Rio Bravo qWeek

Episode 23: Blood Clots: DVT

The sun rises over the San Joaquin Valley, California, today is August 14, 2020. 

Pain relief is a task that always keeps doctors very busy, especially if pain relief can be accomplished by a medication that is easily-administered, given at a convenient frequency, with no adverse effects, and with no addiction potential (specially to fight the so-called “opioid epidemic”). And if that medication contributes to healing the pain-causing condition, then that’s a perfect medication for pain relief. As a result of that endless search for a perfect pain reliever, the University of Southern California Health Sciences presented a new study on July 13, 2020, revealing that kappa opioids, a significantly less addictive opioid, may both preserve cartilage in joints and also ease pain in osteoarthritis (1). Sorry UCLA, we have to accentuate the positive regardless of the source. Go Bruins! 
 

On August 11, 2020, we woke up to the news that Russia’s government registered the first COVID 19 vaccine in the world. President Vladimir Putin stated that his own daughter was inoculated with the vaccine and “she is feeling well and has high number of antibodies”. While some celebrated the Russian “big step for humanity”, some experts expressed concerns about safety, including the World Health Organization, warning Russia to adhere to standard protocols for testing a vaccine (2). 

Coronavirus has brought more than a disease to the world, it has brought extensive material for political debate and controversy. There is a joke that circulated in social media that may be relevant in this case: A patient asks her doctor, “When will this coronavirus be over?”, and the doctor answers, “I don’t know, I’m not that involved in politics”. We hope humanity steps up and joins forces to overcome this devastating disease.

____________________________

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 
____________________________

“[As doctors, let’s], never forget that we have the opportunity to do more good in one day than most people have in a month."― Dr. Suneel Dhand

Dear residents, how many opportunities did you have to do good today? It’s a great privilege to be instruments to relief pain, find a solution, and bring peace and happiness to your fellow men. It’s really a privilege. We have today an experienced doctor with whom I’ve had multiple conversations, and I’m very happy for having him in our residency program. Welcome, Dr Gonzalez.

Question Number 1: Who are you? 

My name is Alejandro Gonzalez Perez, I am a second-year resident in the Rio Bravo Family Medicine Residency Program here in Clinica Sierra Vista, Bakersfield, California. I was born in Cuba where I finished medical school and completed a medical residency in Family medicine, and then a residency in Radiology. I am a father of three children, two boys and one girl. I enjoy spending time with my family and friends. My favorite music: Latin music. Favorite sport: I like to go to the gym but I enjoy seeing martial art combats. Favorite movies: action, fiction, and martial arts.

Comment: I recently watched The Karate Kid in Netflix, it’s a good show, and they’ll have a sequel in Netflix this month with the same actors of the original movie. 

Question number 2: What did you learn this week?

Currently I’m on the Cardiology rotation. My number one goal in this rotation is optimize treatment for patients in the inpatient and outpatient settings. For example, I am learning how to better handle medication for Heart failure, CAD, HTN, and arrhythmias. And, almost all the patients have combined diagnosis, so you need to select the appropriate medication for HF with CAD, or HF combined with CAD and HTN, or HF with Afib, etc. 

In addition, my knowledge about diagnostic tests has improved, ECG, Echocardiogram, Cardiac Cath, troponin management. Also, I have learned how to improve the interactions between different services in the hospital. I hadn’t had a previous rotation with Internal Medicine, but in this rotation, I’m spending time with some IM residents, and it’s been positive for me.

Venous thromboembolism (VTE)

VTE refers to a blood clot that starts in a vein. It is the third leading vascular diagnosis after heart attack and stroke, affecting between 300,000 to 600,000 Americans each year. The mos common presentations are: Deep vein thrombosis (DVT) of the lower extremity and pulmonary embolism (PE). 

Pathophysiology

The Virchow's triad proposes that VTE is a result of three conditions: Alterations in blood flow (i.e., stasis), Vascular endothelial injury, and Alterations in the constituents of the blood.

The causes of venous thrombosis can be divided into two groups: hereditary and acquired.

Hereditary causes: Factor V Leiden mutation, Prothrombin gene mutation, Protein S deficiency, Protein C deficiency, Antithrombin deficiency.

Acquired risk factors: Prior thrombotic event, recent major surgery, presence of a central venous catheter, trauma, immobilization, malignancy, pregnancy, the use of oral contraceptives or heparin, myeloproliferative disorders, antiphospholipid syndrome (APS), and a number of other major medical illnesses. Of note, a special risk factor is the s-called “Sitting Disease” which, broadly speaking, is defined as a condition of increased sedentary behavior associated with adverse health effects.

Provoked vs Unprovoked DVT

The term unprovoked deep vein thrombosis (DVT) implies that there is not an evident cause for DVT. In contrast, a provoked DVT is usually caused by a known event.

Proximal vs Distal DVT

Proximal DVT is located in the popliteal, femoral, or iliac veins. Isolated distal DVT has no proximal component, it is located below the knee, and is confined to the calf veins (peroneal, posterior, anterior tibial, and muscular veins)

Symptomatic vs Asymptomatic DVT

Symptomatic DVT refers to the presence of symptoms that usually leads to the radiologic confirmation of DVT, whereas asymptomatic DVT refers to the incidental finding of DVT on imaging in a patient without symptoms (eg, computed tomography).

Symptoms of DVT

Throbbing or cramping pain in 1 leg (rarely both legs), usually in the calf or thigh.

Swelling in 1 leg (rarely both legs)

Warm skin around the painful area.

Red or darkened skin around the painful area.

Swollen veins that are hard or sore when you touch them.

Diagnosis of DVT

Duplex ultrasonography: It can detect blockages or blood clots in the deep veins.  It is the standard imaging test to diagnose DVT. Comment: Yeah! for POCUS in clinic?

D-dimer: It rules out DVT if it is negative.

Contrast venography: Dye is injected into a large vein in the foot or ankle deep veins in the leg and hip.  It is the most accurate test for diagnosing blood clots but it is an invasive procedure, for that reason, this test has been largely replaced by duplex ultrasonography, and it is used only in certain patients.

Magnetic resonance imaging (MRI) and computed tomography (CT) scan. These tests can provide images of veins and clots, but they are not generally used to diagnose DVT.

Treatment of DVT

Anticoagulants: Anticoagulation (commonly referred to as “blood thinners”) is the mainstay of therapy for patients with deep vein thrombosis (DVT). Anticoagulation is indicated for all patients with proximal DVT and select cases of distal DVT. To decide on anticoagulation, we must weigh the benefits versus the risk of bleeding. The primary objective of anticoagulation is the prevention of further thrombosis and of early and late complications. Major early complications of DVT include clot extension, pulmonary embolism (PE), major bleeding (from anticoagulation), and death. Late complications include recurrent clot, post-thrombotic (post phlebitic) syndrome, and chronic thromboembolic pulmonary hypertension. 

The most frequently used injectable anticoagulants are: unfractionated heparin (IV), Low molecular weight heparin (LMWH) (SQ), and Fondaparinux (SQ).

Anticoagulants that are taken orally (swallowed) include Warfarin and NOACs: Dabigatran, Rivaroxaban, Apixaban, and Edoxaban. All of the anticoagulants can cause bleeding, so people taking them have to be monitored to prevent unusual bleeding. Monitoring can be with INR (Warfarin) or clinically (NOAC).

Thrombolytics: Thrombolytics (commonly referred to as “clot busters”) work by dissolving the clot. They have a higher risk of causing bleeding compared to the anticoagulants, so they are reserved for severe cases.

Inferior vena cava filter: When anticoagulants cannot be used or don’t work well enough, a filter can be inserted inside the inferior vena cava (a large vein that brings blood back to the heart) to capture or trap an embolus (a clot that is moving through the vein) before it reaches the lungs.

Thrombectomy/Embolectomy: In rare cases, a surgical procedure to remove the clot may be necessary.  Thrombectomy involves removal of the clot in a patient with DVT.   Embolectomy involves removal of the blockage in the lungs caused by the clot in a patient with PE.

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

In primary practice, we encounter patients with symptoms that may be suspicious for DVT. We must be able to diagnose and treat these patients in a timely manner to prevent further complications. DVT is just below MI and stroke in frequency.

Question number 4: How did you get that knowledge?

I got interested in this topic because of many previous patients I had with this condition. I investigated multiple sources, including, of course, Up to Date, Medscape, but this knowledge has been accumulated over the years of study.

Question number 5: Where did that knowledge come from?

Up to Date, Medscape, Family Practice Notebook, and Epocrates.

____________________________

Speaking Medical: Phlegmasia cerulean dolens
by Dr. Valerie Civelli

Phlegmasia cerulea dolens means “painful blue inflammation”. It is an uncommon but severe form of DVT which results from extensive blockage by a thrombus of the major and the collateral veins of an extremity. This phenomenon was discovered by Jonathan Towne a vascular surgeon in Milwaukee, USA. 

Phlegmasia cerulea dolens (PCD) is a precursor of frank venous gangrene. It is characterized by severe swelling, cyanosis and blue discoloration. 

The next time you look down at a leg that appears like it’s from the blue man group in Las Vegas or appears smurf-like, think of Phlegmasia cerulea dolens.

____________________________

Espanish Por Favor: Coágulo
by Dr Valerie Civelli

Coágulo may be a word difficult to pronounce, but it is very important in the context of DVT, MI, or stroke. You may guess what coágulo means by remembering the word anticoagulant. Yes, coágulo means blood clot. “Señor Pérez, usted tiene un coágulo en las piernas” means “Mr Perez, you have a blood clot in your legs”. Coágulo may be used by a patient who also has blood clots in her menstrual period during an episode of menorrhagia or during other excessive bleeding. Now you know the Spanish word of the week: Coágulo.

____________________________

For your Sanity 
by Drs. Steven Saito, Gina Cha, and Alyssa Der Mugrdechian

What’s black, long and hangs from an a*hole? A stethoscope.

--Patient: Doctor, my son ate a firefly!
--Doctor: Why did he do that?
--Patient: He wanted a light snack.

--Patient: Doctor, doctor, I’ve had a terrible stomachache after eating tamales.
--Doctor: Were they fresh?
--Patient: I don’t know, how can you tell?
--Doctor:  How did they look when you removed the corn husk?
--Patient: Were you supposed to remove the corn husk?

Now we conclude our episode number 23 “Blood Clots: DVT”. Dr Gonzalez explained the basics of Deep Venous Thrombosis (DVT) and reminded us that DVT can be easily diagnosed by ultrasound, and that timely treatment prevents acute and chronic complications. Phlegmasia cerulean dolens is just another way to say “painful blue inflammation”, a severe type of DVT that occurs when the MAJOR and COLATERAL veins in a limb are occluded; then, were given the advice by Dr Civelli to recall the word anticoagulant to remember the Spanish word coágulo (blood clot). And we cannot finish this episode without mentioning the name of the first registered COVID-19 vaccine. It’s called Sputnik V. We tried several times to record that name in the intro, but we could not stop laughing. We honestly hope the Sputnik V is a great success regardless of its amusing name.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. 

Our podcast team is Hector Arreaza, Alyssa Der Mugrdechian, Alejandro Gonzalez, Steven Saito, Valerie Civelli, Gina Cha, and Ariana Lundquist. Audio edition: Suraj Amrutia. See you soon!

_____________________

References:

University of Southern California - Health Sciences. (2020, July 13). Significantly less addictive opioid may slow progression of osteoarthritis while easing pain. ScienceDaily. Retrieved August 12, 2020 from www.sciencedaily.com/releases/2020/07/200713120014.htm

“Russia registers COVID-19 vaccine, Putin says daughter already inoculated” by Yaron Steinbuch. August 11, 2020, New York Post.

Sterns, Richard H, “Causes of hypotonic hyponatremia in adults”, Up to Date, retrieved on Aug 13, 2020. https://www.uptodate.com/contents/causes-of-hypotonic-hyponatremia-in-adults?search=potomania&source=search_result&selectedTitle=2~2&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!

The sun rises over the San Joaquin Valley, California, today is August 7, 2020.

Have you heard any news about COVID-19? You surely have, who hasn’t? But above all the negativity surrounding this disease, including political issues, there is hope for the future. Have you heard of, for example, mRNA 1273?(1) Could this be the vaccine we have been waiting for? We don’t know yet, but there are more than 21 vaccines being tested right now around the world. If an effective vaccine is found, you’ll certainly hear about it in this podcast.

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”― Viktor E. Frankl

1. Who are you?

I am Dr Velazquez Amador, I am originally from Jalisco, Mexico where I was born and race. I completed my medical studies at the Universidad of Guadalajara, and now I on the third year of FM residency.

1. What did you learn this week?

I learned about a patient whom had an incomplete work up for adrenal insufficiency but still treated. He ended up showing signs of Cushing’s syndrome and resistant hypertension. I want to talk about secondary hypertension and Primary Aldosteronism.

Why that knowledge important for you and your patients?

It is important because it reminds me that secondary causes of hypertension are often under diagnosed. 

How did you get that knowledge?

Reading upon new cases, specially from the inpatient population, it often leads me to find new differentials and new testing modalities. 

Where did that knowledge come from?

First line review data place for me is Uptodate now that I am in residency. But the initial knowledge came while on Medical school. Reading physiology and physiopathology books. The book that I like to consult a lot is Kelly’s Essentials for Internal Medicine, this book chapters encompass anatomy, physiology and the pathology aspect beside diagnoses and treatment. It is very complete. While in residency, also my reference is the AAFM articles. 

• Severe or resistant hypertension 
• An acute rise in blood pressure over a previously stable value 
• Proven age of onset before puberty 
• Age less than 30 years with no family history of hypertension and no obesity 

• Unexplained creatinine elevation and/or acute and persistent elevation in serum creatinine of at least 50% after administration of ACE inhibitor, ARB, or renin inhibitor 
• Moderate to severe hypertension in a patient with diffuse atherosclerosis, a unilateral small kidney, or asymmetry in kidney size of more than 1.5 cm that cannot be explained by another reason 
• Moderate to severe hypertension in patients with recurrent episodes of flash pulmonary edema 
• Onset of hypertension with blood pressure >160/100 mmHg after age 55 years 
• Systolic or diastolic abdominal bruit (not very sensitive) 

• Elevated serum creatinine concentration 
• Abnormal urinalysis 

Drug-induced hypertension:  

• Oral contraceptives 
• Anabolic steroids 
• NSAIDs 
• Chemotherapeutic agents (eg, tyrosine kinase inhibitors/VEGF blockade) 
• Stimulants (eg, cocaine, methylphenidate) 
• Calcineurin inhibitors (eg, cyclosporine) 
• Antidepressants (eg, venlafaxine) 

• New elevation or progression in blood pressure temporally related to exposure 

• Paroxysmal elevations in blood pressure 
• Triad of headache (usually pounding), palpitations, and sweating 

• Cushingoid facies, central obesity, proximal muscle weakness, and ecchymoses 
• May have a history of glucocorticoid use 

Common in patients with resistant hypertension, particularly if overweight or obese 

Loud snoring or witnessed apneic episodes 

Daytime somnolence, fatigue, and morning confusion 

• Hypertension in the arms with diminished or delayed femoral pulses and low or unobtainable blood pressures in the legs 
• Left brachial pulse is diminished and equal to the femoral pulse if origin of the left subclavian artery is distal to the coarct 

• Symptoms of hypothyroidism 
• Elevated serum thyroid stimulating hormone 

• Elevated serum calcium 

Primary Aldosteronism

The evaluation of a patient with hypertension depends upon the likely cause and the degree of difficulty in achieving acceptable blood pressure control since many forms of secondary hypertension lead to "treatment-resistant" hypertension. Because it is not cost effective to perform a complete evaluation for secondary hypertension in every hypertensive patient, it is important to be aware of the clinical clues that suggest secondary hypertension. There are a number of general clinical clues that, in isolation or in combination, are suggestive of secondary hypertension. Primary aldosteronism is  a hormonal disorder that leads to high blood pressure. It occurs when your adrenal glands produce too much of a hormone called aldosterone. 

The classic presenting signs of primary aldosteronism are hypertension and hypokalemia, but potassium levels are frequently normal in modern-day series of primary aldosteronism. The presence of primary mineralocorticoid excess should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. However, most patients with primary mineralocorticoid excess are normokalemic and, rarely, some are hypokalemic but normotensive (primarily in young adult females).

The most common subtypes of primary aldosteronism are:

1. Aldosterone-producing adenomas (APA)
2. Bilateral idiopathic hyperaldosteronism (IHA; bilateral adrenal hyperplasia)

The presence of primary mineralocorticoid excess should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. 

In patients diagnosed with primary aldosteronism, treatment of the mineralocorticoid excess results in reversal or improvement of the hypertension and resolution of the increased cardiovascular risk.

Who should be tested?

Test for primary aldosteronism in the following patients: 

●Hypertension and spontaneous or low-dose, diuretic-induced hypokalemia

The following patients should undergo testing even if they are normokalemic:

●Severe hypertension (>150 mmHg systolic or >100 mmHg diastolic) or drug-resistant hypertension (defined as suboptimally controlled hypertension on a three-drug program that includes an adrenergic inhibitor, vasodilator, and diuretic)

●Hypertension with adrenal incidentaloma

●Hypertension with sleep apnea

●Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (<40 years)

●All hypertensive first-degree relatives of patients with primary aldosteronism

Case-detection testing with measurement of plasma aldosterone concentration (PAC) and renin (plasma renin activity [PRA] or plasma renin concentration [PRC])

The test is performed by measuring a morning (preferably 8 AM), ambulatory, paired, random PAC and PRA or PRC.

The PRA and PRC are typically very low (due in part to the associated mild volume expansion) in patients with primary aldosteronism.

The PAC is usually >15 ng/dL (416 pmol/L), but may be as low as 10 ng/dL (277 pmol/L).

Some clinicians calculate a PAC/PRA ratio as part of the case detection strategy, but we prefer to use the paired random PAC and PRA (or PRC). The mean value for the PAC/PRA ratio in normal subjects and patients with primary hypertension (formerly called "essential" hypertension) is 4 to 10, compared with more than 30 to 50 in most patients with primary aldosteronism 

In general, a PAC/PRA ratio greater than 20 (depending upon the laboratory normals) is considered suspicious for primary aldosteronism, although others use a cutoff criterion of 30. 

1. What is a CGM?
2. A continuous glucose monitor is a special type of device that allows for continuous measurement of glucose levels from the interstitial fluid rather than the blood. 
3. Depending upon the device, glucose levels are measured every 5-15 minutes. 
4. CGM allows for a measurement of a trend in a patient’s glucose levels as compared to a measurement of a glucose level at a single point in time, commonly known as traditional finger prick testing.

1. How is it used?
2. A CGM works by placing a small sensor under the patient’s skin, commonly located on the abdomen or under the arm. 
3. The glucose readings are sent to a monitor via a transmitter. 
4. Depending upon which CGM brand is used, the monitor maybe attached to an insulin pump, which can be easily placed in a patient’s pocket or purse for convenience. 
5. Alternatively, some CGM devices may even send the glucose readings directly to a smartphone, or other smart device, if the patient has the app.

1. Why should we prescribe CGM instead of traditional glucometer?
2. Allows patients to take active control of their Diabetes.
3. It gives patients a better idea on how their sugar levels can fluctuate in a day (visually can see hypoglycemic and hyperglycemic level trends).
4. Decreased incidence of having hypoglycemic emergencies.
5. Some devices come with an alarm that can alert the patient when their glucose levels are too high or too low.
6. Reduced finger stick pricks.
7.  
8. Most popular brand names, or just focus on Free Style Libre (cheapest)
9. Free Style Libre (APPROVED by Medicare lowest cost and widest inaccuracy in low glucose range)
10. It is a CGM system that automatically measures the blood glucose levels of the person wearing it.
11. Apply the sensor with the provided applicator, and a glucose sensing filament is inserted just below the skin.  
12. The sensor measures glucose in the interstitial fluid.
13. By waving the digital reader above the sensor, it records the amount of glucose in the wearer’s system at the moment and stores the data in the digital reader.
14. It allows for immediate access to glucose levels and to trend hypoglycemia and hyperglycemia. 
15. It allows for ease of checking glucose in public discreetly. 
16. The system makes it easy for health care providers to have access to the stored glucose logs by connecting the reader to a computer.
17. Dexcom G6: (Medicare approved, costly sensors and transmitters)
18. Senseonics Eversense CGM (NOT approved by Medicare)
19. Medtronic Guardian 3: Impacted by Acetaminophen use, provides real time alerts for highs and lows

1. Medi-Cal and Medicare Coverage 
2. Medicare covers therapeutic continuous glucose monitors (CGMs) and related supplies instead of blood sugar monitors for making diabetes treatment decisions, like changes in diet and insulin dosage. 
3. For these individuals, coverage of diabetes drugs and technology dramatically increases their chances of living a life free of complications. Despite this, however, continuous glucose monitors (CGM) are not covered by Medi-Cal. 
4. CGMs are covered under California Children’s Services (CCS), a state program for children with certain diseases or health problems, this is limited only to children with multiple co-morbidities and children who are disabled.
5. Not currently covered under Medi-cal insurance.

1. How to set up for patient and for our office
2. Falls under the category of Durable Medical Equipment covered under Medicare
3. In order to be eligible these are the conditions that must be met:
4. Physician must prescribe the equipment for home use, and it must be medically necessary.
5. Physician prescribing the monitoring system, as well as the supplier, must be enrolled in Medicare and accept Medicare assignment.
6. Medicare recipient must have diabetes and must be using a blood glucose monitor to test levels 4 or more times daily. They must also be taking 3 or more daily insulin injections.
7. With Medicare Part B, Medicare covers 80 percent of the approved amount. Medicare recipients are responsible for paying 20 percent of the final, approved cost, and the Part B deductible will apply. 

______________________________

Speaking Medical: Xanthochromia
by Isabelo Bustamante, MS3

Have you seen the word xanthochromia in a Cerebrospinal Fluid (CSF) study result? Xanthochromia has a Greek origin combining “yellow” (xantho) and “color” (chromia). Xanthochromia basically meansyellowish-colored CSF that can be seen with the naked eye. CSF is normally crystal clear. Xanthochromia can be found after several hours of bleeding into the subarachnoid space. This is because of the degradation of red blood cells after Subarachnoid Hemorrhage or SAH. Now you know the medical word of the week, xathochromia. Have a nice week.  

____________________________

Espanish Por Favor: Azúcar
by Dr Claudia Carranza

Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is azúcar.  The word azúcar  was made popular by the famous Cuban singer Celia Cruz; she used it as an expression of happiness and joy “AZÚCAR!”

Azúcar is a sweet crystalline substance derived from many plants such as sugar cane and sugar beet. You guessed it! Azúcar means sugar in Spanish. Azúcar is a substance that is part of us as humans and it literally runs through our veins. 

Azúcar comes from the Hispanic Arabic assúkkar. Azúcar is a vital word to use when talking to patients with diabetes and obesity. Most people will understand blood glucose if you say just azúcar, but if you see a weird look in your patient you may be more specific with the phrase azúcar en la sangre. 

Azúcar alta means high sugar (hyperglycemia), and azúcar baja means low sugar (hypoglycemia). 

Now you know the Espanish word of the week, “AZÚCAR”, I hope you have a sweet day full of joy and happiness! Until next time!

____________________________

Now we conclude our episode number 22 “Salty and Sweet: Hypertension and Diabetes”. We covered the basics on Primary Aldosteronism with Dr Velazquez, the salty part: sodium and potassium; and Continuous Glucose Monitoring with Denise, the sweet part: sugar. Isabello explained xanthochromia, which is yellowish cerebrospinal fluid, and, to put the cherry on this salty and sweet cake, Dr Carranza taught that sugar in Spanish is azúcar.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. 

Our podcast team is Hector Arreaza, Gina Cha, Claudia Carranza, Roberto Velazquez, and the special participation of our medical students Isabelo Lucho Bustamante and Denise Le DeWhitt. Audio edition: Suraj Amrutia. See you soon! 

_____________________

References:

1. mRNA-1273 Approval Status, Reviewed by Judith Stewart, BPharm. Last updated on Jul 27, 2020. https://www.drugs.com/history/mrna-1273.html
2. University of Southern California - Health Sciences. “Significantly less addictive opioid may slow progression of osteoarthritis while easing pain.” ScienceDaily, 13 July 2020. www.sciencedaily.com/releases/2020/07/200713120014.htm, accessed on Jul 30, 2020.

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

The following episode is a didactic activity. Our goal is teaching family medicine residents about these diseases and prepare them to treat their patients. We hope those who are suffering from these diseases do not find this activity offensive. May you find an appropriate treatment and get better. Consult your own family medicine doctor to learn more.

Similar but different, sound-alike but opposite, analogous but heterologous. 

Welcome to the Sick Duel, an epic comparison between two merciless opponents.

Our rivals today are: Ulcerative Colitis, “I will show you how to ulcer”; and Crohn’s Disease, “I will drill your guts”.

Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the GI tract. Ulcerative colitis and Crohn's disease are the main representatives of these disease. Today we will hear why they don’t get along and hopefully we’ll come to a good end.

Here we have our first guest

Arreaza: Who are you?

UC: Ulcerative Colitis is the name, and inflammation is the game. They say to save the best for last, so I tend to stick to the rectum and distal colon.  I like to come and go (no pun intended), creating episodic, mucinous diarrhea for my victims that is usually bloody.  I can be mild or severe, depending on the extent of mucosal involvement and level of inflammation.  

Arreaza: How do you manifest?

UC: I like to make my victims as uncomfortable as possible, creating urgency, pain, and constipation, while leaving them with a feeling like they aren’t “done” yet (aka tenesmus).  

Arreaza: I thought you said diarrhea, and now you mention constipation?

UC: Yes, I may cause periods of constipation when I am merciful, but diarrhea when I am cruel. Regardless of the thickness of the stools, I give them a mucinous and usually bloody discharge, sometimes leading to anemia. 

I like to attack extra intestinal organs such as the skin (causing pyoderma gangrenosum and erythema nodosum), the eyes (causing uveitis), and the joints (causing arthritis). Yes, my aunt Cronh’s can do some things right!

6. Arreaza: I’ve heard Ms Cronh’s is really mean. Where else do you go?

UC: Occasionally, I’ll make my way to the liver and cause primary sclerosing cholangitis.  My primary goal though is creating crypt abscesses and ulcerations.  If I’m lucky enough, I can progress to a fulminant, toxic level creating systemic symptoms and abdominal distention.  I hope to eventually make my way out of the GI tract through perforation (who doesn’t like a pinata?). 

Arreaza: I can see why your last name, colitis, can be deceiving, you can actually get out of the colon… Who are more likely to be your victims?

UC: I like to run in families. I prefer people who eat lots of fatty foods (Standard American Diet anyone?), high omega-6:omega-3 ratio, with history of previous bouts of gastroenteritis.  HLA autoimmune association, especially HLA-DR2. Even though smoking is a risk in many diseases, in my case, cigarette smoking may protect my victims from my attack, but if they smoked before and quit, I have a better chance to show up.

Arreaza: How do you get caught?

UC:  My victims tend to have chronic diarrhea for at least four weeks.  Because I am an inflammatory villain, many inflammatory tests can be non-specific such as ESR, fecal calprotectin/lactoferrin, etc.  Therefore, if you want me, you’re gonna have to come and get me.  Beware of your hospitalized patients, as a colonoscopy will greatly increase my ability to form a toxic megacolon and perforation!  Flexible sigmoidoscopy is recommended and will show you crypt abscesses, friable mucosa, decreased vascular markings and my continuous pattern of inflammation, yes, continuous, you gotta be consistent, unlike Ms. Crohn’s who likes skipping like a loser! 

How do you get eliminated? (What humans call treatment)

UC:  When my victims aren’t suffering as much as I’d like, those doctors first like to throw anti-inflammatories at me (such as mesalamine).  If that doesn’t work, they’ll throw in some steroids. However, if I’ve really done my job, then treatment usually starts with some immunomodulators (Azathioprine, Infliximab, etc.) followed by steroids with the goal of inducing remission.  If all else fails, they’re just gonna have to remove me along with my victims’ colon, so surgeons are their last resource to get rid of me!
Arreaza: What determines how bad you will be? (Prognosis)
UC:  Several factors influence my prognosis such as age of onset. Victims older than 50 have more chances to have a steroid-free remission. 

I hate smoking! Smoke does not let me grow, so when a patient quit smoking I can be more aggressive. 

When the intestinal mucosa heals early in the disease, my victims have a better prognosis. 

My chance of extension is higher in more distal areas, for example, patients with proctitis have 50% chance of extension. 

If my victims had an appendectomy before age 20, they have less chances of hospitalization and colectomy. 

With treatment, my victims may experience long periods of symptomatic remission along with intermittent exacerbations, although a small percentage may continue to have chronic symptoms and are less likely to achieve remission. The latter may require lifelong therapy or possible colectomy (Physicians 1, Me 0). 

Ulcerative colitis, you really know how to ulcer. Now we invite our next guest.

Arreaza: Who are you?

Crohn’s: Hi everyone, I’m Crohn's disease and unlike UC I don’t only affect the colon but I can affect any area of the GI tract from the mouth to the anus. Not only can I affect the whole GI tract but also, I can affect all the layers of the GI wall. Doctors like to call that “transmural inflammation”. Also, I can be sneaky, showing symptoms for a long time before diagnosis or I can happen all of a sudden and be diagnosed acutely.

How do you manifest?

Crohn’s: There are a few ways I can show up, but mainly I cause crampy abdominal pain, diarrhea either bloody or non-bloody, fatigue and weight loss. If I’m only located in the distal ileum, then I will give you right lower quadrant pain. 

Since I have transmural inflammatory forces, I can cause formation of sinus tracts that can result in abscesses or phlegmons. Phlegmon is a word that a lot of radiologist like to use and it pretty much means the formation of an abscess but not yet an abscess, so it can’t be drained but can treated with antibiotics. 

Sinus tracts can end up in microperforations or even fistulas. A fistula is when a connection forms between two tissues that are not supposed to be connected and, yes, it kinda sucks for my victims, especially when this connection happens between the bladder and the colon and you end up with urine mixed with feces coming out of either end. Ohh and if it connects from the GI tract to the skin then you may have continuous leakage of feces. WOW! I’m terrible, I know…

Arreaza: You are really mean!

On a lighter note, sometimes I cause no symptoms… at least not for a while until I make your GI tract so narrow that you defecate less frequently and end up having pain, and eventually your tract becomes obstructed. Man, yeah this pretty much sucks too. My bad!

Arreaza: I know you have more, tell us more about you.

I almost want to stop telling you anything else but there are a few more things. For example, I could give you aphthous ulcers in the mouth, pain in the esophagus or difficulty swallowing, abdominal pain, watery diarrhea, steatorrhea or oily diarrhea. OMG there's a bit more; last but not least some people may also have: arthritis of large joints, skin disorders like erythema nodosum or pyoderma gangrenosum and very few will experience hepatobiliary involvement such as primary sclerosing cholangitis or even eye issues like uveitis, iritis and episcleritis… among others.

Arreaza: You and your nephew UC really like going out of the GI tract, but I think you are more adventurous. Who are more likely to be your victims?

Crohn’s: Unlike UC, I actually like smokers, smoke helps me thrive! Those who have antibiotic exposure are at risk, also those with increased fats in diet, and maybe a little increased risk with NSAIDs and OCPs. Appendectomy may be a result of hidden CD vs a risk factor. 

If you want to avoid CD, high fiber and a Vit D supplementation are associated with decrease risk of CD. If you were breastfed, you have lower risk to get CD.

How are you caught? (diagnosis)

Crohn’s: You can usually suspect CD when there is a combination of suggestive features, such as RLQ pain, chronic intermittent diarrhea, fatigue and weight loss. Laboratory tests can show anemia, vitamin B12 and Vitamin D deficiency (malabsorption). Diagnosis is made certain via imaging, endoscopy and histological findings that show the aforementioned “transmural inflammation”. I think everyone will remember this “transmural inflammation” sign.

How can your victims fight you? (treatment)

Crohn’s: The treatment will be different depending on where I’am at, how bad I am and whether you want to stop me or keep me quiet. 

If I’m mild, then you can use oral 5-aminosalicylates like sulfasalazine or mesalamine, glucocorticoids, immunomodulators such as methotrexate or azathioprine; and biologic therapies such as infliximab, adalilumab, etc. Yep, these are some pretty tough names to combat a tough disease like me!

If I am moderate to severe then you’ll need a combo of meds: anti-TNF like infliximab plus an immunomodulator. The GI doctors are my archenemies! 

What determines how bad you will be? (prognosis)

Crohn’s: It can vary, most of the patients will experience a continuous progression while about 20% of patients can experience remission after initial presentation. Risk factors for progressive disease are smoking, age <40, perianal or rectal involvement, if glucocorticoids needed for treatment. Increased risk for cancer is for the most part unclear, and mortality is slightly higher than overall mortality in the general population. People with obesity have a higher rate of complications.

Dr Arreaza: Now we have the facts. You and UC belong to the same family, but are not the same!  What is the main difference between you two?

-UC: I’m limited to mucosa and submucosal layers, primarily affect rectum and distal colon, continuous inflammatory involvement, more likely to present with bloody diarrhea.  
-Crohn’s: I cause transmural inflammation, can affect any part of the GI tract, patchy distribution of inflammatory involvement. 

Any preference for age or sex groups? 

-UC: I prefer my victims be younger than 30 when I first attack, as this age range has been associated with poorer prognosis and higher relapses.  However, I tend not to go after the younglings.  Small preponderance for males.

-Crohn’s:  Any age is good for me.

Arreaza: And do you affect different parts of the colon?

-Both: Yes! 

Crohn’s: We cannot coexist. I can go to the Complete GI tract, get it? Chron’s “C” for Complete GI tract. Expansionist is my middle name!

-UC: UC stands for Unique to the Colon, and almost always the rectum. I know my territory.

Arreaza: So, I know you are very different, but what do you have in common?

Both, alternated: Blood, diarrhea, pain, inflammation, and extra-intestinal manifestations.

Arreaza: I knew we would find a common ground. Any final words?

Crohn’s: Yes, now that me and UC are on the same team, the IBD team. We have a message for celiac disease and Irritable Bowel Syndrome. 

UC: Yeah, this is for you, celiac and IBS, you got the guts to compare yourself to us? Bring it on! 

Now we conclude The Sick Duel: UC vs CD. Stay tune for more epic battles. 

____________

[This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. 

Our podcast team for this episode was Hector Arreaza, Claudia Carranza, Colby Kulyn, and audio edition by Suraj Amrutia. See you soon! 

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!

The sun rises over the San Joaquin Valley, California, today is Jul 17, 2020.

It feels good to talk about prevention when an effective and safe vaccine is actually available! This is the case for the Pneumococcal Conjugate Vaccine 13 (PCV13 or Prevnar 13®).  

In November 2019, the CDC issued an update on PCV13 vaccination. PCV13 vaccination for ALL immunocompetent adults 65 years and older is NOT recommended. Instead, it is recommended to make a shared decision when these patients do NOT have an immunocompromising condition, CSF leak, or cochlear implant, and have not previously received PCV13. 

Some candidates for PCV13 include patients residing in areas with low pediatric PCV13 uptake; those traveling to settings with no pediatric PCV13 program; those with chronic heart, lung, and/or liver disease, diabetes, or alcoholism; and those who smoke. 

PCV13 is still recommended in a series with Pneumovax® (PPSV23) for all adults 19 years and older (including those 65 years and older) with immunocompromising conditions, CSF leaks, or cochlear implants. A single dose of Pneumovax® for ALL adults 65 years and older is still recommended (1,2).

____________________________

“Perfection is not attainable, but if we chase perfection we can catch excellence.” –Vince Lombardi

Perfection is a very complex concept. Have you seen a surgery that was performed perfectly? I have. Believe it or not, there are perfect surgeries. Some musicians can play a song perfectly. I think perfection in some areas may be attainable. Another example, I think a person can be perfectly punctual for a time. That’s perfection. 

However, in most cases, perfection may not be attainable, but we should at least aim for excellence. And today, we have a resident who is in her pursuit of excellence, she is doing very good in her residency. Her voice may be familiar to you because she has recorded many of our introductions, and people have loved her voice. Welcome Dr Der Mugrdechian. 

1. Question Number 1: Who are you? 

My name is Alyssa Der Mugrdechian, I am a 2nd-year resident in the Rio Bravo Family Medicine Program here in Bakersfield. I am a native to the Central Valley having grown up in Fresno, California. I am of Armenian descent and my family settled in California after surviving the Armenian Genocide in 1915. Coming from a family of mostly educators, I am the first to pursue Medicine. 

I went to UC Irvine for undergrad and majored in Biological Sciences, and my journey to becoming an MD took me to Ross University on the beautiful island of Dominica. 

Though I have traveled a lot during my schooling, I am happy to have the opportunity to have returned to the Central Valley to complete my residency training in an underserved community close to my family and friends. 

For fun, I like to draw/paint, I also enjoy cooking, traveling, going to the beach and going to any Disney park as often as possible.

1. Question number 2: What did you learn this week?

This month my rotation is Gynecology. I am generally seeing patients for gynecologic issues, OB follow ups and routine post-partum visits. During these appointments, a very important question that can often be overlooked is whether the patient is coping with post-partum depression. Furthermore, another important distinction to make is if it is in fact major depression vs. baby blues.

Post-partum Depression (PPD)

The post-partum period can encompass the first 12 months after giving birth, however there’s no set length that’s been agreed upon. 

Major depression is not confined to the post-partum stage, it can also arise during pregnancy.

Factors that increase risk of developing Post-Partum Depression (PPD):

1. Antenatal depressive symptoms
2. History of Major Depressive Disorder
3. Previous Post-Partum Depression

Other factors to take into consideration are home life, socioeconomic factors, previous or current abusive relationships/situations. 

Edinburgh Postnatal Depression scale

The EPDS is a screening tool for postpartum depression. It consists of 10 questions. The test can usually be completed in less than 5 minutes. Responses are scored 0, 1, 2, or 3 according to increased severity of the symptom. Some items are reverse scored (i.e., 3, 2, 1, and 0). You add scores of each question to get a total score. Cut-off scores range from 9 to 13 points. It requires clinical judgment to determine the right timing for referral. For example, if a woman scores 9 or indicating any suicidal ideation, she most likely would benefit from immediate referral. “In women without a history of postpartum major depression, a score above 12 has a sensitivity of 86 percent and specificity of 78 percent for postpartum major depression. You can find the hand out at the end of this document.

Other screening methods include PHQ-9, and diagnosis is based on DSM-5.

Distinguishing Between “Baby Blues” and Postpartum Major Depression

Diagnosis and Treatment

Labs can also be considered, including TSH to rule out other causes of depressive symptoms

Treatment can include both pharmacologic and non-pharmacologic methods such as psychotherapy (interpersonal, cognitive behavioral therapy)

Selective serotonin reuptake inhibitors — SSRIs are widely prescribed in lactating women. Breastfeeding should not be discouraged during treatment with SSRIs.

1. Question number 3: Why is this knowledge important for you and your patients?

Sometimes patients aren’t willing or open to discussing this topic. In other cases, it may not even be touched upon by providers following up with the patients. But especially with everything going on this year with the pandemic, mental health is vital to a patient’s overall well-being. It also affects maternal functioning, and ultimately the well-being of the child

It can lead to lack of breastfeeding, lack of maternal-infant bonding, problems with abnormal child development, problems with infants sleeping properly and also receiving the proper vaccinations. Suicide can also occur, however this rate is very low in the post-partum period 

1. Question number 4: How did you get that knowledge?

I got interested in the topic because of the patients I have seen in clinic. I consulted reliable sources such as UpToDate, our day-to-day companion in clinic; American Academy of Family Physician; and the United States Preventive Services Task Force, which is our main source of preventive services offered in Family Medicine.

1. Question number 5: Where did you get the information from?

An article by Dr Viguera about Postpartum depression in UpToDate, updated on 11/20/2018. I also consulted an article about safe infant exposure to antidepressants in UpToDate. AAFP has a very good source of information about Postpartum depression. See details below.

Edinburgh Postnatal Depression Scale

Edinburgh Postnatal Depression Scale. © 1987 The Royal College of Psychiatrists. The Edinbugh Postnatal Depression Scale may be photocopied by individual researchers or clinicians for their own use without seeking permission from the publishers. The scale must be copied in full and all copies must acknowledge the following source: Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786. Written permission must be obtained from the Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online or by any other medium). Translations of the scale, and guidance as to its use, may be found in Cox JL, Holden J. Perinatal Mental Health: A Guide to the Edinburgh Postnatal Depression Scale. London: Gaskell; 2003. 

Speaking Medical: Borborygmus
by Max Uschuk, MS4 

We all have been in a silent exam and your stomach decides to demonstrate the sound of a humpback whale mating call. That’s borborygmus. What is borborygmus besides an interesting word to say? Technically speaking it is peristaltic movement of gas and fluid through the intestines causing an audible sound that is loud enough to be heard by the naked ear. 

When someone says their stomach is growling or rumbling, that is borborygmus or borborygmi (plural), not to be confused with bowel sound or peristaltic sounds which require a stethoscope to be heard. 

Is it medically pertinent? Many things can cause borborygmus. 

An empty stomach around 2 hours post prandial starts to signal the brain that it is fasting, it triggers peristaltic waves every 90-230 min, and contents are moved through the intestines and function to inhibit migration of bacteria from the large intestine to the small intestine. This movement can cause borborygmus. When someone swallows air while talking, eating or drinking it can increase borborygmus. Incomplete digestion of foods such as milk, gluten, fruits and vegetables, bean, legumes, and high fiber foods can increase borborygmus. 

Now, this can be normal but when paired with bloating, pain, diarrhea or constipation it can be indicative of a pathological process. Some pathologies such as celiac disease, colitis due to infection or necrotizing colitis, diverticulitis, irritable bowel syndrome, carcinoid syndrome or basically anything that really irritates the intestines can cause borborygmus. From the Practical Medicine Series; General Surgery, “the presence of stormy peristalsis or borborygmus in the absence of fever may be considered pathognomonic to intestinal obstruction as it never occurs in adynamic ileus” 

Thank you for listening and I hope you get to use the word borborygmus sometime soon. ____________________________

Espanish Por Favor: Spanish Last Names
by Dr Claudia Carranza

“Hola, me llamo Fernando Hernandez Guerrero Fernandez Guerrero.”That’s a fictional name from Fuller House, but sometimes that’s how Hispanic names sound like to English speakers.

Hi, this is Dr Carranza in our section Espanish por favor, today instead of bringing you a word of the week I wanted to discuss a topic with everyone. It’s the topic of last names! In the States, people usually have one last name, unless once married they chose to hyphenate their last name. Well, in the Hispanic culture we usually have 2 last names. The last names we have are first, our father’s last name, and our second, our mother’s last name. 

So, for example, my name is Claudia Carranza, but the name given to me at birth was: Claudia Roxana Carranza Guzman. I don’t think I have ever met anyone in Peru (where I’m from) that only had one last name. Dr Arreaza brought up an interesting point, which is what if people in Latin American cultures have one last name? I’ll let him expand on this topic.

Dr Arreaza: Having only one last name may have a negative social connotation. When someone has one last name in Venezuela it usually means that you are a “natural son”, or illegitimate, or born from a single mother.

Dr Carranza: In Peru, at least what I saw growing up, if a child only had one parent then they took the full first and second last name of that parent. So, guys when you meet a Hispanic patient with two last names, remember that their 1st last name is the one they will usually go by, not the second. So, for my name Claudia Roxana Carranza Guzman, you would call me: Claudia Carranza, not Claudia Guzman. Hope this helps when you are trying to figure out what last name to use when you see a patient or have a coworker with 2 last names!

____________________________

For your Sanity:
by Steven Saito and Tana Parker

Doctor: I have bad news, and very bad news.
Patient: What's the bad news?
Doctor: You only have 24-hours to live
Patient: And the really bad news?
Doctor: I’ve been trying to contact you since yesterday.

_______________________________

Now we conclude our episode number 20 “Baby Blues”. Dr Der Mugrdechian reminded us to screen for post-partum depression using the Edinburg Postnatal Depression Scale and make sure it is not “baby blues.” Max taught us the word borborygmus, just a fancy way to say “very loud stomach growling,” and Dr Carranza explained that the name you see at the end of a looooong Spanish name may not be the actual last name. The actual last name is the name before the last, I know it may be confusing, but it’s OK to ask your patients their preferred last name.     

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. 

Our podcast team for this episode is Hector Arreaza, Alyssa Der Mugrdechian, Claudia Carranza, Lisa Manzanares, and Max Uschuk (pronounced Use-Chuck). Audio edition: Suraj Amrutia. See you soon! 

_____________________

References:

1. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Updated Recommendations of the Advisory Committee on Immunization Practices, Weekly, November 22, 2019 / 68(46);1069–1075, https://www.cdc.gov/mmwr/volumes/68/wr/mm6846a5.htm#T1_down
2. Shared Decision-Making for Administering PCV13 in Older Adults, AMIT A. SHAH, MD; MARK R. WALLACE, MD; and HEATHER FIELDS, MD, Mayo Clinic, Scottsdale, Arizona, Am Fam Physician. 2020 Feb 1;101(3):134-135. https://www.aafp.org/afp/2020/0201/p134.html

1. Viguera, Adele MD. “Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis” UptoDate. Last updated 11/20/2018.

1. Mary C Kimmel, MD, Samantha Meltzer-Brody, MD, MPH, “Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding” UptoDate. Last updated 11/10/2019.

1. KATHRYN P. HIRST, MD, and CHRISTINE Y. MOUTIER, MD, University of California, San Diego, School of Medicine, La Jolla, California. “Postpartum Major Depression”, Am Fam Physician. 2010 Oct 15;82(8):926-933. https://www.aafp.org/afp/2010/1015/p926.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!

The sun rises over the San Joaquin Valley, California, today is July 10, 2020. In case you did not notice, we did not have an episode last week. We were very busy in our residency. We started a new rotation and a new academic year. We welcomed a new group of PGY1s, along with 3rd-year medical students, and Sub-Is. We also said goodbye to our dear graduates: Greg Fernandez, Ronald Gavilan, Yunior Martinez, and Steven Saito. “Spread your wings, it’s time to fly. Make the leap. Own the sky.”(1) Good luck in your careers! 

Those activities kept us busy, and, as if that wasn’t enough, we saw an increase in the incidence of COVID-19 across the nation. In Clinica Sierra Vista, we went from 270 positive cases in May to 700 positive cases in June, we also increased the total tests performed from 1200 in May to 2800 in June. Our positivity rate increased from 21% to 25%. In the county of Kern we have had 5,500 cases and 82 deaths. In California, the total of cases is 260,000 with total deaths of 6,500(2), which may have changed by the time you listen to this episode (numbers were rounded up for easy listening).

Also, on a positive note, last weekend we celebrated Independence Day. We hope you had a Happy 4th of July! Especially during these tumultuous times, may America continue to be “the land of the free and the home of the brave.”

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.

“All our dreams can come true if we have the courage to pursue them.” Walt Disney

When you want to reach a goal, dreaming is not enough. At some point, you have to start working to make that dream come true. You may need a little dose of faith, and a big dose of action. What dreams do you have? What kind of doctor do you want to become? Your training in residency is the time to prepare to live that dream. Today we have a resident who is working to reach his goals. Dr Sin is a diligent, trustworthy resident and will participate today for the first time in this podcast. 

1. QUESTION NUMBER 1: Who are you?

My name is Hasaney and I am a second-year resident at Rio Bravo Family Medicine residency program. I was born and raised in Long Beach, California, to parents who emigrated from Cambodia. I went to Long Beach Polytechnic High School, and continued my studies at UC Irvine majoring in Biological Sciences. 

I worked in Quality Assurance for a healthcare manufacturing company for a few years, before deciding to pursue a career in Medicine. I enrolled at Ross University School of Medicine in Dominica where I received my medical degree.

I’m a pretty simple guy. I love spending time with my girlfriend, my family, and my friends. I love to go camping, especially in Mammoth, California. I love watching and rooting for the Dodgers.

1. QUESTION NUMBER 2: What did you learn this week?

I had Nephrology clinic for the first time this past Wednesday and Dr. Moreno gave some little teaching points about different syndromes we may see as family physicians, a couple of them being Bartter Syndrome and Gitelman Syndrome.

Bartter Syndrome

Bartter syndrome is an autosomal recessive disorder associated with metabolic abnormalities: hypokalemia, metabolic alkalosis, hyperreninemia and hyperplasia of the juxtaglomerular apparatus, and hyperaldosteronism; There may also be associated hypomagnesemia. It is a fairly rare disease occurring 1 in 1,000,000, however the similar but milder Gitelman syndrome is more common with a prevalence rate of 1 to 10 in 40,000.

In short, Hypokalemia, metabolic alkalosis, and hyperaldosteronism. 

Pathophysiology

The primary defect in both syndromes is an impairment of the sodium chloride reabsorption in the loop of Henle or distal tubule. The impaired sodium chloride reabsorption leads to volume depletion and activation of the renin-angiotensin-aldosterone system. This increased distal flow of sodium enhances potassium and hydrogen secretion at the secretory sites in the connecting tubules and collecting tubules which leads to hypokalemiaand metabolic alkalosis. 

Patients generally have a lower blood pressure than the general population in Bartter syndrome but normal blood pressure in Gitelman syndrome. Bartter syndrome mimics chronic ingestion of a loop diuretic, while Gitelman syndrome mimics chronic ingestion of a thiazide diuretic.

Presentation and Types

Clinical manifestations of Bartter syndrome, besides the metabolic abnormalities we have mentioned, are growth and mental retardation, polyuria and polydipsia. There are four types of Bartter syndrome. Types 1 and 2 are usually severe disorders that cause polyhydramnios during pregnancy and prematurity. They develop hypokalemia, metabolic alkalosis, polyuria and hypocalciuria. Nephrocalcinosis is common and probably contributes to development of kidney dysfunction, sometimes end stage renal disease. Nephrocalcinosis is the deposition of calcium salts in the renal parenchyma. Nephrocalcinosis is related to, but not the same as, kidney stones (nephrolithiasis).

Bartter syndrome Type 3 is the classic form, less severe, and presents later in life with the metabolic abnormalities. Late manifestations of Bartter syndrome include proteinuria and a decline in GFR. Bartter syndrome Type 4 causes severe disease, with antenatal presentation and congenital hearing loss. 

Gitelman syndrome

Clinical manifestations of Gitelman are similar to Bartter, except for having normal blood pressure. Patients may develop cramps of arms and legs due to the metabolic abnormalities, as well as fatigue. Hypertension may develop later in life.

Both syndromes are usually a diagnosis of exclusion. Patients will present with unexplained hypokalemia, metabolic alkalosis and normal to low blood pressure. Surreptitious vomiting and diuretic use must be ruled out as these could present in a similar way. 

Diagnosis

Surreptitious vomiting is ruled out by measuring urine chloride excretion, with Bartter and Gitelman syndrome showing a urine chloride concentration greater than 25mEq/L, whereas vomiting would show a urine chloride concentration that is less than 25 mEq/L.

Suspicion of diuretic use would be ruled out with a urine diuretic screening. Plasma renin and aldosterone levels will be elevated; however, these are not required for diagnosis.

Treatment

Treatment requires ad lib NaCl intake with supplements of KCl and if needed magnesium salts. Most patients will require a drug that blocks distal tubule Na-K exchange such as spironolactone.

1. QUESTION NUMBER 3: Why is this knowledge important?

As family physicians, we see the full spectrum of Medicine. If we see low blood pressure in a pediatric patient, with the metabolic abnormalities akin to these two syndromes an urgent nephrology referral should be placed.

1. QUESTION NUMBER 4: How did you get that knowledge?

Initially, some of it was taught to me by Dr. Moreno. He did not have time to go through most of the details of each syndrome in clinic, so I decided to read a little more about it on Up to Date. Some of the details on Up to Date are very thorough, so I liked to cross reference it with Pocket Pediatrics.

1. QUESTION NUMBER 5: Where did you get that knowledge?

The majority of the information were points that I thought were most important from the Up to Date article “Bartter and Gitelman syndromes”.

Speaking Medical: Nephronia
by Manpreet Kaur, MS3

Nephronia. It may sound like the sister planet of Neptune, but what exactly is it and when would you diagnose a patient with it? 

Well, on the spectrum of upper UTIs, nephronia would fall at the midpoint between acute pyelonephritis and an intrarenal abscess. 

It forms when a patient has an acute bacterial infection that results in a renal mass without liquefaction. We usually see this disorder in the pediatric population but there are case reports of this presentation in adults as well. 

While it sounds rare, it may just be an underdiagnosed disorder. However, with advancements in noninvasive imaging, this diagnosis is being made at an increasing frequency. 

Acute lobar nephronia (ALN) is similar to acute pyelonephritis (APN). ALN is similar to APN. A few differences are that acute lobar nephronia (ALN) is associated with a longer clinical course, longer fever duration even with treatment, and higher inflammatory markers like CRP and WBC count. 

A CT is the most sensitive and accurate modality of making the diagnosis but risks of exposure to radiation and possible sedation have to be weighed in small children. Some studies indicate that about 25% of children with ALN can go on to develop renal abscesses and have a higher incidence of renal scarring. 

Once nephronia has been diagnosed, these patients will require a minimum of 2 weeks of IV antibiotics, followed with 1 week of oral antibiotics. They will show slow improvement with fevers sometimes persisting until the end of the 1st week of treatment.

Now you know the medical word of the week: Nephronia.

Espanish Por Favor: Orina

Orina is that yellowish-colored liquid that comes out of the urethra with a characteristic smell, which in normal circumstances is sterile. Yes, you guessed it, orina is urine in Spanish. Orina can be easily turned into a verb:Orinar. Just like in English, there are several terms to refer to urine (pee, piss, pee-pee), orina can also be called meados(vulgar), orín, pis, pichi, and my favorite: pipí (pronounce pee-pee), normally used with pediatric patients. Now you know the Spanish word of this week: Orina.

For your Sanity: A wet nose
by Steven Saito

What do a puppy and a near-sighted OB doctor have in common? A wet nose.

Conclusion

Now we conclude our episode number 19, “Bartter and Gitelman”. Dr Sin briefly shared the highlights of these rare syndromes. Hypokalemia and hypotension may have a long list of differential diagnoses, but keep Bartter and Gitelman on your list. Ms Kaur explained that nephronia is not a planet, but an intermediate state between pyelonephritis and a renal abscess; and we could not leave the word urine out of this renal episode, so we learned the Spanish word orina.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. Our podcast team for this episode is Hector Arreaza, Hasaney Sin, Manpreet Kaur, and Steven Saito, Audio edition: Suraj Amrutia. See you soon! 

_____________________

References:

1. Ms Moem, http://msmoem.com/2014/poetry-2/spread-your-wings/
2. California Coronovirus Update, https://update.covid19.ca.gov/
3. Emmett M, Ellison DH. Barrter and Gitelman syndromes. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on July 5, 2020)

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

The sun rises over the San Joaquin Valley, California, today is June 26, 2020.

As our nation continues to battle the OPIOID epidemic (along with other epidemics), our good, old-fashioned aspirin at high doses (900 to 1300 mg) was found to be effective and safe to treat acute migraine headaches. Further research is needed to recommend aspirin as a prophylactic therapy, but it’s promising. Findings of this research were published in November 2019 by Dr Biglione and collaborators in The American Journal of Medicine (1,2). Aspirin keeps giving us surprises after more than 120 years on the market! 

Also, the Food and Drug Administration has approved the first over-the-counter ibuprofen and acetaminophen combination drug for the U.S. It’s called Advil Dual Action which contains 250 mg of ibuprofen and 500 mg of acetaminophen. It will be available later in 2020 (3).

Talking about epidemics, have you heard that diabetes is a surgical disease? Some experts support the cure of diabetes with bariatric surgery, and yes, it may not be the first choice, but it is effective when used appropriately. However, according to a research presented during Endo Online 2020, Dr Yingying Luo, stated that having bariatric surgery BEFORE developing type 2 diabetes results in a greater weight loss, especially within the first 3 years after surgery. The probability of achieving BMI less than 30, and the chance of reaching excess weight loss of more than 50%, is higher in patients WITHOUT diabetes before surgery(4). Diabetes prevention is another good reason to send your patients to bariatric surgery in a timely manner when they meet criteria. 

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“A good head and good heart are always a formidable combination. But when you add to that a literate tongue or pen, then you have something very special.” ― Nelson Mandela

I always thought that having a good brain and a good heart were enough to be wise, but Mr Mandela taught me that having a good tongue or pen makes than person even more special. Do you get it? Being wise and compassionate, and being able to communicate that information to others is very important. That’s why we have this exercise called Rio Bravo qWeek– to learn how to transfer information from our head and our hearts to our co-residents and patients. I hope we can become better communicators every day. 

Before I introduce our guest today, I want to take a minute to correct myself. In episode 15, I said “more higher”, I noticed my mistake, and I correct it now: It is not “more higher”, it’s just “higher”. Also, I hope you heard the beautiful quote we used at the end of our episode 17. I want to clarify that we do not have any political affiliation, but we have the same values and principles we shared with the good people of America, including politicians, artists, NGOs, religions, and other groups. I encouraged you to “examine what is said, not him who speaks” (Arab proverb), especially in this podcast. We have a very pleasant and clever resident who has some things to say today. Welcome, Dr Yodaisy Rodriguez.

1. Question Number 1: Who are you?

My name is Yodaisy Rodriguez Acosta. I graduated from medical school in Cuba. Before moving to the US, I worked in Honduras and in Venezuela as part of Medical collaboration programs. I love outdoor activities, gardening, crafting, movies, and dogs. My perfect day is having a picnic with my family.

1. Question number 2: What did you learn this week? 

I learned about cervical polyps this week. 

Clinicians may encounter normal variants and benign neoplasms of the cervix on pelvic examination. It is important, as family medicine doctors, to become familiar with a normal cervix, so we can identify what looks ABNORMAL.

Cervical polyp definition

-A cervical polyp is a growth or tumor found in the cervical canal. It is a lobular or tear-shape growth, red or purple, it can also be very vascularized. After you see a couple of them you learn to recognize them. 

-They present more commonly in post-menarche and pre-menopausal women who have been pregnant. 

- It is included in the Cervical Noncystic lesions.

-The etiology is unknown. Chronic inflammation of the cervical canal may be the cause. Hormonal factors may also play a role, since endometrial hyperplasia and cervical polyps coexist. 

-Differential diagnosis includes an endometrial polyp or prolapsed leiomyoma.

-Malignancy in polyps is uncommon.

What to do when you see a cervical polyp

Polyps should always be removed if they are symptomatic (eg, bleeding, excessive discharge), large (≥3 cm), or appear atypical. Polypectomy is usually a small procedure done in the office. 

Malignancy is rarely found in a cervical polyp, however, polyps that are removed should be submitted to the laboratory for histological study.

1. Question number 3: Why is that knowledge important for you and your patients?

Because cervical cancer is very common. Every year, nearly 13,000 cases of cervical cancer are diagnosed, with more than 4,000 deaths. Cervical cancer is typically asymptomatic. We should become familiar with the screening and management of cervical diseases. Having the right information will help us answer our patient’s concerns.

1. Question number 4: How did you get that knowledge?

I learned because I had a patient with a cervical polyp. When you receive an abnormal pap result, you normally look up the next step by using the ASCCP app, but what do you do when the cervix looks abnormal during the physical exam? How do you perform a polyp removal? Thanks to my OBGYN attendings, and thanks to my gynecology rotations, I have improved my knowledge and abilities in managing abnormal cervix. 

I learned that if a patient has a grossly visible cervical lesion, biopsy should be performed. If biopsy cannot be performed at that visit, cervical cytology should be collected, and the patient should have a biopsy as soon as possible. 

Comment: We had a patient recently with an abnormal cervical exam. It was described as a “cavity” between 3 and 6 o’clock. The resident explained to me that “he has never seen any cervix like that”. Our patient had weight loss and abdominal pain, along with bilateral hydronephrosis. The cervical biopsy was done at the time of the placement of bilateral ureter stents in the OR. The biopsy resulted in squamous cell carcinoma of the cervix. So, I agree with you, grossly abnormal cervix should prompt us to perform a biopsy in a timely manner.

Cervical cytology became the standard screening with the introduction of the Papanicolaou (Pap) smear in 1941. Now we start screening for cervical cancer at age 21 regardless of sexual activity. Cultural concerns should be addressed and respected when possible. A patient at age 21 may decline pelvic exam, you have to be culturally sensitive and discuss the matter with the patient and encourage pap smear with tact, but respect patient’s preferences.

1. Question number 5: Where did that knowledge come from? 

1) Up To Date. 

2) Cervical Cancer: Evaluation and Management by Jennifer Wipperman and collaborators, published in the American Family Physician in 2018.

3) FP notebook app 

4) American Society for Colposcopy and Cervical Pathology (ASCCP) app 

____________________________

Speaking Medical: Pioikilothermia
by Edvard Davtyan, MS4

Good afternoon, my name is Edvard Davtyan, I am a 4th year medical student. I will be presenting the word of the week, Poikilothermia. This may sound like a phrase used in the world of thermodynamics. However, this phrase is more commonly used in the realm of Biology and Medicine. 

The term poikilothermia means “cool extremity”. It is originated from the word poikilothermwhich is used to describe animals or organisms whose internal temperature varies considerably with the temperature of its surroundings. These animals are also referenced by the common vernacular “cold-blooded.” The term is derived from Greek poikilos,meaning “varied”, and thermos, meaning “heat.”

In Medicine, the loss of thermoregulation in humans is referred to as poikilothermia. This is seen in states of sedation (esp. REM sleep), effects of hypnotic drugs and acute limb ischemia. Poikilothermia is 1 of the 6 P’s in clinical presentation of acute limb ischemia: Pain, Pallor, Paresthesia, Pulselessness, Poikilothermia, and Paralysis. 

Hope this has been interesting for you, remember, if your patient has poikilothermia, it doesn’t mean they are cold-blooded, it just means you should probably check their ankle-brachial index (ABI).

____________________________

Espanish Por Favor: Chorro
by Dr Claudia Carranza

(Recorded Previously on 6/10/2020)

Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is chorro. Chorro means jet or stream; some patients use this word to describe their bowel movement. Patients can come to you with the complaint: “Doctor, tengo chorro”, which means “Doctor, I have the runs” or in other words, “I’m having diarrhea”. This is more common in the Spanish-speakers coming from Mexico. You can then continue the interview and ask about how often, for how many days and if it’s bloody or melanotic, etc. Chorro can also mean a ton or lots; so, a patient might say “Doctor, tengo un chorro de problemas” which means “Doctor, I have a ton of problems”. 

Now you know the Spanish word of the week, “CHORRO”.

____________________________

For your Sanity (Medical Joke of the Week): ***
by Dr Steven Saito and Dr Lisa Manzanares

A cosmetic surgeon sign says: “If life gives you lemons, a simple surgery will give you melons”.

____________________________

Now we conclude our episode number 18 “Cervical Polyps”. Dr Rodriguez recommended us to get used to a normal cervix. If a cervix looks odd, do not hesitate to or perform a biopsy schedule patient for biopsy. If you see a cervical polyp, a polypectomy can be easily performed in the office. Remember to send that sample to pathology. Edvard explained that Poikilothermia refers to cold-blooded animals, but it also refers to a “cold limb” as a sign of acute limb ischemia. Chorro was explained by Dr Carranza as a “less elegant” way to say diarrhea in Spanish. 

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. 

Our podcast team is Hector Arreaza, Yodaisy Rodriguez, Claudia Carranza, Edvard Davtyan, Lisa Manzanares, and Steven Saito. Audio edition: Suraj Amrutia. See you soon! 

_____________________

References:

1. The American Journal of Managed Care, https://www.ajmc.com/newsroom/aspirin-effective-in-treating-acute-migraine-preventing-recurrent-migraine-review-finds.
2. Biglione B, Gitin A, Gorelick PB, et al. Aspirin in the treatment and prevention of migraine headaches: possible additional clinical options for primary healthcare providers [published online November 8, 2019]. Am J Med. doi: 10.1016/j.amjmed.2019.10.023.
3. “FDA approves combination ibuprofen-acetaminophen drug for U.S.”, ADA News, March 02, 2020, https://www.ada.org/en/publications/ada-news/2020-archive/march/fda-approves-combination-ibuprofen-acetaminophen-drug-for-us
4. “Bariatric surgery may be less beneficial in diabetes”, Family Practice News, Vol 50, No. 4, April 2020, page 11. 
5. “Benign cervical lesions and congenital anomalies of the cervix” by Marc R Laufer, MD, UptoDate, Last updated on May 28, 2020. https://www.uptodate.com/contents/benign-cervical-lesions-and-congenital-anomalies-of-the-cervix?search=cervical%20polyp§ionRank=1&usage_type=default&anchor=H16&source=machineLearning&selectedTitle=1~28&display_rank=1#H16, accessed on June 22, 2020.
6. “Cervical Cancer: Evaluation and Management” by Jennifer Wipperman, MD, MPH; Tara Neil, , MD; and Tracy Williams, MD, Am Fam Physician. 2018 Apr 1;97(7):449-454. https://www.aafp.org/afp/2018/0401/p449.html
7.  American Society for Colposcopy and Cervical Pathology (ASCCP), App.

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!

The sun rises over the San Joaquin Valley, California, today is June 19, 2020. 

This week we welcomed a new group of residents who started on June 15, 2020. Welcome aboard, Drs. Amodio, Civelli, Grewal, Lorenzo, Lundquist, Martinez, Nwosu, and Viamontes. We are excited for you and all the experiences you will have in the next 3 years. 

On Jun 9, the USPSTF recommended to screen for unhealthy drug use all adults age 18 years or older. This a Grade B recommendation (moderate to substantial benefit). Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Screening in this case refers to asking questions about unhealthy drug use, not testing biological specimens(1).

The search for the miraculous antiviral drug against COVID-19 continues. We previously mentioned remdesivir, which was granted Emergency Use Authorization (EUA) by the FDA on May 1, 2020 in the US. Another drug you should be aware of is avifavir. Avifavir is based on Favipiravir, originally sold in Japan as an antiviral medication to treat influenza. Avifavir has been approved to be used in Russia, and is being tested in the US and the UK as well. Let’s keep avifavir on our radar, if it works, we’ll surely know about it.

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“[Feedback], like rain, should be gentle enough to nourish a man’s growth without destroying his roots.” – inspired by Frank A. Clark

Being corrected is not easy. It takes a lot of courage to accept that we may be wrong sometimes, and trying to fix our mistake requires diligence. Remember that your attendings are not trying to humiliate you (or at least the attending I know), but they are correcting you to help you succeed in your career. Today we have a resident who is excited to talk about his topic. Welcome, Dr Brito.

1. Question Number 1: Who are you?

I was born and raised in the center of the Cuban island. I had the opportunity to study and practice Medicine in my native country. After graduating from medical school, I completed my social service year in an underserved area on the beautiful north coast. Most of my patients were farm workers or fishermen. I also worked in the ER for 6 years before emigrating to the United States. Once in the US, and after years of preparation, I was accepted into the UCLA IMG Program in 2018, and the following year I matched in the Rio Bravo program.

I like fish keeping, outdoor sports such as running, sports in general, my favorite Movie director is Pedro Almodovar. I also love jazz music, Miles Davis, and Chucho Valdes. 

2. Question number 2: What did you learn this week?

I learned about the treatment of Tension-type Headache (TTH).

PREVENTIVE THERAPY

Prophylactic therapy ranges from drugs to nonpharmacologic therapies such as behavioral and cognitive interventions. Prophylactic treatment is indicated if headaches are frequent, long-lasting, or account for a significant amount of total disability. Such as, frequent episodic subtype (1 to 14 headache-days a month) and chronic subtype (>15 headache-days a month) 

Preventive therapy may be also indicated when acute therapy (such as acetaminophen and NSAIDs) fails or is inappropriate because of inadequate response, adverse events, overuse, or contraindications. 

Pharmacologic preventive therapies: Evidence of efficacy is limited and inconsistent, but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. Other medications - mirtazapine and venlafaxine, topiramate, gabapentin, tizanidine have limited data. Trigger point injections require more research. In contrast, SSRIs are not effective.  

Dosing and duration of therapy: Start the drug at the lowest dose, and increase the dose gradually until therapeutic benefit is achieved. Benefit is often first noted only after four to six weeks of therapy. Avoid overuse of analgesic medication, in fact eliminate it, or preventive therapy will likely be ineffective. Measure the effectiveness of therapy by use of a patient headache diary. For example, amitriptyline at 10-12.5 mg nightly, and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated, maximum dose of 100 to 125 mg. TCA are associated with cardiac conduction abnormalities and arrhythmias. Before initiating treatment, patient should be screened, 40 years and older with EKG, younger than 40 can be screened by history for evidence of cardiac disease.  

Behavioral therapies: Regulation of sleep, exercise, and meals. CBT, relaxation, biofeedback—These therapies may be suited for patients who prefer no pharmacologic treatment; those who have insufficient response to, or poor tolerance to pharmacologic treatments; pregnant, nursing, excessive use of analgesics; those who have significant stress or deficient stress-coping skills. 

Studies suggest treatment using biofeedback combined with relation therapy rather than other behavioral therapy options. 

Biofeedback: Electrical sensors connected to a monitor are hooked up to your body. The sensors measure one or more signs of stress. This can include heart rate, muscle tension, or body temperature. The measurements provide feedback about how your body responds to different stimuli. Patients learn to interpret those signals and control them.

Other no pharmacologic therapies such as acupuncture which suggests any benefit is likely to be modest and Physical therapies with unproven benefits. 

ACUTE TREATMENT

The acute or abortive therapy of TTH ranges from nonpharmacologic therapies to simple and combination analgesic medications. In most cases, the treatment of TTH is largely self-directed using OTC medications without any input from a medical provider. 

Nonpharmacologic treatments include heat, ice, massage, rest, and biofeedback.  

Precipitating factors include of TTH: Stress and mental tension are reported to be the most common precipitants. Other precipitants anxiety, major depression, overwork, Lack of sleep, Incorrect posture, etc. Controlling these triggers may help in the acute treatment of TTH.

Medications: Given the available data, the recommended treatment is with simple analgesics such as NSAIDs or aspirin for patients with pure episodic TTH. Acetaminophen 1000 mg is probably less effective than NSAIDs or aspirin. 

Reasonable choices include ibuprofen (200-400), naproxen (220 or 550 mg) or aspirin (650 to 1000). For failing, diclofenac (25 to 100 mg). For those who cannot tolerate NSAIDs or aspirin, acetaminophen 1000 mg is the preferred choice. 

How to judge the success of acute treatment

Reasonable goals:

- Is the patient pain-free and functioning normally in two to four hours after treatment? 

- Does the treatment work consistently without routine headache recurrence? 

- Is the patient able to plan his or her day? (disability)

- Is it tolerable?

The treatment should be considered ineffective if two or more of these criteria are consistently not met. 

What to do in case of treatment failure 

• Consider diagnosis of TTH is inaccurate, less likely secondary etiology, most likely migraine without aura 
• Dx is correct but wrong medication choice, inadequate dose, timing
• Medication overuse
• Patient has depression, and/or anxiety disorder. 

Other acute interventions: Combination analgesics containing caffeine (recommended in suboptimal response), butalbital and codeine (not recommended as initial therapy), Parenteral (chlorpromazine, metoclopramide (limited evidence), Ketorolac, Muscle relaxant (not recommended) 

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

Tension-type headache is the most prevalent headache in the general population and the second-most prevalent disorder in the world. Yearly, prevalence rates for episodic TTH are approximately 80 % in men and women. Understanding the pathophysiology and clinical aspects of TTH is important for accurate diagnosis and optimum treatment. However, TTH is a relatively featureless HA, making it the least distinct of all the primary HA phenotypes. In addition, it is the least studied of all the primary HA disorders, despite having a high socioeconomic impact. 

Societal impact: The prevalence of TTH is greater than migraine and the overall cost of TTH is high. In one population study, persons with episodic TTH reported a mean of nine lost workdays and five reduced- effectiveness days, while persons with chronic TTH reported a mean of 27 lost workdays and 20 reduced-effectiveness days.  

4. Question number 4: How did you get that knowledge?

That knowledge came first from medical school, and second, after years of practicing Medicine. During those years, we as doctors, evaluate and manage a large number of patients with one of the most common medical complaints, headache. 

In terms of finding out more of what to do with patients, how to make them feel better, I had to look some stuff up. My trusty sources in clinic are 1) Up to Date, 2) Faculty, 3) Review/Journal articles. Not necessarily in that order. 

5. Question number 5: Where did that knowledge come from?

The information comes from multiple reliable medical sources such as “Frequent Headaches: Evaluation and Management” by Anne Walling, downloaded from the AAFP website, and “Tension-type headache in adults: Preventive treatment and Acute Treatment” in Up-to-Date. 

____________________________

Speaking Medical: Choluria

Hi this is Harjinder Sidhu, I’m a 3rd-year medical student. I’m here to present the medical word of the week: Choluria. Has your patient ever inform you their urine color is brown (Coca-Cola color)? Choluria has 2 roots, “chol” and “uria.” “Chol” is the combination of bile and gallbladder. “Uria” is the presence of something in urine that should not be present. So choluria is the presence of bile in the urine. What causes the urine to become brownish in color? The presence of bile in urine is caused by an underlying liver disease such as cirrhosis, hepatitis and/or hemolysis. Choluria usually manifests when the serum levels of bilirubin are above 1.5mg/dl. Now that you understand what choluria is, in the future you can look out for our patients by asking any changes in urine as a sign of potential liver problems. Stay tuned for next week’s word of the week!

____________________________

Espanish Por Favor: Señale con un dedo

Hi this is Dr Carranza on our section Espanish por favor. This week I wanted to share a tool for a follow-up question. Not too long ago we learned that DOLOR means pain, and we learned about body parts like “cabeza” head, “rodilla” knee, “pecho” chest, etc. 

Next you will probably want to ask where the “dolor” exactly is, and to simplify things we can ask the patient to point with one finger to where it hurts. We can do this by saying “dónde” which means where, followed by “señale con un dedo”, which means point with one finger. “Señalar” means to point, and “dedo” means finger.

I hope you can use this in your practice, “señale con un dedo”, and you can always ask nicely and add “por favor” which means please. 

Have a great week!

Now we conclude our episode number 17 “Tension Headache”. Dr Brito briefly explained the treatment of tension headache. Lifestyle modifications are key in the treatment, and many non-pharmacological options are available with different degrees of evidence. Thinking about prophylaxis of tension headaches? Amitriptyline is likely a good choice, but remember the side effects as well. Dr Carranza taught us how to ask about location of pain with the phrase “señale con un dedo”, and then we remembered the word choluria, which is bilirubin in the urine. Stay tuned for more next week.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. 

Our podcast team is Hector Arreaza, Ariel Brito, Claudia Carranza, and Harjinder Sidhu. Audio edition: Suraj Amrutia. See you soon! 

_____________________

References:

1. Unhealthy Drug Use: Screening, June 09, 2020, US Preventive Task Force, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening
2. “Avifavir, first COVID-19 drug from Russia: What you need to know”, MSN News, https://www.msn.com/en-ae/news/other/avifavir-first-covid-19-drug-from-russia-what-you-need-to-know/ar-BB14UKvN, accessed on June 15, 2020.
3. “Biofeedback” by Healthline, https://www.healthline.com/health/biofeedback#procedure, accessed on June 15, 2020.
4. Walling, Anne, Am Fam Physician. 2020 Apr 1; 101(7):419-428
5. Taylor, Frederick R, “Tension-type headache in adults: Preventive treatment” (https://www.uptodate.com/contents/tension-type-headache-in-adults-preventive-treatment?search=tension%20type%20headache%20treatment&source=search_result&selectedTitle=2~108&usage_type=default&display_rank=2), and “Tension-type headache in adults: Acute treatment” (https://www.uptodate.com/contents/tension-type-headache-in-adults-acute-treatment?search=tension%20type%20headache%20treatment&source=search_result&selectedTitle=1~108&usage_type=default&display_rank=1), Up to Date, accessed on June 15, 2020.

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

The sun rises over the San Joaquin Valley, California, today is June 12, 2020. 

The results of the DAPA-HF (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure Trial) were presented in November 2019. If you haven’t heard about it, here you have it: In patients with Heart Failure with reduced Ejection Fraction, both WITH and WITHOUT Type 2 Diabetes, dapagliflozin plus standard therapy reduced the risk of worsening Heart Failure events and Cardiovascular death and improved symptoms. 

Did you hear that? It improved heart failure outcomes in patients WITH and WITHOUT diabetes. This certainly opens a new window for potential use of SGLT-2 inhibitors in patients WITHOUT diabetes.

On May 8, the CDC reported a significant decline in childhood immunizations since March. Let’s remember to prioritize well-child visits for patients who need vaccinations. As family physicians, we play an essential role in prevention, and we need to avoid the resurgence of preventable communicable diseases.  

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“The roots of education are bitter, but the fruit is sweet” –Aristotle.

Going to school and learning requires effort, patience, and perseverance, but the consequences of your determination will be well worth it. Dear residents, you will learn something new every day of your lives, even if you don’t realize it. Today we will learn even more from one of our sweetest and smartest residents. Welcome Monica Kumar, thanks for being here with us. I understand you were working nights, but now you are rested and refreshed. Who are you?

1. Question number 1: Who are you?

My name is Monica and I am a second-year family medicine resident at the Rio Bravo Family Medicine Residency Program. So, a little bit about me, I was born in Malaysia, a small country located in Southeast Asia. In 2004, my parents and I moved to Bakersfield, California, a place I now call home. I went to Bakersfield High for high school and then graduated from UC Berkeley with a major in Integrative Biology. 

After undergrad, while trying to plan out the rest of my life career wise, I worked as an air testing chemist for a year, which made me want to run as far away as I can from being stuck in a lab, so I ran all the way to the beautiful island of Saint Marten to pursue a career in Medicine. 

After finishing medical school, I was very fortunate I was able to return home to learn and serve the community that has given me so many opportunities. For fun, I love playing badminton and ping pong, flying kites, walking my dog, gardening, going on adventures, and binge watching romantic comedies and horror movies on Netflix. 

1. Question number 2: What did you learn this week?

So, after working multiple shifts in the ED while wearing the N95 for about 7-9 hours consistently and walking around with a daily headache, I thought it was only appropriate for me to talk a little bit about headaches, particularly the indications for imaging, assessment and management of headaches in the outpatient setting. 

I have had numerous patients who have come to clinic repeatedly complaining of headaches and, though we all have gotten headaches in our lifetimes, we often forget how debilitating it can be for patients who cannot find an appropriate treatment regimen to control their symptoms. 

There is a fine balance about when to treat headaches. We should not overuse medications because overuse can worsen migraine and tension headaches, but at the same time not controlling repeated headaches can result in central sensitization and transformation to chronic headaches that are intractable and difficult to treat. 

When to treat headaches 

First, we should perform a thorough interview of the patient presenting with frequent headaches. We have to ask about 

•   Associated symptoms: nausea, vomiting, photophobia, neck tenderness

•   Duration of episodes and frequency

•   Aggravating and alleviating factors (if the headache is worse with activity or light, or if there is any improvement with noise avoidance)

•   Inquire about the intensity, location and quality of the pain 

•   Medications utilized and its effectiveness

Next, we have to perform a thorough, focused physical exam carefully examining head, neck, eyes including fundoscopy, evaluating extraocular movements, visual fields, assessing sinus tenderness and gait 

Some labs to consider: CBC, CMP, ESR to evaluate for temporal arteritis

The next big question is when is imaging indicated. Being family physicians we do not want to expose our patients to excessive procedures and radiation but we have to find a fine balance by considering the pros and cons. The American Headache Society and American Academy of Neurology recommend the use of the mnemonic SNOOP to guide in the decision of obtaining further imaging 

The mnemonic SNOOP can be used to think about secondary causes of headaches and the need for imaging. 

S in snoop stands for Systemic symptoms and Secondary risk factors. You want to inquire if the patient has been experiencing fevers, chills, weight loss OR if they have a history of HIV or cancer.

N in snoop is for Neurologic symptoms. Ask the patient if they have experienced any confusion, impaired alertness or alteration in consciousness of mentation. The presence of neurologic symptoms should prompt immediate evaluation for focal nervous system lesion.

O stands for Onset: is the headache sudden, abrupt.

O in snoop is for Older. A new onset or progressive headache in an older patient >50 years of age requires further investigation.

P in the mnemonic stands for Papilledema.

Per the American Headache Society and the American Academy of Neurology, if imaging is indicated at the outpatient setting always order an MRI without contrast instead of a CT. A CT should mainly be used in an emergent situation to r/o hemorrhage. 

Non-pharmacologic Treatment

• Reduce stressors, exercise, meditate, keep a headache journal.
• Address lifestyle issues such as poor sleep, lack of exercise, smoking, obesity, caffeine use in triggering headaches
• The US Headache Consortium strongly recommends relaxation training with or without thermal biofeedback and cognitive behavior therapy for the treatment of migraines
• Of note, patients with frequent headaches require both prophylactic and acute pharmacologic treatments.

1. Question Number 3: Why is this knowledge important?

Since headaches are one of the most common complaints we as family medicine physicians encounter, it is very important that we do not miss secondary causes of headaches which can be life threatening. 

1. Question number 4: How did you get that knowledge?

After SNOOPing around AAFP articles pertaining to the treatment and management of headaches in the outpatient setting, I stumbled across the SNOOP mnemonic and thought it would help me and my fellow colleagues remember the indications for imaging and the danger signs that can prevent us from missing a life-threatening diagnosis 

1. Question number 5: Where did you get that knowledge?

The information discussed was condensed from various AAFP articles titled “Frequent headaches: evaluation and management” “Migraine Headache Prophylaxis” as well as UpToDate’s headache article. That’s all for this week, stay tuned for the treatment and management which will be covered during our next episode with Dr Brito, hope you have a nice rest of your week. 

Speaking Medical: Formication or delusional infestation
by Dr Gina Cha

ForMication, with an M, (not to be confused with forNication with an N, which is consensual sexual intercourse between two unmarried people). ForMication is one of the terms used to describe the sensation of small insects crawling on (or under) the skin. 

Formication comes from the Latin word formica, which means ant. A patient with formication perceives the sensation as “real”, they have a fixed, delusion that they are infested by bugs, that’s why we also call it delusional infestation. 

Primary delusional infestation is a psychiatric disorder which cannot be treated only by reasoning with the patient that he or she is not infested by bugs. Delusional infestation is the most common form of monosymptomatic hypochondriac psychosis. 

Formication can also be secondary to substance abuse (methamphetamine, cocaine), or substance withdrawal (alcohol and benzodiazepines). Do not confuse formication with pruritus or paresthesias, which can be explained by an organic cause, but formication has a heavy psychiatric component. 

Espanish Por Favor: Chorro 
by Dr Claudia Carranza

Hi this is Dr Carranza on our section Espanish por favor. This week’s word is cabeza. Cabeza means head, this word comes from Latin root “caput” which literally means head. Patients can come to you with the complaint: “Doctor, me duele la cabeza” or “Doctor, tengo pesadez de cabeza”, which means “Doctor, my head hurts” or “Doctor, my head feels heavy”. You can then continue the interview and ask about timing, duration, exact location, prior trauma, and associated symptoms, just like Dr Kumar eloquently explained before.  

Now you know the Espanish word of the week, “CABEZA”. 

For your Sanity
by Drs Lisa Manzanares, Gina Cha and Alyssa Der Mugrdechian

—What is the medical term for owning too many dogs? A Roverdose

Patient: Doctor, someone decided to graffiti my house last night!
Doctor: So, why are you telling me?
Patient: I can’t understand the writing, was it you?

_______________

Now we conclude our episode number 16 “Snoop That Headache”, Dr Kumar talked about how to determine if a headache needs imaging evaluation. Remember, SNOOP stands for Systemic and Secondary risk factors, Neurologic symptoms, Onset, Older, and Papilledema. ForMication (with an M) is used to describe the sensation of bugs crawling on or under the skin. It is an unusual symptom for a psychiatric or neurologic illness. This week we taught you the spanish word cabeza, which means head, so now you know what your patient is talking about when they said they have pain in their cabeza.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. 

Our podcast team is Hector Arreaza, Alyssa Der Mugrdechian, Gina Cha, Lisa Manzanares, and Monica Kumar. Audio edition: Suraj Amrutia. See you soon! 

___________________________

References:

1. Zoler, Mitchel L., “Heart Failure, Dapaglifozin Equally Effective for Those with and without Diabetes”, Family Practice News, Vol. 49, No. 12, December 2019.
2. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:591–593. DOI: http://dx.doi.org/10.15585/mmwr.mm6919e2external icon
3. Walling, Anne, MB, ChB, “Frequent Headaches: Evaluation and Management”, Am Fam Physician. 2020 Apr 1;101(7):419-428. https://www.aafp.org/afp/2020/0401/p419.html
4. Ha, Hien, PharmD, and Gonzalez, Annika, “Migraine Headache Prophylaxis”, Am Fam Physician. 2019 Jan 1;99(1):17-24. https://www.aafp.org/afp/2019/0101/p17.html
5. Wootton, Joshua, MDiv and col., “Evaluation of headache in adults”, UpToDate, https://www.uptodate.com/contents/evaluation-of-headache-in-adults?search=headache&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1, accessed on 6/11/2020.

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

The sun rises over the San Joaquin Valley, California, today is June 5, 2020.

Have you heard about a new once-a-day gabapentinoid for postherpetic neuralgia? It’s called Gralise®. Keep it in mind, but also be mindful of the price. According to GoodRx, 30 tablets of 300 mg may cost $200 with a discount coupon. Consult your patient’s formulary to verify its coverage.

On Tuesday, May 24, at 9:32 PM, a 3.7-magnitude earthquake was felt in east Bakersfield. The quake’s epicenter was estimated at Corrientes Street near Kern Medical, according to USGS. There was no damage, and the shaking was described as “light” and “a typical Californian earthquake”. This serves as a reminder for emergency preparedness. Make sure you have a plan and good home storage in case of a major event. 

Finally, something different than COVID-19 caught national attention on May 25, 2020. Unfortunately, it was not a positive note. An African-American man named George Floyd was killed by a policeman in Minnesota. This has caused national commotion and has heated up the debate about racism in the US. Hopefully by the time you listen to this episode, justice has been served.  

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“If you are not willing to learn, no one can help you. If you are determined to learn, no one can stop you.” –Zig Ziglar.

If you are determined to learn, you are just unstoppable. Your residency experience can be enriched by your determination to learn. Dear residents, make sure your eagerness to learn works in your favor as a driving force during this unique period of your life. Today we have a resident with a strong determination to learn. She has successfully overcome many obstacles and she’s here with us today as a PGY3. Welcome, Dr Fareedy.

1. Question number 1: Who are you?

My name is Amna Fareedy. I am a third-year resident at Rio Bravo Family Medicine Residency Program in Bakersfield. I was born in New Jersey and moved to Pakistan during high school. I relocated back to the USA after finishing my medical school and getting married. 

I am also a mother to two very active children. My hobbies include reading and watching period dramas, but between my children and residency that has been on a halt for a while. My only entertainment at home currently is watching baby shark with my children.

1. Question number 2: What did you learn this week? 

This week I learned about the different colorectal cancer screenings. As primary care physicians, preventive visits are very important for our patient’s well-being. At age 50, colorectal cancer screening becomes part of preventive care in average risk patients.  I have observed that patients can be hesitant in getting themselves screened for colorectal cancer (CRC) which can be due to number of reasons that I will highlight as we progress in discussion. 

Comment: This is a very good topic. I’m surprised to know that the American Cancer Society (ACS) recommends that people at average risk start screening at age 45 (2018). People who are in good health and with a life expectancy of more than 10 years should continue regular colorectal cancer screening through the age of 75. For ages 76-85, the decision to be screened should be based on a person’s preferences, life expectancy, overall health, and prior screening history. People over 85 should no longer get colorectal cancer screening. The USPSTF recommends screening at age 50 (2016, being revised).

Three different ways to screen for colorectal cancer

Multiple screening tests are available to detect CRC and adenomatous polyps which differ in sensitivity, specificity, availability, effectiveness, and cost.

Stool-based test: Fecal immunochemical test (FIT) for blood in stools

This test directly measures the hemoglobin in stool. 

Test Procedure: FIT is a simple test performed on stool sample provided by the patient in a special collection container. It is performed annually.

Advantages and disadvantages

• It is convenient and has a higher adherence rate. 
• There are no pre-requisites to be completed prior to testing no dietary and medication restriction.
• Does not require bowel prep, sedation or anxiety of an invasive procedure.
• It requires only one sample as compared to the FOBT which requires three.
• It is more sensitive than gFOBT for colon lesions.
• When compared with gFOBT, FIT screening has higher detection rate for CRC and advanced adenomas due to higher sensitivity and higher screening participation rate with FIT
• FIT is less sensitive for detection of right sided than left sided colon lesions.

Comment: Screening for colorectal cancer = Screening for polyps.

Multitargeted stool DNA test with FIT (Cologuard®) 

It is a composite of test that include assay to test for DNA KRAS mutations gene amplification to test for biomarkers associated with colorectal neoplasm, and to test for hemoglobin that might be shedding in to stool from the colon.

Patient collects the stool in a special collection kit and mails it to the company for testing. It has to be received by the company within 72 hrs of collection.

Advantages and disadvantages:

• Testing is done at home.
• No medical dietary restrictions. 
• No bowel prep or sedation. 
• If test is positive, then follow up with colonoscopy. 
• If negative, follow up every three years instead of annually.
• Patient may not completely collect the full stool sample as instructed by collection kit.
• Stool sample needs to be received by the company within 72 hours of collection. 

Comment: In our clinic, all the MAs have the ordering form, just sign it and ask your MA to fax it. Patient will be contacted by manufacturer. You will get the result to discuss it with the patient. 

Colonoscopy

It is the most commonly used screening test in United states. It needs to be performed by trained clinician using endoscope to directly visualize the colon. It is performed every 10 years. 

Advantages and Disadvantages: 

• Definite test for detection of precancerous adenomas and CRC with high sensitivity and specificity.
• It allows for biopsy to be taken. 
• It requires vigorous bowel preparation.
• Sedation is used during colonoscopy.
• Patient might need another attendant on discharge due to sedation effect. 
• Sedation related side effects.
• Colonoscopy related bowel injuries perforation bleeding.
• Less effective in detecting right sided compared to left side colon lesions because of contour or location.

Comment: For the record, we did not cover flexible sigmoidoscopy, CT Colonography, Methylated SEPT9 DNA (mSEPT9), but those are other options to screen for colorectal cancer and adenomatous polyps. 

Polyps

Pedunculated and sessile: Both can turn into cancer, terms only describe the shape (mushroom-like or not). 

Hyperplastic, Hamartomatous, and inflammatory (normally not cancerous, only in certain cases – size, number, location and certain syndromes).

Sessile serrated polyps or adenomatous polyps (considered precancerous polyps and require close surveillance). The GI specialist will normally give patients a follow up instruction. 

1. Question number 3: Why is that knowledge important for you and your patients?

As primary care physicians, this knowledge is important so we can offer our patients all the options available for colorectal cancer screening. Limiting patients to one choice, for example colonoscopy, results in non-adherence due to different factors discussed earlier.

Patients can be offered all the choices: FIT, FOBT, Cologuard®, sigmoidoscopy, etc. in addition to colonoscopy. If patient’s results are positive, further intervention and recommendations can be offered, which is better than not having any screening at all.

Comment: Colorrectal cancer is the second leading cause of cancer death in the US, almost 50,000 patients die every year.

1. Question number 4: How did you get that knowledge?

Many of my patients are resistant to be screened for fears of colonoscopy. I want to offer them different options.

1. Where did that knowledge come from?

For this topic, I specifically read up-to-date test for screening for colorectal cancer, the ACS website, and USPSTF current recommendations.

Speaking Medical (Medical word of the Week): Smegma
by Steven Saito

Smegma, also known as penile cottage cheese,is a white or yellowish secretion found between the glans of the penis and the foreskin of men and other mammals. It is an oily mix of sebum with dead cells that may become “cheesy and smelly” when left stagnant. The combination of warmth and smegma creates a rich breeding media where bacteria can grow and create a characteristic stench. This can lead to infections as well. Smegma is not exclusive to men as women also secrete smegma around the clitoris and labia minora. Believe it or not, smegma is essential for lubrication and good health of the genital organs. Just keep it under control with regular hygiene. An alternative definition by Urban dictionary is “a delicious butter substitute.” 

Espanish Por Favor (Spanish Word of the Week): Diarrea
by Fermin Garmendia

Hello, I am Dr Garmendia and I’m here with our section Espanish Por Favor. The Spanish word of the week is diarrea. When you see the spelling of this word, you can quickly realize it is diarrhea, but the pronunciation is different. Diarrea consists of watery or loose stools. The patient may present to you and tell you: “Doctor, tengo diarrea.” It is a common complaint among our patients, and you need to investigate the characteristics of the stools, any blood? Any mucus? Also, inquire about duration, frequency, triggers, and alleviating factors. Many of our patients relate diarrea to parasites or other infections, and you know it is not always the case. I invite you to read about the work up of diarrhea to learn more, but now you know the Spanish word of the day, diarrea.  

For your Sanity (Medical Joke of the Week)
by Steven Saito

Last week we gave you three questions and we got many good answers. We picked the first person who answered correctly and the winner of our contest is [drum roll] [SURAJ, ADD THE NAME HERE], congratulations! 

Here are the answers to our questions.

1. For the treatment of acute cluster headache, in what nostril is it recommended you administer an intranasal triptan? Dr Manzanares explained that we should administer the intranasal triptan in the nostril contralateral to the symptoms of the acute cluster headache, i.e. if your headache is on the right side, administer Imitrex in the left nostril.
2. What is the other term used for “wet-to-dry” dressings in wound care? Dr Tu recommended the use of the term “moist-to-dry” because the dressing should not be soaking wet, but just moist.
3. Why do we use single-dose vaccine vials instead of multidose vaccine vials? Dr Saito explained that we use single dose vaccine vials to avoid use of thimerosal. Thimerosal is a mercury-containing preservative.

Now we conclude our episode number 15 “Colorectal Cancer Screening”. Dr Fareedy explained the difference between FIT, Cologuard® and colonoscopy. Remember to offer different options to screen your patients who are 50 years and older for colon cancer. Smegma may not be the most elegant of the human body secretions, but it has many benefits. Personal hygiene is key to keep smegma under control and prevent disease. What’s diarrhea without an h? It’s the Spanish word diarrea (Suraj, pronounce dee-ah-RAY-ah). We are happy for [ADD NAME OF WINNER HERE] who is not only wiser for listening to this podcast but also $20 richer. 

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. Our podcast team is Hector Arreaza, Alyssa Der Mugrdechian, Fermin Garmendia, and Seven Saito. Audio edition: Suraj Amrutia. See you soon! 

_____________________

References:

1. American Cancer Society Guideline for Colorectal Cancer Screening, May 30, 2018, https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html, accessed on May 28, 2020.
2. Polyps, F!GHT Colorectal Cancer, https://fightcolorectalcancer.org/prevent/colon-polyps/ , accessed on May 28, 2020.  
3. Colorrectal Cancer: Screening, US Preventive Services Task Force (USPSTF), https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening, accessed on May 28, 2020. 
4. Ahmed, Murtaza, “What is Smegma?: A Guide to the Unappetizing Biofluid That is Smegma”, July 1, 2015, Myheart.Net, https://myheart.net/articles/smegma/

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!

The sun rises over the San Joaquin Valley, California, today is May 29, 2020.

Did you know that educational attainment has been demonstrated to be a strong predictor of health outcomes, including obesity and age of death?(1) That should be a motivation to continue educating yourself, for instance, you can listen to this podcast while you go for a walk around your block… what a great combination! If increasing your health is not enough to motivate you to listen, what if we offer you money? You’ll be surprised at the end of this episode.

Summer is now in full swing. Many of our patients continue to work, or even may have more work, during this season. 

According to Mayo Clinic nephrologist William Haley, heat and lack of proper hydration lead to a higher prevalence of nephrolithiasis in the summer. It’s good to remember that kidney stones between 5-10 mm have a higher passing rate, and tamsulosin may facilitate this process. You would need to treat five patients with kidney stones 5-10 mm to get one stone passage. Stones larger than 10 mm are less likely to pass and may require urology consult. So, this summer, remind your patients to stay well hydrated.

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.[Music continues and fades…] 

“My mission in life is not merely to survive, but to thrive; and to do so with some passion, some compassion, some humor, and some style.” –Maya Angelou.

Passion, compassion, humor, and style(4) —that sounds like a good combination to thrive. Residency is a very special time of your life. Enjoy it! We have a very special resident today. Claudia Carranza was interviewed in Episode 11 “Chlamydia with Clau”, so you probably remember her. That’s why I will change the first question.  

1. Question Number 1: Claudia tell us something random about you. 

My husband and I have a dog, we bought a house in Bakersfield, and I love dancing hip-hop, merengue, and zumba.

1. Question number 2: What did you learn this week? 

This week I learned about what gender identity truly means. I am embarrassed to admit it but although I

think of myself as a very open minded and respectful person, I did not really understand the difference

between gender expression, gender identity, etc. 

I was watching “Becoming”, Michelle Obama’s documentary. At the very end they had young adults introducing themselves and one person said “I’m non-binary”, and then it hit me. Do I, a resident physician, really understand how I would address or refer to a nonbinary patient? And the answer was NO. 

Today I will introduce these concepts in a simple way so we better understand them.

Definition of gender and more

Gender is assigned at birth based on genitalia and chromosomes; male and female which would be the “assigned gender” at birth.

Gender identity is the innate sense of feeling male, female, neither or a bit of both. There is research

with regards to gender identity and how the main drive of it is in the brain. I did have a professor in

medical school who had done research for many years in mice; he studied the brain and different

components. One of his research topics focused on how sex genes/hormones change during

development of an embryo/fetus and, to put it in simple terms, the amount of X and Y did not always

necessarily match the chromosomal make up or genitalia of the fetus. I wish I could find some of his research to share it but after so many moves during med school I do not actually have any of the info, but I promise to upload to our website it when I get a chance to find it.

One research article I did find that was published on Nature is called “Sex Chromosomes and Brain Gender”(5). In a nutshell it states that hormones not only have specific changes in the brain as a whole but also differentiate the “XX” and “XY” brain SEX cells. This is not to say that there is a “female” or “male” brain, which is something I have read on the internet; these types of research from my understanding is attempting to explain that there are many components playing a role in gender identity determination, and that it is not black or white.

Gender expression is the way gender is presented to others; and this can vary depending on cultures, religion, time. How we chose to express our gender in public in terms of clothing, haircut, voice, behavior. 

Gender diversity is a terminology replacing the prior “gender non-conformity” which includes any variation from the cultural norm. 

Transgender is an ADJECTIVE for a person whose gender identity differs from the assigned gender at

birth.

A Transgender man/transman/transmasculine individual is a person with a masculine gender identity who was assigned female sex at birth.

A Transgender woman/transwoman/transfeminine individual is a person with a feminine gender identity who was assigned male sex at birth.

Cisgender is person whose gender identity matches their genital anatomy. For example, I identify myself as cisgender. 

Nonbinary gender identity which is a person of any assigned gender sex at birth who has a gender identity that is neither feminine or masculine, or it could be a combination of both. 

Meaning of LGBT

We have all probably heard about LGBT, but since 1996 there was a Q added to LGBT → LGBTQ for those who identify as queer or are questioning. There is another variant LGBTI or LGBTIQ where the I includes intersex people to LGBT groups. LGBT + encompasses spectrums of sexuality and gender. 

For those of us who are unfamiliar, intersex refers to individuals born with any variation in sex characteristics such as chromosomes, gonads, sex hormones or genitals that do not fit the typical definition of male/female bodies; for example, you might have heard of the previously used term “hermaphrodite”. This word is no longer appropriate for use of humans as it can be misleading.

Comment: There is more about gender than we currently know. We have patients who were raised as boys and later on they realized they had uterus and ovaries. We know there are medical conditions in which sex is not black and white. In those cases, we have to be very sensitive to our patients, and provide the care they need and deserve in a respectful and effective way. 

1. Question number 3: Why is that knowledge important for you and your patients? 

I think understanding and respecting patients and their gender identity is important for any physician. We are here to treat, help and improve the health of our patients. As family physicians or primary care

physicians we are sometimes going to be the first step in a parent understanding a child’s gender

identity. We should support a gender-affirmative model which would include allowing or encouraging

children to express their perceived gender in a supportive and safe environment; this would include not

only in the office but also in their home, school, etc.

It’s important for us to understand that it is a normal part of growing up for children to explore gender

expression and gender roles. Children do assume gender stereotypes for themselves, this usually starts

in preschool and later is more defined in school aged children. One thing to note is that the gender

behavior and expression becomes more persistent with age. 

In a cohort study by Gulgoz S and others “Similarity in transgender and cisgender children’s gender development,”(6) it was found that the persistency of gender expression was coherent between both groups, meaning that transgender and cisgender children began to affirm their gender expression at about the same pace and time. 

For all physicians out there, if you do not know enough or are not comfortable with talking to parents or

patients about gender diversity then PLEASE make sure to refer them to someone who is

knowledgeable! Parents and patients will need lots of guidance especially as they go through

adolescence when gender diverse patients will undergo likely unwanted pubertal changes. 

Some may experience gender dysphoria which is discomfort or distress by a mismatch between gender identity and the gender sex assigned at birth. This can develop into depression or anxiety which can lead patients to participate in risky behaviors. 

Comment: I agree with you, we should educate ourselves on the treatment of this diverse population. You can choose what to believe, you can raise your family the way you want, teach your family values you consider right for you and your family, but at the same time educate yourself how to treat this population, and if you decide to refer to another provider, it is also acceptable. 

1. Question number 4: How did you get that knowledge?

My go-to is always UpToDate, but I have to admit I did use Wikipedia this time and Google to have a

better understanding on when abbreviations changed, or to read about the opinion of the general

population on gender identity issues and just to see what other sources I could find. 

Comment: Yes, UpToDate is an excellent source, but in a topic like this, you can expand your search to many other resources. And you also mentioned that a documentary motivated you to do more research about a topic which you ignored.

1. Question number 5: Where did that knowledge come from?

Besides UpToDate “Gender development and clinical presentation of gender diversity in children and

adolescents”(7) and Wikipedia “LGBT”(8), I read planned parenthood “Sex and Gender Identity”(9), the TREVOR project “Trans + Gender Identity”(10), I also read an article in Nature Neurology “Sex Chromosomes and Brain Gender”, and a Pubmed article “Similarity in Transgender and Cisgender Children’s gender development”.

____________________________

Speaking Medical (Medical word of the Week): 
by Dr Gregory Fernandez

The medical term for this week is Anosognosia. Anosognosia is an inability or refusal to recognize a defect or disorder that is clinically evident. It’s like denying it’s sunny when you are out in Bakersfield at noon in mid-July. Anosognosia is the result of damage to the brain structures, typically to the parietal lobe or a diffuse lesion on the fronto-temporal-parietal area in the right hemisphere. Anosognosia can present as a sign of Alzheimer’s disease, traumatic brain injury, stroke, or mental illness such as anorexia nervosa or schizophrenia. Anosognosia is very similar to denial, but denial is a defense mechanism. When you don’t want to admit that you’ve gained weight, even when your jeans don’t fit you anymore, you don’t have Anosognosia, you are just in denial.     

____________________________

Espanish Por Favor (Spanish Word of the Week): Pecho 
by Dr Claudia Carranza

Hi this is Dr Carranza on our section Espanish por favor. This week’s word is pecho. Pecho means chest or breast and pechos mean breasts. This word comes from Latin root “pectus” which means chest. Patients can come to you with the complaint: “Doctor, me duele el pecho” which means “Doctor, I have chest pain”- take a minute, take a deep breath, this does not necessarily mean you have to start an ACS work up; remember the other etiologies such as costochondritis or muscle pain. Also remember it could mean that their breast hurts; think of this especially in lactating mothers or if the patient says: “Doctor, me duelen los pechos” which means “Doctor, my breasts hurt”. At that point, switch gears and focus on breast pain instead of chest pain. For example, inquire about lactation, relations to menstrual cycle, triggers, or dig for red flags if you suspect cancer. Now you know the Spanish word of the week, pecho. See you next time!

____________________________

For your In-sanity 
by Dr Steven Saito

Send your answers to [email protected]. 

This podcast was created for family medicine residents, but we have listeners of all walks of life in different parts of the world. So, this week, we want to reward your loyalty to medical education whoever you are. We are going to give you three questions about topics covered in this podcast, and the first listener to give us the correct answers to the three questions will be awarded an Amazon gift card. The three questions are:

1. For the treatment of acute cluster headache, in what nostril is recommended you administer an intranasal triptan? 
2. What is the other term used for “wet-to-dry” dressings in wound care? 
3. Why do we use single-dose vaccine vials instead of multidose vaccine vials? 

If you want a clue about these questions, a key number would be 3-6-9. 

Now we conclude our episode number 14 “Gender Diversity”. Dr Carranza taught us what “non-binary” means and gave us an introduction to the terminology LGBTIQ. Is it chest pain or breast pain? That’s the question you should ask when a patient tells you in Spanish they have pain on their pechos. Anosognosia is the inability to recognize a sign of disease even when it is grossly evident. For your IN-sanity this week, we asked three questions: 1. In what nostril should you apply intranasal triptans to treat an acute cluster headache? 2. What’s another term for wet-to-dry dressing? and 3. Why do we use single-dose vaccine vials? The first listener who answers correctly to the three questions will get a prize. Getting pay to keep learning –It cannot get any better than that. Send your answers to [email protected]. 

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

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. 

Our podcast team is Hector Arreaza, Steven Saito, Claudia Carranza, Terrance McGill, and Gregory Fernandez. Audio edition: Suraj Amrutia. See you soon! 

__________________________

References:

1. Jones, Daniel W., “One Doctor’s Opinion on Why the US Obesity Pandemic Persists, The American Journal of Medicine,” Elsevier, April 2020, Vol 133, Number 4, 401-403.
2. Sparks, Dana, “Greater Risk for Kidney Stones in Summer”, Mayo Clinic, https://newsnetwork.mayoclinic.org/discussion/greater-risk-for-kidney-stones-in-summer/  , August 4, 2015.
3. POEMs (Patient-Oriented Evidence that Matters), “Tamsulosin Beneficial for Passage of 5-10 mm Distal Ureteral Stones”, Am Fam Physician, 2017, Jan 15; 95(2):123a-124. https://www.aafp.org/afp/2017/0115/p123a.html
4. Brainy Quotes, https://www.brainyquote.com/authors/maya-angelou-quotes
5. Arnold, A., “Sex chromosomes and Brain Gender”. Nat Rev Neurosci5, 701–708 (2004). https://doi.org/10.1038/nrn1494
6. Selin Gülgöz, Jessica J. Glazier, and col., “Similarity in transgender and cisgender children’s gender development”, PNASDecember 3, 2019, 116 (49) 24480-24485; https://doi.org/10.1073/pnas.1909367116
7. “Gender development and clinical presentation of gender diversity in children and adolescents”, by Michelle Forcier, MD, MPHJohanna Olson-Kennedy, MD, UpToDate, https://www.uptodate.com/contents/gender-development-and-clinical-presentation-of-gender-diversity-in-children-and-adolescents, accessed on May 21, 2020.
8. LGTB, Wikipedia, https://en.wikipedia.org/wiki/LGBT, accessed on May 21, 2020.
9. “Sex and Gender Identity”, Planned Parenthood, https://www.plannedparenthood.org/learn/gender-identity/sex-gender-identity , accessed on May 21, 2020.
10. Trevor Support Center, “Trans + Gender Identity”, https://www.thetrevorproject.org/trvr_support_center/trans-gender-identity/  

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!