Rio Bravo qWeek

The sun rises over the San Joaquin Valley, California, today is March 18, 2020. Last week marked the 5thanniversary since we opened our home at East Niles Community Health Center. The grand opening was on March 6, 2015. Also, Match Day 2020 is coming soon! We are happy to inform that we matched all 8 positions. We will know the residents’ names in a few days. This will be our 6th class. We are excited to welcome a new group of motivated residents starting in June 2020.  

Also, COVID-19 has infected over 200,000 and caused almost 9,000 deaths worldwide. A few hours ago, a non-resident in Kern County was confirmed to be positive for coronavirus(1). This pandemic continues to evolve every day, but we will not talk about it any further today. Visit the CDC website, or contact your local public health department for accurate and updated information.

___________

“If you think education is expensive, try ignorance.” (Unknown author, possibly Ann Landers)

Headache is among the top 10 chief complaints among primary care visits, we are happy to address this relevant topic with one of our chief residents. Today our guest is Lisa Manzanares. Lisa is on her third year. I am pleased to see you today. By the way, she has also been the voice of our “Speaking Medical” section. How are you doing today?

You know we ask 5 questions in this podcast. We’ll start with the first question.

1. Question number 1: Who are you?

You want the short or the long answer? I have to talk for 20 minutes they say, so you’re getting the ‘long.’  I’m a U.S. Navy veteran, mom of 3 little girls, a wife, a rock climber, explorer of the Sierras, a long board enthusiast, and a ….right, and a third year family medicine resident in the Rio Bravo Family Medicine Program.  I took the circuitous route here: after graduating medical school in 2013 from Western University of Health Sciences in Pomona, CA, I did an Intern year at Naval Medical Center San Diego. After that, the Navy sent me to the Central Valley where I practiced outpatient general medicine.  I took care of Active Duty members and their families while stationed at the Naval Hospital in Lemoore.  

Comment: What a nice bio, we are happy to have you as one of our residents. 

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

I learned about the acute treatment cluster headaches in the clinic. 100% oxygen via nonrebreather facial mask with flow of at least 12L/min.   You should continue x 15 minutes to prevent the attack from returning, though the patient may feel better in as little as 5 minutes.  As for medications: subcutaneous sumatriptan 6mg is beneficial in about 75% of patients, intranasal sumatriptan  or zolmitriptan can also be used but is slower in onset.  Sometimes only 3mg sumatriptan SQ can benefit patients.  Intranasal triptans are administered CONTRALATERAL to the pain side, because patients with cluster headache often have rhinorrhea and congestion on the side ipsilateral to the pain, impeding the delivery of the medication.  Intranasal lidocaine in a 4-10% solution can also be used, and is effective in about 1/3 of patients.  The lidocaine is administered on the IPSILATERAL side. 

Comment: We may not see the patient during the acute pain, but if you see a patient with acute cluster headache this is the treatment that needs to be given. Some patients have chronic cluster headache without remission periods.

Cluster headache is more prevalent in men and typically begins between 20 and 40 years of age. Trigeminal autonomic cephalgia: Unilateral, located on the temporal or periorbital area, accompanied by at least one ipsilateral symptom in the eye, nose, or face (rhinorrhea, conjunctival injection); it causes restlessness or agitation, duration of 15 to 180 minutes, One episode every other day to eight episodes per day. It is a severe headache(2). 

One of my patients explained it to me in a very painful way. He put a pen on his eye and stabbed himself on the eye, thankfully he only injured the medial aspect of his eye lid, but you can tell how intense the pain is if your patient is willing to stab himself in the eye to describe it.

Prophylaxis:As for prophylaxis of cluster headache, verapamil is the first-line therapy. Other meds that aren’t 1st line but may work: glucocorticoids, lithium, topiramate; more invasive treatments such as nerve stimulation and surgery may be helpful in refractory cases.

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

Cluster headaches are miserable.  In fact, the pain is described as a severe ‘suicide headache’ under diagnostic criteria in journal articles on cluster headache. My job as a family physician is to reduce common miseries.  About 1 in 1000 US adults has experienced a cluster headache, and cluster headache has a large associated morbidity: 80% of these patients report restricting daily activities. Common + miserable =something we need to learn about for the sake of our patients. Plus, oxygen is something that is in every clinic. This is one way to be able to treat the patient on the spot, and have them walking out of the clinic feeling better.

Comment: Tell us about the triggers of cluster headaches.

Triggers include vasodilators (e.g., alcohol, nitroglycerin) and histamine, tobacco exposure (first hand or second hand)

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

There’s always that question about 100% oxygen and cluster headaches on the boards, on shelf exams.  This is probably not news to anyone listening to the podcast. So the oxygen thing was something that actually stuck from med school.  

In terms of finding out more of what to do with the patient, how to make her feel better, I had to look some stuff up.  

My trusty sources in clinic are 1.) Up to Date and 2.) Faculty.  3.) Review/Journal articles. Not necessarily in that order.  

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

The info is an amalgam of: knowledge from Dr. Schlareth, our faculty member here, “Cluster Headache” by Dr. Weaver-Agostoni downloaded from the AAFP website, and “Cluster Headache: Treatment and Prognosis” on Up-to-Date(3). See details in our website.

Now we conclude our episode number 3 “The Suicide Headache”. Cluster headache is no joke. When you encounter a patient with a cluster headache, remember to use oxygen and abortive treatment as explained before. Do not forget to prescribe prophylaxis treatment if indicated.

________________

Speaking Medical (Medical word of the Day) 
by Monica Kumar, MD

Hi, my name is Dr Kumar, today I want to teach you the medical word of the day. Since everyone is fighting over toilet paper, we thought it was only appropriate to introduce to you the explosive medical term of the week. Steatorrhea. “Steatorrhea” is the excess of fat in the stools often due to the impaired transport of nutrients across the apical membrane of the enterocytes, that results in oily, foul smelling stools.

Some of the underlying causes of steatorrhea are celiac disease, cystic fibrosis, pancreatitis, lactose intolerance and gastrointestinal infections. 

If you see a patient with steatorrhea (not caused by the consumption of unhealthy amounts of burger and fries), please investigate further by asking onset, duration, frequency, triggers, and travel history, perform a complete physical exam, and order additional studies based on your assessment.  In young children presenting with failure to thrive and steatorrhea, do not forget about cystic fibrosis. 

Remember the medical word of the day steatorrhea.

_________________

Espanish Por Favor (Spanish Word of the Day) 
by Greg Fernandez

Welcome to your section Espanish Por Favor, this is Dr Fernandez and today’s Spanish word of the day which is “Piquete”. “Piquete” is translated as a prick, shot, jab, injection or a stinging pain or discomfort. The scenario where someone would use this word would sound like this: “Doctor, me da un piquete en el pecho” or “Doctor, tengo piquetes en las piernas”. 

It means “Doctor, I have a shot-like pain on my chest” or “Doctor, I have pricks on my legs.”  People can use this word to refer to an acute, sudden, short-duration, stinging, sharp pain. It is like a “bird bite”. The etiology of this pain can be very broad and can include muscle spasms, neuropathy, leg cramps, or many other conditions. It may also be a sign of no disease at all. Now you know the Espanish word of the day, “piquete”. 

All you have to do is go and assess your patient’s “piquetes”. That’s all for today, have a great week, and remember to wash your hands, avoid touching your face and avoid crowded places. Thank you.  

____________________ 

For your Sanity (Medical joke of the day)
by Simron Gill, MS4 and Monica Kumar, MD

--Why did the teacher with tertiary syphilis get fired? 

--Why?

--He couldn't control his pupils

--What is an EKG finding of hypospadias? 

--It doesn’t make sense, what does an EKG shows in hypospadias?

--Inverted P waves 

Duck Hunting 

A family medicine doc, an internist, a surgeon, and a pathologist are out one day duck hunting. 

First up is the family doc, he raises his gun to take aim at a flock of birds passing overhead and says to himself, "It looks like a duck, flies like a duck, quacks like a duck, it must be a duck." BANG! He bags himself a duck.

The internal medicine doctor then steps up, raises his gun to take aim at a second flock of birds flying overhead. He says to himself, "Looks like a duck, flies like a duck, quacks like a duck, rule out quail, rule out pheasant, goose versus duck likely." BANG! He, too, bags himself a duck.

A third flock of birds then flies overhead and the surgeon steps up and raises his gun at the flock. BANG! BANG! BANG! BANG! BANG! He fires multiple rounds at the flock and dead birds are dropping all around. The surgeon lowers his gun, walks over to one of the dead birds, picks it up, hands it to the pathologist and says, "Tell me if this is a duck."

References:

1. The Bakersfield Californian, Non-resident tests positive for coronavirus in Kern County, https://www.bakersfield.com/news/non-resident-tests-positive-for-coronavirus-in-kern-county/article_618b45b2-686c-11ea-ab78-e70420b5c2fd.html , accessed on March 17, 2020.
2. Jacqueline Weaver-Agostoni, DO, MPH, University of Pittsburgh Medical Center Shadyside Hospital, Pittsburgh, Pennsylvania. Am Fam Physician. 2013 Jul 15; 88(2):122-128. https://www.aafp.org/afp/2013/0715/p122.html#afp20130715p122-t1
3. Arne May, MD,  Cluster headache: Treatment and prognosis, Up to Date, https://www.uptodate.com/contents/cluster-headache-treatment-and-prognosis?search=cluster%20headache%20treatment&source=search_result&selectedTitle=1~72&usage_type=default&display_rank=1, accessed on March 17, 2020.

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

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

This week, the United States Preventive Services Task Force (USPSTF) updated its recommendation for hepatitis C screening to include all asymptomatic adults, with no evidence of liver disease, aged 18 to 79 years. A one-time screening for most adults is enough, more frequent screenings is recommended in patients with continued risk for Hepatitis C infection. There is limited evidence to recommend a screening frequency(1) at this time.

Also, COVID-19 is spreading but not as fast as corona-phobia. The Coronavirus is still a hot topic in the media with over 100,000 confirmed cases and 3,500 deaths worldwide. There are over 250 infected patients and 14 deaths reported in United States(2). We’ll have time to talk about Coronavirus later on in this episode.

We are all very ignorant what happens is that not all ignore the same things. Albert Einstein.

_____________________

Hello! Our quote for today is very proper because we are going to try to fight ignorance about a hot, current topic. Welcome again to Rio Bravo qWeek, I am Dr Arreaza, a faculty in Rio Bravo residency program. I am happy to inform that Our pilot episode was a success, we received feedback, and we hope to keep improving. Thanks to all who have supported this project, including Rene Mendizabal and Sheila Toro, two podcasters who gave me technical support, and Suraj Amrutia, however, he may edit this later to delete his name.

Our Episode number 2 is called “The Wicked Crown”, do you want to be the king or the queen who receives this crown? Listen until the end to find out if you want it, you may be surprised! 

Today our guest is Dr Terrance McGill, one of our PGY2s, who accepted the challenge to talk about Coronavirus, you are very brave, Terrance, thank for being here. How are you?

So, this podcast is based in 5 questions. We are going to jump right in.

QUESTION NUMBER 1: Who are you? 

I am Terrance McGill, 2nd year resident born and raised in Bakersfield, California where our residency program is located. 

QUESTION NUMBER 2: What did you learn this week?

This week, I learned about Coronavirus.

What is it?

Coronaviruses are pleomorphic, single-stranded RNA virus measuring 100-160nm in diameter. The name derives from “crown-like” appearance due to club-shaped projections surrounding the viral envelope. In general, human coronaviruses are difficult to cultivate in vitro, and some strains only grow in human tracheal organ cultures [1].

The current coronavirus disease outbreak is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This virus is thought to have an animal origin. The primary source of infection became human-to-human transmission in early January 2020.

Epidemiology

The coronavirus disease outbreak (COVID-19) began in Wuhan, China, in December 2019, and has since spread to 103 countries and territories, including the United States. 

As of March 9, 2020, there were 80,000+ reported cases in mainland China, and more than 20,000 cases in locations outside mainland China. 423 cases have been confirmed in the US, and 19 deaths have been reported in the CDC, as of the last update on March 9, 2020, with at least 13 people dead at Life Care Center nursing home in suburban Seattle, according to the King County Health Department.

Public health measures may not be able to fully contain the spread of COVID-19 because of its characteristics, however they will be effective in delaying the onset of widespread community transmission, reduce peak incidence and its impact on public services, thus decreasing the overall attack rate. Also minimizing the size of the outbreak can reduce global deaths by providing health systems the opportunity to scale up and respond. Vaccines are currently in development and the containment of the coronavirus will provide more time for vaccines to become manufactured.

This is what I call “seeing the glass half full”. The mortality rate is estimated to be 3.4% by the World Health Organization.

Presentation:

Coronavirus has an incubation period that lasts 2 to 7 days. Usually begins as a systemic illness marked by onset of fever accompanied with malaise, headache, myalgias and followed and one – two days by nonproductive cough, dyspnea. In severe cases, respiratory function may worsen during second week of illness and progress to frank ARDS accompanied by multi-organ dysfunction. Risk factors for severe disease include age greater than 50 years and comorbidities such as cardiovascular disease, diabetes, and hepatitis.

The presentation of coronavirus is similar to influenza, and all persons age six months and older should receive annual influenza vaccination. Vaccination will help to prevent influenza and in turn possibly prevent unnecessary evaluation for COVID-19.

Uncommon symptoms include runny nose, sore throat, productive cough, and GI symptoms. Labs: leukopenia (25%), leukocytosis (30%), lymphopenia (63%), and elevated ALT and AST (37%). Thrombocytopenia (36%). Most patients have normal serum levels of procalcitonin on admission. Chest CT images have shown bilateral involvement in most patients. Multiple areas of consolidation and ground glass opacities are typical findings reported to date.

When to test?

Positive symptoms and close contact with confirmed infected patients or travel within 14 days to China, Iran, Italy, Japan, South Korea. This list may change over time. Contact your local public health department if a person under investigation is identified. Start isolation protocol. Samples from nasopharynx, oropharynx and possibly sputum will be needed, also notify immediately the CDC’s Emergency Operations Center (EOC) at 770-488-7100.  

Treatment

There is currently no antiviral therapy available for the coronavirus so prevention and containment is key. The best ways to stay safe are to wash your hands with soap and water, or alternatively use alcohol-based hand sanitizers with at least 62% alcohol. Avoid touching your face as this is an easy way to prevent contact with mucosal membranes. Stay up-to-date on this information by visiting CDC and WHO websites. 

Hand washing cannot be overstated. Wash your hands for 20 seconds (sign happy birthday twice or you can get creative with your favorite song), use cold or warm water (work about the same), liquid soap is preferred (if no soap, use only water), wash all surfaces of hands, common missed places are the back of hands, the lower palm and around fingernails. Hand washing is not only a chemical disinfection, but also a mechanical removal of germs. Don’t forget to dry your hands(3)  

What about mask use?

Wear a mask if you are sick or if you are taking care of an infected patient. 

QUESTION NUMBER 3: Why is that knowledge important for you and your patients? 

Coronavirus is a current cause of nationwide fear and is a persistent headline in the news. Is important for us as providers to be able to educate our patients on the signs and symptoms of the coronavirus and to identity which patients may be affected by the coronavirus.  

QUESTION NUMBER 4: How did you get that knowledge?

Interest in this topic came from the various news headlines and news leaders regarding updating guidelines on preventing the spread of coronavirus.

QUESTION NUMBER 5: Where did that knowledge come from? 

Harrison’s Principles of Internal medicine, CDC, WHO, AAPF.

Harrison’s is a classic! CDC and WHO are reliable sources of information. Terrance, now give us a summary

COVID-19 is a novel acute viral illness that affects the respiratory system, it is transmitted person-to-person, with a mortality rate of 3.4%; being elderly or chronically ill places patients at higher risk of mortality. The preventive measures proven to be effective so far are hand washing and isolation of infected patients. 

Reasons to be worried? 

Limited surge capacity of our health system, partial availability of testing (improving), limited supply of protective equipment which may put healthcare workers at risk (avoid “panic shopping”), vulnerable population at risk, no cure and no vaccine(4). 

Reasons to be optimistic? 

Disease is mild in most people, children seem particularly protected from severe disease, and there has been extraordinary global cooperation from doctors, scientists and public health officials(4).

We can end this podcast on that positive note. Thanks for the information, Terrance. So, “corona” is the Latin word for crown or halo. The coronavirus is a crown you don’t want to get, but if you get it and survive it, you should consider yourself a king or queen who got crowned with the wicked crown. 

____________________________

Speaking Medical
by Lisa Manzanares

The medical word of the day is Dermatophagoides farinae. (Farin-EYE) This name doesn’t sound very common, but it actually refers to a very common organism, the American House Dust Mite.  Why do we care?  Dermatophagoides farinae is a common household allergen known to cause asthma, allergic rhinitis, and atopic dermatitis.  The feces of the mites are responsible for the majority of the reactions from Dermatophagoides farinae. Yuck.  Even worse, their meal of choice is dead human skins cells that have been shed. So, next time one of your patients complains that their allergies are flaring and they don’t know why, think: Dermatophagoides farinae.

___________________________

Espanish Por Favor
by Roberto Velazquez (Dr RAVA)

Today's word of the day is cuadril, which actually means the buttocks. People may use this word to refer to the pelvic girdle, and it refers to the area of the lower back, pelvis, hips, and buttocks. The scenario when someone will use may sound like this: “Doctor, ayer me caí y me duele mucho el cuadril”. This means: “Doctor, I fell yesterday and my pelvic area hurts… or somewhere in there”.  This points to a nonspecific location, since the area that is hurting can be anywhere in the lower back, the sacroiliac joint, the buttocks, hips, or anywhere else in the pelvis. It’s a broad term, huh?  Now you know the Spanish word of the day, cuadril, all you need to do now is to assess your patient’s cuadril.___________________________

For your Sanity
by Terrance McGill

This week we bring you a riddle. Pay attention.

A father and son were in a car accident where the father was killed. The son was brought by ambulance to the hospital in critical condition. The little boy was on the verge of death. He needed emergency surgery. The best trauma surgeon in town was called to the operating room. The surgeon came to the OR, looked at the little boy and said “I can't operate on him. He is my son.”

Who is the doctor? 

If you thought the surgeon was the mother of the boy. You are correct! 

If you already knew the answer to this riddle, maybe you will enjoy the twist that when this was told to a female surgeon, she also looked momentarily blank before being horrified by her reaction(4). Yes, we have very competent trauma surgeons who are women.

March 8, 2020, was International Women’s Day. For all those great women who listen to us, Happy International Women’s Day!

_________________________

References:

1. USPSTF, Hepatitis C Virus Infection in Adolescents and Adults: Screening,  Release Date: March 2020,  https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/hepatitis-c-screening1 , accessed on March 6, 2020.
2. World-O-Metters, https://www.worldometers.info/coronavirus/, accessed on March 6, 2020.
3. 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.
4. Infectious Disease Doctor: What Does (And Doesn't) Scare Me About The Coronavirus, https://www.wbur.org/commonhealth/2020/03/02/infectious-disease-doctor-coronavirus , accessed on March 9, 2020.
5. Sandra Ondraschek-Norris, https://www.theguardian.com/women-in-leadership/2013/aug/15/guilty-of-unconscious-bias-job-roles
6. Harrison’s Principles of Internal medicine- 19th edition. Deniis L. Kasper, et. Al
7. World Health Organization. Coronavirus disease 2019 (COVID-19) situation report–34. Geneva, Switzerland: World Health Organization; 2020.
8. Jernigan DB. Update: Public Health Response to the Coronavirus Disease 2019 Outbreak — United States, February 24, 2020. MMWR Morb Mortal Wkly Rep 2020;69:216–219.
9. Can we contain the COVID-19 outbreak with the same measures as for SARS?The Lancet Infectious Annelies Wilder-Smith,Calvin J Chiew,Vernon J Lee.

5 March 2020

1. Nursing Home Hit by Coronavirus Says 70 Workers Are Sick. New York Times. Mike Baker. March 8, 2020

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

This is the first episode of our podcast, published on March 3, 2020.  Dr Arreaza explains the  format of the podcast and explains toxic synovitis.  

Episode 1 has a purposefully confusing name. Dr Arreaza briefly explains toxic synovitis and we introduce our sections Espanish Por Favor, Speaking Medical and For Your Sanity. 

The sun rises over the San Joaquin Valley, California, this week the Coronavirus is all over the internet. The official name is COVID-19. As of February 27, 2020, over 80,000 people are estimated to be infected with coronavirus worldwide, with about 2,700 deaths2. It is spreading fast. There are 60 confirmed cases of COVID-19 in the United States1. No deaths have been reported so far. The coronavirus story is developing as I talk right now. 

In the meantime, there are about 40 million people infected by Influenza A&B (yes, 40 million), which have caused about 40,000 deaths around the world (40,000). Headlines about influenza A&B are less common these days.  

___________

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.

__________

Hello everyone, this is our first episode of Rio Bravo qWeek Podcast, which I called “The limping embryo”. An embryo is the elemental stage of an organism which evolves into a baby and then becomes an adult. This is the first episode (the embryo) of many more episodes that will come. BUT Why is this a “LIMPING” embryo? I invite you to listen until the end to find out.

Let me introduce myself. My name is Hector Arreaza. As you can tell, I was not born in Minnesota or Oregon, and I’m reminded frequently about it when people ask me “Where are you from?”. The answer to that question is not easy, but I’ll try to keep it simple. I was born and raised in Venezuela (South America, or how some people may call it, “one of those Mexican countries”). I graduated from Medical school there, and when I was 24 years old, I served as a missionary in Salt Lake City, Utah. I went back to Venezuela for a few months and returned to the United States searching to further my education in a residency program. After spending some years as a Spanish translator, I found a residency spot in Bakersfield, California, where I completed a residency in Family medicine. I practiced primary care in a community health center for about 1 and a half years, and Dr Stewart, who is the program director of my residency program, offered me a position as faculty in the very same residency I graduated from. It has been over one year, and I am loving it.

This podcast has been created to promote teaching and learning among residents, medical students, and faculty, and whoever listens to us wherever you are in the world. I hope you can enjoy it. 

“What we know is a drop… what we do not know is an ocean.” (Isaac Newton) 

“What we know is a drop”. That little drop of knowledge that we know is becoming larger and larger over time. Medicine has experienced many advances recently, and it is complicated to keep up with all the knowledge available to us. The idea of this podcast is to provide some traces of knowledge, maybe a mini-micro-drop to complement your study during your residency.

During our podcast we will focus on 5 questions. A different guest will be invited to participate every week, and I will conduct the interview. The questions are:

Question Number 1: Who are you? (the interviewee will have about 20 seconds to introduce him or herself)

Question number 2: What did you learn today? (any topic is valid, the interviewee will explain what he or she learned, some additional questions may be asked to clarify the topic)

Question number 3: Why is that knowledge important for you and your patients? (practical application)

Question number 4: How did you get that knowledge? (learning habits)

Question number 5: Where did that knowledge come from? (cite source)

So, because this is the first episode, I want to follow the same pattern which I have established for the podcast. 

QUESTION NUMBER 1: Who are you? 

I already answered the first question about who I am. 

QUESTION NUMBER 2: What did you learn today?

Today, I learned about toxic synovitis. 

Toxic synovitis is the most common cause of acute hip pain and limp in children ages 2-12. 

Irritable hip is a non-specific term referring to acute limping, hip pain, and stiffness which may be used in clinical practice instead of toxic synovitis.

Toxic synovitis is a term that can be confusing for patients or even professionals who are unfamiliar with this condition, because it has nothing to do with a “toxic state or toxic appearance”. 

Other names are: Postinfectious arthritis, Transitory coxitis, Coxitis fugáx, Acute transient epiphysitis, but in general, a very appropriate name for this condition is transient synovitis. 

It is “transient”because it is a self-limited, inflammatory disorder of the hip (typically the hip, but it may affect other joints) affecting young children between ages 2-12, more commonly boys. 

Presentation: Typically presents with mild to moderate hip pain and limping with a history of recent upper respiratory infection (runny nose, cough, fever), which may not be always present, and it can be any kind of extraarticular viral infection, some examples: rubella, parvovirus B19, and coxsackie virus. 

The patient normally keeps his or her hip in abduction and external rotation, hip motion may be limited, but the patient will usually allow movement through a limited arc of motion. Normally the patient will be able to bear weight.

Evaluation: 

History and Physical exam are very important. Physical exam findings include hip pain with movement, and no external signs of inflammation.

Labs may include a Complete Blood Count, Erythrocyte Sedimentation Rate and C Reactive Protein, however, they are usually normal. Lab studies may be ordered to rule out other causes, especially septic arthritis.

X-ray of hip is normal, however, you can have minor changes: early radiographic signs may include capsular distention, joint space widening, decreased definition of soft tissue planes around the hip joint, or slight demineralization of the bone of the proximal femur. The primary role of plain radiographs is ruling out other disorders.

Ultrasound may detect joint effusion, and absent joint effusion rules out septic arthritis.

Differential Diagnosis: 

1. Septic arthritis, the most important condition to rule out. Septic arthritis presents with toxic appearance, the hip pain is more intense and elevation of inflammatory markers is present.

In transient synovitis, think about this 4 elements: Fever, weight bearing, ESR and serum WBC. 

• Fever <101.3°F (<38.5°C)
• Child able to bear weight
• ESR (erythrocyte sedimentation rate) < 40 mm/hour
• Serum white blood cell count <12,000 cells/mm³

Predicted probability of septic arthritis is <0.2% if you have all these elements, and 3.0% for only one predictor.

Other Differential Diagnosis: Lyme arthritis (late manifestation), Osteomyelitis, Legg-Calvé-Perthes disorder (pronunciation is questionable), Pyogenic sacroiliitis, Juvenile idiopathic arthritis, fractures, and tumors. 

Treatment: It is supportive with activity restrictions and NSAIDs as needed. Recurrence is not common. Observation in hospital may be warranted if septic arthritis needs to be ruled out. Follow up in 7-10 days is advised. 

A reminder: Transient synovitis is uncommon in adults, it is more common in fall and winter, less common in African American children, rarely bilateral, and if recurrent or persistent, it may be the initial feature of a chronic inflammatory condition such as juvenile idiopathic arthritis.

QUESTION NUMBER 3: Why is that knowledge important for you and your patients? 

As family Medicine physicians, we encounter all kind of complaints across all ages. Knowing how to approach hip pain in children allows you to provide appropriate and timely treatment for your patients. Misdiagnosis of hip pain, may cause serious consequences to your patients, including permanent disability. Using your clinical judgement to decide on the appropriate laboratory studies and imaging in hip pain allows you practice cost-effective, and accurate medicine.

QUESTION NUMBER 4: How did you get that knowledge?

I got interested in the topic because of an email I got from the New England Journal of Medicine titled Question of the Week3.

QUESTION NUMBER 5: Where did that knowledge come from? 

After answering the question of the week, I went deeper into the topic by reading the abstracts of the citations mentioned in the question: John J and Chandran L. “Arthritis in children and adolescents”. Pediatr Rev 2011, Nov, AND Huntley JS. “Diagnosing and managing hip problems in childhood”, 2013 5, 6, 7. See details in our website. 

I also consulted Online Epocrates4, which is a handy resource when you need a rapid review of a certain topic.

Remember transient synovitis is a diagnosis of exclusion of hip pain in children after an upper respiratory infection. And now you know why this episode was called “The Limping Embryo”.

Now we conclude our first episode “The Limping Embryo”, an embryonic podcast episode about limping. We hope our limping embryo turns into a flying eagle in the future, as this podcast continues to grow and evolve. 

Espanish Por Favor

The Spanish word of the week is Coyuntura. Coyuntura actually means joint; the type of joint that are made out of bones ok. The definition of joint is a structure in the human or animal body at which two parts of the skeleton are fitted together, coyuntura. Coyuntura is a common word among the elderly, although it’s not uncommon to hear it from younger people. People may use this word while explaining any pain in any joint. As an example, your patient may complain saying: “Doctor me duelen las coyunturas”. This translates “Doctor my joints hurt”; meaning most of their joints are hurting. Although they may also refer to a particular joint such as the hip or the knee or any other coyuntura. Now you know the Spanish word of the week, co-yun-tu-ra, and you know what it means, all you need to do now is to assess your patient’s coyunturas. 

For your Sanity

-How do you hide a one-hundred-dollar bill from a Family Medicine Resident?

-How?

–Well, you put it in their in basket/in-box

-LOL

-Ah, and how do you hide it from a Radiologist?

– I don’t know, I guess you put it in a dark room.

– Hahahah it’s a good answer but no, you give the dollar bill to the patient. LOL

– And how do you hide the one-hundred-dollar bill from a Plastic Surgeon?

– I have no clue.

– Yes, you are right, you can’t. You can’t hide money from a Plastic Surgeon. 

Speaking Medical

The medical word of the week is: Sphenopalatine ganglioneuralgia

Can you guess what that means? 

Wow. What a mouthful, huh.  A mouthful of ice cream that is!  Sphenopalatine ganglioneuralgia is the medical term for ‘brain freeze.’ The sphenopalatine ganglia is the largest of the 4 parasympathetic ganglia associated with the trigeminal nerve.  Consists of the largest collection of neurons in the head outside of the brain.

Sphenopalatine ganglioneuralgia is NOT considered a disease.  Vasoconstriction causes a brief alteration of blood flow to the brain, causing an acute spasmodic pain of the nose, orbit, face and head.  Its likely the brain’s defense mechanism to ensure abrupt changes in temperature don’t occur.

What’s the treatment?  Stop shoveling ice cream in your mouth!!

Sphenopalatine ganglioneuralgia

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 Alyssa Der Mugrdechian. Content review by Carol Stewart. Audio editing by Suraj Amrutia. 

References:

1. New York Times, https://www.nytimes.com/2020/02/24/world/asia/china-coronavirus.html, accessed 2/24/2020 at 10:00 AM, PST.
2. WorldOmetters, Coronavirus, https://www.worldometers.info/coronavirus/
3. NEJM Knowledge+, Question of the Week, accessed on 2/11/2020.
4. Online Epocrates, accessed 02/11/2020, https://online.epocrates.com/diseases/761/Transient-synovitis-of-the-hip
5. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec;81(12):1662-70.
6. John J and Chandran L. Arthritis in children and adolescents. Pediatr Rev 2011 Nov; 32:470.
7. Huntley JS. Diagnosing and managing hip problems in childhood. Practitioner 2013 Jun; 257:19, 22.

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!