Rio Bravo qWeek

Episode 151: Martian Medicine 102

Future Dr. Collins discussed with Dr. Arreaza two common complications of astronauts in a hypothetical travel to Mars: Spaceflight-Associated Neuro-ocular Syndrome and mental illness.  

Written by Wendy Collins, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.

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

Arreaza: We are back for another episode of Martian Medicine! A couple months ago we published the episode Martian Medicine 101. We talked about radiation and its health risks for astronauts going beyond Low Earth Orbit such as a crew going to Mars. Today, we are going to be covering Martian Medicine 102, where we discuss some more risks from the article “Red risks for a journey to the red planet”. So, let’s just jump into it! The next risk we are going to talk about is Spaceflight-Associated Neuro-ocular Syndrome or SANS.  

Wendy: Yes, so this used to be called Vision Impairment Intracranial Pressure because the syndrome affects astronauts' eyes and vision and can appear like idiopathic intracranial hypertension. But the name changed to SANS because is not associated with the classic symptoms of increased intracranial pressure in idiopathic intracranial hypertension such as severe headaches, transient vision obscurations, double vision, and pulsatile tinnitus. Also, it has never induced vision changes that meet the definiti on of vision impairment, as defined by the National Eye Institute. Its name change also reflects that the syndrome can affect the CNS well beyond the retina and optic nerve. 

Arreaza: Let’s talk about SANS some more. SANS presents with an array of signs including edema of the optic disc and retinal nerve fiber, and what else?

Wendy: Edema of chorioretinal folds, globe flattening, and refractive error shifts. Flight duration is thought to play a role in the pathogenesis of SANS, as nearly all cases have been diagnosed during or immediately after long-duration spaceflight such as missions of 30 days duration or longer. But signs have been discovered as early as mission day 10. SANS has been studied in ISS crewmembers who are tested with optical coherence tomography (OCT), retinal imaging, visual acuity, a vision symptom questionnaire, Amsler grid, and ocular ultrasound.

Arreaza: About 69% of the US crewmembers on the ISS experience an increase in retinal thickness in at least one eye, indicating the presence of optic disc edema. This can cause an astronaut to experience blind spots and reduced visual function. Fortunately, to date, blind spots are uncommon and have not had an impact on mission performance.

Wendy: And chorioretinal folds if severe enough and located near the fovea, an astronaut can experience visual distortions or reduced visual acuity that cannot be corrected with glasses or contact lenses. Fortunately, and despite a prevalence of 15–20% in long-duration crewmembers, chorioretinal folds have not yet impacted astronauts’ visual performance during or after a mission.  

Arreaza: A change in your glasses prescription is due to a change in the distance between the cornea and the fovea, and it occurs in about 16% of crewmembers during long-duration spaceflight. This risk is reduced by giving crewmembers with several pairs of “Space Anticipation Glasses” (or contact lenses). The crewmember can then select the appropriate lenses to correct visual acuity. 

Wendy: From a longer-term perspective, SANS presents two main risks to crewmembers: optic disc edema and chorioretinal folds. It is unknown if a multi-year spaceflight like that to Mars will be associated with a higher prevalence, duration, and/or severity of optic disc edema compared to what has been experienced onboard the ISS. Since the retina and optic nerve are part of the CNS, if optic disc edema is severe enough, the crewmember risks a permanent loss of optic nerve and retinal nerve fiber tissue and thus, a permanent loss of visual function. But again, no astronaut has experienced SANS-related permanent vision loss and choroidal folds usually improved post-flight in affected crewmembers. 

Arreaza: It is important to understand the pathogenesis of SANS. In microgravity, fluid can distribute uniformly. The fluid that normally pools in your legs due to gravity can now move to your head and cause congestion of the cerebral veins. The pathophysiology of SANS is that CSF outflow can be blocked, which increases intracranial pressure. 

Wendy: There can be confounding variables such as exercise, high-sodium dietary intake, and high carbon dioxide levels. It is difficult to know much about SANS because there are not many crewmembers who have completed long-duration spaceflight. There is now enough evidence to state that SANS is not a male-only syndrome. Optical Coherence Tomography (OCT) has been used on the ISS since 2013, and it has allowed NASA to build a database of retinal and optic nerve images to understand SANS better. Research from this has shown that most long-duration astronauts present with some level of optic disc edema.

Arreaza: Now all NASA crewmembers receive pre- and post-flight MRIs of the brain. There is evidence that brain changes structure with longer space flights. For example, the ventricles of the brain enlarge with 2–3 mL of CSF in astronauts. Luckily, there has been no cognitive problems with this. Like with most space health concerns, more research is needed. 

Wendy: In summary, SANS is a red risk and top priority to NASA and the human research program. The main concern with SANS is optic disc edema because it could lead to permanent vision impairment. And choroidal folds are also concerning for both short- and long-term flights. But for now, loss of visual acuity is successfully combatted with glasses. Certainly, the more astronauts and flights we take, the more we will learn about SANS.

Wendy: Sorry we took so long on SANS, it’s probably one of my favorites of all the red risk. Now let’s move onto the red risk that includes behavioral health and performance. Future long duration mission in which you are in an isolated and confined space such as a space craft surrounded by an inhospitable environment which humans are not meant to survive could be a problem for the crew’s behavioral and mental health. 

Arreaza: This could affect the astronauts and their ability to complete their mission. Typically, astronauts enjoy space and report it is a positive experience. But psychological changes from being in space for a long time will likely be even more challenging. 

Wendy: In the past, astronauts have reported ‘hostile’ and ‘irritable’ crew and symptoms of depression. 

Arreaza: Stressors to the ISS include long work hours and high workload, and the discomfort of space motion sickness. No one likes vomiting. 
 

Wendy: Being on the ISS, you are close to Earth, and it is easy to communicate with family and friends when needed. Going to Mars there will be communication delay and will make support more difficult. Astronauts on the ISS also have routinely received care packages, which will also not be available to boost morale. Crew members can also change by swapping out astronauts over a certain period, but the crew to Mars will also not have this ability to work with new people. 
 

Arreaza: There are simulation projects to test human resilience. NASA does these kinds of testing at the Johnson Space Center. There is also research in Antarctica that has shown decreased mood and increased stress for scientists in extreme environments. There is also the Mars 500 mission.  

Wendy: Yes, the Mars 500 mission was where a crew of 6 went into isolation in Moscow for 520 days to simulate a trip to Mars. The astronauts had to complete behavioral questionnaires weekly. One of the six reported depressive symptoms based on the Beck Depression Inventory. Two crew members who had the highest ratings of stress and exhaustion, also reported conflicts and sleep difficulties. Two crew members reported no adverse behavioral symptoms during the mission.

Wendy: So, I believe we’re done. We’ve covered Radiation, SANS, and behavioral health. I know this topic is probably unique for qWeek, but a lot of what we learn medically from our time in space does have applications to us on Earth. As a medical student advice, I have gotten from others in the field is pursue what you’re passionate about. Aerospace medicine is a growing field for clinicians from all specialties, so there’s no golden path to take. If you are interested more in this field, I highly recommend joining relevant associations specifically AsMA and AMRSO. And if you ever want to discuss aerospace medicine further, feel free to reach out to me at my Ross email!

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Conclusion: Now we conclude episode number 151, “Martian Medicine 102.” Future Dr. Collins explained that ocular issues are a potential problem when astronauts go to Mars, including Spaceflight-Associated Neuro-ocular Syndrome and vision impairments that would require changes in glass prescription, so, don’t forget to take extra pairs of glasses when you go to the red planet. Dr. Arreaza also joined the conversation by talking about the mental health challenges that many astronauts may face as they embark on a long trip to Mars in a secluded spacecraft. We look forward to more information on Martian Medicine as primary care on Mars may look surprisingly similar to primary care on Earth.

This week we thank Hector Arreaza and Wendy Collins. 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. Patel, Z.S., Brunstetter, T.J., Tarver, W.J. et al. Red risks for a journey to the red planet: The highest priority human health risks for a mission to Mars. npj Microgravity 6, 33 (2020). https://doi.org/10.1038/s41526-020-00124-6
2. Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022, from https://freemusicarchive.org/music/Scott_Holmes/. 

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 150: Re-update on COVID Vaccines and Cervical Cancer

COVID vaccines have been updated (again). The bivalent m-RNA COVID-19 vaccines are no longer authorized in the US. Sabrina explains that the monovalent COVID-19 vaccines will be available soon to target XBB lineage and more. Future Dr. Rodriguez explains the USPSTF cervical cancer screening guidelines. Dr. Arreaza adds comments and insight.  

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.

Celebrating our episode 150.

Written by Hector Arreaza, MD.

In our previous episode, we gave you an update on COVID-19 vaccines, but we need to give a new update. This is the risk you take when you try to become a news agency instead of an educational podcast, so you need to keep giving updates, and we’ll tell you about the newest change in COVID-19 vaccines in a few minutes. 

This is episode number 150! And I wanted to take a moment to celebrate this milestone. Our first episode was released a few days before the lockdown for COVID-19 on March 3, 2020. Those were gloomy days. I was excited about having a weekly podcast, but I also was overwhelmed by COVID-19. I remember considering putting a hold on the podcast, but I decided to continue. We had a few episodes about COVID-19 and, as expected for a novel disease, we made some mistakes. For example, we gave the wrong recommendations to not wear a mask at the very beginning of the lockdown, but that was the initial recommendation. However, I got to accentuate the positive, I’m proud that we were probably the first place to report hiccups as a symptom of COVID. Soon I realized it would be impossible to keep up with the daily changes in recommendations and updates on COVID, so we focused on other topics, and it has been a great experience so far. 

This podcast was created for the Rio Bravo residents, and thankfully the medical students have become the main collaborators of this program. I have enjoyed every second I have spent with all our guests, including residents, nurses, medical assistants, specialists, scientists, and of course medical students. I feel very fortunate to have reviewed many relevant topics of family medicine with you. A colleague once mentioned to me that I may run out of topics, but I think it is impossible to run out of topics in family medicine, don’t you think? So, I’m hoping to continue bringing to you brief discussions and pearls of knowledge every week. Now, let’s listen to Sabrina.

Re-update on COVID-19 Vaccines.

Written by Sabrina Hawatmeh, MSIII, Ross University School of Medicine.

Hi, my name is Sabrina Hawatmeh, I’m a 3rd-year medical student from Ross University School of Medicine. I’m so excited to be here today, huge thank you to Dr. Arreaza for having me here today! As mentioned by Dr. Arreaza, during our episode 149 we gave you an update on COVID-19 vaccines and now today it’s time for a new update. 

Most recently, Pfizer/BioNTech and Moderna have updated their vaccines to target specific strains of the virus, and the American Academy of Family Physicians has given its approval to federal actions allowing the use of these updated vaccines for the Fall/Winter of 2023. The decision follows FDA approval for these vaccines for children and adults aged 12 and older, as well as CDC recommendation of emergency use authorization for children aged 6 months to 11 years. The AAFP's Board Chair, Sterling Ransone, M.D., accepted the recommendation to approve these actions as of September 14th, 2023. The vaccines may be available soon for administration. 

Bivalent vaccines were the most recent formula administered for immunization. Studies had shown that there was continued protection against circulating sublineages of Omicron and XBB.1.5. However, the vaccine effectiveness against Omicron decreases over time. Neutralizing antibody titers against XBB sublineages via bivalent vaccines are lower compared to titers induced by the matched BA.4/BA.5 sublineage. 

So, it makes sense that all this data suggested that vaccine modification be directed toward more closely matched strain composition to current circulating sublineages. I also think it's worth noting that the original version of Omicron is no longer circulating—neither is the original strain of the SARS-CoV-2 virus. For that reason, updated vaccines were created by Moderna and Pfizer/BioNTech, so the bivalent vaccines are no longer authorized for use in the United States. 

The updated vaccine recommendations include eligibility criteria for different age groups, regardless of previous vaccination status, and specify the number of doses needed. The CDC has also updated its vaccine recommendations, especially for moderately or severely immunocompromised individuals. The new vaccines are monovalent mRNA vaccines, designed to protect against omicron subvariant, XBB 1.5. 

While the subvariant XBB.1.5 is the target of the vaccines, the expectation is that they will offer immunization against multiple current strains. (XXB lineage, EG.5.1 (Eris), Fl.1.5.1 (Fornax), BA.2.86). Moderna (randomized controlled trial of 101 individuals) and Pfizer (mouse studies) evidence suggests that the vaccines will also serve to protect against the new mutated subvariant that has recently sparked some concern, BA.2.86. 

As a reminder, FDA granted emergency use authorization for Novavax COVID-19 vaccine, Adjuvant in July 2022 for the prevention of COVID-19 pneumonia in patients aged 12 and older. Now the updated Novavax formula for 2023-2024 (targeting the XBB strain) was authorized by CDC on September 12, 2023, but it is still under review by the U.S. FDA for emergency use authorization for individuals aged 12 and older. When authorized, Novavax's protein-based vaccine will be the only non-mRNA COVID vaccine available in the U.S. 

These updated vaccines are expected to be covered by most public and private insurance plans, but concerns have been raised about uninsured individuals having to pay out of pocket for the vaccines, which cost $120 to $130. The AAFP urged the government to ensure equitable access and financial support for primary care practices offering these vaccines.

Cervical Cancer Screening Guidelines. 

Written by Adriana Rogriguez, MSIV, Ross University School of Medicine.

Arreaza: Cervical canceris the 3rd most common gynecological cancer in the US. For 2023, the American Cancer Society estimates that about 13,000 new cases of cervical cancer will be diagnosed, and more than 4,000 women will die this year. Cervical cancer was once one of the most fatal types of cancer in women, but the mortality rate has been significantly decreased with the increased use of pap smears and the HPV test. 

Adriana: Another fun fact is that cervical cancer is the only cancer preventable by a vaccine—the HPV vaccine.

Arreaza: Why is cervical cancer screening important?

Adriana: Cervical Cancer screening is very important as it reduces mortality due to cervical disease. Intervention at early stages reduces the development of squamous cell carcinoma or adenocarcinoma of the cervix due to HPV. In fact, studies have shown that in resource-poor settings, one cervical screening reduces the incidence of cervical cancer by up to 50%. 

Arreaza: What would prevent a patient from wanting to get a Pap smear?

Adriana: Many things can and do deter a patient from obtaining their cervical cancer screening. Patient discomfort and the psychosocial consequences of performing these screenings such as anxiety should be taken into consideration. Personal example. Also, a patient may be concerned about the costs, the effects of false-positive results, the risks of treatment during pregnancy (ex., increased risk/o 2nd-trimester pregnancy loss, PPROM, preterm delivery, perinatal mortality). 

Arreaza: We should mention the cultural implications of a pap smear in a 21-year-old who is considered a “virgin”. Some cultures try to preserve the hymen intact as a sign of purity. You can address this concern with your patients and explain that a hymen is not always present, it may be easily ripped by sports, biking, tampon use, and more. A small speculum may be used for your patients who have never been sexually active at age 21. 

Arreaza: We perform screening BEFORE we diagnose a disease. The age of diagnosis of cervical cancer is age 50, most patients fall between 35 and 45 years old. How can we determine who is at risk and needs a pap smear? 

Adriana: When looking at cervical screening guidelines and recommendations, we are looking at the patient who is: 

1. At average risk for cervical disease – a patient who is asymptomatic, immunocompetent, and has had all previous cervical cancer screening results within normal limit.
2. At sufficiently low-risk for cervical disease and can return to routine age-based screening: 
   1. <25 yo with Atypical Squamous Cells of Undetermined Significance (ASCUS) and  HPV(-).
   2. <25 yo with low-grade squamous intraepithelial lesion (LSIL), or ASCUS with HPV(+), followed by 2 consecutive (-) cytology results.
   3. >25 yo with LSIL, following colposcopy w/o CIN 2 or worse AND following consecutive co-testing results (-) x3.

Arreaza: Those are the patients we are going to screen for cervical cancer. Let’s start with the basics of the United States Preventive Services Task Force (USPSTF) guideline. We start screening at age 21 regardless of sexual activity.

Adriana: Yes 

• <21: No screening in asymptomatic, immunocompetent patients, regardless of age of initiation of sexual activity. Adolescents are more likely to clear HPV infection and associated abnormalities.

Arreaza: Actually, the treatment of CIN2 and CIN3 before age 21 may increase the risk of adverse pregnancy outcomes.

Adriana: 21-29: begin at age 21, cervical cytology Q3yrs.

• USPSTF recommends Cytology > HPV testing (primary or co-testing) because of higher rates of false-positives from higher rates of transient infection in this particular age-group; it is not adjusted for HPV-vaccination status.

Arreaza: Tell me about patients older than 30.

Adriana: 30-65: Primary HPV testing (FDA approved test) Q5yrs, Co-testing (Pap AND HPV) Q5yrs, or Pap test alone Q3yrs. 

• Here we have options, and the USPSTF does not recommend one method over the other regardless of vaccination status and still recommends screening even if the patient reports sexual abstinence. 

Arreaza: The most common method in our clinic is: 

• Pap + HPV (contesting) every 5 years after age 30. 

What about the grandmas older than 65?

Adriana: >65: Both USPSTF and ACS suggest discontinuing screening in average-risk patients if she has had adequate screening with NORMAL results. Discontinuing screening predicated on meeting both following criteria: 

1. No history of CIN 2 or higher for the past 25 yrs.
2. Adequate prior screening: 
   • 2 consecutive (-) primary HPV tests or co-testing w/n past 10 yrs, most recent w/n past 5 yrs.
   • 3 consecutive (-) Pap tests w/n past 10 yrs, most recent w/n 3 yrs. 
   • If results of screening w/n prior 10 yrs is not known à not adequate à Screen.

Arreaza: The guidelines also recommend keeping routine screening for at least 20 years after spontaneous regression or appropriate management of a precancerous lesion, even if the patient turns 65 years of age.

Adriana: Data for stopping age for cervical cancer screening are limited. Other countries use older age to stop screening. For example, Australia has the lowest cervical cancer mortality rate in the world, and their guidelines recommend discontinuing screening at 74 yo. With that said, some clinicians continue to offer screening through age 74 for those w/ life expectancy of at least 10 yrs. Conversely, screening can also be d/c’d for patients w/ limited life expectancy.

Arreaza: Who does not get screened?

Adriana: Women before age 21 or older than 65 who have had adequate screenings, as we just described a few moments ago, and Patients s/p hysterectomy for benign disease. 

Arreaza: You mentioned patients s/p hysterectomy receive different screening.

Adriana: Yes, they do! 

• If a Patient has a hysterectomy for benign dz: Routine screening not performed. However, there is a caveat. If they have HIV-related disease progression (for example, viral count increases, or CD4 decreases), then Q1yr screening w/ Pap test or co-test and pelvic exam is indicated. 
• Then if a Patient had a hysterectomy because of Invasive cervical cancer their surveillance is different. They receive PET/CT imaging 3-6mos post-treatment; H&P Q6-12 mos x5 years w/ cervicovaginal cytology Qyearly if no radiation therapy, or w/o cervicovaginal cytology if previously received radiation therapy.

Arreaza: You mentioned that the guidelines earlier were for patients at average risk for cervical disease. What would make a Patient high risk?

Adriana: High risk patients include patients with immunosuppression, ie., a person whose immune system cannot fight off hrHPV, and is at higher risk of developing squamous cell carcinoma or adenocarcinoma of the cervix later on. Also at high risk are patients with in-utero exposure to di-ethyl-stilbestrol (DES).

Arreaza: Let’s review the recommendation for patients who are immunosuppressed.

Adriana: HIV Patients and Immunosuppressed patients w/o HIV: 

• Receive both screening and colposcopy at the time of diagnosis, and between 21-29 yo are screened with cervical cytology every year x3, if normal perform cytology every 3 years. >30yo cytology or co-testing. Primary HPV testing is not approved in Patients w/ HIV. 
• Subsequent screening: continues through lifetime and does not end at 65 yo.

Arreaza: Normal: Sample was adequate for evaluation and the report may state: Negative for intraepithelial lesion. What is considered an abnormal result?

Adriana: Results are abnormal if any of the following occur: 

1. Pap test satisfactory for evaluation but limited
2.  Pap test unsatisfactory
3.  ABNL HPV testing but NL Pap testing
4.  ABNL HPV testing w/o Pap test 
5.  ABNL Pap results (ASCUS, LSIL, HSIL, Atypical and malignant glandular cells)
6.  Cervical cancer

These are all a wide array of results and considered abnormal, but receive different surveillance and or treatments. 

Arreaza: So, what happens if the average Patient has a history of abnormal cervical cancer screenings? 

Adriana: These patients are now managed w/ active surveillance, not screening. It gets a little complicated and out of the scope of this episode.

Arreaza: At this point, I recommend to our listeners to download the ASCCP app. 

Adriana: Conclusion: Pap smear is one the strongest arsenals in the physicians’ toolbox. Start screening at age 21, until 65 years old.
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Conclusion: Now we conclude episode number 150, “Re-update on COVID Vaccines and Cervical Cancer.” Sabrina gave a very good summary of the updated COVID vaccines, and we are hoping to have good coverage for the most common strains. Make sure you get your updated vaccine as it becomes available soon. Future Dr. Rodriguez explained that pap smears and HPV tests are some of the most powerful tools we have to prevent cervical cancer. Dr. Arreaza added some ideas about how to overcome the cultural barrier to start screening at the age of 21.

Today we celebrate our episode 150! We look forward to many more episodes in the future! This week we thank Hector Arreaza, Sabrina Hawatmeh, and Adriana Rodriguez. 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. Feldman, MD, MPH, Sarah, et al. “Screening for cervical cancer in resource-rich settings.” UpToDate, Aug 28, 2023. https://www.uptodate.com/contents/screening-for-cervical-cancer-in-resource-rich-settings
2. Recommendation: Cervical Cancer: Screening, United States Preventive Services Taskforce, August 21, 2012. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening
3. Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022, from https://freemusicarchive.org/music/Scott_Holmes/. 

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 149: COVID Vaccines Update [Historic episode].  

Future Dr. Williams presented an update on COVID-19 vaccines. This update is only for immunocompetent individuals, and it was recorded on August 24, 2023. Dr. Arreaza added comments and insight.  

Written by John Williams, MS4, Ross University School of Medicine. Editing by Hector Arreaza, M.D.  

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.

Currently, there are two types of vaccines that have been approved by the FDA:

• Moderna and Pfizer developed mRNA vaccines.
• Novavax developed a lesser-known protein subunit vaccine.
• As of May 6, 2023, the vaccine developed by Johnson & Johnson has expired and is not available in the U.S.

Novavax: This vaccine contains pieces (proteins) of the virus that causes COVID-19, the spike protein plus an adjuvant. It works by activating the immune system against the spike protein, so it will be ready to fight the actual virus when you get infected. 

Regardless of vaccine type, the shots are administered in the upper arm and have been demonstrated, for most people, to be safe and effective. There have now been hundreds of million vaccines administered in the US alone and the effectiveness of the vaccine to reduce the risks of severe illness, hospitalization, and death has been well documented. The most common side effects consist of mild to moderate cases of fever, chills, headache, and tiredness that are self-resolving.

What is new about COVID-19 Vaccines?

The updated vaccine is known as “bivalent”. This term is important because it refers to the vaccine’s ability to confer protection against both the original COVID-19 virus as well as new variants Omicron BA.4 and BA.5. Rollout of the updated vaccine began in September 2022 for those aged 12 years and older and became widespread in March 2023 with approval granted for use in children aged 6 months – 4 years. Selected individuals over age 65 or those who are immunocompromised may receive additional doses to provide comparable and safe protection. The receipt of the updated vaccine supersedes any previous doses and provides coverage against the most recent known variants determined to be either most widespread or that have been projected to be more prevalent.

• Children aged 6 months – 4 years who received the original Pfizer vaccine
  • Those who received either 2 or 3 doses of the original vaccine should receive 1 dose of the updated vaccine.
  • Those who received 1 dose of the original vaccine should receive 2 doses of the updated vaccine.
  • You are considered up to date if you have received 3 vaccine doses, including at least 1 updated dose.
• Children aged 5 years who received the original Pfizer vaccine
  • Those who received 1+ doses of the original vaccine should receive 1 dose of the updated vaccine.
  • You are considered up to date if you have received at least 1 updated dose.
• Children aged 6 months – 4 years who received the original Moderna vaccine
  • Those who received either 2 or 1 dose(s) of the original vaccine should get 1 updated vaccine.
• Children aged 5 years who received the original Moderna vaccine
  • Those who received either 2 or 1 dose(s) of the original vaccine should get 1 updated vaccine.
• Unvaccinated children 6 m-4 years should receive the new bivalent vaccine, 2 doses of
  • Moderna or 3 doses of Pfizer, but if you are 5 years old and unvaccinated, you will receive 1 dose of Pfizer or 2 doses of Moderna.

For 6-11 yo patients who have been vaccinated with 1 or more doses of monovalent (Moderna or Pfizer) will receive 1 dose of Bivalent Moderna or Pfizer. If you already received 2 monovalent doses and 1 bivalent dose, you are done, no more vaccines are needed. If you have not received any COVID-19 vaccine and you are in this age group (6-11 yo), you only need 1 bivalent dose, and you are done.

>12 yo and Adults. If you received 1 or more doses of monovalent or if you are not vaccinated, you need 1 dose of bivalent (Pfizer or Moderna). If you already had 2 doses of monovalent and 1 dose of bivalent, you are done!

An FDA advisory committee convened on June 15, 2023, to discern the importance for additional updates to the most recent COVID-19 vaccine series. It was determined that the latest circulating variant currently making rounds is from the Omicron group known as XBB. The committee decided it is prudent to proceed with a preference for the XBB 1.5 variant. The updated vaccine will be a monovalent version available in the Fall of 2023. As with the previous version, the FDA will provide strict oversight and safety monitoring of the vaccine.

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Conclusion: Now we conclude episode number 149, “COVID Vaccines Updates.” Future Dr. Williams explained that the bivalent COVID vaccines are currently recommended for unvaccinated patients, or for those who were previously vaccinated with monovalent vaccines. This episode focused on patients who are NOT immunocompromised. We encourage our audience to check the CDC website for recommendations about patients who are immunocompromised.

As a clarification, our sub-intern, John Williams, has a great sense of humor and he claimed to be the composer of the music for many famous Hollywood movies. We don’t doubt his musical talent, but we must make clear that it was a joke! 

This week we thank Hector Arreaza and John Williams. 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. Tin, Alexander, New COVID vaccine and booster shots for this fall to be available by end of September, CBS Texas, published online on August 9, 2023. https://www.cbsnews.com/texas/news/covid-vaccine-booster-xbb-variants-september-2023/, accessed on September 7/, 2023.
2. Center for Disease Control and Prevention, Overview of COVID-19 Vaccines, updated May 23, 2023, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/overview-COVID-19-vaccines.html, accessed on September 7, 2023.
3. Updated COVID-19 Vaccines for Use in the United States Beginning in Fall 2023, United States Food and Drug Administration. https://www.fda.gov/vaccines-blood-biologics/updated-covid-19-vaccines-use-united-states-beginning-fall-2023, accessed on September 7, 2023.
4. Royalty-free music used for this episode: Gushito - Latin Chill. Downloaded on July 29, 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 148: Leg Cramps

Future Dr. Weller explains the pathophysiology, management, and prevention of leg cramps. Hector Arreaza adds comments and anecdotes about leg cramps.  

Written by Olivia Weller, MS4, American University of the Caribbean 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.

Definition: Known also as “Charlie horses,” leg cramps are defined as recurrent, painful, involuntary muscle contractions. They can last anywhere from seconds to several minutes, with an average of nine minutes per episode. They are usually nocturnal and thus may be associated with secondary insomnia. 

Location: A muscle cramp can happen in any muscle in the body, but they occur most commonly in the posterior calf muscles, but they can also involve the thighs or feet. They are more common in women than men and the risk increases with age.Although they are experienced by 7% of children and up to 60% of adults, the exact mechanism remains unknown and there is no definitive treatment at this time. 

Pathophysiology

There is one leading hypothesis for nocturnal cramps that occur in the posterior calf muscles, and it is related to your sleeping position. When you are laying down in bed your toes are pointed which causes passive plantar flexion while the muscle fibers are shortened maximally. This causes uninhibited nerve stimulation with high-frequency involuntary discharge from lower motor neurons, which causes cramping. 

Another possible etiology is nerve damage because neurologic conditions such as Parkinson’s disease are associated with a higher-than-normal incidence of cramps. Peripheral neuropathy, or damage to the connection between motor nerves and the brain can lead to hyperactive nerves when they are not being properly regulated. Thus, diabetes mellitus is a major risk factor for nocturnal cramps due to the high blood sugar levels damaging the small blood vessels which supply the muscles. 

Decreased blood flow has also been attributed as a cause of leg cramps. People with diseases that affect their vasculature, such as varicose veins or peripheral arterial disease also have a higher incidence of leg cramps. Decreased blood flow to the muscles means less delivery of oxygen and nutrients to the muscles which makes them more susceptible to fatigue. 

Muscle overuse is one of the dominant explanations for cramping. This can be related to doing too much high-intensity exercise without adequate stretching before and after. Pregnant women have added weight which puts extra strain on the muscles, along with sitting or standing for long periods of time, poor posture and flat feet. Notably, when we age, our tendons naturally shorten and they cannot work as hard, or as quickly which makes them more susceptible to overuse. 

Additionally, there are mineral deficiencies such as magnesium and potassium or decreased levels of B and D vitamins. With this in mind, people with renal failure that are on hemodialysis have an increased risk of nocturnal leg cramps. And finally, we have medications, some of which are related to mineral deficiencies. The main contributors are statins, diuretics, conjugated estrogens, gabapentin or pregabalin, Zolpidem, clonazepam, albuterol, fluoxetine, sertraline, raloxifene, and teriparatide (analog for parathyroid hormone). 

Management and prevention

There is no magic treatment to make them go away immediately, however, there are different remedies you can try to help facilitate. My Grandma told me about an old wives' tale, that if you put a bar of soap in your bed at your feet while you sleep, you won’t get cramps at night. Maybe it works by the placebo effect, maybe there's a mechanism going on there I don't understand who knows, I’ll have to do a study on it. 

If you get them very often, you can keep a foam roller or a heating pad next to your bed in preparation for when they come. Stretching the muscle is known to be very effective, as well as applying heat or ice to the affected area. You can also try massaging the muscle with your hands or getting out of bed to stand or walk around. Elevating the leg while laying down in bed can also be beneficial. 

In terms of prevention, you can try out different sleeping positions to see if one works better for you. If you usually sleep on your back, you can stick a pillow under your feet to help keep your toes pointed upward. Or, if you sleep on your stomach you can try to keep your feet hanging off the bed. Another tip is loosening the sheets or blankets around your feet. 

Daily stretching, especially before and after exercise as well as before bed is useful. Make sure to exercise, stay hydrated, and limit your alcohol and caffeine consumption. You also want to wear supportive shoes or use orthotic inserts in your shoes, especially if you spend lots of time on your feet during the day. 

Medications/supplements: Since various deficiencies can cause cramps, one way to prevent them is to take supplements such as magnesium, vitamin D, and B12 complex. And as a last resort, you can try medications. Calcium channel blockers such as diltiazem or verapamil have been used, and muscle relaxants including Orphenadrine (Norflex®) and Carisoprodol (Soma®). 

Gabapentin is an anticonvulsant commonly used as a neuropathic pain medication; this used to be used to treat leg cramps but later it was found that they can actually increase the frequency of muscle cramps so they are no longer used. Quinine was also used for many years to treat leg cramps; however, it is no longer recommended because of drug interactions and serious hematologic effects such as immune thrombocytopenic purpura (ITP) and hemolytic uremic syndrome (HUS). 

Summary: Leg cramps are common, the pathophysiology is unclear, but may be related to problems with blood flow, the nervous system, sleeping position, and muscle overuse. Treatment includes nonpharmacologic therapies such as changes in sleeping position, heat, and massaging; and medications/supplements that may be useful include Carisoprodol (Soma®), diltiazem, gabapentin (Neurontin), magnesium, orphenadrine (Norflex®), verapamil, and vitamin B12 complex.

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Conclusion: Now we conclude episode number 148, “Leg Cramps.” Future Dr. Weller explained that the etiology of leg cramps is multifactorial. Some theories about why leg cramps happen include poor circulation, muscle overuse, dysfunctions in the nervous and musculoskeletal systems, electrolyte imbalances, mineral deficiencies, and more. Some therapies were discussed, including changes in position while sleeping, massage, heat pads, and medications such as calcium channel blockers, muscle relaxants, and supplements of magnesium and Vitamin B12. Gabapentin is a medication that can cause leg cramps, but some sources recommend it as a treatment as well. 

This week we thank Hector Arreaza and Olivia Weller. 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. Leg Cramps. Cleveland Clinic. (2023, May 6). https://my.clevelandclinic.org/health/diseases/14170-leg-cramps
2. Allen, R. E., & Kirby, K. A. (2012, August 15). Nocturnal leg cramps. American Family Physician. https://www.aafp.org/pubs/afp/issues/2012/0815/p350.html
3. Mayo Foundation for Medical Education and Research. (2023, March 2). Night leg cramps. Mayo Clinic. https://www.mayoclinic.org/symptoms/night-leg-cramps/basics/definition/sym-20050813
4. Royalty-free music used for this episode: Simon Pettersson - Good Vibes_Sky's The Limit_Main. Downloaded on July 29, 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 147: Routine Prenatal Care

Written by Elika Salimi, MSIV. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments and editing by Hector Arreaza, MD.

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

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Elika: So, we’re going to talk about some general principles of prenatal care and some of the most important diagnostic methods that we mainly use for taking care of pregnant women. I will forewarn you that there will be a ton of details in this talk, and I do recommend possibly taking notes as things can get easily confusing. This way you can have something to refer back to whenever you have a pregnant patient of your own.

Arreaza: You can also download the episode notes from our website.

Elika - So your patient is pregnant and she comes to you for care. How do we go about it? Well, this is assuming she had it at home urine pregnancy positive test and we got a blood hCG on her and everything’s good and we know she’s pregnant. Ok so now what happens next?

Arreaza – We need to confirm the patient wants to keep the pregnancy.

Elika - First, we’re going to talk about the frequency of the check-ups. In this case, we are talking about a situation where the mother is coming to her appointments as she was supposed to but we all know that sometimes that doesn’t happen if everything is going as it is supposed to then typically we get the initial examination at about 10 weeks of gestation and then until the 28th week there should be monthly visits, then from the 28th through the 36th there should be biweekly visits, and from the 36th week until birth, the visits are every week.

Areaza – What´s next?

Elika - Now I’d like to note that during the prenatal period, informed consent is very important and it should be obtained during this time because you want to prevent and manage any ethical conflicts that might exist between the mother and possibly the healthcare providers because we all know that any pregnancy can become high-risk at some point and pregnant individuals should be informed about the potential need for a c-section for example and be encouraged to discuss any concerns ahead of time. 

Elika - Now while we’re talking about ethics, if the doctor finds him/ or herself in a situation where the patient is asking for something that the Dr does not feel comfortable with such as a certain type of treatment or a certain method of delivery or if they’re, let’s say, desiring an abortion and the doctor doesn’t do abortions, then in this case you would refer the patient to a physician that is comfortable with the patient’s desired outcome or treatment. And this is perfectly legal and fine just as long as you help the patient find somebody else. 

Arreaza – Abortion is legal in most states, but check your local regulations.

Elika - So as mentioned earlier, the initial visit occurs at about 10 weeks of gestation. We start with checking their personal and family history and finding out about any previous pregnancies including at what GA baby born and weight if they know, any complications, gestational diabetes or preeclampsia, any history of postpartum hemorrhage requiring blood transfusion, any abortions (if present at what GA), and the method of deliveries, whether it was vaginal or a cesarean and what kind of C-section they had done. These are very important for you to obtain from your patient. You will also assess for depression and domestic partner violence.

Arreaza – In California, we have a wonderful service called CPSP: Comprehensive Perinatal Services Program. What comes next? 

Elika - Upon receiving the history, we will do the gynecological examination and send in some samples. We will also send her to do some lab work. Now what do those labs entail? Well, we are going to get a CBC such as screening for anemia, we will also do TSH but only in people who have possible signs of thyroid disorder so not everybody needs to get this. And, we are going to send for a blood typing to find out about their ABO group and the Rhesus status. 

We will also obtain a urine analysis to screen for proteinuria and asymptomatic bacteriuria because in pregnancy, unlike outside of pregnancy, you do need to treat asymptomatic bacteriuria. We will also ensure that the mother is on prenatal vitamins, so folic acid, if not already, and iron, if indicated, and vitamin B6 if the patient has signs of nausea or hyperemesis gravidarum and this can be combined with doxylamine. Usually, pregnant women don’t get a glucose screening test at the first visit unless let’s say they have high risk of diabetes or they there was glucose in the urine. 

Arreaza – I like the topic of diabetes in pregnancy. So, in a high-risk population, we want to make sure a pregnant patient does not have diabetes, or pregestational diabetes.

Elika - We will also screen for STI’s including HIV, syphilis, hepatitis B, Hep C, and we also check for gonorrhea and chlamydia (pap) screening particularly in those under 25, or over 25 with high risk of infection. We will also test for rubella and varicella. Some places also order a QuantiFERON gold for tuberculosis. There are certain women that have indications for third-trimester screening for STI’s on top of the ones that they already got in their first trimester. Those include chlamydia, gonorrhea, HIV, syphilis, and Hep B, and C but each of those have its own indications so for the purposes of time I will let you look that up on your own.

Arreaza – Summary: Physical exam and labs to rule out preexisting conditions that may interfere with pregnancy, either infectious or metabolic, to mention some diseases. 

Elika - And finally, we will do an ultrasound assessment to get a more accurate reading of the fetus’s gestational age.

Arreaza – What comes after the first trimester?

Elika- So like I mentioned they’re going to need to be following up and some particular things need to be done at specific weeks. So we are going to discuss those. 

At every follow visit you need to obtain: the patient’s weight, BP and other vitals, fetal heart sounds, the baby’s measurement from the mother’s pubic symphysis up until the fundus of the uterus, as well as a urine analysis to check for any glucose or protein in the urine because we are always concerned of possible preeclampsia or gestational diabetes. 

Another examination that I should mention is a Doppler ultrasound and this is usually indicated if there is suspected fetal growth restriction or if there’s pregnancy-induced hypertension or if there’s suspected fetal deformities or there is growth discordance in multiple pregnancies.

Now we are going to discuss assessing for any abnormalities in the fetus. All pregnant women regardless of age should be offered noninvasive and aneuploidy screening test before 20 weeks of gestation. The 1st trimester combined screening occurs at about 10 to 13 weeks gestation, where we can order some blood tests for the mom such as the amount of hCG in maternal serum, as well as PAPP-A, on top of nuchal translucency that will see on the ultrasound. 

There is also the triple screen at 15-20 weeks which consists of ordering hCG, alpha-fetoprotein aka AFP, and estriol then there’s also the quad screen test at 15-22 weeks gestation that consists of hCG, AFP, Estriol and Inhibin A. We also have the cell free fetal DNA testing that can occur after 10 weeks gestation at which the fetal DNA is isolated from the maternal blood specimen for genetic testing and this one actually happens to be the most sensitive and specific screening test for common fetal aneuploidies, and it is used for secondary screening after the ultrasound.

Arreaza – Actually that test is done in all our patients on Medi-Call (cfDNA).

Elika - If any of the screening tests are abnormal then we can provide counseling to mothers for more invasive diagnostic tests such as chorionic villus sampling, amniocentesis, and cordocentesis. At that point, you want to refer the patient to perinatology. 

Finally, in general an anatomical scan occurs ~18-22 weeks. 

Arreaza – Excellent, we have done the non-invasive genetic screening. What’s next? 

Elika - Now we are going to talk about what happens in the third trimester specifically and what test you need to order. In the third trimester, you will order a CBC again, particularly at 24 weeks you want to do a repeat hemoglobin. We will also do the indicated repeat STI checks. We are also going to do gestational diabetes screening with the oral glucose test that I briefly mentioned earlier at around 24-28 weeks. 

This is usually done with a 50g 1 hr glucose tolerance test and if abnormal then a 100g 3 hour glucose test. You will also be repeating the Rh antibody just to make sure that the mother is still Rh negative because at 28 weeks, Rh negative mother should be administered RhoGAM 300 mcg intramuscularly and they need to get it again within 72 hours of delivery. 

Don’t forget to give a TDAP vaccine at 27 weeks. 

And at 36 weeks you need to be obtaining a GBS culture (vaginal and rectal) for the patient just to make sure that there is no colonization because if there is then the patient is going to need GBS prophylaxis at admission because colonization by these bacteria can cause chorioamnionitis and neonatal infection such a sepsis. 

Overall when third trimester approaches you’re going to make sure the plans for delivery have been properly scheduled or discussed with the patient and typically around 34 weeks you also want to check with your patient to see if they desire sterilization and obtain a consent if they will be having a C-section and they want to be sterilized after that. In those not requesting sterilization, it is a good idea to discuss what they want to do after this pregnancy for birth control since it is not safe to get pregnant again for another year. From 36 weeks' gestation, use Leopold maneuvers for assessment of fetal presentation but I'll let you look that up on your own. At this time, you may also use ultrasound as needed to confirm fetal lie and placental position.

Patients with maternal conditions such as gestational diabetes or gestational hypertension/pre-eclampsia, or fetal condition such as heart defects or fetal growth restriction need to get biweekly NST/BPP tests at clinic in the third trimester because there is an increased risk of fetal hypoxic injury or death. 

An NST is basically a non-stress test that measures fetal heart rate reactivity to fetal movements. BPP /biophysical profile is a noninvasive test that evaluates the risk of antenatal fetal death usually after the 28th gestational week and what it consists of is the ultrasound assessment of fetal movement, fetal tone, fetal breathing, and amniotic fluid volume or we can also perform a contractions stress test that basically measures fetal heart rate reactivity in response to uterine contractions. 

Arreaza – I like talking about obesity. Weight gain is expected during pregnancy. Patients with normal weight are expected to gain 25-35 pounds. Patients with obesity are recommended to gain 11-20 only.

Summary: Now I know that this was very extensive talk with a ton of details but if you took notes and refer back to it then I think things will somewhat make more sense and come together that way. The best thing we can do is try to adhere to guidelines to make sure that we don’t miss anything. Sometimes it could be particularly difficult to manage patients that don’t or can’t come to their appointments regularly and you may sometimes have to give them bad news and what not so overall it is not always happy moments we face but the best we can do is try to give them the best care possible to avoid complications and have the patient deliver a healthy baby. Thank you for listening to me once again and hopefully I’ll be back again soon on another talk on an OB/GYN related topic soon. Thank you very much. 

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Conclusion: Now we conclude episode number 147, “Routine Prenatal Care.” Future Dr. Salimi gave an excellent summary of the care provided during the different trimesters of pregnancy. Remember to collect a detailed history, perform a comprehensive physical exam, and order the labs to rule out pre-existing conditions that could interfere with pregnancy or detect complications early to start timely interventions or refer to a higher level of care. 

This week we thank Hector Arreaza, Elika Salimi, and Verna Marquez. 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. AAP, ACOG. Guidelines for Perinatal Care. American College of Obstetricians and Gynecologists Women's Health Care Physicians; 2017
2. Zolotor AJ, Carlough MC. Update on prenatal care. Am Fam Physician. 2014; 89(3): p.199-208. pmid: 24506122.
3. World Health Organization. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization; 2016
4. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR. Recommendations and Reports. 2021; 70(4): p.1-187. doi: 10.15585/mmwr.rr7004a1
5. Murray ML, Huelsmann G, Koperski N. Essentials of Fetal and Uterine Monitoring. Springer Publishing Company; 2018
6. Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/.

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 146: RA vs OA    

Future Dr. Magurany explains how to differentiate rheumatoid arthritis from osteoarthritis.  

Written by Thomas Magurany, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.

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

1. Etiology:

 

Rheumatoid Arthritis (RA):

 

RA is an autoimmune disease wherein the immune system mistakenly attacks healthy tissues, particularly the synovial joints, usually between the ages of 30-50. Genetic predisposition, environmental factors such as smoking or infections, hormonal imbalances, and lower socioeconomic status have been associated with an increased risk of developing RA(1).

Osteoarthritis (OA):

 

OA primarily arises due to mechanical stress on the joints over time. Factors contributing to OA include age, obesity, joint injury or trauma, repetitive joint use or overuse, genetic abnormalities in collagen structure, and metabolic disorders affecting cartilage metabolism (2).

The greatest risk factor for the development of OA is age with most patients presenting after 45 years of age. The greatest modifiable risk factor for OA is weight. People with a BMI >30 were found to have a 6.8 times greater risk of developing OA. (3) 

Primary

 OA is the most common and is diagnosed in the presence of associated risk factors such as: older age, female gender, obesity, anatomical factors, muscle weakness, and joint injury (occupation/sports activities) in the absence of trauma or disease. 

Secondary

 OA occurs alongside a pre-existing joint deformity including trauma or injury, congenital joint disorders, inflammatory arthritis, avascular necrosis, infectious arthritis, Paget disease, osteopetrosis, osteochondritis dissecans, metabolic disorders (hemochromatosis, Wilson’s disease), Ehlers-Danlos syndrome, or Marfan syndrome.

2. Pathogenesis:

Rheumatoid Arthritis (RA):

In some patients, RA is triggered by some sort of environmental factor in a genetically predisposed person. The best example is tobacco use in a patient with HLA-DRB1. The immune response in RA starts at sites distant from the synovial joints, such as the lung, gums, and GI tract. In these tissues, modified proteins are produced by biochemical reactions such as citrullination. (4)
In RA, an abnormal immune response leads to chronic inflammation within the synovium lining the joints. The inflammatory cytokines released cause synovitis and lead to the destruction of articular cartilage and bone erosion through pannus formation. Immune cells infiltrate the synovium causing further damage. (4) In summary: formation of antibodies to citrullinated proteins, these antibodies begin attacking wrong tissues.

Osteoarthritis (OA):
The primary pathological feature of OA is the degeneration of articular cartilage that cushions the joints causing surface irregularity, and focal erosions. These changes progress down the bone and eventually involve the entire joint surface. Mechanical stress triggers chondrocyte dysfunction, leading to an imbalance between cartilage synthesis and degradation that cause cartilage outgrowths that ossify and form osteophytes. This results in the release of enzymes that degrade the extracellular matrix, leading to progressive cartilage loss. As more of the collagen matrix is damaged, chondrocytes undergo apoptosis. Improperly mineralized collagen causes subchondral bone thickening; in advanced disease, bone cysts infrequently occur (5). In summary: Osteophytes formation and cartilage loss.

3. Clinical Presentation:
Rheumatoid Arthritis (RA):

The most common and predominant symptoms include joint pain and swelling, usually starting insidiously over a period of weeks to months. 
RA typically affects multiple joints symmetrically, commonly involving small joints of the hands, wrists, feet and progresses to involve proximal joints if left untreated. Morning stiffness lasting more than an hour is a characteristic feature. The affected joint will be painful if pressure is applied to the joint or on movement with or without joint swelling. Synovial thickening with a "boggy" feel on palpation will be noted. The classical physical findings of ulnar deviation, metacarpophalangeal joint subluxation, swan neck deformity, Boutonniere deformity, and the "bowstring" sign (prominent and tight tendons on the dorsum of the hand) are seen in advanced chronic disease. (4) Around ¼ of patients with RA may present with rheumatoid noduleswhich are well demarcated, flesh-colored subcutaneous lumps. They are usually described as being doughy or firm and are not typically tender unless they are inflamed. They are usually found on areas susceptible to repeated trauma or pressure and include the elbows, fingers and forearms. 

Osteoarthritis (OA):

OA primarily affects weight-bearing joints such as knees, hips, spine, and hands. Symptoms include joint pain aggravated by activity and relieved with rest, morning stiffness lasting less than 30 minutes, joint swelling due to secondary inflammation, and occasionally the formation of bony outgrowths called osteophytes (6). Tenderness may be present at joint lines, and there may be pain upon passive motion. Classic physical exam findings in hand OA include Heberden’s nodes (posterolateral swellings of DIP joints), Bouchard’s nodes (posterolateral swellings of PIP joints), and “squaring” at the base of the thumb (first Carpal-Metarcapal or CMC joints), bony enlargement, 

crepitus, effusions

 (non-inflammatory), and a limited range of motion. Patients may also experience bony swelling, joint deformity, and instability (patients complain that the joint is “giving way” or “buckling,” a sign of muscle weakness). (5)

4. Lab findings:

Rheumatoid Arthritis: 

Laboratory testing often reveals anemia of chronic disease (increased ferritin, decreased iron and TIBC) and thrombocytosis. Neutropenia may be present if Felty syndrome is present. RF is present in 80-90% of patients with a sensitivity of 69%. In patients who are asymptomatic or those that have arthralgias, a positive RF and especially CCP predicts the onset of clinical RA. Patients with RA with RF, ACPA, or both are designated as having seropositive RA. About 10% of RA patients are seronegative. ESR and levels of CRP are usually elevated in patients with active disease and can be used to assess disease activity. The synovial fluid in RA will also reveal low C3 and C4 levels despite elevated serum levels.(4) Some non-specific inflammatory markers such as ESR, CRP can help you guide your diagnosis of RA.

Osteoarthritis:

Lab findings are not significant. Clinical diagnosis if the following are present: 1) pain worse with activity and better with rest, 2) age more than 45 years, 3) morning stiffness lasting less than 30 minutes, 4) bony joint enlargement, and 5) limitation in range of motion. Blood tests such as CBC, ESR, rheumatoid factor, ANA are usually normal but usually ordered to rule out an inflammatory process. Synovial fluid should show a white blood cell count less than 2,000/microL, predominantly mononuclear cells (non-inflammatory). X-rays of the affected joint can show findings consistent with OA, such as marginal osteophytes, joint space narrowing, subchondral sclerosis, and cysts; however, radiographic findings do not correlate to the severity of the disease and may not be present early in the disease. (5)

5. Treatment Approaches:

Rheumatoid Arthritis (RA):

There is no cure for RA.
The goal of treatment in RA is inducing remission and optimizing quality of life. This is initially done by beginning DMARDs, include methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide. Methotrexate is the initial DMARD of choice. Anti-TNF-alpha inhibitors include etanercept, infliximab, adalimumab, golimumab, and certolizumab may be used if DMARDs fail. NSAIDs are used to control joint pain and inflammation. Corticosteroids may be used as a bridge therapy to DMARDs in a newly diagnosed patient with a very active disease. (7) 

Coronary artery disease has a strong association with RA. RA is an independent risk factor for the development of coronary artery disease (CAD) and accelerates the development of CAD in these patients. Accelerated atherosclerosis is the primary cause of morbidity and mortality. There is increased insulin resistance and diabetes mellitus associated with RA and is thought to be due to chronic inflammation. When treated with specific DMARDs such as hydroxychloroquine, methotrexate, and TNF antagonists, there was a marked improvement in glucose control in these patients. (8) RA is not just a disease of the joints, it is able to affect multiple organ systems.

Osteoarthritis (OA):

OA treatment aims at reducing pain and improving joint function through a combination of non-pharmacological interventions like exercise programs tailored to strengthen muscles around affected joints, weight management strategies, and assistive devices like braces or walking aids if required (9). Medications including analgesics or nonsteroidal anti-inflammatory drugs may be prescribed for pain relief when necessary. Duloxetine has modest activity in relieving pain associated with OA. Intraarticular glucocorticoid joint injections have a variable response but are an option for those wanting to postpone surgical intervention. In severe cases where conservative measures fail, surgical options like joint replacement may be considered (9). Weight loss is a critical intervention in those who have overweight and obesity; each pound of weight loss can decrease the load across the knee 3 to 6-fold. (5) Summary: Medications (NSAIDs, topical, duloxetine), weight loss, PT, intraarticular injections of corticosteroids, and joint replacement.

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Conclusion: Now we conclude episode number 146, “RA vs. OA.” Future Dr. Magurany explained that rheumatoid arthritis is an autoimmune disease that presents with joint pain and inflammation, mostly on hands and small joints, accompanied by morning stiffness longer than 1 hour. The rheumatoid factor and ACPA may be positive in a percentage of patients but not always. The base of treatment is early treatment with disease-modifying antirheumatic drugs to induce remission of the disease. OA affects weight-bearing joints with little to no inflammation, treatment is mainly lifestyle modifications, analgesics, intraarticular injections, and joint replacement.

This week we thank Hector Arreaza and Thomas Magurany. 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. Myasoedova E, Crowson CS & Gabriel SE et al. (2010). Is the incidence of rheumatoid arthritis rising?: Results from Olmsted County, Minnesota, 1955-2007. Arthritis and Rheumatism, 62(6), 1576-1582.
2. Goldring MB & Goldring SR. (2007). Osteoarthritis. Journal of Cellular Physiology, 213(3), 626-634.
3. King LK, March L, Anandacoomarasamy A. Obesity & osteoarthritis. Indian J Med Res. 2013;138(2):185-93. PMID: 24056594; PMCID: PMC3788203.
4. Chauhan K, Jandu JS, Brent LH, et al. Rheumatoid Arthritis. [Updated 2023 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
5. Sen R, Hurley JA. Osteoarthritis. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
6. Hunter DJ, Bierma-Zeinstra S. & Eckstein F. (2014). OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for primary hip and knee osteoarthritis: An expert consensus initiative of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) Task Force in collaboration with the Osteoarthritis Research Society International (OARSI). Osteoarthritis Cartilage, 22(7), 363-381.
7. van Everdingen AA, Jacobs JW, Siewertsz Van Reesema DR, Bijlsma JW. Low-dose prednisone therapy for patients with early active rheumatoid arthritis: clinical efficacy, disease-modifying properties, and side effects: a randomized, double-blind, placebo-controlled clinical trial. Ann Intern Med. 2002 Jan 1;136(1):1-12. doi: 10.7326/0003-4819-136-1-200201010-00006. PMID: 11777359.
8. Nicolau J, Lequerré T, Bacquet H, Vittecoq O. Rheumatoid arthritis, insulin resistance, and diabetes. Joint Bone Spine. 2017 Jul;84(4):411-416.
9. Fernandes L, Hagen KB, Bijlsma JWJ et al. (2019). EULAR recommendations for non-pharmacological core management of hip and knee osteoarthritis. Annals of Rheumatic Diseases, 79(6), 715-722.
10. Royalty-free music used for this episode: "Driving the Point." Downloaded on July 29, 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 145: Family Planning for the LGBTQIA+

Future Dr. Hoque explains how to assist with family planning for the LGBTQIA+ community. Some principles such as avoiding unintended pregnancies and reducing and early treatment of STIs are discussed.  

Written by Ashfi Hoque, MBA, MS4, 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: Welcome to episode 145 of the Rio Bravo qWeek podcast. My name is Hector Arreaza, a faculty member of the Rio Bravo Family Medicine Residency Program.

Ashfi: Hello everyone, I am Ashfi Hoque a 4th-year medical student at Ross University School of Medicine. I am from Long Beach, California. Patient advocacy and patient-centered care have always been a priority of mine. I’ve volunteered for years at the LGBT+ center in Weho and Long Beach. Today we will be discussing Family Planning for everyone while learning ways to become LGBTQIA+ inclusive. 

Arreaza: Yes, family planning is important, and I’m glad you included all types of families. I believe medical care must be offered to everyone, and I also believe in freedom of conscience, that’s why I can freely express that I support traditional family for me. Why did you choose this topic?

Ashfi: I chose this topic because my partner recently went to get her physical. Her provider had an extensive conversation about family planning and even discussed the anticipated cost of freezing her oocytes. I really loved the way this provider went about the conversation so I started researching ways I can support my community and also teach others to provide Queer inclusive medical care. 

What is LGBTQIA+?

LGBTQIA+ stands for Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual, etc. The community will be referenced as the Queer community, an umbrella term for people who are not heterosexual or not cisgender. There are many inequalities that the community faces and we can do our due diligence to educate ourselves continuously and be aware that terminology and health needs may change. We have another Rio Bravo episode, Caring for LGBTQ+ Patients on Episode 103, that discusses healthcare disparities, but during this episode, we will be diving into an introduction to bridging health gaps, creating health equity, and building trust with the community. 

A 2023 Global Survey found that the self-identified Queer community represents 9% of the population, while the true estimate may be higher due to safety concerns. While diabetics are 10-13% of the population. These statistics show that as a medical provider, you'll encounter Queer patients more often than you think. One of the healthcare issues that Queer folks face is a lack of family planning.

What is Family Planning?

The World Health Organization (WHO) defines family planning as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through the use of contraceptive methods and the treatment of involuntary infertility.”

Family planning serves three critical needs: 

1. Avoiding unintended pregnancies
2. Reducing sexually transmitted diseases (STDs)
3. Early treatment of STDs to reduce rates of infertility

When discussing family planning for patients, here are some examples of questions you can ask. 

• What name may I use to address you?
• What are your pronouns?
• What is your gender? (Only if necessary for care, what is your assigned sex at birth?)
• Are you sexually active?
• What is the gender(s) of your partner(s)?
• Are you concerned about unintended pregnancy?
• Are you currently using any contraceptive measures?
• Are you taking any precautions to reduce STI/STD such as physical barriers like condoms, dental dams, or any harm reduction such as PrEP?
• What kind of STI/STD screening are you requesting?
• Do you need me to request additional labs such as oral or anal swabs?

Those questions must be asked in a natural, non-judgmental way. While STD/STI screening and treatment is part of family planning, the part that we tend to neglect is the desire for Queer folks to build a family. 

Why is Family Planning Important for the LGBTQIA+ community?

The Queer community gained the legal right to marry eight years ago, in 2015. They did not have the nationwide right to adopt until the last state, Mississippi, overturned the unconstitutional restrictions for the Queer community to adopt in 2016. 

A UCLA study in 2018 titled, “How many same-sex couples in the US are raising children?” reported cis-heterosexual couples: 3% are raising at least one adopted child and 95% are raising biological children while same-sex couples: 21.4% are raising at least one adopted child and 68% have a biological child. 

When it comes to family planning, there is more than adoption for Queer people. Queer folks are not offered the same pregnancy planning options, such as cis hetero-couples who are experiencing infertility or cis-women planning for advanced maternal age pregnancy. However, the options are quite similar. These options require specific types of planning, and that information can be provided to patients by their primary care doctor. A couple needs to know their options and consider the long-term financial planning necessary for surrogacy, in vitro fertilization (IVF), or donor insemination. The main difference for many Queer couples is the method of conception needed. Depending on sexual orientation and gender identity, patients may have varying reproductive needs as part of their family planning. We cannot make assumptions about how family planning should look and need to remember this journey looks different from person to person and couple to couple.

How to approach family planning with the LGBTQIA+ community? 

Basic tenants of providing medical care for queer patients: 

Clinics specializing in Queer family planning found patient-centered care leads to better outcomes. The best approach is to be mindful, conscious, and to communicate without assumptions. We have to start with providers building trust, being honest, showing sensitivity assisting with reproductive services, and working towards being more knowledgeable about Queer parenthood. A provider could ask questions such as: 

• Would you like information about family planning?
• What do you imagine your future family to look like?
• Would you like to see options and potential costs?
• Would you need a referral for a specialist?

Or it can be as simple as being honest about your scope of knowledge by stating, “I am not well versed in LGBTQIA+ community issues but what ways can I support you?” It is ethically appropriate to transition care to a physician with better knowledge if you feel unable to assist a person from the LGBTQ+ community. Make sure to do it in a polite and respectful way.

Gender inclusive: 

With more people openly identifying as non-binary and trans, there is a need for a gender-neutral approach to discussing a patient’s biological and reproductive needs. 

First, we will avoid assuming gender identity based on the biological sex of a patient. Episode 14 of Rio Bravo does a great job of breaking down gender diversity and the difference between gender identity and biological sex. For transgender and nonbinary patients, providing care for medical transitioning often includes conversations about family planning before starting HRT. It is common to ask patients about to begin HRT if they would like to freeze their sperm or eggs. 

Second, we want to avoid assuming anything based on what reproductive organs a patient has. We can ask a patient about their intention to start a family. Avoid asking if a trans patient has received transitional surgery (bottom surgery) unless it is completely necessary for the care we are providing. Instead, it is appropriate to ask the patient if birthing is an option? Have you given birth before? Were there any complications? Is there any current hormonal treatment? This mindful strategy is also useful for patients who may have limitations in: producing oocytes or sperm, the ability to house a fetus in utero, or implantation and fertility. 

Third, we are going to address our underlying beliefs and assumptions about gendered parenthood. Parenthood is almost always thought of as motherhood and fatherhood, but this can be alienating for transgender patients. There are many possible ways of being a parent, and to be inclusive let’s consider the possibility of a masculine woman or transmasculine man being a birthing parent or of a transgender woman being the mother of a child without giving birth to the child. There are many more scenarios we can discuss at another point. In the interest of time, we are going to shift into discussing family planning for lesbian and gay people and couples. 

Sexuality inclusive:

For homosexual cis-gendered people who are single or in relationships, family planning can look similar to couples facing infertility issues. When having family planning conversations with these patients, a provider should ask broad, unassuming questions. If you have established that a queer person or couple wants a child, then you can ask if they have a family plan. 

If the patient or couple has a plan, follow the couple’s lead. If the patient(s) do not have a plan, then you can begin to ask questions like: Do you have someone in mind to be a birth giver? Do you have a sperm donor? Do you have an egg donor? These questions are a great transition into discussing the following options for family planning.

What are the options for having a newborn and the financial and ethical cost?

Having a child can cost up to $100k, and this does not even include the cost of childcare. Infertility treatment is not covered by regular insurance, so patients need either infertility insurance or private financing to cover the cost of treatment. However, fertility insurance does not cover same-sex couples. There is a large emotional, physical, and ethical cost to deciding which route to choose. Let’s discuss options and obstacles.

1. Donor Insemination: The most affordable route is having a birth-giving parent who is fertile with a known sperm donor. This method can be as simple as using a syringe to inseminate the uterus-carrying person, but we need to consider necessary attorney fees to terminate the parental rights of the sperm donor. Sperm from a sperm bank requires an extensive workup including STD panel, HIV, and genetic disorder screening. The sperm donor gives up all parental rights during the process. The price of these procedures is constantly changing and depends on location.

California Cryobank costs start at $1200 for anonymous donors and $1900 for identification disclosure donor which the child will receive information about the donor at age 18. Selecting a donor can include specifics such as race, talents, education, hobbies, physical attributes, and showing donor baby photos. There are two common insemination processes:

• Intracervical insemination: semen inside the cervical opening and covers the cervix
• Intrauterine insemination: semen is inserted through the cervix and placed directly into the cavity

The next option jumps up in cost significantly.

2. Freezing Eggs (Oocyte Cryopreservation):Pacific Fertility Center Los Angeles, reports a single cycle of egg freezing can cost $6-10k per freezing cycle and may need multiple cycles without medication. The medications are typically around $3-6k depending on how much your body needs. Storage is an additional cost of $700-$1,000 a year. This is an option for parents planning pregnancy during advanced ages.

3. In Vitro Fertilization (IVF): It is a process where an oocyte is collected similarly to freezing eggs but fertilized with a partner’s or donor’s sperm.Pacific Fertility Center Los Angeles reports it costs $8-13k per cycle of fertilization. It is an option for those who have issues with infertility, previous pelvic inflammatory diseases, surgeries, and issues with implantations.

4. Surrogacy: This is the process of hiring a professional birthing surrogate to carry an embryo. This is an alternative option for couples who decline or cannot carry a pregnancy. The surrogate has no legal rights or biological relation to the fetus. Family Tree Surrogacy reports it costs about $45-65k.

5. Adoption: Foster care adoption in California can be $1-5k. American Cost of Adoption, reports the cost of adoption for infants in California $40-70k including the medical expenses for the birth-giving person and legal expenses for the process. Versus adopting an infant from another country due lack of resources and poverty may better their lives or cause a higher demand for infants which may be an ethical issue. Also, transcultural adoption where the race of the parents and the children are different, and navigating culture and race with the children. Adoptees have reported having racial identity crises.

With all these studies, it is well documented that providers will not be perfect at giving care to the Queer community. These studies do not represent every queer person and do not take the intersectionality of race, class, or gender identity into consideration. It is our job as providers to be supportive of all types of patients in order to increase their access to proper medical care. 

_______________

Conclusion: Now we conclude episode number 145, “Family Planning for the LGBTQIA+.” Future Dr. Hoque explained how queer people can be included in family planning conversations, even before heterosexual couples. She described some options such as donor insemination, freezing eggs, IVF, and adoption. Dr. Arreaza explained that it is important to ask reproductive questions in a natural, non-judgmental way to all your patients, and refer to another professional when needed. 

This week we thank Hector Arreaza and Ashfi Hoque. 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. American Adoptions—How Much Does a Private Adoption Cost in California? [And Why?]. (n.d.). Retrieved July 14, 2023, fromhttps://www.americanadoptionsofcalifornia.com/adopt/cost-of-adoption-in-california
2. American Adoptions—LGBTQ Adoption: Can Same-Sex Couples Adopt? (n.d.). Retrieved July 14, 2023, fromhttps://www.americanadoptions.com/adopt/LGBT_adoption
3. Carpenter, E. (2021). “The Health System Just Wasn’t Built for Us”: Queer Cisgender Women and Gender Expansive Individuals’ Strategies for Navigating Reproductive Health Care. Women’s Health Issues, 31(5), 478–484.https://doi.org/10.1016/j.whi.2021.06.004
4. Choosing the Right Sperm Donor | California Cryobank. (n.d.-a). Retrieved July 14, 2023, from HTTPS://www.cryobank.com/how-it-works/choosing-your-donor/
5. Choosing the Right Sperm Donor | California Cryobank. (n.d.-b). Retrieved July 14, 2023, from HTTPS://www.cryobank.com/how-it-works/choosing-your-donor/
6. Cost of Egg & Embryo Freezing in the U.S. | PFCLA. (n.d.). Retrieved July 14, 2023, fromhttps://www.pfcla.com/blog/egg-freezing-costs. (2012, April 25).
7. Donor Insemination. American Pregnancy Association.https://americanpregnancy.org/getting-pregnant/donor-insemination/
8. Hollingsworth, L. D. (2003). International adoption among families in the United States: Considerations of social justice. Social Work, 48(2), 209–217.https://doi.org/10.1093/sw/48.2.209
9. In vitro fertilization (IVF): MedlinePlus Medical Encyclopedia. (n.d.). Retrieved July 14, 2023, fromhttps://medlineplus.gov/ency/article/007279.htm
10. Ingraham, N., Fox, L., Gonzalez, A. L., & Riegelsberger, A. (2022a). “I just felt supported”: Transgender and non-binary patient perspectives on receiving transition-related healthcare in family planning clinics. PLOS ONE, 17(7), e0271691.https://doi.org/10.1371/journal.pone.0271691
11. Ingraham, N., Fox, L., Gonzalez, A. L., & Riegelsberger, A. (2022b). “I just felt supported”: Transgender and non-binary patient perspectives on receiving transition-related healthcare in family planning clinics. PLOS ONE, 17(7), e0271691.https://doi.org/10.1371/journal.pone.0271691
12. Ingraham, N., & Rodriguez, I. (2022a). Clinic Staff Perspectives on Barriers and Facilitators to Integrating Transgender Healthcare into Family Planning Clinics. Transgender Health, 7(1), 36–42.https://doi.org/10.1089/trgh.2020.0110
13. Ingraham, N., & Rodriguez, I. (2022b). Clinic Staff Perspectives on Barriers and Facilitators to Integrating Transgender Healthcare into Family Planning Clinics. Transgender Health, 7(1), 36–42.https://doi.org/10.1089/trgh.2020.0110
14. Klein, D. A., Malcolm, N. M., Berry-Bibee, E. N., Paradise, S. L., Coulter, J. S., Keglovitz Baker, K., Schvey, N. A., Rollison, J. M., & Frederiksen, B. N. (2018). Quality Primary Care and Family Planning Services for LGBT Clients: A Comprehensive Review of Clinical Guidelines. LGBT Health, 5(3), 153–170.https://doi.org/10.1089/lgbt.2017.0213
15. PFCLA. (n.d.). The Cost of IVF in California. Retrieved July 14, 2023, fromhttps://www.pfcla.com/blog/ivf-costs-california
16. PODCAST. (n.d.). Rio Bravo Residency. Retrieved July 14, 2023, fromhttps://www.riobravofmrp.org/qweek/episode/fcb76527/episode-103-caring-for-lgbtq-patients
17. Rotabi, K. S. (n.d.). From Guatemala to Ethiopia: Shifts in Intercountry Adoption Leaves Ethiopia Vulnerable for Child Sales and Other Unethical Practices.
18. Smoley, B. A., & Robinson, C. M. (2012). Natural Family Planning. American Family Physician, 86(10), 924–928.
19. Surrogate Compensation | How Much Do Surrogater Paid in CA? (n.d.). Https://Familytreesurrogacy.Com/. Retrieved July 14, 2023, fromhttps://familytreesurrogacy.com/blog/surrogate-pay-california/
20. The National Academies Press. (n.d.). Retrieved July 14, 2023, fromhttps://nap.nationalacademies.org/
21. thisisloyal.com, L. |. (n.d.). How Many Same-Sex Couples in the US are Raising Children? Williams Institute. Retrieved July 14, 2023, fromhttps://williamsinstitute.law.ucla.edu/publications/same-sex-parents-us/
22. Royalty-free music used for this episode: "Rain in Spain." Downloaded on October 13, 2022, 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 144: Risk Factors for Pediatric Overweight and Obesity

Future Dr. Lal describes multiple risk factors associated with childhood overweight and obesity. Dr. Arreaza adds comments about caring for pediatric patients with obesity. Practice guidelines are mentioned throughout this episode.

Written by Krustina Lal, MSIII, Western University College of Osteopathic of the Pacific. Comments by Hector Arreaza, MD.

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

Introduction:

• Obesity is one of the most common pediatric chronic diseases affecting 14.4 million children and adolescents (about twice the population of New Jersey).
• A recent simulation study from the US found that by 2030, a staggering 55–60% of today’s children will be obese.
• 1 in 4 children in California have obesity.
• Research shows that the ages between 0 and 5 years is a critical period in the development of overweight and obesity. Obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. Pediatricians and other primary care physicians need to be aware of the risk factors for pediatric obesity to provide early anticipatory guidance for prevention, close monitoring, and early intervention when the weight trajectory increases.

We will discuss the risk factors for children and adolescents to develop overweight and obesity, we will be diving deep into general, environmental, and familial factors. This is based off the AAP (American Academy of Pediatrics) “Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.” This guideline was published in February 2023, it is available online for free, and this is the first edition.

A. General Factors
- Socioeconomic Status

• A longitudinal analysis of predominantly non-Hispanic white children in the United States found that low socioeconomic status before 2 years of age was associated with higher obesity risk by adolescence in both boys and girls.
• Poverty is associated with toxic stress, limited access to healthy foods, and low physical activity.

-Children in Families That Have Immigrated to the US

• Recently arrived immigrants tend to be healthier than their US-born counterparts. However, as immigrants try to adjust to a new culture, they may adopt Americanized foodways, which are high in fat, sugar, and salt.
  Second-generation Hispanic immigrants are 55% more likely to have obesity than nonimmigrant white children, whereas first-generation Asian immigrants had a 63% lower risk of having obesity.
• Larger body sizes may be an indication of health and wealth in some cultures. This cultural factor may make it more difficult for parents to understand the gravity of their children’s obesity.
• Comment: This is a common concern among Hispanic families that bring their children to the clinic to get “vitamins” to gain weight because they look “sick,” but their BMIs are normal. PCPs should be prepared to address that concern in the clinic.

B. Neighborhood and Community Environments

-School Environment

• The presence of fast foods, vending machines, and/or sweetened beverages in schools may negatively influence children’s food choices, this effect is larger in younger grades.
• One day I went to have lunch with Devin, I liked that they had to go through the salad bar before they went to get other foods. They had the choice between vegetables or fruits.

-Lack of Fresh Food Access

• Neighborhood food environment has been shown to have a mixed association with children’s BMI.
• Children and families in these settings may be unable to access fresh fruits and vegetables and safe physical activity spaces. There may be limitations in transportation, cost, affordability, and availability.

-Fast food proximity

• Low-priced, calorie-rich fast foods with elevated levels of saturated fat, simple carbs, sugar, and sodium are commonly sold in fast food restaurants. Because they are easily available, they taste good, and they are strategically marketed, fast foods tend to be popular among children and adolescents.
• Some studies, not all, have shown an association between fast food locations near schools and obesity in children; a stronger association is seen in populations with lower socioeconomic status.

-Access to safe physical activity

• Greater exposure to green space has been shown to be associated with higher levels of physical activity and a lower risk of obesity.
• That is something we have to recommend during our well-child visits. We are seeing a lot of aversion to going outside among the new generations. Going out seems to be torture when they find so much fun inside their houses (countless amounts of videos, video games, air conditioning/heater, etc...). A strategy for parents can be recommended 1 hour of playing outside before allowing screen time.

-Environmental Health  

• Exposure to environmental hazards during the prenatal period, infancy, and childhood can have impacts on the health and well-being of children.
• Exposure to endocrine-disrupting chemicals may occur through breastfeeding, inhalation, ingestion, or absorption through the skin. We are basically surrounded by hazardous chemicals used in cleaning agents, food packaging, pesticides, fabrics, upholstery, etc. Exposure during early childhood can affect the programming of several systems, including endocrine and metabolic systems, which may affect BMI, cardiovascular, and metabolic outcomes later in life.

C. Family and home environment factors
-Parenting feeding style

• Four types of parent feeding styles have been described:

1. Authoritative
2. Authoritarian
3. Permissive or indulgent
4. Negligent

• Authoritative feeding is considered protective against excessive weight gain. Children tend to eat more healthy foods, be more physically active, and have healthier BMI compared with children raised in homes with authoritarian, permissive or indulgent, or negligent parenting styles.

-Sugar-sweetened beverages within the home

• A systematic review of 20 prospective cohort studies and randomized controlled trials from 2013 to 2015 found that sugar-sweetened beverages (SSBs) were positively associated with obesity in children in all but 1 study.
• Comment: Sugary drinks are an easy way to get calories in your body. People tend to think that drinks don’t count, but they can be loaded with carbs. Orange juice can have up to 25 grams of sugar in a cup, some sodas may have double, and both are high in sugar.

-Portion sizes and snacking behavior 

• Positive association but need long-term studies

-Dining out and family meals

• Eating outside of the home—irrespective of the type of restaurant establishment visited—is associated with a higher risk of weight or BMI gain.
• Conversely, 2 meta-analyses found that an increased frequency of eating family meals was associated with a lower risk of childhood obesity.

-Screen time – This is one of the major struggles we have as parents. It’s a daily fight.

• A recent meta-analysis reported a 42% greater risk of being overweight or obese with more than 2 hours per day of television (TV) compared with 2 or fewer hours.
• Meta-analysis showed that even short exposure to unhealthy food and beverage marketing targeted at children resulted in increased dietary intake and behavior during and after the exposure.
• Marketing occurs via television, websites, online games, supermarkets, and outside schools.
• Male children and adolescents tend to spend more time on media screen devices and other Internet technology than female children and adolescents do.
• There is no conclusive guideline about it, but in general, we can recommend sleep hygiene to avoid insomnia or abnormal sleep patterns, such as avoiding “screens” 1 hour before bed.

-Sedentary behavior

• No association. However, many confounding factors include physical activity, screen time, and unhealthy food intake.

-Sleep duration

• Children 13 years and younger with short sleep duration (∼10 hours) had a 76% increased risk of being overweight or obese compared with their counterparts with longer sleep duration (12.2 hours).
• Sleep restriction may be associated with increased calorie consumption, fatigue, and decreased physical activity.

-Environmental smoke exposure

• Children under 8 years old exposed to environmental tobacco smoke (ETS) have been found to have higher BMI compared with their nonexposed counterparts.
• I wonder If this is a direct or indirect effect of smoke.

-Psychosocial stress

• A meta-analysis showed that prenatal psychological stress was associated with a higher risk of childhood and adolescent obesity.
• Psychosocial and emotional issues may lead to weight gain through maladaptive coping mechanisms, including eating in the absence of hunger to suppress negative emotions, appetite up-regulation, low-grade inflammation, decrease in physical activity, increase in sedentary behavior, and sleep disturbance. Depression has been shown to be a risk factor in both pediatric and adult obesity.

-Adverse childhood experiences

• ACEs include a history of physical, emotional, or sexual abuse; exposure to domestic violence; household dysfunction from parental divorce or substance abuse; economic insecurity; mental illness; and/or loss of a parent because of death or incarceration.
• A study found that having many ACEs increased two times the risk of children having overweight or obese compared with children with no history of ACEs. Stress may result in abnormal coping strategies—such as binge eating, eating in the absence of hunger, impulsive eating, and poor sleep hygiene—which may result in further weight gain.

Summary: The consequences of childhood obesity are far-reaching and extend beyond physical health issues. Children with obesity are more likely to experience a range of health complications, including type 2 diabetes, high blood pressure, sleep apnea, joint problems, and psychological issues such as low self-esteem and depression. Moreover, children with obesity are at a higher risk of carrying their weight-related problems into adulthood, increasing their susceptibility to chronic conditions such as cardiovascular disease, certain types of cancer, and premature mortality. 

As medical providers, we all need to keep general, environmental, and familial factors in mind when discussing weight changes among our pediatric patients. Having knowledge of such influences will help us intervene and prevent further progression. 

______________________________

Conclusion: Now we conclude episode number 144, “Risk Factors for Pediatric Overweight and Obesity.” Future Dr. LaL reminded us that childhood obesity is a disease linked to multiple risk factors, including but not limited to: low socioeconomic status, lack of access to safe spaces for exercise, parenting feeding styles, sleep disturbances, and adverse childhood events. Dr. Arreaza emphasized the importance of providing obesity care with kindness and empathy, especially when caring for pediatric patients.

This week we thank Hector Arreaza and Krustina Lal. 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. Sarah E. Hampl, Sandra G. Hassink, Asheley C. Skinner, Sarah C. Armstrong, Sarah E. Barlow, Christopher F. Bolling, Kimberly C. Avila Edwards, Ihuoma Eneli, Robin Hamre, Madeline M. Joseph, Doug Lunsford, Eneida Mendonca, Marc P. Michalsky, Nazrat Mirza, Eduardo R. Ochoa, Mona Sharifi, Amanda E. Staiano, Ashley E. Weedn, Susan K. Flinn, Jeanne Lindros, Kymika Okechukwu; Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics February 2023; 151 (2): e2022060640. 10.1542/peds.2022-060640. https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and?autologincheck=redirected.
2. Weihrauch-Blüher, S., Wiegand, S. Risk Factors and Implications of Childhood Obesity. Curr Obes Rep 7, 254–259 (2018).
3. Hemmingsson, E. Early Childhood Obesity Risk Factors: Socioeconomic Adversity, Family Dysfunction, Offspring Distress, and Junk Food Self-Medication. Curr Obes Rep 7, 204–209 (2018).
4. Royalty-free music used for this episode: "Latina Havana Boulevard." Downloaded on October 13, 2022, 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 143: Pulmonary Cocci Basics

Dr. Lovedip Kooner explains the history, diagnosis, and treatment of pulmonary coccidioidomycosis (cocci for short.) Disseminated cocci infection was also discussed. Dr. Arreaza added some anecdotes of patients seen with this infection.  

Written by Lovedip Kooner, MD. 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.

Definition:

Coccidioidomycosis, also known as Valley Fever, is an infection caused by the fungi Coccidioides immitis and Coccidioides posadasii. Coccidioides is also referred to as cocci. Generally speaking, C. immitis is found in California and C. posadasii is found in Arizona, and Central and South America. More recently Cocci has also been found as far north as Washington and British Columbia. 

History:

The fungal infection was first reported by Wernicke and Posadas in Argentina in 1892 where they described a case where a man had cutaneous cocci of the head, arm, and trunk. To this day, the head is preserved in Argentina. 4 For many years, only disseminated cases were recognized and described as “coccidioidal granulomas.” 

The work of Dixon and Gifford in 1935 elucidated that a pneumonic disease of unknown cause termed “San Joaquin Valley Fever” was, in fact, the primary coccidioidal infection and the port of entry of almost all coccidioidal disease. Initial infection occurs predominantly by inhalation of aerosolized arthroconidia and rarely by direct cutaneous inoculation.1,2

Coccidioides spp. survive best in areas with low rainfall (12–50 cm per year), limited winter freezes, and alkaline soils. With climate change models, predicting the geographical range expansion.

These dimorphic fungi exist in a mycelial form in the soil. Coccidioides species have been found in animal burrows near the Kern River and in Armadillo burrows in South American countries like Brazil. The mycelia produce arthroconidia (spores) that are ultimately airborne and inhaled.

The inoculum required for infection is low and in animal models as few as a single arthroconidium may cause infection.3 

Infection:

Once arthroconidia are inhaled into the lung, there is typically a 1-3-week incubation period. The arthroconidia undergo morphologic changes into spherules, which are large structures that contain endospores.4 As spherules mature, they rupture and release endospores. Endospores can be spread hematogenous or through lymphatics to essentially any organ, leading to the development of new spherules and potentially disseminated disease.5 Not everyone who inhales the arthroconidia gets the infection. 

Clinical Manifestations.

About 60% of patients who inhale arthroconidia are asymptomatic. 30% have a mild respiratory illness, like the flu. 10% have a more serious disease course and are diagnosed. Other symptoms may include fever, drenching night sweats, and weight loss. Extreme fatigue that limits baseline activity may also raise concerns. Symptom onset up to 2 months after endemic exposure should lead to coccidioidomycosis on the differential. Coccidioidomycosis cases have been documented in Michigan, Europe, and China. These cases were of people who traveled to endemic areas for as little as a few days and then were later diagnosed. 

1-3% of all coccidioidomycosis cases are disseminated, severe, or chronic pulmonary infections. If undiagnosed, coccidioidomycosis may lead to significant morbidity and mortality. 

Dissemination sites include the skin, lymph nodes, bones, and Central Nervous System (CNS) which is the most severe. Any organ can be infected, including documented cases of the prostate and adrenal gland. 

Arreaza: Recap: 60% are subclinical, 30% are mild, 10% serious, 1-3% are disseminated. What are some risk factors for severe infection? Should I stop biking?

Risk factors for severe infection:

Severe pulmonary infections can happen in anyone but occur more commonly in diabetics, tobacco users, and people older than 65 years of age.

Oceanic or Filipino ethnicity and black or African American have a higher rate of dissemination. 

Immunosuppression, including HIV, transplant patients, and immunosuppressive medications like corticosteroids or TNF-alpha inhibitors have been shown to be risk factors for dissemination. 

Pregnant patients, particularly in the third trimester have higher rates of severe infection as well.

Arreaza: How do we diagnose the disease?

Diagnosis:

Diagnosis is commonly made serologically. EIA (enzyme immunoassay) is used more often. There are more false positives than false negatives and varies by manufacturer. Kern County Health Department uses Immunodiffusion IgG and IgM and Complement Fixation are used. Immunodiffusion IgG and IgM are scaled by non-reactive, weakly reactive, reactive and strongly reactive. Compliment fixations are scaled by a ratio/dilution. Serum Compliment fixations <1:2 are considered negative and 1:2 and greater are considered positive. CSF Compliment Fixation of <1:1  are considered negative and 1:1 and greater are considered positive. 

Culture or histopathology with endo-sporulating spherules can also be used to diagnose. 

Serological diagnoses are less reliable early in the disease process and may take up to 6 weeks to be positive. 

Arreaza: Let’s talk about the most common manifestation of cocci, pulmonary.

Primary pulmonary infections:

In endemic regions, 25 % of community-acquired pneumonia may be attributed to coccidioidomycosis. The primary pulmonary infection may be associated with erythema nodosum or erythema multiforme. Imaging typically demonstrates segmental or lobar consolidation and mediastinal adenopathy. 5-15% of cases are complicated by effusion. Optimal treatment is unclear, due to lack of prospective, randomized controlled clinical trials. 

Retrospective studies have shown that about 95% of immunocompetent cases resolve on their own without treatment. 

Arreaza: How do we treat it? 

Treatment:

The most recent guidelines are the 2016 Infectious Diseases Society of America Clinical Practice Guideline for the Treatment of Coccidioidomycosis (IDSA), and they recommend patient education, close observation, and supportive measures such as reconditioning physical therapy for mild or non-debilitating symptoms, or who have substantially improved or resolved their clinical illness by the time of diagnosis.

The Valley Fever Institute treats most patients with primary disease and all patients with disseminated disease; including coccidioidal meningitis, which requires lifelong treatment with a triazole.

A double-blind randomized clinical trial done by the mycosis study group showed no superiority of treatment between either fluconazole or itraconazole.

Fluconazole remains the mainstay of treatment. Fluconazole suppresses the growth of fungi, it does not directly kill fungi.

Fluconazole dosage varies from person to person, and institution to institution. Institutions from Arizona are more likely to treat with 400mg while Valley Fever Institute tends to give a minimum of 600mg-800mg/daily. 

Duration of treatment is variable; taking into consideration symptoms and serology. 

Side effects of fluconazole include xerosis, alopecia, and fatigue.

Therapeutic drug monitoring is a debated topic amongst experts. The Valley Fever Institute routinely monitors drug levels.

Arreaza: Fluconazole is the mainstay of treatment. For our primary care peers, you can start fluconazole, making sure there is no contraindication or medication interactions.

Failure of treatment.

Treatment can be stopped for intolerance and/or for treatment failure. In either case, switching to other triazoles is recommended. Those triazoles include: itraconazole, posaconazole, or voriconazole. Amphotericin B is also used for refractory cases. Each has its own dosages and adverse effect profile. 

Disseminated disease requires closer monitoring and possibly IV amphotericin, or intrathecal amphotericin. 

Arreaza: What can we expect about the future of treatment?

Future of coccidioidomycosis treatment

Although there are not any FDA-approved vaccines for fungal infections, there are vaccines being developed that have shown promise in animal models for coccidioidomycosis. 

Different drugs are also under development that have different targets than triazoles like fluconazole. 

The role of therapeutic drug monitoring may become clearer.

Further research is also needed to provide more specific guidelines.

We are optimistic about the future. We see this disease commonly in the clinic and the hospital, and many patients may become disabled in cases of complicated/disseminated cocci. This is just an introduction for our listeners to keep learning about this disease.

A message for primary care doctors: In a patient with respiratory illness, and you suspect pulmonary cocci, order serology, and chest x-ray, and if you find pulmonary cocci, start treatment with fluconazole. Learn to identify patients at risk for dissemination/severe disease and refer to infectious disease when needed. 

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Conclusion: Now we conclude episode number 143, “Pulmonary cocci basics.” Dr. Kooner explained that this fungal infection can present with symptoms of community-acquired pneumonia. He explained that infection can disseminate to other organs or cause severe disease in a small percentage of infected patients. Because of the consequences of severe infection, Dr. Arreaza recommended primary care providers keep a high level of suspicion when patients present with any symptoms compatible with cocci infection in endemic areas.

This week we thank Hector Arreaza and Lovedip [pronounced as Love-DEEP] Kooner. We give special thanks to the Valley Fever Institute for providing information for this episode. 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. Johnson, Royce H et al. “Coccidioidomycosis: a review.” Journal of investigative medicine: the official publication of the American Federation for Clinical Research vol. 69,2 (2021): 316-323. doi:10.1136/jim-2020-001655.
2. Wernicke R: Ueber einen protozoenbefund bei mycosis fungoides. Zentralblatt Bakteriol 1892; 12:859-861.
3. Posadas A. Un nuevo caso de micosis fungiodea con posrospemias. An Cir Med Argent 1892; 15:585-97.
4. Bays, Derek J, and George R Thompson 3rd. “Coccidioidomycosis.” Infectious disease clinics of North America vol. 35,2 (2021): 453-469. doi:10.1016/j.idc.2021.03.010.
5. Nnadi NE, Carter DA. Climate change and the emergence of fungal pathogens. PLoS Pathog. 2021 Apr 29;17(4):e1009503. doi: 10.1371/journal.ppat.1009503. PMID: 33914854; PMCID: PMC8084208.
6. Gorris ME, Treseder KK, Zender CS, Randerson JT. Expansion of Coccidioidomycosis Endemic Regions in the United States in Response to Climate Change. Geohealth. 2019 Oct 10;3(10):308-327. doi: 10.1029/2019GH000209. PMID: 32159021; PMCID: PMC7007157.
7. Cordeiro, R A et al. “Phenotypic characterization and ecological features of Coccidioides spp. from Northeast Brazil.” Medical mycology vol. 44,7 (2006): 631-9. doi:10.1080/13693780600876546.
8. Davis, Matthew R et al. “Tolerability of long-term fluconazole therapy.” The Journal of antimicrobial chemotherapy vol. 74,3 (2019): 768-771. doi:10.1093/jac/dky501.
9. Galgiani, J N et al. “Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group.” Annals of internal medicine vol. 133,9 (2000): 676-86. doi:10.7326/0003-4819-133-9-200011070-00009.
10. Ampel, Neil M. “THE TREATMENT OF COCCIDIOIDOMYCOSIS.” Revista do Instituto de Medicina Tropical de Sao Paulo vol. 57 Suppl 19, Suppl 19 (2015): 51-6. doi:10.1590/S0036-46652015000700010.
11. Royalty-free music used for this episode: "Rain in Spain." Downloaded on October 13, 2022, 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 142: Tirzepatide II

Future Dr. Beuca explains that tirzepatide has shown benefits in patients with obesity that go beyond its weight-reducing effects and includes reduction of blood pressure, among others. Dr. Arreaza explains that Wegovy (semaglutide approved for weight loss) is also very beneficial for weight loss and explains.  

Written by Maria Beuca, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.

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

Maria: Hello everyone, today is June 2, 2023, and we want to re-visit our discussion about the drug Tirzepatide from our May 19th, 2022. 

A little re-cap for those of you who don’t know, tirzepatide, also known by the brand name Mounjaro, is a drug that was approved by the FDA a year ago for the treatment of type 2 Diabetes. It is similar to the drug Semaglutide, also known by the brand name Ozempic which many of you may be more familiar with, thanks to the Kardashians and other celebrities making it popular as a “weight loss” drug. 

Arreaza: The brand name for weight semaglutide is Wegovy.

Maria: Both of these drugs are injected once a week and mimic the effect of the incretin hormone GLP-1 by binding to its receptor. Incretin hormones are a group of hormones that cause insulin to be released from the pancreas after eating to help lower blood sugar levels.  These incretin hormones also help suppress the appetite, causing you to eat less and lose weight. Tirzepatide is different because it is the first drug to mimic the action of two hormones, both GLP-1 and GIP. 

In our last episode, we also discussed the SURPASS-2 study that showed tirzepatide to be superior to semaglutide because of this dual incretin action, with greater weight loss, lower HA1c levels, and lower triglyceride and VLDL levels. At that time, we also mentioned the SURMOUNT-1 Phase 3 clinical trial that was ongoing at the time. Well, it is now complete, and the results are in. There were 2,539 obese or overweight participants without diabetes in the study who lost between 16-22.5% of their starting weight on Tirzepatide. On 15 mg dose, participants lost about 52 lbs (24 kg), on 10 mg 49 lbs (22 kg) and on 5 mg about 35 lbs (16 kg), but those on the placebo lost only 2.4% or about 5 lbs (2 kg). As you can see there is very little difference in weight loss between the 10 mg dose and the 15 mg dose, although a big difference is seen compared to the 5 mg dose. It’s important to note that they took Tirzepatide for 72 weeks or a year and a half. 

Arreaza: That’s very significant weight loss. It is important to emphasize that these patients did NOT have diabetes. 

Maria: These weight loss results have proven to be comparable to bariatric surgery. The study also showed improvement in cardiovascular and metabolic risk factors such as lower blood pressure, fasting insulin, lipid levels and even aspartate aminotransferase levels in comparison to the placebo. By the end of the study, more than 95% of the participants who had pre-diabetes had converted to normal glucose levels. This study was so impressive that it was presented at the 82nd Scientific Sessions of the American Diabetes Association and was also published in The New England Journal of Medicine. 

Arreaza: It seems like tirzepatide is ahead of the game for weight loss.

Maria: Although it is approved as a drug for diabetes, the next step is to approve it for weight loss and to begin treating obesity as a chronic disease that needs to be treated. 

Maria: And this makes sense. Currently, more than 4 in 10 American adults have obesity, and obesity is the cause of many other conditions. Just yesterday, I was seeing patients in the orthopedic clinic and I had several patients being seen for knee pain due to obesity, and they are postponing surgery because they have been losing weight on tirzepatide and are already feeling better. I think avoiding knee surgery alone is a pretty good reason to approve these drugs for weight loss, but there are many other conditions that are improved by weight loss. 

Arreaza: My anecdotes are related to semaglutide, but I can imagine that this may also apply to tirzepatide. I had a patient who was able to stop all antihypertensive medications because of 40-lb weight loss. 

Maria: Dr. Caroline Apovian, director of the Center for Weight Management and Wellness at Brigham Women’s Hospital, states that “If everybody who had obesity in this country lost 20% of their body weight, we would be taking patients off all these medications for reflux, for diabetes, for hypertension. We would not be sending patients for stent replacement.”

Maria: Last month, officials from Eli Lilly, the company that makes tirzepatide, stated that they are hoping to have a fast-track approval to sell it for chronic weight management by sometime this year. 

The problem is that many of these patients who were prescribed Tirzepatide have not been able to get it because it has been out of stock for the last few months in all the local pharmacies. They get the prescription, start taking Tirzepatide and begin to lose weight or improve their blood sugar levels and then it is out of stock and now you have people with Diabetes who have gotten off insulin because Tirzepatide worked so well and suddenly they can’t get it and are at risk for getting pretty sick without it. 

Arreaza: The manufacturer of Wegovy announced this, “we will only be able to supply limited quantities of 0.25 mg, 0.5 mg, and 1 mg dose strengths to wholesalers for distribution to retail pharmacies which will not meet anticipated patient demand. We anticipate that many patients will have difficulty filling Wegovy® prescriptions at these doses through September 2023. We do not currently anticipate supply interruptions of the 1.7 mg and 2.4 mg dose strengths of Wegovy®”. Why is this happening? 

Maria: The problem is that this drug was not meant for the masses, for all these young girls wanting to lose a few pounds for aesthetic reasons. It was meant for people with a BMI 30 or with a BMI 27 plus another comorbidity such as hypertension. Celebrities have brought attention to these drugs for weight loss, for example Ozempic has over 433 million views on TikTok. It has gotten so bad that people are turning to questionable sources online to purchase these drugs, where it is given cute names like “skinny shots.” 

And if your insurance does not cover Tirzepatide, it is still expensive, starting at around $1000 per month. Some of the insurers who used to cover the cost stopped covering it or placed new restrictions on who qualifies. 

Another downside is that tirzepatide and other drugs of this class have not been on the market that long, so the long-term effects are still not known. So far, early evidence shows that most people gain the weight back as soon as they stop taking it, so are the weight loss benefits sustainable at this high cost? 

Maria: We talked about the adverse effects in the last episode, but it’s important to go over them again. Patients can have diarrhea, nausea, vomiting, constipation, and abdominal pain that can often bring these patients into the clinic or even the Emergency room thinking they are ill, when in fact it is an adverse effect of their medication, especially the first few days of starting or increasing the dose. So, educating patients is very important before they start this new drug. There is also a small risk of pancreatitis or gallbladder problems, so it is important to have blood work done to check the pancreas and gallbladder prior to starting tirzepatide. There is also a warning to avoid using it if you have a family or personal history of thyroid cancer. 

Arreaza: Reminder, MEN type 1. I would like to mention the so-called “Ozempic face”. It is the face you get with rapid weight loss, making you look a little older due to fat loss on the face. 

As a summary, tirzepatide is a very effective medication for weight loss, pending FDA approval. It is not free of side effects, so we still need to follow the recommendations from FDA and other reputable sources to prescribe it responsibly. There is room for further research on these medications. Currently, there are no clear guidelines regarding labs before starting treatment (lipase?) or labs for monitoring after treatment. The evidence regarding these medications continues to evolve and we should stay up to date with the changes. 

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Conclusion: Now we conclude episode number 142 “Tirzepatide II.” Future Dr. Beuca came back almost one year later to shed more light on the use of tirzepatide in the treatment of obesity. Dr. Arreaza provided some insight into the management of side effects and the potential harm of this novel medication. Overall, tirzepatide is effective and safe and may be the answer to many of our patients with diabetes and obesity. 

This week we thank Hector Arreaza and Maria Beuca. 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. Brownie, Grace. “The Problematic Arrival of Anti-Obesity Drugs.” Wired, 25 January 2023. https://www.wired.com/story/anti-obesity-drugs/
2. Dockrill, Peter. “Experimental Drug Breaks Record for Weight Loss in Latest Clinical Trial Results.”ScienceAlert, 9 May 2022, https://www.sciencealert.com/experimental-drug-breaks-record-for-weight-loss-in-latest-clinical-trial-results.
3. Frías, Juan P., et al. “Tirzepatide versus Semaglutide Once Weekly in Patients with Type 2 Diabetes.”New England Journal of Medicine, 5 August 2021, https://www.nejm.org/doi/full/10.1056/NEJMoa2107519.
4. Jastreboff, Ania  M., et al. “Tirzepatide Once Weekly for the Treatment of Obesity.” New England Journal of Medicine, 21 July 2022, www.nejm.org/doi/full/10.1056/NEJMoa2206038.
5. “Label as Approved by FDA. - Pi.lilly.com.”Mounjaro Prescribing Information, Lilly USA, LLC, May 2022, https://pi.lilly.com/us/mounjaro-uspi.pdf.
6. Mounjaro. Prescribing Information. Lilly USA, LLC.  May 2022. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi
7. “Surmount-1 Study Finds Individuals with Obesity Lost up to 22.5% of their Body Weight when Taking Tirzepatide.” 4 June 2022. https://diabetes.org/newsroom/press-releases/2022/surmount-1-study-finds-individuals-%20with-obesity-lost-up-to-22.5-percent-body-weight-taking-tirzepatide.
8. Royalty-free music used for this episode: "Happy-Go-Lucky." Downloaded on October 13, 2022, 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!