Rio Bravo qWeek

Episode 42: Baker’s Cyst.

What is a Baker’s cyst and how to treat it? Alzheimer’s disease may be linked to sleeping pills, polyarthalgia question. 

Today is March 1, 2021.

Arreaza: Spring season is here! A renewal of life and a renewal of hope in the future, and for some, a renewal of allergies. But we will not talk about allergies in our intro today, we will talk about dementia.

Civelli: Research is increasingly showing that poor sleep correlates to dementia[1]. In 2019, an article was published by the Alzheimer’s Association International Conference (AAIC) which highlighted several links between sleep medication, sleep disorders and dementia, while also showing us what we still don’t know.  

Arreaza: Investigators at Utah State University (go Aggies! – my wife told me to say that) found interesting sex-related differences: For Men who reported using sleep medication for sleep issues, there was a 3-fold risk of developing Alzheimer’s disease than men who did not use sleep medications. Women however had different results. For Women who did NOT report having any sleep disturbance but still used sleep meds, the risk of Alzheimer’s disease was nearly 4x’s greater. However, in Women who DID self-report sleep disturbances at baseline, but also took sleeping pills, there was actually a 33% reduction in risk for Alzheimer’s disease. 

Civelli: Another study by investigators at University of California, San Francisco (UCSF) did not echo these findings. They found no sex-related differences, and they adjusted for a variety of genetic and lifestyle confounders. In this UCSF research, frequent sleep meds and later dementia were strongly correlated – but only in Caucasian adults. The specific sleep medications were not identified however, some meds such as benzos, antihistamines, antidepressants, or others were included. 

Arreaza: At the University of East Anglia in Norwich, England, in 2018 it was found that long-term exposure to anticholinergic drugs, some antidepressants and antihistamines were specifically associated with a higher risk of dementia, while use of benzodiazepines were not.

Civelli: Meanwhile in pursuit of physical proof: 337 brains from the U.K. brain bank were examined. 17% and 21% had known benzodiazepines and anticholinergic chronic exposures. Slight signals in neuronal loss in the nucleus basalis of Meynert were identified. Whether benzodiazepine exposure relates to dementia remains controversial.

Arreaza: Suvorexant (Belsomra), the only orexin receptor antagonist that regulates wakefulness, is being tested in Alzheimer’s disease. This targeted therapy decreases sleep fragmentation and increases total sleep time. It may be the future. We will see.

Civelli: Lastly, although not a magic bullet, trazodone, has been shown to increase total sleep time in patients with Alzheimer’s disease without affecting next-day cognitive performance, and even slowing down cognitive decline in patients who complained of sleep disturbance. According to Dr. Karageorgiou of UCSF “You’re not going to see long-term cognitive benefits if it’s not improving your sleep, So, whether trazodone improves sleep or not in a patient after a few months can be an early indicator for the clinician to continue using it or suspend it”. More prospective research is needed. 

Arreaza: The bottom line is: Dementias are associated with serious circadian rhythm disturbances. Physicians are encouraged to focus on improving sleep to help patients with, or at risk for, dementia by consolidating their sleep rhythms. So, what will you do to help your patients sleep better today? 

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

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Question of the Month: Polyarthralgia
by Ikenna Nwosu 

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, no chest pain, no 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 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 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 be announced and will receive a prize.

Quote: “Coming together is a beginning; keeping together is progress; working together is success.”
—Edward Everett Hale 

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Popliteal (Baker’s) Cyst

Introduction: Baker’s cyst is named for William Morrant Baker, a 19th-century surgeon who first described the condition. It presents as swelling in popliteal fossa due to enlargement of gastrocnemius-semimembranosus bursa. It is often due to degenerative inflammatory joint disease or injury. It usually communicates with the adjacent knee joint space. The Prevalence increases with age. It is often Accompanied by OA.

Clinical Features: Posterior knee pain, stiffness, swelling, and other symptoms related to OA.
Complications: Enlarging, dissection and/or rupture, leading to compressing of adjacent structures and signs resembling thrombophlebitis.

Diagnosis: Clinically, there is a medial popliteal mass most prominent with standing and knee fully extended. Swelling softens or disappears with flexion to 45 degrees (Foucher’s sign). Imaging, usually plain radiography and US, performed if diagnosis is uncertain or another condition suspected. Differentials include DVT, other cystic masses, tumors, or popliteal aneurysms.

Management:

Treat underlying joint disorder: Such OA, RA, or meniscal injury which may be causing increased synovial fluid. Initial therapy: Arthrocentesis of knee and intraarticular injection with glucocorticoids (40mg triamcinolone). Decrease in size of cyst and/or discomfort observed in approx. 2/3 of patients within 2 days to 1 week from time of injection.

Glucocorticoid injections into joint space can also be effective in patients with cysts but without joint effusion. 

In refractory cases: initial diagnosis of a Baker's cyst should be re-evaluated. In patients who do not respond to intraarticular injection, ultrasound-guided direct aspiration of popliteal cysts, followed by injection of glucocorticoids, can be performed by clinicians experienced in this procedure. 

Generally, surgical excision should be reserved only for those cases where more conservative interventions have failed and where there is significant functional impairment that can be ascribed to the cysts.

Overall good prognosis:   Most popliteal cysts do not cause symptoms or complications. Some cysts resolve without any intervention, and most respond to treatment of associated disorders of the knee joint.

Arreaza:

After we turned off the mics, we always come up with good topics of conversation. So, after I turned off the mics, Dr McGill reminded me of an important principle in medicine. What’s true today, may be not true tomorrow. We remembered when enlarged tonsils were treated successfully with Nasopharyngeal Radium Irradiation[2] for more than 20 years, until the late 1960s. Those practices were discontinued because of improved treatments were created and because of concerns with carcinogenesis. During this COVID-19 pandemic I feel we have woken up every day with a new recommendation in favor or against multiple clinical practices, too many to count. One of them is the use of face masks. At the beginning, it was not recommended, later it was recommended, most recently double masking is showing some evidence of effectiveness. My message is, make sure you stay on top of the updates, especially during this era of “information”, which some may later be called “the era of misinformation” or “the era of fake news”.  

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For your Sanity: ***
by “AJ” Arash Farzan, MS3

A patient goes to the doctor and after a full discussion on diets the doctor says: “I guess you need to cut carbs”. The patient got very excited and asked: “Should I cut the with a fork or a knife?”

Now we conclude our episode number 42 “Baker’s Cyst”, a common complaint in patients who have any kind of joint effusion such as ACL tears, meniscal tears, rheumatoid arthritis, but especially osteoarthritis. Remember our question for this month. What is the etiology of polyarthralgia in a 49-year-old female with increased fatigue for 1 month? What workup would you order (if any)? Clue: Listen carefully to the history of the patient. Send us your answer by email before March 22, 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, Valerie Civelli, Terrance McGill, Ikenna Nwosu, and “AJ” Arash Farzan. Audio edition: Suraj Amrutia. See you next week!

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References:

Smith Jennies, Sleep aids and dementia: Studies find both risks and benefits, MDedge News, August 7, 2019, https://www.mdedge.com/chestphysician/article/206002/alzheimers-cognition/sleep-aids-and-dementia-studies-find-both-risks?sso=true.

NRI: General Information, Centers for Disease Control and Prevention, https://www.cdc.gov/nceh/radiation/nri/default.htm

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 41: Otitis Media.

Diagnosis and treatment of acute otitis media in children, when to avoid antibiotics, use of short course of antibiotics, question of the week about polyarthralgia and fatigue.

Today is February 22, 2021.  

Question of the Month  
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, no chest pain, no 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)? Send us your answer to [email protected] before March 22, 2021. The winner will be announced and will receive a prize.

Introduction to episode:

This week we announced 3 new chief residents. Dr Manny Tu will replace Dr Lisa Manzanares, a big supporter of this podcast and chief for more than 1 year, who graduated last week as didactics chief. Dr McGill and Dr Gomes will continue to be chiefs until they hand over the baton to Dr Gina Cha and Dr Alejandro Gonzalez-Perez. Congrats, dear residents! (or should we say sorry?)

When you treat an infection, you need to know the recommended duration of treatment. Normally, the more severe an infection is, the longer the duration of treatment. 

In many instances, shorter courses of antibiotics can have similar efficacy to longer courses[1], and treating for shorter periods may also reduce the development of resistance and infections by C. difficile. 

Some infections in which this applies are, for example, community-acquired pneumonia (CAP), where treatment can be shortened to 3-5 days instead of 7-10 days; nosocomial pneumonia which can be treated for 7 days instead of 10-15 days; pyelonephritis, 5-7 days instead of 10-14 days; intra-abdominal infection (after source control) for 4 days instead of 10 days; COPD exacerbation, less than 5 days instead of more than 7 days; bacterial sinusitis, 5 days instead of 10; uncomplicated cellulitis, 5-6 days instead of 10 days. Of course, you must use your clinical judgement when deciding to use a shorter course of antibiotic treatment.

As a reminder, FDA has also warned about the relationship between fluoroquinolones and an increased risk of aortic dissection. On their website, it states that “Health care professionals should avoid prescribing fluoroquinolones to patients who have an aortic aneurysm or are at risk for an aortic aneurysm, such as patients with peripheral atherosclerotic vascular diseases, hypertension, certain genetic conditions such as Marfan syndrome and Ehlers-Danlos syndrome, and elderly patients”. They also say you “may prescribe fluoroquinolones to these patients only when no other treatment options are available”[2]. 

Other safety concerns reported by FDA about fluoroquinolones include: significant decrease in blood sugar and certain mental health side effects, disabling side effects of the tendons, muscles, joints, nerves, and central nervous system, restriction in use for certain uncomplicated infections, peripheral neuropathy, and tendinitis and tendon rupture. Therefore, think about this warning before prescribing fluoroquinolones[2].

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

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Acute Otitis Media.

Dr Katherine Schlaerth is a native of Pennsylvania. She graduated from Manhattan College and received her medical degree from the State University of New York, Buffalo. Dr. Schlaerth completed her pediatrics residency at Children’s Hospital LA and an Infectious disease fellowship at LAC-USC Medical Center. She is board certified in pediatrics, pediatric infectious diseases, family medicine and has a Certificate of Added Qualifications in Geriatrics. Dr. Schlaerth was an associate professor at Loma Linda and is an associate professor emeritus at USC. She has a special interest in research and has published in addiction medicine, child development and other areas.

Some topics discussed during this episode included definition of otitis media; risk factors such as bottle feeding, tobacco exposure, viral illness; common symptoms such as fever, irritability, ear tugging; diagnosis by pneumatic otoscopy; erythema of tympanic membrane as a sign of otitis media; treatment with antibiotics; use of amoxicillin as the first line of treatment; amoxicillin/clavulanate if amoxicillin fails; use of azithromycin, cefdinir and ceftriaxone for treatment, prevention with vaccination against Hib, pneumococcus and influenza, and more. 

Page Break

Tips:

Tip #1: Tympanocentesis

Although impractical in primary care, tympanocentesis may be done in children with severe, ongoing symptoms despite use of multiple antibiotics. Middle ear fluid can then be cultured and antibiotics adjusted based on bacterial sensitivities. 

Tip #2: Common pathogens

Common pathogens in neonates with acute otitis media include Group B streptococci, gram-negative enteric bacteria, and Chlamydia trachomatis. Empiric sepsis treatment should be started without delay, especially in neonates younger than 2 weeks with fever and acute otitis media.

Tip #3: When to give antibiotics

Give antibiotics in these cases: acute otitis media with otorrhea or severe symptoms at any age, and BILATERAL otitis without otorrhea in younger than 2-year-olds. Observation without initial antibiotics AND follow up in 48-72 hours is an option in low-risk children who are older than 2 years old with otitis WITHOUT otorrhea. 

Tip #4: Pain control

Don’t forget to treat pain related to otitis media. To provide short term pain relief, use acetaminophen, ibuprofen, or alternating between the two. 

Tip #5: Failure of treatment

Failure of antibiotic treatment occurs when the severe symptoms do not improve within 48 to 72 hours after initiation of treatment, or if acute otitis media is diagnosed again within 30 days after appropriate treatment.

Tip #6: Duration of antibiotics

For patients under 2 years of age OR with severe symptoms, give PO antibiotics for 10 days; in patients older than 2 years without severe symptoms and without otorrhea, 5-7 days may be enough. Make sure parents understand that fever and ear pain may persist for 48-72 hours. Some signs to look for that warrant a trip back to clinic or the ER include vomiting, headaches, high fever, and pain behind the ears. If recovery is uneventful, follow up 3 months after completing antibiotics or during the next well child visit, whichever comes sooner.

Tip #7: Tympanostomy

Consider tympanostomy tubes in children with 3 or more episodes of acute otitis media within 6 months, or 4 episodes within one year, with one episode in the preceding 6 months. 

After the mics turned off: Topical treatment

After having this conversation with Dr Shclaerth, she gave me this additional information about use of topical antibiotics in acute otitis media and otorrhea:

Tympanic membrane perforation is not commonly seen in purulent otitis media, but often stops the pain because it is essentially the draining of an abscess, i.e. otitis media. A culture of the purulent material can be done if concern exists for unusual bacteria. Generally, the rupture of the tympanic membrane heals over rapidly. 

Topical ofloxacin and ciprofloxacin has not been studied extensively in the treatment of children with ACUTE otitis media with acute tympanic membrane perforation. These topical medications should be used for 7 to 10 days in children with CHRONIC suppurative otitis media or in otorrhea with TYMPANOSTOMY tube, in those cases, topical antibiotics are equivalent to oral therapy. However, ACUTE otitis media with tympanic membrane perforation is treated with ORAL antibiotics, not topical. 

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For your Sanity: Jokes
by Steven Saito and Tana Parker

Why are pediatricians always in a rush? They have little patients.

I told my wife she was drawing her eyebrows too high. She looked surprised.

Someone stole my mood ring. I don’t know how I feel about that.

Why do cows were bells? Because their horns don’t work.

Now we conclude our episode number 41 “Acute Otitis Media”. Dr Schlaerth explained when to use antibiotics and when to use a more conservative approach in the treatment of acute otitis media. Remember that antibiotics are not always the right answer, we want to avoid undesired side effects and prevent antibiotic resistance whenever possible. The question of the month is: 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)? Send us your answer to [email protected] before March 22, 2021 and 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, Claudia Carranza, Valerie Civelli, Katherine Schlaerth, Alex Tompkins, Steven Saito, and Tana Parker. Audio edition: Suraj Amrutia. See you next week! 

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References:

Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME. Short- versus long-course antibacterial therapy for community-acquired pneumonia: a meta-analysis. Drugs. 2008;68(13):1841-54. doi: 10.2165/00003495-200868130-00004. PMID: 18729535. https://pubmed.ncbi.nlm.nih.gov/18729535/

FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients, FDA, https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics

Gaddey HL, Wright MT, Nelson TN. Otitis Media: Rapid Evidence Review. Am Fam Physician. 2019 Sep 15;100(6):350-356. PMID: 31524361. https://pubmed.ncbi.nlm.nih.gov/31524361/

Wright D, Safranek S. Treatment of otitis media with perforated tympanic membrane. Am Fam Physician. 2009 Apr 15;79(8):650, 654. PMID: 19405408. https://pubmed.ncbi.nlm.nih.gov/19405408/

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 40: Emotional Support Animals.

Service Animals vs Emotional Support Animals, meet Ronica and Fred, HTN medications at night, jokes about being 40. 

Today is February 15, 2021.

We hope you had a beautiful Valentine’s Day. Today I’d like to share some information that may be not so new anymore, but for some people it may be new. It’s about hypertension chronotherapy. An article published in AAFP News in November 2019 explains that taking hypertension medication at bedtime improves cardiovascular risk. This was a large prospective study that compared taking meds at bedtime vs taking meds in the morning. It was called The Hygia Chronotherapy Trial. It was originally published in October 2019 in the European Heart Journal. 

The study was conducted in Spain (ole!), and involved almost 20,000 patients with hypertension who were divided into two groups: One group took all their hypertension medications at bedtime, and another group took all their hypertension medications in the morning. In the next 6 years, 1,752 participants experienced cardiovascular-related death, myocardial infarction, coronary revascularization, heart failure or stroke. And the good news is that the bedtime medication group showed an improved blood pressure control and lower risk than the morning medication group. Taking BP medications at bedtime dropped the death rate by 45%. Incidence of myocardial infarction, stroke and heart failure were all significantly reduced. Taking thiazides at bedtime may be challenging, on the bright side, the study also found that moving only one medication to bedtime is still beneficial. 

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. 

Emotional Support Animals

Arreaza: Our guest does not need introduction because you have listened to her voice in several episodes, especially in our recent episode about menopause. Welcome, Valerie Civelli, it’s a pleasure to have you here. Random question, what is the farthest place you have visited? What will be talking about today?

Civelli: Emotional Support Animals (ESA). Many people with disabilities use a service animal in order to fully participate in everyday life. Dogs can be trained to perform many important tasks to assist people with disabilities, such as providing stability for a person who has difficulty walking, picking up items for a person who uses a wheelchair, preventing a child with autism from wandering away, or alerting a person who has hearing loss when someone is approaching from behind.

Arreaza: So, is it like a service animal? 

Civelli: Service animals and emotional support animals are not the same, so be sure to note the different. According to the APA, American Psychology Association:  Species: Any animal can be an emotional support animal. Under federal law, only dogs and miniature horses can be service animals[2]. Such is the case of Abrea Hensley who has flown from Nebraska to Chicago with her miniature mare, Flirty in August 2019. 

Arreaza: There was revival on the topic again. A story went viral in February 2020, one year ago, as Ronica Froese flew from Michigan to Ontario (California) with her service animal who is a miniature horse named Freckle Butt Fred, or Fred for short. They traveled together in first class. The picture went viral online, and it created positive and negative comments among travelers and internauts. Miniature horses were approved as service animals in 2011 by the ADA (Americans with Disability Act).

Civelli: Purpose: An emotional support animal assists through its presence alone. A service animal is specially trained to perform tasks for someone with a disability. Training: An emotional support animal requires no training; all that's needed is a letter from a mental health professional explaining its therapeutic value. Service animals must undergo individualized training. 

Arreaza: Animals for sure generate a reaction in humans whenever they enter a room. Tell us about the legal protections. "An animal's eyes have the power to speak a great language." ― Martin Buber. "An animal's eyes have the power to speak a great language." ― Martin Buber

Civelli: While the Americans with Disabilities Act (ADA) protects service animals, it does not cover emotional support animals. Emotional support animals are covered only under the Air Carrier Access Act and Fair Housing Act. Keep in mind, the criteria of mental or emotional disability is defined in the DSM 5, by the Americans with Disability Act (ADA), the Fair Housing Act, the Rehabilitation Act of 1973 (section 504), as well as the Air Carrier Access Act (49 U.S.C. 41705 and 14 C.F.R. 382).

Arreaza: Where can service animals go?

Civelli: A service animal can go anywhere its owner goes. While owners of emotional support animals may get away with bringing them into places where pets aren't allowed, the only places legally required to welcome them are aircraft—where they fly for free in the main cabin—and housing units.

Arreaza: Or with the owner, and in the case of Fred, the miniature horse. However, Fred probably had his last flight because the US Department of Transportation now allows only service dogs to fly with their human owners in an airplane. Airlines may have different rules, but are required by law to accept service dogs only. So, before you fly with your service animal or emotional support animal, check with your airline. 

Civelli: Let’s talk about ESA letters. They can be written by any licensed mental health professional, such as a therapist, psychologist, or psychiatrist, which should state that pet therapy is an important part of your treatment plan. To get an ESA letter, you must consult professionals who are authorized to prescribe emotional support animal letters in your area. Here is a list of people who can prescribe an ESA Letter:

A Primary Care Physician

A Licensed Therapist

Any Licensed Mental Health Professional

A Licensed General Physician

Arreaza: Elements that should be included on an ESA Letter: It must clearly state the patient suffers from a mental illness that can be managed by an emotional support animal. It should be on proper letterhead

Civelli: And it should contain the following elements:

Licensed person’s name and signature

License number, date of the license, and state where it’s issued

Date of issuance

State 

Patient’s name and date of birth

Pet details-optional

Although not required, it’s recommended to keep the letter updated each year. 

Arreaza: Let’s say you decide to take your service dog to a museum. What questions can employees ask you to determine if your dog is a service animal?

Civelli: In situations where it is not obvious that the dog is a service animal, staff may ask only two specific questions: (1) is the dog a service animal required because of a disability? and (2) what work or task has the dog been trained to perform? Staff are not allowed to request any documentation for the dog, require that the dog demonstrate its task, or inquire about the nature of the person's disability.

Arreaza: Do service animals have to wear a vest or patch or special harness identifying them as service animals?

Civelli: No. The ADA does not require service animals to wear a vest, ID tag, or specific harness.

Arreaza: Anxiety is a very prevalent condition, especially during these times of pandemic. If someone has a dog who calms when having an anxiety attack, does this qualify it as a service animal?

Civelli: It depends. The ADA makes a distinction between psychiatric service animals and emotional support animals. If the dog has been trained to sense that an anxiety attack is about to happen and take a specific action to help avoid the attack or lessen its impact, that would qualify as a service animal. However, if the dog's mere presence provides comfort, that would not be considered a service animal under the ADA.

Arreaza: A sample letter is provided in our website and also as a dot phrase in Epic. Just type .RIOBRAVOESA and a letter will pop up for your patient.

Page Break

                                             Sample Template for Emotional Support Animal Letter

Date:  2/21/20

ESA Breed: Dog, Golden Retriever

ESA Name: Max

To Whom It May Concern:

Maria Gonzalez is currently a patient receiving care at our facility.  I am familiar with her/his medical history and with her functional limitations.  This person meets the criteria of mental or emotional disability as defined in the Diagnostic and Statistical manual of Mental Disorders 5 (DSM 5), the Americans with Disability Act (ADA), the Fair Housing Act, the Rehabilitation Act of 1973 (section 504), as well as the Air Carrier Access Act (49 U.S.C. 41705 and 14 C.F.R. 382). This individual has certain limitations associated to social interactions and coping with stressful situations.  

To enable his/her ability to live independently and alleviate these difficulties, Maria Gonzalez has an emotional support animal (ESA).  The ESA is necessary to mitigate symptoms experienced. In the setting of airline travel and/or hotel stay, please allow her/him to have the ESA accompanied by her/him at all times as needed. 

Sincerely, 

    Alan Smith

Alan P. Smith, MD

Medical License #: 12345

Date of License Issued: 1/1/1985

NPI #: 17283930

Medical Board of California 

Clinical Sierra Vista|7800 E. Niles St.|Bakersfield, CA 93306| 661-328-4284 

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Questions of the Month: Diabetes management 
by Ikenna Nwosu, MD

Hi, I’m Ike, I’m a first-year resident, and today I’m filling in for Dr Carranza, who normally hosts the question of the month. We are happy to inform that we have a winner! Her name is Lubna Nasr. We chose her answer because it’s the most accurate and concise of all the answers. 

Question: 

What is the first treatment approach for type 2 diabetes mellitus? For example, for a patient who had polydipsia, polyuria for a few weeks, and at your office had a random BG of 210. 

Ok, let’s call our winner.

Answer: The first treatment approach for this patient includes diabetes education, intensive lifestyle modification and Hemoglobin A1c measurement. 

Diabetes education: Participation in a comprehensive diabetes self-management education program to learn more about the disease, glucose monitoring, management and complications. 

Intensive lifestyle modification (nutrition, physical activity and weight reduction): Nutrition should be based on foods who are low in carbs, include proteins and good fats. 

Physical activity: focusing on aerobic exercise (150 minutes weekly or more, at least 3days/week, AND resistance training with free weights or weight machines (2–3 sessions/week). 

Hemoglobin A1c measurement: To determine if the patient needs to start treatment with metformin and/or other medications for diabetes, including insulin, if indicated.

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For your Sanity: 40
by Steven Saito

This is our 40th episode, so we have some jokes related to being 40 years old. 40 is the perfect age for people. You’re old enough to recognize your mistakes but young enough to make some more. 40 — it’s all fun until it happens to you! You know you’re 40 when your back is hairier than your head. You know you’re 40 when you have a party and the neighbors don’t even realize it. You know you’re 40 when someone offers you a seat on the bus. And you don’t refuse it.

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Now we conclude our episode number 40 “Emotional Support Animals”. Dr. Civelli explained that Emotional Support Animals are companions to provide comfort to patients, but they do not have a particular skill and do not need training. We congratulate Lubna for her concise answer about diabetes management. Diabetes is the bread and butter of primary care, you “gotta” learn diabetes if you want to make a positive impact in your community. We’ll bring you another question next week. 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, Ariana Lundquist, Valerie Civelli, Claudia Carranza, and Ikenna Nwosu. Audio edition: Suraj Amrutia. See you next week! 

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References:

Crawford, Chris, “Taking Hypertension Medication at Bedtime Improves CVD Risk”, AAFP News, https://www.aafp.org/news/health-of-the-public/20191106bedtimehbpmeds.html.

O’Kane, Caitlin, “A woman took her 115-pound miniature horse on a plane as a service animal. Now, she's worried it could be his last flight”, CBS News, February 20, 2020, https://www.cbsnews.com/news/miniature-horse-on-plane-woman-took-service-animal-flight-could-be-his-last-airlines/

U.S. Department of Justice Civil Rights Division Disability Rights Section, Frequently Asked Questions about Service Animals and the ADA, accessed = February 11, 2021. https://www.ada.gov/regs2010/service_animal_qa.html

“Emotional support animal vs. psychiatric service animal”, Monitor on Psychology, American Psychological Association, September 2016, Vol 47, No. 8, https://www.apa.org/monitor/2016/09/pet-aid-sidebar. 

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 40: Erectile Dysfunction Basics. 

Erectile dysfunction fundamentals, allergy to penicillin label removal, jokes

Today is February 5, 2021.

Question of the month: Diabetes management

This is a reminder of our question for this month. Please answer before Feb 15, 2021. The best answer will receive a prize. Question: What is the first treatment approach for type 2 DM? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random BG of 210.

Send your answer to [email protected]. Don’t miss this chance to win.

Penicillin Allergy Study: How many times have you heard a patient say that they are allergic to penicillin? Exactly, a lot! Skin allergy testing continues to be the best test to diagnose penicillin allergy. All patients who have a negative penicillin allergy skin test should be challenged with penicillin in a medical setting for 1-2 hours to ensure that immediate reaction does not occur. Many patients labeled as “allergic to penicillin” may not be truly allergic. We recognize that true penicillin allergy exists, and allergic reactions range from mild rash to life-threatening anaphylaxis, but many patients needing penicillin may not get it because of a wrong diagnosis of penicillin allergy. 

Up to 15% of the US population are labeled as “allergic to penicillin”. The American Journal of Respiratory and Critical Care Medicine published in February 2020 a way to remove low-risk penicillin allergy labels in an ICU. The investigators created a risk-stratification tool after evaluating 318 patients in an allergy clinic. Low risk indicators include urticaria to penicillin >5 years ago, a self-limited rash, GI symptoms only, a remote childhood history, a family history only, avoidance from fear of allergy only, a known tolerance to penicillin since the reported reaction, or non-allergic symptoms. 

Using that tool, 216 patients admitted to the MICU labeled as “allergic to penicillin” were evaluated. 68 patients qualified as “low risk.” 54 patients agreed to be challenged with a single oral dose of 250 mg amoxicillin and observed for 1 hour. None of the challenged patients had any immediate or delayed reaction. Their penicillin allergy label was removed. Later, 41 of the 54 challenged patients received multiple doses of either penicillin’s (17 patients) or cephalosporins (24 patients) without any reaction. This tool has not been validated to be used in an outpatient setting yet, but it sets the foundation for further investigation in this matter.

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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Erectile Dysfunction. 

Arreaza: Today our guest is Dr. John Ihejirika.  

Ihejirika: My name is Dr. John Ihejirika. I am one of the third/Final-year residents at the Rio Bravo Family Medicine residency program, here in Bakersfield, California.  I am glad to be back on the podcast and thanks for having me again.

Arreaza: What topic are you discussing today?

Today I will be talking about Erectile dysfunction.

Arreaza: What is Erectile dysfunction?

Ihejirika: Erectile dysfunction [ED] can be defined as the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. 

It is very common, affecting at least 12 million men in the United States. The condition can be caused by vascular, neurologic, psychological, medications and hormonal factors. 

Arreaza: What are common conditions associated with ED?

Ihejirika: Common conditions related to ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment. 

Performance anxiety and relationship issues are common psychological causes. 

Medications and substance use can also cause or exacerbate ED

Medications: Antidepressants are a common cause especially the SSRI and SNRI drugs.  

Substances: Tobacco, alcohol, and illicit drugs can cause ED. Marijuana use may cause ED, although further study is needed.

Arreaza: Is ED related to any other risks?

Ihejirika: Cardiovascular risk: ED is associated with an increased risk of cardiovascular disease, particularly in men with metabolic syndrome. 

Initial treatment: Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions. 

Arreaza: Let’s talk about the “blue pill.”

Ihejirika: Oral phosphodiesterase-5 inhibitors are the first-line treatments for ED. Second-line treatments include alprostadil and vacuum devices. 

Arreaza: Vaccum: No medication interaction.

Ihejirika: Surgically implanted penile prostheses are an option when other treatments have been ineffective. Counseling is recommended for men with psychogenic ED.

Arreaza: However, most cases have an organic cause. How is Erectile Dysfunction assessed?

Ihejirika: The American Urological Association (AUA) recommends that the initial evaluation of ED include a complete medical, sexual, medication and psychosocial history. 

The five-item version of the International Index of Erectile Function Questionnaire is a validated survey instrument that can be used to assess the severity of ED symptoms.

Five-Item Version of the International Index of Erectile Function Questionnaire

note: The score is the sum of the above five question responses. Erectile dysfunction is classified based on these scores: 17 to 21 = mild; 12 to 16 = mild to moderate; 8 to 11 = moderate; 5 to 7 = severe.

* —Much less than one half the time.

† —About one half the time.

‡ —Much more than one half the time.

Summary of diagnosis and Treatment of Erectile Dysfunction.

Sources: I got this knowledge from the AAFP website, Up to Date, Review/Journal and from some my faculty. You can see our website for further details on theses references.

Conclusion:  It is very important to be aware of this condition because as stated earlier It is very common, affecting at least 12 million men in the United States. Most male patients feel depressed or “incomplete” when experiencing ED and it is one of the most common reasons for male patients to visit the doctor, although most patients do not disclose the reason for the visit during the rooming process or with a female provider. Knowledge of the management of ED is also vital to have as a provider as it helps you restore your patients’ self-esteem and gives you reciprocal gratification in addition, so be ready to treat your patients. 

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For your Sanity: Jokes
by Claudia Carranza, Gina Cha, an guest notary public

-What do you call a bear with no teeth? A gummy bear.
-How do you keep geese from speeding? Goose bumps.
-Why do fish choirs always sign off-key? Because you can’t tuna fish.
-Why did the toilet paper run down the hill? To get to the bottom.
-How do make a slug drink? Stick it in the blender.
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Now we conclude our episode number 39 “Erectile Dysfunction Basics.” Today, Dr Ihejirika gave us the tools to address this common issue among our male patients. Diabetes and hypertension are to blame for ED in most cases. He taught us how to assess and treat our patients with many methods, including the famous “blue pill.” We also hope you enjoyed our goofy jokes. 

Don’t forget to participate in our contest by answering our question of the month and receive a prize. Our question is: What is the first treatment approach for type 2 Diabetes? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random blood sugar of 210. Send your answer to [email protected] before February 15, 2021.

And remember… Even without trying, every night you go to bed being wiser than when you woke up. 

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

References:

Stone CA Jr et al., Risk-stratified management to remove low-risk penicillin allergy labels in the intensive care unit. Am J Respir Crit Care Med 2020 Feb 21; [e-pub]. (https://doi.org/10.1164/rccm.202001-0089LE) https://www.jwatch.org/na51025/2020/03/25/approach-removing-penicillin-allergy-labels

Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peña BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11:322.

Rew, Karl T. and Joel Heidelbaugh, MD, Erectile dysfunction, University of Michigan Medical School, Ann Arbor, Michigan. Am Fam Physician. 2016 Nov 15;94(10):820-827. https://www.aafp.org/afp/2016/1115/p820.html. 

Khera, Mojit, MD, MBA, MPH, Peter J Snyder, MD, Michael P O'Leary, MD, MPH and Kathryn A Martin, MD, Treatment of male sexual dysfunction, Up To Date, accessed on February 1, 2021. https://www.uptodate.com/contents/treatment-of-male-sexual-dysfunction?search=erectile%20dysfunction&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

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 38: Menopause Tips. 

Asthma treatment update, menopause tips, MMR associated fever and seizures.

Today is January 25, 2021.
Updates on asthma: As you know asthma is a significant burden for our healthcare system, and for the most part it is not preventable nor curable, but advances in management have changed many patient’s lives over the last 40 years. On our episode 27, we mentioned the updated practice guidelines by the Global Initiative of Asthma (GINA). Today we will give you the updated recommendations by the National Asthma Education and Prevention Program (NAEPP) posted on December 3, 2020. It contains recommendations for the treatment of asthma in children, adolescents, and adults[1]. This is an update from the NAEPP 2007 guidelines and are slightly different than GINA regarding step 1 and step 2 management.

-Step 1 (intermittent asthma): NAEPP did not make any changes from 2007. They continue to recommend short-acting β2-agonists [SABAs] for rescue therapy. Remember that GINA recommends against use of SABA as a sole therapy for step 1. 
-Step 2 (mild persistent asthma): Either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA. 
-Step 3 and step 4 (moderate persistent asthma): formoterol combined with an inhaled corticosteroid in a single inhaler (also known as single maintenance and reliever therapy – SMART) is recommended as the preferred therapy. For step 3 a LOW-dose ICS-formoterol therapy is recommended, and for step 4 a MEDIUM-dose ICS-formoterol therapy is recommended for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. 
-Step 5 (severe persistent), adding a long-acting muscarinic antagonist (LAMA) is recommended in patients whose asthma is not controlled by ICS-formoterol therapy. 

-Fractional exhaled nitric oxide testing (FeNO) is recommended to ASSIST in diagnosis and monitoring of symptoms, but is should not be used ALONE for the diagnosis and monitoring of asthma, and do NOT use in younger than 5 yo patients. Another recommendation is to control allergens in patients with relevant sensitivity. This may not sound so new, but there are several strategies for allergen mitigation, for example, use of impermeable pillow and mattress covers only as part of a multicomponent allergen mitigation intervention. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort. If you are still confused about these 2020 NAEPP guidelines updates, I recommend you go online and review them, it is easier to read them than listening to them. Find the link in our posted script.

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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Menopause Tips

by Valerie, That's me, Dr. Civelli w/ a C!

and your friendly medical student neighbor Patrick De Luna

TIP #1: Hot Flashes. 
Hot flashes, aka vasomotor symptoms occur in 70% of women in menopause. Hot flashes can last 1-5 minutes; can be characterized by perspiration, flushing, chills, clamminess, anxiety, and on occasion, heart palpitations; and can cause sleep disturbances. Hot flashes are the most common indication for hormone replacement therapy (HRT). Contraindications for HRT include undiagnosed vaginal bleeding, a history of breast cancer, VTE, or Severe liver disease.
Dr Wonderly, how do you treat hot flashes? [Listen to her answer in Episode 38]

TIP #2: Hormonal replacement therapy for hot flashes.

Estrogen or estrogen/progesterone combo is the most effective therapy for menopausal hot flashes. It’s FDA-approved and has a grade A research according to AAFP and ACOG. Topical methods are preferable as they have fewer adverse effects. But how do you choose? There’s Estrogen? Or estrogen/Progesterone combo? And what is the cancer risk? Remember if using hormones: Dose, duration and risk factors are key! Combined estrogen/progestogen therapy is recommended over estrogen alone, but still increases the risk of breast cancer after three to five years of use. There is no evidence that using low-dose local estrogen increases the risk of breast cancer recurrence. Combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene may also be used, especially when the patient still has a uterus. The decision to start HRT or to continue for more than three to five years should be made after reviewing all risks, benefits, and symptoms with each patient. 

Dr Wonderly, when do you decide to continue HRT for longer than 3-5 years? [Listen to her answer in Episode 38]

TIP #3: Nonhormonal options to treat hot flashes.
Vasomotor symptoms are best managed with systemic HT, but FDA approved, nonhormonal treatment options are available which are SSRIs, SNRIs, and clonidine. All have been shown to be effective. Antidepressants for nonhormonal treatment of vasomotor symptoms specifically include: citalopram, escitalopram, clonidine, desvenlafaxine, venlafaxine, gabapentin, pregabalin, and paroxetine. 

TIP #4: Natural remedies for menopause. 
There is no high-quality, consistent evidence that all-natural herbal alternatives are effective. This includes black cohosh, botanical products, omega-3 fatty acid supplements, or lifestyle modifications.  AAFP and ACOG do not endorse any of these as appropriate alternatives. For effective, evidenced based, proven therapies to alleviate hot flashes, think estrogen, estrogen/progesterone combo or antidepressants. 

TIP #5: The “timing hypothesis” in HRT? 
It is possible that a patient may ask you about your opinion regarding the timing hypothesis. This hypothesis suggests that starting hormone therapy early in menopause (compared with starting it 10 years or more after the onset of menopause) may be cardioprotective because of estrogen's apparent ability to slow the progression of atherosclerosis in younger women.  Although the evidence suggests that beginning hormone therapy near the start of menopause decreases the risk of cardiac disease, further study is needed. Current guidelines recommend against using hormone therapy to prevent or treat cardiac disease. Further, the American Academy of Family Physicians recommends against using hormone therapy for the prevention of chronic conditions. 
Dr Wonderly, when is the ideal time to start HRT? [Listen to her answer in Episode 38]

TIP # 6: Genitourinary syndrome in menopause (GSM). 
In 2014, a consensus conference endorsed new terminology: the term genitourinary syndrome of menopause is now recommended to use and replaces the terms vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy. Keep in mind this change is because new terminology accounts for the genital tract symptoms that commonly occur in women with menopause.

Genitourinary Syndrome of Menopause (GSM) is a chronic, progressive, vulvovaginal, sexual, and lower urinary tract condition characterized by a broad spectrum of signs and symptoms due to the lack of estrogen that characterizes menopause. Even though the condition mainly affects postmenopausal women, it is seen in many premenopausal women as well. The low estrogen level causes structural changes such as vaginal dryness, dyspareunia, and reduced lubrication. These can have a great impact on patients’ quality of life.

Treatment: Women with GU syndrome in menopause may benefit from vaginal estrogen, nonhormonal vaginal moisturizers, or ospemifene (the only nonhormonal treatment approved for dyspareunia due to menopausal atrophy). 
Dr Wonderly, do you think UTIs are commonly misdiagnosed in menopause when the GU symptoms are actually being caused by low estrogen? [Listen to her answer in Episode 38]

TIP #7: The MenoPro® app.
This app has several unique features, including the ability to calculate your 10-year risk of heart disease and stroke, which is important in deciding whether a treatment option is safe for you. It also has links to online tools that assess your risk of breast cancer and osteoporosis and fracture[7].
Dr Wonderly, do you know any comprehensive app to be used in menopause? [Listen to her answer in Episode 38]

Conclusion: Menopause is likely undertreated because patients suffer in silence and do not disclose their symptoms to the doctor because these symptoms are seeing as “normal part of life” and lack of treatment is not fatal, but treatment can improve quality of life significantly. So, be aware of these symptoms and be prepared to treat them appropriately.

Estrogen Medications for the Treatment of Vasomotor Symptoms

*—Estimated retail price of one month's treatment based on information obtained at http://www.goodrx.com(accessed June 13, 2016).

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Speaking Medical: MMR 
by Heather Langner, MS4

MMR is a vaccine against measles, mumps, and rubella which contains live attenuated viruses. In the US, children should get two doses of MMR vaccine, starting with the first dose at 12 to 15 months of age, and the second dose at 4 through 6 years of age (usually before starting preschool or kindergarten).  MMRV (MMR combined with varicella, brand name ProQuad) has been proposed as a way to simplify administration. Let’s listen to what our future doctor has to say about it[8].

According to the CDC there are 2 adverse events that occur most often during the 42 days after the first dose of the MMR/MMRV vaccine: Fever of 102F or higher and rash. The highest rates happening between 5-12 days after vaccination. 

Risk of fever: When the MMR vaccine and the Varicella vaccine are given separately the risk of fever (above 102F) is slightly higher than when given the combined MMRV vaccine (1 in 7 vs 1 in 5 children). 

Risk of seizures: A study published in Pediatrics explored the risk of febrile seizures in the MMR vs MMRV vaccine. The study included over 83,000 MMRV vaccine recipients and over 376,000 MMR+V vaccine recipients. The study found that the fever and seizures were clustered around day 7-10. The MMR+V vaccine had a febrile seizure risk of 4 in 10,000 doses and the MMRV vaccine had 5 in 10,000 doses. So, the risk of seizures is slightly higher when MMR and varicella are given combined (MMRV).

After first dose: Data suggests febrile seizure post MMR vaccination are primarily seen after the first dose in children aged 12-47 months. The second dose of the vaccine is less likely to cause fever than the first dose. This means that having a febrile seizure after the first vaccination is not a contraindication for receiving subsequent doses. Something to consider: if there is a personal or family history (parent or sibling) of febrile seizures, the child should receive the separate MMR and Varicella vaccine. As children get older the risks for the MMR vs MMRV vaccine are the same.

Contraindications: Per the AAP the only absolute contraindications for the MMR or MMRV vaccine: anaphylactic reaction to MMR vaccine or its components (neomycin or gelatin), pregnancy, and immunosuppression. Relative contraindications include: history of thrombocytopenia (small risk for thrombocytopenia post vaccination, but no hemorrhagic complications have been reported), recent receipt of blood products (may interfere with seroconversion), patients receiving high-dose steroid therapy (immunosuppression), and severe acute illness (precaution intended to prevent complicating management with vaccine reactions). Egg allergy reactions to the MMR vaccine are now considered extremely rare and is therefore no longer a contraindication. Breastfeeding and fevers are also not contraindications for MMR vaccine administration.

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Question of the month: Diabetes management

by Steven Saito, MD

This is a reminder of our question for this month. Please answer before Feb 8, 2021. The best answer will receive a prize.

Question: What is the first treatment approach for type 2 DM? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random BG of 210.

Send your answer to [email protected]. Don’t miss this chance to win.

____________________________

For your Sanity: Random Jokes
by Katherine Schlaerth, Manuel Tu, and Cassandra Levitske

-If those who can’t hear are deaf, and those who can’t see are blind, what do you call those who can’t smell or taste?
-Covid positive

-What does a gynecologist and a deaf person have in common? They're pretty good at reading lips.

-Why did Tigger stick his head in the toilet?
-He was looking for Pooh.

-Why is pea soup more special than mashed potatoes?
-Because anyone can mash potatoes.

Conclusion: Now we conclude our episode number 38 “Menopause Tips”, we started with some updates on asthma management, then Dr Civelli and our “future doctor” De Luna gave us some tips about the treatment of menopause symptoms. Our wonderful Dr Wonderly also answered a few questions about the management of this unavoidable, “period-free” period in a woman’s life. Then doctor-to-be Heather explained her findings on risks associated with MMR, specifically fever and seizure risks. Don’t forget our question for this month. Send us a brief, original, and relevant answer to our email before Feb 8, 2021. We hope you enjoyed this episode.  

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, Patrick De Luna, Sally Wonderly, Cassandra Levitske, Manuel Tu, Katherine Schlaerth, Tana Parker, and Steven Saito. Audio edition: Suraj Amrutia. See you next week! 

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References:

Cloutier MM, Dixon AE, Krishnan JA, Lemanske RF, Pace W, Schatz M. Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program. JAMA. 2020;324(22):2301–2317. doi:10.1001/jama.2020.21974 (https://jamanetwork.com/journals/jama/article-abstract/2773482)

2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group, https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines. 

Asthma: Updated Diagnosis and Management Recommendations from GINA, Am Fam Physician. 2020 Jun 15;101(12): 762-763. https://www.aafp.org/afp/2020/0615/p762.html.  

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2020. Available from: www.ginasthma.org

ACOG Releases Clinical Guidelines on Management of Menopausal Symptoms, Am Fam Physician. 2014 Sep 1;90(5):338-340. https://www.aafp.org/afp/2014/0901/p338.html

Hormone Therapy and Other Treatments for Symptoms of Menopause. Am Fam Physician. 2016 Dec 1;94(11):884-889. https://www.aafp.org/afp/2016/1201/p884.html

Habib, Jamie, NAMS Launches Free Mobile Menopause App, Contemporary OB/GYN, October 16, 2014, https://www.contemporaryobgyn.net/view/nams-launches-free-mobile-menopause-app

David W. Kimberlin, ACIP, AAP support choice of MMRV or separate MMR, varicella vaccines, AAP News January 2010, 31 (1) 10; DOI: https://doi.org/10.1542/aapnews.2010311-10. https://www.aappublications.org/content/31/1/10.1

Meissner, H. Cody, MD, FAAP, What are the indications, precautions, contraindications for MMR vaccination?

AAP News, May 14, 2019, https://www.aappublications.org/news/2019/05/14/idsnapshot051419. 

Febrile Seizures and Childhood Vaccines, Questions and Concerns, Centers for Disease Control and Prevention, last reviewed on August 14, 2020, https://www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html.

MMRV Vaccine and Febrile Seizures, Centers for Disease Control and Prevention, last reviewed on June 4, 2020, https://www.cdc.gov/vaccinesafety/vaccines/mmrv/mmrv-febrile-seizures.html.

VSD MMRV Safety Study, Centers for Disease Control and Prevention, last reviewed on June 29, 2020, https://www.cdc.gov/vaccinesafety/vaccines/mmrv/vsd-mmrv-safety-study.html.

Klein Nicola P., Bruce Fireman, W. Katherine Yih et al, Measles-Mumps-Rubella-Varicella Combination Vaccine and the Risk of Febrile Seizures, Pediatrics, July 2010, 126 (1) e1-e8; DOI: https://doi.org/10.1542/peds.2010-0665. https://pediatrics.aappublications.org/content/126/1/e1.

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 37: Honey in Medicine. 

Smoking cessation update. Honey in medicine. Uses, precautions, honey-related terms. Macroglossia and presbycusis are defined. Jokes about honey. 

Today is January 15, 2021. 

The American Thoracic Society approved a clinical practice guideline regarding pharmacologic treatment of tobacco dependence in adults. This guideline was published in May 2020 in the American Journal of Respiratory and Clinical Care Medicine. Seven recommendations about initial medications used in smoking cessation were given, five are STRONG recommendations and two are CONDITIONAL recommendations.

Let’s start with the STRONG recommendations for tobacco-dependent adults in whom treatment is being initiated:

Varenicline over a nicotine patch is recommended. Remarks: Be prepared to counsel your patients about the relative safety and efficacy of varenicline compared with a nicotine patch.

Varenicline over bupropion is recommended.

In patients who are not ready to quit smoking, treatment with varenicline rather than waiting until patients are ready to stop tobacco use is recommended.

In patients with comorbid psychiatric conditions, including substance-use disorder, depression, anxiety, schizophrenia, and/or bipolar disorder, varenicline over a nicotine patch is recommended.

For tobacco-dependent adults for whom treatment is being initiated with a controller, extended-duration (>12 weeks) over standard-duration (6–12 weeks) therapy is recommended. A controller is a medication with a delayed onset of effect that reduces the frequency and intensity of smoking (i.e. varenicline), whereas a reliever is a medication with acute effect to reduce cravings (i.e. nicotine gum). 

CONDITIONAL recommendations:

Varenicline plus a nicotine patch over varenicline alone is suggested (conditional recommendation, low certainty in the estimated effects).

Varenicline over electronic cigarettes is recommended. Remarks: serious adverse effects of e-cigarettes have been reported. The recommendation will be reevaluated if these reports continue. 

Quotes about honey: 

You catch more flies with honey than with vinegar.

No bees, no honey; no work, no money.

Honey is sweet but bees sting.

Be like the honey bee, anything it eats is clean, anything it drops is sweet, and the branch it sits upon does not break (Iman Ali, Pakistani actress)

When you go in search of honey you must expect to be stung by bees (Joseph Joubert, French moralist)

Life is the flower for which love is the honey (Victor Hugo, French poet)

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Claudia: Today we have a special episode to honor those with a sweet tooth. We will talk about the ultimate nature candy: honey. Yes, we will talk anything related to honey in medicine.

But... what is honey? It is a sticky, sweet, clear yellowish-brown fluid made by bees. How? you might wonder; well they collect nectar in their honey stomach or what they call the “crop” and as you might be guessing they create honey by vomiting this digested nectar. 

Hector: Let’s start with honeycomb lung. 

Claudia: Honeycomb lung — This is something many medical students and residents might hear for the first time and think huh? Unfortunately hearing a patient has honeycomb lungs is not at all “sweet news.” Honeycomb lung is indicative of end-stage pulmonary fibrosis, and many disorders such as Idiopathic Pulmonary Fibrosis, sarcoidosis, hypersensitivity pneumonia, and eosinophilic granuloma can progress to end-stage fibrosis, but cannot be detected by pathologists at this stage of the disease. For that reason, biopsy of extensive honeycomb lung is not helpful and should be avoided.

This Honey-comb appearance of lungs in CT scan has been found to be common in COVID-19.

Hector: Yes, honeycombing fibrosis seems to follow ground-glass opacities(1) in COVID 19 patients. Honeycombing are small cystic spaces with irregular thickened walls made out of fibrous tissue. A friend told me this bold statement: “A CT scan is more sensitive than PCR to detect COVID-19”. That puzzled me, and I had to look it up. The American College of Radiology issued a statement saying that “viral testing remains the only specific method of diagnosis. Confirmation with the viral test is required, even if radiologic findings are suggestive of COVID-19 on CXR or CT. CT is reserved for hospitalized, symptomatic patients with specific clinical indications for CT.”(2) Do not use CT for COVID-19 diagnosis.

Claudia: Next term is Honeymoon cystitis — Now why would you ruin a honeymoon which is supposed to be fun with the not so fun word cystitis.? Well because this uncomfortable infection is common in sexually active women and it makes sense that it can occur more often in newly-weds during a much-anticipated vacation. 

Hector: Recurrent urinary tract infections are a common problem in sexually active women. Anatomy is to blame of this problem. Sexual intercourse may cause local irritation of the urethral meatus and lead to cystitis ("honeymoon cystitis"). 

Claudia: Honey-colored crusts are present in Impetigo — This one is not as pretty as it sounds. Think of honey equals pus for this “honey colored crust”. Impetigo occurs most commonly on the face and can present with bullae, honey-colored crusts, erythema, edema, and exudate.

Hector: A very very important topic is Honey in infants— Because it must not be given to them! And here is why.  Infant botulism occurs when C. Botulinum spores, which can live in honey, are ingested, colonize the GI tract, and release a wicked toxin. In the US, most cases are thought to result from ingestion of environmental dust and soil containing C. botulinum spores. 

Claudia: The incidence of reported cases of infant botulism is highest in Utah, Pennsylvania, and California, states in which soil botulinum spore counts are high. 

Hector: Did you know Utah is called the beehive state? Infant botulism has been associated with the ingestion of raw honey, but telling people “Don’t give honey to your babies” has not changed the incidence of infant botulism in the United States.

[Insert joke here: Hey, a patient was admitted to the ICU because of botulism. Dr Saito: Did it take care of his wrinkles?

Claudia: Honey has a high fructose content, and it is part of the FODMAPs (fermentable oligo-, di-, mono-saccharides and polyols). A diet low in FODMAPs is recommended in patients with IBS. So, if you have IBS, honey is likely not the best sweetener for you. 

Now, let’s talk about Honeymoon phase of type 1 diabetes — A few weeks after the diagnosis and initiation of insulin therapy, a period of decreasing exogenous insulin (such as lispro or lantus) requirement occurs, commonly referred to as the "honeymoon" or remission phase of diabetes. During this period, the remaining functional beta cells in your pancreas secrete some endogenous insulin resulting in reduced exogenous requirement, so you give yourself less of the injectable insulin. 

Hector: I had a real case with this condition. He is a male patient on his mid 20s. He was diagnosed with diabetes let’s say in October 2019. He was admitted to the ICU because of DKA. His A1C was >11. He was sent home on insulin and then in January 2020 he decided to stop insulin “to see if he really needed it”. He came to me in July 2020, and I freaked out, I thought, “this guy’s sugar is going to be 500 and A1C will be in the double digits”. My surprise was that his insulin was 5.3! 

Claudia: Close monitoring of blood glucose is critical as hypoglycemic episodes are likely if the insulin is not adjusted appropriately. Some clues that the honeymoon phase in type 1 diabetes may be ending are: rising blood glucose levels, higher A1C, and increasing exogenous insulin need, that’s why monitoring is very important. The duration of this phase is variable and may last several months to several years. 

Hector: Let’s talk about folk medicine. This treatment has been known for centuries: Use of Honey in common cold – honey is an option for treating cough in children who are older than 1 year old with common cold symptoms. Honey can be given straight in 0.5 to 1 teaspoon or diluted in liquid like tea or juice. Corn syrup may be substituted if honey is not available. Honey has a modest beneficial effect on nocturnal cough and is unlikely to be harmful in children older than one year of age. Just as a reminder of what we covered earlier: Honey should be avoided in children younger than one year because of the risk of botulism.

Claudia:  In a randomized trial, 300 children (one to five years of age) with upper respiratory infection and nocturnal cough were assigned to receive a single dose (10 g) of honey (eucalyptus, citrus, or labiatae) or placebo (a date extract similar to honey in appearance and taste) before bedtime; caregivers completed a symptom survey on the days before and after the intervention; 270 children completed the study. Symptoms improved in all children after the intervention. However, children who received honey had greater mean improvement in cough frequency (1.85 versus 1.00 points), severity (1.94 versus 0.99 points) and bothersomeness (2.16 versus 1.25 points) than those who received placebo. 

Hector: Adverse effects such as abdominal pain, nausea, vomiting occurred in five patients, approximately evenly distributed among each of the honey and the placebo groups. The findings of this trial were confirmed in a 2018 systematic review and meta-analysis of randomized trials (mean difference in cough frequency -1.62, 95% CI -3.02 to -0.22)[3]. Honey also reduced cough frequency compared with no treatment and diphenhydramine.

Claudia: Given the relative safety and low cost of honey, the World Health Organization (WHO) and American Academy of Pediatrics (AAP) suggest it as a potential treatment for URI in young children who are older than one year. The American College of Chest Physicians suggests that honey is more effective than placebo for cough due to the common cold.

Hector: Now we can talk about one of the favorite topics of Dr Tu (listen to our episode 6 about wound care), let’s talk about the use of Honey in wound care — Did you guys know that honey has been used since ancient times for the management of wounds? Honey has broad-spectrum antimicrobial activity due to its high osmolarity and high concentration of hydrogen peroxide. 

Claudia: Medical-grade honey products are now available as a gel, paste, and impregnated into adhesive, alginate, and colloid dressings. Based upon the results of systematic reviews evaluating honey to aid healing in a variety of wounds, there are insufficient data to provide any recommendations for the routine use of honey for all wound types; specific wound types, such as burns, may benefit, whereas others, such as chronic venous ulcers and ingrown toenails after surgery, may not.

Hector: Honey in chemoprophylaxis in partial-thickness burns — so this is an interesting one; as we mentioned a couple of minutes ago honey has a broad spectrum antimicrobial activity, remember? High osmolarity and hydrogen peroxide content. Partial thickness burns are prone to rapid bacterial colonization which can potentially become an invasive infection. It makes sense that we can use honey for partial thickness burns.

Claudia: Anything more significant than sunburn or superficial burn since those do not need topical antimicrobials, normally, non-perfumed moisturizing cream is all that is needed. Silver Sulfadiazine can also be used but tends to delay healing. Modern hydrocolloid and silver impregnated dressings can be superior but surprise → honey “the ancient wound medicine” is still an effective treatment.

Hector: Great, we talked about honeycomb lung, honeymoon cystitis, honey-colored crusts in impetigo, honey in infants, honeymoon phase of type 1 diabetes, honey in common cold, wound care and burns. Fun fact: Honey can be stored indefinitely.

Jokes about Honey
by Katherine Schlaerth, Manuel Tu, Claudia Carranza, Gloria Villegas, and Gracie

Why do bees have sticky hair? --> because they use honey combs.

How do bees get to school? --> on the school buZZZ

What kind of bees make milk? --> BOO bees

What do you call a bee that lives in America? --> a USBee

What does a bee sit on? --> it’s Bee-hind 

What kind of bees live in graveyards? --> zom-bees

And remember, a bee that will not stop eating will eventually become a little Chuh-Bee!

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[Music] 

Speaking Medical: Macroglossia
by Xeng Xiong, MS4

Your tongue can say a lot about your health. Today, I will go over the medical term macroglossia which means enlargement of the tongue. Symptoms associated with macroglossia may include drooling, speech impairment, difficulty eating, snoring and airway obstruction. 

Macroglossia is an uncommon anatomical abnormality and is usually a sign of an underlying condition. Some of the diseases associated with macroglossia are Down syndrome, hypothyroidism, tuberculosis, sarcoidosis, and angioedema. 

Examination often reveals an enlarged appearance on the lateral margins of the tongue caused by crowding against the teeth.  It is important to consider macroglossia as a sign of an underlying disorder and proceed with focused diagnostic testing, including possible biopsy. 

Treatment should be directed at the underlying disorder. 

Thanks for listening to macroglossia and have a Tongue-tastic day!

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Speaking Medical: Presbycusis

Hi, I’m Dr Rodriguez and I am presenting the Medical Word of the week. 

If you remember, in episode 28, we talked about presbyopia, so today I will teach you about presbycusis. Presbycusis is just one form of hearing loss that happens as you age. Presbycusis affects more than half of all adults by the time they reach the age of 75. Presbycusis is a progressive sensorineural hearing loss that mostly affects hearing of high-pitched sounds. That means that a person with presbycusis might have trouble hearing a bird chirping, phone ringing, crowded places but still be able to hear a truck rumbling.

Multiple factors can influence the onset and severity of presbycusis, including white race, loud noise exposure, ototoxins (such as aminoglycosides), ear infections, smoking, hypertension, diabetes. 

In a patient with presbycusis, an audiogram will show decreased pure tone thresholds with relative preservation of word recognition. Even though hearing aids may offer some help, only a small percentage of patients actually receive effective treatment with amplification. Auditory rehabilitation, when available, is usually practiced in combination with hearing devices in presbycusis. For patients with severe presbycusis with poor response to conventional amplification, cochlear implantation offers hope to restore hearing.

So, remember the medical word of the week: presbycusis

Alyssa: Before you go, let me ask you a serious question. Many people told Beethoven that he would not make good music because he was deaf, but did he listen?

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[Music] 

Question of the week: Diabetes management

by Claudia Carranza, MD

Q: What is the first treatment approach for type 2 DM? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random BG of 210.

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Now we conclude our episode number 37: “Honey in Medicine.” We started with an update on medications used for smoking cessation. Then, Dr Carranza and Dr Arreaza presented medical conditions related to the word “honey”, and they explained evidence-based uses of honey in medicine. Dr Rodriguez defined presbycusis, and future Dr Xiong explained macroglossia. You may ask, “what does smoking, honey, deafness, and big tongues have in common?” The answer is: Family Medicine. Remember, the question of the week is: What is the first treatment approach for type 2 diabetes? The listener with the best answer will receive a prize! Send you answer to our email: [email protected].

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, Alyssa Der Mugrdechian, Yodaisy Rodriguez, Xeng Xiong, Katherine Schlaerth, Gloria Villegas, Manuel Tu, and Gracie Pena. Audio edition: Suraj Amrutia. See you next week!

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References:

Leone, Frank T.; Zhang, Yuqing; Evers-Casey, Sarah, and col., Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline,  American Journal of Respiratory and Critical Care Medicine, American Thoracic Society,  https://doi.org/10.1164/rccm.202005-1982ST

Combet M, Pavot A, Savale L, Humbert M, Monnet X. Rapid onset honeycombing fibrosis in spontaneously breathing patient with COVID-19. Eur Respir J. 2020;56(2):2001808. Published 2020 Aug 27. doi:10.1183/13993003.01808-2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338404/

ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection, American College of Radiology, https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection, accessed on Jan 13, 2021. 

Oduwole O, Udoh EE, Oyo-Ita A, Meremikwu MM. Honey for acute cough in children. Cochrane Database Syst Rev. 2018 Apr 10;4(4):CD007094. doi: 10.1002/14651858.CD007094.pub5. PMID: 29633783; PMCID: PMC6513626. https://pubmed.ncbi.nlm.nih.gov/29633783/

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 36: Birth Control and HTN.  

Gonorrhea treatment update. Use of birth control in hypertension. Explanation of allodynia and hyperalgesia. Tips on contraceptives. Jokes.

HAPPY NEW YEARS EVERYONE! Welcome to our first episode of 2021. We are full of hope and optimism for this new year, even though this year is looking just the same so far.

Outdated treatment for gonorrhea: Ceftriaxone 250 mg IM and azithromycin 1 gram PO.

Updated treatment of gonorrhea: On December 18, 2020, the CDC recommended a new treatment of uncomplicated urogenital, rectal, or pharyngeal gonorrhea with a single IM dose of 500 mg of ceftriaxone (instead of 250 mg). For patients who weigh more than 150 kg (300 lbs), the single intramuscular dose is 1 gram. If chlamydial infection has not been excluded, doxycycline 100 mg orally twice a day for 7 days is recommended (instead of azithromycin). However, azithromycin, 1 g PO single dose, is still recommended in pregnancy.

Allergy to cephalosporins: In patients with cephalosporin allergy, a single 240 mg IM dose of gentamicin PLUS a single 2 GRAMS oral dose of azithromycin is an option.

Expedited Partner Therapy – EPT: When permitted by state law, the partner may be treated with a single 800 mg oral dose of cefixime, and ADD oral doxycycline 100 mg twice daily for 7 days if chlamydia infection has not been excluded.

Test of cure: A TOC is not needed for patients with uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, a test-of-cure is recommended for pharyngeal gonorrhea, 7–14 days after initial treatment. 

Retest: ALL persons treated for gonorrhea should be retested 3 months after treatment. If retesting at 3 months is not possible, we should retest within 12 months after initial treatment.

Summary: treat urogenital, rectal, and pharyngeal gonorrhea with single IM dose of 500 mg of Ceftriaxone PLUS doxycycline 100 mg BID for 7 days. 

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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Interview to Dr Tammela by Dr Arreaza (unscripted)

Highlights of the interview:

What measurement is essential before starting combined oral contraceptives? The answer is blood pressure measurement.

Dr Tammela is the chief of women’s health in Clinica Sierra Vista. She is a practicing OB/Gyn specialist. 

Some topics discussed during the interview includes: 

Why is blood pressure measurement essential before starting combined hormonal contraception?

Contraindications to combined hormonal contraception

Three scenarios and recommend what type of contraception should be used: 

Patient younger than 35, healthy, well-controlled hypertension

Patient older than 35, well-controlled HTN, or patient of any age with BP 140-160/90-100 mm Hg

Patient of any age with blood pressure >160/100

Continued blood pressure monitoring after initiation of combined hormonal contraception

When to stop CHC

TIPS 
by Valerie Civelli, MD and Patrick De Luna, MS3

Which OCP to choose?

Tip #1:

In general, higher estrogen in birth control pills (35mcg) means better cycle control but worse estrogen-related side effects: such as nausea or breast tenderness. Lower dose estrogen birth control, (typically 20 µg) are better for those experiencing estrogen related side effects and must be taken at the same time every day. Remember: the lower the dose of Estrogen means the higher risk of breakthrough ovulation and breakthrough bleeding. LoLo® is a great option!

Dr. Karen Tammela, OBGYN, when asked about her OCP preference for patients, she states, “I pretty much always use monophasic pills. They seem in general to provide improved cycle control. I think most OB/GYN‘s agree...”

Tip #2:

For patients who c/o bloating, weight gain, hirsutism and acne, think about Yaz®, and its higher dose sister Yasmin®: Drosperinone + Ethinyl Estradiol. Yaz or Yasmin have a special type of progesterone, Drospirinone, which makes it unique. 

Tip #3:

Yaz and Yasmin: Let’s talk about insurance coverage (Family Pact and Kern Health) 12-month Supply may be provided twice in one year. For a 3rd dispense of 12-month supply, TAR is required for prior authorization. If you see this med was not covered, it’s likely the patient has been prescribed two-12/month supplies OCPs already. Submit a TAR in this case for coverage.

Tip #4:

Yaz or Yasmin are special because it is not just a low androgen option (which is what you look for in a pill for patients in need of acne control), but it is actually an ANTI-androgen, so it is THE BEST OPTION for acne. It also is the best option to reduce pill related weight gain, as the progesterone element (drospironone) acts as a diuretic.  Did you know Drosperinone has antiandrogenic properties equivalent to 25mg of spironolactone? 

Tip #5:

Menstrual headaches? Think Mircette®. Mircette® is good for patients with menstrual headaches, because it reduces the stark drop in estrogen that happens from the active pills to the placebo (and it is the drop that is believed to be the trigger for menstrual headaches) by having a smoother estrogen step-down effect and a shorter placebo pill length. In patients with migraines with aura, it is best to avoid Combined Hormonal Contraceptives, especially if older than 35.

Speaking Medical: Allodynia
by Xeng Xiong, MS4

Ouch my hair hurts! Are you serious? Yes. There is a condition where a person can experience pain from stimuli that isn't normally painful; the term is called allodynia. But wait, can that pain also be considered hyperalgesia? This is so confusing. Allodynia and hyperalgesia are both related to hypersensitivity to pain, so let’s break them down. 

Allodynia is the feeling of pain caused by usually nonpainful stimuli, such as brushing your hair. Allodynia results from increased pain receptors. Some people with migraine may have allodynia and will often describe this experience by saying, “My hair hurts.”

Hyperalgesia, on the other hand, is an increased numbers of action potentials and spontaneous discharges in response to painful stimuli leading to a lower threshold. This means a patient will experience more pain with a stimulus that was previously less painful. In practice, patients on high dose opioid may experience hyperalgesia and stroking on their skin can cause pain. The treatment for this condition is to lower the opioids dose.  

In the mist of all this medical jargons, allodynia and hyperalgesia are referred to as hypersensitivity to pain. However, their pathophysiology is different. Allodynia is related to stimuli that are generally non-painful which becomes painful upon stimulation, while hyperalgesia is related to stimuli that are generally painful but becomes significantly more painful when stimulated. By this time if you’re still confuse, Allodynia = non-painful stimuli; Hyperalgesia = painful stimuli. I hope listening to this was not so painful for you[3]. 

For your Sanity: Jokes
by Lisa Manzanares, MD

Finland has closed its borders, no one can cross the Finnish line.

Did you hear the rumor about butter? Well, I’m not going to spread it.

A cheese factory exploded in France. Da Brie is everywhere.

I have two dogs named Rolex and Timex. They are my watch dogs.

The difference between a numerator and a denominator is a short line. Only a fraction of people would understand this.

I know a lot of jokes about retired people, none of them work.

Now we conclude our episode number 36 “Birth Control and Hypertension”. Dr Tammela explained that whenever you have a patient with uncontrolled hypertension, be alert of the contraindications to hormonal birth control. Dr Civelli and Patrick gave us some interesting tips on birth control pills, and Xeng explained the difference between allodynia and hyperalgesia.  

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, Lisa Manzanares, Steven Saito, Valerie Civelli, Patrick De Luna, Xeng Xiong, and Mohammad Suleman. Audio edition: Suraj Amrutia. See you next week! 

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References:

St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1911–1916. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm?s_cid=mm6950a6_w#B1_down

Onusko, Edward, M.D., Diagnosing Secondary Hypertension, Am Fam Physician. 2003 Jan 1;67(1):67-74. https://www.aafp.org/afp/2003/0101/p67.html#afp20030101p67-t1.

Zeng, Thomas, MD, Comprehensive Handbook, Obstetrics & Gynecology, Second Edition, 2012 by Phoenix Medical Press LLC, pages 176-178.

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 35: Palliative Care and Hospice. 

COVID-19 vaccines and USPSTF recommendations. Palliative care and hospice briefly explained by Dr Tu. Pyogenic granuloma is defined. Feliz Navidad, and jokes.

Hepatitis B screening in adolescents and adults

First, on December 15, 2020, the USPSTF recommended to offer screening for Hepatitis B virus infection to all adolescents and adults at increased risk for infection, regardless of their immunization status[1]. Some examples of patients at increased risk are:

Those coming from countries with HepB prevalence above 2% (for example, most countries in Africa and Southeast Asia, South Korea, Italy, Colombia, Ecuador, and Peru, among others). 

Also, US-born children if they did not receive the HepB vaccine as infants AND their parents come from countries with a prevalence above 8% (check the list online).

Other groups include: IV drug users, MSM, HIV, even household contacts of persons known to have POSITIVE HepB surface antigen. 

Remember to order the right test for screening: HepB surface antigen. As a reminder, Hep B screening in pregnant women at the first prenatal visit is a USPSTF “A” recommendation. 

Screening for high blood pressure in children and adolescents

On November 10, 2020, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for high blood pressure in children and adolescents. This is a Grade I recommendation[2]. When screening, clinicians should consider risk factors, such as obesity, family history of hypertension, and ethnicities such as African-American or Hispanic. The grade I recommendation means that more research is needed. Maybe you guys can use that as a research idea.

Announcement of Coronavirus Vaccines

On December 11, 2020, the FDA granted an Emergency Use Authorization for tozinameran or the BNT162b2 vaccine, manufactured by Pfizer-BioNtech, becoming the first coronavirus vaccine approved in the USA. A week later, on December 18, 2020, the mRNA-1273 vaccine, manufactured by Moderna, was also approved for emergency use. The two vaccines are being administered as we speak to front-line health care providers across the nation. The two vaccines have an efficacy above 90%, and consist of two doses: 3 weeks apart for Pfizer, and 4 weeks apart for Moderna. They seem to reduce the risk of severe COVID-19.

Reported side effects include: injection site pain, fatigue, headache, muscle pain, and joint pain. Some people may experience fever. Side effects are more common after the second dose; younger adults, who have more robust immune systems, reported more side effects than older adults. Staggering vaccinations among staff is recommended.

The vaccines have not been tested in children or pregnant women yet. The American College of Obstetricians and Gynecologists (ACOG), recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on ACIP-recommended priority groups. ACOG recommends that pregnant individuals should be free to make their own decision in conjunction with their clinical care team. 

Efforts across the globe are being made to find a vaccine and medications to treat COVID-19. Sputnik V was a vaccine created in Russia and being distributed in allied countries; the Soberana 1 and Soberana 2 were created in Cuba and are under investigation; and in October, a “molecule” called DR-10 was announced in Venezuela that reportedly neutralizes 100% of SARs-CoV-2. There is so much to say about this topic, and the conversation may go beyond just science, but we invite you to follow the news from trustworthy sources as they continue to evolve. 

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

“You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.”

Dame Cicely Mary Saunders

End-of life care may be challenging but also very rewarding. You get to take care of people during this critical time or their lives. Some people think it’s the end of a life, some people see it as a period of your existence, a passage to a “better life” or whatever your belief is about it. As doctor, we consider seriously the principle of sanctity of life vs quality of life.  Today, we have Dr Tu, who previously talked about wound care, and now he comes with a new topic to discuss. Welcome again Dr Tu.

1.  Question #1: Who are you?

Presently I am a second-year family medicine resident.  And I recently finished my palliative care-hospice elective 2 weeks ago with Dr. Warren Wisnoff.  And I had a wonderful and full of learning experience during this rotation.  And I really want to share some of those experiences with you.

2.  Question #3: What did you learn this week?

Just like what I said I recently finished my elective KM with Dr. Wisnoff for palliative care and hospice.  I learned the difference between palliative care and hospice and the different services that are involved in this specialty. Palliative care and hospice service also known as end-of-life care and focuses more on comfort care and quality of life.

Difference between palliative care and hospice  

I am not an expert on palliative care and hospice but based on my recent elective and previous experience working in hospice care as a registered nurse there are overlapping similarities but also significant differences in terms of services being offered in palliative care and hospice.

Palliative care

Palliative care service is not reimbursable under CMS regulation.  Palliative care focuses on improving quality of life for patients with serious illness in their families.  This approach may include providing relief from pain and or other distressing symptoms, integrating psychological and spiritual aspects of care, assisting with difficult decision making, and supporting patients and families.  

Another main difference of palliative care from hospice is specialty services that patient can still benefit from chemotherapy and other specialty visits.

History

The specialty of palliative medicine arose as a direct result of the hospice movement.  Palliative medicine incorporates the holistic care developed by hospice, focusing on symptom management, supporting and assisting with communication, and providing such care to avoid a group of patients including those who are not dying or who cannot receive or choose not to receive hospice services.  Palliative care aims to relieve suffering and no stages of disease and is not limited to end-of-life care.

Type of services offered by palliative care service

Assessment and treatment of physical symptoms most especially pain.  Around 80% of cancer patient patients will complain of severe pain.  Or patient will also complain of breathlessness especially patients with congestive heart failure.  Symptom assessment and management are necessary not only to provide diagnosis but also to help in controlling these symptoms.  The symptoms are a big burden to patient's quality of life and there are management available to address these symptoms.  Pain management is critical and cancer patient and opiate management in patients with breathlessness.

Psychological, social, cultural, and spiritual aspect of care. Attention to the psychological, social, cultural, and social needs of patients and families is an important part of good medical care.  Symptoms of depression, anxiety, social and financial stressors, and caregiver burden are, and serious illnesses.  Patient's and family's approach of serious illness, death, and dying, and spiritual needs are often heightened near the end of life.  All clinicians who care for patients with serious illness need basic skills to recognize and treat uncomplicated depression and anxiety, recommending appropriate social supports, and eliciting and respecting cultural traditions since with well preferences.

Serious illness communication skills.  Basic serious illness communication skills include communicating bad news, eliciting patient preferences, establishing goals of care, identifying a surrogate decision maker, deciding about future CPR and mechanical ventilation and providing emotional support.  These skills are required routinely in the care of seriously ill patients and should therefore be familiar to all clinicians who provide palliative care.

Care coordination.  Basic care coordination in serious illness means of ensuring the transfer between healthcare settings are timely and reflect patient/family needs and goals.  Primary team must also have basic knowledge about how to refer patients for hospice care.

Hospice care is a model and philosophy of care that focuses on providing palliative care to patients with life limiting illness, focusing on palliating patient's pain and other symptoms, attending to their and their family's emotional and spiritual needs and providing support for their caregivers.

Candidates for hospice

Hospice is appropriate when patients are entering the last week to months of life and patients and their families decide to forego disease modifying therapies with curative/life-prolonging intent in order to focus on maximizing comfort and quality of life.  In the United States guidelines from Medicare are available to help in the determination of terminal status for hospice qualification.  Commonly if the patient meets the indication for an estimate of 6-month life expectancy using a decline in clinical status.

The hospice team

Registered hospice nurse: Primary case manager and is responsible for skilled nursing care and coordination of other members of the interdisciplinary team.

Hospice physician: They have medical and administrative roles, they may be board-certified in the specialty of hospice and palliative medicine.  Some hospice physicians visit patients at home particularly if the patient does not have an involved attending physician.  Hospice physician also acts as a liaison with attending clinicians and can assist with symptom management.

Primary attending physician or referring physician: They are encouraged to remain involved in the care of their patients after referral to hospice, unfortunately for the continuity of the doctor-patient relationship, this does not occur often. Ideally, the primary attending physician works directly with the hospice nurse and also in collaboration with the hospice medical director to monitor symptoms in order intervention such as medications or skilled nursing care.

Social worker: They provide psychological support for patients and families including counseling, bereavement support, burial/funeral planning, and/or referrals to other support systems.

Chaplain: He or she oversees the spiritual needs of patients and families.  Spiritual care is offered to patients with both formal and unstructured religious beliefs.

Home health aides: Home health aides and other direct care workers help the patient and caregivers in the home, including personal care, food preparation, and shopping.

Bereavement counselors: They are available to provide support to bereave once of hospice patients for the 13 months after patients that.

Community volunteers: Volunteers are a mandatory component of hospice care and received training and support for their work. They will provide extra support for patients and families such as reading to patients, visiting, and assisting with errands.

Managing common symptoms during end-of-life care

Clinician should follow certain guiding principles when prescribing medication for symptoms management at the end of life.  Medication should be used to treat the primary etiology of these symptoms.  For example, if the patient is anxious because of shortness of breath, treatment should focus on the dyspnea to alleviate the primary symptom and the resulting anxiety.  Medication should generally start at lower doses a titrate up or down until you get desired effect.  The dosing should initially be as needed (prn) and then transition to a standing dosage or long-acting medication for symptom management. Whenever possible, proactive regimens that prevent symptoms should be used, because it is generally easier to prevent than treating an acute symptom.

Pain: It is a common symptom occurring in approximately 50% of person in the last month of life.  It is important to recognize the patient's total pain which includes not only physical symptoms but also the psychological, social, and spiritual components of distress. Some medications include fentanyl, hydromorphone, morphine, oxycodone, and hydrocodone.

Dyspnea: Although dyspnea is common in patients with end-stage pulmonary and cardiac disease, it is also regularly observed in patients with cancer, CVA, or dementia. Opiates are the medications of choice for the management of breathlessness and end-of-life care, especially morphine.

Delirium and agitation: Patients often experience delirium and agitation in the last days and weeks of life.  Symptoms that do not cause the patient distress can be managed conservatively without medication.  It is essential to assess reversible or treatable causes of delirium such as medication adverse effects, uncontrolled pain or discomfort, constipation, or urinary retention. Medications: antipsychotics such as haloperidol and risperidone are effective in the treatment of delirium and agitation at the end of life.  Dosing for delirium tends to be significantly lower than for psychosis and schizophrenia.  Benzodiazepine should be used with caution for the treatment of agitation and delirium because they can potentially provoke increased symptoms in older patients.  However, benzodiazepines can effectively treat anxiousness and agitation in the last hours and days of life because of the potentially sedating effects.

Nausea and vomiting: These are common symptoms during the end of life. Multiple receptor pathways in the brain and in the gastrointestinal tract mediate nausea and vomiting. Medications that target dopaminergic pathways are effective like haloperidol, risperidone, metoclopramide, and prochlorperazine.

Constipation: Effective management of constipation is critical because constipation can lead to pain, vomiting, restlessness, and delirium. Common causes of constipation are low oral intake of food and fluids and adverse effects of opiates. Medications: stimulant laxative like senna, stool softener like docusate, and polyethylene glycol.

Oropharyngeal secretions: It is common for patients to lose the ability to manage oropharyngeal secretions as they progressed through the dying process.  This can result in noisy breathing pattern, sometimes referred to as death rattle. Medications: hyoscyamine, atropine sulfate, glycopyrrolate, and scopolamine.

Fever: Treatment of fever at the end of life is based on the patient's life expectancy and goals of care. Medication: acetaminophen, NSAIDs, corticosteroids.

Common end-of-life medications (hospice comfort kit):  Effective management of symptoms at the end of life is challenging but often can be achieved with fewer than 4 or 5 key medications which are commonly found in hospice comfort kit in the patient's home. The kit is composed of antipsychotics, antipyretics, benzodiazepines, opiates, and secretion medication.

Question #3: Why is that knowledge important for you and your patients?

There are significant number of patients that during the end of life still suffer significantly whether it is from pain, nausea and vomiting, severe dyspnea, or constipation. Hospice care provides medical care and support services that focus on quality of life rather than life prolongation or cure. Hospice philosophy seems to help patient achieve comfort and quality of life until they die with dignity, and the care and treatment provided are based on the patient and family goals and values.  As of 2015 and estimated 1.38 million Americans yearly are being served by hospice programs around the country, and around 50% of Medicare patients utilize hospice at some point in their care.

Question #4: How did you get that knowledge?

Before getting accepted in the residency program I worked as an RN case manager both in home health and hospice here in Bakersfield, and recently I finished an elective at Kern Medical with Dr. Warren Wisnoff. My other sources include the American Academy of Palliative and Hospice Medicine book, up-to-date, and the American Academy Family Physician website.

____________________________

Speaking Medical: Pyogenic Granuloma
by Muhammad Suleman, MS4 

I’m going to present to you a case and then I’ll explain our Medical word of the week. Just imagine you have a patient who is an 8-year-old child with no significant past medical history. He comes to the clinic with a concern of a red ball-like mass on his lower lip. The mother states it started as a small pimple and has progressively gotten bigger over the last 2 weeks. It is mildly tender, nothing makes it better or worse. Patient denies trauma, recent sick contact, or infections, or weight loss. Skin lesion is a friable, pedunculated mass on right side of lower lip, beefy red, moist, with no purulent discharge. It measures 1 cm x 1cm. What do you think it is?

This is a pyogenic granuloma (PG). Not to be confused with the other PG Pyoderma gangrenosum (another type of PG). Pyogenic granuloma is a benign vascular tumor of the skin or mucous membranes characterized by rapid growth and friable surface. Pyogenic granuloma occurs at any age, although it is seen more often in children and young adults. In children, most common in age 6-10 years old. Trauma can be a trigger of PG. It may also be drug induced (antineoplastic agents). It may also be found in chronic inflammation in ingrown toenails.

PG is usually solitary but can be disseminated. Sizes rarely exceed 1cm. PG may be pedunculated or sessile. The base is often surrounded by thick ring of epidermis. In pregnant women 2-3 trimester, we can see PGs in the oral cavity, which tends to regress after birth. 

PG usually regresses but can be treated with surgical treatments, such as full-thickness excision or cryotherapy) and topical and intralesional therapies.

So, remember the medical word of the week: Pyogenic granuloma (PG).

Espanish Por Favor: Feliz Navidad
by Yosbel Martinez, MD

As residents, we always want to have a good relationship with our patients. That is what we call rapport. Rapport is all we need to have a bidirectional conversation. Having a harmonious relationship with your patient will allow you to collect a more comprehensive history, perform an effective physical exam, discuss treatments and have a more enjoyable patient encounter. The ideal doctor-patient relationship should be one full of trust, accountability, and respect. This Christmas, if you have a Spanish-speaking patient, an easy way to break the ice may be telling them “Feliz Navidad”. We wish everyone of you a Merry Christmas and a Happy New Year from our Rio Bravo Family. 

____________________________

For your Sanity: Christmas Jokes
by Julia Peters, MS3, and Jennifer Amezcua, MA

Resident 1: What do you get when you cross a snowman with a vampire?
Resident 2: A mean, flying snowman? I don’t know. 
Resident 1: A Frostbite!

Resident 1: What do you get if you cross Santa with a detective?
Resident2: Santa Holmes?
Resident 1: Good thought: Santa Clues!

Resident 1: What do you call Santa when he's got no money?
Resident 2: Saint-NICKEL-less!

Resident 2: What do elves post on social media?
Resident 1: Elf-ies!

Resident 2: Someone must be mad at Frosty the Snowman.
Resident 1: Why?
Resident 2: Because they gave him two black eyes

Now we conclude our episode 35, “Palliative Care and Hospice.” We gave you an update on the USPSTF screening guidelines, and gave you the long-waited news about the coronavirus vaccines. Yes, we are full of excitement and hope. Then, Dr Tu explained the importance of providing palliative and hospice services to our chronically-ill and terminally-ill patients. Our patients deserve special care during those critical moments of their lives. Moe explained pyogenic granuloma, a small growth that can be alarming for patients but easily treated in office. Dr Martinez reminded us of the holidays by wishing us “Feliz Navidad”, and Jenni and Julia made us laugh with their silly jokes about Santa. May you enjoy the holidays!

This is the end of Rio Bravo qWeek. If you have any feedback about this podcast, send us an email to [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, Manual Tu, Xeng Xiong, Yosbel Martinez, Julia Peters, and Jennifer Amezcua. Audio edition: Suraj Amrutia. See you soon! 

References:

Screening for Hepatitis B Virus Infection in Adolescents and Adults, December 15, 2020, U.S. Preventive Services Task Force(USPSTF), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-screening.

High Blood Pressure in Children and Adolescents: Screening, November 10, 2020, U.S. Preventive Services Task Force(USPSTF), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/blood-pressure-in-children-and-adolescents-hypertension-screening#bootstrap-panel--6.

“Your questions about the coronavirus vaccine, answered”, The Washington Post, 

https://www.washingtonpost.com/health/2020/11/17/covid-vaccines-what-you-need-to-know/?arc404=true , accessed on December 21, 2020.

“Venezuela Developed A Drug That Eliminates The Coronavirus 100 Percent”, The Venezuelan Journal, https://thevenezuelanjournal.com/maduro-bivenezuela-developed-a-drug-that-eliminates-the-coronavirus-p2791-155.htm, accessed on November, 12, 2020.

Ross H. Albert, MD, PhD, End-of-Life Care: Managing Common Symptoms, Am Fam Physician. 2017 Mar 15;95(6):356-361. https://www.aafp.org/afp/2017/0315/p356.html, accessed on November 9, 2020.

Thompson Ruth M., Chirag Rajni Patel, and Kate M. Lally, Essential Practices in Hospice and Palliative Me, 5th edition, Unipac 1, Medical Care of People with Serious Illness, AAHPM.

Dawn A. Marcus, M.D., Treatment of Nonmalignant Chronic Pain, Am Fam Physician. 2000 Mar 1;61(5):1331-1338. https://www.aafp.org/afp/2000/0301/p1331.html.

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

Bonus Episode: Our History.  

Listen to some of the founders of the program as they share memories, dreams, anecdotes and vision for the Rio Bravo Family Residency Program. End of Season 1.

The sun rises over the San Joaquin Valley, California, today is November 6, 2020.

The 2021 Match season is in full development. We have reviewed many applications and interviews will begin this coming week. We wish good luck to all candidates. May you find a residency that meets your expectations and provides you the training you want.

Today we present a bonus episode to remember our program history. How did this residency program start? Who helped with the foundation of the program? What improvements are expected in the future? We will answer those and other questions in this bonus episode, and you will hear from some of the founders of the program.

Stay tuned.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.

“The only thing necessary for the triumph of evil is for good men to do nothing.” – Edmund Burke

Congratulations to the winner of the presidential elections in the United States of America. Good men need to be actively engaged in improving our society, otherwise evil will prevail and chaos, suffering and misery will spread. I think our residency program is an example of good things that have been done by good people. We will listen to an interview done by Dr Manzanares, our current chief resident, with Mr Schilling, former CEO of Clinica Sierra Vista and founder of the program. Sandra Lopez, our first residency coordinator, will also share her thoughts. And we will also hear from two graduates of our first class, Dr Cindy Her and Fernando Palacios. Dr Stewart will close the episode sharing her vision for the future. 

Foundation of the Rio Bravo Family Medicine Residency Program

The first class started on June 23, 2014. The first residents were: Hector Arreaza, Josue Balart, Rafael Chiquillo, Cindy Her, Fernando Palacios, and Adan Romero. Program Director: Carol Stewart; Program Coordinator: Sandra Lopez. Faculty: Irene Sunday and Ryan Cabatbat. 

The program was housed in the Greenfield Community Health Center until March 6, 2015, when the East Niles Community Health Center was officially opened to the public.

The program increased the number of residents in each class from 6 to 8 every year in 2019. 

Statistics: Graduates as of November 2020: 21, with 2 residents graduating by the end of January 2021, for a total of 23 residents. Stayed in the Central Valley: 14. Underserved areas: 19. Stayed in Bakersfield: 11. Stayed with Clinica Sierra Vista: 12.

Our mission: To Seek, Teach and Serve​

Educate and train high quality family medicine residents in multicultural, rural and underserved settings.

Support a family medicine-centered education service and research in Kern County.

Facilitate the development and sustenance of a regional service-education network for family physicians and allied health professionals.

Serve in a general capacity to facilitate, research and organize innovative approaches to health care in family and community medicine.

​Our Goals

Excellence in medical education.

Facilitate selection of practice sites in the Central San Joaquin Valley.

Provide ongoing support in practice through continuing medical education efforts, research activities and program educational activities.

Develop and implement the health team concept in the health care delivery system for this region.

Respect for resident’s well-being.

Instruct residents in longitudinal care of their patients with an understanding of the impact of psychosocial factors on their health and wellbeing.

Teach residents the principles of health maintenance, disease prevention, health education and community-oriented primary care, in addition to caring for a broad range of acute and chronic problems encompassing the fields of pediatrics, adult medicine, and OB/GYN.

Highest quality patient care.

Sustain learning environments that foster academic excellence, inspire the highest standards of professionalism, and ensue the delivery of safe, high-quality care to patients.

Serve in a general capacity to facilitate, research and organize innovate approaches to health care in family and community medicine.

Needs met by the residency program: 

Patients seen: Each resident sees a minimum of 1650 patients in clinic and 1040 patients in hospital before graduation. That’s 2,690 patients per resident. If we have 23 graduates = 61,870 patients seen in by our graduates, and that does not include the patients seen by all other residents who are in the program.

Our service area

The population we serve has a variety of acute and chronic conditions. 

Unique to this area is Valley Fever. Residents who are interested in infectious Disease may find a variety of acute and chronic infections, including HIV, STIs, hepatitis, tuberculosis, and more.

Training in the care of patients with substance abuse and addiction, including to opioids.

Diverse makeup of resident group

Currently we have residents with at least 17 different backgrounds and between residents and faculty, we speak 9 languages, 90% of our team is bilingual. 

Rotations with top specialists in the community

Our main hospital is Kern Medical, but we also have relationships with other specialists in our community, which includes multiple private practices in Radiology, Dermatology, Occupational Medicine, and more, to be integrated in Bakersfield and offer a well-rounded training for residents and a multidisciplinary treatment for our patients.

Wellness, familial atmosphere, leading into high retention rate

We have a spirit of friendship in our residency. We have a cake for every birthday and we have wellness activities every 5th Wednesday. 

We have an annual and semiannual retreat to promote wellness among residents.

We have multiple family-friendly social event throughout the year (Halloween, Christmas, other special occasions)

Program growth since opening

Dr Arreaza, Dr Marquez and Dr Saito are graduates from the residency and now are part of the core faculty.

“New” location: From Greenfield to East Niles.

More faculty with new initiatives

New initiatives: POCUS, research, podcast, increased OB/GYN procedures and continuity deliveries, increased in the number of residents from 18 to 24)

Improved hospital experience by increasing the number of residents on the inpatient team, improved night float support

The program has gained a good reputation in the hospital, as residents rotate through different services (from unknown to colleagues).

These are the graduates by class:

First Class:

Hector Arreaza –Bakersfield, CSV, trained in obesity medicine, residency core faculty

Josue Balart- Bakersfield, CSV, trained in obesity medicine

Rafael Chiquillo- HIV fellowship, Los Angeles

Cindy Her- Kaiser in Sacramento area

Fernando Palacios- hospitalist in Temecula, CA

Adan Romero – Los Angeles

Second Class:

Jasmeet Bains – Taft CHC, Psych fellow

Olga Meave – Bakersfield, CSV, CMO

Omar Salamanca – Lamont/Arvin, CSV, per diem preceptor

Arlenis Barroso – CSV Greenfield

Verna Marquez – Bakersfield, CSV, residency core Faculty

Rhett Pelaez – Bakersfield, Kern Medical

Third Class:

Yoel Olazabal – Lamont, CA, CSV Lamont

Hamlet Garcia – Ventura, CA

Matthew Beare – Bakersfield, CSV, Medical Director of Special Populations, per diem preceptor

Jorge Palomino – Weed, CA 

Mark Rivera –Bakersfield, private practice

Fourth Class:

Ronald Gavilan – Taft, CA, per diem preceptor

Yunior Martinez – Bakersfield, CSV, per diem preceptor

Amna Fareedy –Central Valley, graduated in November 2020

Greg Fernandez – Fresno, CSV, walk-in Supervisor

Steven Saito – CSV, residency core faculty

Lisa Manzanares –Central Valley, will graduate Jan 2021.

Now we conclude our first season with episode number 34 - a bonus episode about Rio Bravo’s History. We appreciate all those who have set the foundation of the program, and we anticipate a brilliant future as it continues to expand and improve!

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 week we thank Lisa Manzanares, Tana Parker, Stephen Schilling, Sandra Lopez, Cindy Her, Fernando Palacios, Carol Stewart, and Hector Arreaza. Audio edition: Suraj Amrutia. See you next season!

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!

Saba and Dr Arreaza gave us a brief review on the flu shot. Influenza vaccination starts at 6 months of age. Vaccinate everyone including pregnant women. Pectoriloquy is basically being able to understand the voice of a patient with a stethoscope placed on their chest. We learned the Spanish word gripe (gree-pay) which means cold and flu in Spanish. 

The sun rises over the San Joaquin Valley, California, today in October 30, 2020.

Halloween is just around the corner! Today we will talk about vaccines because the new influenza season just started. If you have not realized it yet, this podcast is a strong defender of vaccines. So today we bring you what you need to know about the feared flu shot.

Some fun facts about cold and flu symptoms. 

A cough can travel as fast as 50 mph and expel almost 3,000 droplets in just one go. Sneezes can travel up to 100 mph and create about 100,000 droplets. Yikes![1] During a pandemic, coughing or sneezing in public may even be more embarrassing than farting. 

Did you know that the average adult produces about 1.5 quarts of mucus a day, that’s 48 ounces! and we swallow most of it. As a reference, a Big Gulp has about 30 ounces. The amount of mucus can double or triple during infections. That’s a lot to swallow!

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse and you say that you are neutral, the mouse will not appreciate your neutrality.” — Desmond Tutu.

This is not a podcast about politics, but with elections coming soon, we remind everyone to vote for the candidate who represents their values and beliefs. The two big contenders, Donald Trump and Joe Biden, have their own opinions and two different visions of what they want to do in the following 4 years in America. So, go and vote! You can decide who is the oppressor and who is the oppressed, based on your own judgement.

Here we have Saba Ali, a fourth-year medical student who will talk about influenza vaccine.

Timing of vaccine

Saba: Remember to start influenza vaccination at 6 months of age. Any patient who has not received any influenza vaccine before age 8 should receive 2 doses 1 month apart. Vaccination is most effective if received by the end of October, although a vaccine administered in December or later is likely still beneficial.

Intranasal vaccine

Arreaza: And for those who are scared of needles, we have good news: The “intranasal vaccine” or live attenuated influenza vaccine (LAIV4) is approved for use in healthy non-pregnant individuals, 2 years through 49 years of age. 

Saba: Don’t use LAIV4 in younger than 2 years or older than 50 years, pregnant women, patients with severe allergies to previous flu vaccines, patients younger than 18 receiving aspirin or salicylate-containing medications, immunosuppressed patients, caregiver of immunosuppressed patients, children younger than 5-year-old with asthma, people on antiviral medications, patients with active communication between the CSF and oropharynx, nasal pharynx, nose, or ear, or any other cranial CSF leak, and patients with cochlear implants, asplenia or persistent complement component deficiencies.

Types of vaccines

Arreaza: CDC recommends using any age-appropriate influenza vaccine: 1. inactivated influenza vaccine [IIV], 2.  recombinant influenza vaccine [RIV], or 3. live attenuated influenza vaccine (LAIV). No preference is expressed for any influenza vaccine over another. 

Egg Allergy

Saba: A common question we have from patients is “I have egg allergy; can I still get the flu shot?”

Arreaza: The answer is: The influenza vaccine contains potential allergic components that may cause an anaphylactic reaction. One such allergen is egg proteins. Currently, all vaccines except for (Flublok (RIV4) quadrivalent for ≥18yo, and Flucelvax (IIV4) quadrivalent for ≥4yo) may contain trace amounts of egg proteins such as ovalbumin. Healthcare providers should be aware that allergic reactions, although rare, can occur at any time, even in the absence of a history of previous allergic reactions to vaccines. Therefore, providers giving the vaccination should have a plan for emergencies and be trained in cardiopulmonary resuscitation. 

Saba: The following are recommendations for patients with a history of egg allergies:

1. Patients with only urticaria after exposure to egg should receive an influenza vaccine appropriate for their age and health status. 
2. Patients that report having more severe reactions to egg and required epinephrine or other emergency intervention can also get any vaccine appropriate for age and health status. If a vaccine other than CCIIV4 or RIV4 is given, it should be given in an inpatient or outpatient setting supervision of a healthcare provider who can manage and identify severe allergic reactions. No post-vaccination observation is recommended; however, providers are advised to observe patients for 15 minutes after administering the vaccine for concern of injury secondary to syncope. 

Contraindications

Arreaza: When is the flu shot contraindicated? The only true contraindication to the influenza vaccine is a severe allergic reaction to a previous influenza vaccination regardless of the suspected allergen responsible for the reaction. 

Gillian-Barre Syndrome

Saba: Let’s talk briefly about Guillain-Barre Syndrome (GBS). GBS is a rare autoimmune disorder which causes muscle weakness and paralysis. GBS can last a few weeks or longer. Most people recover fully, but some people have long-term nerve damage. GBS can be deadly if the respiratory muscles are affected. In the United States, an estimated 3,000 to 6,000 people develop GBS each year, about 80 to 160 cases each week, regardless of vaccination. 

Arreaza: Since 1973, the data about increased risk associated with influenza vaccines is variable and inconsistent across flu seasons. When there has been an increased risk, it has consistently been in the range of 1-2 additional GBS cases per million flu vaccine doses administered.

Saba: Anyone can develop GBS; however, it is more common among older adults. The incidence of GBS increases with age, and people older than 50 years are at greatest risk for developing GBS. What if the patient has history of GBS? Should they get vaccinated? 

Arreaza: A history of GBS within 6 weeks of a previous dose of any type of influenza vaccine is considered a precaution to vaccination. Persons who are not at higher risk for severe influenza complications and who are known to have experienced GBS within 6 weeks of a previous influenza vaccination generally should not be vaccinated. As an alternative to vaccination, providers might consider using influenza antiviral chemoprophylaxis for these persons. 

Influenza and COVID-19

Saba: And what about COVID-19 patients? Visits for routine vaccination should be deferred for asymptomatic and pre-symptomatic persons who have tested positive for SARS-CoV-2, the virus that causes Influenza vaccine should be postpone in patient with asymptomatic COVID-19 for 10 days from their positive test result. 

Arreaza: For symptomatic persons with suspected or confirmed COVID-19, visits for routine vaccination should be deferred until criteria have been met for them to discontinue isolation: at least 10 days after symptom onset AND 24 hours with no fever without the use of fever-reducing medications AND COVID-19 symptoms are improving, AND the person is no longer moderately to severely ill. Moderate to severe illness with or without fever is a precaution to vaccination for all vaccines. 

Saba: If a patient has been exposed to a person with COVID-19, wait until their 14-day quarantine period has ended. For additional considerations regarding influenza vaccination of persons who are already in healthcare or congregate settings, we invite you to review the most current information from the CDC and ACIP websites.

____________________________

Speaking Medical: Pectoriloquy
by Levi Shen, MS3

The word for today is pectoriloquy.

Normally, you should not be able to understand the words “One-two-three” when you auscultate the lungs. 

Pectoriloquy refers to the increased resonance of the voice through lung structures so that it is intelligible during auscultation. It is a useful tool that clinicians may employ to identify areas of consolidation in a patient’s lung, which may indicate pneumonia, fibrosis or even cancer. 

Types of pectoriloquy include: 

1. Egophony: It is a result of enhanced transmission of high-frequency sound across fluid or solid, with lower frequencies filtered out. In practice, this would involve a patient making a long E sound which is then heard as an A sound by the physician; this is known as the E to A transition.
2. Bronchophony: Normally, the sound of a patient's voice is less clear in peripheral airways as compared to the larger airways. In bronchophony however, the patient's voice remains loud at the periphery, indicating possible consolidation. 
3. Whispered pectoriloquy: It is similar to bronchophony, except that in this test, the patient is told to whisper. If there is consolidation, the physician should be able to hear the patient clearly during auscultation. Bronchophony and whispered pectoriloquy take advantage of the fact that sound travels faster through fluid and solid, resulting in decreased loss of volume. 

Common words that physicians ask patients to repeat are “one-two-three”, "toy boat”, "Scooby Doo", and “blue balloons”. Another common word used is “ninety-nine.” There is historical significance to this. When the test was originally described by a German physician, he used the phrase "neunundneunzig”, which he found would cause maximum vibration of the chest. And what does that word mean in English? Ninety-nine.

When physicians find pectoriloquy during physical, they may confirm diagnosis with labs and imaging.

Remember the word of this week, pectoriloquy.

____________________________

Espanish Por Favor: Gripe
by Anabell Lorenzo, MD

“Doctora, tengo gripe”. 

The Spanish word of the week is gripe. When you see the spelling of the Spanish word gripe, in English you may think the patient has a colic. That’s why you can find “gripe water” which is a non-prescription medication for colicky in babies. But gripe (gree-pay) means having a cold or the flu. People may use the word gripe for any runny nose, cough, sneezing… or any upper respiratory symptoms. Your job is to determine what is causing the gripe based on your clinical judgment, and use additional studies as needed. Most gripes are viral colds, and most of them need only conservative management (rest, fluids, acetaminophen), but don’t forget to rule out other serious causes, including COVID-19 and influenza. During this flu season, remember the Spanish word gripe.

____________________________

For your Sanity: Skeletons
by Tana Parker, MD, and Steven Saito, MD

Where do you send a patient injured in a Peek-a-Boo accident? Straight to the I.C.U.

Why don’t skeletons ever go trick-or-treat? Because they have no body to go with.

Why didn’t the skeleton cross the road? Because it did not have the guts to do it.

Within minutes the detectives knew what the murder weapon was. It was a brief case.

Conclusion: Now we conclude our episode number 33: “Flu”. Saba and Dr Arreaza gave us a brief review on the flu shot. Remember to start influenza vaccination at 6 months of age, and vaccinate everyone including pregnant women. Then we learned the word pectoriloquy, which is basically being able to understand the voice of a patient with a stethoscope placed on the chest. And to finish up our episode, we learned the Spanish word gripe (gree-pay) which means cold and flu. 

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, Saba Ali, Anabell Lorenzo, and Levi Shen. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

1. “How Fast Is a Sneeze Versus a Cough? Cover Your Mouth Either Way!”, May 12, 2016, American Lung Association, https://www.lung.org/blog/sneeze-versus-cough#:~:text=Sneezes%20win%20though%E2%80%94they%20can,create%20upwards%20of%20100%2C000%20droplets, accessed on October 29, 2020. 

1. “Mucus is gross. But here are 9 things you should know about it.”, VOX, https://www.vox.com/2015/2/11/8013065/mucus-snot-boogers, accessed on October 29, 2020. 

1. Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2020–21 Influenza Season. MMWR Recom Rep 2020;69(No. RR-8):1–24. DOI: http://dx.doi.org/10.15585/mmwr.rr6908a1

1. Influenza Vaccination: Updated 2020–2021 Recommendations from ACIP, Am Fam Physician. 2020 Oct 15;102(8):505-507. https://www.aafp.org/afp/2020/1015/p505.html

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