Rio Bravo qWeek

Episode 191: Diagnosis of ADHD

Future Dr. Granat explains how to diagnose Attention Deficit Hyperactivity Disorder. She explained the influence of social media in increasing awareness of ADHD. Dr. Arreaza added input about the validated tools for ADHD diagnosis and highlighted the importance of expert evaluation for the diagnosis of this disorder.  

Written by Yen Stephanie Granat, MSIV. Ross University School of Medicine. Comments and editing by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Steph: I love podcasts—many of us do—and if you, like me, spend any amount of your leisure time listening to podcasts, perusing the news, or scrolling social media; you’ve likely noticed an alarming trend in the number of discussions we seem to be having about ADHD. It has grown into a very hot topic over the past couple of years, and for some of us, it seems to have even begun sneaking into our “recommended videos” and across our news feeds! Naturally, for the average person this can spur questions like:

“Do I have ADHD? Do we all have it? How can I be certain either way, and what do I do if I find myself relating to most of the symptoms that I’m seeing discussed?”

Granted that there is a whirlpool of information circulating around this hot topic, I was hoping to spend a bit of time clearly outlining the disorder for anyone finding themselves curious. I believe that can best be achieved through outlining a clear, concise, and easy-to-understand definition of what ADHD is; outlining what it is not; and helping people sift through the fact and the fiction. As with many important things we see discussed on the internet, we’re seeing is that there is much more fiction than fact. 

Arreaza: I’m so glad you chose this topic! I think it is challenging to find reliable information about complex topics like ADHD. Tik Tok, Instagram and Facebook are great social media platforms, but we have to admit that fake news have spread like a fire in recent years. So, if you, listener, are looking for reliable information about ADHD, you are in the right place. With ADHD, there aren’t any obvious indicators, or rapid tests someone can take at home to give themselves a reliable “yes” or “no” test result. People’s concerns with ADHD are valid, and important to address, so we will discuss the steps to identify some of signs and symptoms they are seeing on TikTok or their favorite podcaster. 

Steph: Healthcare anxiety is a vital factor to consider when it comes to large cultural conversations around our minds and bodies; so, I hope to sweep away some of the misconceptions and misinformation floating around about ADHD. In doing so, I want to help alleviate any stress or confusion for anyone finding themselves wondering if ADHD is impacting their lives! We might even be able to more accurately navigate these kinds of “viral topics” (for lack of a better term) next time we see them popping up on our news feeds.

Arreaza: The first thing I want to say about ADHD is “the crumpled paper sign.”

Steph: What is that?

Arreaza: It is an undescribed sign of ADHD, I have noticed it, and it is anecdotal, not evidence based. When I walk into a room to see a pediatric patient, I have noticed that when the paper that covers the examination table is crumpled, most of the times it is because the pediatric patient is very active. Then I proceed to ask questions about ADHD and I have been right many times about the diagnosis. So, just an anecdote, remember the crumpled paper sign.  

Steph: When you have patients coming to you asking for stimulants because they think they have ADHD, hopefully, after today, you can be better prepared to help those patients. So, for the average person—anyone wanting to be sure if this diagnosis applies to them—how can we really know?”

Arreaza: So, let’s talk about diagnosis.

Steph: Yes, the clearest information we have is the DSM-5, which defines these disorders, as well as outlines the specific criteria (or “checkpoints”) one needs to meet to be able to have a formal diagnosis. However, this manual is best utilized by a trained professional—in this case, a physician—who can properly assess your signs and symptoms and give you a clear answer. 

Steph: ADHD stands for Attention Deficit Hyperactivity Disorder. It is among the most common neurodevelopmental disorders of childhood. That is not to say it does not affect adult—it does—and because it can be easy to miss, it’s very possible for someone to have ADHD without knowing. 

Arreaza: I recently learned that ADD is an outdated term. Some people with ADHD do not have hyperactivity but the term still applies to them. 

Steph: Yes, there are multiple types that I will explain in just a bit. But overall the disorder is most simply characterized by a significant degree of difficulty in paying attention, controlling impulsive behaviors, or in being overly active in a way that the individual finds very difficult to control. (CDC)

Arreaza: How common is ADHD?

Steph: The most recently published data from The CDC estimates that 7 million (11.4%) of U.S. children between the ages of 3 and 17 have been diagnosed with ADHD. For adults, it is estimated that there are 15.5 million (6%) individuals in the U.S. who currently have ADHD. 

Arreaza: I suspected it would be more than that. [Anecdote about Boy Scout camp]. 

Steph: I totally agree. With short videos on TikTok, or paying high subscription fees to skip ads, it feels like as a society we all have a shorter attention span. 

Arreaza: Even churches are adapting to the new generation of believers: Shorter sermons and shorter lessons.

Steph: When it comes to better understanding these numbers, it's also important to know that there are three distinct presentations of ADHD recognized by The CDC and The World Health Organization. 

Arreaza: The DSM-5 TR no longer uses the word “subtypes” for ADHD. Instead, it uses the word "presentation" to describe the different ways that ADHD may manifest in a person. That reminded me to update my old DSM-5 manual and I ordered it while reading today about ADHD. This means people with ADHD are no longer diagnosed as having a “subtype”. Instead, they are diagnosed with ADHD and a certain “presentation” of symptoms.

Steph: These presentations are:

Inattentive Type

People often have difficulty planning or completing tasks

They find themselves easily distracted (especially when it comes to longer, focus-oriented tasks)

They can often forget details and specifics, even with things that are part of their daily routine

This used to be referred to as “ADD” (you’ll notice the absence of an “H”, segue).

Hyperactive-Impulsive Type

People often have a sense of intense “restlessness”, noticeable even in calm environments.

They tend to be noticeably more talkative, and might often be seen interrupting others, or finishing their sentences.

They find significant difficulty in being still for extended periods. Because of this, they are often unable to sit through a movie or class time, without fidgeting or getting up and moving around.

With this category of ADHD, we often see an impulsiveness that unwittingly leads to risky behavior. Because of this, accidents and bodily injury are more common in individuals with this type of ADHD.

Combined Type

These are individuals who exhibit symptoms from both “Inattentive” and “Hyperactive-Impulsive” ADHD equally.

Some listeners might have noticed that the categories are quite different, meaning that ADHD presents in different ways depending on the person! Two people who have ADHD can be in the same room and have vastly different presentations, whilst still having many of the same types of challenges. You also might have noticed what makes the discussion so interesting to the general public, which is also the thing that makes speaking to a professional to get formally tested so important:

The diagnostic criteria rely heavily on patterns of behavior, or external variables; rather than on how a person might feel, or certain measurements taken from lab tests.

Arreaza: Diagnosing ADHD requires evaluation by a professional who is properly trained for this. Fortunately, we have tools to assist with the diagnosis. The attention deficit must be noted in more than one major setting (e.g., social, academic, or occupational), that’s why the information should be gathered from multiple sources, including parents, teachers, and other caregivers, using validated tools, such as:

• The Neuropsychiatric EEG-Based ADHD Assessment Aid (NEBA), recommended by the American Academy of Neurology
• The Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) and the Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS), recommended by the Society for Developmental and Behavioral Pediatrics.
• For adults: The validated rating scales include the Adult ADHD Self-Report Scale (ASRS) and the Conners Adult ADHD Rating Scales (CAARS).

Steph: This is important because nearly everyone alive has experienced several, if not most, of these behavioral patterns at least once. Whether or not an individual has ADHD, I’m certain we could all think of moments we’ve had great difficulty focusing or sitting still. Perhaps some of us are incredibly forgetful, or act more impulsively than the average person might find typical. Getting a professional diagnosis is important because it is in skillfully assessing “the bigger picture” of a person’s life, or their patterns of behavior, that a skilled physician, who understands the nuances and complexities in these disorders, can properly tell each of us whether we have ADHD, or not.

Essentially, most of us could stand to use a bit more focus these days, but far fewer of us would meaningfully benefit from the kinds of treatments and therapies needed by individuals with ADHD to live healthier, more happy and regulated lives.

Arreaza: I had a mother who came to discuss the results of the Vanderbilt Questionnaire. I think she left a little disappointed when she heard that, based on the responses from her and the teacher, her son did not have ADHD. Some kids may have behaviors such as being distracted during a meeting, forgetting about homework or having a lot of energy, but that does NOT mean necessarily that they have ADHD, right?

Steph: Absolutely! The important thing to remember here is that these patterns of behavior outlined in the DSM-5 are merely an external gauge for a neurological reality. What the science is showing us is that the brains of people with ADHD are wired differently than that of the more “neurotypical” brain. Much like a check engine light would serve as a signal to a driver that something under the hood needs attention; these patterns of behavior, when they begin impeding our day to day lives, might tell us that it’s time to see a professional (whether it be an auto mechanic or a trained physician). I think we all know someone who drives with their check engine light and not a care in the world. 

Arreaza: How serious/urgent is ADHD? Why should we care to make the diagnosis?

Steph: Although we’ve yet to see anyone incur harm solely from having ADHD, it does lead to quite a range of more serious issues, some of which might prove more urgent. In the cases of ADHD, specifically, what we know is that there is a notable degree of dysregulation in some key neurotransmitters, like dopamine and norepinephrine. More plainly, what we are seeing in the brains of people with ADHD is a disruption, or alteration, of some of the brain’s key chemicals.

These neurotransmitters are largely responsible for much-needed processes like Motivation, Satisfaction, Focus, Impulse control, even things like energy and feelings of happiness. Many of these things serve as “fuel” for our day-to-day lives; things we’d call our “executive function”.  These are also what prove dysfunctional in those struggling with ADHD. It is in this sense that we might be able to bridge a meaningful gap between ADHD as being seen through 

patterns of behavior

that signal a 

real, neurological reality.

Steph: We often hear of the brain referenced as a kind of supercomputer. A more accurate assessment might be that the brain is more of a network of interconnected computers that run different processes and require continual communication with one another for our brain to function properly and seamlessly. What we’re seeing in members of the population with this diagnosis, is a significant disruption in these lines of communication. Although this is a very broad oversimplification, for the purposes of our metaphor is to think of it like our brain chemicals getting caught in a traffic jam, or parts of our brain attempting to communicate to one another with poor cell signal. 

Arreaza: Making the diagnosis is critical to start treatment because having that level of dysfunction sounds like having a very difficult life.

Steph: Yeah! I think that’s why this conversation matters so much. There’s a sense of urgency there, because much of life is, in fact, boring. Things like paying bills, exercising and eating well, work and school—these are all things that are vital to health and wellbeing in day-to-day life; and for the more neurotypical brain, these things might prove occasionally challenging. Yet, they are still doable. For those with ADHD however, this goes far beyond mere boredom or “laziness” (which proves to be a trigger term for many—more on that in just a bit).

For folks listening, I wanted to offer some statistics that show why this is such a big concern for the public, whether one has a formal ADHD diagnosis or not. 

The facts are figures are:

• Children with ADHD are more than five times as likely as the child without ADHD to have major depression.
• A significant increase in the prevalence of anxiety is seen in ADHD patients, ranging from 15% to 35%, when accounting for overlap in symptoms.
• There are significant correlations in youth diagnosed with ADHD, and those diagnosed with what are known as “externalizing disorders”. These are things like Conduct Disorder, Disruptive Mood Dysregulation Disorder, and Oppositional Defiant Disorder.
• We are seeing a much higher rate of academic problems in kids who have ADHD, like reading disorder, impaired verbal skills, and visual motor integration.

We’re finding that many, if not most, of these connections are being made after diagnosis. In the case of the “internalized disorders”, like depression and anxiety, we’re often seeing years between ADHD diagnoses and the diagnoses of major depressive disorder or anxiety disorders. Given this framework, much of the data is theorized to point towards what we call “negative environmental circumstances”, otherwise known as “ADHD-related demoralization”.

For children, this often looks like struggling with sitting still during class, failing to get homework done (because they forgot, or couldn’t focus on the tasks at hand), and struggling to focus their attention on what their teacher is saying during lecture. These things often lead to bad grades, discipline or forced time sitting still in detention. This can be seen in more problems at home, with children being disciplined often for behavior that they struggle immensely to control.

For adults, this can mean forgetting to pay your bills, missing work meetings, having trouble making appointments, or having difficulty with day-to-day tasks, really anything that requires sustained attention. We often see adults with ADHD who are chasing normalcy with caffeine addictions or even struggling with substance use. 

Arreaza: Substance use disorder actually can be a way for some people living with ADHD to self-treat their symptoms. 

Steph: These differences between the individual’s experience and the world around them can lead to really powerful feelings of failure or inadequacy. They can affect your social life, your sense of community, and even further limit your capacity to seek help.

Literacy in these things is so important—not just for the individual who feels that they may have ADHD, but also for those who are likely to encounter people with ADHD in their own lives. Understanding why some of these patterns pop up, even those who might not have a formal diagnosis, can go a long way to properly approaching these behaviors with success and with empathy.

Arreaza: Learning about ADHD is fundamental for primary care doctors. We talked about the high prevalence and the influence of the media in increasing awareness and sometimes increasing public panic. So, we have to be prepared to diagnose or undiagnosed ADHD. 

Steph: Whether we’re the physicians in the room, or the patient in the chair, I think it’s important to have a clear understanding of what ADHD is and how it can affect lives. Thanks for listening, I hope we were able to teach you a little more about ADHD. 

______________

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! 

_______________

References:

1. NICHQ-Vanderbilt-Assessment-Scales PDF: https://nichq.org/wp-content/uploads/2024/09/NICHQ-Vanderbilt-Assessment-Scales.pdf
2. ADHD: The facts. ADDA - Attention Deficit Disorder Association. (2023, January 11). https://add.org/adhd-facts/
3. American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, Inc. https://doi.org/10.1176/appi.books.9780890425596.
4. Gnanavel S, Sharma P, Kaushal P, Hussain S. Attention deficit hyperactivity disorder and comorbidity: A review of literature. World J Clin Cases. 2019 Sep 6;7(17):2420-2426. doi: 10.12998/wjcc.v7.i17.2420. PMID: 31559278; PMCID: PMC6745333.
5. Staley BS, Robinson LR, Claussen AH, et al. Attention-Deficit/Hyperactivity Disorder Diagnosis, Treatment and Telehealth Use in Adults — National Center for Health Statistics Rapid Surveys System, United States, October – November 2023. CDC.Gov, MMWR Morb Mortal Wkly Rep 2024;73:890-895.
6. Danielson ML, Claussen AH, Arifkhanova A, Gonzalez MG, Surman C. Who Provides Outpatient Clinical Care for Adults With ADHD? Analysis of Healthcare Claims by Types of Providers Among Private Insurance and Medicaid Enrollees, 2021. J Atten Disord. 2024 Jun;28(8):1225-1235. doi: 10.1177/10870547241238899. Epub 2024 Mar 18. PMID: 38500256; PMCID: PMC11108736. https://pubmed.ncbi.nlm.nih.gov/38500256/
7. Mattingly G, Childress A. Clinical implications of attention-deficit/hyperactivity disorder in adults: what new data on diagnostic trends, treatment barriers, and telehealth utilization tell us. J Clin Psychiatry. 2024;85(4):24com15592. https://www.psychiatrist.com/jcp/implications-adult-adhd-diagnostic-trends-treatment-barriers-telehealth/
8. Didier J. My four kids and I all have ADHD. We need telehealth options. STAT News. Published October 10, 2024. Accessed October 10, 2024. https://www.statnews.com/2024/10/10/adhd-medication-shortage-telehealth-dea-congress/.
9. Hong J, Mattingly GW, Carbray JA, Cooper TV, Findling RL, Gignac M, Glaser PE, Lopez FA, Maletic V, McIntyre RS, Robb AS, Singh MK, Stein MA, Stahl SM. Expert consensus statement for telepsychiatry and attention-deficit hyperactivity disorder. CNS Spectr. 2024 May 20:1-12. doi: 10.1017/S1092852924000208. Epub ahead of print. PMID: 38764385. https://pubmed.ncbi.nlm.nih.gov/38764385/
10. Gabor Maté: The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture. (2022). Youtube. Retrieved April 27, 2025, from https://www.youtube.com/watch?v=ttu21ViNiC0. 
11. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 190: Measles Basics

Future Dr. Kapur explained the basics of measles, including the pathophysiology, diagnosis and management of this disease. Dr. Schlaerth added information about SPPE and told interesting stories of measles. Dr. Arreaza explained some statistics and histed the episode.  

Written by Ashna Kapur MS4 Ross University School of Medicine. Comments by Katherine Schlaerth, MD, and Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Introduction.

According to the CDC, as of April 24, 2025, a total of 884 confirmed measles cases were reported by 30 states, including California, and notably Texas. This is already three times more cases than 2024. There are 3 confirmed deaths so far in the US. What is measles?

Measles is a disease that’s been around for centuries, nearly eradicated, yet still lingers in parts of the world due to declining vaccination rates. Let's refresh our knowledge about its epidemiology, clinical features, diagnosis, management, and most importantly — prevention.

Definition.

Measles, also known as rubeola, is an acute viral respiratory illness caused by the measles virus. It’s a single-stranded, negative-sense RNA virus belonging to the Paramyxoviridae family. It’s extremely contagious with a transmission rate of up to 90% among non-immune individuals when exposed to an infected person.

Epidemiology

Before the introduction of the measles vaccine in 1963, nearly every child got measles by the time they were 15 years old. With the introduction of vaccination, cases and deaths caused by measles significantly declined. For example, in 2018, over 140,000 deaths were reported in the whole world, mostly among children under the age of 5.

Measles is still a common disease in many countries, including in Europe, the Middle East, Asia, and Africa. Measles outbreaks have been reported recently in the UK, Israel, India, Thailand, Vietnam, Japan, Ukraine, the Philippines, and more recently in the US. So, let’s take prevention seriously to avoid the spread of this disease here at home and abroad. How do we get measles, Ashna?

Mode of Transmission:

● Air: Spread primarily through respiratory droplets.

● Surfaces: The virus remains viable on surfaces or in the air for up to 2 hours. (so, if a person with measles was in a room and you enter the same room within 2 hours, you may still get measles)

● Other people: Patients are contagious from 4 days before until 4 days after the rash appears.

Pathophysiology

The measles virus first infects the respiratory epithelium, replicates, and then disseminates to the lymphatic system.

It leads to transient but profound immunosuppression, which is why secondary infections are common. It affects the skin, respiratory tract, and sometimes the brain, leading to complications like pneumonia or encephalitis.

Clinical Presentation

The classic presentation of measles can be remembered in three C’s:

● Cough

● Coryza (runny nose)

● Conjunctivitis

Course of Disease (3 Phases):

1. Prodromal Phase (2-4 days)

○ High fever (can peak at 104°F or 40°C)

○ The 3 C’s

○ Koplik spots: Small white lesions on the buccal mucosa.

2. Exanthem Phase

○ Maculopapular rash begins on the face (especially around the hairline), then spreads from head to toe. The rash typically combines into 1 big mass as it spreads, and the fever often persists during the rash.

3. Recovery Phase

○ Rash fades in the same order it appeared.

○ Patients remain at risk for complications during and after rash resolution.

Complications:

● Pneumonia (most common cause of death in children)

● Otitis media (most common overall complication)

● Encephalitis (can lead to permanent neurologic sequelae)

● Subacute sclerosing panencephalitis (SSPE): A rare, fatal, degenerative CNS disease that can occur years after measles infection.

High-risk groups for severe disease include:

● Infants and young children

● Pregnant women

● Immunocompromised individuals

Diagnosis

Clinical diagnosis is sufficient if classic symptoms are present, especially in outbreak settings.

Ashna: Laboratory confirmation:

● Measles-specific IgM antibodies detected by serology.

● RT-PCR from nasopharyngeal, throat, or urine samples.

Notify public health authorities immediately upon suspicion or diagnosis of measles to limit spread. 

Management

There is no specific antiviral treatment for measles. Management is supportive:

● Hydration (by mouth and only IV in case of severe dehydration)

● Antipyretics (e.g., acetaminophen) for fever

● Oxygen if hypoxic

Vitamin A supplementation:

● Recommended for all children with acute measles, particularly in areas with high vitamin A deficiency. It has shown to reduce morbidity and mortality.

Hospitalization may be necessary for:

● Severe respiratory compromise

● Dehydration

● Neurologic complications

Prevention: We live in perilous times and vaccination is under scrutiny right now. Before the measles vaccine, about 48,000 people were hospitalized and 400–500 people died in the United States every year. Measles was declared eradicated in the US in 2000, but the vaccination coverage is no longer 95%. How do we prevent measles?

Vaccination is the cornerstone of prevention.

● MMR vaccine (Measles, Mumps, Rubella):

○ First dose at 12-15 months of age.

○ Second dose at 4-6 years of age.

○ 97% effective after 2 doses.

The Advisory Committee on Immunization Practices (ACIP) has noted that febrile seizures typically occur 7 to 12 days after vaccination with MMR, with an estimated incidence of 3.3 to 8.7 per 10,000 doses. The Centers for Disease Control and Prevention (CDC) states that febrile seizures following MMR vaccination are rare and not associated with any long-term effects. The risk of febrile seizures is higher when the MMR vaccine is administered as part of the combined MMRV (measles, mumps, rubella, and varicella) vaccine compared to the MMR vaccine alone.

Post-exposure prophylaxis:

● MMR vaccine within 72 hours of exposure (if possible).

● Immunoglobulin within 6 days for high-risk individuals (e.g., infants, pregnant women, immunocompromised).

Herd immunity requires at least 95% vaccination coverage to prevent outbreaks.

Key Takeaways

● Measles is a highly contagious viral illness that can lead to severe complications.

● Diagnosis is often clinical, but lab confirmation helps with public health tracking.

● Treatment is mainly supportive, with Vitamin A playing a critical role in reducing complications.

● Vaccination remains the most effective tool to eliminate measles worldwide.

While measles might seem like a disease of the past, it can make a dangerous comeback without continued vigilance and vaccination efforts.

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! 

_____________________

References:

1. Centers for Disease Control and Prevention (CDC). Measles (Rubeola), Clinical Overview, July 15, 2024. Accessed on May 1, 2025. https://www.cdc.gov/measles/hcp/clinical-overview/index.html.
2. World Health Organization (WHO). Measles, November 14, 2024. https://www.who.int/news-room/fact-sheets/detail/measles
3. Gans, Hayley and Yvonne A. Maldonado, Measles: Clinical manifestations, diagnosis, treatment, and prevention, UpToDate, January 15, 2025. Accessed on May 1, 2025. https://www.uptodate.com/contents/measles-clinical-manifestations-diagnosis-treatment-and-prevention
4. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 189: Intermittent Fasting (Religious and Sports)

Future Doctors Carlisle and Kim give recommendations about patients who are fasting for religious reasons, such as Ramadan. They also explain the benefits and risks of fasting for athletes and also debunked some myths about fasting. Dr. Arreaza add input about the side effects of fasting and ways to address them.    

Written by Cameron Carlisle, MSIV (RUSM) and Kyung Kim, MSIV (AUC). Editing by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Introduction: 

In the last episode on fasting (#179), we explored how intermittent fasting (IF) can help manage type 2 diabetes by improving insulin sensitivity, promoting weight loss, and lowering inflammation. We discussed the benefits of methods like 16:8 time-restricted eating and the 5:2 meal plan, and even compared IF to medications like metformin. Today, we’re bringing that science into real life. We’ll talk about how people fast for religious reasons, like during Ramadan, how athletes use IF to stay in shape, and how we can use IF as a tool in family medicine to support community health and A1c control.

Intermittent Fasting in Religious Practice

Ramadan just ended on 3/30/25, but this is a great time to talk about the broader role of fasting in religion and health. Many faiths incorporate fasting into spiritual practice and understanding this can help us better support our patients.

Islam (Ramadan): Ramadan is a month where Muslims fast from dawn to sunset, focusing on spiritual reflection and self-control. No food or drink is consumed during daylight hours. Despite this, studies have shown that with good planning, fasting during Ramadan does not significantly impair physical performance or metabolic health.

Key health tips for patients observing Ramadan:

• Hydrate well between iftar (sunset) and suhoor (pre-dawn).
• Break the fast with dates and water to gently replenish energy and electrolytes.
• Eat balanced meals with complex carbs, protein, and healthy fats
• Avoid greasy, heavy foods right after fasting
• Light exercise (such as a walk) after iftar is beneficial
• Review medications with a healthcare provider, especially for those on insulin or sulfonylureas.

For example: Metformin should be taken when you break your fast and then again before dawn. If its an extended-release metformin, take it at night. Metformin does not cause significant hypoglycemia and can be continued during Ramadan. Basal insulin is advised to be given at Iftar, and the dose should be reduced by 25-35% if the patient is not well managed. And regarding the fast-acting insulin, it requires a little more reading, so you can look it up and learn about it. 

Judaism: In Judaism, fasting is practiced on days like Yom Kippur and Tisha B’Av, typically lasting 25 hours without food or water. These fasts are spiritual and reflective, and patients with medical conditions may seek guidance on how to participate safely.

Christianity: Many Christians fast during Lent, either by abstaining from certain foods or limiting meal frequency. Some practice partial-day fasts or water-only fasts for spiritual renewal.A branch of Christianity known as The Church of Jesus Christ of Latter-day Saintsoften observe a 24-hour fast on the first Sunday of each month, known as Fast Sunday, where they abstain from food and drink and donate the cost of meals to charity. This practice is both spiritual and communal.

Cameron: Fasting for religious reasons, when done safely, can align with IF protocols and be culturally sensitive for diverse patients in family medicine.

IF in Athletes and Performance

Intermittent fasting is gaining popularity in the sports world. Athletes are using IF to improve body composition, increase fat oxidation, and enhance metabolic flexibility. A recent study, known as the DRIFT trial and published in Annals of Internal Medicine, found that fasting three non-consecutive days a week led to more weight loss than daily calorie restriction. Participants lost an average of 6.37 pounds more over 12 months.

Why? Better adherence. People found the 3-day fasting schedule easier to stick to than counting calories every day.

Benefits of IF for athletes:

• Encourages fat burning (via AMPK activation and GLUT4 upregulation, listen to ep. 179).
• Helps maintain lean muscle while reducing fat.
• No major drop in performance when meals and workouts are timed properly.

What are some practical tips?

• Schedule workouts during or just before eating windows.
• Eat protein-rich meals post-workout.
• Avoid intense training during long fasts unless adapted.
• Stay hydrated, especially in hot environments or endurance sports.

Broader Applications and Myths Around IF

Hormonal Effects of IF: In addition to improving insulin sensitivity, IF also affects hormones such as ghrelin (which stimulates hunger, remember it as growling) and leptin (which signals fullness). Over time, IF may help the body regulate appetite better and reduce cravings. IF can also decrease morning cortisol levels, the stress hormone. That’s why it's important to monitor sleep, hydration, and stress levels when recommending IF.

Circadian Rhythm Alignment:

 Emerging research shows that aligning eating times with natural light/dark cycles—eating during the day and fasting at night—can improve metabolic outcomes. This practice, known as early time-restricted eating (eTRE), has been shown to lower blood glucose, reduce insulin levels, and improve energy use. Patients who eat earlier in the day tend to have better results than those who eat late at night.

Myths and Clarifications on IF:

-“Fasting slows metabolism” In fact, short-term fasting may boost metabolism slightly due to increased norepinephrine. 

-“You can’t exercise while fasting.” Many people can safely train during fasted states, especially for moderate cardio or strength training. 

-“Skipping breakfast is bad.” For some, skipping breakfast is a useful IF strategy—as long as total nutrition is maintained. You can break your fast at 2:00 pm, it does have to be at 7:00 AM.

What to Eat When Breaking a Fast

Breaking a fast properly is just as important as fasting itself. Whether it’s after a Ramadan fast or a 16-hour fast, the goal is to replenish energy gently and restore nutrients.

Ideal foods to break a fast:

• Dates and water: provide quick energy, potassium, and fiber
• Soups: lentil or broth-based soups are gentle on digestion
• Complex carbs: whole grains like brown rice or oats
• Lean proteins: chicken, fish, eggs, legumes
• Fruits and vegetables: hydrate and provide fiber
• Healthy fats: nuts, avocado, olive oil
• Probiotics: yogurt or kefir for gut support

Balanced meals with carbs, protein, and healthy fats help the body transition smoothly back to a fed state.

Using IF in Family Medicine and Community Health

Intermittent fasting can be a practical, cost-effective strategy in family medicine. In areas with high rates of obesity and diabetes, like Kern County, IF offers a lifestyle-based tool to improve metabolic health, especially in underserved populations. IF is free!

How IF can help in family medicine:

• Lower A1c levels: improves insulin sensitivity and glucose control
• Promote weight loss: decreases insulin resistance and inflammation
• Reduce medication dependence: fewer meds needed over time for some patients
• Encourage patient engagement: flexible and easier to follow than strict calorie counting
• Fit diverse lifestyles: aligns with religious and cultural practices
• Address food insecurity: structured eating windows can help patients stretch limited food resources

How to apply IF in clinic:

• Start the conversation by asking if the patient has heard of IF
• Recommend simple starting points: 12:12 or 14:10
• Emphasize hydration and nutrient-dense meals
• Monitor labs and symptoms, especially in diabetic patients
• Adjust medications to avoid hypoglycemia
• Provide follow-up and patient education handouts if possible

What if a patient isn't ready to try fasting?

• For those not ready to commit to intermittent fasting, one effective alternative is walking after meals. A simple 10–20 minute walk post-meal can help stimulate GLUT4 receptors in skeletal muscle, promoting glucose uptake independent of insulin. This reduces the demand on pancreatic beta cells and may help improve blood sugar control over time. This strategy is particularly useful for patients with insulin resistance or early-stage type 2 diabetes.

Conclusion: 

Intermittent fasting is not one-size-fits-all, but it can be a powerful tool for both individual and community health. From Ramadan to race day, IF has a place in family medicine when used thoughtfully. Encourage patients to work with their healthcare providers to find an approach that fits their lifestyle, medical needs, and personal values. IF is a cost-effective tool

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! 

_____________________

References:

1. American Academy of Family Physicians. (2022). "Intermittent Fasting: A Promising Treatment for Diabetes." AAFP Community Blog. https://www.aafp.org/pubs/afp/afp-community-blog/entry/intermittent-fasting-a-promising-treatment-for-diabetes.html
2. Healthline. (2023). "What Breaks a Fast? Foods, Drinks, and Supplements." https://www.healthline.com/nutrition/what-breaks-a-fast.
3. Sarri KO, Tzanakis NE, Linardakis MK, Mamalakis GD, Kafatos AG. Effects of Greek Orthodox Christian Church fasting on serum lipids and obesity. BMC Public Health. 2003 May 16;3:16. doi: 10.1186/1471-2458-3-16. PMID: 12753698; PMCID: PMC156653. https://pmc.ncbi.nlm.nih.gov/articles/PMC156653/.
4. Shang, Y., et al. (2024). "Effects of Intermittent Fasting on Obesity-Related Health Outcomes: An Umbrella Review." eClinicalMedicine.https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00098-1.
5. Abaïdia AE, Daab W, Bouzid MA. Effects of Ramadan Fasting on Physical Performance: A Systematic Review with Meta-analysis. Sports Med. 2020 May;50(5):1009-1026. doi: 10.1007/s40279-020-01257-0. PMID: 31960369. https://pubmed.ncbi.nlm.nih.gov/31960369/.
6. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 188: RSV Management and Prevention

Dr. Sandhu and future Dr. Mohamed summarize the management of RSV and describe how to prevent it with chemoprophylaxis and vaccines. Dr Arreaza adds some comments about RSV vaccines.

Written by Abdolhakim Mohamed, MSIV, Ross University School of Medicine. Comments by Ranbir Sandhu, MD, and Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

What is RSV? 

-The Respiratory syncytial Virus (RSV) is an enveloped, negative-sense, single-stranded RNA virus of the Orthopneumovirus genus within the Pneumoviridae family. 

-RSV is a major cause of acute respiratory tract infections, particularly bronchiolitis and pneumonia, in infants and young children, and it also significantly affects older adults and immunocompromised individuals. 

-RSV infections cause an estimated 58,000–80,000 hospitalizations among children younger than 5 years and 60,000–160,000 hospitalizations among adults older than 65 years each year.

-RSV is highly contagious and spreads through respiratory droplets and direct contact with contaminated surfaces. The virus typically causes seasonal epidemics, peaking in the winter months in temperate climates and during the rainy season in tropical regions. 

-Virtually all children are infected with RSV by the age of two, and reinfections can occur throughout life, often with milder symptoms.

-Per the 2014 Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis, from the American Academy of Pediatrics, the most common etiology of bronchiolitis is RSV. 

-About 97% of children are infected with RSV in the first 2 years of life, about 40% will experience lower respiratory tract infection during the initial infection. Other viruses that cause bronchiolitis include human rhinovirus, human metapneumovirus, influenza, adenovirus, coronavirus, and parainfluenza viruses.

When is RSV season?

-Classically, the highest incidence of infection occurs between December and March in North America. Per CDC, there were typical prepandemic RSV season patterns, but the COVID-19 pandemic disrupted RSV seasonality during 2020–2022. 

-Before we dive into the seasonality patterns, for context, in order to describe RSV seasonality in the US, data was gathered and analyzed from polymerase chain reaction (PCR) test results reported to the National Respiratory and Enteric Virus Surveillance System (NREVSS) during July 2017–February 2023. 

-Seasonal RSV epidemics were defined as the weeks during which the percentage of PCR test results that were positive for RSV was ≥3%. Per 2017–2020 data, RSV epidemics in the United States typically follow seasonal patterns, that began in October, peaked in December or January, and ended in April. 

-However, during 2020–21, the typical winter RSV epidemic did not occur. The 2021–22 season began in May, peaked in July, and ended in January. 

-The 2022–23 season started (June) and peaked (November) later than the 2021–22 season, but earlier than prepandemic seasons. CDC notes that the timing of the 2022–23 season suggests that seasonal patterns are returning toward those observed in prepandemic years, however, warn that clinicians should be aware that off-season RSV circulation might continue.

Treatment of RSV

Some key points of the 2014 pediatric guidelines from the American Academy of Pediatrics.

-AAP strongly do not recommend beta agonists or steroids for viral associated bronchiolitis because of no significant improved outcomes. “Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).”

-Epinephrine is not recommended for infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

-Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department (Evidence Quality: B; Recommendation Strength: Moderate Recommendation), but hypertonic saline may be administered when they are hospitalized (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings]).

-Chest physiotherapy should not be used in infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

-Antibiotics should not be administered in bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

-Oxygen therapy may not be administered if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low level evidence and reasoning from first principles]).

-Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally (Evidence Quality: X; Recommendation Strength: Strong Recommendation).

How do we prevent RSV?

Infant Immuno-prophylaxis:

A clinical trial in 2022 demonstrated that a single injection of nirsevimab (Beyfortus®), administered before the RSV season, protected healthy late-preterm and term infants from RSV-associated lower respiratory tract that required medical treatment. Nirsevimab is a monoclonal antibody to the RSV fusion protein that has an extended half-life.

Additionally, on August 3, 2023, the Advisory Committee on Immunization Practices (ACIP) recommended nirsevimab for all infants younger than 8 months who are born during or entering their first RSV season and for infants and children between 8-19 months who are at increased risk for severe RSV disease and are entering their second RSV season. On the basis of pre-COVID-19 pandemic patterns, nirsevimab could be administered in most of the continental United States from October through the end of March.

Maternal Vaccination: 

The CDC recommends the administration of the RSVPreF vaccine to pregnant women between 32 0/7 and 36 6/7 weeks of gestation. This vaccination aims to reduce the risk of RSV-associated lower respiratory tract infection in infants during the first 6 months of life.

At this time, if a pregnant woman has already received a maternal RSV vaccine during any previous pregnancy, CDC does not recommend another dose of RSV vaccine during subsequent pregnancies.

Older individuals: 

-Each year in the U.S., it is estimated that between 60,000 and 160,000 older adults are hospitalized and between 6,000 and 10,000 die due to RSV infection

-ABRYSVO’s approval will help offer older adults protection in the RSV season.

-On June 26, 2024, ACIP voted to give these recommendations: all adults older than 75 years and adults between 60–74 years who are at increased risk for severe RSV disease should receive a single dose of RSV vaccine (Abrysvo®).

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! 

_____________________

References:

1. Hamid S, Winn A, Parikh R, et al. Seasonality of Respiratory Syncytial Virus — United States, 2017–2023. MMWR Morb Mortal Wkly Rep 2023;72:355–361. DOI: http://dx.doi.org/10.15585/mmwr.mm7214a1
2. Hammitt LL, Dagan R, Yuan Y, Baca Cots M, Bosheva M, Madhi SA, Muller WJ, Zar HJ, Brooks D, Grenham A, Wählby Hamrén U, Mankad VS, Ren P, Takas T, Abram ME, Leach A, Griffin MP, Villafana T; MELODY Study Group. Nirsevimab for Prevention of RSV in Healthy Late-Preterm and Term Infants. N Engl J Med. 2022 Mar 3;386(9):837-846. doi: 10.1056/NEJMoa2110275. PMID: 35235726.
3. Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502. doi: 10.1542/peds.2014-2742. Erratum in: Pediatrics. 2015 Oct;136(4):782. doi: 10.1542/peds.2015-2862. PMID: 25349312.
4. CDC, per their published article Seasonality of Respiratory Syncytial Virus — United States for 2017–2023, in the United States
5. What U.S. Obstetricians Need to Know About Respiratory Syncytial Virus.Debessai H, Jones JM, Meaney-Delman D, Rasmussen SA. Obstetrics and Gynecology. 2024;143(3):e54-e62. doi:10.1097/AOG.0000000000005492.
6. Maternal Respiratory Syncytial Virus Vaccination and Receipt of Respiratory Syncytial Virus Antibody (Nirsevimab) by Infants Aged <8 Months - United States, April 2024.Razzaghi H, Garacci E, Kahn KE, et al. MMWR. Morbidity and Mortality Weekly Report. 2024;73(38):837-843. doi:10.15585/mmwr.mm7338a2. 
7. Use of Nirsevimab for the Prevention of Respiratory Syncytial Virus Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices - United States, 2023.Jones JM, Fleming-Dutra KE, Prill MM, et al. MMWR. Morbidity and Mortality Weekly Report. 2023;72(34):920-925. doi:10.15585/mmwr.mm7234a4.
8. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 187: Autism Fundamentals

Future Dr. Ayyagari explains the recommended screenings for autism, how to diagnose it and sheds some light on the management. Dr. Arreaza mentions the Savant Syndrome and the need to recognize ASD as a spectrum and not a “black or white” condition.

Written by Tejasvi Ayyagari, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Introduction:

Autism, or Autism Spectrum Disorder (ASD), is a neurodevelopmental disorder that affects how a person thinks, interacts with others, and experiences the world. It is characterized by deficits in social communication and interaction and restricted and/or repetitive behavior patterns, interests, and activities. Autism is considered a "spectrum" disorder because it encompasses a wide range of symptoms, skills, and levels of functioning, including Asperger’s, Auditory processing disorder, Rett syndrome, etc. The exact causes of autism are not fully understood, but many question genetic and environmental factors at play.  

What are some of the main characteristics of autism?

1. Social difficulties: Individuals with autism may experience trouble understanding social cues or body language, leading to difficulty forming meaningful relationships. Children may display little interest in playing with others or engage in limited imaginative play (doll playing, pretend playing).

2. Repetitive behaviors and interests: People with autism may engage in repetitive movements with their arms or hands and focus intensely on specific topics or activities. They may become distressed when routines are disrupted.

3. Overstimulation: Individuals with autism may find multiple stimuli too overwhelming and gravitate towards either minimal stimulation or certain appealing stimulations best suited for their needs. 

4. Intellectual variation: People with autism can have varying intellectual abilities, from severe mental disabilities to those who excel in specific disciplines, such as accounting or history (savants). 

Savant syndrome. It is a syndrome popularized by movies, TV shows and social media. The Good Doctor is a good example of it. Savant syndrome manifests by having a superior specific set of skills in a developmentally disabled person. Savants are like human supercomputers—while the rest of us are buffering, they can recall in 4K. We must not assume all people with autism are savants, unless we are particularly told about their exceptional talent.

Another famous person with Savant syndrome was Kim Peek, portrayed by Dustin Hoffman in the 1988 movie The Rain Man. Kim Peek was later diagnosed with the FG syndrome and not autism spectrum disorder.

What is the prevalence of autism?

Worldwide, it is estimated that about 1 in 100 to 1 in 150 children are diagnosed with autism, though this number can vary based on the country and diagnostic practices. In the United States, according to the CDC, as of 2023, approximately 1 in 36 children are diagnosed with autism.  Some studies even claim that boys are 4x more likely to be diagnosed with autism than girls.

It is a very prevalent condition, and we have some recommendations about screenings. I feel like most parents have a “feeling” that something may be wrong with their kid, but I think most parents may feel that way, especially when they have their first baby.

The American Academy of Pediatrics recommends that all children should be screened for autism at 18 months and 24 months of age during routine well-child visits, using standardized tools like the Modified Checklist for Autism in Toddlers (M-CHAT) or other validated autism screening tools.   

MCHAT is a two-step screening that requires a second visit if the first test shows moderate risk. Also, we must continue to follow up the development of kids in well child visits and be on the lookout for signs of autism, even outside of the recommended screening ages. 

How is autism diagnosed?

Autism is typically diagnosed between the ages of 2 and 3, but it is often identified in early childhood. According to the DSM-5, there are two main clusters of symptoms for autism.

- Cluster A: Involves social communication and interaction impairments in various settings.

- Cluster B: Involves repetitive behavioral patterns, limited areas of interest, and atypical sensory behaviors/experiences.

According to the DSM-5-TR criteria, a diagnosis of ASD requires that the following criteria are met:

All three of the following Cluster A symptoms:

- Social-emotional reciprocity: Difficulty engaging in mutually enjoyable conversations or interactions due to a lack of shared interests or understanding of others' thoughts and feelings.

- Nonverbal communicative behaviors to socialize, such as using aspects with eye contact, facial expressions, gestures, and tone of voice, which makes communication more difficult.

- Difficulty developing, understanding, and maintaining relationships: This could manifest as difficulty adjusting behavior to social settings, an inability to show expected social behaviors, a lack of interest in socializing, or difficulty making friends despite wanting to.

Two or more of the following Cluster B symptoms:

- Stereotyped or repetitive movements, use of objects, or speech: Echolalia or flapping the hands repeatedly.

- Persistent sameness, where patients require adherence to routines or ritualized patterns of behavior, such as difficulty with transitions or a need to eat the same food each day.

- Highly restricted, fixated interests: This may include an intense focus on specific objects (trains) or topics (such as dinosaurs or natural disasters).

- Sensory response variations, including heightened or diminished responses to sensory input, such as adverse reactions to sounds, indifference to temperature, or excessive touching/smelling of objects.

Additionally, the symptoms must:

- Significantly impair social, academic/occupational, and daily functioning,

- Not be better explained by intellectual disability or global developmental delay, and

- Be present in early childhood. (However, symptoms may only become apparent when social demands exceed the child's capacity; in later life, they may be masked by learned strategies.)

How can we go about managing autism?

There is no "cure" for Autism. However, various therapies can help manage the condition. Treatment tailors to the individual's age, strengths, and weaknesses. Our main goal is to maximize function, encourage independence, and improve the patient's overall quality of life.

During office visits as primary care doctors, we have to use different strategies to make the visits more focused on individual needs, making sure the caregivers are involved as well as the patient. 

We communicate with caregivers before and during the visit to optimize patient compliance, allow enough time for the family/caregiver to talk about the patient's history, allow the patient to play with instruments/materials provided, and use simple instructions. Sometimes, the physical exam can be the most challenging aspect of the exam because it is so overstimulating for the patient. Hence, allowing enough time for the patient to be comfortable is key.

This is a multidisciplinary management that includes, family med, pediatricians, social workers, behavioral health, etc.

Personal experiences interacting and managing patients with autism in the clinic or in the hospital:

Dr. Arreaza: I have seen a lot of adult patients with autism.I see a challenge commonly found is agitation and the use of medications. I prefer to defer any prescriptions to psychiatry, if needed, but behavioral concerns can be successfully managed by behavioral health with participation of family, caregivers, and especial education.

TJ:  Personal story with Auditory Processing Disorder (APD).

Conclusions: 

Dr. Arreaza: Autism is a spectrum, not all persons with ASD are the same. They are not all geniuses, and they are not all developmentally delayed, they are not just black or white, but there are several shades of gray in between. 

TJ:  Not one doctor or one family will take care all responsibility, it requires a multifaceted approach.People with autism can live a long and meaningful lives.

Thank you for listening to this week’s episode on Autism. We will see you next time.  Have a nice day.

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! 

_____________________

References:

1. Centers for Disease Control and Prevention. Data and statistics on autism spectrum disorder. CDC.gov. Accessed on March 13, 2025. https://www.cdc.gov/autism/data-research/index.html
2. Weissman Hale, Laura, “Autism spectrum disorder in children and adolescents: Overview of management and prognosis,” UpToDate, accessed on March 13, 2025. https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-management-and-prognosis.
3. Volkers, N. (2016). Early Signs. The ASHA Leader.https://doi.org/10.1044/leader.ftr1.21042016.44
4. Urquhart-White, Alaina, “'The Good Doctor' Puts The Spotlight On A Rare, Mysterious Syndrome,” Bustle, September 25, 2017. https://www.bustle.com/p/whats-real-about-savant-syndrome-is-something-the-good-doctor-should-explore-2439405
5. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 186: Exercise Prescriptions

Dr. Sandhu and future Dr. Daoud explain the way to prescribe exercise, what are the general guidelines for exercise and how to overcome barriers to exercise. Dr. Arreaza emphasized the importance to screen our patients before exercise and using the term “physical activity” to improve receptivity by patients.  

Written by Wessam Daoud, MSIV, Ross University School of Medicine. Edits and comments by Ranbir Sandhu, MD, and Hector Arreaza, MD.  

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Arreaza: I’m Dr. Arreaza, and today, we will talk about a topic that is both simple and powerful: exercise. Previous episodes: 158, 100 (sexercise), 95, We all know exercise is good for us, but how do we prescribe it like we do medications? How can we tailor exercise recommendations to our patients' needs and lifestyles? To help us unpack this, I’m joined today by Dr. Ranbir Sandhu, and Medical Student, Wessam Daoud, who has a passion for preventive medicine. Welcome to the show!

Ranbir: Thanks, Dr. Arreaza! We’re excited to be here and to discuss something so fundamental to health.

Segment 1: Understanding Exercise Prescription

Arreaza: Let’s start with the basics. In medicine, we prescribe medications with precise instructions—dosage, frequency, duration. But how do we apply this concept to exercise?

Ranbir: Great question! Before we prescribe exercise, we have to make sure that it is not contraindicated. We can use a system to stratify our patients based on risk factors, such as older age, smoking, baseline level of activity, etc. For example, a patient who had a heart attack within the last 6 weeks should not exercise yet, a person with heart failure exacerbation, asthma exacerbation, uncontrolled heart arrhythmia, etc. 

Wes: Exercise prescription follows a structured approach, similar to medications. We use the FITTE mnemonics to guide recommendations: 

Frequency – How often?

Intensity – How hard should the patient work?

Time – How long should each session last?

Type – What kind of exercise is best?

Enjoyment – Does the patient enjoy this activity?

By adjusting these components, we can tailor exercise to each patient’s needs, whether it’s improving cardiovascular health, managing chronic disease, or building strength.

Segment 2: How Much Exercise Do Adults Need?

Arreaza: Now, when we talk about exercise, there’s a lot of conflicting advice out there. What do the official guidelines say about how much adults should exercise?

Ranbir: The American College of Sports Medicine (ACSM) and CDC provide clear guidelines:

Aerobic Exercise: At least 150 to 300 minutes of moderate-intensity exercise per week, OR 75 to 150 minutes of vigorous-intensity exercise (or a mix of both).

Muscle Strengthening: At least two days per week of resistance training targeting major muscle groups.

Balance & Flexibility: Particularly important for older adults to reduce fall risk.

These guidelines are adaptable, meaning patients can break them into shorter sessions throughout the week.

Arreaza: For weight regain, you may need to exercise a little bit more, about 300 minutes/week, and >2 days of resistance activity.

Segment 3: Choosing the Right Type of Exercise

Arreaza: With so many options—cardio, strength training, yoga—how do you guide patients in choosing the right type of exercise for them?

Wes: It depends on the patient’s goals, health conditions, and personal preferences. Here’s how we might break it down:

For cardiovascular health: Activities like brisk walking, jogging, cycling, or swimming.

For strength and bone health: Resistance exercises, bodyweight exercises, or weightlifting.

Ranbir: For flexibility and balance: Yoga, Pilates, or tai chi, especially for older adults.

For chronic disease management: Customized plans—e.g., low-impact options for arthritis or supervised exercise for heart disease.

The key is finding something they enjoy, because sustainability is the most important factor.

Arreaza: We can use our physical therapy friends to design an appropriate plan for our patients.

Segment 4: Overcoming Common Barriers to Exercise

Arreaza: I hear this all the time in the clinic—patients want to exercise but struggle to stay consistent. What are the biggest barriers, and how do we help patients overcome those barriers?

Wes: Absolutely. Some common barriers include:

Lack of time: Patients think they need hours at the gym, but even short bouts of 10 minutes throughout the day add up.

Low motivation: Encouraging goal setting and accountability, such as a workout buddy or an activity tracker, helps.

Arreaza: Instagram post from Ranbir: Go to the gym even if you don’t want to go. 

Wes: Pain or chronic illness: We can adapt exercises—low-impact options like swimming or chair exercises work well.

No access to a gym: Many exercises require no equipment—walking, stair climbing, bodyweight exercises.

Ranbir: As physicians, we need to normalize movement as part of daily life rather than an all-or-nothing approach.

Segment 5: The Role of Healthcare Providers in Exercise Counseling

Arreaza: We often focus on medications and procedures, but exercise is one of the best treatments we have. What role should physicians play in promoting physical activity?

Ranbir: Our role is critical! Exercise is preventive medicine and can reduce the risk of heart disease, diabetes, obesity, and even depression. As physicians, we can:

-Ask about exercise levels at routine visits.

-Provide specific, personalized exercise prescriptions rather than just saying 'you should exercise more.'

-Address patient concerns by modifying recommendations to their abilities.

-Follow up and reinforce progress like we would with any other treatment.

-Even a brief conversation about physical activity can significantly impact patient motivation and adherence.

Arreaza: Exercise vs physical activity. Ask your patients as a routine. 

Closing Thoughts & Call to Action

Arreaza: Ranbir andWessam, this has been a fantastic discussion. Any final thoughts for our listeners?

Ranbir: My biggest takeaway is that any movement is better than none. Exercise doesn’t have to be perfect—it just has to be consistent. Start small, find an activity you enjoy, and build from there!

Arreaza: Any take-home message, Wes?

Wes: Same for me, find an activity you enjoy, start where you are, and keep moving!

Arreaza: Great advice! If you found this episode helpful, share it with your colleagues and patients. 

Ranbir: Until next time—stay active and stay healthy!

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! 

_____________________

Sources:

1. Some information in this podcast was inspired by conferences from the Obesity Medicine Association, https://obesitymedicine.org/.
2. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 185: Aging 101.  

Dr. Schlaerth explained the physiology, how to slow down and how to prevent aging. Dr. Ayyagari inquired about how to fight ageism in our clinic and in our society. Dr. Arreaza highlights the importance of treating elderly patients with dignity and empathy. A new book written by Dr. Schlaerth is introduced (“The Ways our Bodies Age.”)  

Written by Katherine Schlaerth, MD (Clinica Sierra Vista). Edits and comments by Hector Arreaza, MD (Clinica Sierra Vista), and Tejasvi Ayyagari, MSIV (Ross University School of Medicine.)

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Interview

Arreaza: Question 1: 

1. What are some early signs that may indicate that your body is aging? (Pain? Memory? Weight loss?)

Schlaerth: Maximum bone mass, muscle strength and mass and general strength and endurance generally peak in the third and early fourth decades of life. However, genetics and environment play a big role in aging for each of us. People can have problems with visual accommodation in their early forties, if not before. Many people feel that a realization of the possibility of aging begins when they must have magnification to read very small print.  Women often complain of menopause as a benchmark for aging. Men don’t really have such a well demarcated event in their lives. 

Arreaza: Sure, men do not have a specific event, but I think an undeniable sign of aging in men is urinary frequency. I normally tell my patients that the nose, the ears, and the prostate are organs that tend to grow with age. So, if a male patient complains that they must use the bathroom more frequently, that may be a sign that their prostate is growing, after ruling out other conditions, if needed, we can reassure the patient that this can be a normal sign with aging. We will not neglect the patient because “it is normal” but we must offer interventions when needed.

Schlaerth: The bottom line may be that aging is multifactorial, involves everything from the demands of one’s employment, through genetics, diet, and exercise right up to how many friends one has. It is also a stealth process, and all our body parts may even age at different rates! One individual may have great kidneys but an erratic thyroid, and another a shrinking liver but a superb array of teeth.

Arreaza: (Humor) Plastic surgery and cosmetics can hide some signs of aging (not all). A wise woman said that you can hide your age, but your hands and neck will surely reveal it.

Schlaerth: Many of us use external clues to measure aging. Teenage daughters accuse us of being behind the times, or new wrinkles and white streaks in our hair bring the reality of time passing to us. 

So, the realization of aging may be rather subjective, or it may be signaled by reduced energy, a falling off of the athletic skills we once had, or weight gain when we eat the same exact quantity and type of food we did at a younger age without gaining weight. So subjective aging mirrors incompletely the aging we are undergoing at a cellular and subcellular level.

TJ: Question 2:

1. How can we slow down aging?

Schlaerth: One unpopular way would be to increase the age at which people are eligible for social security if in good health. WHY would this help? Because work adds a valuable dimension to the daily lives of seniors. It provides socialization, intellectual challenges, exercise and allows people to continue giving the results of their valuable life experience to others. 

Now there are issues here. Positions may have to change to accompany the changes of aging. People may choose different occupations from those held in adulthood. Part time work may compel employers to decrease salaries and to make accommodating changes in the workplace. 

Arreaza: I see your point. As you stay active, your aging slows down. 

Schlaerth: On the opposite side of the equation, social security may be saved from being turned into a funding responsibility of the federal government, raising taxes on younger workers and making them even less likely to be able to afford housing and even children. 

TJ: [In your experience Dr. Schlaerth, are professions, especially healthcare, moving in that direction to provide appropriate accommodations for aging workforce?] 

Schlaerth: There are variability. 

Schlaerth: To continue about slowing down aging, as an alternative, acquire a new skill or hobby that allows you to grow instead of vegetating in front of a TV or other screen, and brings you into contact with others, young and older, who share your interest.

More popular ideas would include expanding opportunities to exercise and socialize within one’s own community, with local initiatives geared to the specifics of the community’s location and interests. 

But in the long run, education and motivation will be the biggest interventions. People need to know more about their bodies over time, because preparing for aging takes knowledge and starts in one’s thirties or forties. This means establishing an exercise habit which will endure for decades and is consistent with one’s responsibilities to one’s family and one’s job. It must work and be doable over time. 

Arreaza: So, we must develop an exercise routine that we enjoy, it’s challenging, and sustainable over decades. Brain exercise also works (new ways to go to work, learning a new language, etc.)

Schlaerth: -Eating habits must be changed, which will involve less eating out and more home cooking. 

TJ: [As much as I enjoy a good In-N-Out burger, nothing beats a home cooked meal. Aside from controlling the ingredients for individualized diets/spice levels, cooking for me is therapeutic and helps relieve stress, especially when I cook Indian food (my specialty).] 

Schlaerth: Choosing the right lifelong partner and staying married is a big help. That may also require a bit of education, starting in childhood! All studies show that being married prolongs life!

Tongue in cheek, I would suggest choosing the right location to settle down. Los Angeles and New York City don’t currently look like stress free places to live. That may change though.

Arreaza: I guess if you have a good social support in those cities, it may work. What else can we recommend our patients?

Schlaerth: People who are happy and optimistic and have lots of friends and family statistically do well. Join your local church, synagogue, temple, mosque, etc. Living according to your code of ethics and beliefs with others who share these is always reinforcing and offers support in times of trouble. 

One recently widowed octogenarian who had had a very strong and fulfilling marriage knew that she had to reinvent purpose in her life. So, she became the neighborhood unofficial social worker. Did a friend’s child need a place to stay until he or she got their own apartment? Come on over, there’s an extra bedroom. Was a trip to the doctor needed by someone who couldn’t drive? Let’s go! 

Another widow opened her home to students at a university, charging rent and becoming a “mother hen” to her student lodgers.

A man who loved aeronautics served as a docent for a local museum and became a fount of information about the intricacies of World War II planes right down to structural details. 

All of these and similar strategies kept people interested and interesting, promoted exercise and took a bit of creativity and yes, energy.

Arreaza: So, to slow down aging, stay physically, spiritually, and mentally active. Question 3:

1. Why are people so afraid of aging? 

(TJ: There are some concepts we can introduce for discussion: 
-Gerascophobia is an abnormal or incessant fear of growing older or ageing. 
-Gerontophobia is the hatred or fear of the elderly. 
-Ageism refers to age discrimination) 

Schlaerth: There are very personal and idiosyncratic reasons for a fear of aging. 

One gentleman saw his wife die a painful death from cancer and this triggered his fear.

Another saw his grandparents age and had to help care for them. Sometimes this kind of experience can engender love and respect for one’s older family members, and sometimes the opposite. 

-One’s teeth leave, food is no longer palatable, balanced precludes getting a kid’s ball off your roof, constipation and aches are a daily struggle, even the TV shows you loved are now old reruns. You no longer feel welcome in this new world. And anyway, you can’t drive at night, and you can’t hear well enough in a crowd to join in a restaurant conversation.

-But probably the biggest reasons include a loss of function and autonomy (the Bible even alludes to this fear!), loss of employment and loneliness when one’s friends and especially one’s lifelong partner are no longer there.

-Cultural change can also be a factor. The community one grew up in no longer exists. Communication is by computer or cell phone and much too complicated to learn. The old lot where baseball was played so long ago is now a derelict and abandoned shopping center! 

-You don’t look beautiful anymore.

-A strong religious faith often mitigates a lot of these fears. 

TJ: Question 4:

1. How can we fight age discrimination (ageism) in our clinics, hospitals, and society?

Schlaerth: The humanity of each person needs to be recognized. It is said that people feel about 20 years younger than their chronologic age. This may not be true for children, teenagers, or young adults though. 

When interacting with older folk, the need for environmental issues like good illumination, comfort, clear and low-pitched speech, the absence of extraneous noise, eye contact should be addressed to facilitate communication. If a younger person accompanies the older person, address at least some comments specifically to the older person. 

Allow time for a slower gait or response to questions. 

If possible, add a small complement that acknowledges the senior’s personality or accomplishment. For example, an older lady with her daughter was left out of a conversation about her health because she was deaf, spoke a language other than English, and couldn’t recall the particulars of a recent visit to a specialist. However, she’d raised 13 children who were all gainfully employed raising their own children and assets to society. When she was praised for this monumental accomplishment in the face of scanty resources, she brightened up like a wilted flower given water. 

-In society, again let older people perform when they have the capacity, be this in the workplace, the home, or in a social situation. Recognize everyone’s humanity, even if it means just smiling at an elderly man in a wheelchair. And if the old lady can cross the street by herself, let her do so, even if you are a boy scout!

Arreaza: In summary, treat your elderly patients with dignity and acknowledge them. Question 5.

1. Give us three fundamentals of aging for primary care.

Schlaerth:

• Help people in their thirties and forties prepare for old age by evaluating genetic and other risk factors, attacking the early stages of chronic diseases, encouraging lifelong good habits and working on eliminating bad ones, and vaccinate early.
• Help people maintain function as long as possible, even if total cure is no longer possible.
• Recognize the humanity and need for recognition in every person no matter how old and frail.

TJ: Let’s talk about your book: What was your motivation to write it? 

Arreaza: What is the basic message of your book? 

TJ: Give advice to new or aspiring writers or medical authors. 

Arreaza: The book can be found in Amazon: The Ways our Bodies Age by Katherine Schlaerth, MD.

Conclusions:

Arreaza: My take-home point for this episode is that aging is a physiologic process that takes place at a different pace in every individual. We can slow down or speed up the process depending on many factors, such as genetics, diet, occupation, and physical activity. We all will undergo the process of aging. So, let’s be prepared and prepare our patients for that process with the advice given by Dr. Schlaerth.

TJ: I want to have smooth conversation with our patients about aging.

_____________________

References:

1. Schlaerth, Katherine R., The Ways Our Bodies Age, Archway Publishing, 2025. Available for purchase at Amazon.com.
2. Theme song, Works All The Time, by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 184: Multiple Myeloma Basics

Sub-Interns and future Drs. Di Tran and Jessica Avila explain the symptoms, work up and treatment of multiple myeloma. 

Written by Di Tran, MSIV, Ross University School of Medicine; Xiyuan Yang, MSIV, American University of the Caribbean. Comments by Jessica Avila, MSIV, American University of the Caribbean. Edits by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Di: Hi everyone, this is Di Tran, 4th year medical student from Ross university.  It’s a pleasure to be back.  To be honest, this project is a part of teamwork of two medical students, myself and another 4th year, her name is XiYuan.  She came from the AUC. Unfortunately, due to personal matters she was unable to make it to the recording today which makes me feel really sad. 

Jessica: My name is Jessica Avila, MSIV, American University of the Caribbean.

Di: The topic we will present today is Multiple Myeloma. Multiple myeloma is typically a rare disease and it’s actually a type of blood cancer that affects plasma cells in the bone marrow.

Jessica: Let’s start with a case: A 66-year-old male comes to his family doctor for an annual health checkup. He is not in any acute distress but he reports that he has been feeling tired and weaker than usual for the last 3 months. He also noticed that he tends to bruise easily. He has a history of arthritis and chronic joint pain, but he thinks his back pain has gotten worse in the last couple of months. Upon checking his lab values, his family doctor found that he has a calcium level of 10.8 and a creatinine level of 1.2, which has increased from his baseline. Given all that information, what do you think his family doctor is suspecting? And what kind of tests she can order for further evaluation?

Di: Those symptoms sound awfully familiar – are we talking about the CRAB? You know, the diagnostic criteria for Multiple Myeloma.

Jessica: Exactly! Those are called “myeloma-defining events.” Do you remember what those are?

Di: CRAB criteria comes in 4 flavors.  It’s HYPERCALCEMIA with >1mg/dL, RENAL INSUFFICIENCY with serum creatinine >2mg/dL, ANEMIA with hemoglobin value <10 g/dL, or more than 2g/dL below normal, and BONE LESION, with one or more osteolytic lesions seen in imaging, be it CT or PET/CT scans.

Jessica: You’re correct about the CRAB criteria! If our patient meets those conditions, myeloma is highly suspected.  Other than the CRAB, there’s something else that has to be met before we can diagnose multiple myeloma.  Patients must undergo a bone marrow biopsy and if there are > 10% plasma cells, PLUS any one or more of the CRAB features, we can make the official diagnosis of multiple myeloma. 

Di:  Before we go deeper, let’s back up a little bit and do a little background.  So, what do we know about the immunoglobulins, also known as antibodies? Back from years of studying from medical school, we know that the plasma cells are the ones that producing the antibodies that help fight infections.  There  are various kinds that come with various functions.  Each antibody is made up of 2 heavy chains and 2 light chains.  For heavy chains, we have A, D, E, G, M and for light chains we have Kappa and Lambda.

Jessica: Usually, the 5 possible types of immunoglobulins for heavy chains would be written as IgG, IgA, IgD, IgE, and IgM.  And the most common type in the bloodstream is nonetheless the IgG. 

Di: What is multiple myeloma? In myeloma, all the abnormal plasma cells make the same type of antibody, the monoclonal antibody.  The cause of myeloma is unknown, but there are lots of studies and evidence that show a number of potential etiologies, including viral, genetic, and exposure to toxic chemicals, especially the Agent Orange, which is a chemical used as herbicide and defoliant. It was used as a chemical warfare by the U.S. military during the Vietnam War from 1961 to 1971.

Jessica: We need to order some specific blood tests to see if there is elevated monoclonal proteins in the blood or urine. So, to begin with we’ll need to take a very thorough history and physical exam. Next, we’ll do labs, such as CBC, basic metabolic panel, calcium, serum beta-2 microglobulin, LDH, total protein, and some not so common tests: serum protein electrophoresis (SPEP), immunofixation of blood or urine (IFE), quantitative immunoglobulins (QIg), serum free light chain assay, and serum heavy/light chain ratio assay.

If any of the results is abnormal, we should consider referring our patient to an oncologist.

Di: Interesting! I read that Multiple Myeloma symptoms vary in different patients.  In fact, about 10-20% of patients with newly diagnosed myeloma do not have any symptoms at all.   Otherwise, classic symptomatic presentations are weakness, fatigue, increased bruising under the skin, reduced urine output, weakened bones that is likely prone to fractures, etc. And if multiple myeloma is highly suspected, a Bone Marrow biopsy should be done with testing for flow cytometry and fluorescent in situ hybridization (FISH). Actually, if any of the “Biomarkers of malignancy (SLIM)” is met we can also diagnose multiple myeloma even without the CRAB criteria. 

Jessica: The diagnosis is made if one or more of the following is found: >= 60% of clonal plasma cells on bone marrow biopsy, > 1 lytic bone lesion on MRI that is at least 5mm in size, or a biopsy confirmed plasmacytoma. 

Di: Imaging comes in at the final step especially if we able to find one or more sites of osteolytic bone destruction > 5mm on an MRI scan.

Jessica: What if the bone marrow biopsy returns > 10% of monoclonal plasma cells, but our patient doesn't have either the CRAB or the Biomarker criteria? 

Di: That’s actually a very good question, since Multiple Myeloma is part of a spectrum of plasma cell disorders. That’s when smoldering myeloma comes into play. It is a precursor of active multiple myeloma. Smoldering myeloma is further categorized as high-risk or low-risk based on specific criteria.

A less severe form is called Monoclonal Gammopathy of Undetermined Significance, or simply MGUS, with < 10% bone marrow involvement. Those are diagnoses we give once we rule out actual multiple myeloma, which are defined by the amount of M-protein in the serum.

Jessica:  When to get started on treatment? Multiple Myeloma is on a spectrum of plasma cells proliferative disorders, starting from MGUS to Smoldering Myeloma, to Multiple Myeloma and to  Plasma Cell Leukemia.  Close supervision/active watching is enough for MGUS and low risk Smoldering Myeloma. But once it has progressed to high-risk smoldering myeloma or to active Multiple Myeloma, chemotherapy is usually required. Some situations may require emergent treatment to improve renal function, reduce hypercalcemia, and to prevent potential infections.

Di: As of 2024, treatment of Multiple Myeloma comprises the Standard-of-Care approved by the FDA. In fact, the quadruple therapy is a combination of 4 different class of drugs that include a monoclonal antibody, a proteasome inhibitor, an immunomodulatory drug, and a steroid. 

Jessica: They are Darzalex (daratumumab), Velcade (bortezomib), Revlimid (lenalidomide) and dexamethasone.  Other treatment plans for Multiple Myeloma include chemotherapy, immunotherapy, radiation therapy (for plasmacytomas) and stem cell transplants. The patient will also be on prophylaxis acyclovir and Bactrim while on chemotherapy. Sometimes anticoagulants are also considered because the chemo increases the risk of venous thromboembolic events.

Di: Although the disease is incurable, but with the advancing of novel therapies and clinical trials patients with multiple myeloma are able to live longer.  Problem is the majority of patients diagnosed with Multiple Myeloma are older adults (>65), the risk of falling is adding to multiple complications of the disease itself, such as bone density loss, pain, neurological compromises, distress and weakness.  Palliative care may come in help at any point in time throughout the course of treatment but is most often needed at the very end of the course. Jessica, can you give us a conclusion for this episode?

Jessica: Multiple Myeloma may not be the most common cancer, but we have to be aware of the symptoms and keep it in our differential diagnosis for patients with bone pain, easy bruising, persistent severe headaches, unexplained renal dysfunction, and remember the CRAB: HyperCalcemia, Renal impairment, Anemia and Bone lesions.

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! 

_____________________

References:

1. International Myeloma Foundation. (n.d.). International Myeloma Working Group (IMWG) criteria for the diagnosis of multiple myeloma. https://www.myeloma.org/international-myeloma-working-group-imwg-criteria-diagnosis-multiple-myeloma 
2. Laubach, J. P. (2024, August 28). Patient education: Multiple myeloma symptoms, diagnosis, and staging (Beyond the Basics). UpToDate. https://www.uptodate.com/contents/multiple-myeloma-symptoms-diagnosis-and-staging-beyond-the-basics.
3. University of California San Francisco. (n.d.). About multiple myeloma. UCSF Helen Diller Family Comprehensive Cancer Center. https://cancer.ucsf.edu/research/multiple-myeloma/about 
4. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 183: Colorectal Cancer in Young Adults

Future Dr. Avila and Dr. Arreaza present evidence-based information about the screening and diagnosis of colorectal cancer and explain the increasing incidence among young adult and the importance to screen early in high risk groups.  

Written by Jessica Avila, MS4, American University of the Caribbean School of Medicine. Edits and comments by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Introduction

Jessica: Although traditionally considered a disease only affecting older adults, colorectal cancer (CRC) has increasingly impacted younger adults (defined as those under 50) at an alarming rate. According to the American Cancer Society, CRC is now the leading cause of cancer-related death in men under 50 and the second leading cause in women under 50 (American Cancer Society, 2024). 

Arreaza: Why were you motivated to talk about CRC in younger patients?

Jessica: Because despite advancements in early detection and treatment, younger patients are often diagnosed at later stages, resulting in poorer outcomes. We will discuss possible causes, risk factors, common symptoms, and why early screening and prevention are important. 

Arreaza: This will be a good reminder for everyone to screen for colorectal cancer because 1 out of every 5 cases of colorectal cancer occur in adults between the ages of 20 and 54. 

The Case of Chadwick Boseman

Jessica: Many people know Chadwick Boseman from his role as T'Challa in Black Panther. His story highlights the worrying trend of increasing CRC in young adults. He was diagnosed with stage III colorectal cancer at age 39. This diagnosis was not widely known until he passed away at 43. His case shows how silent and aggressive young-onset CRC can be. Like many young adults with CRC, his symptoms may have been missed or thought to be less serious issues. His death drew widespread attention to the rising burden of CRC among young adults and emphasized the critical need for increased awareness and early screening efforts.

Arreaza: Black Panther became a hero not only in the movie, but also in real life, because he raised awareness of the problem in young AND in Black adults. 

Epidemiology

Jessica: While rates of CRC in older populations have decreased since the 1990s, adults under 50 have seen an increase in CRC rates of nearly 50%. (Siegel et al., 2023). Currently, one in five new CRC diagnoses occurs in individuals younger than 55 (American Cancer Society, 2024).

Arreaza: What did you learn about the incidence by ethnic groups? Are there any trends? 

Jessica: Yes, certain ethnic groups are shown to have higher rates of CRC. Black Americans, Native Americans, and Alaskan Natives have the highest incidence and mortality rates from CRC (American Cancer Society, 2024). Black Americans have a 20% higher incidence and a 40% higher mortality rate from CRC compared to White Americans, primarily due to disparities in access to screening, healthcare resources, and early diagnosis. Hispanic and Asian American populations are also experiencing increasing CRC rates, though to a lesser extent.

Arreaza: It is important to highlight that Black Americans have the highest rate of both diagnoses and deaths of all groups in the United States. Who gets colorectal cancer?

Risk Factors

Jessica: Anyone can get colorectal cancer, but some are at higher risk. In most cases, environmental and lifestyle factors are to blame, but early-onset CRC are linked to hereditary conditions. 

Arreaza: There is so much to learn about colorectal cancer risk factors. Tell us more.

Jessica: The following are key risk factors:

Modifiable risk factors:

• Diet and processed foods: A diet high in processed meats, red meat, refined sugars, and low fiber is strongly associated with an increased risk of CRC. Fiber is essential for gut health, and its deficiency has been linked to increased colorectal cancer risk (Dekker et al., 2023).
• Obesity and sedentary lifestyle: Obesity and physical inactivity contribute to CRC risk by promoting chronic inflammation, insulin resistance, and metabolic disturbances that promote tumor growth (Stoffel & Murphy, 2023).
• Gut microbiome imbalance: Disruptions in gut microbiota, especially an overgrowth of Fusobacterium nucleatum, have been noted in CRC pathogenesis, potentially causing tumor development and progression (Brennan & Garrett, 2023).

Arreaza: As a recap, processed foods, obesity, sedentarism, and gut microbiome. We also have to mention smoking and high alcohol consumption as major risks factors, but the strongest risk factor is a family history of the disease.

Non-modifiable risk factors:

• Genetic predisposition: Although only 20% of early-onset CRC cases are linked to hereditary syndromes such as Lynch syndrome and familial adenomatous polyposis (FAP), individuals with a first-degree relative with CRC are at a significantly higher risk and should undergo earlier and more frequent screening (Stoffel & Murphy, 2023).

Arreaza: Also, there is a difference in incidence per gender assigned at birth, which is also not modifiable. The rate in the US was 33% higher in men (41.5 per 100,000) than in women (31.2 per 100,000) during 2015-2019. So, if you are a man, your risk for CRC is slightly higher. Protective factors, according to the ACS, are physical activity (no specification about how much and how often) and dairy consumption (400g/day). Jessica, let’s talk about how colon cancer presents in our younger patients.

Clinical Presentation and Challenges in Diagnosis

Jessica: Young-onset CRC is often diagnosed at advanced stages due to delayed recognition of symptoms. Common symptoms include:

• Rectal bleeding (often mistaken for hemorrhoids)
• Young individuals may ignore it, believe they do not have time to address it, or lack insurance to cover a comprehensive evaluation.
• Unexplained weight loss
• Fatigue or weakness
• Changes in bowel habits (persistent diarrhea or constipation)
• This may also be rationalized by dietary habits.
• Abdominal pain or bloating
• Iron deficiency anemia.

Arreaza: All those symptoms can also be explained by benign conditions, and colorectal cancer can often be present without clear symptoms in its early stages. 

Jessica: Yes, in young adults, symptoms may be dismissed by healthcare providers as benign conditions such as irritable bowel syndrome (IBS), hemorrhoids, or dietary intolerance, leading to significant diagnostic delays. 

Arreaza: We must keep a low threshold for ordering a colonoscopy, especially in patients with the risks we mentioned previously. 

Jessica: We may also be concerned about the risk/benefit of colonoscopy or diagnostic methods in younger adults, given the traditional low likelihood of CRC. Approximately 58% of young CRC patients are diagnosed at stage III or IV, compared to 43% of older adults (American Gastroenterological Association, 2024). Early recognition and prompt evaluation of persistent symptoms are crucial for improving outcomes. Empowering and informing young adults about concerning symptoms is the first step in better recognition and better outcomes for these individuals.

Arreaza: This is when the word “follow up” becomes relevant. I recommend you leave the door open for patients to return if their common symptoms worsen or persist. Let’s talk about screening. 

Screening and Prevention

Jessica: Due to the trend of CRC being identified in younger populations, the U.S. Preventive Services Task Force (USPSTF) lowered the recommended screening age for CRC from 50 to 45 in 2021 (USPSTF, 2021). Off the record, some Gastroenterologists also foresee the USPSTF lowering the age to 40. 

Arreaza: That is correct, it seems like everyone agrees now that the age to start screening for average-risk adults is 45. It took a while until everyone came to an agreement, but since 2017, the US Multi-Society Task Force had recommended screening at age 45, the American Cancer Society recommended the same age (45) in 2018, and the USPSTF recommended the same age in 2021. This podcast is a reminder that the age of onset has been decreased from 50 to 45, for average-risk patients, according to major medical associations.

Jessica: For individuals with additional risk factors, including a family history of CRC or chronic gastrointestinal symptoms, screening starts at age 40 or 10 years before the diagnosis of colon cancer in a first-degree relative. Dr. Arreaza, who has the lowest and the highest rate of screening for CRC in the US? 

Arreaza: The best rate is in Massachusetts (70%) and the lowest is California (53%). Let’s review how to screen:

Jessica: Recommended Screening Methods:

• Colonoscopy: Considered the gold standard for CRC detection and prevention, colonoscopy allows for identifying and removing precancerous polyps.
• Fecal Immunochemical Test (FIT): A non-invasive stool test that detects hidden blood, recommended annually.
• Stool DNA Testing (e.g., Cologuard): This test detects genetic mutations associated with CRC and is recommended every three years.

Arreaza: Computed tomographic colonography (CTC) is another option, it is less common because it is not covered by all insurance plans, it examines the whole colon, it is quick, with no complications. 

Conclusion:

Colorectal cancer is rapidly emerging as a serious health threat for young adults. The increase in cases over the past three decades highlights the urgent need for increased awareness, early symptom detection, and proactive screening. While healthcare providers must weigh the risk/benefit of testing for CRC in younger adults, patients must also be equipped with knowledge of concerning signs so that they may also advocate for themselves. Early detection remains the most effective tool in preventing and treating CRC, emphasizing the importance of screening and risk factor modification.

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! 

_____________________

References:

1. American Cancer Society. (2024). Colorectal Cancer Statistics, 2024. Retrieved fromhttps://www.cancer.org
2. American Gastroenterological Association. (2024). Delays in Diagnosis of Young-Onset Colorectal Cancer: A Systemic Issue. Gastroenterology Today.
3. Brennan, C. A., & Garrett, W. S. (2023). Gut Microbiota and Colorectal Cancer: Advances and Future Directions. Gastroenterology.
4. Dekker, E., et al. (2023). Colorectal Cancer in Adolescents and Young Adults: A Growing Concern. The Lancet Gastroenterology & Hepatology.
5. Siegel, R. L., et al. (2023). Colorectal Cancer Statistics, 2023. CA: A Cancer Journal for Clinicians.
6. Stoffel, E. M., & Murphy, C. C. (2023). Genetic and Environmental Risk Factors in Young-Onset Colorectal Cancer. JAMA Oncology.
7. U.S. Preventive Services Task Force. (2021). Colorectal Cancer Screening Guidelines.
8. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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

Episode 182: HPV Vax

Future Dr. Zuaiter and Dr. Arreaza briefly discuss HPV infection but pocus on the prevention of the infection with the vaccine. Dr. Arreaza mentions that HPV vaccine is also recommended by ASCCP to medical professionals. 

Written by Amanda Zuaiter, MS4, Ross University School of Medicine. Edits and comments by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Human Papilloma Virus (HPV).

According to the World Health Organization, cervical cancer is the 4th most common cancer affecting women globally. Annually, there are over 600,00 new cases and more than 300,000 deaths. The leading cause of cervical cancer is HPV. HPV, or human papillomavirus, is a prevalent virus that is spread through close skin-to-skin contact, mainly by sexual intercourse. It is the most common sexually transmitted disease in the United States. 

The term STI and STD are used indistinctively, but some people make a difference, such as Dr. Cornelius Reitmeijer. STI refers to sexually transmitted infection, which can be asymptomatic, and STD stands for sexually transmitted disease, which are the signs and symptoms caused by the multiplication of the infectious agent and disruption of bodily functions. STI is the preferred term, as recommended by experts during the last few years.  

Low risk vs High risk HPV.

There are over 200 strains of HPV which fall into two categories: low risk and high risk. The low-risk types, HPV 6 and 11, cause warts around the genitals, anus, mouth or throat. The high-risk types, HPV 16 and 18, are linked to cervical, vaginal, anal, and other cancers. Persistent infection with high-risk HPV types is the primary cause of cervical cancer, accounting for 70% of cervical cancer cases. While often asymptomatic, persistent HPV infections can develop into papular lesions which can cause bleeding and pain or cause sore throat and hoarseness if warts develop in the throat.

Not all warts will turn into cancer, but the risk of a wart turning into cancer is higher than normal skin or mucosa that has not been infected by HPV.

Even though cervical cancer is the most well-known condition linked to HPV, it’s important to note that HPV isn’t just a women’s health issue. It can also cause cancers in men, such as throat, penile and anal cancers. Men, however, are not screened for HPV if they have no signs or symptoms of infection.

HPV Prevention: 

1. General measures that can be taken are maintaining a healthy immune system by exercising regularly and a balanced diet and quitting smoking.
2. Male circumcision has been shown to reduce the risk of penile cancer in men and their sexual partners may have a lower risk of cervical cancer. 
3. Screening: Women should undergo regular pap smears with HPV screening. Pap smear screening begins at the age of 21 and is recommended every 3 years. From ages 30-65, co-testing should be done every 5 years, according to the guidelines by the American College of Obstetrics and Gynecology. Also, HPV test self-collection is now available in the US since May 2024, and it is useful especially in rural areas.
4. The most effective ways to prevent the transmission of HPV is to practice safe sex, using condoms, and getting vaccinated. 

HPV vaccine. 

For medical providers: It was announced only to ASCP (American Society for Colposcopy and Cervical Pathology) members in the middle of the pandemic. On February 19, 2020, ASCCP recommended HPV vaccination for clinicians routinely exposed to the virus.

This recommendation encompasses the complete health care team, including but not limited to, physicians, nurse practitioners, nurses, residents, and fellows, as well as office and operating room staff in the fields of obstetrics and gynecology, family practice, gynecologic oncology, and dermatology. 

Let’s remember that in 2018, the FDA a supplemental application for Gardasil 9 to include persons aged 27 to 45 years old. The ASCCP letter states “While there is limited data on occupational HPV exposure, ASCCP, as well as other medical societies, recommend that members actively protect themselves against the risks” among medical providers. 

For patients: The vaccine is given to prevent the types of HPV that are most likely to cause cancer and other health problems. It works by training the immune system to recognize and fight HPV before an infection can take hold. 

Gardasil-9® is the brand name that is offered in the US. The 9 means it targets 9 strains of the virus (6, 11, 16, 18, 31, 33, 45, 52, and 58). It’s important to note that the vaccine is preventative, and it is not considered a treatment. This means it’s most effective when given BEFORE any exposure to HPV, ideally during adolescence. The HPV vaccine is recommended for boys and girls ages 11-12 but can be started as early as the age of 9. 

We need to be prepared to manage vaccine hesitancy because some parents may be concerned when you explain the vaccine to them. A study done in Scotland found that there were NO cases of invasive cervical cancer in adults who received any doses of the HPV vaccine at 12 to 13 years of age. To get to that conclusion, they reviewed the cancer data of 447,845 women who were born between 1988 and 1996. The data demonstrated that the HPV vaccine prevents invasive cervical cancer, especially when given between 12 to 13 years of age. When the vaccine is given later in life, it tends to be less effective. Amanda

How is HPV vaccine given?

The vaccine schedule is as follows: 

-For ages 9-14, two shots are given with the second dose 6-12 months after the first. 

-For those ages 15-26, three shots are given. After the first shot, the second is given after 1-2 months, and the third shot 6 months after the first. This is the same schedule for immunocompromised people regardless of their age. 

-People over the age of 26 can still receive the vaccine, as the FDA has approved the vaccine for individuals up to the age of 45. With that being said, those over the age of 26 may not fully benefit from the vaccine due to the fact they may have already been exposed to HPV. Still, vaccination can provide protection against other strains of the virus.

Other HPV Vaccine considerations:

Is HPV vaccine effective?

-Studies have shown that the HPV vaccine is nearly 100% effective at preventing cervical pre-cancers caused by HPV 16 and 18.

Are boosters needed?

-The vaccine provides protection for at least 10 years and boosters are not required. The vaccine is recommended for boys too, as they are also at risk for HPV causing cancers, and administration of the vaccine helps to reduce the spread of the virus. It is safe to administer the HPV vaccine with all other age-appropriate vaccinations. 

What if my patient misses a dose?

-If a dose is missed, it can be resumed at any time without restarting the series. There are no known severe side effects or reactions to the vaccine. The vaccine can be given even if the person has already been exposed to HPV as it can protect against the other types of HPV.

Conclusion: HPV is a common cause of cervical cancer, and the benefits of the HPV vaccine are profound. Countries with high vaccination rates have already seen significant drops in HPV infections, genital warts, and cervical pre-cancers. Vaccination protects individuals and helps achieve herd immunity, benefiting entire communities.

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! 

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References:

1. Sabour, Jennifer, “The Difference Between STD and STI,” Verywell Health, August 22, 2024, https://www.verywellhealth.com/std-vs-sti-5214421. 
2. ASCCP Letter, February 19, 2020, https://www.asccp.org/hpv-vaccination
3. Barry HC. Scottish Screening: No Cases of Invasive Cervical Cancer in Women Who Received At least One Dose of Bivalent HPV Vaccine at 12 or 13 Years of Age. Am Fam Physician. 2024 Aug;110(2):201-202. PMID: 39172683. https://pubmed.ncbi.nlm.nih.gov/39172683/
4. World Health Organization. “Cervical Cancer,” March 5, 2024, www.who.int/news-room/fact-sheets/detail/cervical-cancer
5. ACOG, “Cervical Cancer Screening FAQ,” www.acog.org/womens-health/faqs/cervical-cancer-screening. Accessed January 9, 2025.
6. ACOG, “HPV Vaccination FAQ,” www.acog.org/womens-health/faqs/hpv-vaccination. Accessed January 9, 2025.
7. Cox, J. Thomas and Joel M Palefsky, UpToDate, www.uptodate.com/contents/human-papillomavirus-vaccination, accessed January 9, 2025.
8. National Cancer Institute. “HPV and Cancer.” National Cancer Institute, 18 Oct. 2023, www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer .
9. Theme song, Works All the Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

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!