ADAPT-2, as it is our duty to understand the health crises that affect our patients on a daily basis, and the tools we can use to treat them.

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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Question of the Month
Written by Hector Arreaza, MD, read by Jennifer Thoene, MD

This is a 69-yo male patient, who has history of controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke, but uses recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. 

What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?

Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?

Send us your answer before May 7, 2021, to [email protected] and the best answer will win a prize!

Hearing Carotid Lung

By Valerie Civelli, MD, and Ariana Lundquist, MD

Screening for hearing loss in older adults

Hearing loss definition: To answer this, let’s first talk Hertz and Decibels. Many studies and guidelines define mild hearing loss as the inability to hear frequencies associated with speech processing under 25 dB and moderate hearing loss as the inability to hear those frequencies under 40 dB[5].  The most important range for speech processing is typically 500 to 4000 Hz. To check hearing, we often use pure-tone audiometry, which is the most standard quantitative measurement; however, this is not a perfect test. There is often discordance between objectively measured deficits and subjective perceptions of hearing problems. In one study, 1 in 5 persons who reported hearing loss had a normal hearing test result, while 6% of those with severe hearing loss detected on audiometry did not report feeling that they had hearing loss.[6]  

I wonder if their significant other would agree with the 6% who self-reported no hearing loss but failed the hearing test?  That would be a great study! 

Risk factors for hearing loss: The #1 risk factor for hearing loss is increasing age. Hearing loss increases with age after 50 attributable to normal degeneration of hair cells in the ear.  This leads to the most common cause of hearing loss in older adults: Presbycusis.  Presbycusis is your diagnosis for patients with gradual, worsening of perceived high-frequency tones. 

Insufficient evidence for screening: If the patient reports hearing loss, you should order a hearing test. However, on March 23, 2021, for asymptomatic adults 50 years or older, the US Preventive Services Task Force (USPSTF) published a statement that re-confirmed the 2012 recommendations. That is, current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults without symptoms. This statement aligns with the AAFP and is referenced in their practice guidelines. 

This recommendation applies to asymptomatic older adults (age >50 years) who have not noticed any issues with their hearing. It excludes adults with conductive hearing loss, congenital hearing loss, sudden hearing loss, or hearing loss caused by recent noise exposure, or those reporting signs and symptoms of hearing loss.

Screening for Carotid Artery Stenosis

Do not screen: For the general adult population without symptoms of carotid artery stenosis, do not screen. This is a Grade D recommendation for all adults without a history of stroke or neurologic signs or symptoms of a transient ischemic attack. 

This is a re-endorsement statement made in Feb of this year, 2021, recommitting to 2014 statements.  The evidence continues to show that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. 

The USPSTF has made other recommendations related to stroke prevention and cardiovascular health. These include: 

Screening for high blood pressure in adults

Screening for abdominal aortic aneurysm

Interventions for tobacco smoking cessation in adults, including pregnant persons

Interventions to promote a healthy diet and physical activity for the prevention of cardiovascular disease:

In adults with cardiovascular risk factors

In adults without known cardiovascular risk factors

Aspirin use to prevent cardiovascular disease and colorectal cancer

Statin use for the primary prevention of cardiovascular disease in adults

Lung Cancer Screening

Grade B recommendation: On March 9, 2021, there are updated Grade B recommendations by the USPSTF.  For patients 50-80 years old, with a 20 pack-year history of smoking and still smoke or quit within 15 years, annual screening with low dose CT is now recommended.

Stop screening when a person has not smoked for 15 year, or has a condition that substantially limits life expectancy or limits their ability to undergo curative lung surgery

The USPSTF modified guidelines so we are screening earlier and with lower pack years.  It used to be recommended to do low dose Chest CT at age 55-80, but it’s now at 50-80.  Also, pack-years was 30 but it’s now at 20 pack-years that we should screen for lung cancer.  So, screen sooner at 50, and at lower threshold of 20. Screen for lung cancer in male and female patients.

Conclusion: Now we conclude our episode number 47 “Hearing Carotid Lung”. Dr Civelli gave us an update on USPSTF screening in asymptomatic adults. For hearing loss, there is insufficient evidence to give a recommendation. For carotid artery stenosis, there is a grade D, meaning do not screen. And for lung cancer screening, it is a grade B recommendations, meaning screen your patients. Don’t forget to order a low dose CT of chest in patients of ANY sex, OLDER than 50 years, WITH a 20 pack/year smoking history, and currently smoking or quit less than 15 years ago. That’s a mouthful, but once you start following the guideline, it gets easier to recall.

Remember, 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, Jennifer Thoene, Valerie Civelli, Kafiya Arte, Arianna Lundquist, Jacqueline Uy, and voluntarily unidentified medical assistants. Audio edition: Suraj Amrutia. See you next week! 

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References:

The Impact of Methamphetamine in Kern County: 2014, Update September 2014, Kern County Mental Health Department, https://transforminglocalcommunities.com/wp-content/uploads/2018/05/tlc-the-impact-of-meth-in-kern-county-2014-update.pdf

Klein, Kerry, To Bakersfield Cops, Concern For Opioids Grows - But Meth Is Still King. Valley Public Radio News, NPR for Central California. May 1, 2019, https://www.kvpr.org/post/bakersfield-cops-concern-opioids-grows-meth-still-king#stream/0

California Opioid Overdose Surveillance Dashboard, California Department of Public Heallh, https://skylab.cdph.ca.gov/ODdash/, accessed on March 27, 2021.

Klein, Kerry, Meth Is Making A Comeback In California – And It’s Hitting The San Joaquin Valley Hard. Valley Public Radio News, NPR for Central California. June 28, 2019, https://www.kvpr.org/post/meth-making-comeback-california-and-it-s-hitting-san-joaquin-valley-hard#stream/0

Feltner C, Wallace IF, Kistler CE, et al. Screening for Hearing Loss in Older Adults: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Mar. (Evidence Synthesis, No. 200.) Chapter 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK569275/  

US Preventive Services Task Force. Screening for Hearing Loss in Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(12):1196–1201. doi:10.1001/jama.2021.2566. https://jamanetwork.com/journals/jama/fullarticle/2777723.   

Screening for Hearing Loss in Older Adults, March 23, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hearing-loss-in-older-adults-screening#fullrecommendationstart

Screening for Asymptomatic Carotid Artery Stenosis, February 02, 2021, US Preventive Services Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening.

Lung Cancer: Screening, March 09, 2021, US Preventive Services Task Force, https://uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening. 

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!

Hepatic encephalopathy basics, disseminated gonococcal infections, polyarthralgia question winner, jokes.

Today is March 29, 2021.

On December 23, 2020, the California Department of Public Health (CDPH) sent a “Dear Colleague” letter because of the increasing reports of disseminated gonococcal infections (DGI). Today, we want to share with you parts of that letter. 

CDPH is working with local health departments to investigate these cases of DGI, where some patients have experienced homelessness or using illicit drugs, particularly methamphetamine. The CDC noted a similar increase in cases in Michigan in late 2019.

What is DGI? DGI is an uncommon but severe complication of untreated gonorrhea. DGI occurs when the sexually transmitted pathogen Neisseria gonorrhoeae invades the bloodstream and spreads to distant sites in the body, leading to clinical manifestations such as septic arthritis, polyarthralgia, tenosynovitis, petechial/pustular skin lesions, bacteremia, or, on rare occasions, endocarditis or meningitis. Patients have initially presented with joint pain attributed to another cause, which was only later determined to be due to DGI. 

Why is DGI increasing? Increased cases may be caused by decreased STD testing and treatment because of the COVID-19 pandemic, and not necessarily because of a more virulent strain of gonorrhea. 

What do we need to do as medical providers?

Screen: Reinstate routine screening recommendations for STDs in females <25 years of age (or older females with risk factors for STDs), pregnant females, men who have sex with men (MSM) and individuals with HIV, and other risk groups.

Suspect: For patients reporting joint pain, obtain a social history that includes a sexual and drug use history, and housing status. Suspect DGI in patients with joint pain and treat them according to the CDC STD Treatment Guidelines. Remember that most cases of uncomplicated gonococcal infections are now treated with a single dose of Ceftriaxone 500 mg IM PLUS doxycycline for 7 days. DGI, however, needs IV meds and longer duration of treatment.

Test: Order Nucleic acid amplification test (NAAT) and culture specimens from urogenital, extragenital mucosal sites (e.g., pharyngeal and rectal), and from disseminated sites (e.g., skin, synovial fluid, blood, and cerebrospinal fluid) before initiating empiric antimicrobial treatment for patients with suspected DGI. Hospitalization and consultation with ID is recommended for initial therapy. Test all isolates from DGI cases for antibiotic susceptibility, and send all isolates from DGI cases to the local public health laboratory.  

Report: all suspected and confirmed cases of DGI to public health within 24 hours of identification. Instruct patients to refer their sex partners for evaluation, testing, and presumptive treatment for gonorrhea.

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. 

Hepatic Encephalopathy
Guest: Stephanie Rubio, MS3

What is it?

Hepatic encephalopathy is a reversible decline in brain function in patients with advanced liver failure and/or portosystemic shunting and may present with ascites. The liver cannot effectively remove ammonia and other toxins from the blood causing a buildup in the bloodstream. Bacteria in the gut can also increase these toxins leading to a rapid progression of signs and symptoms of hepatic encephalopathy. 

How is the presentation?

A wide spectrum of neurological and/or psychiatric abnormalities may be seen, including but not limited to sleep disturbance, mood changes, and euphoria. Motor symptoms include asterixis, dyspraxia, and bizarre behavior.

A Subtle form of hepatic encephalopathy known as minimal hepatic encephalopathy presents in 80% of patients with cirrhosis. Neurocognitive signs require higher clinical suspicion because the deficits tend to be mild in presentation. 

Symptoms to look for while evaluating a patient with cirrhosis: 

Working memory discrepancies (for example, trying to remember a phone number and write it down, and being unable to recall the number within seconds)

Learning impairment (for example, inability to learn new concepts or skills, new recipe)

Inhibition control (for example, being unable to avoid eating cake when you are dieting) 

A brief mini mental status assessment will help guide toward a proper diagnosis. 

Severity of manifestations is graded due to the importance of differentiating between overt hepatic encephalopathy and covert minimal hepatic encephalopathy for clinical studies.

Minimal is graded as abnormal results on psychometric or neurophysiological testing without clinical manifestations vs. Grade I-IV beginning with changes in behavior, mild confusion, slurred speech, or disordered sleep; progressing to coma and unresponsiveness to pain.   

Who is at risk?

Some of the most common causes of liver failure or cirrhosis are patients with severe alcohol abuse, nonalcoholic steatohepatitis (NASH), or hepatitis. It affects 30-45% of patients with liver failure and 10-50% of patients with Transjugular Intrahepatic Portal-systemic Shunts (TIPS).  

Sarcopenia after TIPS has been identified as a risk for hepatic encephalopathy as well. Having muscle mass provides a protective effect against encephalopathy.

Inpatient management?

The management of hepatic encephalopathy would require a whole episode by itself. Management is focused on managing symptoms and identifying and treating the cause of the encephalopathy. Mild cases can be managed as outpatient, but admission is needed for severe cases, typically ICU admission.

To control symptoms, lactulose is the typical treatment used in the hospital, it is used to remove toxins by increasing the amount and number of stools. Initial dose: 30-45mL orally every hour until first stool, then reduce the dose to 30-45mL 3 to 4 times daily for a total of three soft stools a day. Lactulose can also be used rectally in patients who cannot use the PO route.

Other medications are used to reduce ammonia-producing bacteria in the intestines, such as Rifaximin (an antibiotic). Electrolyte imbalances may also occur in these patients and must be replenished as needed, frequently hypokalemia.

Identification and treatment of trigger requires a full investigation. Labs: CBC, CMP, ABG, PT/INR/PTT, hepatitis panel, Utox, blood culture and imaging as indicated by your clinical judgement.

How much benzo is safe?

Hepatic encephalopathy may lead to agitation in patients that frequently resolves with appropriate treatment. Though, the patient might be a hazard to self or others during periods of agitation. Restrains may be used initially. If pharmacological treatment is required, benzodiazepines should be avoided for two reasons. One, benzos may precipitate hepatic encephalopathy. Two, benzo’s may cause over sedation. 

However, signs and symptoms of agitation may be overlapping with alcohol withdrawal in patients who stopped drinking within 4 days of presentation of symptoms. In cases of severe agitation caused by alcohol withdrawal, 2mg lorazepam (Ativan) IV Q15 minutes until reaching the desired sedation level can be used. CIWA (Clinical Institute Withdrawal Assessment for Alcohol) <8 or RASS 0 to -1 (Richmond Agitation-Sedation Scale). Lorazepam use in the wards is generally safe. 

How much lorazepam is safe? It depends on your clinical judgement, but some patients may require up to 2,000 mg of lorazepam to control their initial agitation. For example, if you have a patient who is requiring more than 4 doses of 2-4 mg of lorazepam in a row.

To reiterate we must keep in mind, advanced cirrhotic patients may have amplified sensitivity to benzodiazepines due to increased receptor ligands in the brain which may lead to over sedation. Instead, haloperidol is the better option to avoid an adverse effect and aid in sedation to calm the patient. Haloperidol is used if your suspicion for alcohol withdrawals is low.

Prevention of hepatic encephalopathy.

Prevention of hepatic encephalopathy include avoiding precipitating factors such as:

Gastrointestinal bleeding, hypokalemia, metabolic acidosis, renal failure, hypoxia, hypoglycemia or constipation. Hepatic encephalopathy can reoccur after treatment; which is why prevention should be a patient/provider oriented goal to inhibit repetitive episodes.

Typically, after an occurrence, patients are discharged home with lactulose (initial dose: 30-45mL orally 3 to 4 times daily to have 2-3 bowel movements a day) to continue the removal of ammonia and further prevent complications. 

Probiotics may also aid to prevent reoccurrence, but more research is needed before probiotics can be recommended for all patients to treat and/or prevent hepatic encephalopathy.

Restricting dietary protein is not recommended for the majority of patients.

All of this discussion has led us to the question of: What if Homer Simpson is not stupid but just has chronic jaundice and hepatic encephalopathy? (Joke).

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Question of the Month: Polyarthralgia
Written by Claudia Carranza, MD
Answered by Stephanie Rubio, MS3

As a reminder, the question is about a 49-year-old female who comes to clinic with bilateral wrist and ankle pain for 1 month. She was diagnosed with COVID-19 six weeks ago, did not require hospitalization, but she complains of persistent fatigue. 

Question: What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? 

The patient’s polyarthralgia is the result of COVID-19. There are limited studies indicating coronavirus as a direct cause of polyarthralgia and fatigue, but in October 2020, The Lancet Rheumatology published an association between COVID-19 and ankle viral arthritis 25 days after her infection[5]. 

The association between COVID-19 and persistent symptoms has been well documented. Some persistent symptoms include fatigue, dyspnea, chest pain, cough, anxiety, depression, post-traumatic stress disorder, and poor memory and concentration. Joint pain is a less common symptom. Persistent symptoms are more common in patients with severe disease or 

those who were hospitalized. This syndrome may be unique to COVID-19 but other viral illnesses have similar presentation. 

Acute COVID-19 refers to symptoms for up to 4 weeks after onset of illness.

Ongoing symptomatic COVID-19 occurs 4-12 weeks after onset of illness.

Post-COVID-19 refers to persistent symptoms for more than 12 weeks, not explained by an alternative diagnosis.

In our patient, it’s reasonable to obtain CBC with diff and CMP. 

Autoantibodies tests such as ANA with reflex to titer and cascade may be ordered if your clinical suspicion is high for an autoimmune disease, such as SLE or RA, but are generally not needed. 

Imaging studies are not needed in our patient.

[Jokes provided by voluntarily-unidentified medical assistants]

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Now we conclude our episode number 46 “Hepatic Encephalopathy”, we thank our 3rd-year medical student Stephanie Rubio for preparing that discussion for us. We also congratulate her for winning our question of the month about polyarthralgia. We hope you enjoy your prize. During this episode, we were reminded that mild hepatic encephalopathy can be treated successfully as outpatient, but moderate to severe symptoms require hospital admission. Remember that lactulose and rifaximin can be used not only to treat hepatic encephalopathy but also to prevent it. Keep in mind our introduction today, keep your eyes open to detect new cases of disseminated gonococcal infections (DGI) and treat suspected cases accordingly. Remember, 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, Jacqueline Uy, Claudia Carranza, Stephanie Rubio, Siamak Amrollahie, and Vikram Sharma. Audio edition by Suraj Amrutia. See you next week! 

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References:

Health and Human Services Agency California Department of Public Health, STD Control Branch,  https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Dear-Colleague-Letter-for-Medical-Providers-Increasing-DGI-in-CA-12.23.20.pdf

Parisi, Simone; Richard Borrelli; Sabina Bianchi; Enrico Fusaro; Viral arthritis and COVID-19, The Lancet Rheumatology, October 05, 2020. DOI: https://doi.org/10.1016/S2665-9913(20)30348-9. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30348-9/fulltext

Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, Weissenborn K, Wong P. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014 Aug;60(2):715-35. doi: https://doi.org/10.1002/hep.27210. Epub 2014 Jul 8. PMID: 25042402.

Bajaj JS. Review article: the modern management of hepatic encephalopathy. Aliment Pharmacol Ther. 2010 Mar;31(5):537-47. doi: 10.1111/j.1365-2036.2009.04211.x. Epub 2009 Dec 7. PMID: 20002027.

Ferenci, P., MD. (2020, June 9). Uptodate. Retrieved March 16, 2021, from https://www.uptodate.com/contents/hepatic-encephalopathy-in-adults-treatment

Ferenci, P., MD. (2020, September 22). Uptodate. Retrieved March 16, 2021, from https://www.uptodate.com/contents/hepatic-encephalopathy-in-adults-clinical-manifestations-

Prabhakar, S., & Bhatia, R. (2003, December 22). Management of agitation and convulsions in hepatic encephalopathy. Retrieved March 16, 2021, from https://pubmed.ncbi.nlm.nih.gov/15025257/

Ciećko-Michalska, I., Szczepanek, M., Słowik, A., & Mach, T. (2012, December 17). Pathogenesis of hepatic encephalopathy. Retrieved March 16, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534214/

Nardelli S, Lattanzi B, Torrisi S, Greco F, Farcomeni A, Gioia S, Merli M, Riggio O. Sarcopenia Is Risk Factor for Development of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt Placement. Clin Gastroenterol Hepatol. 2017 Jun;15(6):934-936. doi: https://doi.org/10.1016/j.cgh.2016.10.028. Epub 2016 Nov 2. PMID: 27816756.

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 45: Osteoporosis Update. 

Dr Linares (endocrinologist) explains the basics of screening and treatment of osteoporosis, referring frequently to the updated guidelines of osteoporosis by AACE and ACE (2020). A new group of residents is introduced. 

Congratulations to our new group of residents:  Amelia Martinez Lopez, Amardeep Singh Chetha, Cecilia Selena Covenas, Funmilayo Helen Idemudia, Licet Imbert Matos, Su Myat Hlaing, Timiiye Dawn Yomi, and Young Na Sung. This group of residents will start in July 2021 and will graduate in July 2024. We hope you enjoy your time with us.

Today is March 22, 2021.

Implanted pacemakers and defibrillators are equipped with a switch that responds to magnetic forces to stop them when needed. Magnetic interference between these cardiac implantable electronic devices (CIEDs) and mobile devices have been investigated for years. It has been established that magnetic fields stronger than 10 gauss can deactivate these cardiac devices, causing pacemakers to give asynchronous pacing and ICDs to stop tachyarrhythmia detection.

The Heart Rhythm Society journal, published in October 2009 (that was 11 years ago), an association between portable headphones and significant electromagnetic interference (EMI) in patients with implantable cardioverter-defibrillators (ICD) and pacemakers (PM). 

100 patients with implanted devices were tested with different portable headphones. Headphones effectively deactivated implanted devices when held less than 2 cm from skin on the left side of chest. There was not interference when headphones were placed farther than 3 cm. In this study, normal functioning of the devices was restored in 29 out of 30 cases when the headphones were removed from the patient’s chest. The recommendation from that study was to recommend patients to keep their portable headphones at least 3 cm away from their implanted device.

More recently, in January 2021, the same journal posted the effect of iPhone 12 on ICDs deactivation. iPhone 12 and MagSafe technology, which allows faster wireless charging, contain strong magnets. iPhone 12 successfully deactivated a Medtronic Inc. ICD when tested by a group of investigators in a patient[2]. 

The official Apple Support website posted on February 25, 2021, “To avoid any potential interactions with these devices, keep your iPhone and MagSafe accessories a safe distance away from your device (more than 6 inches / 15 cm apart or more than 12 inches / 30 cm apart if wirelessly charging)”[3]. Other devices such as fitness tracker wristbands, and even e-cigarettes have been involved in deactivation of ICDs.

Bottom line: Make sure your patient discusses with you or their cardiologist before buying wearable or mobile technology that may interfere with their implanted cardiovascular devices.

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. 

“The secret of getting ahead is getting started” —Mark Twain.

Osteoporosis Update

During this conversation, we discussed some parts of the guidelines from the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE)[2], updated in 2020. This is not a complete analysis of those guidelines. For a comprehensive explanation of the guidelines, visit the AACE or ACE websites. The recommendations from these organizations may be different than the ones given by the American Academy of Family Physicians (AAFP) or the United States Preventive Services Taskforce (USPSTF), which are organizations we are more familiar with as family physicians.

The questions analyzed during this conversation includes:

When would you consider a DEXA scan to screen a woman younger than 65 for osteoporosis?

What to do when the report says Osteopenia (T score -1.0 to -2.5)? Let’s mention the recommended dose of Vitamin D and Calcium.

What is the FRAX score? 

What is an easy work up we can do to rule out a secondary cause of osteoporosis before sending patient to you?

The new guidelines divide patients in two categories: “High risk/no risk of fractures” and “VERY High risk/prior fractures”, What’s the difference in management between those two categories? (alendronate in high risk vs abaloparatide in very high risk).

How can you tell the patient has a good response after 1 year of treatment (Dexa scan, bone turnover markers)? What is a drug holiday?

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Now we conclude our episode number 45 “Osteoporosis Update”. Dr Linares explained what the FRAX score is and mentioned the different options we have for treatment of osteoporosis. DEXA scan continues to be the gold standard for screening, diagnosis and monitoring of osteoporosis. We will announce the winner of the question of the month about polyarthralgia next week, and we wish our new group of residents a great start in July 2021. Remember, 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, Maria Linares, and Claudia Carranza. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Lee S, Fu K, Kohno T, Ransford B, Maisel WH. Clinically significant magnetic interference of implanted cardiac devices by portable headphones. Heart Rhythm. 2009 Oct;6(10):1432-6. doi: 10.1016/j.hrthm.2009.07.003. Epub 2009 Jul 8. PMID: 19968922. https://www.heartrhythmjournal.com/article/S1547-5271(09)00740-1/fulltext

Greenberg, Joshua C.; Mahmoud R. Altawil; Gurjit Singh; Letter to the Editor—Lifesaving Therapy Inhibition by Phones Containing Magnets, Heart Rhythm, January 04, 2021. DOI:https://doi.org/10.1016/j.hrthm.2020.12.032.  https://www.heartrhythmjournal.com/article/S1547-5271(20)31227-3/fulltext

“About the magnets inside iPhone 12, iPhone 12 mini, iPhone 12 Pro, iPhone 12 Pro Max, and MagSafe accessories”, Apple Support, https://support.apple.com/en-us/HT211900, accessed on March 2, 2021. 

AACE Releases 2020 Clinical Practice Guidelines for Postmenopausal Osteoporosis, Physician Weekly, September 11, 2020, https://www.physiciansweekly.com/aace-releases-2020-update-clinical-practice-guidelines-for-postmenopausal-osteoporosis/

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 44: Diabetic Retinopathy. 

Dr Carranza explains the effect of diabetes on the retina, domestic abuse among female doctors, jokes.

Today is March 15, 2021.

Domestic Abuse among Female Doctors

There are topics which are very sensitive, but we need to talk about them.

Such is the case of domestic abuse among doctors. Do you know what is the most important risk factor to be a victim of domestic abuse? Yes, being female, and doctors are not an exception. 

Recently, in February 2021, the British Journal of General Practice (BJGP) posted an article addressing this topic.  The aim of the article was to understand the experience of female doctors as victims of domestic abuse, the barriers they faced to find help, and the impact that domestic abuse had on their work. 

The study was limited to doctor mothers because the author had access to this group and she was a member of the online forum and a single doctor herself. 114 doctors expressed interest in the study but a total of 21 participants were interviewed. The criteria to be included in the study were being a single mother working as a doctor and having previously left an abusive relationship. 

Each interview lasted between 44 and 113 minutes and were conducted from August 2019 and March 2020. The interviews were recorded. The principal author of the study can be seen and heard in an interview on the BJGP’s podcast.  

The doctors felt that stress of domestic abuse affected their quality of work but were unable to participate in seeking help because of the social stigma. One of the barriers for seeking help included lack of confidentiality when the other partner was a doctor as well. 

One of the participants expressed that the social services did not treat her with respect when the abuser was a doctor himself. Also, the participants expressed embarrassment and shame because of their status as a doctor as she stated that doctors “should know better.”  

Another negative connotation going through domestic abuse as a doctor is that the particular individual “is not capable of taking care of the patients if she cannot take care of her personal life.” 

The barriers to find help included “owning up” to domestic abuse, not seeking help from social services and work hours. The doctors feel socially and professionally isolated because they are not able to talk about abuse and fear the consequences of reporting. 

One of the most helpful thing for victims of domestic abuse was an online social group. The author added that domestic abuse training should be taught in medical school as doctors can be victims as well.

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. 

Question of the Month: Polyarthralgia
by Valerie Civelli (written by Claudia Carranza)  

This is match week! congrats to everyone, and we hope you matched to your dream residency.  

This is the question of the month. This is the last week you have to answer this question. We have received very interesting answers but we are hoping to receive yours. 

A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling very fatigued. You note on her chart that she was diagnosed with COVID-19 six weeks ago that did not require hospitalization. She denies any relevant past medical history. She denies trauma, bleeding, headaches, chest pain, SOB, or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation to bilateral wrist and ankle. No signs of inflammation on joints are noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? 

Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical ankle and wrist pain with fatigue for 1 month. What workup would you order? Clue: Listen carefully to the history of the patient. Send us your answer to [email protected] before March 22, 2021. The winner will receive a prize.

Diabetic Retinopathy 

A lot of us send out referrals for diabetic retinopathy screenings every day. Now we all learned about this topic in med school but it is important to do an overview as to what diabetic retinopathy entails. These will help us, providers, to be able to explain it to your patients better and also for all listeners to have a better understanding of a much-unwanted complication of diabetes. 

Basics on Diabetes.

So for all of our listeners I wanted to do a quick review on diabetes. A lot of us have heard about “high sugars” and diabetes but what is it really? It is a disease in which carbohydrates are not processed correctly in our body leading to an increase of glucose in our blood. Insulin is made in the pancreas and its job is to regulate carbs by sending them to the liver, fat, skeletal muscle. You need glucose to function and not in your blood vessels but in your organs. For the listeners, what should they look out for with regards to symptoms?

Lots of urination, also called polyuria and nocturia, increased thirst, weight loss, increased appetite, blurred vision, UTIs, fatigue, numbness and tingling of extremities. In other words, think of any symptoms you would have if honey was running through your bloodstream. 

Hemoglobin A1c is the number people hear when they have diabetes. I tell this to all my patients, this number is a way to measure the sugar coating of your RBCs over the last 3 months. If your cells are exposed to higher amounts of glucose then the number will be higher. Prediabetes is 5.8-6.4, and diabetes is >6.5. 

Diabetic Retinopathy (DR).  

The main targets of diabetes are the eyes, kidneys and nerves since the first things to get damaged are the smallest blood vessels and those feed these organs. Today you are going to tell us more about the damage diabetes can do to your eyes or as we call it Diabetic Retinopathy.

DR is actually one of the most important causes of visual loss worldwide and the main reason for impaired vision in patients 25-74 as the retina becomes damaged. An issue is that people will not develop symptoms until they are in late stages of DR. 1 in 5 patients with newly diagnosed diabetes will have signs of DR. 

In patients with diabetes, glucose runs through the circulatory system. Glucose and the protein at the walls of blood vessels react and overtime damage the collagen. Collagen keeps the blood vessels plump. When damaged, the capillaries thicken and the walls break down. 

The timing of your diabetes is a good predictor for DR. After 10 years 50%, 15 yrs 90% but it all really depends on your A1c. The more uncontrolled, the quickest you will have side effects and damage and will end up with DR.

Proliferative and non-proliferative diabetic retinopathy.  

Non-proliferative diabetic retinopathy is also known as “background retinopathy” meaning it just kinda sits in the background for years. 95% of people with DR have Non-Proliferative Diabetic Retinopathy (NPDR). Usually it is at an early stage and the progression is very slow. 

It is the result of capillary breakdown with leakage of fluid into retina, aneurysms at the blood vessels that can burst and show “blot and dot” hemorrhages that are small and round and can be seen on fundoscopic exam.

When it worsens, there is decreased blood flow to the retina causing ischemia of superficial retinal nerve fibers. This can also be seen in fundoscopic exam as the infamous “cotton wool spots”. Worsening capillary break down can also lead to beading of larger retinal veins. 

The other type of DR is the Proliferative retinopathy. The way this one occurs is that when vessels are very damaged they occlude completely and you end up with no blood supply. 

Our bodies are smart and usually try to fix themselves. How does the retina reacts to this lack of blood flow? It sends chemicals, like VEGF (vascular endothelial growth factor) that stimulate growth of new vessels. This process is called “neovascularization”. This sounds pretty great, right? The problem is that these new vessels are not top notch. They are abnormal, friable and prone to leaking. On top of that they grow in the wrong places. For example, if it grows in the vitreous jelly, which has framework of proteins, it tugs at these proteins and you end up with retinal detachment. These vessels can also bleed into the eye and cause vision loss. And if they grow into the iris, they can block the trabecular meshwork and cause Neovascular Glaucoma.

Proliferative retinopathy (PR) can advance quickly and ½ of the patients can go blind if it is left untreated.

Macular edema.

The macula is the functional center of the retina which has a high concentration of photoreceptors, it’s basically the center of high-definition and color vision. It’s the center of the retina. 

Macular edema it occurs in 10% of patients with diabetic retinopathy, more commonly with severe retinopathy. The leakage of capillaries and microaneurysms cause macular retina to swell with fluid. Once this swelling goes away, on fundoscopic exam you will see the “hard exudates”. These hard exudates are fatty lipids that are left behind after the swelling stops. I highly encourage all of our listeners to google the images for the findings mentioned today as they are quite impressive when you compare them to a healthy retina. 

I think it is best for us as physicians to recommend to our patients and try our best to work with them to control their A1c so they don’t end up with diabetic retinopathy and also have yearly eye checkups. 

Treatments.

Laser treatment is one of the options. The laser seals the leaking vessels and microaneurysms; which can be done when there is only a few and they are well defined. If the area is too large then PRP (Pan-retinal photocoagulation) can be done. What is does is that it burns thousands of spots around the peripheral retina in a way to decrease the stimulus to form new vessels. The side effects are decreased peripheral vision and night vision as you end up with less peripheral rods receptors. 

Another treatment is with anti-VEGF agents. These are used to treat proliferative diabetic retinopathy. They are injected into the vitreous. There are 3; Ranibizumab, bevacizumab, and aflibercept. Interesting fact; Bevacizumab is used “off-label” for retinopathy and it has to be repackaged to a strength of 1:500th of the dose used for cancer treatment. 

Vitrectomy. For progressive disease, vitrectomy can be performed and it is the removal of the vitreous humor. At this point the vitreous humor would be filled with blood, inflammatory cells and debris. I had read that it is usually replaced with saline but learned from an ophthalmologist that you don’t always have to replace with saline but can also be replaced with air or gas. 

Conclusion: Diabetic retinopathy is a consequence of poor glycemic control. The consequences can be serious and cause severe physical, mental and social dysfunctions in our patients. Keep an eye on your care gaps, and order an annual retinopathy screening in all your patients with diabetes. But do not limit yourself to order annual screening, always ask about vision changes in your patients, and if there is any concern about worsening vision, send your patients promptly to ophthalmology.

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For your Sanity: Jokes
by Anonymous Medical Assistants

-There is a lot of people with 20/20 vision. How come none of them warned us about corona?

-I'm beginning to think adult supervision is a myth. In fact, my vision just seems to be getting worse.

-What do you call a fish without an eye? A fsh.

-Why did the cross-eyed teacher quit her job? She couldn’t control her pupils.

Now we conclude our episode number 44 “Diabetic Retinopathy.” We learned that high glucose is very harmful to the retina. Let’s teach our patients the importance of glycemic control to prevent blindness. Remember to order a retinopathy screening at least once a year, or whenever your patients reports changes in their vision. This is the last week to answer our question about polyarthralgia and fatigue in a 49 year-old-female who has a key element in her history. Send us your answer this week and you will receive a prize. Remember, even without trying, every night you go to bed being 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, Claudia Carranza, Steven Saito, Udayveer Brar, Valerie Civelli, and anonymous Medical Assistants. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Donovan, Emily; Miriam Santer; Sara Morgan; Gavin Daker-White; and Merlin Willcox, Domestic abuse among female doctors: thematic analysis of qualitative interviews in the UK, British Journal of General Practice, February 8, 2021; BJGP.2020.0795. DOI: https://doi.org/10.3399/BJGP.2020.0795. 

Fraser, Claire E; Donald J D'Amico; et al, Diabetic retinopathy: Prevention and treatment, UpToDate, Last updated: Oct 29, 2019, accessed on March 4, 2021. https://www.uptodate.com/contents/diabetic-retinopathy-prevention-and-treatment

Root, Timothy, MD, OphthoBook, Chapter 4: Retina (47-53), published on July 20, 2009.

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 43: Testicular Cancer. 

Testicular cancer screening and diagnosis (basics), chlorthalidone vs hydrochlorothiazide, and jokes.

Today is March 8, 2021. 

For many years, we have heard about the superiority of chlorthalidone over hydrochlorothiazide to control hypertension, but in clinical practice, hydrochlorothiazide is prescribed more often as the initial therapy for most patients with hypertension as compared to chlorthalidone. 

As a matter of fact, the Microsoft Word automatic corrector detects hydrochlorothiazide as a correct word, but flags chlorthalidone as misspelled. Also, we know how to abbreviate hydrochlorothiazide (HCTZ), but did you know that chlorthalidone has an abbreviation as CTD?

We have been neglecting chlorthalidone regardless its apparent effectivity.  

In January 2006, the American Heart Association published on its journal Hypertension, a comparison between chlorthalidone and hydrochlorothiazide to control hyperension[1]. 

A randomized, single-blinded, 8-week active treatment, crossover study compared 12.5mg/day chlorthalidone (force-titrated to 25 mg/day at week 4) and HCTZ 25mg/day (force-titrated to 50mg/day at week 4) in untreated hypertensive patients. 24-hour BP monitoring was assessed at baseline and week 8 plus standard office BP readings every 2 weeks. 

30 patients completed the active treatment period.  At week 8 there was a greater reduction in baseline systolic blood pressure with chlorthalidone 25mg vs HCTZ 50mg. The effectiveness of chlorthalidone was evidenced by ambulatory blood pressure measurement (ABPM) although this difference was not apparent with office BP measurements. It was a short duration study with a small sample size.

More recently, in January 2021, the Journal of Hypertension, which is the official journal of the International Society of Hypertension and the European Society of Hypertension[2], published on PDF a more comprehensive review of these long-time rivals. According to the short version of this article, there is no difference in the short-term net clinical benefit between CTD and HCTZ, BUT long-term available data suggests that CTD is better at reducing major adverse cardiovascular events (MACE) over HCTZ. Stay tuned for the final version of this study.

Way to go chlorthalidone!

______________________________

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

Question of the Month: Polyarthralgia
by Claudia Carranza  

A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain is worse with movement and responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling more fatigued than usual this past month. You note on her chart that she was diagnosed with COVID-19 approximately 6 weeks ago for which she did not need to be hospitalized.  She denies history of diabetes, thyroid disease, lupus, rheumatoid arthritis, trauma, or anemia. She denies fecal, urinary, or vaginal bleeding, no headaches, chest pain, SOB or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation at bilateral wrist and ankles. No signs of inflammation on joints is noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? 

Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical POLYARTHRALGIA and fatigue for 1 month, and what workup would you order (if any)? Clue: Listen carefully to the history of the patient. Send us your answer to [email protected] before March 22, 2021. The winner will receive a prize.

“I am not my body. My body is nothing without me.” Tom Stoppard

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Testicular Cancer

Testicular cancer is the most common solid tumor among males 15 to 34 years of age, with an estimated 8,850 new cases and 410 deaths in the past years. The good news is that with effective treatment, the overall five-year survival rate is 97%[3]. 

Risk factors. 

Cryptorchidism: The relative risk of developing testicular cancer ranges from 2.9 to 6.3; the risk is increased in both testes, although the risk is much higher in the ipsilateral testis (6.3 vs. 1.7). Among these patients, the risk of cancer increases when orchiopexy is delayed until after puberty or never performed compared with early orchiopexy. Even after early orchiopexy, the risk of testicular cancer remains elevated compared with the general population.  

Personal or family history of testicular cancer: Patients with a personal history of testicular cancer have a 12-times greater risk of developing a contralateral testicular cancer than the general population. However, the greatest risk is in the first five years after diagnosis. Patients with a father or brother with testicular cancer have a 3.8- and 8.6-times greater risk, respectively. 

Infertility: Men with infertility have an increased risk of testicular cancer, with a standardized incidence ratio of 1.6 to 2.8, although the underlying mechanism is unclear. 

HIV: Human immunodeficiency virus infection/AIDS increases the risk of seminoma, but this is negated with highly active antiretroviral treatment.  

Inconclusive risk: Associations between testicular cancer and marijuana use, inguinal hernia, diet, maternal smoking, and body size are inconclusive.  

Not a risk factor: Testicular microlithiasis, vasectomy, and scrotal trauma are not risk factors for testicular cancer. 

Screening for testicular cancer. 

The U.S. Preventive Services Task Force, National Cancer Institute, and American Academy of Family Physicians recommend against screening for testicular cancer (by a clinician or through self-examination) in asymptomatic adolescents and adults because of its low incidence and high survival rate. 

The American Cancer Society states that a testicular examination should be part of a routine cancer-related checkup but does not include a recommendation on regular testicular self-examinations for all men.

Assessment of suspected testicular cancer patient.

History and physical exam are the foundation for the diagnosis. Men with symptoms should receive a complete history and physical examination. Scrotal ultrasonography is the preferred initial imaging study. Testicular cancer may present as a painless scrotal mass, an incidental radiologic finding, posttraumatic symptom, or scrotal pain. Less commonly, presenting symptoms may indicate metastatic disease.  

Symptoms of testicular cancer include scrotal symptoms such as acute pain in the testis or scrotum, scrotum or abdomen discomfort or aches, painless mass of the testis, scrotal heaviness and swelling. Symptoms related to metastasis are non-specific and depend on the location of metastasis, including dyspepsia, abdominal pain or discomfort, gynecomastia, headaches, low back pain, neck mass, chest pain, cough, dyspnea, and hemoptysis.

Testicular changes may be detected by the patient or by a sex partner. Epididymitis is an important part of the differential diagnosis of a scrotal mass.

The normal testis is 3.5 to 5 cm in length, smooth, homogenous, movable, and detached from the epididymis. Hard, firm, or fixed areas within or adjacent to the testes are abnormal and warrant further evaluation. 

Physical examination should also include evaluation of the inguinal and supra-clavicular lymph nodes, the abdomen, and the chest for gynecomastia (related to tumor secretion of beta human chorionic gonadotropin). If a solid intratesticular mass is discovered, orchiectomy is both diagnostic and therapeutic. 

Imaging.

Scrotal ultrasonography is the preferred initial imaging study for evaluating a testicular mass.

Ultrasonography has a sensitivity of 92% to 98% and specificity of 95% to 99.8%. A solid intratesticular mass on ultrasonography warrants rapid referral for radical inguinal orchiectomy because this procedure provides pathologic diagnosis and is the cornerstone of treatment.

Staging. 

Staging through chest radiography, chemistry panel, liver function tests, and tumor markers guides treatment. Active surveillance, chemotherapy, retroperitoneal lymph node dissection, and radiation therapy are treatment options following orchiectomy. 

For patients desiring future fertility, sperm banking should be discussed early in the course of treatment. 

Treatment. 

Radical inguinal orchiectomy, including removal of the spermatic cord to the internal inguinal ring, is the primary treatment for any malignant tumor found on surgical exploration of a testicular mass. Testis-sparing surgery is generally not recommended but may be performed for a small tumor in one testis or for small bilateral tumors. Orchiectomy may be delayed if life-threatening metastases require more urgent attention. The risk of testicular cancer recurrence is greatest within two to three years of primary treatment, and surveillance is continued for up to five years.

Classification of Testicular Tumors: 

Germ cell tumors (95% of all testicular cancers)

Derived from germ cell neoplasia in situ

Seminoma

Nonseminoma (nonseminomatous germ cell tumors)

Embryonal carcinoma

Yolk sac tumor (postpubertal)

Trophoblastic tumors (e.g., choriocarcinoma, placental site trophoblastic tumor)

Teratoma (postpubertal) with or without malignant transformation

Mixed and unclassified germ cell tumors

Not derived from germ cell neoplasia in situ

Spermatocytic tumor

Teratoma (prepubertal)

Yolk sac tumor (prepubertal)

Sex cord–stromal tumors (< 5% of all testicular cancers)

Leydig cell tumor

Sertoli cell tumor

Granulosa cell tumor

Mixed and unclassified sex cord–stromal tumors

Mixed germ cell and stromal tumors (proportion of all testicular cancers not well defined) 

Gonadoblastoma

Miscellaneous tumors (proportion of all testicular cancers not well defined) 

Ovarian epithelial-type tumors 

Hemangioma 

Hematolymphoid tumors 

Tumors of the collecting duct and rete testis (adenocarcinoma)

Differential diagnosis of testicular cancer.

Tip 1: Testicular torsion is one of the most important differential diagnosis of testicular cancer. Testicular torsion is an emergency, and the presentation is quite different than cancer as it presents with acute, sudden, severe, unilateral testicular pain. Patients are very apprehensive to the exam. The scrotum may appear discolored and swollen; and the affected testicle is typically horizontal and at a higher position than expected in the scrotum. The treatment is surgical. In isolated areas, where surgery cannot be performed in a 2-hour period, a manual testicular detorsion can be attempted with appropriate analgesia and/or sedation. Try to rotate the affected testicle twice, 360 degrees, from medial to lateral. A “drop” of the testicle in the scrotum is felt with relief of pain. One-third of patients need detorsion to the opposite direction, from lateral to medial instead.

Tip 2: Epididymitis presents as a pain for about 1-2 weeks. Tenderness is located behind the testicle and patient may complain of dysuria as well. Perform a urine test or urethral swab for gonorrhea and chlamydia. In patients younger than 35, consider empiric treatment while you wait for the results with ceftriaxone PLUS doxycycline or azithromycin. In patients older than 35, consider gram negative coverage with levofloxacin or trimethoprim-sulfamethoxazole.

Tip 3: Consider other causes of infection in testis or scrotum, including viruses such as mumps (in unvaccinated populations) and even tuberculosis. If you are curious, read my article about it in PubMed titled “A Case of Testicular Granulomatous Inflammation Mistaken for Malignancy: Tuberculosis Identified Post Orchiectomy”[4]. 

Tip 4: Epidydimal cyst, spermatocele, and hydrocele are asymptomatic or minimally symptomatic, they are not located in the testis, but you can palpate a distinctive mass posterior or higher than the testis. You can try transillumination of these masses, and they should be translucent. Confirm with testicular ultrasound if in doubt.

Tip 5: A testicular hematoma can happen after blunt trauma, but don’t be fooled by the history of traumas as up to 10% of testicular cancers may be discovered after trauma. Perform ultrasound and tumor markers to establish a diagnosis.

Tip 6: A scrotal hernia may cause concerns in a patient. Clinically, the inguinal canal appears full and the mass in the scrotum is reported to improve with rest. If the mass is exquisitely tender and not reducible, emergent evaluation by surgery is warranted to rule out hernia strangulation, especially if scrotal pain is accompanied by abdominal distension, abdominal pain, nausea, and vomiting.        

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For your Sanity: Jokes
by Anonymous Medical Assistants

How does a deaf gynecologist communicate? They read lips!

How do you get a squirrel to like you? Act like a nut.

Why did the math book look so sad? It had a lot of problems.

Why can’t a nose be 12 inches long? Because then it’d be a foot.

What’s brown and sticky? A stick.

Why did the rope go to the doctor? Because it had a knot on the stomach.

Why did the mattress go to the doctor? Because it had Spring fever.

Now we conclude our episode number 43 “Testicular cancer”, marking our podcasts one year anniversary!. Dr. RAVA covered the recommendations given by USPSTF and the American Cancer Society regarding screening for testicular cancer. Screening in asymptomatic adults is mostly not recommended but it can be a part of a cancer-related checkup. As part of our introduction today, we mentioned effective chlorthalidone is in preventing major adverse cardiovascular events. Our question of the month is still on, and we look forward to reading your answers. The question is: What is the etiology of polyarthralgia in a 49-year-old woman with pain on wrists and ankles for 1 month, and what work up would you order (if any)? The listener who sends the best answer will win a prize! Remember, 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, Sapna Patel, Manjinder Samra, Dr. RAVA, and voluntarily-unidentified medical assistants. Audio edition: Suraj Amrutia. See you next week! 

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References:

Roush, George C.a; Messerli, Franz H. Chlorthalidone versus hydrochlorothiazide, Journal of Hypertension: January 19, 2021 - Volume Publish Ahead of Print - Issue - doi: 10.1097/HJH.0000000000002771. https://journals.lww.com/jhypertension/Abstract/9000/Chlorthalidone_versus_hydrochlorothiazide__major.96738.aspx

Ernst, Michael E., Barry L. Carter, Chris J. Goerdt et al., American Heart Association, Hypertension, Volume 47, Issue 3, 1 March 2006, Pages 352-358, https://doi.org/10.1161/01.HYP.0000203309.07140.d3

Baird DC, Meyers GJ, Hu JS. Testicular Cancer: Diagnosis and Treatment. Am Fam Physician. 2018 Feb 15;97(4):261-268. PMID: 29671528. https://www.aafp.org/afp/2018/0215/p261.html

Civelli VF, Heidari A, Valdez MC, Narang VK, Johnson RH. A Case of Testicular Granulomatous Inflammation Mistaken for Malignancy: Tuberculosis Identified Post Orchiectomy. J Investig Med High Impact Case Rep. 2020 Jan-Dec;8:2324709620938947. doi: 10.1177/2324709620938947. PMID: 32618206; PMCID: PMC7493239. https://pubmed.ncbi.nlm.nih.gov/32618206/

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!