Rio Bravo qWeek

The sun rises over the San Joaquin Valley, California,today is May 8, 2020. 

On April 28, 2020, the USPSTF released a final recommendation about prevention of tobacco use in children and adolescents. It is recommended that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among children and adolescents. Note that it doesn’t say prevention of “smoking”, it says prevention of “tobacco use” because we know that vaping is “a thing” among youth nowadays. This is a grade B recommendation, which means there is moderate to substantial benefit for this service. 

Now, an update about COVID-19. As of May 4, 2020, the CDC reports a total of 1,160,000 cases and 68,000 deaths due to COVID-19 in the USA. It has been a rough year so far for humanity! 

On May 1st, 2020, the FDA issued an Emergency Use Authorization to remdesivir for the treatment of COVID-19. Remdesivir can be used in hospitalized patients with severe disease. Remdesivir may shorten the time it takes to recover from the infection. It is given intravenously only. The issuance of an Emergency Use Authorization is different than FDA approval. Let’s stay up-to-date as this pandemic continues to evolve.

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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…] 

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"As you would have people do to you, do to them; and what you dislike to be done to you, don't do to them." Taken from Al-Kafi, a Muslim book.

In a way or another, the Golden Rule is preached by many major and minor religions, “Do unto others as you would have them do unto you.” I think it’s a wonderful rule. Today we have a very sweet guest who is a very positive person and a hard worker. Welcome Dr Claudia Carranza, thanks for accepting my invitation to talk in front of the microphone… again! As you know, we ask 5 questions in this podcast, and we’ll start with question number 1.

Question Number 1: Who are you?

My name is Claudia Carranza, I am a second-year family medicine resident in the wonderful Rio Bravo Family Medicine Residency program in Bakersfield, CA. I grew up in Peru then moved to the States for college, attended a couple of community colleges before transferring to UCSD as a Biology major. Then went to Ross University School of Medicine in the Caribbean where I earned my medical degree. I did 1 year of Internal Medicine residency, and then transferred to Family Medicine and I could not be happier!

I am also a wife to a very busy IM resident, I am a Dog mom to Chewie. I don’t have lots of time for hobbies but when there’s time I like to do some strength training, dance, go on walks or runs with Chewie, cook healthy meals, bake and hang out with my hubby and friends. My favorite movie is Love Actually, and my favorite sport is swimming.

Question number 2: What did you learn this week?

This week I learned about the difference between Chlamydia Test of Cure (TOC) and Retesting. 

At our clinic, we have quite a few obstetrics patients, and they all get tested for Chlamydia as new OB patients, as part of their prenatal lab panel. When they are positive, they get treatment, and after treatment they undergo a Test Of Cure or TOC, no earlier than 3 weeks after completion of therapy. All patients with documented infection should also undergo retesting; this includes pregnant patients. 

When we have a pregnant patient who is infected we inquire about their partner and encourage the partner's treatment. Those partners, just like anyone with a documented infection, should have retesting done. 

Example: Let’s say we get a positive C. trachomatis test on one of our pregnant patients. We have to notify the patient of the results and the need for treatment. The recommended regimen for treatment is 1g oral Azithromycin given as a single dose.

If you have a patient who CANNOT tolerate Azithromycin then you may treat with either amoxicillin or erythromycin.

Recommended doses: Amoxicillin 500mg orally TID for 7 days, Erythromycin base 500mg QID for 7 days or 250mg QID for 14 days, Erythromycin ethylsuccinate 800mg QID for 7 days or 400mg QID for 14 days.

Remember after treating the patient and hopefully also their partner, the pregnant patient will need a TOC. Other patients who require a test of cure are any patients that show persistent symptoms or that were treated using a regimen with inferior cure rates, such as erythromycin or amoxicillin. 

Retesting

Retesting is done to check if a patient has been re-infected. This can be done 3 months after treatment or at their first visit thereafter within 12 months of treatment.

Now, think you are at the hospital and you have a pregnant patient that comes to triage in active labor. They brought some of their prenatal records and you know they had a positive C. trachomatis test, and she was treated but she did not have a test of cure, or you don’t have the records to confirm the results. In this case, there is usually not enough time to get a test of cure or retest prior to delivery, so these patients NEED TO BE TREATED upon admission with one of the recommended regimens. 

Of note, when treating pregnant patients; the antibiotics contraindicated during pregnancy (and lactation) are: Doxycycline, levofloxacin, ofloxacin, and erythromycin estolate.

Comment: The pregnancy categories by letters (A, B, C, D, X) were updated on June 30, 2015, by the FDA. Now, all medications are required to include three sections with explanations: Pregnancy, Lactation and Females and Males of Reproductive Potential. Erythromycin should not be used during the first trimester of pregnancy. However, it may be appropriate as an alternative agent for the treatment of chlamydial infections in pregnant women (consult current guidelines)

Treatment of the partner(s)

There are certain states in which Expedited Partner Therapy (or EPT) is permissible. This means a physician can treat the sex partner of a patient who is being treated for chlamydia; in other words, prescribe their partner medication without having examined them. California is one of the 44 states in which EPT is permissible.

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

C. trachomatis is the most commonly reported sexually transmitted disease. First of all, the reason why it is important to treat a pregnant patient is to prevent infection transmission during vaginal delivery. If infection is present during delivery the newborn is at risk for developing conjunctivitis or pneumonia. 

The most effective therapy if the newborn develops either or both is oral erythromycin; Why can we just treat the newborns? It is not that simple. There are studies that have shown an increased risk of hypertrophic pyloric stenosis (IHPS), especially if the infant is treated before 2 weeks of life. 

How likely is an infant to get IHPS if treated with erythromycin? There is a study by Rosenman and associates that compared the use of erythromycin prophylaxis with watchful waiting in a hypothetic cohort of neonates exposed to C. trachomatis. For every30infants treated with erythromycin, one additional case of pyloric stenosis would occur. This would be quite a few infants if we let chlamydia go untreated and newborns requiring treatment.

Pyloric stenosis in a nutshell is a disorder in which the pylorus or gastric outlet can become very narrow or even obstructed which leads to forceful vomiting and requires surgery to fix it.

Another caveat to treating an infant is that Erythromycin is effective in up to 90 percent of cases of conjunctivitis and approximately 80 percent of cases of pneumonia caused by C. trachomatis. Therefore, the infant needs close monitoring and at times a second round of treatment. 

I want the listeners to think for a minute and Just ask your adult self: How fun is it to take antibiotics? The answer is most likely, NOT at all fun; there are always side effects and your GI system is usually the most affected. Now imagine how a tiny little baby must feel.  I would NOT want to put an infant through this treatment unless it is ABSOLUTELY necessary, so if we can prevent it by testing  and treating mothers then let’s do that!

Question number 4: How did you get that knowledge? 

I mostly read UpToDate, AAFP, NEJM, and check the CDC website for updates. If I am not quite sure where I will be able to find a specific topic then sometimes I google what my question is and look through the list to see if any of the sources are reputable or if the articles are from a well known journal then I read the contents. 

Question number 5: Where did that knowledge come from? 

For this topic, I initially had the help of our host Dr Arreaza and then I read different articles in UpToDate, such as “Treatment of Chlamydia Trachomatis infection” and “Chlamydia trachomatis infection of the newborn”. I also read an AAFP article from American Family Physician “Chlamydia trachomatis exposure in newborn”, the CDC “Legal Status of Expedited Partner Therapy”, “Chlamydial infections”, “STDs Clinical Prevention Guidance” and finally Pubmed “Azithromycin in early infancy and pyloric stenosis.”

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OTHER SECTIONS

Speaking Medical: Cataplexy
by Terrance McGill

The Medical word of the week is Cataplexy. Cataplexy is emotionally-triggered transient muscle weakness. Most episodes are triggered by strong, generally positive emotions such as laughter, joking, or excitement. Episodes may also be triggered by anger or grief in some individuals. Cataplexy develops within three to five years of the onset of sleepiness in 60 percent of people with narcolepsy. Remember the word of the week: Cataplexy, See you next week!

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Espanish Por Favor: Agruras 
by Yodaisy Rodriguez

The Spanish word of the week is agruras. Agruras means heartburn (the medical term is pyrosis), and it is typically described as a burning sensation in the retrosternal area, most commonly experienced in the postprandial period, but can be used as well when trying to describe reflux. The scenario will be a patient saying: “Doctor, tengo agrugras”. Agruras is probably a common complaint among our “chili pepper lovers”. Patients with agruras may require additional evaluation if they have red flags, such as weight loss, hematemesis, loss of appetite, vomiting, or more.

Now you know the Spanish word of the day, agruras, all you need to do now is asses your patient’s heartburn.

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For your Sanity
by Fermin Garmendia and Terrance McGill

—Doc, Doc
—Who’s there?
—Disease
—Disease who?
—Disease the worse disaster I’ve ever seen

What’s the anesthesiologist’s ABC? Airway, Book, Chair!

Conclusion: Now we conclude our episode number 11 “Chlamydia with Clau”. Remember to order a TEST OF CURE for ALL your positive chlamydia patients who are pregnant, and RETEST everyone after 3 months of treatment. Don’t forget to treat sexual partner (or partners) to prevent chlamydia reinfection. It is permissible to send a prescription for the partner, even if you have not seen them. Cataplexy is an interesting symptom in narcolepsy, although it’s uncommon, you need to recognize it when you see it. And, if you have a heartburn after eating your pizza, remember the Spanish word of the day, agruras. 

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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. 

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Our podcast team is Hector Arreaza, Claudia Carranza, Yodaisy Rodriguez, Terrance McGill and Fermin Garmendia. Audio edition: Suraj Amrutia. See you soon! 

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References 

1. “Treatment of Chlamydia trachomatis infection”  by Katherine Hsu, MD, MPH, FAAP, last updated: Mar 02, 2020, UpToDate, https://www.uptodate.com/contents/treatment-of-chlamydia-trachomatis-infection?search=Treatment%20of%20Chlamydia%20Trachomatis%20infection&source=search_result&selectedTitle=1~143&usage_type=default&display_rank=1

1. “Chlamydia trachomatis infections in the newborn” by Margaret R Hammerschlag, last updated: Nov 15, 2018, UpToDate, https://www.uptodate.com/contents/chlamydia-trachomatis-infections-in-the-newborn?search=2)%09Chlamydia%20trachomatis%20infection%20of%20the%20newborn&source=search_result&selectedTitle=1~143&usage_type=default&display_rank=1

1. “Chlamydia Trachomatis Infections: Screening, Diagnosis, and Management” by Ranit Mishori, Erica McClaskey and Vince J. Winklerprins, Georgetown University School of Medicine, Washington, District of Columbia, American Family Physician, www.aafp.org/afp, Volume 86, Number 12, December 15, 2012.

1. “Legal Status of Expedited Partner Therapy”, Centers for Disease Control and Prevention, https://www.cdc.gov/std/ept/legal/default.htm , accesed on May 6, 2020.

1. “Chlamydial infections”, Centers For Disease Control and Prevention, https://www.cdc.gov/std/tg2015/chlamydia.htm , accessed on May 6, 2020.

1. “STDs Clinical Prevention Guidance”, Centers for Disease Control and Prevention, https://www.cdc.gov/std/tg2015/clinical.htm , accessex on May 6, 2020.

1. “Azithromycin in early infancy and pyloric stenosis” by Matthew D. Eberly, Matilda B. Eide, Jennifer L. Thompson and Cade M. Nylund, Pediatrics, The Official Journal of the Amercan Academy of Pediatrics, March 2015, https://pediatrics.aappublications.org/content/135/3/483

1. “Clinical features and diagnosis of narcolepsy in adults” by Thomas E Scammell, last updated: Feb 12, 2020, UpToDate, https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-narcolepsy-in-adults?search=8)%09Clinical%20features%20and%20diagnosis%20of%20narcolepsy%20in%20adults,%20Author:%20Thomas%20E%20Scammell,%20MD&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1

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!

Urinary Retention

The sun rises over the San Joaquin Valley, California, today is April 29, 2020. Clinica Sierra Vista’s CEO, Brian Harris, resigned from his position on April 24. We appreciate Brian’s leadership and enthusiasm. He brought positive changes to this institution, and we wish him a successful future. 

How many times have you checked UpToDate today? UpToDate is probably one of the most used point-of-care reference tools in the world. We’d like to recognize the work of Dr. Burton (Bud) Rose, the founder of UpToDate, who passed away on April 24. Thanks, Bud, for your contributions to the spreading of evidence-based medical knowledge. 

This week the media have been flooded by comments about “disinfectants”. A disinfectant is a chemical that destroys vegetative forms of harmful microorganisms (such as bacteria and fungi) especially on inanimate objects. President Trump discussed with experts the possibility of developing a “disinfectant” that can be injected to kill SARS-CoV2 inside the body. An official recommendation to “inject disinfectants” was not issued, but misinterpretations and countless remarks, comments, and jokes were made. Please make sure to tell your patients that common household disinfectants are for external use only.

Quote: “Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid.” Albert Einstein.

Dear Residents, what are you good at?  What are your talents?  I invite you to explore those things you know how to do, and continue to perfect them, we are all geniuses. Today our guest is Dr. John Ihejirika. John is one of our second-year residents in the program. We ask 5 questions in this podcast. We’ll start with the first question.

Question number 1: Who are you? 

My name is Dr. John Ihejirika. I am one of the second-year residents at the Rio Bravo Family Medicine Residency Program, here in Bakersfield California. 

I am originally from Nigeria. My last name was quite a battle for most of my colleagues/coworkers to pronounce at the beginning, but most have now figured out the almost perfect pronunciation, but some still call me Dr. “Ihe” or Dr. “I”, which is still ok, ha-ha. It is pronounced “E – hay- gi- ri- car” which in my local language literally means “What I have that makes me greater than you”.  I grew up in a very humble family and attended and graduated from the College of Medicine University of Nigeria after which I practiced for a few years in General practice especially in very low resource limited communities before immigrating to the United States. 

It was always my dream to further my Medical career in the US, so with lots of studying, effort, persistence, hopes and prayers I find myself here today in the mist of such a wonderful group of Residents and Faculty, and lucky to be in one of the best Family Medicine Residency Programs in the country. Some of my hobbies are cooking especially Nigerian dishes, playing soccer, traveling, meeting people of different cultures, and watching movies. I am very pleased to be here today and thank you for having me.

Question number 2: What did you learn this week? 

What I learned this week was about the management of acute urinary retention (AUR). 

Acute urinary retention is defined as the inability to voluntary pass urine.  

I had a 68 y/o male patient that came to the clinic as a walk-in for complaints of lower abdominal pain and constipation since the previous night. Upon further questioning, I realized that he had not urinated in over 12 hours, and physical examination revealed lower abdomen/suprapubic tenderness and distention. We were able to get about 1L of urine after straight catheterization in clinic with complete resolution of his symptoms. 

AUR is usually common in older men and etiologies may include (1) Outflow obstruction (most common) e.g. Benign prostatic hyperplasia BPH, (2) Neurologic impairment, e.g. damage of sensory or motor nerve supply to the detrusor muscle like in spinal cord injuries, demyelination syndromes or neuropathy, (3) Inefficient detrusor muscle, (4) Medications, e.g. anticholinergics, sympathomimetic and some muscle relaxants, (5) Infections, e.g. acute prostatitis, and 6. Trauma.    

Evaluation of patients with AUR

Initial evaluation involves getting a thorough history and Physical examination which usually reveals a patient in discomfort with suprapubic tenderness and distention. We usually pass a 14-18 Fr urethral catheter (depending on degree of resistance) to decompress the bladder and note the amount and color of urine collected. If urinary output is less than 150ml, AUR is less likely.

Urine samples should be sent for urinalysis and culture. Other labs like a Basal metabolic panel (BMP) to assess any possible damage to kidney from chronic retention. PSA is usually not ordered because it can be elevated in acute episodes of urinary retention. If the urinary output exceeds 400 mL, the catheter is usually left in place for about 3-5 days after which a voiding trial is done. 

If postvoid residual urine volume is >300ml or patient still has lower urinary tract symptoms after the voiding trial, the catheter is usually kept in place until evaluation by Urology.  

Medications

An alpha-1-adrenergic blocker (tamsulosin) and 5-alpha reductase inhibitor (finasteride) medications are usually prescribed, and a referral to Urology is placed at the time of initial catheterization.      

Contraindications of catheterization

Urethral catheterization may be contraindicated in patients who have had recent urologic surgery, trauma to or structurally abnormal urethral opening (meatus), or failed urethral catheterization even with the smallest 10 or 12 Fr catheters. These patients should be referred urgently to Urology for possible suprapubic catheterization.      

Complications after drainage of urine with a catheter.

Some complication can occur during bladder decompression, which may include; Hematuria (usually resolved spontaneously or with irrigation), transient hypotension and Post obstructive diuresis (which is usually seen in chronic urinary retention).

Post obstructive diuresis.

Postobstructive diuresis is defined as as urine output of 200 mL/hr for two consecutive hours or >3L/24hours. It is a polyuric response initiated by the kidneys after the relief of a ureteral obstruction to eliminate accumulated solute and volume(2). This can be managed by increasing fluid intake in patients who are unable to do so or have severe post-obstructive diuresis, we measure the urine output and replace one half the urine volume with half normal saline. For example, 1 litter of urine should be replaced with 500 mL of normal saline.

Summary of Management of AUR(4).

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

Acute urinary retention is a very painful and uncomfortable situation for the patient, and It is the most common urologic emergency in men.  It is also important for patients as it may be the first sign of a prostate abnormality/enlargement like BPH, as some men may not have the classic signs and symptoms of lower urinary tract obstruction previously.  It is important for you as the provider because you should be able to look out for the signs in the history e.g. constipation, inability to voluntary urinate etc. and on physical examination for patients that may be presenting with AUR especially when working in an Urgent care or Emergency room.  It also provides a mutual sense of satisfaction to both patient and provider especially when a prompt diagnosis is made and with immediate relief of symptoms after bladder decompression. 

Question number 4: How did you get that knowledge?

I got this knowledge from my faculty, Up to Date, Review/Journal articles and from some of my personal experience.

Question number 5: Where did that knowledge come from? 

This knowledge came from one of our very knowledgeable faculty here Dr. Parker, An article titled “Urinary Retention in Adults: Evaluation and initial management” from the AAFP website; “The Management of acute urinary retention” from the American Journal of Medicine; and  “Acute urinary retention” review topic on Up-to-Date.  You can see our website for further details on theses references.

Comment: Insertion of a urinary catheter needs to be learned. I recommend you guys review the technique and practice with your nurses how to place a Foley. Maybe we can have a workshop about catheter placement. It’s important to remember the size 14-18 Fr, you can use a larger one in case of BPH. 

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Speaking Medical: Tumescence 
by Steven Saito

During our daily COVID updates we are given ways to relieve stress for our medical workers.  Today we were told that self-massage was a useful form of stress relief.  Back in the military, when they told me I could massage myself, they did not use as polite a phrasing.

In keeping with the theme, the word of the day is tumescence. Tumescence is the quality or state of being tumescent or swollen. Tumescence usually refers to the normal engorgement with blood of the erectile tissues. Nocturnal penile tumescence is a spontaneous erection of the penis during sleep or when waking up. Along with nocturnal clitoral tumescence, it is also known as sleep-related erection. All men without physiological erectile dysfunction experience nocturnal penile tumescence, usually 3-5 times during a period of sleep, typically during rapid eye movement (REM) sleep.

Nocturnal penile tumescence (NPT) testing can be used in diagnostic work up for erectile dysfunction. Monitoring devices are now available that provide accurate, reproducible information quantifying the number, tumescence, and rigidity of erectile episodes a man experiences as he sleeps. Nocturnal penile tumescence testing is generally performed when the clinician is trying to assess between psychogenic and organic erectile dysfunctions (ED). Typically, men with psychogenic ED will have normal NPT results. Physiologic ED will have impaired NPT results. 

Espanish Por Favor: Mal de Orín
by Roberto Velazquez

The Spanish word for the week is “Mal de orín”, which is actually three words: Mal – de – orín, meaning: the disease of the urine, and obviously, people use this phrase when they have any urinary symptoms, most commonly: dysuria, urinary frequency, and/or foul-smelling urine. 

The scenario when your patient complains of “mal de orín” may sound: “Doctor, tengo mal de orín, y no dejo de ir al baño”, what they are trying to tell you is “Doctor, I have dysuria and I may have a UTI”. As temperatures continue to raise this summer, I recommend you assess your patient’s hydration status too. Highly concentrated urine may have a stronger smell and may be confused with “mal de orín”. Now you know the Spanish word of the week, “Mal de orín”, all you need to do is to assess your patient’s “mal de orín”. 

For your Sanity 
By Alejandra Felix (MA) and Monica Kumar (MD)
Ale: My doctor told me to start killing people, well, not in those exact words, he told me to reduce stress in my life. Same thing. 

Ale: Doctor, I have a cucumber up my nose, a carrot in my left ear and a banana in my right ear, what’s the matter with me?
Dr Kumar: Oh my, you are not eating properly!

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Conclusion: Did you know that our In-Training Exam scores in 2019 were low in male reproductive medicine? That’s why our episode number 10 was filled with “manly” topics. Dr Ihejirika talked about Acute Urinary Retention, a condition that can be effectively diagnosed and treated, resulting in a relieved patient, a satisfied resident, and a proud attending. We stayed in the same anatomical area and remembered the word tumescence, and learned the Spanish phrase “Mal de orín” as a sign of possible UTI. At the end of the episode, our MA Alejandra was a little stressed. Don’t blame her, we had a long day in clinic.

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, John Ihejirika, Golriz Asefi, Steven Saito, Roberto Velazquez, Monica Kumar, and Alejandra Felix. Audio edition: Suraj Amrutia. See you soon! 

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References:

Merriam-Webster Dictionary, https://www.merriam-webster.com/dictionary/disinfectant

Singh, Amardeep and Bhagwan Dass, Cureus Journal of Medical Science, “Post-obstructive Diuresis: A Cautionary Tale”, December 8, 2019, https://www.cureus.com/articles/25149-post-obstructive-diuresis-a-cautionary-tale

Fitzpatrick JM, Kirby RS., Management of acute urinary retention. BJU Int. 2006;97 (suppl 2):16–20, discussion 21–22. https://www.amjmed.com/article/S0002-9343(09)00496-3/fulltext

“Urinary Retention in Adults: Evaluation and initial management” by DAVID C. SERLIN, MD; JOEL J. HEIDELBAUGH, MD; and JOHN T. STOFFEL, MD, University of Michigan Medical School, Ann Arbor, Michigan, AAFP. 2018 Oct 15;98(8):496-503. 

https://www.aafp.org/afp/2018/1015/p496.html

Glen W Barrisford MD, Graeme S Steele MD, “Acute urinary retention”, Up to Date.

https://www.uptodate.com/contents/acute-urinary-retention?search=acute%20urinary%20retention&source=search_result&selectedTitle=1~88&usage_type=default&display_rank=1

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

The sun rises over the San Joaquin Valley, California, today in April 23, 2020.

This week the FDA approved the first IV medication for prophylaxis of migraine: Epti-nezu-mab- jjmr (brand name Vyepti®). This is a humanized monoclonal antibody that blocks the calcitonin gene-related peptide (CGRP). Blocking this receptor results in prevention of migraines. Epti-nezu-mab is administered every 3 months(1).

Do you remember those headlines in January 2019? “Insulin loses its place as the first-line injectable treatment”(2) for type 2 diabetes. The family of GLP-1 agonists (the medications that end in “tide”, such as liraglutide, dulaglutide, exenatide, etc.) became the preferred injectable for most patients with type 2 diabetes. In case you didn’t know, in September 2019, the FDA approved the first ORAL GLP1 agonist for use in type 2 diabetes(3). Rybelsus® (semaglutide) (yeah! No needles!). The benefits in weight loss and glycemic control of the ORAL semaglutide (Rybelsus®) are comparable to the INJECTABLE semaglutide (Ozempic®).

In case you did not know, in July 2019, the European Commission approved the first oral medication for adults with type 1 diabetes: Dapaglifozin (Forxiga® in Eruope, Farxiga® in USA). It is an SGLT2 inhibitor previously approved for TYPE 2 diabetes, but now it is being used in Europe for TYPE 1 diabetes as well. The FDA did not approve Farxiga for Type 1 diabetes in the USA. 

Now you know it, there is an IV medication for migraine prophylaxis (Vyepti®), an oral GLP-1 agonist for diabetes type 2 (Rybelsus®), and at least one oral medication for Type 1 diabetes (Forxiga, used only in Europe).  

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Quote: “Being aware of your ignorance gives you the gift of curiosity” –Unknown Author (6)

“Curiosity killed the cat… but satisfaction brought it back”. Curiosity can be a driving force to guide you in your residency training. When used properly, curiosity will take you to unexplored areas and will increase your knowledge and expertise to help more and more patients. I am happy to be with you today in another episode of our podcast. My name is Hector Arreaza, and I am a faculty in the Rio Bravo Family Medicine Residency Program. We received feedback about a word that I mispronounced: Irrelevant. Also, during a previous episode we talked about leucorrhea. Do you know another cause of leucorrhea in little girls? Tiny pinworms: Enterobius vermicularis. Today we have a different kind of episode. I left Dr Saito and Dr Manzanares take over the main part of the podcast. Just a warning, it is rated PG-13 today, enjoy it.  

1. Question number 1: Who are you? 

This is Steven Saito. I am a former Navy doctor, having spent 6.5 years in the service primarily working out of a branch clinic having taken on a variety of additional duties including prior department head and senior medical officer.  I have since come to Rio Bravo BFM to continue to give my service. I’m here to give you your weekly suppository of information. Relax and let it in (joke).

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

As an introduction, Prazosin is an alpha-1 blocker used for treatment of PTSD. It may cause priapism, which is defined as painful erections longer than 4 hours. If this happens to you, just call more people (joke). Main topic: So, I encountered a mother who was against vaccinations.  I wanted to talk a little about vaccine hesitancy and approach to discussion with parents/patients for vaccination.  Hold onto your butts because this is a topic that definitely will not get any controversy or angry emails from Facebook moms groups!

We reviewed information on vaccine hesitancy from the World Health Organization, the Center for Disease Control, and the AAFP. 

In a “short” 253-page paper, the World Health Organization laid out its review of literature and its conclusions for strategies for addressing vaccine hesitancy.  It found that there are few well-studied strategies for addressing vaccine hesitancy due to wide variation in studies for setting and target populations. This 2014 paper acknowledges that vaccine hesitancy is a rather novel issue at the time of this study.  However, they did condense the useful information that was gleaned into a 2-hr PowerPoint that I’m going to attempt to condense into something that hopefully will not put you to sleep on the drive home from work.

First, we have to address what hesitancy is.  It is not outright refusal but whether or not the patient/parent has uncertainty.  There will be people that refuse regardless of whatever information is presented.

There are multiple factors which contribute to hesitancy:

• Complacency:  people feel that there is low risk or that the disease are not dangerous enough and therefore don’t prioritize it;
• Confidence: lack of trust either in vaccines or health authorities. Patients get multiple inputs from that can influence their confidence including media/politics/religion/culture/personal knowledge;
• Convenience: as it relates to barriers to access/availability;

WHO recognizes that there may not be any one specific measure to overcome hesitancy but there are general recommendations include: 

1. Default conversation: Start with presumption of vaccination as default: “It’s time for your vaccination” or “You are due for XYZ”, as opposed to “Do you want your vaccinations?”. This reinforces our understanding of the importance of vaccinations as opposed to sounding ambivalent on the necessity.

1. Motivational interviewing: A majority of patients are likely to comply with health maintenance. For those who don’t, it is generally not recommended to take a directive or argumentative response as that style of communication can result in decreased trust and has shown vaccine uptake does not improve.  A better recommendation would be to start with motivational interviewing.  Motivational interviewing is focused on collaborative and patient centered exploration of their hesitancy with a focus on how to change attitude or behavior. Some principles of motivational interviewing include: 

• Open-ended questions:
• Use “what”, “why”, “how”, “tell me…” to explore reasons behindhesitancy
• Reflect and respond
• Simple reflection:“I understand that you are afraid.”
• Complex reflection: “You want to make the best choice for your child but you are nervous.”
• Affirm strengths and validate concern
• “It is great that you are starting to think about vaccines.”
• “The health of your children is important to you.” 
• “Protecting yourself from illness is important for you and the health of your community.”
• Ask-Provide-Verify
• Ask information on what they know: “So what do you already know about vaccination?”
• Provide information:“Could I provide you with some information, based on what you just shared?”
• Verify that they understood: “Given our discussion, how do you view the decision now? Remember I am here to help talk through any concerns you may have.”
• Summarize 
• “The reason that’s important is…”
• “What that means to you is…”
• “The main point to remember is….” 

At this point during the traditional 2-hr PowerPoint involves some roleplaying, so grab your dice and where going to roll up some characters and fight a dragon.

1. Build trust: Healthcare workers can work toward building trust by both demonstrating competence and caring.  Humans are emotional and simply demonstrating your competence / reason / data may not be enough.  It is okay to admit you do not know at a particular moment.

Frequently-Asked Questions about Vaccines (WHO)

• Can vaccinations lead to infertility?

No, vaccinations cannot lead to infertility. In fact, medical experts suggest that some vaccines actually protect fertility indirectly by preventing the need for treatment.

• Can vaccines cause harmful side effects, illness and even death?

No, vaccines are very safe. Most side effects from vaccines are minor and temporary, such as a sore arm or mild fever. Serious adverse events or death are VERY rare (e.g. 1 per millions of doses) for most vaccines.

• Can needles used for immunization cause infection?

For every vaccine, we always use one-time or auto-disable syringes that cannot be reused, which eliminates the risk of transmitting infections from needles.

• Isn’t giving three needles too many in one visit?

No, receiving multiple vaccines in one visit is completely safe as you/your child’s immune system is strong enough to handle them. 

• “Won’t breast feeding protect babies from infection?”

Yes, breast milk will give some protection against some infection, but it does not have the direct ability to prevent infection like vaccines. Vaccines are very specific to the given infection and their prevention capacity is very high.

• “Can vaccines cause the infection they are supposed to prevent?”

Inactivated vaccines do not have live germs and cannot cause infections. Live vaccines have weakened germs that are unable to cause disease in healthy people. Rarely a mild form of infection may occur. 

• “Is protection from natural infection more effective protection?”

Natural infection comes with the risks of serious complications related to that infection. With vaccines, the immune system is stimulated to develop protection without infection, hence it is more effective. 

• “Shouldn’t vaccines be delayed until children are older and there is less risk of side effects?”

There is no evidence that side effects are more common in infants/babies than older children. Delaying vaccines leaves young children at risk of the disease and its complications.

Other resources to address vaccination hesitancy: The CDC and the AAFP has a very similar approach so I won’t be reiterating. Although I did find some nice handouts on their website including a handout to make sure that parents understand the risks and responsibilities for their decision. 

On the AAFP website there are some videos to demonstrate motivational interviewing: https://www.aafp.org/patient-care/public-health/immunizations/video.html. 

A Review of Anti-Vaccination Literature

Now, to discuss more controversial stuff including a look at antivaccination literature: Now to start with let me be clear, antivaccination arguments are difficult to fully quantify because new arguments can be added without evidence, individuals may have unique responses, and the memetic mutations on Facebook and other online communities change stories at alarming regularity so I will be focusing on the more common concerns that I have seen.

1. Autism: 

Let me be frank, there is no known connection between vaccinations and autism. Epidemiologic evidence does not support an association between immunization and Autism Spectrum disorder, but let’s discuss some of the reasons why our population may be concerned.

There is an apparent increase in autism rates in the 1990s. Two primary factors seem be associated with this increase: There was a definitional change in Autism to allow a greater number of children to get the diagnosis.  This means that children who may have been given another diagnosis or had been low enough on the spectrum may not have been categorized.  From an outsider perspective, this would look like a doubling of incidence.

The second was that we change the way we do surveillance including active surveillance.  As part of routine screening for toddlers, the M-CHAT was introduced with an update in 2009 to the M-CHAT R/F.  Note that this means that the prior incidence was likely higher than previously thought which may represent our prior lack of identifying individuals who may have needed the additional services.  Let me be further clear: it is a good thing that we are identifying more individuals.  By identifying more children on the spectrum, they can access interventions to be more successful later in life for which they would otherwise be denied.

A study in 1998, published by Mr Wakefield (formerly a doctor who lost his credentials) was found to be fraudulent, and in 2004, ten out of the thirteen authors retracted their statement and the Lancet fully retracted it in 2010.Since then, multiple additional studies have demonstrated no epidemiological association with vaccination and autism.  In short, those receiving the vaccine and those who did not, had autism at the same incidence. Other studies which have sought to demonstrate a biologic mechanism to demonstrate a causal link have to failed to demonstrate such.

1. Thimerosal:

Thimerosal is a mercury-containing preservative used in multidose vials for vaccines. The mercury it contains, prevents the growth of dangerous bacteria and fungus. In 1999, the FDA removed mercury and thimerosal for as many products as possible. The use of thimerosal has been removed from childhood vaccinations. Now, we use single-use vials for vaccines instead of multidose vials. Mercury in vaccines is not the cause of autism.

1. Mistrust of science.Several people will not believe in science, but discussing that may take a little longer.

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

Vaccines are good and useful, but sometimes we do not do a good job at communicating to our patients due to long lists of complaints. Once there is a COVID 19 vaccination, we will face some resistance.

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

As a general rule, I refer to multiple online sources like UpToDate to read articles and get suggestions for primary source citation. Check the bibliography from UTD to see their sources and see if you agree with their evidence for your evidence-based medicine and primary sources.  However, for this talk I wanted to get some additional sources to discuss.  My usual go to locations for additional broad information is to first start with important medical institutions including the Center for Disease Control, World Health Organization, and AAFP.

1. Question number 5: Where did that knowledge come from? See details below in the references. 

____________________________

“Speaking Medical” (Medical word of the Week) 
by Hasaney Sin

Have you even wonder how to say B.O. in medical terms? Bromhidrosis is a condition of abnormal or offensive body odor, to a large extent determined by apocrine gland secretion, although other sources may play a role. Apocrine glands are located on the axillae, perianal area, and some parts of the external genitalia. Perspiration itself actually has no odor, but when sweat comes in contact with bacteria, bromhidrosis can occur. So, next time when you encounter a patient with B.O., called it the right way, bromhidrosis. I am very thankful for my prescription strength deodorant, or else I would be dealing with bromhidrosis.

____________________________

“Espanish Por Favor” (Spanish Word of the Week) 
by Roberto Velazquez

“Hey, muñeca, qué linda eres”. This is compliment a man can say to a cute girl walking down the street. This is Dr Rava on your section Espanish Por Favor. Today’s Spanish word is Muñeca. Muñeca means doll, as in a toy such as Barbie, but it also refers to a body part, the wrist. Hearing this word is fairly common, and it is the appropriate word to use even in medical terminology. So, don’t get confused when people tells you that their muñeca is broken or twisted or that it hurts because they are talking about the wrist, not their Barbie doll. The way your patient will complain may sound, “Doctor, me torcí la muñeca,” meaning to say, “Doctor, I think I hurt my wrist.” Once a patient called me muñeco, but that’s a different story. Now you know the Spanish word of the week, muñeca. All you need to do now is to assess your patient’s muñeca. 

____________________________

“For your Sanity” (Medical joke of the day)
by Steven Saito 

I delivered a beautiful baby in the hospital recently, the husband pulls me aside to thank me and asks: “So, doc, when is the soonest we can have sex again?” I looked at him, winked, and said: “I’ll meet you in the parking lot in 10 minutes”.

____________________________

Conclusion: Now we conclude our episode number 9, “Vaccine Hesitancy”. We reviewed how to deal with patients (or parents) who are unsure about their shots. We hope to have that kind of discussion when an effective and safe vaccine against SARS-CoV2 is created (fingers and toes crossed). We were reminded of the medical word for B.O., bromhidrosis, which is probably the “ultimate human fragrance” without deodorants; and then we learned how to say wrist is Spanish, muñeca. We’ll see you 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, Lisa Manzanares, Steven Saito, Roberto Velazquez, and Hasaney Sin. Audio edition: Suraj Amrutia. See you soon! 

_________________________

References:

1. Pain Medicine News, Apr 2020, Vol 18, Number 4, page 4, PainMedicineNews.com.
2. Dotinga Randy, “New Diabetes Guidelines, Insulin loses its place as the first-line injectable treatment”, Family Practice News, January 2019, Vol 49, No. 1, Page 1, 
3. “FDA approves first oral GLP-1 treatment for type 2 diabetes”, September 20, 2019, https://www.fda.gov/news-events/press-announcements/fda-approves-first-oral-glp-1-treatment-type-2-diabetes
4. “Rybelsus (Oral Semaglutide) Review”, http://mydiabetesvillage.com/rybelsus-review/  
5. Healio Endocrine Today, “Europe embraces, FDA rejects use of SGLT inhibitors for type 1 diabetes”, July 23, 2019. https://www.healio.com/endocrinology/diabetes/news/online/%7B59034289-fcf0-4cd2-888f-23c57e85bfcc%7D/europe-embraces-fda-rejects-use-of-sglt-inhibitors-for-type-1-diabetes
6. “Ignorance Breeds More Ignorance”, posted on November 23, 2017, Exploring Your Mind, https://exploringyourmind.com/ignorance-breeds-ignorance/  
7. “Strategies for Addressing Vaccine Hesitancy, A systematic Review”, World Health Organization, October 2014, https://www.who.int/immunization/sage/meetings/2014/october/3_SAGE_WG_Strategies_addressing_vaccine_hesitancy_2014.pdf?ua=1
8. Understanding Thimerosal, Mercury, and Vaccine Safety; Centers for Disease Control and Prevention, CDC.gov, reviewed in February 2013, https://www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/vacsafe-thimerosal-color-office.pdf
9. AAFP, Conversations: Improving Adult Immunizations Rates Using Simple and Strong Recommendations, https://www.aafp.org/patient-care/public-health/immunizations/video.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!

Wash Your Hands!

The sun rises over the San Joaquin Valley, California, today is April 20, 2020.

During this time of reflection, we bring a difficult question for you: Who are we as humans? 

The estimated ratio of human cell to microbe is at least 1:1, some people estimate it is 1:10, that is one human cell per one to ten microbes in our bodies(1). Based on that, we are at least half bacteria. 

Also, water is the main component in the human body(2), between 80% at birth to 60% in an average adult. Based, on that, well, we are basically “dirty water,” but is that really the answer of who we are? Most certainly we are more than bacteria and water.

The understanding of who we are may go beyond the physical aspect of our bodies, and we may find more answers from different sources. We invite you to reflect on who you are. This is our food for thought to start our podcast today.  

“To avoid criticism, do nothing, say nothing, and be nothing.” – Elbert Hubbard

A poet said, “Let the dogs bark, it is a sign that we are moving forward”, and I just learned that maybe this is not a quote from Don Quixote (sorry to disappoint you who like Don Quixote). But seriously, it is always difficult to receive feedback, however, it is a good way to improve ourselves.  Today we have a star resident. She is loved for her spice and her compassion. Welcome Tamara Hilvers, known by her friends as Tammy. This podcast is an experiment, we will continue to improve over time. We ask five basic questions, but I may surprise you with another question to make it more spontaneous. Don’t worry it will be easy. 

Question number 1: Who are you? 

I always hate these types of questions where I have to talk about myself. So, who am I? Well, I was born and raised right here in Bakersfield, CA, I grew up on a dairy farm and I am 1 of 4 girls! A few interesting facts about me: I know and hold a degree in American Sign Language; I took Calculus and Physics courses in undergrad for the fun of it, and I am actually very shy! My greatest achievement in life thus far is being a single mother and raising a sweet and beautiful, both inside and out, 12-year-old daughter. As if single motherhood wasn’t challenging enough, I made, what some may call a crazy, the decision to pack the two of us up, 2 months after she was diagnosed with epilepsy, to attend medical school on a small Caribbean Island.  I am currently nearing the end of my first year of Residency with the Rio Bravo Family Medicine Program. I remember when I first started, everyone said that my first year would fly by… Yeah, they lied. But, I am looking forward to continuing this journey and can’t wait to see what the next year brings!

Comment: We have enjoyed working with you. You are a smart woman with a big heart.

Question number 2: What did you learn this week?

This week, I looked into America’s #1 topic today, hand hygiene. Washing your hands is the best way to protect yourself and others from getting sick and to stop the spread of ‘germs’. I looked into the ‘when’, ‘how’ and the ‘with what’ of hand hygiene. 

So, the ‘when’. When should we wash our hands? Always! Always wash your hands! It’s that simple. Many of us all know that we should wash our hands after things such as: preparing food, treating a wound, caring for someone who is sick, after using the restroom, touching animals or even touching garbage. However, during this pandemic we are experiencing, the CDC is also reminding people to wash their hands after being in public, after touching public surfaces that are frequently touched by others, such as door handles, shopping carts and gas pumps, and always before touching your eyes, nose or mouth. 

Now the ‘how’. What is the proper way to wash your hands? Well, if washing your hands with soap and water, there are 5 easy steps to follow: wet, lather, scrub, rinse, and dry. First you need to wet your hands with clean, running water before applying the soap. Then, you should lather the soap by rubbing your hands together making sure to get the back of the hands, between fingers and under the nails. You should continue to scrub your hands for at least 20 seconds. On the CDC website, they suggested humming the ‘Happy Birthday’ song two times through. I say, just count to 20. Either way, whatever your preference, continue for 20 seconds, then rinse off hands under clean running water. Hands should then be dried using a clean towel or air dried. 

Now, if you are using an alcohol based disinfectant, you should apply the product to the palm of one hand and then rub both hands together, covering all surfaces, until hands are dry. This process should take 15-20 seconds.

Comment: Water temperature is irrelevant, we know warm water feels nicer, but it is not required(3). Make sure you scrub all surfaces like Dr Hilvers said, we usually miss the back of our hands and lower aspect of our palms. Ok, what should we use to wash our hands?

Last, the ‘with what’. What’s better, soap and water or alcohol based disinfectant? According to the CDC, they recommend that the general population use hand sanitizer only when soap and water are not available. 

Even though sanitizers can quickly reduce the number of germs on your hands, it does not kill all the germs, it does not remove harmful chemicals and it may not be effective when hands are visibly dirty. However, when it comes to healthcare providers, alcohol based disinfectants are favored over soap and water unless dealing with a patient with infectious process such as C. diff or norovirus as alcohol does not kill the spores. 

As far as which soap to use, liquid, bar or powdered forms are all acceptable, with none having preference over the other. When bar soap is used, they suggest using small bars and soap racks to allow drainage. 

Comment: Wet soap bars can grow bacteria, that’s one of the reasons for the defenders of liquid soap, but any soap is better than no soap

In 2016, the FDA stated that there is no added health benefit using antibacterial soaps(5). So plain soaps are acceptable.

Drying hands should be done with disposable towels or air dried. Multiple use hand towels are not recommended. 

Alcohol based disinfectants should contain at least 60% of alcohol.

Comment: What if we do not have any soap or hand sanitizer? Use plain water. Washing with plain water will wash off some bacteria, not as many but some of it. Remember the size of the viral inoculum can make a difference on the severity of many viral illnesses. The larger the size of the inoculum, the more severe the illness is. 

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

Hand Hygiene is important because it is the single most important measure to reduce the transmission of microorganisms from one person to another, or from one site to another. It will protect yourself and your patients from potentially deadly germs. Hand Hygiene should be performed before and after every patient contact. It is also important to note, that wearing gloves does not replace the need to wash hands properly. 

Question number 4: How did you get that knowledge?

Hand Hygiene has been instilled in all of us from the first day of medical school and every day since. When taking STEP 2, the Clinical Skills portion of the exam, hand hygiene is an important part of the patient encounter. This is stressed in every review book as well as online practice exams. We all know the importance of hand hygiene, however, all of us are guilty of skipping this process a time or two. 

It is very important to make hand hygiene a routine in patient care. To help me get the proper techniques of hand hygiene and the most current recommendations, I reviewed several articles from reliable sources such as the CDC and Up-to-Date. 

Hand hygiene is very important in the field of medicine and think that it is important to stay on top of the most current recommendations, not only for our own practice but also to help educate others. 

Question number 5: Where did that knowledge come from?

This information was obtained from “Hand Hygiene for Healthcare Providers” downloaded from the CDC website and “Infection prevention: Precautions for preventing transmission of infection” on Up-to-Date. 

_______________________________

Speaking Medical (Medical word of the week) 
by Steven Saito

Did you know that 3% of the population in the United States (that’s more than 3 million people) can’t smell? So, some couples actually don’t fight over farts… because one of them suffers from anosmia. Anosmia is certainly not funny for those who suffer from it, as it may cause social withdrawal, depression, and weight loss. Weight loss may be positive for some people. 

Anosmia can also pose a risk to safety when there is inability to detect the odors of spoiled nasty food, smoke, and leaking gas, both natural and from your pipes. Anosmia can also be a symptom in 20-35% of people with COVID-19.

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Espanish Por Favor (Spanish Word of the week) 
by Hector Arreaza

“Doctor, tengo mareos, estoy mareado”. Mareo is a common complaint in our clinic. The word mareo comes from the Latin “mare” which means “mass of water”. In Spanish the ocean or sea is called “mar”, and mareo likely comes from the feeling people experience while on a ship. The translation of mareo to English is challenging, as it encompasses a variety of symptoms and conditions. 

Mareo is used by patients to describe dizziness, but it also includes other symptoms such as motion sickness, vertigo, pre-syncope, syncope, lightheadedness, and even generalized weakness. Mareos can be a real challenge in diagnosis, but my goal today is to teach you the Spanish word of the day, mareo. Your homework is to go and study the workup and treatment for your dizzy patients.

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For your Sanity (Medical joke of the week)
by Steven Saito and Lisa Manzanares

---Doctor, I got a heartburn every time I eat birthday cake
---Next time, take off the candles.

---What’s the difference between a family doc and a specialist? The family doc treats what you have, the specialist thinks you have what he treats.

Two doctors and an HMO manager died and lined up at the pearly gates for admission to heaven. St. Peter asked them to identify themselves. 
One doctor stepped forward and said, "I was a pediatric spine surgeon and helped kids overcome their deformities." St. Peter said, "You can enter." 
The second doctor said "I was a psychiatrist. I helped people rehabilitate themselves." St. Peter also invited him in. 
The third applicant stepped forward and said, "I was an HMO manager. I got countless families cost-effective health care." 
St. Peter said, "You may enter, but," he adds, "You can only stay three days. After that you go to h---.”

___________________

Now we conclude our episode number 8, “Wash Your Hands.” Dr Hilvers taught us how to perform a simple task that can protect you, your patients, your family, and even your community. Washing your hands continues to be one of the most useful ways to prevent the spread of COVID-19. Mareo means dizziness among other symptoms, but you get the idea, and anosmia was a reminder that COVID-19 may present with a loss of sense of smell. May you continue to enjoy your training, stay safe and see you next week.  

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, California, 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 by visiting 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, Tammy Hilvers, Lisa Manzanares, and Steven Saito. Audio edition: Suraj Amrutia. See you soon! 

_____________________________________

References:

Abott, Alison, “Scientists Bust Myth That Our Bodies have More Bacteria than Human Cells,” nature international weekly journal of science, https://www.nature.com/news/scientists-bust-myth-that-our-bodies-have-more-bacteria-than-human-cells-1.19136, January 8, 2016. 

“The Water in You: Water and the Human Body,” United States Geological Services, https://www.usgs.gov/special-topic/water-science-school/science/water-you-water-and-human-body?qt-science_center_objects=0#qt-science_center_objects, accessed on April 16, 2020. 

Brenda Goodman, MA, The Power of Hand-Washing to Prevent Coronavirus, March 06, 2020, https://www.medscape.com/viewarticle/926373?src=soc_fb_200310_mscpedt_news_mdscp_handwash&faf=1, accessed March 9, 2020.

Anderson, Deverick J, “Infection prevention: Precautions for preventing transmission of infection,” Up to Date, https://www.uptodate.com/contents/infection-prevention-precautions-for-preventing-transmission-of-infection?search=hand%20washing&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 , accessed on April 16, 2020.

“Antibacterial Soap? You Can Skip It, Use Plain Soap and Water,” U.S. Food and Drug Administration,  https://www.fda.gov/consumers/consumer-updates/antibacterial-soap-you-can-skip-it-use-plain-soap-and-water

Burton, Maxine; Emma Cobb, [...], and Wolf-Peter Schmid, “The Effect of Handwashing with Water or Soap on Bacterial Contamination of Hands,” Published: 6 January 2011, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3037063/  

The Raging Idiots, https://www.youtube.com/watch?v=Ze8TtIITxqE

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 April 15, 2020. Viral diseases anyone? The American Society for Colposcopy and Cervical Pathology (ASCCP) recommended HPV vaccination for clinicians routinely exposed to HPV. This recommendation encompasses the complete provider team, including physicians, nurse practitioners, nurses, residents, and fellows, and others in the fields of OB/GYN, family practice, gyn-onc, and dermatology. While there is limited data on occupational HPV exposure, ASCCP, recommends that members actively protect themselves against the risks(1). 

 

This recommendation on HPV vaccination for health care workers was published on February 19, 2020. We thought it would be pertinent to remind you about the viral infections that we CAN prevent, since there are some viruses for which we do NOT have a vaccine yet. 

 

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing never stops

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. 

Quote: “Improvement begins with I.” – Arnold H. Glasow

Improvement is a never-ending process, and we must remind ourselves who needs to improve first? It’s normally us. That’s why “improvement begins with I”, I think that was a brilliant quote. 

Today our guest is Golriz Asefi. She is a smart, compassionate, dynamic PGY1 who is excited to talk to us after her community medicine rotation. She told me she enjoyed a lot working with Dr Beare, our street medicine doctor, whom I hope can be our guest in this podcast one day. Welcome, Dr Asefi. As you know we will ask you 5 questions. Let’s start with our first question number 1. 

1. Who are you?

I’m Dr Golriz Asefi, I’m a PGY1 here at Rio Bravo family medicine residency program. I grew up in the Bay Area (California). I went to UC Berkeley and then to Ross University School of Medicine. I picked our residency program because I was very interested in community medicine and helping the underserved. On my “spare time” I like to take long walks by the beach and go hiking with my friends. I also have a newly found love for yoga and barr method. 

2. What did you learn this week?

This week I learned about suboxone. Suboxone is a combination of buprenorphine (a partial opioid agonist) and naloxone (an opioid antagonist). It is used in the treatment of opioid use disorder along with counseling and other behavioral therapy. Suboxone is a class III controlled substance in the form of sublingual pill, sublingual film or buccal film.

Comment: Suboxone is part of the Medication-Assisted Treatment (MAT) of opioids. It is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. These medications operate to normalize brain chemistry, block the euphoric effects of opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug.

Suboxone is a combined medication. Why do we have both an agonist and antagonist in the same dose you might ask? Well it’s to prevent abuse, you see naloxone when taken sublingually as directed is minimally absorbed, whereas when injected, it is a strong blocker of the opioid receptor. So, you can get the antagonistic effect of naloxone. When taken sublingually naloxone is poorly absorbed, therefore patients experience less withdrawal symptoms. 

The “Ceiling effect”

Buprenorphine exhibits what’s called a “ceiling effect”, which occurs because suboxone partially stimulates opioid receptors even when saturated. Even exponentially increasing the dose only achieves limited additional effect– similar to approaching an asymptote - remember those hyperbolas and parabola in high school geometry? Basically, never reach full effect.  Therefore, it has a lower chance of abuse and accidental overdose. 

Suboxone vs Methadone

Methadone is full opioid agonist. It is a PO liquid administered through methadone clinics to which patients must go to everyday, and get the medication. Take-home privileges can be eventually earned for methadone.  

Suboxone has lower chances of overdose because it is a partial agonist, however, dropout rates are higher. Suboxone can be prescribed to be taken at home, so it is more convenient(2).

Candidates for suboxone

Opiate users who are motivated for treatment and are willing to adhere to scheduled visits and treatment.  They should understand the indications, risks, benefits, and alternatives. Ideally, they should not be on other CNS depressants, such as alcohol and benzos, however, suboxone is preferable over methadone for people who use CNS depressants or are at higher risk of respiratory failure. Suboxone can also be used during pregnancy.

Contraindications to suboxone:

-Severe liver impairment.
-Conditions that already increases risk of respiratory depression such as head injuries or taking CNS depressants such as benzodiazepines or alcohol. Mixing large amounts of other medications with buprenorphine can lead to overdose or death(2).

Required Training to Prescribe Suboxone

Prescription is regulated by the DATA (Drug Addiction Treatment Act of 2000), you need to complete a MAT (medication assisted treatment) training which is currently available free of cost. To qualify as an MD, you need to have an active medical license and DEA license. The training takes about 8 hrs for MDs, 24hrs for NPs, CNMs, and PAs. You can take the training at anytime, even as a resident, and save the certificate until you receive your MD license and DEA license. The training is 100% online, you can print your certificate and apply for an X-license to prescribe suboxone. The information is found online at PCSSNOW.ORG (Providers Clinical Support System)(3)

3. Why is this knowledge important for you and your patients?

Suboxone is underutilized by primary care providers. Opioid use disorder leads to a lot of socioeconomic problems, such as increased rates of suicide, accidental overdose, HIV, HepC, marital problems, and unemployment. About 46,000 people died of opiate related deaths in 2018, steadily rising from 21,000 in 2010. Of that, 18,000 was due to prescription opioids(4). Luckily, treatment of the disorder decreases all of the above. 

MAT has shown to improve mortality due to opioid overdose, increase retention in treatment, decrease illicit opiate use and other criminal activity, increase patient’s ability to gain and maintain employment, improve birth outcomes in pregnant women with substance use disorder, lower risk of contracting HIV and HepC. You can see, Dr Arreaza, you can make a big impact in your patients if you get this training, you will change lives and whole communities by providing this life-changing treatment. 

Comment: This is something I learned recently. Having a substance use disorder reprograms your brain, it is like being thirsty and not finding water to drink. So when we tell our patients, “Just stop taking Norco”, it is similar to tell them, “Just stop drinking water.” We have to develop empathy to some of the most neglected patients in our society. Not many people are helping these patients! And many of them also have mental illness, as many as 30-60%, depending on the source you read. So, it’s a good idea to get trained to help this vulnerable population.

4. How did you get this knowledge?

I was working with Dr. Beare during my community medicine rotation. I really enjoyed learning about suboxone and seeing how rewarding this experience was between him and his patients. This made me want to do more research and present this topic to my colleagues. As Dr. Beare likes to say: “Treating addiction is like treating any other complex chronic disease. There is no such thing as quick fix.” We as physicians need to listen to our patients, to care and to treat this difficult condition.

5. Where did this knowledge come from?

-SAMHSA – substance abuse and medical health service administration, The National Institutes of Health, an Up to Date article, and other articles. See details below.

______________________

Speaking Medical
by Lisa Manzanares 

The medical word of the day is leukorrhea.  It is the flow of whitish, yellowish, or greenish discharge from the vagina. Leukorrhea can be normal, or it can be a sign of infection. Leukorrhea commonly occurs during pregnancy, and is normal if the discharge is thin, white, and odorless. Physiologic leukorrhea is a normal condition occurring within several months to 1 year of onset of menses in adolescent girls.  Leukorrhea that is not normal can be caused by bacteria: bacterial vaginosis, chlamydia, gonorrhea, or postpartum endometritis. Fungal causes include candida species. Parasites can cause it, too: specifically, Trichomonas vaginalis.

So, when your patient complains of vaginal discharge, be sure to sound smart in your notes and document that the patient has leukorrhea.

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Espanish Por Favor (Spanish Word of the Day) 
by Claudia Carranza

Hi this is Dr Carranza on our section Espanish por favor. The Spanish word for this week is rodilla. What comes to your mind when you hear the word rodilla? Does it sound to you like a popular Mexican food? Well, rodilla has nothing to do with quesadilla. Rodilla is a large joint in our body that may wear off over time and gets injured easily. Yes, you guessed it, rodilla means knee. This word comes from the Latin root “rota” or “rueda” which means round or wheel. Patients may come to you with the complaint: “Doctor, me duelen las rodillas” or “Doctor, tengo la rodilla hinchada” which means: “Doctor, my knees hurt” or “Doctor, my knee is swollen”. Most likely the patient will point at one or both of their knees which will guide your assessment. 

Now you know the Spanish word of the day, rodilla. Have a great week and take care!

__________________________________________

For your Sanity (Medical joke of the day)
by Golriz Asefi and Lisa Manzanares

The Expensive Dentist
Patient: Doctor, how much to have this tooth pulled?
Dentist: $100.00. 
Patient: What? $100.00 for just a few minutes of work? 
Dentist: Well, I can extract it very slowly if you like.

The Invisible Patient
Clerk: Doctor, there's a man on line 1 who thinks he's invisible.
Doctor: Well, tell him we can't see him right now.

__________________________________________

Conclusion: During this episode, we had a glimpse of the Medication Assisted Treatment for Opioid Use Disorder. Suboxone can be the answer to many patients who are desperately looking for help to overcome their addictions. Suboxone can make a difference, one film at a time. We also were reminded of another way to say vaginal discharge, leukorrhea; and learned how to say knee in Spanish, rodilla. May you continue to enjoy your training and stay safe. See you 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 by visiting 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, Lisa Manzanares, Claudia Carranza, and Golriz Asefi. Audio edition: Suraj Amrutia. 

________________________________

References

1. “ASCCP: Clinicians Routinely Exposed to HPV Should Receive Vaccine”, OBG Project Alert, https://www.obgproject.com/2020/03/03/asccp-clinicians-routinely-exposed-to-hpv-should-receive-vaccine/, accessed on April 13, 2020.
2. Buprenorphine, SAMHSA, https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine , accessed on Apr 13, 2020.
3. Waiver Training for Physicians, Providers Clinical Support System, https://pcssnow.org/medication-assisted-treatment/waiver-training-for-physicians/   
4. Overdose Death Rates, National Institute on Drug Abuse, https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
5. Strain, Eric, MD, “Pharmacotherapy for opioid use disorder”,  https://www.uptodate.com/contents/pharmacotherapy-for-opioid-use-disorder?search=suboxone&source=search_result&selectedTitle=2~19&usage_type=default&display_rank=1, accessed on March 23, 2020. 
6. Velander JR. “Suboxone: Rationale, Science, Misconceptions”, Ochsner J. 2018;18(1):23–29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855417/ , accessed on March 23, 2020.
7. Srivastava, Anita; Kahan, Meldon; Nader, Maya (March 2017), "Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone?". Canadian Family Physician. 63(3): 200–205. ISSN1715-5258. PMC5349718. PMID28292795.

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!

Learning About Wound Care

The sun rises over the San Joaquin Valley, California, today is April 9, 2020.

This week, for pregnant patients who are not at increased risk for preterm delivery the USPSTF recommended AGAINST screening for bacterial vaginosis (BV). This is a D recommendation. So, do NOT screen for BV in these patients. 

For your patients who actually ARE at INCREASED RISK for PRETERM delivery, the data is INSUFFICIENT to recommend screening for bacterial vaginosis. This is an I recommendation. So, you may or may not screen.

To recap: Not at risk for preterm delivery = No screening for BV. At risk for preterm delivery = Insufficient data. 

This week, smiling to our patients has become a little harder to do through a surgical mask. We don’t know how long we will be required to wear a surgical mask to see all patients in clinic. This is the week of “Spring Break”. Movie theaters, museums, parks and many public places are now closed. However, the flowers and trees seem to be unaware of the pandemic and are not in quarantine. They rebelled against the rules and are blooming beautifully this time of the year. The Spring season surely brings optimism for a brighter future. May the Easter weekend be a time of reflection and renewal for you. Our message is: Keep blooming wherever you are planted!

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.

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“Do not correct a fool, or he will hate you; correct a wise man and he will appreciate you.” Adapted from the Holy Bible.

Correction, or how we like calling it in education: Feedback, is a good tool to get trained as residents. As a resident, you can decide how you will take that feedback, will you take it as an offense? Will you make a plan to correct the mistake instead? I’ll let you think about it.

Dr Manuel Tu is a talented man who is a great asset for our residency program. He has brought an interesting topic to the table today and I am excited to receive him today. Dr Tu is known by his friends and colleagues as Manny. As you know we ask 5 questions, and let’s start with question number 1. 

Question Number 1: Who are you? 

Hello everybody my name is Dr Manuel Tu Jr. and presently I am a First-year Family Medicine resident here in Bakersfield, California. I was born and raised in the Philippines, finished my bachelor's degree in Nursing from Perpetual Help College in Manila, and graduated in Medicine from the University of the City of Manila, Philippines. 

Dr Tu also worked for some years as a nurse for Clinica Sierra Vista and did a fantastic job before his residency. 

Question number 2: What did you learn this week?

This week I would like with you some things about WOUND MANAGEMENT, specifically about the types of wounds, factors that inhibit wound healing and general principles on how to heal a wound. 

A wound is a disruption of the normal structure and function of the skin and underlying soft tissue. It may be acute like trauma to the skin or chronic like a venous stasis or diabetic ulcer.

ACUTE WOUNDS

Typically, due to some form of trauma.

May be blunt or penetrating causes with different array of sizes, depths, and locations.

Abrasion, puncture, crush, burns, gunshot, animal bites, surgery, and other etiologies that cause initially intact skin to break down. 

CHRONIC WOUNDS

Any mechanism that decreases blood flow in the skin for a prolonged period of time has the potential to cause ischemic breakdown of the skin. 

Skin perfusion may be impaired due to:

proximal arterial obstruction (peripheral artery disease)

vascular compression (hematoma, immobility causing focal pressure)

microvascular occlusion or thrombosis (vasculitis, cholesterol crystals) 

venous or neuropathic ulcers like in diabetic patients.

FACTORS THAT INHIBIT OR AFFECT WOUND HEALING:

Infection: Bacterial infection produce multiple inflammatory mediators that inhibit wound healing. The inflammatory phase of healing is prolonged and disrupted, there is depletion of the components of the complement cascade, disruption of the clotting mechanisms, disordered leukocyte function, less efficient angiogenesis and formation of friable granulation tissue. New tissue growth cannot occur in the presence of inflammation or necrotic tissue, and the presence of necrotic tissue promotes bacterial proliferation. A wound that is infected has an unbalanced host-bacteria relationship, because you cannot get rid of all the bacteria on the surface of a wound, but you can establish an equilibrium to promote healing.  In 1980 Bucknall published an experiment with rats showing how the granulation tissue looks in an infected wound: There is an increased in hydroxyproline (collagen) and abundant new vessel formation(1). It was interesting for me to know that because I thought those processes ere inhibited but actually, they are increased but are disorganized, resulting in a granulation tissue that is disorganized and friable.  

Smoking: Nicotine and other chemicals in tobacco impair wound healing by inducing vasoconstriction causing relative ischemia on tissues, also by reducing inflammatory response, impairing bactericidal mechanisms, and altering collagen metabolism. Smoking is associated with postoperative wound healing complications, which occur more often in smokers compared with non-smokers as well as in former smokers compared with those who never smoked(2).

Aging: Likely due to comorbidities such as diabetes, peripheral artery disease, chronic venous insufficiency, and lower serum protein levels causing lower collagen. Lower collagen in the body slows down wound healing. For example, Kennedy pressure ulcer.

Kennedy Ulcer: It is a dark sore that develops rapidly during the final stages of a person’s life. Not everyone experiences these ulcers in their final days and hours, but they’re not uncommon. They are different from pressure sores or bed sores; because they develop rapidly; they are typically located in the sacral area  are necrotic(3). 

Malnutrition: Patients with hypoalbuminemia tend to be more prone to infection, and infection as we said, affects wound healing. Prealbumin and albumin are not perfect markers of wound healing but helpful specially for patients with non-healing wounds. 

Diabetes mellitus: Causes several factors that contribute to impaired wound healing: Decreased or impaired growth factor production, angiogenic response; macrophage function, collagen accumulation, quantity of granulation tissue, dysfunctional keratinocyte and fibroblast migration and proliferation. Also, diabetes causes neuropathy and vasculopathy. Trying to explain the pathophysiology of slow und healing in diabetes would take a lecture by itself. 

Obesity: The cause of wound complications in obese individuals may be secondary to decrease vascularity of the subcutaneous tissue which may impair antibiotic delivery and increased wound tension.  Poor skin circulation also makes obese individuals prone to pressure injury which can be aggravated by difficulties in repositioning and increased shearing during movement.

Others: Vascular disease (PAD, CVI), immunosuppressive therapy, edema, size and depth of the wound, autoimmune diseases, vasculitis, and many medications. 

It is impossible to cover all the factors but my message to residents is: When a wound is not healing, think about the most common factors interfering with healing and take them out of the way! Mainly infection, smoking, diabetes and malnutrition.

DIFFERENT WAYS TO HEAL WOUNDS: 

Wound Debridement: It is the removal of non-viable tissue, contaminants, or foreign body to expose healthy wound bed to assist with wound healing. Devitalized tissue refers to slough or eschar. The body normally uses phagocytosis and autolysis to get rid of devitalized tissues, but in some instances those processes are impaired, so we have to assist with debridement. These can be accomplished by different means: surgical (scalpels, scissors, electrocautery), irrigation, chemical (soaps, detergents), enzymatic (collagenases, fibrolysin, DNAsses, i.e. Santyl), and biosurgical (maggots). The point is to eliminate all the dead tissue because it is basically “on the way” and can potentially be an environment where bacteria can thrive. These “excess” tissues are not going to regenerate and need to be removed. Another way to put it is: “Debridement is turning a chronic wound in an acute wound with more potential for healing.” 

Moist-to-dry dressings: Mechanical debridement can be accomplished by moist-to-dry dressings. We need the proper amount of moisture to promote moist healing environment. Too much moisture or “wet gauze” provides more than needed moisture and it may cause more harm than good, for example, maceration. Get the gauze wet and squeeze it and that should be enough moisture for the wound. 

Irrigation: Irrigation is a way to remove bacteria and debris. It should be a part of routine wound management. Low-pressure irrigation is done with a syringe or bulb, and high-pressure irrigation is typically performed in the OR with a commercial device. There is no high-level evidence to support the use of any particular additive to the irrigant, nor any particular additive over another. The act of irrigation and the volume of irrigant probably provides the positive benefits. Warm, isotonic (normal) saline is typically used; however, systematic reviews have found no significant differences in rates of infection for tap water compared with saline for wound cleansing. The addition of dilute iodine or other antiseptic solutions (eg, chlorhexidine, hydrogen peroxide, sodium hypochlorite) is generally unnecessary. Such additives have minimal action against bacteria, and some, but not all, may impede wound healing(4).

Certification in wound care: As residents, you can start by taking elective rotations on wound care, or attend wound care trainings available for doctors, nurses, physical therapists and other health care professionals. The process results in a Wound Care Certified Certification, but you need an unrestricted license as an MD or RN, or other profession. You need FIRST education and SECOND experience before you can sit for the certification exam. You can find more information on the website of the National Alliance of Wound Care and Ostomy (https://www.nawccb.org/).

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

Healing wounds is very rewarding. This knowledge is important for me because I want to help my patients with acute and chronic wounds. We encounter patients in the hospital and in the clinic with multiple kinds of wounds, and I feel I can help many people with this knowledge. 

Question number 4: How did you get that knowledge? 

I got this knowledge from attending wound care trainings here in Kern County, from reading lecture notes and books, and from years of experience caring for patients with various and complex wounds.

Question number 5: Where did that knowledge come from? 

The information I shared with you came from the books “Skin and Wound Care” by CT Hess, Wound Care Guides, and Uptodate, and you, Dr Arreaza also shared some information with me. 

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“Speaking Medical” (Medical word of the Day) 
by Lisa Manzanares

The word of the day is proctalgia fugax.  What IS that? Well, it’s a pain in the butt. Literally.  Proctalgia fugax is a functional anorectal disorder characterized by severe, intermittent episodes of rectal pain that are self-limited.  In Latin, fugax means “fleeting.” Patients with proctalgia fugax have attacks of severe anorectal pain that lasts from seconds to minutes, with an average duration of five minutes. The patient with proctalgia fugax is completely asymptomatic between episodes.  The diagnosis requires that all other causes of rectal or anal pain are excluded. Proctalgia fugax is estimated to affect 4-18% of the general population, but only about 20% of those affected actually report their symptoms to a physician.  Proctalgia fugax usually affects those between 30 and 60 years of age and is more common among women. Some studies have suggested that the pain may be precipitated by stress, sitting, intercourse, defecation, or menstruation, but in many cases is unknown. 

So there is a term for a temporary pain in the butt, and no, it’s not your ex-boyfriend or girlfriend: it’s proctalgia fugax.

__________________________________

“Espanish Por Favor” (Spanish Word of the Day) 
by Claudia Carranza

Hi this is Dr Carranza on our section Espanish por favor. This week’s word is “ronquera”. “Ronquera” means hoarseness, or if you want to get more technical it is called dysphonia. In Spanish,  people usually use this word when they are complaining of having a hoarse voice. So you may have a patient coming to you saying “Doctor, tengo ronquera,” or “Doctor, estoy ronco,” meaning “Doctor, my voice is hoarse or I have a raspy voice”. 

At this point you can ask the usual questions of how long? Any precipitating factors? And more.  Some people might come in and sound hoarse, in which case you can always ask: Tiene ronquera? To find out if this is abnormal for them or if this is their baseline. 

Now you know the Spanish word of the day, ronquera or ronco, all you have to do is go and assess your patient’s hoarse voice. Have a great week and take care!

__________________________________

“For your Sanity” (Medical joke of the day)
by Lisa Manzanares, Claudia Carranza, and Terrance McGill

-What type of jokes are allowed during the coronavirus? Inside jokes!
-What do you call an acid with an attitude? A-MEAN-O-ACID
-Why are nails used to seal coffins? To prevent oncologists from cracking them open to give another round of chemo… and What do oncologists see when they finally open the coffin? A note from Nephrology: “Patient taken to dialysis”
-I could not decide in med school between proctology and neurology, so I flipped a coin, heads or tails.

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This was our Episode number 6, Learning about Wound Care. During this episode, we learned some basic principles of wound care. It was a good reminder of how infections, smoking, malnutrition and diabetes can affect wound healing, and of the importance of debridement and moist-to-dry dressings to promote healing. Proctalgia fugax made us think of a common condition that may go undiscussed during our clinic visits. The Spanish word ronquera reminded us of hoarseness. And remember that according to psychologists, humor is a MATURE defense mechanism, so we are trying to be “mature” with our jokes. Stay tuned for more interesting topics every week.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, California, 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 by visiting 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, Lisa Manzanares, Manuel Tu, Claudia Carranza, and Terrance McGill. Audio edition: Suraj Amrutia. See you soon! 

__________________________________

References:

1) Cutaneous Wound Healing, Edited by Vincent Falanga, 2001, Martin Dunitz Ltd, a member of the Taylor & Francis group, Florence, Kentucky, USA. 

2) Armstrong, David G and Andrew J Meyr, “Risk factors for impaired wound healing and wound complications”, UpToDate, https://www.uptodate.com/contents/risk-factors-for-impaired-wound-healing-and-wound-complications?search=smoking%20consequences&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5 , accessed on April 9, 2020.

3) Kennedy Ulcers: What They Mean and How to Cope, https://www.healthline.com/health/kennedy-ulcer#symptoms , accessed on April 4, 2020.

4) Armstrong, David G and Andrew J Meyr, “Basic principles of wound management”, UpToDate,  https://www.uptodate.com/contents/basic-principles-of-wound-management?search=wet%20to%20dry%20dressing&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 , accessed on April 9, 2020.

5) Skin and Wound Care by CT Hess 7th Ed, 2012, United States of America

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. 

BIG NEWS! Our program has relinquished our affiliation with UCLA and we have decided to join USC instead. Just kidding, April fools. Today is April, 1, 2020. This week the United States became the country with the most coronavirus cases in the world with over 213,000 confirmed cases, probably more by the time this podcast is over. COVID 19 continues to spread around the world, Italy being the country with the most casualties with over 12,000 deaths. 

It is difficult to talk about anything else during these times of turmoil. You may ask yourself, is this the result of a spontaneous viral mutation? Is it a conspiracy against Capitalism? Are extraterrestrials involved? Was the virus created for economic reasons? There are many theories, you can draw your own conclusion. What we can’t deny is that this pandemic has touched every aspect of our lives.

"When there is a crisis, let your heart pray, but let your hands work” - John Kramer

I am reminded of another quote: “Pray as if everything depends on God, work as if everything depends on you”, attributed to Ignatius. Religious freedom is great, isn’t i?  Today our guest is Gina Cha. Gina is known as “the intern” at Kern Medical by her inpatient team. I am glad she accepted the invitation to come and talk to us about a relevant topic today.

As you know, Gina, we have 5 questions in our podcast. Let’s start with question number one.

1. Who are you?

My name is Gina Cha, I am called “the intern”. I was born and raised in a small town about one hour north east of here called Porterville. I am Hmong and I have 7 siblings. I went to the American University of the Caribbean, Saint Martin.

1. What did you learn this week? 

This is case I’ve personally experienced this week in the hospital. 

We had a patient in her late 20s with no significant past medical history present with yellowing of the skin for 1 day. Other associated symptoms include right upper quadrant abdominal pain for one day that had since resolved. She also had episodes of nausea that had since resolved. She had noticed continual yellowing of the skin and reported to the ED. 

Comment: With the history that you obtained what did you think? 

Yellowing of the skin is called jaundice. Differential diagnosis of increased bilirubin, yellowing of the skin in this case including:

1. Chronic alcohol use (indicative of chronic liver damage) 
2. Hepatitis (viral infections of the liver affecting liver function)
3. Gallstones (that can be block bilirubin excretion) 
4. Hemolysis (increased break down of hemoglobin)

Comment: Ascending cholangitis triad (Charcot’s): jaundice; fever, usually with rigors; and right upper quadrant abdominal pain. When the presentation also includes low blood pressure and mental status changes, it is known as Reynolds' pentad. How did you narrow down your differential?

Physical exam: unremarkable, no abdominal guarding, no Murphy’s sign. 

Comment: What is the Murphy’s sign? 

Well this is a technique is highly sensitive for diagnosis of acute cholecystitis. The way we perform this is by having the patient lay down by gently press on the right upper quadrant of the abdomen and having the patient take a deep breath. We are essentially feeling for the gallbladder and with a patient taking a deep breath, it allows the gallbladder to descend and be palpated. 

Comment: The same principle applies when a technician is performing a RUQ US, if there is pain with inspiration, it is a positive Murphy sign. What is cholecystitis? 

In short this is infection and inflammation to the gallbladder that can be quite serious if left untreated. It can cause symptoms such as fever, chills, an increase in a patient’s WBC, and can lead to perforation of the gallbladder and sepsis. 

Comment: What are other things you looked for? 

It is important to take into consideration lab values. Lab findings remarkable on a comprehensive metabolic panel: elevated liver enzymes including AST, ALT, Alk Phos, total bilirubin. Interestingly enough a meta-analysis of 22 studies revealed that an elevated serum bilirubin has a sensitivity of 69% and specificity of 88% for diagnosis of a stone in the bile duct. 

Comment: With those findings, were you able to narrow down the diagnosis? 

With this clinical picture and laboratory findings were indicative of a blockage somewhere in the biliary duct as the patient had RUQ pain that were “colicky” in nature, she was not anemic, hepatitis panel was negative. With these findings we were able to rule out some of our suspected differential diagnosis. 

To be sure, we obtained an Abdominal US and the patient had a dilated Common bile duct, approximately 8 mm in diameter. The common bile duct is a tube-like structure that carries bile from the liver to be expelled into the intestines.  Any CBD measuring more than 6mm with an elevated serum total bilirubin is highly predicative of a stone obstruction. Which leads to our patient’s diagnosis called Choledocholithiasis. 

Comment: Choledocholithiasis is a mouthful.  

[Chole] stands for “bile”, [doch] stands for duct. [lith[ stands  for stone. So choledocholithaisis is a fancy way of saying stone in the the bile duct. 

What makes up the biliary tree is the left and right hepatic duct coming together to make the common HEPTATIC DUCT that meets with the cystic duct to make up the command bile duct, which meets the pancreatic duct and drains into the duodenum via the ampulla of Vater. 

Cholelithiasis is a stone in the gallbladder, and Choledocholithiasis is a stone anywhere in the biliary out of the gallbladder.

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

According to the national health and nutrition examination survey there are over 20 million Americans who reported that they have either gallstones or a history of cholecystectomy. It is important to recognize the common signs and symptoms of anyone with gallbladder disease, that way proper work up can be ordered and proper management can be performed.  

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

Most of the knowledge that I have is from my clinical experience. I’m much more of a hands-on learner than obtaining information from text books. During my rotations in surgery and in during my GI rotation I saw many of these cases. It made it much easier to go home and review in literature cases that I saw in the hospital.  

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

There are multiple resources that we have access to including American Academy of Family Physicians and Up to date and multiple questions that I’ve reviewed on USMLE world. For this particular case, I reviewed the articles by Arain, Mustafa and Zakko , Salam F, and Nezam H Afdhal in Up to Date.

_____________________

Speaking Medical 
by Lisa Manzanares

The word of the day is amblyopia.  This is a non-lazy way of saying “lazy eye.” Amblyopia is the functional reduction in visual acuity caused by abnormal visual development early in life, up to age 6 years.  Amblyopiais decreased vision in an eye that otherwise typically appears normal.  Amblyopia is THE most common childhood cause of monocular vision loss.  In Greek, amblyopia means “dullness of vision.” It occurs in 2-6% of U.S. children. 

Causes of amblyopia include strabismus, which is the most common, followed by refractive amblyopia, and then depravation amblyopia such as that caused by a scar or mass, which is the least common.  Methods of treatment include: patching, atropine, and Bangter filter applied to glasses lens of the good eye, depend on what type and how severe the amblyopia is.  

If there is suspicion for Amblyopia, don’t think, “That’s all Greek to me,” place pediatric ophthalmology referral because amblyopia is nearly irreversible by 9 years of age.

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Espanish Por Favor (Spanish Word of the Day) 
by Roberto Velazquez 

Hi this is Dr RAVA on our section Espanish por favor. This week’s Spanish word is “angina”, which it is spelled the same as angina. Although, angina in Spanish means tonsils. People usually use this word in its plural form anginas referring to both tonsils. This word comes from the Latin root angina which means strangling or choking or narrowing of the throat. So you can have a patient coming to you saying, “Doctor, me duelen las anginas,” and literally it sounds “Doctor, I have angina pain”. If you hear this, don’t panic, your patient is not having a heart attack. He or she is telling you that they have a sore throat.  Now you know the Spanish word of the day, angina or anginas, all you need to do is to assess your patient’s tonsils. Have a great week and take care. 

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[Music] For your Sanity (Medical joke of the day)
by Lisa Manzanares and Roberto Velazquez

Q: Did you hear about the optometrist that fell into his lens grinding machine?
A: He made a spectacle of himself

Q: Does an apple a day keep the doctor away?
A: Only if you aim it well enough

Q: Why did Dracula go to the doctor?
A: He couldn't stop his coffin

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During this episode we talked about Choledocholithiasis. Remember, think about the liver, alcohol, gallbladder, hemolysis, and infections when you see a yellow-skin patient. A millimetric stone obstructing the biliary tree can cause a big trouble if it is not diagnosed and treated on time. Don’t forget the medical word of the day Amblyopia or “lazy eye”, and the Spanish word “Angina”, which has little to do with the English word Angina. See you 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 by visiting 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, Lisa Manzanares, Roberto Velazquez, and Gina Cha. Audio edition: Suraj Amrutia. 

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References

Arain, Mustafa A, et al. “Choledocholithiasis: Clinical Manifestations, Diagnosis, and Management.” UpToDate, 2 Mar. 2020, www.uptodate.com/contents/choledocholithiasis-clinical-manifestations-diagnosis-and-management?search=choledocholithiasis&source=search_result&selectedTitle=1~112&usage_type=default&display_rank=1.

Zakko , Salam F, and Nezam H Afdhal . “Acute Calculous Cholecystitis: Clinical Features and Diagnosis.” UpToDate, Uptodate, 8 Nov. 2018, www.uptodate.com/contents/acute-calculous-cholecystitis-clinical-features-and-diagnosis?search=cholecystitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

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