Rio Bravo qWeek

Episode 161: Depression Fundamentals

Future doctors Madeline Tena and Jane Park define depression and explain different methods to diagnose it. Non-pharmacologic and pharmacologic treatment is mentioned briefly at the end.  

Written by Madeline Tena, MSIII, and Jane Park, MSIII. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. 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.

Definition. 

Per the language of Mental Health, depression can be defined as a mood, a symptom, a syndrome of associated disorders, or a specific mental disorder. 

As a state of mood, depression is associated with feelings of sadness, despair, emptiness, discouragement, and hopelessness. The sense of having no feelings or appearing tearful can also be a form of depressed mood. A depressed mood also can be a part of a collection of symptoms that explain a syndrome. 

Depression as a mental disorder can encompass depressive syndromes. Per the American Psychiatric Association DSM-5-TR, depressive disorders commonly include sad, empty, irritable mood, accompanied by changes in one’s functional capacity. They can be classified by severity and recurrence, and associated with hypomania, mania, or psychosis. Depressive disorders include major depressive disorder (including major depressive episodes), persistent depressive disorder, premenstrual dysphoric disorder, substance-induced depressive disorder, depressive disorder due to medical condition, other specified depressive disorder, and unspecified depressive disorder.

Today, we will cover unipolar depressive disorder, also known as major depressive disorder. 

MDD.

Major depressive disorder is a mood disorder primarily characterized by at least one major depressive episode without manic or hypomanic episodes. Depressive episode is a period of at least 2 weeks of depressed mood or anhedonia in nearly all activities for most of the day nearly every day, with four or more associated symptoms in the same 2 weeks. We will discuss specific symptoms for diagnosis further on. 

Epidemiology of depression.

Nationally or regionally representative surveys in 21 countries estimate that the 12-month prevalence of major depressive disorder across all countries is 5 percent. Furthermore, the prevalence of major depressive disorder plus persistent depressive disorder in developed countries (United States and Europe) is approximately 18 percent. 

Multiple studies consistently indicate that in the general population of the United States, the average age of onset for unipolar major depression and for persistent depressive disorder (dysthymia) is approximately 30 years old. 

During 2020, approximately ⅕ US adults have reported receiving a diagnosis by a healthcare provider, with the highest prevalence found among young adults age (18-24 year age… generation Z). Within the US there was considerable geographic variation in the prevalence of depression, with the highest state and county estimates of depression observed along the Appalachian and southern Mississippi Valley regions. 

Why do we care about depression?

Because depression is associated with impaired life quality. It can impair a patient’s social, physical, and psychological functioning. Also, depression is associated with mortality. A study done by UPenn Family Practice and Community Medicine in 2005 showed that among older, primary-care patients over a 2-year follow-up interval, depression contributed as much to mortality as did myocardial infarction or diabetes. 

A prospective study from 2005-2017 that followed 186 patients for up to 38 years further showed that patients with major depressive disorder had 27 times higher incidence rate of suicide than the general population. (1, 2). Also, patients dying by suicide visit primary care physicians more than twice as often as mental health clinicians. It is estimated that 45% of patients who died by suicide saw their primary care physician in the month before their death. Only 20% saw a mental health professional a month before their death. (3)

Suicidality in depression.

It seems that primary care physicians often do not ask about suicidal symptoms in depressive patients. A 2007 study by Mitchell Feldman at the University of California San Francisco showed that 152 family physicians and internists who participated in a standardized patient with antidepressants, suicide was explored in only 36% of the encounters. (4)

Physicians, including primary care physicians, should ask patients with depression about suicidality with questions such as: Do you wish you were dead? In the past few weeks, have you been thinking about killing yourself? Do you have a plan to kill yourself? Have you ever tried to kill yourself? (5) 

Screening for depression.

The USPSTF recommends screening for depression in all adults: 18 years old and over regardless of risk factors. Some factors increase the risk of positive screening, such as temperament (negative affectivity/neuroticism), general medical illness, and family history. First-degree family members of people with MDD have a 2-4 times higher risk of MDD than the general population. Furthermore, social history can increase risk as well: sexual abuse, racism, and other forms of discrimination.

It is important to highlight the risk in women because they may also be at risk related to specific reproductive life stages (premenstrual period, postpartum, perimenopause). The USPSTF includes pregnant individuals and patients in the postpartum period to be screened for depression. 

Screening tools. 

The US Preventive Services Task Force recommends depression screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years (grade B). Similarly, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) has also recommended annual screening for depression in children aged 12 and older. (6) Some tools used for screening in this age group are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI). 

For the general adult population, it is recommended that all patients not currently receiving treatment for depression be screened using the Patient Health Questionnaire-2 (PHQ-2) (7)

PHQ 2 is a survey scored 0-6. The survey asks two questions: Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.

Answers should be given in a numerical rating. 0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day. A score ≥ 3 is considered positive, and a follow-up full clinical assessment is recommended. 

The PHQ-2 has a sensitivity of 91% and a specificity of 67% when compared to a semi-structured interview. Keep in mind that the PHQ-2 may be slightly less sensitive to older individuals. Individuals who screen positive with PHQ-2 should have additional screening with the PHQ-9, which is a nine-item, self or clinician-administered, brief questionnaire that is specific to depression. (8) Its content maps directly to the DSM-5 criteria for major depression. (9)

The PHQ-9 is a set of 9 questions. The answers are scored similarly to PHQ-2, with a numerical scoring between 0 and 3. (0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day). Dr. Arreaza, you will be my patient today, are you ready? 

It’s important that you think about the last 2 weeks.

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things. [Dr. Arreaza answers, “sometimes”. Jane asks, “is it several days or nearly every day?”. Dr. Arreaza answers, “nearly every day” 3]
2. Feeling down, depressed or hopeless [Dr. Arreaza: every day 3]
3. Trouble falling or staying asleep, or sleeping too much [Dr. Arreaza: not at all 0]
4. Feeling tired or having little energy [Dr. Arreaza: not at all 0]
5. Poor appetite or overeating [Dr. Arreaza: every day 3]
6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down [Dr. Arreaza: several days 1]
7. Trouble concentrating on things, such as reading the newspaper or watching television [Dr. Arreaza: Several days 2]
8. Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. [Dr. Arreaza: Not at all 0]
9. Thoughts that you would be better off dead, or of hurting yourself [Not at all 0]

Jane: Your score is 12.

Maddy: Regarding severity, a total score of 1-4 suggests minimal depression. 5-9 suggests mild, 10-14 moderate, 15-19 moderately severe, and 20-27 severe depression. PHQ-9 with patients’ scores over 10 had a specificity of 88% and sensitivity of 88% for MDD. (10)

But if there are at least 4 non-zero items, including question #1 or #2, consider a depressive disorder and add up the scores. If there are at least 5 non-zero items including questions #1 or #2, consider major depressive disorder specifically. The questionnaire is the starting point for a conversation about depression.

A couple of things to note: 1. Physicians should make sure to verify patient responses given the questionnaire can be self-administered. Diagnosis also requires impairment in the patient’s job, social, or other important areas of functioning. 2. Diagnosis requires a ruling-out of normal bereavement, histories of manic episodes, depressive episodes better explained by schizoaffective disorder, any superimposed schizophrenia, a physical disorder, medication, or other biological cause of depressive symptoms.

Once a patient is newly diagnosed and/or started on treatment, a regular interval administration (e.g. 2 weeks or at every appointment) of PHQ-9 is recommended. The PHQ-9 has good reliability, validity, and high adaptability for MDD patients in psychiatric hospitals for screening and evaluation of depression severity. (12) Other than PHQ-9, there is also Geriatric Depression Scale-15 for older patients with mini mental status exam (MMSE) that scored over 10. (13)

For postpartum depression, the preferred screening tool is the Edinburgh postnatal depression scale[Click here (stanford.edu)].

Non-pharmacologic and pharmacologic treatment.

Now that we have diagnosed the patient, we have to start management. Patients can consider non-pharmacologic treatment such as lifestyle modifications. This can include sleep hygiene, reduction in drug use, increased social support, regular aerobic exercise, finding time for relaxation, and improved nutrition. 

Furthermore, based on severity, patients can start psychotherapy alone or psychotherapy + pharmacotherapy. Admission is required for pts with complex/severe depression or suicidality. There should be an assessment of efficacy at 6 weeks.

There is a warning about patients aged 18-24 who are at increased risk of suicide when taking SSRI within the first couple weeks of treatment. 

Mediations: SSRI, SNRI, tricyclic antidepressants, MAOIs, and Atypical antidepressants: including trazodone, mirtazapine (Remeron), bupropion (Wellbutrin SR). More research is being done on psychedelic drugs such as ketamine and psilocybin as possible treatments. There are therapies such as ECT available too.

Potential Harm of Tx: 

Potential harms of pharmacotherapy: 

-SNRI:  initial increases in anxiety, insomnia, and restlessness, and possible sexual dysfunction and headaches as well. Compared with the SSRI class, the SNRI class tends to induce more nausea, insomnia, dry mouth, and in rare cases hypertension.

-Tricyclic: Cause of numerous side effects, very infrequently prescribed unless the patient is not responding to other forms of treatment. Side effects that are included are: dry mouth. slight blurring of vision, constipation, problems passing urine, drowsiness, dizziness,  weight gain, excessive sweating (especially at night). Avoid TCAs in elderly patients.

-MAOIS: MAO-IS can cause side effects too, including dizziness or lightheadedness, dry mouth, nausea, diarrhea or constipation, drowsiness, and insomnia. Furthermore, other less common side effects can include involuntary muscle jerks, hypotension, reduced sexual desire/ ability to orgasm, weight gain, difficulty starting urine flow, muscle cramps, and paresthesia.

Remember to screen your patients. In case you establish a diagnosis, discuss treatments, including non-pharmacologic and pharmacologic options. Warn your patients about side effects and the timing to see the benefits of the medication, usually after 6 weeks. 

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Conclusion: Now we conclude episode number 161, “Depression Fundamentals.” Future doctors Park and Tena discussed depression and its risk factors, screening, and treatment. They went through the PHQ2 and PHQ9 as screening tools, as well as commonly used treatments and their side effects, such as SSRIs. Dr. Arreaza also highlighted the importance of asking about suicidality in your depressed patients, there is a lot of room for improvement in that aspect. 

This week we thank Hector Arreaza, Madeline Tena, and Jane Park. Audio editing by Adrianne Silva.

Talk_Outro

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. Angst F, Stassen HH, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34-38 years. J Affect Disord. 2002;68(2-3):167-181. doi:10.1016/s0165-0327(01)00377-9. https://pubmed.ncbi.nlm.nih.gov/12063145/
2. Miron O, Yu KH, Wilf-Miron R, Kohane IS. Suicide Rates Among Adolescents and Young Adults in the United States, 2000-2017. JAMA. 2019;321(23):2362-2364. doi:10.1001/jama.2019.5054. https://pubmed.ncbi.nlm.nih.gov/31211337/ 
3. Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Let's not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007;5(5):412-418. doi:10.1370/afm.719. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000302/.
4. Brief Suicide Safety Assessment,National Institute of Mental Health (NIMH), July 11, 2020. 
5. https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/adult-outpatient/bssa_outpatient_adult_asq_nimh_toolkit.pdf
6. Beck A, LeBlanc JC, Morissette K, et al. Screening for depression in children and adolescents: a protocol for a systematic review update. Syst Rev. 2021;10(1):24. Published 2021 Jan 12. doi:10.1186/s13643-020-01568-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802305/
7. Williams, John; Nieuwsma, Jason. Screening for depression in adults, UpToDate, updated on November 30, 2023. https://www.uptodate.com/contents/screening-for-depression-in-adults.
8. Instrument: Patient Health Questionnaire-9 (PHQ-9), National Institute on Drug Abuse, https://cde.nida.nih.gov/instrument/f226b1a0-897c-de2a-e040-bb89ad4338b9.
9. Lowe B, et al. Monitoring depression-treatment outcomes with the Patient Health Questionnaire-9 (PHQ-9). Med Care, 42, 1194-1201, 2004.
10. Sun, Y., Fu, Z., Bo, Q. et al.The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BMC Psychiatry20, 474 (2020). https://doi.org/10.1186/s12888-020-02885-6. 
11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701937/
12. Conradsson M, Rosendahl E, Littbrand H, Gustafson Y, Olofsson B, Lövheim H. Usefulness of the Geriatric Depression Scale 15-item version among very old people with and without cognitive impairment. Aging Ment Health. 2013;17(5):638-645. doi:10.1080/13607863.2012.758231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701937/.
13. Royalty-free music used for this episode: Old Mexican Sunset by Videvo, downloaded on Nov 06, 2023 from https://www.videvo.net

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 160: Artificial Intelligence in Primary Care.      

Future Dr. Manophinives explains the present and future of AI in diagnosing and treating diseases.    

Written by Rosalynn Manophinives, MS-IV, American University of the Caribbean. 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.

Today, we embark on an intriguing journey at the crossroads of technology and healthcare: The Future of Healthcare in Artificial Intelligence (AI) and Machine Learning (ML). Let’s start by establishing the groundwork for AI and ML. Artificial Intelligence involves machines mirroring cognitive functions like learning and problem-solving, while machine learning empowers machines to learn from data and refine their capabilities over time. In healthcare, these technologies aim to elevate diagnostic precision and treatment effectiveness which are pivotal aspects in primary care medicine.

Accurate diagnosis is the cornerstone of effective patient care in all forms of medicine because an accurate diagnosis guides treatment decisions and influences patient outcomes. This is why the integration of AI and ML holds immense promise in this field.

Section 1: AI in Diagnostic Assistance (4 mins)

Let’s explore how AI utilizes algorithms to analyze extensive datasets, enhancing diagnostic accuracy significantly.

AI serves as a revolutionary force in analyzing a large amount of data, particularly in medical imaging. Imagine AI algorithms as super brains, employing machine learning to decipher intricate details from X-rays, MRIs, and CT scans. Notably, studies have demonstrated their precision matching and even surpassing that of human experts. For instance, research published in the Journal of the American Medical Association revealed AI algorithms outperforming radiologists in detecting conditions like breast cancer.

AI's skills extend beyond images. It digs into genetic information, medical history, and treatment outcomes, acting as a detective to spot patterns, predict responses, and customize interventions. Studies support this, showcasing AI models outperforming dermatologists in diagnosing skin cancer from images. 

Will AI replace doctors?

The beauty of AI is that it does not replace doctors but acts as a super investigator in your healthcare corner, expediting diagnoses, and refining treatments. So, AI isn’t merely accelerating processes; it’s enhancing healthcare outcomes, making diagnoses quicker, and treatments more precise, and minimizing errors. The future appears very promising with AI leading the way to more precise and tailored healthcare.

Section 2: Case Studies in Diagnosis (4 mins):

Help in research: Let’s delve into real-life examples of AI in action, further amplifying diagnostic accuracy. In a research study, Rajkomar and collaborators crafted an AI algorithm predicting patient deterioration within hours, leveraging electronic health record data. This tool allowed for proactive care, identifying potential issues before they escalated. Taking it up a notch, Aliper and collaborators compared AI to human researchers, resulting in AI outsmarting human brains in designing drugs targeting age-related diseases. These experiments underscore AI's potential in diagnostics, from catching issues early to designing groundbreaking drugs.

AI here enhances doctors' capabilities and acts as an additional set of eyes, boosting their superpowers, spotting nuances, and proposing game-changing solutions in medicine.

Section 3: AI in Risk Prediction (4 mins):

Let’s shift our focus to AI's role in predicting risks and prognosis, particularly in conditions like COPD.

AI employs sophisticated algorithms to analyze patient data comprehensively, including demographics, hospital visits, diagnoses, prescribed medications, and lab results. In COPD, AI not only predicts mortality but also anticipates hospital readmissions for respiratory issues or flare-ups. By scrutinizing various markers, AI resembles Sherlock Holmes, unraveling clues within data.

And AI doesn’t stop there, AI integrates risk predictions into medical practices, which fosters personalized care tailored to individual risk factors. A study led by Choi and their team analyzed retrospective patient data and they were able to identify individuals at risk of undiagnosed COPD, emphasizing the significance of catching potential issues early, finding those who might slip through the cracks otherwise, which is huge! 

Section 4: AI in Treatment Planning (4 mins):

Let’s now explore how AI is revolutionizing treatment planning within medicine.

AI, equipped with machine learning algorithms, tailors treatments by analyzing patient-specific data and medical history. In cancer, for example, AI analyzes biopsy images and quantifies biomarkers, facilitating personalized treatments. Beyond cancer, AI extends its reach to cell therapies, predicting their effectiveness through genomic information and drug responses.

And here's the techie part: AI employs various smart algorithms like Convolutional Neural Networks (CNN) and Recurrent Neural Networks (RNN) to provide personalized treatment recommendations. It’s like having personalized treatment recommendations by experts that fit you like a glove, catering to individual needs. 

Section 5: Fuzzy Cognitive Maps and Reduction of Medical Errors (4 mins):

Lastly, let me tell you about the impact of AI-driven treatment planning, specifically in reducing medical errors. Imagine this—medical decisions? They're tough. Sifting through tons of data, inaccessible medical records, physicians' lack of experience, and loads of conflicting info, makes the decision often not crystal clear. This is where a high percentage of medical errors occur, which is where Fuzzy Cognitive Maps (FCMs) come in.  FCMs are like a super-smart tool that mimics human reasoning, tackling the messiness of medical data with grace.

FCMs are all about modeling complex systems, by combining fuzzy logic and neural networks, just like our brain does—connecting the dots between concepts and their cause-and-effect relationships. From patient records to test results, they make sense of it all.

And FCM is not just theory—FCMs are the real deal and they're not the newbies in town; they've been around for a while, evolving from their early days. They've proven their worth in various medical areas too – in radiotherapy planning, diagnosing language impairments, and even in grading tumors!

So, in a nutshell, FCMs are useful tools for medical decision support by taking on the complexities of diagnosing and treatment planning.

Closing:

In conclusion, the integration of Artificial Intelligence and Machine Learning in healthcare is a thrilling frontier, offering invaluable tools to enhance diagnostic accuracy and patient outcomes. As we evolve, responsible use of these advances is paramount, ensuring they optimize rather than replace the indispensable human touch in healthcare.

Thank you for joining me in exploring the future of healthcare in AI and Machine Learning. I trust this discussion has sparked curiosity and appreciation for the transformative potential of technology in healthcare. 

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Conclusion: Now we conclude episode number 160, “Artificial Intelligence in Primary Care.” This is a new and somewhat unknown field of medicine that is rapidly evolving these days. Future Dr. Manophinives explained that AI and ML can be a useful tool in the diagnosis of diseases by, for example, interpreting images accurately. AI also can help develop plans of care by interpreting large amounts of complex data and predicting trends, possible complications, and the effectiveness of multiple treatments. Keep your eyes and mind wide open to learn more about this advancing technology that will continue to support our efforts to bring health and well-being to our communities.

This week we thank Hector Arreaza and Rosalynn Manophinives. Audio editing by Adrianne Silva.

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. Obermeyer Z, Emanuel EJ. Predicting the Future - Big Data, Machine Learning, and Clinical Medicine. N Engl J Med. 2016;375(13):1216-1219. doi:10.1056/NEJMp1606181. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070532/.
2. Rajkomar, Alvin, et al. "Scalable and accurate deep learning with electronic health records." npj Digital Medicine, 08 May 2018. https://www.nature.com/articles/s41746-018-0029-1
3. Choi, Ellen, et al. "Retrospective analysis of real-world data to identify patients at risk for undiagnosed chronic obstructive pulmonary disease." PLoS ONE, 2020.
4. Choi, Ellen, et al. "Machine Learning in Primary Care: Predicting Hospitalizations and Critical Events." AMIA Annual Symposium Proceedings, 2018.
5. Beam AL, Kohane IS. Translating Artificial Intelligence Into Clinical Care. JAMA. 2016;316(22):2368-2369. doi:10.1001/jama.2016.17217. https://pubmed.ncbi.nlm.nih.gov/27898974/
6. Johnson, Kipp W., et al. "Automated Fuzzy Cognitive Maps Generation for Supporting Clinical Decisions in Primary Care." IEEE Transactions on Fuzzy Systems, 2020.
7. Royalty-free music used for this episode: Gushito, “Gista Mista”, downloaded on November 16th, 2023, from https://www.videvo.net/

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 159: Transcranial Magnetic Stimulation Basics

Future Dr. Ameri explains how transcranial magnetic stimulation can be useful in the treatment of certain mental conditions.  

Written by Omeed Ameri, MS-IV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. 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.

Transcranial Magnetic Stimulation (TMS)

TMS is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and Obsessive-compulsive disorder (OCD). TMS uses the principles of electromagnetic inductions as described by Faraday’s Law. When an electric current passes through the TMS coil, it creates a rapidly charging magnetic field, which passes unimpeded through the scalp and skull, inducing a secondary current in neural tissues of the brain, causing depolarization of neuronal membranes in targeted brain regions, mainly in the superficial layers of the cortex 1.5 to 2.5 cm beneath the coil.

How it works.

Depending on the frequency and pattern of magnetic pulses, TMS can either increase or decrease cortical excitability. High-frequency TMS (Generally > 1 Hz) is associated with increased cortical excitability and is often used for depression treatment. In contrast, low-frequency TMS (< 1 Hz) is typically used for anxiety and pain.

This stimulation alters neurotransmitter release such as dopamine, serotonin, and norepinephrine. The repeated stimulation over sessions promotes synaptic plasticity, leading to more lasting changes in brain activity patterns associated with improved clinical outcomes. This is thought to have cascading effects throughout brain networks, and modulate dysfunctional circuits implicated in depression and restoring normal function. 

Effectiveness.

The effectiveness of TMS can vary widely between individuals due to differences in anatomy, age, and specific conditions being treated. As such, ongoing research into how to personalize and optimize TMS parameters is ongoing. 

Research supporting the use of TMS in treatment-resistant depression.

Research into the effectiveness of TMS and other therapy modalities targeting Treatment-Resistant Depression has been an ongoing effort for many years. In 2009, the American Academy of Family Physicians published Dr. Little’s article titled “Treatment-Resistant Depression,” which noted that there was little evidence that TMS could significantly treat patients with treatment-resistant depression. 

Since that time, the American Journal of Psychiatry published a groundbreaking study in 2020, led by Dr. Cole, which explores the effectiveness of a novel treatment for treatment-resistant depression. This trial, known as Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT, which demonstrates promising results in combating depression where traditional methods have failed. 

It was an open-label study that provides a new perspective on depression treatment, emphasizing rapid and targeted intervention. Twenty-two participants received 50 intermittent theta burst stimulation (iTBS), which is a more recent protocol for TMS treatment, over the course of five days. Each session included 1,800 pulses per session, with a 50-minute intersession interval, ten times a day. As a result of this intensive regimen, one participant withdrew from treatment, and 19 of the remaining 21 met remission criteria, with a score of less than 11 on the Montgomery-Asberg Depression Rating Scale. 

There were no serious adverse events reported, the participant who withdrew did so due to anxiety. Side effects included fatigue and some discomfort. 70% of participants continued to meet response criteria one-month post-treatment.

TMS application for patients with OCD. 

Studies have shown promising results for the treatment of OCD with TMS. Typically, OCD is difficult to manage and requires the highest doses of SSRIs. In 2019, The American Journal of Psychiatry published Dr. Carmi’s Article titled: “Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial”, which presents a comprehensive study on the effectiveness of dTMS in treating OCD. This multicenter, randomized, double-blind, placebo-controlled trial involved 99 OCD patients across 11 centers, who were treated with either high-frequency dTMS or sham dTMS, and focused on changes in the Yale-Brown Obsessive Compulsive Scale (YBOCS) scores.

The treatment phase extended to 6 weeks with a total of 29 treatment sessions, following a 3-week screening phase and a 4-week follow-up phase. Patients were aged 22-68, with YBOCS scores greater than or equal to 20. At the start of the study, patients were already on a maintenance treatment with therapeutic dosages of SSRIs, or previously failed an SSRI and were currently being treated with Cognitive Behavioral Therapy. The results revealed that dTMS treatment participants showed a significantly greater reduction in YBOCS score compared to sham treatment (6.0 points vs. 3.3 points). 

The most frequent adverse effect was headaches. There was one incident of severe suicide ideation. On investigation, it was revealed that the suicide ideation preceded the treatment and required hospitalization for the patient. 

TMS therapy has shown promising results in treating both treatment-resistant depression and OCD. More research is required to assess the long-term viability of the treatment modality, and which treatment regimens have the greatest efficacy for various psychiatric disorders. I hope our listeners will keep TMS in mind when confronted with treatment-resistant depression and OCD.

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Conclusion: Now we conclude episode number 159, “Transcranial Magnetic Stimulation,” also known as TMS. We learned from future Dr. Ameri that TMS has proven to be an effective option for treatment-resistant depression and Obsessive-compulsive disorder. When medications and therapy are not enough, you may consider this therapy for your patients. 

This week we thank Hector Arreaza and Omeed Ameri. Audio editing by Adrianne Silva.

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. Cole, E., Stimpson, K. H., Bentzley, B. S., Gulser, M., Cherian, K., Tischler, C., Nejad, R., Pankow, H., Choi, E., Aaron, H., Espil, F. M., Pannu, J., Xiao, X., Duvio, D., Solvason, H. B., Hawkins, J., Guerra, A. T., Jo, B., Raj, K. S., . . .Williams, N. (2020). Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression. American Journal of Psychiatry, 177(8), 716–726. https://doi.org/10.1176/appi.ajp.2019.19070720
2. Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., Ward, H. E., Lapidus, K., Goodman, W. K., Casuto, L., Feifel, D., Barnea‐Ygael, N., Roth, Y., Zangen, A., & Zohar, J. (2019). Efficacy and Safety of Deep transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A prospective multicenter randomized Double-Blind Placebo-Controlled Trial. American Journal of Psychiatry, 176(11), 931–938. https://doi.org/10.1176/appi.ajp.2019.18101180
3. Little, A. (2009, July 15). Treatment-Resistant depression. AAFP. https://www.aafp.org/pubs/afp/issues/2009/0715/p167.html
4. Royalty-free music used for this episode: If You Were the One, downloaded on November 15, 2023, from https://www.videvo.net/ 

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 158: Strength Training Principles

Future Dr. Hasan explains the importance of adding muscle strength exercises to our routine physical activity. Dr. Arreaza asked questions about some terminology and reminded us of the physical activity guidelines for Americans.    

Written by Syed Hasan, MSIV, Ross University School of Medicine. 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.

An Introduction to Strength Training Principles.

Arreaza: Hello, everyone. Welcome to episode 158. [Introduce myself]. We are recording this episode right before Christmas but by the time you listen to this episode it will be 2024, so Happy New Year! It has been a busy time in our residency, we had lots of interviews, parties, and, of course, lots of learning and teaching. I apologize for our absence in the last few weeks, but we are back for good. We have Syed today, hi, Syed, please introduce yourself.

Syed: Hi Dr. Arreaza, and hello everybody. My name is Syed. I am a fourth-year medical student at Ross University School of Medicine. I’m also a lifting enthusiast. One of my many goals in life is to look like I lift. Until I reach that goal, I will take solace in the fact that at least I sound like I lift. 

Arreaza: You are getting there, keep going! Give us an intro for today’s episode. 

Syed: (laughs) Thanks! Well, today, I want to present a framework with which to approach resistance training. The benefits of weight training are well-known, and a quick Google search gives us plenty to learn about them. But a clear framework for resistance training is a bit more difficult to come by. So, in this podcast, I will attempt to provide you, the listeners, with such a framework. By the end of the episode, my goal is to get most of you to start thinking about strength training seriously. 

Arreaza: I’m excited to hear it. I’m ready to learn more. I exercise, but I have to confess that I need to add more lifting to my routines. I enjoy cardio exercise, especially if I’m listening to my favorite music or watching a Netflix show. So, today I will go to bed being a little wiser. I have low gym literacy, but I think many of our listeners will appreciate my silly questions. 

Syed: (laughs) If you’re thinking it, it’s not a silly question, Dr. Arreaza! Before we begin though, some housekeeping. Because there is some technical stuff like names of muscles, their function, and exercises to target them, we will add a quick glossary at the end of the attached transcript. I will also include sources for the information I present. As well, a lot of other sources on hypertrophy training and exercise science. 

Arreaza: So, let’s start with the definition of strength training, Syed. 

Syed: Yeah. So put simply, any exercise where you produce force against a resistance can be thought of as a resistance training exercise. Doing this kind of exercise over a long period of time is what causes strength and muscle gain. By the way, strength and muscle gains are like chicken and eggs. Scientists are not sure which comes first, just that both are correlated. Practically, it means that when we look at two people, the person with bigger muscles is probably going to be stronger.

Arreaza: On the Physical Activity Guidelines for Americans, available online at health.gov, we find that it is recommended that adults engage in “muscle-strengthening activities of moderate or greater intensity… [involving] all major muscle groups on 2 or more days a week,” and that’s ON TOP of the 150-300 minutes of moderate physical activity a week for general health benefits.

Syed: Yeah, and we are talking about it today because a lot of times it’s unclear to people what such exercise entails. Some common examples are bodyweight exercises like push-ups, pull-ups, and squats. 

Syed: In these exercises, our body is the resistance against which our muscles are producing force. So, in push-ups, it is our chest and triceps that are mostly involved. In pull-ups, it is our back and biceps that work the hardest. When it comes to squats, it is our quads and glutes that are used most. Quads are the muscles in the front part of the thighs, and glutes are the buttock muscles. 

Arreaza: Push-ups, pull-ups, and squats are examples of bodyweight exercises. 

Syed: Yeah, so now let’s talk about free weight exercises. Just like in body weight exercises, we are using our body weight as resistance, in free weight exercises we use free weights, like barbells or dumbbells, as resistance. So, instead of a push-up, we could do a bench press with a barbell or dumbbell, for example. 

Arreaza: Barbells and dumbbells. What’s the difference?

Syed: The difference is the size, dumbbells fit in your hand and barbells are larger. Bench press with them is a substitute for push-ups. These would target the chest and triceps just like push-ups. For pull-ups, the substitute would be barbell rows or dumbbell rows, to target the upper back. And the free-weight version of bodyweight squats is simply having a barbell on the upper back/shoulders and do squats. This exercise is called barbell squat. If we don’t have barbells but have dumbbells, we can grab one, hold it with both hands in front of our chest, and do squats. That is called a goblet squat.

Arreaza: And don’t forget the kettlebells that can be used for squats too.

Syed: That’s right. So far in our discussion, some themes have emerged. 

1. There are big muscle groups that work together, like the back and biceps, chest and triceps, and quads and glutes.
2. There are exercise groups that target these muscle groups.
3. These big muscle groups are either part of the trunk or are nearest to the trunk of the body

• Most people know what trunk is, but I’ll describe it as the area between the neck and groin. You can imagine our limbs and neck sprouting from our trunk just as branches sprout from a tree trunk.
• So, chest is part of the trunk, and biceps are near the trunk; back is part of the trunk, and triceps are near the trunk. For our lower body, quads and glutes are near the trunk.

Now, let’s also summarize the muscle groups and exercise groups mentioned so far. 

1. Chest and triceps: Can be targeted with push-ups, bench press (when using barbells), or dumbbell press (when using dumbbells).
   • By the way, in the world of lifting, the same exercise might have different names. I don’t want anyone to be married to the names. Understanding the movement pattern is the important thing.
   • So, again, reiterate #1
2. Back and biceps can be targeted with pull-ups, barbell rows, or dumbbell rows. There is also an exercise called lat pull-down that is like the movement pattern of pull-ups (basically starting with arms above our body and then bringing our elbows towards the ribs). But a lat-pull down uses a cable machine found at most gyms.
   • So again, for back and biceps, we can do pull-ups, barbell or dumbbell rows, or lat pull-downs, depending on what we have access to.
3. Finally, we talked about quads that can be targeted with body weight squats, barbell, or dumbbell squats. To these exercises, we can also add lunges, that can be done with bodyweight, dumbbells, or barbells.

Arreaza: What are lunges?

Syed: Lunges are like walking but you lower your hips and bend your knees with every step. And you do this with dumbbells in hands or a barbell on the back. You can also do it with just body weight. 

Arreaza: You said these muscle and exercise groups cover the big muscles on or nearest to the trunk. You have not mentioned the shoulders and the back of the thighs. 

Syed: To that, I would say, thank you for listening so closely! All of these exercises have been compound movements, meaning they target more than one muscle group. These are the exercises that give you the biggest bang for your buck, that is time.

Syed: The compound exercises for back of the thigh is deadlifts. Muscles in the back of the thigh are called hams (short for hamstrings). The bread-and-butter compound exercise for hams is the deadlift. It can be done with a barbell or dumbbells. On top of targeting your hams, it also makes your erector muscles work hard. Erectors are also called erector spinae. These are a group of muscles in the back that work hard to keep your spine stable and help us stand straight. They also allow us to bend our spine side to side and even backwards a bit. So the deadlift is done with the lifter bending at the hips and knees, keeping the back straight. And reversing that movement to stand back up.

Arreaza: It is important to exercise your erectors. Deadlifts for your hams. And for your shoulders?

Syed: For shoulders, the go-to compound lift is the shoulder press (and again, this can be done with a barbell or dumbbell). It targets your delts, short for deltoids. Shoulder press also targets our triceps, traps, and upper chest. 

Syed: The thing with both deadlifts and shoulder press is that they are taxing on your spine. It’s true for squats too, but squats are a relatively simple movement compared to deadlifts and shoulder press. With deadlifts and shoulder press, you have to pay special attention to keeping a neutral spine, and that does not come intuitively. Often the best way to master these movements without putting your spine in a compromised position is under expert supervision, at least when learning the movement. Don’t get me wrong; it can be learned by paying close attention to exercise videos online as well. But yeah, it takes practice.

Arreaza: So we have covered all big muscles groups that can be trained together using compound movements: back and biceps; chest and triceps; hams, erectors, and glutes; quads and glutes. 

Syed: Yes, glutes and abs are freebies. They get worked in a lot of movements. More directly in some exercises and less in others. So, these muscle groups really don’t need extra attention in most cases, at least not at the beginner level. So, now we know the muscle groups and the compound exercises to target these muscle groups. The final piece is how much and how often to train them. The recommended frequency, in general, for strength training is two days or more per week. 

Syed: How many exercises in a session? Generally, 3-5. 

Syed: How many sets for each exercise? The standard answer is 2-5 sets of 5-15 reps per exercise. Stopping 2-3 reps shy of failure (this is called the reps-in-reserve or RIR model). Make sure to take plenty of rest between sets. 

Arreaza: How much is plenty? 

Syed: 1) your muscles feel sufficiently recovered, 2) your breathing is back to normal or almost normal, and 3) your will to push for another set is back. You can use this 3-point checklist for both rest periods between sets and rest periods between training sessions. Between sets, the rest time may be 2 minutes; it may be 5 minutes. It may go from 5 to 2 minutes as your cardio improves over time. But the most important thing is, listening to our body.  Not overexerting. Otherwise, our subconscious is going to tell us, you just punish me when exercising. So, now it is going to rebel. And before we know it, weeks have passed between training sessions, we have lost the momentum for training, and we missed out on potential gains. 

Arreaza: My patients talk about being afraid of injuries when lifting. Can you talk about that? 

Syed: Anything in life has risks and benefits. I heard a resident at Rio Bravo once say, “being alive has its risks.” The good news is, resistance training of any kind, whether it is Olympic lifting, powerlifting, or bodybuilding, carries a lot less risk of injury compared to any other sport. And the benefits, physical, mental, and reduced all-cause mortality far outweigh the risks. I have never regretted a training session. 

This is something you will hear most people who lift say. And for good reason. The only thing is, start slowly, and increase weights slowly over time. 

Arreaza: Injury prevention is important. You need to make sure you are keeping a correct posture and body positioning during weight-lifting. A personal trainer can be a way to prevent injuries but if you are very motivated, you can find videos to guide you. Do you have any recommendations on sources where our listeners can learn more about this?

Syed: To learn about the principles of muscle hypertrophy, the people I benefited the most from are Dr. Eric Helms, Dr. Mike Israetel,  Dr. Milo Wolf, and Barbell Medicine (Drs. Baraki and Feigenbaum whose articles I referred to when preparing for this podcast). All these people have tons of sources available in the forms of books, articles, YouTube videos, and Instagram posts. In other words, they are everywhere trying to teach us!. I can link some of the playlists for exercises by muscle groups.

Arreaza: Thanks.

Syed: Thank you for listening, I hope this episode gives us a better idea to guide our patients or ourselves in strength training. 

Glossary

A strength training exercise that involves the use of multiple muscle groups and joints to perform the movement.

The pecs work to help us push things away in front of us. 

Compound exercises targeting chest also work the front delts. 

The triceps help us straighten our arms.

Chest and tris can be thought of as pushing muscles.

Delts or deltoids (front, medial, and rear)

The delts raise arms up to around shoulder level, although some evidence suggests they work even when the arm has crossed the 90-100 degree mark.

Back 

helps us bring elbow close to our body (either from in front of us in a horizontal plane or from above us in a vertical plane).

Most back exercises also work other muscles in the back like rear delts, traps, and erectors.

Have many functions including pelvic stability, overall posture, force production in athletic movements, and so much more. Involved heavily in exercises for the quads and hams. 

A group of muscles in the front of the torso. When body fat is low (10-15% in men and 15-25% in women), they lead to the appearance of the “six packs” (the rectus abdominis). They are used in most exercises when we brace before executing the movements. 

Note: In most cases, being leaner than the percentages mentioned above is not good for overall hormonal health. 

_____________________

Conclusion: Now we conclude episode number 158, “Strength Training Principles.” Future Dr. Hasan explained how to strengthen groups of muscles by adding bodyweight and free weight exercises. He answered some questions about basic terminology and Dr. Arreaza added a few words about injury prevention. 

This week we thank Hector Arreaza and Syed Hasan. Audio editing by Adrianne Silva.

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. Baraki A, Feigenbaum J, et al. Practical guidelines for implementing a strength training program for adults. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.). https://www.uptodate.com/contents/practical-guidelines-for-implementing-a-strength-training-program-for-adults
2. Franklin BA, Sallis RE, et al. Feigenbaum J, et al. Exercise prescription and guidance for adults. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.) https://www.uptodate.com/contents/exercise-prescription-and-guidance-for-adults
3. Sullivan J, Feigenbaum J, et al. Strength training for health in adults: Terminology, principles, benefits, and risks. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.) https://www.uptodate.com/contents/strength-training-for-health-in-adults-terminology-principles-benefits-and-risks
4. Royalty-Free Music: Sur-La-Tabla_Beat. Downloaded on May 19th, 2023, from  https://www.videvo.net/

Suggested Reading:

1. Helms, E., Morgan, A., & Valdez, A. (2019). The Muscle & Strength Pyramid: Training. Muscle and Strength Pyramids, LLC.
2. Helms, E., Morgan, A., & Valdez, A. (2019a). The Muscle & Strength Pyramid: Nutrition. Muscle and Strength Pyramids.
3. Israetel, M. (2021). Scientific principles of hypertrophy training. Renaissance Periodization. Schoenfeld, B. (2021).Science and development of muscle hypertrophy. Human Kinetics.

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 157: Urine Testing

This episode includes the pitfalls of urine tests, how to detect adulterated urine, and more.  

Written by Janelli Mendoza, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD. Comments by Carol Avila, 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: Urine drug screenings are valuable tools used every day by physicians to monitor illicit substance use, as well as proper use or misuse of prescription drugs. However, studies suggest that physicians using “clinical judgment” on who and when to test is often wrong and confounded by implicit racial bias. The implications of this are an inappropriate discontinuation of treatment.

For example, a study by Gaither, Gordon, and Crystal et. al found that compared to white patients, black patients were 10% more likely to undergo urine drug screening. In addition, they were 2-3 times more likely to have long-term opioid medication abruptly discontinued as a result of a UTOX positive for marijuana.

False positive urine tests:

Before getting into the current guidelines, let’s discuss the interpretation of Urine Drug Screenings. It’s important to be aware of prescription drugs that may cause false positives:

· Bupropion, labetalol, pseudoephedrine, trazodone → Amphetamines

· HIV antivirals, sertraline → Benzodiazepines

· HIV antivirals, NSAIDs, PPI’s → Cannabinoids

· Diphenhydramine, Naloxone, Quetiapine, Quinolones, Verapamil → Opioids

· Dextromethorphan, diphenhydramine, ibuprofen, tramadol, venlafaxine → Phencyclidine

Tampering of urine: Other factors to consider are the tampering of collected urine. The tampering of collected urine may include diluting the urine, or adding other chemicals and substances. Laboratory results that should prompt consideration of adulteration are: Creatinine <20 mg/dL, pH <3 or >11, Specific gravity <1.001 or > 1.035, Temp <90 F or > 100 F

How long urine tests are positive:

The detection window for common substances in urine drug screenings are as follows:

· Amphetamines: 2-3 days

· Cocaine: 1-2 days

· Opioids: 1-3 days, but up to 14 days if the patient is on methadone.

· Phencyclidine: up to or less than 1 week, may be longer if chronic use.

Cannabinoids are a little different as the THC component builds up and is stored in adipose tissue. Therefore, a patient's weight, body fat percentage, exercise level, and diet can all influence the detection window. This is more so an issue for chronic daily users.

· For single-time use: 2-3 days.

· Daily use: 2-4 weeks

· Chronic heavy use: >6-8 weeks as we said, the exact time will be influenced by many factors depending on how long it takes to deplete THC molecules stored in adipose tissue.

Monitoring use of prescription drugs:

Dr. John Hayes and Dr. Kristen Fox at the Department of Family Medicine and Community Medicine College of Wisconsin have developed a patient-centered approach in utilizing urine drug screenings for monitoring the use of controlled prescription drugs. If physicians should not test based on suspected misuse of medications, then when should they test? 

The frequency of screening should be determined based on a patient’s risk for substance use disorder. This will be determined by use of evidence-based tools such as a risk calculator. On MD calc, clinicians can find the ORT (Opioid Risk Tool for Narcotic Abuse) created by Dr. Lynn Webster. This stratifies patients into high-risk, moderate risk and low- risk of opioid related aberrant behaviors. Factors contributing to high-risk include age between 16-45, history of preadolescent sexual abuse, history of depression, history of ADD, OCD, Bipolar disorder, or schizophrenia, illicit substance use, history of misuse of prescription drugs. Family history also significantly contributes to risk assessment independently taking into consideration FHx of alcohol abuse, illicit substance abuse, and prescription drug misuse.

How often can we test the urine for patients on controlled medications?

Based on the risk assessment the frequency of Urine drug screenings for patients on controlled medications should be as follows:

· Low- risk patients should be tested annually

· Moderate-risk patients should be tested at least 2x per year

· High-risk patients should be tested at least 3x per year

Based on the results, if it is found that a patient is recurrently misusing their medication, rather than abruptly discontinuing a patient off of their medication, it is recommended that the provider share their concern with the patient to initiate an open discussion. Medication should be tapered, and the patient should receive a referral and support from an addiction specialist.

Unhealthy Drug Use: Screening by USPSTF (published on June 09, 2020):For adults age 18 years or older, the USPSTF recommends screening by asking questions about unhealthy drug use. Testing biological specimens is not recommended for this purpose. “Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.”

Conclusion: Now we conclude episode number 157, “Urine Testing.” Future doctor Mendoza and Dr. Avila explained when to test your patients to verify their compliance with treatment. Urine tests need to be interpreted wisely. Make sure you establish a good relationship of trust with your patients and rule out other causes for a positive or negative urine test. For example, some patients may be positive for cannabinoids if they are taking certain medications such as PPIs. Dr. Arreaza also reminded us f the recommendation to screen for unhealthy drug use in adults by asking questions, not by testing biological specimens. 

This week we thank Hector Arreaza, Janelli Mendoza, and Carol Avila. Audio editing by Adrianne Silva.

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. Recommendation: Unhealthy Drug Use: Screening, United States Preventive Services Taskforce, uspreventiveservicestaskforce.org, published on June 9, 2020. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening.
2. Argoff CE, Alford DP, Fudin J, et al. Rational urine drug monitoring in patients receiving opioids for chronic pain: consensus recommendations. Pain Med. 2018; 19:97-117. https://doi.oerg/10.1093/pm/pnx825.
3. Gaither JR, Gordon K, Crystal S, et al. Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients. Drug Alcohol Depend. 2018;192:371-376.
4. Kale N. Urine drug tests: ordering and interpreting results. Am Fam Physician. 2019;99:33-39.
5. Saitman A, Park H-D, Fitzgerald RL. False-positive interferences of common urine drug screening immunoassays: a review. J Anal Toxicol. 2014;38:387-396. https://doi.org/10.1093/jat/bku075
6. TAP 32: Clinical drug testing in primary care. Rockville, MD: Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services; 2012. Technical Assistance Publication (TAP) 32; HHS Publication No. (SMA) 12-4668. 2012.
7. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005 Nov-Dec;6(6):432-42. doi: 10.1111/j.1526-4637.2005.00072.x. PMID: 16336480.
8. Royalty-free music used for this episode: Gushito, “Gista Mista”, downloaded on November 16th, 2023, from https://www.videvo.net/

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 156: Obesity, Fertility, and Pregnancy

Future Dr. Hamilton defines obesity and explains the pathophysiology of obesity and its effects on fertility and pregnancy. Dr. Arreaza adds some input about the impact of epigenetics on newborn babies.  

Written by Shelby Hamilton, MS3, American University of the Caribbean School of Medicine. 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.

Definition of obesity

Obesity is a multifactorial chronic disease that is increasing in prevalence across the globe. It can be defined as a body mass index (or BMI) greater than 30 kg/m2. According to the CDC from 2017-March 2020, the prevalence of obesity in United States adults was 41.9%.

Classification of obesity by BMI.

Obesity can further be divided into three classes: class I which is a BMI between 30-34.9; class II which is a BMI between 35-39.5; and class III which is a BMI greater than 40. We recommend avoiding the term “morbid obesity” because of the negative connotation of the word “morbid.” Class III or severe are better terms in those cases. 

This classification is based on the individual risk of cardiovascular disease. One of the greatest health consequences affecting individuals with obesity is the cardiovascular effects including hypertension, dyslipidemia, and coronary artery disease. Other effects include insulin resistance and diabetes, cholelithiasis, non-alcoholic fatty liver disease, osteoarthritis, and even depression.

How Does Obesity Affect Fertility?

Obesity can have an extensive effect on the overall health of an individual. In addition to these commonly discussed effects, obesity can also influence a person’s fertility. This is especially observed in women with polycystic Ovary Syndrome (PCOS) who have a greater BMI and also have symptoms of anovulation. Excess adipose tissue plays a role in the effects that obesity has on fertility. 

White adipose tissue can secrete a specific group of cytokines known as ‘adipokines’. These adipokines include leptin, ghrelin, resistin, visfatin, chemerin, omentin, and adiponectin. With a greater percentage of adipose tissue, there are higher rates of hypothalamic gonadotropin hormonal dysregulation, which can be combined with insulin-related disorders, low sex hormone binding proteins, and high levels of androgens. The combination of these factors can result in decreased ovarian follicle development and decreased progesterone levels.

Hormonal changes

Obesity is an endocrine disorder. One specific adipokine that affects the hypothalamic-gonadotropin axis is chemerin. Chemerin impairs the release of follicle-stimulating hormone (FSH) from the pituitary gland. This reduction in FSH release consequently leads to anovulation, meaning that no egg will be released from an ovarian follicle, contributing to infertility. 

Shelby: Another adipokine affecting fertility is adiponectin. The receptors of adiponectin are predominantly expressed in reproductive tissues, including the ovaries and endometrium. In individuals with a greater BMI, a decrease in adiponectin secretion has been observed, resulting in decreased stimulation of its receptors, especially in the endometrium, which has been linked to recurrent implantation failure. Adiponectin has also been shown to affect glucose uptake in the liver. With reduced adiponectin levels, there is reduced hepatic glucose uptake, leading to insulin resistance. As tissues become less sensitive to insulin, the body compensates by secreting higher amounts of insulin, leading to hyperinsulinemia. Higher levels of circulating insulin have also been proven to cause hyperandrogenemia in women by blocking the hepatic production of sex hormone-binding globulin. 

Insulin can also act on the IGF-1 receptors in the theca cells, increasing steroidogenesis, and thus, increasing androgens. With hyperandrogenemia, there is also increased granulosa cell apoptosis as well as increased peripheral conversion of androgens into estrogen. This creates negative feedback to the hypothalamic-pituitary axis to decrease the release of gonadotropins such as FSH which are critical in ovulation.

Leptin is another adipokine that is shown to be increased in obesity. Studies on mice have shown that leptin impairs the development of ovarian follicles, resulting in a decrease in ovulation. In these studies, it was also observed that leptin reduces the production of estriol by the granulosa cells in the ovarian follicles as well as increases the rate of apoptosis in granulosa cells, both of which affect ovulation. Leptin decreases hunger, but persons with obesity may be resistant to its effects and that’s why they have higher levels than a person with normal weight. They have high levels of leptin but are still hungry because they have leptin resistance.

Studies have also shown that the fatty acid composition of follicular fluid found in ovarian follicles also plays a role in fertility. In individuals with a high BMI, this fluid contains high levels of oleic acid, which can cause embryo fragmentation after fertilization occurs. Stearic acid is another fatty acid found in elevated levels in the follicular fluid of women with a greater BMI, which can also affect the quality of the embryo while in the blastomere stage.

The bottom line is obesity decreases fertility. It does not mean that patients with obesity will not get pregnant, but it can make it harder to get pregnant. Female patients who are losing weight must be warned about their improved fertility once they start to lose weight.

What effect does obesity have on pregnancy?

While obesity may make it more difficult for a woman to get pregnant, it is not impossible. However, there are potential risks both to the mother’s health as well as the baby’s health. Therefore, it is very important to monitor these patients even more carefully.

Women who have a greater BMI pre-pregnancy are at a greater risk of developing gestational hypertension. Gestational hypertension is defined as blood pressure greater than 140/90 on more than one reading in the second half of pregnancy. Hypertension during pregnancy can also have serious complications such as kidney failure, stroke, myocardial infarction, or even heart failure. Gestational hypertension can also result in preterm birth or low birth weight.

Treatment of mild hypertension in pregnancy

Recent studies published in the AFP Journal support the treatment of mild hypertension in pregnancy. It states that “evidence and expert opinion support treating mild chronic hypertension in pregnancy with approved antihypertensives, with a strength of recommendation: B”. There was a randomized control trial with about 2,000 women who were randomized to receive antihypertensive treatment vs no treatment. The treatment group had a lower incidence of preeclampsia with severe features, preterm birth, placental abruption, and neonatal or fetal death. There was not an increase in fetal growth restriction or maternal or neonatal complications. So, it is advisable to treat chronic, mild hypertension in pregnancy, according to the AFP Journal.

Preeclampsia

Preeclampsia is another condition that is at a higher risk in women with obesity, which is a more serious manifestation of hypertension in the second half of pregnancy. Along with high blood pressure, there are also effects on the kidneys and liver. Hypertension accompanied by proteinuria is indicative of preeclampsia and should be taken seriously. Preeclampsia can become eclampsia, where the patient also experiences seizures. There is also the risk for stroke, HELLP syndrome, placenta abruption, preterm birth, and fetal growth restriction.

Gestational diabetes

Another risk is gestational diabetes. Elevated blood glucose during pregnancy can result in a larger baby and delivery by cesarean. There may also be a greater risk of the mother and child developing diabetes mellitus later on in life.

OSA

Women with a greater BMI may also be at risk of developing obstructive sleep apnea during pregnancy. Not only can this result in fatigue but can also contribute to the development of gestational hypertension and preeclampsia.

Effect of obesity on the fetus

As mentioned, there are some risks to the fetus in women with a greater pre-pregnancy BMI. There is a greater risk for these babies to be born with birth defects such as congenital heart defects and neural tube defects. Another risk previously discussed is macrosomia, or large for gestational age. Larger babies are also at increased risk for shoulder dystocia during delivery as well as resulting clavicle fractures, brachial plexus injuries, and nerve palsies. Preterm birth is another risk, which also increases the risk of short-term and long-term health complications. Lastly, a higher BMI is directly correlated with the risk of spontaneous abortion or stillbirth.

Summary

As the prevalence of obesity increases, it is important to discuss the health risks that are associated with this disease. In our patients of childbearing age and who may be hoping to conceive, it is even more important to discuss how a higher BMI may affect fertility and pregnancy. While discussing these topics with patients, it is important to try our best to build rapport with the patient so that the discussion is seen more as one of concern and support rather than one of criticism regarding their weight. We may want to help by not only telling patients to “lose weight” or “diet”, but we can also provide them with resources regarding dietary adjustments and ways they can incorporate physical activity into their lives without just telling them to eat less and move more. Stay tuned for our episode on the management of obesity in pregnancy.

Conclusion

Now we conclude episode number 156, “Obesity, fertility, and pregnancy.” Future Dr. Hamilton explained how obesity affects the hormonal regulation of fertility. She also explained the obstetrical risks associated with obesity. Primary care professionals need to educate our patients about the benefits of preconception weight control. Dr. Arreaza explained that hypertension is a common condition in pregnant patients with obesity and mentioned the benefits of treating mild hypertension in pregnancy. We hope to bring you an episode on the management of obesity in pregnancy soon, so stay tuned! 

This week we thank Hector Arreaza and Shelby Hamilton. Audio editing by Adrianne Silva.

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. Gautam, D., Purandare, N., Maxwell, C., Rosser, M., O’Brien, P., Mocanu, E., McKeown, C., Malhotra, J., & McAuliffe, F. (2023) The challenges of obesity for fertility: A FIGO literature review. International Journal of Gynecology & Obstetrics, 160(S1), 50-55. https://doi.org/10.1002/ijgo.14538
2. Pandey, S., Pandey, S., Maheshwari, A., & Bhattacharya, S. (2010). The impact of female obesity on the outcome of fertility treatment. Journal of Human Reproductive Science, 3(2), 62-67. https://doi.org/10.4103/0974-1208.69332.
3. Perreault L. Obesity in adults: Prevalence, screening, and evaluation. In: UpToDate, Pi Sunyer FX (Ed) Wolters Kluwer. https://www.uptodate.com (Accessed on October 6, 2023).
4. Obesity and Pregnancy FAQ, The American College of Obstetricians and Gynecologists (ACOG), https://www.acog.org/womens-health/faqs/obesity-and-pregnancy, Accessed on October 10, 2023.
5. Adult Obesity Facts, Centers for Disease Control and Prevention (CDC), https://www.cdc.gov/obesity/data/adult.html, Accessed on October 7, 2023. 
6. Dresang L, Vellardita L. Should Medication Be Prescribed for Mild Chronic Hypertension in Pregnancy?. Am Fam Physician. 2023;108(4):411-412. 
7. Royalty-free music used for this episode: "I Think We Have a Chance."  downloaded on November 11, 2023,  from https://www.videvo.net/.

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 155: Diabetic Foot Infection Guidelines

Future Dr. Perez presents the updates on lung cancer screening by the American Cancer Society. Future Dr. Danusantoso explains the classification, diagnosis, and treatment of diabetic foot infections according to the guidelines published by the International Working Group on the Diabetic Foot (IWGDF). Dr. Arreaza adds comments and anecdotes.  

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.

Intro: Lung cancer screening update.
Written by Luz Perez, MSIII, Ross University School of Medicine. Editing by Hector Arreaza, MD.

Hello, my name is Luz Perez and today I will talk about lung cancer screening.

As a reminder, lung cancer is the top cause of cancer-related death in men and women worldwide. In the United States, lung cancer causes the death of about 154,000 people each year[4]. 

Smoking is the most significant risk factor for developing lung cancer, a risk that directly correlates to how much and how long a person has smoked[2]. Despite the efforts to decrease lung cancer-related deaths, which include screening of patients at risk and counseling on smoking cessation, many patients go undiagnosed in part because lung cancer can be asymptomatic but also because many people at risk did not meet the criteria for screening, according to previous guidelines… 

BUT On November 1, 2023, the American Cancer Society updated its guidelines for lung cancer screening to decrease mortality by lung cancer in the US. 

The updated lung cancer screening guidelines were published in November, which is Lung Cancer Awareness Month. This guideline aims to expand eligibility criteria for lung cancer screening. 

Previously, the guidelines covered people only between the ages of 55-74 who were current smokers or had quit within the past 15 years and had a 30 or more pack-year smoking history[3].

The new guidelines recommend annual screening with low-dose CT (LDCT) scan for people who are 50-80 years old who are current or former smokers and who have a 20 or more pack-year of smoking history [1]. 

This change means that about 5 million people who would previously not qualify for screening are now eligible for this potentially lifesaving screening exam.

Additionally, the American Cancer Society emphasizes the significance of shared decision-making between patients and healthcare providers on lung cancer screening and smoking cessation. This includes ways to help patients stop smoking by providing counseling and interventions including medications. 

For patients who are eligible for screening, having a full discussion of the lung cancer screening process including the purpose of the procedure, risks and benefits of low-dose CT, and recommendations from other organizations, is key in the shared decision-making process[1]. 

Perhaps, the most important step in the implementation of these new guidelines is ensuring that medical professionals talk to their patients about them and make them aware of the importance of screening for lung cancer. In this way, we can reduce mortality and other consequences of this devastating disease. 

Written by Maria Danusantoso, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.

Update to Guidelines for Treatment of Diabetic Foot Infections

Introduction

In October 2023, the International Working Group on the Diabetic Foot (IWGDF) and the Infectious Disease Society of America (IDSA) collaborated and published an update to the 2019 guideline on the diagnosis and management of infections of the foot in persons with diabetes mellitus.

The present guidelines include a list of 25 recommendations for diagnosis and management and clinically useful figures and tables including a treatment algorithm, a classification system for defining diabetic foot infections, and empirical antibiotic therapy according to clinical presentation and microbiological data.

The goal of this episode is not to provide an exhaustive review of the updated guidelines and algorithms but to highlight what I believe are the most important recommendations. I hope this brief presentation is viewed as an introduction and that this encourages you, the listener, to independently read the guidelines in full and implement them into your own clinical practice.

Wound Colonization Versus Wound Infection

Before jumping into some of the recommendations, I want to take some time to discuss briefly how to classify diabetic foot infections. Most clinicians, including myself, will see a patient with diabetes with a foot ulcer or wound and want to treat it with antibiotics or admit the patient to the hospital. However, the updated guidelines propose that antibiotics and/or admission are not always indicated. 

For clinicians, there needs to be an awareness that wound colonization and wound infection are not the same. Wound colonization by bacteria is defined by the presence of bacteria on a wound surface without evidence of invasion of the host tissues. Colonization, then, can be considered a constant phenomenon as we live in a bacteria-filled world. 

Comment: If we culture our intact skin, we may find pathogens, that’s why wound cultures even if they are positive, do not indicate there is infection. Tell us about infection.

In contrast, wound infection is a disease state caused by the invasion and multiplication of microorganisms in host tissues that induce an inflammatory response in the host, usually followed by tissue damage. Therefore, since all wounds are colonized – often with potentially pathogenic microorganisms – we cannot define wound infection using only the results of wound cultures. Instead, diabetic foot infections are a clinical diagnosis based on the presence of manifestations of an inflammatory process involving a foot wound located below the malleoli. These signs and symptoms of inflammation may be masked in persons with diabetes especially if they have some level of baseline peripheral neuropathy, peripheral artery disease, or immune dysfunction.

Classification of Diabetic Foot Infections.

To assist with the classification of diabetic foot infections, the updated guidelines include a table for defining the presence and severity of an infection of the foot in a person with diabetes. Again, diabetic foot infections are a clinical diagnosis, and the clinical classification of infection can be described as: 

1) uninfected, 2) mild, 3) moderate +/- O if osteomyelitis is present, 4) severe +/- O if osteomyelitis is present. 

Uninfected has no systemic or local symptoms or signs of infection. 

Mild infection is when at least two of the following are present: local swelling or induration, erythema between 0.5-2 cm around the wound in any direction, local tenderness or pain, local increased warmth, purulent discharge, and there is no other cause of an inflammatory response of the skin present (e.g., trauma, gout, acute Charcot neuro-arthropathy, fracture, thrombosis, or venous stasis).

Moderate infection is without systemic manifestations and involves erythema extending 2 cm or more from the wound margin and/or involves tissue deeper than skin and subcutaneous tissues (e.g., tendon, muscle, joint, and bone) +/- the presence of osteomyelitis. The surrounding erythema and the depth of wound are key element in the classification of the wounds. 

Severe infection is associated with systemic manifestations and meets systemic inflammatory response syndrome (SIRS) criteria as manifested by 2 or more of the following: temperature below 36°C or above 38°C, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute, white blood cell count greater than 12,000/mm3 or greater than 10% immature (band) forms +/- presence of osteomyelitis. 

Features of Osteomyelitis on Plain X-Ray

We have mentioned osteomyelitis quite a few times in this episode, so what are some ways we can diagnose osteomyelitis? Most commonly, osteomyelitis is diagnosed via imaging either with plain X-rays  or MRI. When looking at plain X-rays, there are a few features that are characteristic of diabetes-related osteomyelitis of the foot of which we should be aware regardless of our status as radiologists. 

Some of these features include bone sclerosis with or without erosion, abnormal soft tissue density or gas density in the subcutaneous fat, or new or evolving radiographic features on serial images spaced several weeks apart such as loss of bone cortex, focal demineralization, periosteal reaction or elevation. Changes in x-ray may be a late finding and indicate that the osteomyelitis is established.

General Treatment Recommendations for Diabetic Foot Infections

In the updated guidelines, recommendation 11 states to not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy when the goal is to reduce the risk of new infection or to promote ulcer healing. 

As previously said, diabetic foot infections are a clinical diagnosis. So if clinically the wound does not meet criteria to be classified as a mild, moderate, or severe infection, this recommendation proposes that no antibiotic treatment is the best treatment so as not to expose patients to potentially unnecessary and harmful treatment and to not promote antibiotic resistance in patients, which would potentially make treating diabetic foot infections more challenging in the future. 

We still want to very closely monitor the wound every 2-7 days and promote wound healing with pressure offloading, keeping the wound and the surrounding skin clean and dry, and other non-antibiotic management for local wound care.

What are some common bacteria?.

When it is indicated to treat diabetic foot infections per the guidelines, recommendation 14 states to target aerobic gram positive pathogens only for people with a mild diabetes related foot infection. These pathogens include beta hemolytic streptococci and Staphylococcus aureus including methicillin-resistant strains if indicated. Additionally, recommendation 15 advises not to empirically target antibiotic therapy against Pseudomonas aeruginosa in cases of diabetes-related foot infection in temperate climates. However, it is appropriate to use empirical treatment of P. aeruginosa if it has been isolated from cultures of the affected site within the previous few weeks or in a person with moderate or severe infection who resides in tropical/subtropical climates.

Antibiotic Treatment Duration Recommendation

The final recommendation we have time to discuss in this episode is regarding antibiotic treatment duration. 

For mild infections, oral antibiotics (such as cephalexin or Bactrim) for a duration of 1-2 weeks is appropriate. However, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease, it is reasonable to consider extending treatment for up to 3-4 weeks.

For moderate or severe infections without osteomyelitis, a total treatment duration of 2-4 weeks is recommended starting initially with IV antibiotics before transitioning to oral antibiotics. Antibiotic selection will depend on multiple factors, such as recent antibiotic use, or MRSA risk factors. For example, if the patient took antibiotics recently, they could receive Zosyn® and ceftriaxone. 

If osteomyelitis is present, antibiotic treatment duration can be anywhere from 2 days to 6 weeks depending on the amount of source control achieved. Ideally, we should wait to have bone resection before giving antibiotics, but we know that antibiotics are given promptly in the ER.

In the cases of a resected infected bone or joint (when complete source control is achieved), a duration of 2-5 days is recommended, starting with IV antibiotics before transitioning to oral antibiotics. 

If there is minor amputation of the infected foot but there remains a positive wound culture or positive margins are seen on pathology (inflammatory cells are seen at the proximal margin of the amputated section), a 3-week antibiotic treatment duration is recommended, again starting with IV before transitioning to oral antibiotics.

For diabetes-related foot osteomyelitis without bone resection or amputation, a 6-week course of antibiotics is recommended, again initially with IV antibiotics before transitioning to oral. 

In all the situations where there is a transition from IV to oral antibiotics, this transition may only occur once there are clinical signs of improvement, for example, improving erythema surrounding the wound, resolution of tenderness or purulent drainage, or SIRS criteria is no longer met.

Summary: For more details regarding the 2023 update to the guidelines on the diagnosis and treatment of foot infection in persons with diabetes, please refer to the complete guidelines which can be accessed on the IWGDF Guidelines website and via the citations listed in the References. As a reminder, this podcast episode is not an exhaustive review of the guidelines, but, instead, a brief introduction to some of the recommendations. Thank you for listening and I hope you learned something new!

_____________________________

Conclusion: Now we conclude episode number 155 “Diabetic foot guidelines.” Future Dr. Perez started this episode with an introduction about the new guidelines to screen for lung cancer, then future Dr. Danusantoso gave an excellent summary about the classification and treatment of diabetic foot infections. Our patients with diabetes must have foot self-awareness and report any concerns to their family physicians or podiatrists so they can get prompt treatment.

This week we thank Hector Arreaza, Luz Perez, and Maria Danusantoso. Audio editing by Adrianne Silva.

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. McDowell, Sandy, New Lung Cancer Screening Guideline Increases Eligibility. American Cancer Society, published on November 1, 2023, Cancer.org. https://www.cancer.org/research/acs-research-news/new-lung-cancer-screening-guidelines-urge-more-to-get-ldct.html
2. Wolf AMD, Oeffinger KC, Shih TY, et al. Screening for lung cancer: 2023 guideline update from the American Cancer Society [published online ahead of print, 2023 Nov 1]. CA Cancer J Clin. 2023;10.3322/caac.21811. doi:10.3322/caac.21811. Link: https://pubmed.ncbi.nlm.nih.gov/37909877/
3. Moniuszko, Sara. Lung cancer screening guidelines updates by American Cancer Society to include more people. CBS News, updated on November 3, 2023. https://www.cbsnews.com/news/lung-cancer-screening-guideline-american-cancer-society-update/
4. Deffebach, M. E., & Humphrey, L. (2023). Screening for lung cancer. UpToDate. Retrieved November 6, 2023, UpToDate. https://www.uptodate.com/contents/screening-for-lung-cancer
5. Éric Senneville, Zaina Albalawi, Suzanne A van Asten, Zulfiqarali G Abbas, Geneve Allison, Javier Aragón-Sánchez, John M Embil, Lawrence A Lavery, Majdi Alhasan, Orhan Oz, Ilker Uçkay, Vilma Urbančič-Rovan, Zhang-Rong Xu, Edgar J G Peters, IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023), Clinical Infectious Diseases, 2023; ciad527, https://doi.org/10.1093/cid/ciad527
6. Senneville, Éric et al. 2023. “IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Foot Infection in Persons with Diabetes.” IWGDF Guidelines. Retrieved November 6, 2023 (https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-2023-04-Infection-Guideline.pdf). 
7. Royalty-free music used for this episode: Gushito, “Gista Mista”, downloaded on November 16th, 2023, from https://www.videvo.net/ 

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 154: Heart Failure and GDMT

Dr. Malave explains the four main medications that are part of the guideline-directed medical therapy of heart failure with reduced ejection fraction. Dr. Arreaza added comments and questions.  

Written by Maria Fernanda Malave, MD. 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.

Brief introduction: Heart failure (HF) is a common condition that affects about 23 million people in the world, and it is estimated that 50% of cases are due to heart failure with reduced ejection fraction (HFrEF). It is a major public health concern because of the high morbidity and mortality with a 5-year survival rate of 25% after hospitalization due to HFrEF.

In recent years, the management of HFrEF has evolved due to increased evidence in favor of certain medications. Guideline-directed medical therapy (GDMT) is the foundation of medical therapy for these patients, and it is the result of multiple randomized controlled trials and reviews favoring four main drug classes: 1. renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors -ACEi- and angiotensin receptor blockers -ARB), 2. evidence-based β-blockers, 3. mineralocorticoid inhibitors, and 4. sodium-glucose cotransporter 2 inhibitors -SGLT-2i-. 

The benefit of this therapy is mostly seen when these four groups of medications are used in conjunction. During this episode, we will provide some key elements about the prescription of these medications, but this is only an overview, and you are invited to continue learning from reputable sources.

Definitions: HF is defined as the impairment of the heart to meet the metabolic demands of the body. It can be caused by multiple conditions that interfere with the filling up of the heart or conditions that prevent an effective ejection of blood out of the heart. 

Classification of HFrEF: Based on the EF by echocardiogram, heart failure can be classified as:

1. Heart failure with preserved ejection fraction (HFpEF) when the EF is 50% or more.
2. Heart failure with mildly reduced ejection fraction when EF ranges between 41-49%.
3. Heart failure with reduced ejection fraction (HFrEF) when EF is 40% or less.

GDMT: Once we make the diagnosis of HF, it is key to educate our patients and re-educate them every single visit about the importance of guideline-directed medical therapy (GDMT) and lifestyle modifications, because this can change the prognosis and exacerbation rates. Many patients think that since they are feeling well after starting GDMT they can stop it, but that’s going to increase exacerbations, hospitalizations, and decrease quality of life. 

Key points to discuss with patients.

First, discuss that GDMT are disease-modifying drugs that regulate the neurohormonal system to stop the progression of the disease. We should explain to our patients that medications should be taken despite feeling well. Also, patients should be educated about regular follow-ups and medication titration. We can even instruct our patients about increasing their furosemide dose if they observe signs of overload, such as a weight increase of 2-3 kgs in 3-4 days, tight rings, socks or bracelets, also Paroxysmal nocturnal dyspnea, dyspnea on exertion, and more.  

Second, lifestyle modifications such as: quit smoking and alcohol. Additionally, in general, water restriction between 1.2-1.5L daily, salt restriction (there is no official recommendation about how many grams, but in general we recommend less than 2g daily). 

Third, it is highly recommended to do aerobic exercise that produces mild dyspnea since this improves cardiovascular capacity and decreases hospitalization risk. 

Patients should be encouraged to have their annual influenza vaccine and pneumococcal vaccine according to their own immunization schedule. According to the AFP journal, in September 2022, researchers found a clinically and statistically significant reduction in all-cause mortality for patients who received an influenza vaccine right after an MI, with a number needed to treat of 50, the effectivity of the vaccine may vary by season.

GDMT, groups of medications:

What are the basic medications any patient with HF should be on? At least, patients should be on angiotensin receptor blockers ARBs/ACEIs and Beta-blockers. Let’s keep in mind that beta-blockers should be given cautiously in cases of exacerbation, but in general low doses are safe. 

We also have the angiotensin receptor/neprilysin inhibitors (ARNIs), a group of medications whose representative is the combination of sacubitril/valsartan, aka Entresto®. This medication should be the target once ARBs/ACEIs are tolerated. ARBs/ACEIs/ARNIs should be discontinued in the setting of advanced CKD, with a GFR of 30 or less. 

This applies to other medications used in HF such as SGLT-2 and mineralocorticoid receptor antagonist (MRA, such as spironolactone/eplerenone). 

Remember that SGLT-2 inhibitors should be started regardless diabetes status, and BB are safe in the setting of CKD. 

We also have other groups that are considered safe in patients with advanced CKD such as hydralazine/isosorbide dinitrate (combined or not), which are used in African Americans whose BP and HF symptoms do not improve with maximally tolerated dose of ARBs/ACEIs + BB.

Ivabradine: Let’s not forget about ivabradine, which is an SA node inhibitor like BB. Patients need to meet criteria such as a maximally tolerated dose of beta-blocker, heart rate of a least 70 or more and being on normal sinus rhythm to be started on this medication. 

Ivabradine does not improve survival as BB do, so even though they are not contraindicated in HF exacerbation, BB are still preferred since ivabradine does not decrease mortality.

Titration and follow-ups in the HF management:

-ARBs/ACEIs/ARNIs should be titrated approx. Q2 weeks until the maximally tolerated dose is achieved, ARNI should be titrated up Q2-4weeks. With these medications, we should monitor BP, potassium levels and Glomerular Filtration Rate (GFR). 

-BB can also be titrated up Q2weeks until the maximally tolerated dose is achieved. HR, BP and signs of congestion should be observed in patients on BB. Same for hydralazine/isosorbide, with BP follow-up. 

-MRA, such as spironolactone/eplerenone, these meds can be added in patients who remain symptomatic despite maximally tolerated doses of “ARBs or ACEIs or ARNIs” plus Beta-blockers. For MRA, potassium level, and GFR should be monitored every 2-3 days after initiation, 7 days after titration, monthly for 3 months, and then Q3 months. To start a patient on MRA, K+ must be lower than 5.

Patients with HF should be followed up at least in a 2-week interval either via telephone, telemedicine, or clinic visit to assess symptoms, vital signs, bloodwork and to perform a physical exam. 

Monitoring EF: After 3-6 months of the patient´s stabilization, we should reorder an echo, EKG, BNP and Basic Metabolic Panel. The ejection fraction improves in all patients after GDMT initiation and compliance, and in some patients, this improvement is very significant, so we need to reassess EF after stabilization. 

Comorbidities: Also, let´s keep in mind that most of the patients have associated comorbidities such as Afib, diabetes, valve disease, or anemia. These comorbidities must be addressed either by starting anticoagulation, adjusting anti-diabetes medications, starting iron, or referring to cardiology if a valve replacement is needed.

When to refer to Cardiology? 

Some patients will qualify for device therapy (ICD) as a primary prevention for ventricular arrhythmias that can degenerate either into torsades or ventricular fibrillation. These patients must be symptomatic, at least in 3 months of maximally tolerated GDMT, and EF between 30-35%. Symptomatic <35%, asymptomatic <30%. Other patients will require ICD implantation for secondary prevention. 

Other criteria to refer a patient to the cardiologist are: patients resistant to GDMT despite target or maximally tolerated doses, or with worsening symptoms, two or more hospitalizations in 12mo, low blood pressure, tachycardia, and end-organ failure. 

__________________________

Conclusion: Now we conclude episode number 154, “Heart Failure and GDMT.” Remember that GDMT can improve not only the symptoms of heart failure with reduced ejection fraction, but it can also improve mortality. The four main classes of medications are renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid inhibitors, and SGLT-2 inhibitors.

This week we thank Hector Arreaza and Maria Fernanda Malave. Audio editing by Adrianne Silva.

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. Murphy SP, Ibrahim NE, Januzzi JL Jr. Heart Failure With Reduced Ejection Fraction: A Review [published correction appears in JAMA. 2020 Nov 24;324(20):2107]. JAMA. 2020;324(5):488-504. doi:10.1001/jama.2020.10262. Link: https://pubmed.ncbi.nlm.nih.gov/32749493/
2. Patel J, Rassekh N, Fonarow GC, et al. Guideline-Directed Medical Therapy for the Treatment of Heart Failure with Reduced Ejection Fraction. Drugs. 2023;83(9):747-759. doi:10.1007/s40265-023-01887-4. Link: https://pubmed.ncbi.nlm.nih.gov/37254024/
3. Royalty-free music used for this episode: Latin Chill, downloaded on July 20, 2023, from https://www.videvo.net/.

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 153: Sudden Infant Death Syndrome.    

Future doctors Nisha and Afolabi explain the way to prevent sudden infant death syndrome and Dr. Arreaza adds comments about prevention through vaccines.  

Written by Selena Nisha, MS4; and Oluwatoni Afolabi, MS4. 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.

Today, we are going to talk about sudden infant death syndrome, also known by its acronym SIDS. This topic is a heavy one and it may be triggering for some parents or those who may personally know a family member affected by SIDS, so please refrain from listening to this podcast at any point you see fit. 

First and foremost, we tend to hear a lot about SIDS in the news or social media outlets that cover these tragic incidents, but let's define what exactly sudden infant death syndrome is. Sudden Infant Death Syndrome, or SIDS, is the abrupt and unexplained death of an infant <1 year of age. It usually occurs during sleep; it is sometimes referred to as "crib death". According to the CDC, SIDS is the leading cause of death in babies between 1 month and 1 year of age in the United States. 

It occurs mostly between 1-3 months. 

Q: What causes SIDs? 

The exact cause of SIDS is unfortunately unknown. However, there are many studies that have identified several risk factors for SIDS and most of them are definitely preventable. 

• The most important risk factors for SIDS are related to the sleep position and the sleep environment of the baby. Babies placed to sleep on their side or their stomach are at increased risk for SIDs compared to babies placed to sleep on their back. In addition, bed-sharing is also strongly associated with increased risk for SIDs.
• Smoking during pregnancy and postnatal exposure to tobacco. Second-hand smoking exposure is probably the most important risk factor for SIDS.
• Drug use or alcohol use during pregnancy
• Overdressing/overheating the baby
• Babies that are born premature and/or low birth weight
• Late or no prenatal care.

Q: Are there any ethnic or genetic components involved in SIDS? 

• Yes, there are. According to the CDC, African American, American Indian or Native Alaskan babies have a higher risk.
• Surprisingly, some studies have even shown an increase in SIDS in baby boys compared to baby girls and if a baby’s sibling had died of SIDS, that may be linked to a genetic disorder.
• Asian babies are less likely to suffer from SIDS, and African Americans are disproportionally affected by SIDS.

Interesting fact: Several people have been accused of killing their own babies and later forgiven because a diagnosis of SIDS was established after autopsy and extensive investigation. Some examples are: Kathleen Folbigg (Australia), Sally Clark (England), and Angela Cannings (UK).

Q: What are the clinical recommendations to reduce the risk of SIDS that parents and caregivers should be aware of?

• It is important to know that although short episodes of tummy time are beneficial for the baby, we need to be sure to not put the baby to sleep on their belly or side. In fact, the incidence of SIDS has decreased more than 50% in the past 20 years, largely as a result of the “Back to Sleep” campaign in 1992 that recommended that babies be placed on their backs to sleep to reduce the risk of SIDs.
• When choosing a crib and mattress, make sure you pick a crib that is well made and sturdy and a mattress that is firm and flat. It is important for the angle of the mattress to not be higher than 10 degrees. I know that we all love to see fluffy and cute little blankets and toys in the baby’s crib, however, we also need to make sure none of those things are present while the baby is sleeping in order to avoid any chance of suffocation.

Q: A friend of mine who recently had a baby always feels anxious when breastfeeding her baby because she feels that her baby is not getting enough air to breathe in. She actually feels the same way when her baby is using the pacifier too. Is it true that the baby is truly struggling to breathe in these instances? 

• This is a common misconception that many mothers tend to have. Many women genuinely fear that their baby isn’t properly breathing while breastfeeding and are worried that this can increase the risk of SIDS. However, the opposite is actually the truth. Turns out that breastfeeding for 6 months to a year actually decreases the risk of SIDS.
• We know that many parents make use of pacifiers, especially in situations relating to soothing the baby but interestingly enough, pacifiers can decrease the risk of SIDS as well. The only important thing to know about pacifier use is that if the baby does not want the pacifier, please don’t force it. Also, make sure the pacifier does not have any hanging parts to it such as cords or straps and if they are sleeping, be sure to not put the pacifier back in the mouth.

Q: After listening to all of these recommendations, it seems like the baby should be sleeping with the parents in the first year of life just to be sure nothing happens to them. This way, the parents will be able to jump into action as quickly as possible because they will be right next to the baby. As safe as this sounds to me, is co-sleeping even recommended?

• It may seem like a good idea in retrospect however studies have shown that co-sleeping in an adult bed can actually increase the chances for SIDS. Although there may be many reasons as to why parents choose to have their baby in bed with them, we need to try to refrain from co-sleeping with the baby. It is definitely okay to have them sleep in the same room as you, but make sure they are in a bassinet or someplace nearby instead of sleeping in your actual bed. There are risks involved that you may not think can occur but certainly have in past cases such as accidentally rolling over on your baby or the baby may become trapped between the headboards if there is empty space present.

Q: These are some excellent recommendations and very helpful tips that parents will be able to utilize when prepping for the baby and after the baby arrives. Luckily, we have many well-known baby cameras and devices that can also be put into place to ensure that the baby is safe. Do you think this is enough to be reassured? 

• There are many baby monitors and devices on the market currently that claim to help reduce the risk of SIDS. While that may seem true, I would argue that nothing is more reliable than utilizing the safe sleep practices we mention here today as no device or monitor can do the same.

Q: Who can parents talk to if they aren’t sure that what they are doing is right or if they need more help in figuring out ways to practice safe sleep? 

• This is what your well-baby visits are for. Parents can always verbalize their worries or questions to their pediatricians during the visits. As important as it is for doctors to make sure that the babies are developing well, it is also their job to make sure your questions and concerns are taken care of.

Q: How exactly is the diagnosis of SIDs made, especially since many of these risk factors seem majorly accidental?

• It is important to note that there is no specific diagnostic test for SIDs. The diagnosis of SIDs is made only when all other causes have been ruled out following a thorough clinical history, death scene investigation, and autopsy. It is a postmortem diagnosis.
• Clinical history is gathering all information about the infant which includes certain lab work or other studies that may have been abnormal during their life. As we have mentioned, it is very important to rule out all the other possible causes of death before making a SIDS diagnosis.
• Not only is the clinical history important, but the death scene is also crucial to making a diagnosis as well. Some may think that just by looking at the scene you will be able to figure out exactly how the death occurred. But that is not always the case. There are certain parameters officers and investigators have to follow prior to coming to a conclusion. For instance, some may use a doll to demonstrate the position of the baby in certain instances where the baby may have been in a crib that was not well made or if they were wedged between objects.
• Other things to ask would be when the baby was awake and when they went to sleep, where they were found, what time they were found. If they happen to be found in a bed, it is important to ask how many people were on the bed sleeping with the baby and how firm or soft the actual mattress was that the baby was sleeping on. Other things to observe are what type of bedding did the crib or bed have and what clothes the baby had on.

Q: There were so many factors to consider after death. Selena, what would the autopsy show at this point that would lead to SIDS being the cause of death?

• First, we have to make sure there is no evidence of trauma or anything that points to abuse externally. Some external findings for SIDS could be fluid in the nose that is tinged with blood or it may even look frothy. The infant itself should look well-developed. Internal findings could be upper respiratory tract inflammation, congestion or pulmonary edema, petechiae in the intrathoracic region or hepatic hematopoiesis that is persistent. After hearing about all this, if I ever have my own baby, I would feel so afraid to leave them with anyone but me.
• Please don’t feel this way. This information is not meant to scare you. There are many caregivers and family that have a ton of love for the baby and would be more than happy to take care of them. I would say to set boundaries and ask questions about how your baby will be cared for when you are not around. This will bring you lots of ease that your baby is in safe hands. Sometimes it is very important to remind our family or caregivers the proper safe sleep practices, especially if it has been a while since they’ve been around a baby.

Q: How can boundaries be set in a way that doesn’t seem offensive? What are some questions parents can ask or what can they do before leaving their baby in the care of someone else? 

• Encourage parents to not feel afraid to ask questions. That is the best thing you can actually do to ensure your needs are being met for safe sleep. Let me give you some examples of questions to ask that will be direct, but in no way will it seem offensive.

1. Ask what sleeping arrangements they have for your child in their home. There is no harm in providing your own if you feel that the arrangements are not safe.
2. If the baby happens to fall asleep in things like a car seat or bouncer, ask them what they would do upon seeing that.
3. Be sure to ask in what position they put the baby to sleep and remind them that babies should only be sleeping on their backs. Ask them where tummy time will be taking place and make sure to see the location yourself.

Since we can’t control the people who are around or go into the caregivers' house, it is crucial to ask if anyone who tends to smoke tobacco or use vaping products will be in the vicinity of the baby. This is especially important to ask as many people may not consider this to be harmful to the baby, but even secondhand smoke increases the risk for SIDS greatly. 

Q: How to approach parents affected by SIDS?

• These families are truly living their worst nightmare. It is a situation that you or I cannot even fathom being in. It is very heartbreaking for all those involved especially since the deceased is such a young baby that had more life to live. First and foremost, it is very important that the parents have a good support system.
• Be sure to show compassion and empathy. This goes a very long way. Simple things such as saying, “I am here for you”, “I am so sorry for your loss”, “I can’t even imagine what you’re going through”, “please, let me know if there is anything I can help you with during this time”, or “I am here if you need to talk” will allow the parents to feel supported and their emotions to feel validated. Just being there is a huge step in the right direction to help a family who is processing all of this trauma and tragedy.

SIDS is definitely a traumatic event in a family. Let’s not forget about vaccinations to reduce the risk of SIDS. I’m glad that the incidence has been decreasing in the last decades thanks to research. Let’s wrap up this episode.

Vaccines: The CDC recently recommended RSV vaccination to all pregnant women between 32 through 36 weeks of pregnancy from September through January.

The diagnosis of SIDS requires the exclusion of other causes of death, including investigation of the death scene and autopsy.

Prevention is key. The most evidence-based preventive measures are back sleeping, pacifier use, breastfeeding, and proper bedding, and avoid co-sleeping. 

If you made it to the end of this episode, I really hope you can take some of these tips and recommendations and apply them to your practice and share this useful information to your patients who are family planning or those with infants. We know it is such a difficult topic to bring up to patients but it is very important to let them know how to prevent SIDS and the unfortunate consequences that can come out of not practicing safe sleep. 

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Conclusion: Now we conclude episode number 153, “Sudden Infant Death Syndrome.” Future Doctors Nisha and Afolabi explained how to prevent SIDS. Evidence supports some preventive measures such as: avoiding second-hand smoke exposure, avoiding co-sleeping, and avoiding overdressing and overheating of the baby. The preferred sleeping position for babies is on their backs. Dr. Arreaza also emphasized the prevention of SIDS by giving appropriate vaccinations to infants. Dr. Schlaerth highlighted the importance of proper beds and bedding for babies. Remember to recommend parents use a firm mattress for cribs and avoid blankets, stuffed animals, or any other items on babies’ beds that could cause accidental suffocation.

This week we thank Hector Arreaza, Selena Nisha, Toni Afolabi, and Katherine Schlaerth. Audio editing by Adrianne Silva.

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. Adams SM, Ward CE, Garcia KL. Sudden infant death syndrome. Am Fam Physician. 2015 Jun 1;91(11):778-83. PMID: 26034855. https://www.aafp.org/pubs/afp/issues/2015/0601/p778.html
2. Centers for Disease Control and Prevention (CDC). CDC Grand Rounds: Public Health Approaches to Reducing U.S. Infant Mortality. MMWR Morb Mortal Wkly Rep. 2013;62(31):625-628. https://www.cdc.gov/grand-rounds/pp/2012/20121016-infant-mortality.html
3. Mitchell EA, Ford RP, Stewart AW, et al. Smoking and the sudden infant death syndrome. Pediatrics. 1993;91(5):893-896. https://pubmed.ncbi.nlm.nih.gov/8474808/
4. Kim H, Pearson-Shaver AL. Sudden Infant Death Syndrome. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 32809642. https://www.ncbi.nlm.nih.gov/books/NBK560807/
5. Bass M, Kravath RE, Glass L. Death-scene investigation in sudden infant death. N Engl J Med. 1986;315(2):100-105. doi:10.1056/NEJM198607103150206. https://pubmed.ncbi.nlm.nih.gov/3724796/
6. Berry PJ. Pathological findings in SIDS. J Clin Pathol. 1992;45(11 Suppl):11-16. https://pubmed.ncbi.nlm.nih.gov/1474151/
7. Moon RY, et al. Task Force on Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. Sleep-related infant deaths: Updated 2022 recommendations for reducing infant deaths in the sleep environment. Pediatrics. 2022; doi:10.1542/peds.2022-057990. https://publications.aap.org/pediatrics/article/150/1/e2022057990/188304/Sleep-Related-Infant-Deaths-Updated-2022?autologincheck=redirected
8. Safe Sleep NC. (2019, September 13). Talking to Families about Safe Sleep - Safe Sleep NC. https://safesleepnc.org/healthcare-providers/talking-to-families-about-safe-sleep/
9. Royalty-free music used for this episode: Latin Chill, downloaded on July 20, 2023, from https://www.videvo.net/.

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 152: ALS Fundamentals

Future Dr. Rodriguez explains the symptoms of ALS, including UMN and LMN symptoms. Dr. Arreaza discusses the principles of symptomatic treatment by primary care. This is a brief introduction to ALS.  

Written by Adraina Rodriguez, 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.

Arreaza: It is rare but you may encounter it and you should be able to identify the most common symptoms. ALS Challenge in 2014: Ice bucket challenge. 

Adriana: Patrick Quinn was an ALS patient and activist who created the ICE Bicket Challenge and helped raise US$220 million for medical research.

Arreaza: What is ALS?

Adriana: ALS stands for Amyotrophic Lateral Sclerosis, formerly known as Lou Gehrig’s Disease. It is the most common form of acquired motor neuron disease. ALS is a progressive, incurable neurodegenerative motor neuron disorder with Upper motor neuron (UMN) and/or Lower motor neuron symptoms that cause muscle weakness, disability, and eventually death. There is no single diagnostic test that can confirm or entirely exclude the diagnosis of motor neuron disease. 

Arreaza: When should you suspect ALS in a patient?

Adriana: The classic patient presentation is insidious, slowly progressive, and unremitting UMN and/or LMN symptoms present in one of four body segments - cranial/bulbar, cervical, thoracic, and lumbosacral - followed by spread to other segments over a period of months to years. 

Arreaza: What would you see on the physical exam when the Patient is in the clinic? There is a system to send signals from your brain to your muscles. It involves basically two neurons: Upper and lower motor neurons. The UMN goes from your cerebral cortex to your spinal cord and there it connects to a lower motor neuron through synapsis. The LMN then sends the signal to your muscles, causing contraction or relaxation. Tell us about the UMN and LMN symptoms.

Adriana:

• LMN Symptoms: Weakness, Fasciculations, Muscular atrophy, Decreased muscle tone (flaccidity) and reduced or absent reflexes. 
• UMN Symptoms: Increased tone and increased extremity deep-tendon reflexes, presence of any reflexes in muscles that are profoundly weak and wasted, pathological reflexes (crossed adductors, jaw jerk, Hoffman sign, Babinski sign 50%), syndrome of pseudobulbar affect (inappropriate laughing, crying, forced yawning).

Arreaza: What are important factors to help narrow your differential to ALS?
Multifocal motor neuropathy, cervical radiculomyelopathy, benign fasciculations, inflammatory myopathies, post-polio syndrome, monomelic amyotrophy, hereditary spastic paraplegia, spinobulbar muscular atrophy, myasthenia gravis, hyperthyroidism, and many others.

There are pertinent negatives to look out for: 

• Usually negative neuropathic or radiculopathic pain, sensory loss, sphincter dysfunction, ptosis, or extraocular muscle dysfunction (20-30% positive sensory symptoms or “pins and needles” and “electricity” in the affected limbs).
• Note: Cognitive dysfunction does not exclude ALS

Arreaza: What are the diagnostic criteria for ALS

Adriana: Gold Coast Criteria 2019 proposed over El Escorial criteria:

• Progressive upper and lower motor neuron symptoms and signs in one limb or body segment, OR
• Progressive lower motor neuron symptoms and signs in at least two body segments, AND
• Absence of electrophysiologic, neuroimaging, and pathologic evidence of other disease processes that might explain the signs of lower and/or upper motor neuron degeneration.

Arreaza: What diagnostic tests should be ordered for further evaluation?

Adriana: 

• Electrodiagnostic studies: Electromyogram and nerve conduction studies (EMG and NCS)
• Laboratory testing: creatine phosphokinase up to 1000u/L
• Neuroimaging: to exclude other causes mainly. Brain MRI whenever bulbar disease is present. Cervical and lumbosacral spine MRI for LMN findings in the arms and legs.
• Genetic testing: FALS 10% of ALS defect in C9ORF72 gene that makes motor neuron and brain nerve cell protein, the exact cause is unknown. 

Arreaza: Finally, how do you treat ALS?

Adriana: Disease-modifying treatment: Riluzole is recommended for all patients with ALS. Shown to prolong survival and slow functional deterioration. The mechanisms of action that reduce glutamate-induced excitotoxicity: 1) inhibit glutamic acid release, 2) non-competitive block of N-methyl-D-aspartate (NMDA) receptor-mediated responses, 3) direct action on the voltage-dependent sodium channel. 

Arreaza: Riluzole is given 50 mg by mouth twice a day. It may cause drowsiness or somnolence, hepatic injury: Not recommended for patients with elevation of transaminases >5 times the upper limit of normal. It is recommended to monitor for hepatic injury and discontinue if there is evidence of liver dysfunction, such as hyperbilirubinemia.

Adriana: Symptom-based management is the mainstay of treatment. You may involve a multidisciplinary team to treat the symptoms. For example: palliative, hospice, respiratory function management (Noninvasive Positive Pressure Ventilation vs mechanical ventilation.

Arreaza: PCPs may be in charge of managing symptoms because you are the closest provider to the patient. Wherever available, it is recommended to refer your ALS patients to a specialized center. Many patients do not have availability to an ALS center or a neurologist, but they have you to manage their symptoms or complications.

Adriana: Dysphagia: It is a common and distressing symptom. It is suggested PEG tube placement for patients with ALS with normal or moderate respiratory function who have dysphagia. It is controversial, some studies found no benefit on survival or quality of life and other studies suggest that it is safe to give a high-carb, hypercaloric diet to ALS patients. 

Arreaza: Spasticity: Use medications such as baclofen and tizanidine may be helpful, and botulinum injections are an option for those who are not responding to oral muscle relaxants. 

Adriana: Sialorrhea: Use medications such as atropine, hyoscyamine, amitriptyline, and scopolamine. If these medications are not effective or tolerated, used botox injections into the salivary glands. It is considered safe and useful for treating sialorrhea in patients with ALS. Botox is not only for wrinkles!

Arreaza: There are many other symptoms that will require management, but you are invited to review your preferred source of information such as Up to Date, AAFP, or the ALS Association website. 

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Conclusion: Now we conclude episode number 152, “ALS Fundamentals.” You heard from future Dr. Rodriguez that ALS can present with upper motor neuron symptoms, such as spastic muscles and hyperreflexia; or lower motor neuron symptoms, such as flaccid and weak muscles. Some other symptoms include dysphagia, shortness of breath, difficulty talking, fatigue, thick mucus, and pseudobulbar affect. Dr. Arreaza explained that primary care physicians are in a special situation to help diagnose and treat the symptoms of ALS, especially in communities with limited access to an ALS center. You may need to involve a multidisciplinary team to improve the quality of life and possibly the survival of ALS patients. 

This week we thank Hector Arreaza and Adriana Rodiguez. Audio editing by Adrianne Silva.

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. Galvez-Jimenez, Nestor and Colin Quinn, Symptom-based management of amyotrophic lateral sclerosis, Up To Date, updated on July 31, 2023. https://www.uptodate.com/contents/symptom-based-management-of-amyotrophic-lateral-sclerosis. 
2. Royalty-free music used for this episode: Good Vibes: Sky's The limit, downloaded on July 20, 2023 from https://www.videvo.net/ 

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!