Rio Bravo qWeek

Episode 203: Microinduction and harm reduction in OUD.  Nathan Bui and Sanjay Reddy describe how to manage opioid use disorder (OUD) by using microinduction and harm reduction, strategies that are reshaping the way we treat opioid use disorder. Written by Sanjay Reddy, OMSIV and Nathan Bui, OMSIV. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific.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.IntroWelcome to episode 203 of Rio Bravo qWeek, your weekly dose of knowledge.Today, we’re tackling one of the biggest health challenges of our time: opioid use disorder, or OUD. Nearly every community in America has been touched by it: families, friends, even healthcare providers themselves. For decades, treatment has been surrounded by barriers, painful withdrawals, stigma, and strict rules that often do more harm than good. Too many people who need help never make it past those walls. But here’s the hopeful part, new approaches are rewriting the story. They are less about rigid rules and more about meeting people where they are. Two of the most promising strategies for treatment of OUD are buprenorphine microinduction and harm reduction. Let’s learn why these two connected strategies could change the future of addiction recovery. Background information of treatment: The X-waiver (short for DATA 2000 waiver) was a special DEA requirement for prescribing buprenorphine for opioid use disorder. Doctors used to take extra training (8 hours) and apply for it. Then, they could prescribe buprenorphine to a very limited number of patients. The X-waiverhelped regulate buprenorphine but also created barriers to access treatment to OUD. It was eliminated in January 2023 and now all clinicians with a standard DEA registration no longer need a waiver to prescribe buprenorphine for OUD. Why buprenorphine?Buprenorphine is one of the safest and most effective medications for opioid use disorder. It has some key attributes that make it both therapeutic and extremely safe: 1) As a partial agonist at mu-opioid receptors, it binds and provides enough partial stimulation to prevent cravings and withdrawal symptoms without producing strong euphoria associated with full agonists. 2) Because it has a strong binding affinity compared to full agonists, it easily displaces other opioids that may be occupying the receptor. 3) As an antagonist at kappa-opioid receptors, it contributes to improved mood and reduced stress-induced cravings. 4) The “ceiling effect”: increasing the dosage past a certain point does not produce a stronger opioid effect. This ceiling effect reduces the risk of respiratory depression and overdose, making it a safer option than full agonists. 5) It also had mild analgesic effects, reducing pain. 6) Long duration of action: The strong binding affinity and slow dissociation from the mu-opioid receptor are responsible for buprenorphine's long half-life of 24–60 hours. This prolonged action allows for once-daily dosing in medication-assisted treatment for OUD. Induction vs microinduction:The problem is, starting it—what’s called “induction”—can be really tough. Patients usually need to stop opioids and go through a period of withdrawal first. Drugs like fentanyl, which can cause precipitated withdrawal —a sudden, severe crash may push people back to using opioids. Because buprenorphine binds so tightly to the mu-opioid receptor, it can displace other opioids, such as heroin or methadone. If buprenorphine is taken while a person still has other opioids in their system, it can trigger sudden and severe withdrawal symptoms.Opioid withdrawal sign sand symptoms:Opioid withdrawal symptoms are very uncomfortable; patients may even get aggressive during withdrawals. As a provider, once you meet one of these patients you never forget how uncomfortable and nasty they can be. The symptoms are lacrimation or rhinorrhea, piloerection "goose flesh," myalgia, diarrhea, nausea/vomiting, pupillary dilation, photophobia, insomnia, autonomic hyperactivity (tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia), and yawning. Think about all the symptoms you run for COWS (Clinical Opiate Withdrawal Scale). It is estimated 85 % of opioid-using patients who inject drugs (PWID) reported opioid withdrawal. Fortunately, even though opioid withdrawal is very uncomfortable, it is not life-threatening (unlike alcohol or benzodiazepine withdrawal, which can be fatal).Many patients who start the journey treating opioid use disorder experience “bumps in the road” --they avoid treatment or drop out early. What is Microinduction? Microinduction is a fairly new strategy started in Switzerland around 2016. It is also known as the “Bernese method” (named after the city of Bern, Switzerland). With this method, instead of stopping opioids cold turkey, patients start with tiny doses of buprenorphine—fractions of a milligram. These doses gradually increase over several days while the patient continues their regular opioid use. While they begin this titer, they can continue use of the full agonist they were previously using–methadone, fentanyl, or heroin, while the buprenorphine begins to take effect. Once the buprenorphine builds up to a therapeutic level, the full agonist is stopped. This method uses buprenorphine’s unique pharmacology to stabilize the brain’s opioid system without triggering those really nasty withdrawal symptoms.Early studies and case reports suggest this is safe, tolerable, and effective method to do. Microinduction is changing the game, and it has been spreading quickly in North America. Instead of forcing patients to stop opioids completely, the dose is slowly increased over the next three to seven days, while the patient keeps using their usual opioids.By the end of that week, the buprenorphine has built up to a therapeutic level and the full agonist is stopped. The difference is really dramatic. Instead of a painful crash into withdrawal, patients describe the process as a gentle step down, or a ramp instead of a cliff. It’s a flexible method. It can be done in a hospital, a clinic, or even outpatient with good follow-up. Once a patient and doctor develop a strong relationship built on the principles of patient autonomy and patient-centered care, microinduction can be closely monitored on a monthly basis including televisits. Microinduction has been shown to help more patients stay in treatment. The Role of Harm Reduction Instead of demanding perfection, harm reduction focuses on best practices providers can implement to reduce risk and keep patients safe. Harm reduction can vary from providing naloxone to reverse overdoses, giving out clean syringes, or offering safer injection education. It also means allowing patients to stay in treatment even if they keep using other substances, and tailoring care for groups like adolescents, parents, or people recently released from incarceration. Harm reduction says that instead of demanding perfection, let’s focus on progress. Instead of all-or-nothing, let’s devote resources to keeping people alive and safe. As mentioned,an option is providing naloxone kits so overdoses can be reversed in the moment. Also, giving out clean syringes so the risk of HIV or hepatitis infection is reduced while injecting heroin. Another way to reduce harm is teaching safer injection practices so people can protect themselves until they’re ready for that next step in their treatment. It also means keeping the doors open, even when patients slip. If someone is still using other substances, they still deserve care. And it means tailoring support for groups who oftentimes get left behind. For people like adolescents, parents balancing childcare, or people coming out of incarceration who are at the highest risk of overdose. Harm reduction recognizes that recovery isn’t a straight line. It’s about meeting people where they are and walking with them forward. Conclusion:Microinduction is itself a harm reduction strategy. It lowers barriers by removing the need for painful withdrawal.When paired with a harm reduction culture in clinics, patients are more likely to enter care, stay engaged, and build trust with doctors for continued care. Managing opioid use disorder is one of the greatest health challenges of our time. But solutions like buprenorphine microinduction and harm reduction strategies are reshaping treatment—making it safer, more humane, and more accessible. If we embrace these approaches, we can turn barriers into bridges and help more people find recovery. 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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Bluthenthal, R. N., Simpson, K., Ceasar, R. C., Zhao, J., Wenger, L., & Kral, A. H. (2020). Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs. Drug and Alcohol Dependence, volume 211, 1 June 2020, 107932. https://doi.org/10.1016/j.drugalcdep.2020.107932.De Aquino, J. P., Parida, S., & Sofuoglu, M. (2021). The pharmacology of buprenorphine microinduction for opioid use disorder. Clinical Drug Investigation, 41 (5), 425–436. https://doi.org/10.1007/s40261-021-01032-7. Taylor, J. L., Johnson, S., Cruz, R., Gray, J. R., Schiff, D., & Bagley, S. M. (2021). Integrating harm reduction into outpatient opioid use disorder treatment settings. Journal of General Internal Medicine, 36 (12), 3810–3819. https://doi.org/10.1007/s11606-02

Episode 202: BPA OverviewWritten by Cameron Carlisle, 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._____________________Arr: Welcome to another episode of Rio Bravo qWeek. My name is Hector Arreaza, I’m an associate program director and faculty in the Rio Bravo Family Medicine Residency Program. Today my co-host is Cameron Carlisle, who is a 4th-year medical student finishing his last rotation of med school. Welcome, Cameron, please introduce yourself.Arreaza: What are we talking about today, Cameron?Cam: Dr. Arreaza, did you know you’re probably carrying around a chemical in your body that mimics estrogen? In fact, a 2004 CDC study found over 92% of Americans had detectable levels of Bisphenol A (BPA) in their urine. Today’s topic is BPA.BPA is everywhere: receipts, water bottles, canned foods, baby bottles, and even our dental fillings. It’s one of the most ubiquitous endocrine-disrupting chemicals (EDCs), which interferes with the body’s hormone systems. That’s why today’s episode is about making the invisible visible. Our goals for today’s podcast:Break down what BPA isShow how it affects the human bodyExplain how you and your patients can limit exposureEmpower both clinicians and the public with real, practical informationArreaza: Thanks for clarifying BPA today. It seems like we always have to learn about a new carcinogen or toxic substance that we are exposed to. I remember when I was a child, Yellow #5 became very concerning for the general public but it is still being used in our foods. So, it’s good you are talking about this. What Is BPA?Cam: Bisphenol A (BPA) is an industrial chemical used since the 1950s, primarily in polycarbonate plastics and epoxy resins. It makes plastic clear, and is often found in:Water bottlesCanned food liningsBaby bottles (pre-2012)Takeout containersCash register receiptsDental sealantsArreaza: So, I’ve seen the “BPA-free” labels many times, and today I’m glad you are going to shed some light about it.Cam: What’s alarming is that BPA leaches out of these products, especially when exposed to heat, acidity, or repeated use. A Harvard study found that people who drank from plastic bottles for just one week had a 69% increase in urinary BPA levels (Carwile & Michels, 2009).Arreaza: That’s a lot of people 69%. Section 3: What happens when BPA gets into our body? How BPA Works in the BodyCam: BPA is classified as an endocrine disruptor, meaning it can bind to estrogen receptors and mimic or block natural hormone functions.It affects:Reproductive systems (both male and female)NeurodevelopmentThyroid signalingPancreatic β-cell functionMetabolism and fat storageEven low-dose exposure can disrupt cellular function. BPA acts as a xenoestrogen (foreign estrogen) and has been shown to alter DNA methylation, leading to epigenetic changes that persist across generations (Manikkam et al., 2013).Arreaza: So, BPA can cause epigenetic changes that can be inherited. BPA can persist for generations in your offspring.BPA’s Health Impacts – What the Research SaysHere’s where it gets serious. Let’s go system-by-system:1. Reproductive HealthFemales: Linked to PCOS, infertility, and early puberty (Peretz et al., 2014).Males: Reduced sperm count and motility; altered testosterone levels.2. Pregnancy and Birth OutcomesIncreased risk of preterm birth, gestational diabetes, and low birth weight (Snijder et al., 2013).Studies show BPA crosses the placenta, directly affecting the fetus.3. Neurological DevelopmentAssociated with ADHD, anxiety, and impaired executive function in children exposed in utero (Mustieles et al., 2015).4. Metabolism and DiabetesBPA exposure is linked to insulin resistance, obesity, and type 2 diabetes, even at low doses (Lang et al., 2008).5. CancerAnimal and human data link BPA to increased risk of breast and prostate cancer via estrogenic mechanisms.6. MortalityA 2020 JAMA study found individuals with higher BPA levels had a 49% increased risk of all-cause mortality compared to those with lower levels (Gao et al., 2020).Arreaza: You are scaring me. I wonder what my BPA level is in my blood. Actually, BPA can be detected in urine. This is the most common approach for population-level biomonitoring, because BPA and its metabolites are mostly excreted in urine. Studies have found that BPA is present in most people, even up to 85–99% in large cohorts. Cam: That’s literally everyone. Sources of BPA ExposureLet’s talk about things we use every day:Thermal receipts (like from Target or Starbucks): BPA can transfer onto your skin and be absorbed, especially if your hands are wet or lotioned.Canned soups: One study showed that eating canned soup daily for five days led to a 1000% increased urinary BPA levels (Carwile et al., 2011).Plastic water bottles left in the car on hot days or plastic food trays for microwaving = chemical leaching.Baby bottles and pacifiers (pre-2012): primary concern for newborns.Arreaza: So, Cameron, you were exposed to BPA as a baby.Cam: Here’s the jaw-dropper: We ingest up to 5 grams of plastic per week, roughly the weight of a credit card (WWF, 2019; University of Newcastle). This includes microplastics like BPA, which enter through food, water, and air.Arreaza: So, it translates into 40 lbs of plastic in a lifetime, by age 70. What can we do as family physicians?Family Medicine and Preventive CareAs family physicians, we are at the frontlines of prevention. Our role includes:Anticipatory guidance: during prenatal visits, well-child visits, and chronic disease managementScreening opportunities: ask about storage habits, microwave use, and receipt handlingEnvironmental health counseling: AAFP recommends addressing endocrine disrupting chemicals (EDCs) when relevant to a patient’s concerns.It’s not just about treating diabetes or obesity. It’s about recognizing that environmental exposure may be a root cause.Arreaza: Prevention is my favorite topic!Cam: One helpful clinical practice:Arreaza: What else can we do to reduce BPA exposure?Practical Steps to Reduce BPAHere’s what patients and doctors alike can do today:Switch to BPA-free products, but be careful, as replacements like BPS or BPF may also be harmful (Rochester & Bolden, 2015).Avoid microwaving or dishwashing plastic containers.Use digital receipts.Filter tap water using carbon filters, which can reduce microparticle ingestion.Choose fresh produce over canned goods when possible.Also, wash your hands after handling receipts, especially before eating or touching your face.Arreaza: What is our government doing to protect us?Public Health and Policy UpdatesRegulations are slowly catching up:The FDA banned BPA in baby bottles and sippy cups in 2012.The European Union has stricter limits, and France banned BPA in all food packaging in 2015.California’s Proposition 65 requires BPA warning labels.Arreaza: Proposition 65, passed by direct voter initiative in 1986, “WARNING: This product contains chemicals known to the State of California to cause cancer and birth defects or other reproductive harm.”Arreaza: The FDA is planning to phase out petroleum-based food dyes (certified color additives) from the American food supply – marking a significant milestone in the efforts to protect the public. Cam: Many products still contain BPA analogs (BPS, BPF), which are not yet well-regulated.This is where clinician advocacy matters, where we can guide public opinion and support legislative change.Arreaza: So, millions of pounds of toxic substances are produced by many industries in the US. As physicians, we have to stay informed and update our patients.Cameron: How can we wrap up this episode?Conclusion and TakeawaysBPA is a hormone disruptor hiding in plain sight.People are exposed to BPA every day, but small lifestyle changes can dramatically reduce it.Family medicine has a role in education, prevention, and advocacy.Let’s all be part of the solution for our health and future generations. Stanley (tumblers) are not sponsoring this episode, and we did not receive any money from them. Arreaza: That’s it for today’s episode of Rio Bravo qWeek. If you enjoyed this episode, share it with a colleague or medical student who may need to know about BPA. I’m Dr. Arreaza, signing off.Cameron: Hopefully, in the future I will talk to you about more endocrine disrupting chemicals. Thanks for listening._____________________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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Carwile, J. L., & Michels, K. B. (2009). Urinary bisphenol A and obesity: NHANES 2003–2006. Environmental Research, 111(6), 825–830.Carwile, J. L., et al. (2011). Canned soup consumption and urinary bisphenol A: A randomized crossover trial. JAMA, 306(20), 2218–2220.Centers for Disease Control and Prevention (CDC). (2004). Fourth National Report on Human Exposure to Environmental Chemicals.Gao, X., et al. (2020). Urinary bisphenol A and mortality risk. JAMA Network Open, 3(8), e2011620.Lang, I. A., et al. (2008). Association of urinary bisphenol A with medical disorders and laboratory abnormalities in adults. JAMA, 300(11), 1303–1310.Manikkam, M., et al. (2013). Epigenetic transgenerational inheritance of disease. PLOS ONE, 8(1), e55387.Mustieles, V., et al. (2015). Bisphenol A and neurodevelopmental outcomes in children. Environmental Health Perspectives, 123(7), 689–695.Peretz, J., et al. (2014). Bisphenol A and reproduct

Episode 201: AKI Roadmap.  Future Dr. Ayyagari describes the different types of acute kidney injury and shares some elements of management for each category. Dr. Arreaza shares some input about statistics and the importance of drinking water during summer.Written by Tejasvi Ayyagari, MSIV, Ross University School of Medicine. Edits and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.INTRODUCTION:Dr. Arreaza: Hello everyone, and welcome back to Rio Bravo qWeek — your weekly dose of knowledge. I’m Dr. Arreaza, I am a faculty member and associate program director of the Rio Bravo FM residency program. In Episode 126, we briefly introduced the topic of Acute Kidney Injury (AKI), but today, we’re taking a deep dive into the matter. I have here alongside my cohost, future Dr. Ayyagari, AKA TJ. Please, TJ, introduce yourself.TJ: Hey everyone, good to be back on the podcast. My name is TJ Ayyagari, and I am currently finishing my last rotation of medical school with Rio Bravo CSV outpatient.  I hope everyone is doing well and staying safe.Dr. Arreaza: So, TJ prepared this discussion about acute kidney injury, also known as AKI. This is a critical topic for our Kern community, especially during the summer months when the risk of AKI increases. You will face many patients with AKI on the wards, in the clinic, and especially on your future board exam. Hopefully, by the end of this episode, you all will have more information on AKI, but also the three different types: prerenal, intrinsic, and postrenal. TJ: Without further ado, let’s get started, Dr. Arreaza.SECTION 1 – What is AKI?Dr Arreaza: Let’s start with the definition. Let’s explain what AKI is. TJ: Absolutely.  So, an AKI is not just a bump in the patient’s creatinine. According to the Kidney Disease Improving Global Outcomes (KDIGO) definition, an AKI embodies any of the following criteria:Increase in serum creatinine by ≥0.3 mg/dL within 48 hours, ORIncrease in serum creatinine to ≥1.5 times baseline within the prior 7 days, ORUrine volume <0.5 mL/kg/h for 6 hoursDr. Arreaza: The numbers show that AKI is increasing in our hospitals. According to the CDC, the incidence rate of newly diagnosed AKI has increased from 80 per 1,000 patient-years in 2007 to 242 per 1,000 patient-years in 2022. We must be vigilant and diagnose AKI appropriately because time is gold. We need to correct it and prevent further kidney damage, if possible. A critical step in the treatment is determining why the AKI is happening. Let’s start by discussing prerenal AKI. SECTION 2 – Prerenal AKIDr. Arreaza: Let’s remember our Latin language, “pre” means before, and “renal” means kidney. So, when you say pre-renal, it sounds like you’re referring to an event that happens before the kidneys.TJ: You’re right.A prerenal AKI is the most common type, and it refers to a problem that occurs before the kidney. The keyword here is perfusion — the kidneys are fine structurally, but they’re not getting enough blood flow.Common causes:Hypovolemia: vomiting, diarrhea, bleeding, and overdiuresis (surreptitious diuretic use).Low cardiac output: heart failure, MI (if the heart cannot pump blood effectively across the body, the kidneys suffer)Systemic vasodilation: sepsis, cirrhosis (with widespread vasodilation and increased capillary permeability, resulting in more fluids shifting across the vasculature to tissues, which means less is available for the kidneys).Dr. Arreaza: So, less perfusion means less oxygen, less nutrients and more damage to the kidney.TJ: However, the good news is that it’s often reversible if you fix the underlying cause quickly. Dr. Arreaza: What would we expect to see on lab values?TJ: As a result of low kidney perfusion, the kidneys do their best to conserve sodium and water, and urea reabsorption is increased in the proximal tubule. Subsequently, BUN rises disproportionately compared to creatinine (BUN: Cr ratio > 20:1).  There is also a lab value called the Fractional excretion of sodium, otherwise known as FeNa, which will appear as <1% suggesting a prerenal AKI because the kidneys are holding onto sodium to preserve volume.Dr. Arreaza: Let’s talk about correction of prerenal AKI. If there is no perfusion, let’s improve renal perfusion!TJ: Of course!  The treatment is to restore volume — fluids if hypovolemic, improve cardiac output if heart-related, and treat infection if septic. But remember, in CHF or cirrhosis, fluids can be tricky.SECTION 3 – Intrinsic AKIDr. Arreaza: Excellent explanation, TJ. So, let’s talk about the second type of AKI: intrinsic. Intrinsic AKI means the problem is inside the kidney itself.  If you’re comparing it to simple terms, the plumbing and water pressure are fine (perfusion is normal), the drains are fine (no obstructions), but the kidney’s filter is damaged.TJ: Major categories:Acute tubular necrosis (ATN): Most common intrinsic cause. Usually from ischemia or toxins (like aminoglycosides, IV contrast, ethylene glycol).Acute interstitial nephritis (AIN): Often an allergic reaction to drugs.  Here’s a quick little mnemonic with the 6Ps to help remember the most common causes. Pee — diuretics like furosemide or thiazides.Pain-free — NSAIDs.Penicillin — and other beta-lactam antibiotics.Proton pump inhibitors — like omeprazole.rifamPin — and other rifamycin antibiotics.Cimetidine — yes, the old-school H₂ blocker still shows up on exams.Glomerulonephritis: Autoimmune, post-infectious, or vasculitis. You’ll see proteinuria, hematuria, and RBC casts.Dr. Arreaza: A common cause of AKI is diabetes. Diabetes causes prerenal AKI (dehydration caused by uncontrolled diabetes) and intrinsic from renal parenchymal damage and tubular necrosis. So clinically, what would we expect?TJ: With Intrinsic AKI, as a result of tubular damage, there is impaired urea reabsorption.  Subsequently, BUN and creatinine both rise more proportionally (BUN: Cr ratio closer to 10 –15:1). With ATN, muddy brown casts can be appreciated in UAWith AIN, look for fever, rash, and especially eosinophilia, as well as a UA displaying eosinophils or WBC casts.With Glomerulonephritis, look for RBC casts and proteinuria on UA, and you may even see edema on physical exam with hypertension.Dr. Arreaza: Treating intrinsic AKI will depend on etiology. Hydration would not fix the problem in most cases. Let’s mention some treatment options for intrinsic AKI.TJ: Intrinsic AKI is a bit like fixing a flooded house — you don’t just start bailing water; you find the source of the leak, stop it, and protect what’s left. Whether it’s ATN, AIN, or GN, the playbook is: remove the injury, give the kidney a rest, and treat the underlying cause.Dr. Arreaza: Sure. We start with supportive care, especially treating hyper or hypotension, maintaining normovolemia, correcting electrolyte imbalances, and using antibiotics in case of infection. -We must identify and remove reversible causes, such as discontinuing nephrotoxic agents such as NSAIDs, aminoglycosides, and iodine contrast. -Also, other reversible factors must be corrected such as hypovolemia (IV fluids), hypotension (vasopressors) to prevent further kidney damage.TJ: -Hemodialysis or renal replacement therapy (RRT) is reserved for severe cases of refractory hyperkalemia, metabolic acidosis, volume overload unresponsive to diuretics, and uremic symptoms (encephalopathy, pericarditis, pleuritis).Dr. Arreaza: Immunosuppression is required for specific types of glomerulonephritis. For instance, rapidly progressive crescentic glomerulonephritis warrants high-dose glucocorticoids and cyclophosphamide. In ANCA-associated vasculitis, glucocorticoids plus cyclophosphamide or rituximab, and sometimes plasma exchange, are standard.SECTION 4 – Postrenal AKIDr. Arreaza: We spent enough time in intrinsic AKI.  Why don’t we move on to our last topic of AKI, postrenal.TJ: So, withpostrenal AKI, imagine that urine leaving the kidney encounters a roadblock.  Urine can’t get out, so pressure builds up, damaging the kidney.Common causes:For men, benign prostatic hyperplasia (BPH) is a significant factor (as the prostate grows bigger, it can compress the urethra, leading to urine backflow, which can not only cause AKI, but can also lead to possible UTIs in the process).Kidney stones, tumors, strictures, and neurogenic bladderWhen doing my urology and nephrology rotations at Kern Medical, I encountered many kidney stones and urethral strictures, and unfortunately, a fair number of patients suffering from RCC that caused not only the AKI but also extreme discomfort.Dr. Arreaza: It seems like we need some imaging to diagnose postrenal AKI.TJ: Yes.If you’re concerned about obstruction, a renal U/S can quickly help diagnose an underlying obstruction, or a CT scan for more details.Lab patterns?In the early phase (before tubular injury):BUN: Cr ratio >20:1 — looks like prerenal.FeNa <1%.Urine osmolality >500 mOsm/kg.In the later phase (after prolonged obstruction → tubular injury):BUN: Cr ratio ~10–15:1 — now looks intrinsic.FeNa >2%.Urine osmolality ~300 mOsm/kg.Dr. Arreaza: BUN:Cr ratio and FeNa are not reliable to diagnose postrenal AKI, so we must rely more in imaging and clinical presentation. Let´s talk about the management of postrenal AKI.TJ: Absolutely!  The main way to treat a post-renal AKI is to relieve the obstruction causing it in the first place, whether it be through surgery, TURP, lithotripsy, etc.Dr. Arreaza: I think the favorite treatment done by urology to relieve obstruction is a ureteral stent, which, remember, needs to be removed later. Typically, 1-2 weeks is sufficient to treat kidney stones. The risk

Episode 200: All About Ascites.     Jesica Mendoza explains the pathophysiology, diagnosis and management of ascites. Dr. Arreaza adds input about early detection and prevention of spontaneous bacterial peritonitis. Written by Jesica Mendoza, OMS IV, Western University, College of Osteopathic Medicine of the Pacific. Edits and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Welcome to our episode 200! It is an honor to welcome back a wonderful medical student, her name is Jesica, and she has prepared this topic, and she is excited to share this information with us. Jesica presented in June this year an episode about gestational diabetes (episode 193) and today she will talk about ascites. Jesica, please tell us who you are again. What is ascites?Ascites is the buildup of fluid in between the visceral peritoneum and the parietal peritoneum in the abdomen. This is often caused by cirrhosis of the liver due to the increased portal HTN which leads to increased nitrous oxide (NO) and prostaglandins which then causes splanchnic vasodilation and decreased effective arterial volume. The decrease in arterial volume then causes an increase in the renin–angiotensin–aldosterone system (RAAS) and antidiuretic hormone (ADH) from the renal system which leads to sodium and water retention. This then causes a net reabsorption of fluids and ascites.Evaluation of ascites.Once someone has been found to have ascites the next step will be a diagnostic paracentesis. This includes removing fluid from the peritoneal cavity in order to determine the SAAG (Serum Ascites Albumin Gradient) score. SAAG : (serum albumin) − (albumin level of ascitic fluid). The two values should be measured at the same time.This score helps determine the cause of the ascites with a score >1.1 g/dL indicating portal hypertension usually due to liver disease such as cirrhosis. A SAAG score of <1.1 g/dL will suggest causes such as tuberculosis, malignancy, pancreatitis, nephrotic syndrome, or inflammatory conditions. A paracentesis can be done for diagnostic purposes in a new-onset ascites or if a patient with known ascites has clinical deterioration (such as fever, abdominal pain, hepatic encephalopathy, renal dysfunction, or leukocytosis). In cases of tense or refractory ascites, the paracentesis can be done for both diagnostic and therapeutic purposes. Tell us more about the serum ascites albumin gradient (SAAG).If the SAAG is greater than 1.1 (portal hypertension) you then use the serum protein levels for further management. For a low serum protein (<2.5) you proceed with an abdominal US with doppler. The ultrasound will tell you whether the liver is cirrhotic and if the hepatic vessels are patent. Once cirrhosis is identified in the patient, the workup for chronic liver disease management can be started. Another cause of low protein is Budd-Chiari syndrome. In this case anticoagulation is used. Budd-Chiari syndrome is caused by obstruction of the hepatic venous outflow tract, most commonly the hepatic veins or the intra-/suprahepatic inferior vena cava, in the absence of cardiac or pericardial disease. This causes hepatic congestion, which can present with acute or chronic abdominal pain, hepatomegaly, ascites, and, in some cases, progressive liver dysfunction or portal hypertension; but up to 20% of cases may be asymptomatic. The most frequent underlying cause is a prothrombotic state, particularly cancer (Jes: myeloproliferative neoplasm). That’s why you mention the treatment: anticoagulation.A SAAG greater than 1.1 with a high serum protein level (>2.5) the cause points towards right sided heart failure or constrictive pericarditis. In both cases a referral to cardiology should be placed for management of the underlying cause of the ascites. Another cause of elevated protein levels is portal or splenic vein thrombosis. If this is the case, the patient is managed with anticoagulation again. Treating the underlying cause.Patients with cirrhosis causing ascites will need treatment for the underlying cause. If that cause is Hepatitis C or Hepatitis B, then starting antiviral therapy is crucial to reduce the liver’s inflammation. Diuresis is also very important to help with decreasing the ascites and in turn all the symptoms of ascites. Usually Furosemide and/or spironolactone can be used. In cases of mild ascites spironolactone is usually first line treatment. If the patient has recurrent ascites, they often are given a combination of spironolactone and loop diuretics like furosemide. The recommended ratio of furosemide (Lasix) to spironolactone for the treatment of ascites is 40 mg of furosemide to 100 mg of spironolactone (a 1:2.5 ratio). Recommended max dose: 160 mg furosemide and 400 mg spironolactone daily. Dose adjustments can be made every 72 hours to minimize electrolyte disturbances. Once the patient has ascites under control the diuretic dose is adjusted to the lowest effective dose to minimize side effects.Medications to avoid, sodium and water restriction.In conjunction with medical management, it is ideal that the patient stops alcohol if the patient has alcohol induced cirrhosis causing the ascites. The patient should also follow a low-sodium diet (less than 2 grams/day) to help prevent the fluid overload that worsens the ascites. Also, something very important is that the patient must avoid use of NSAIDs, b-blockers, and ACE/ARBs. Patients need to be educated on the importance of avoiding NSAIDS especially because these medications can be found over the counter and are readily accessible but very harmful to cirrhotic patients.Fluid (water) restriction is generally not recommended for patients with liver cirrhosis and ascites unless they have moderate to severe hyponatremia (serum sodium ≤125–126 mEq/L). When indicated, fluid restriction is typically set at 1,000 mL per day for moderate hyponatremia. The fluid management in ascites is focused on sodium restriction.Refractory ascites. Sometimes there are people who have already received diuretics and have tried lifestyle changes, but the ascites continues to recur. In these cases, serial therapeutic paracentesis or trans jugular intra-hepatic portosystemic shunts (TIPS) can be done. One special case is when the ascites is caused by a malignancy. In this case fluid will continue to accumulate even with repeat paracentesis. PleurX is another available treatment. PleurX is a thin, flexible silicone catheter and a one-way valve that is inserted into the peritoneal cavity to allow for drainage of the fluid. Usually, the patients are sent home with this catheter and have caregivers who help them drain fluid using vacuum bottles. This is useful in reducing hospitalization in patients. However, it is not recommended in patients with infection, chylous effusions, mediastinal shifts, or hemorrhage risks. If the patient is a good candidate, they can be put on a list for liver transplant. Spontaneous bacterial peritonitis. A patient with SBP usually presents with systemic inflammatory response syndrome (SIRS) and large volume ascites on abdominal US. SBP is confirmed via paracentesis with >250 PMNS/mL. Fluid should be sent to the lab for culture and then antibiotics should be started. IV 3rd generation cephalosporins are typically used. Fluoroquinolones are also used to prevent the recurrence of SBP.If you desire to learn more about SBP, listen to our episode 123. By the way, propranolol is a frequently used medication to prevent GI bleeding from esophageal varices in cirrhosis and also to decrease the development of ascites. It should be used in patients who have compensated cirrhosis and must be avoided in patients with refractory ascites, hypotension, renal dysfunction or active infection. So, to wrap things up we should remember that once we identify ascites with our physical exam of the patient, we should make sure to obtain a paracentesis as these results will be the main guide for our treatment. The treatment can then range from medical treatment such as spironolactone and/or loop diuretics to TIPS procedures, PleurX or even liver transplant. Always be on the lookout for SBP in patients with ascites and always remember to obtain a culture on the ascitic fluid prior to starting antibiotics. 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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Ascites, Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/14792-ascites.Huang LL, Xia HH, Zhu SL. Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites. J Clin Transl Hepatol. 2014 Mar;2(1):58-64. doi: 10.14218/JCTH.2013.00010. Epub 2014 Mar 15. PMID: 26357618; PMCID: PMC4521252. https://pmc.ncbi.nlm.nih.gov/articles/PMC4521252/.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 199: Essential Screenings for Young AdultsDr. Lopez presents the most important screening tests for young adults. Dr. Arreaza adds some input on screening for depression and anxiety. Written by Alejandra Lopez, MD. Edits by Hector Arreaza, MD. Rio Bravo Family Medicine Residency Program. 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.Dr. Lopez: Screening is testing done to help identify disease in a person or population that typically appears healthy. Our goal as clinicians is to see which children are at increased risk of disease and will merit additional testing. For clinicians, testing should be both easy to perform and interpret. Now let’s talk about prevention in young adults.Dr. Arreaza: I can see it is important to talk about young adults because that population may be very hesitant to go to the doctor, in general. Tell us more about it.Dr. Lopez: We all know that early detection and prevention are key, but many young adults skip routine check-ups. Why is that? Sometimes it’s lack of awareness, fear, or just not knowing where to start. That’s why today, we’ll focus on four key screenings that every adolescent and young adult should know about.The Annual Physical ExamDr. Arreaza: I’m excited to talk about it. Many young adults only see a doctor when they’re sick, but screenings help catch issues early, sometimes before symptoms even appear. Tell us about the annual wellness exams and why they matter.Dr. Lopez: Let’s start with the basics—annual wellness exams. Many young people don’t feel the need to see a doctor if they’re feeling fine. So, these check-ups are important because many serious health conditions start silently, meaning no symptoms at first. Dr. Arreaza: What do we look for in an annual exam?Dr. Lopez: An annual check-up:· It is important to track growth and development (especially important for adolescents)It also helps monitor blood pressure, weight, and BMI to help find out who is at risk for elevated or low BP, underweight or overweight/obesity, by analyzing both weight and body mass index.· Discuss lifestyle habits like diet, exercise, and sleep· Evaluate whether you are up to date on vaccinations or due for age-appropriate vaccines.· Address any mental health concernsIt’s also a great opportunity for young people to establish a relationship with a provider they trust. This makes it easier to discuss sensitive topics like sexual health or mental health.Dr. Arreaza: So, you say that the annual physical exam helps identify all these issues early, and at the same time, you establish a relationship of trust with a doctor who you may need at any time. STI ScreeningDr. Arreaza: That brings us to our second key screening: testing for sexually transmitted infections (STIs). There are many STIs. Let’s focus on gonorrhea, chlamydia, syphilis, and HIV. Dr. Lopez, can you breakit  down for us? Who needs STI screening, and why is it so important?Dr. Lopez: Absolutely. The CDC recommends that ALL sexually active women under age 25 get screened for chlamydia and gonorrhea annually. HIV testing should also be done at least once for all young adults and annually for those at higher risk. Why is this the case? Because Many STIs have no symptoms, but untreated infections can lead to serious complications like infertility or pelvic inflammatory disease (PID) in women. The good news is that these infections are easily treatable if caught early. If caught later in life, then women and men alike are at risk for worse conditions. Dr. Arreaza: Let's talk about how do we do it?Dr. Lopez: STI screening is simple:· For chlamydia and gonorrhea, it’s usually a urine test or a vaginal/cervical/oral swab.· For HIV, it’s a quick blood test or even an oral swab.Many young adults avoid testing because of fear, stigma, or concerns about privacy, but most clinics offer confidential or even anonymous testing. Doctors do not share any information regarding the minor or young adult or any patient for that matter. AND if we are requested to share any information with others- then it is our obligation as doctors to ALWAYS ASK THE PATIENT before sharing ANY health information with third parties/other entitiesDr. Arreaza: And that includes parents of minors. Doctors are not allowed to discuss STI test results with parents of minors unless they are authorized by the patient or if the patient is in danger, for example, if this is a result of sexual abuse.Mental Health ScreeningsDr. Arreaza: Now, let’s talk about something that’s just as important as physical health—mental health. Depression and anxiety are very common in young people, but many don’t seek help. How do doctors screen for depression?Dr. Lopez: Screening for depression is now a standard part of primary care. The most commonly used tool is the PHQ-9 questionnaire, which asks about:· Mood changes (sadness, hopelessness)· Loss of interest in activities· Sleep disturbances· Changes in appetite· Difficulty concentratingA score on this test can help determine whether someone is at risk of depression and needs further evaluation or support.Dr. Arreaza: And why should we screen for depression?Dr. Lopez: Because early treatment makes a huge difference. Depression can affect school, work, relationships, and even physical health. But with therapy, lifestyle changes, and sometimes medication, people can and do recover.I always tell young adults: Mental health is just as important as physical health. Seeking help is a sign of strength, not weakness.Dr. Arreaza: This is a USPSTF recommendation GRADE B. We are encouraged to screen adults, including pregnant and postpartum women, as well as older adults.HPV Screening & VaccinationDr. Lopez: Dr. Arreaza, finally, let’s talk about HPV—one of the most preventable causes of cancer. The human papillomavirus (HPV) is the most common STI worldwide, and it’s responsible for almost all cases of cervical cancer, as well as throat, anal, and penile cancers. The good news? The HPV vaccine is over 90% effective at preventing these cancers. Dr. Arreaza: In fact, from 2015 to 2018, U.S. women ages 14 to 19 experienced an 88% decrease in HPV-related disease. That’s a direct result of the vaccine's effectiveness.Dr. Lopez: It’s recommended for:· All boys and girls, starting at the age of 9. ACIP gave new recommendations for use of a 2-dose schedule for girls and boys who initiate the vaccination series at ages 9-14 years. Three doses remain recommended for persons who start HPV vaccination at ages 15-26 years and for immunocompromised persons.· Catch-up vaccination is recommended for people up to age 26 (and in some cases, up to 45 with provider recommendation)Dr. Arreaza: And what about screening for HPV? How do we screen?Dr. Lopez: Great question, Dr. Arreaza. Pap smears start at age 21, for all women regardless of sexual activity, and are repeated every 3-5 years depending on HPV testing. Many people think Pap smears check for STIs, but they actually look for abnormal cervical cells that could lead to cancer. HPV vaccination plus routine screening means cervical cancer is one of the most preventable cancers today!Closing Thoughts & Call to ActionDr. Arreaza: That wraps up today’s discussion on essential health screenings for young adults! Dr. Lopez, any final take-home messages?Guest: My biggest message is don’t wait until something is wrong to see a doctor. Preventative care is simple, quick, and can save lives.If you’re between the ages of 13-26, here’s what you should do:-Get an annual wellness exam-Get tested for STIs if sexually active-Check in on your mental health and talk to someone if you need support-Get the HPV vaccine if you haven’t already and follow up on screeningTaking these small steps today leads to better health for years to come!Host: That’s fantastic! Dr. Lopez. I hope all our primary care providers can take these easy steps to keep our young community healthy. If you found this episode helpful, share it with a friend, and don’t forget to subscribe to our podcast for more practical health discussions.Dr. Lopez: Until next time—thanks for chiming in, medical community. Take care and take charge of your health!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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Screening Recommendations and Considerations Referenced in Treatment Guidelines and Original Sources. U.S. Centers for Disease Control and Prevention, CDC.gov, https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm, accessed on June 26, 2025.Recommendation: Anxiety Disorders in Adults: Screening, United States Preventive Services Taskforce, June 20, 2023, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening, accessed on June 26, 2025.Recommendation: Depression and Suicide Risk in Adults: Screening, United States Preventive Services Taskforce, June 20, 2023, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-adults, accessed on June 26, 2025.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 198: Fatigue.  Future doctors Redden and Ibrahim discuss with Dr. Arreaza the different causes of fatigue, including physical and mental illnesses. Dr. Arreaza describes the steps to evaluate fatigue. Some common misconceptions are explained, such as vitamin D deficiency and “chronic Lyme disease”. Written by Michael Ibrahim, MSIV, and Jordan Redden, MSIV, Ross University School of Medicine. Edits and comments by Hector Arreaza, MDYou 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.Dr. Arreaza: Today is a great day to talk about fatigue. It is one of the most common and most complex complaints we see in primary care. It involves physical, mental, and emotional health. So today, we’re walking through a case, breaking down causes, red flags, and how to work it up without ordering the entire lab catalog.Michael:Case: This is a 34-year-old female who comes in saying, "I’ve been feeling drained for the past 3 months." She says she’s been sleeping 8 hours a night but still wakes up tired. No recent illnesses, no weight loss, fever, or night sweats. She denies depression or anxiety but does report a lot of work stress and taking care of her two little ones at home. She drinks 2 cups of coffee a day, doesn’t drink alcohol, and doesn’t use drugs. No medications, just a multivitamin. Regular menstrual cycles—but she’s noticed they’ve been heavier recently.Jordan:Fatigue is a persistent sense of exhaustion that isn’t relieved by rest. It’s different from sleepiness or muscle weakness.Classification based on timeline:    •   Acute fatigue: less than 1 month    •   Subacute: 1 to 6 months    •   Chronic: more than 6 monthsThis patient’s case is subacute—going on 3 months now.Dr. Arreaza:And we can think about fatigue in types:    •   Physical fatigue: like muscle tiredness after activity    •   Mental fatigue: trouble concentrating or thinking clearly (physical + mental when you are a medical student or resident)    •    Pathological fatigue: which isn’t proportional to effort and doesn’t get better with restAnd of course, there’s chronic fatigue syndrome, also called myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which is a diagnosis of exclusion after 6 months of disabling fatigue with other symptoms.Michael:The differential is massive. So, we can also group it by systems.Jordan:Let’s run through the big ones.Endocrine / Metabolic Causes    • Hypothyroidism: A classic cause of fatigue. Often associated with cold intolerance, weight gain, dry skin, and constipation. May be subtle and underdiagnosed, especially in women.    • Diabetes Mellitus: Both hyperglycemia and hypoglycemia can cause fatigue. Look for polyuria, polydipsia, weight loss, or blurry vision in undiagnosed diabetes.    • Adrenal Insufficiency: Think of this when fatigue is paired with hypotension, weight loss, salt craving, or hyperpigmentation. Can be primary (Addison's) or secondary (e.g., due to long-term steroid use).Michael: Hematologic Causes    • Anemia (especially iron deficiency): Very common, especially in menstruating women. Look for fatigue with pallor, shortness of breath on exertion, and sometimes pica (craving non-food items).     • Vitamin B12 or Folate Deficiency: B12 deficiency may present with fatigue plus neurologic symptoms like numbness, tingling, or gait issues. Folate deficiency tends to present with megaloblastic anemia and fatigue.    • Anemia of Chronic Disease: Seen in patients with chronic inflammatory conditions like RA, infections, or CKD. Typically mild, normocytic, and improves when the underlying disease is treated.Michael: Psychiatric Causes    • Depression: A major driver of fatigue, often underreported. May include anhedonia, sleep disturbance, appetite changes, or guilt. Sometimes presents with only somatic complaints.    • Anxiety Disorders: Mental fatigue, poor sleep quality, and hypervigilance can leave patients feeling constantly drained.    • Burnout Syndrome: Especially common in caregivers, healthcare workers, and educators. Emotional exhaustion, depersonalization, and reduced personal accomplishment are key features.Jordan: Infectious Causes    • Epstein-Barr Virus (EBV):Mononucleosis is a well-known cause of fatigue, sometimes lasting weeks. May also have sore throat, lymphadenopathy, and splenomegaly.    • HIV:Consider it in high-risk individuals. Fatigue can be an early sign, along with weight loss, recurrent infections, or night sweats.    • Hepatitis (B or C):Can present with chronic fatigue, especially if liver enzymes are elevated. Screen at-risk individuals.    • Post-viral Syndromes / Long COVID:Fatigue that lingers for weeks or months after viral infection. Often, it includes brain fog, muscle aches, and post-exertional malaise.Important: Chronic Lyme disease is a controversial term without a consistent clinical definition and is often used to describe patients with persistent, nonspecific symptoms not supported by objective evidence of Lyme infection. Leading medical organizations reject the term and instead recognize "post-treatment Lyme disease syndrome" (PTLDS) for persistent symptoms following confirmed, treated Lyme disease, emphasizing that prolonged antibiotic therapy is not effective. Research shows no benefit—and potential harm—from extended antibiotic use, and patients with unexplained chronic symptoms should be thoroughly evaluated for other possible diagnoses.Michael: Cardiopulmonary Causes    •   Congestive Heart Failure (CHF): Fatigue from poor perfusion and low cardiac output. Often comes with dyspnea on exertion, edema, and orthopnea.    •   Chronic Obstructive Pulmonary Disease (COPD): Look for a smoking history, chronic cough, and fatigue from hypoxia or the work of breathing.    •   Obstructive Sleep Apnea (OSA): Daytime fatigue despite adequate hours of sleep. Patients may snore, gasp, or report morning headaches. High suspicion in obese or hypertensive patients.Jordan:Autoimmune / Inflammatory Causes    •   Systemic Lupus Erythematosus (SLE): Fatigue is often an early symptom. May also see rash, arthritis, photosensitivity, or renal involvement.    •   Rheumatoid Arthritis (RA): Fatigue from systemic inflammation. Morning stiffness, joint pain, and elevated inflammatory markers point to RA.    •   Fibromyalgia: A chronic pain syndrome with widespread tenderness, fatigue, nonrestorative sleep, and sometimes cognitive complaints ("fibro fog").Cancer / Malignancy    •   Leukemia, lymphoma, or solid tumors: Fatigue can be the first symptom, often accompanied by weight loss, night sweats, or unexplained fevers. Consider when no other cause is evident.Michael:Medications:Common culprits include:    ◦   Beta-blockers: Can slow heart rate too much.    ◦   Antihistamines: Sedating H1 blockers like diphenhydramine.    ◦   Sedatives or sleep aids: Can cause grogginess and daytime sedation.    •   Substance Withdrawal: Fatigue can be seen in withdrawal from alcohol, opioids, or stimulants. Caffeine withdrawal, though mild, can also contribute.Dr. Arreaza:Whenever we evaluate fatigue, we need to keep an eye out for red flags. These should raise suspicion for something more serious:    •   Unintentional weight loss    •   Night sweats    •   Persistent fever    •   Neurologic symptoms    •   Lymphadenopathy    •   Jaundice    •   Palpitations or chest painThis patient doesn’t have these—but that doesn’t mean we stop here.Dr. Arreaza:Those are a lot of causes, we can evaluate fatigue following 7 steps:Characterize the fatigue.Look for organic illness.Evaluate medications and substances.Perform psychiatric screening.Ask questions about quantity and quality of sleep.Physical examination.Undertake investigations.So, students, do we send the whole lab panel?Michael:Not necessarily. Labs should be guided by history and physical. But here’s a good initial panel:    •   CBC: To check for anemia or infection    • TSH: Screen for hypothyroidism    • CMP: Look at electrolytes, kidney, and liver function    • Ferritin and iron studies    • B12, folate    • ESR/CRP for inflammation (not specific)    • HbA1c if diabetes is on the radarJordan:And if needed, consider:    • HIV, EBV, hepatitis panel    • ANA, RF    • Cortisol or ACTH stimulation testImaging? Now that’s rare—unless there are specific signs. Like chest X-ray for possible cancer or TB, or sleep study if you suspect OSA.Dr. Arreaza:Unaddressed fatigue isn’t just inconvenient. It can impact on quality of life, affect job performance, lead to mood disorders, delay diagnosis of serious illness, increase risk of accidents—especially driving. So, don’t ignore your patients with fatigue!Jordan:And some people—like women, caregivers, or shift workers—are especially at risk.Michael:The cornerstone of treatment is addressing the underlying cause.Jordan:If it’s iron-deficiency anemia—treat it. If it’s depression—get mental health involved. But there’s also: Lifestyle Support: Better sleep hygiene, light physical activity, mindfulness or CBT for stress, balanced nutrition—especially iron and protein, limit caffeine and alcoholDr. Arreaza:Sometimes medications help—but rarely. And for chronic fatigue syndrome, the current best strategies are graded exercise therapy and CBT, along with managing specific symptoms. Beta-alanine has potential to modestly improve muscular endurance and reduce fatigue in older adults, but more high-quality research is needed.SSRI: fluoxetine and sertraline. Iron supplements: Even without anemia, but low ferritin [Anecdote about low ferritin patient]Jordan:This case reminds us to take fatigue seriously. In her case, it may be multifactorial—work stress, caregiving burden, and possibly

Episode 197: Continuous Glucose MonitoringWritten by William Zeng, MSIII, and Chris Kim, MSIII. University of Southern California.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.Will: IntroToday we’re exploring Continuous Glucose Monitoring, or CGM. We’ll break down what CGM is, who benefits, how to access it, options available for our patients, the pros and cons, and a few final reflections on where this technology is heading. Chris, So what is CGM?Chris:Continuous glucose monitoring refers to the use of a small wearable sensor placed just under the skin to track glucose levels in real time throughout the day and night. These sensors measure glucose in the interstitial fluid and transmit readings to a receiver or smartphone at regular intervals, allowing for 24/7 glucose trend tracking. Will:CGM has been shown to improve glycemic control, increase “time in range,” and reduce hypoglycemia. Let’s review some evidence.Chris:A 2023 meta-analysis published in Diabetes Technology & Therapeutics reported a mean Hemoglobin A1c reduction of 0.43% across multiple trials. Will:In people with Type 1 diabetes, the IMPACT and DIAMOND studies showed sustained improvement in Hemoglobin A1c and hypoglycemia reduction over 6–12 months. CGM use in insulin-treated Type 2 diabetes patients also resulted in significant benefits, including reduced variability and fewer severe glucose excursions. Chris:Clinically and economically, CGMs help prevent long-term complications such as cardiovascular disease, nephropathy, and retinopathy. Chris, What patients specifically benefit the most from CGM?Will: CGMs are most commonly indicated for people with Type 1 diabetes and for those with Type 2 diabetes who are using intensive insulin regimens—typically defined as multiple daily injections or insulin pump therapy. Chris:And what are the qualifications in order to be covered by insurance?Will:In the United States, Medicare covers CGM as durable medical equipment for qualifying patients, and coverage requires a prescription, documentation of insulin use, and regular follow-up. Most major private insurers—including Blue Cross, Aetna, UnitedHealthcare, Cigna, and Kaiser—follow similar guidelines. Coverage is generally granted for patients with Type 1 diabetes or insulin-requiring Type 2 diabetes who monitor glucose at least four times daily or use an insulin pump. Chris:Some plans require demonstration of hypoglycemia unawareness or frequent glucose variability. For patients not on insulin, OTC CGMs may be an option, but coverage is typically not provided. That said, new FDA decisions are allowing over-the-counter access to CGMs like Abbott’s FreeStyle Libre and Dexcom’s Stelo, expanding availability for lifestyle or preventive purposes.Will:[There are a lot of products on the market. Which are the main products and how are they different?]Chris:The three main players in the CGM space are Dexcom, Abbott (FreeStyle Libre), and Senseonics (Eversense), each with unique offerings.Let’s start with Dexcom. Dexcom G7 is a real-time CGM system approved for both Type 1 and Type 2 diabetes. It combines a sensor and transmitter into one compact wearable patch worn on the abdomen or upper arm for up to 10 days. It updates glucose readings every 5 minutes and connects directly to a smartphone or Apple Watch via Bluetooth. Dexcom also integrates with insulin pumps like Tandem’s t:slim and the Omnipod 5. Data can be shared with providers through Dexcom Clarity, which integrates into electronic medical records (EMRs) like Epic. OTC access is not yet available for DEXCOM G7, but a new non-prescription product called Dexcom Stelo is being rolled out in 2025, targeting non-insulin-using Type 2 patients. Dexcom Stelo will also offer 15-day wear, smartphone integration, and factory calibration. The estimated OTC cost for Dexcom Stelo is expected to be around $99 for a 15-day sensor, or about $198/month.Will:$200! Abbott FreeStyle Libre comes in several versions. The Libre 2 offers 14-day wear and requires users to scan the sensor with their smartphone or reader to retrieve a glucose value. It has optional real-time alarms for high and low readings and transmits data to LibreView, which can integrate with most EMRs. Libre 3 is a real-time CGM with 1-minute interval updates, Bluetooth transmission, and a slimmer profile. Libre sensors are widely used in primary care and available OTC for non-insulin users. Libre 2 sensors cost approximately $70–$85 for a 14-day sensor, while Libre 3 is slightly higher, around $85–$100 per sensor—totaling about $140–$200/month out of pocket without insurance.Chris:Senseonics Eversense E3 is the only implantable CGM on the market. It involves a minor in-office procedure to insert the sensor under the skin of the upper arm, which lasts up to 180 days (and a newer version, Eversense 365, lasts up to one year). A removable transmitter worn on top of the skin sends data every 5 minutes to a mobile app and vibrates for alerts. It requires 1–2 calibrations per day using a traditional fingerstick meter. It integrates with Eversense DMS software for physician monitoring. The total cost for Eversense depends on the insertion procedure and insurance, but cash pay for the full 6-month system is estimated at $2,400–$3,000, or about $400–$500/month including follow-up visits.Will:Additional lower-cost CGMs such as the Medtrum A6 TouchCare are available internationally and in select U.S. pilot programs. These devices offer 14-day wear, smartphone syncing, and daily calibration, but are not yet FDA-approved for wide use and lack full EMR integration.Chris:In terms of performance and value, Dexcom G7 offers the most advanced real-time feedback and integration, making it ideal for those on insulin pumps or needing tight control. Will:FreeStyle Libre offers the best affordability and convenience, especially for non-insulin users or those who prefer not to deal with constant alerts. Eversense offers a niche but compelling option for people who want to avoid frequent sensor changes. Chris, [Are there any downsides or risks that patients should be aware of before trying out CGM?]Chris:CGMs are generally safe and well-tolerated, but they do have limitations. Dexcom G7 has a known failure mode where sensors sometimes fail prematurely, often before the full 10-day duration. Some users have reported “signal loss” errors or random disconnections, especially when switching between phone models or operating systems. There are occasional reports of inaccurate highs or lows due to compression during sleep or dehydration. Though the G7 is factory-calibrated, abrupt changes in hydration or blood flow can affect its readings.Will:FreeStyle Libre systems, particularly Libre 2, require the user to scan the sensor to retrieve data unless alerts are enabled. These devices may be affected by vitamin C (ascorbic acid), which can falsely elevate glucose readings, and they do not currently allow for automated insulin delivery integration. Some Libre 2 users have noted adhesive-related rashes or spontaneous detachment. Libre 3, while more advanced, still may lose Bluetooth connection intermittently, particularly if the phone is out of range or the app is not running in the background.Chris:Senseonics Eversense carries procedural risks due to its implantable nature. Minor scarring or infection at the insertion site has been reported. The transmitter must be worn during waking hours to provide alerts, and users report anxiety over losing the transmitter since data logging is interrupted without it. Calibration is still required, which adds to daily tasks. Additionally, the sensor does not communicate with insulin pumps or closed-loop systems.Will:All CGMs can cause mild skin irritation from adhesive, particularly in users with sensitive skin. Alert fatigue is another consideration, as frequent low- or high-glucose warnings may cause stress or lead users to silence notifications entirely. Finally, relying solely on CGM without periodic fingerstick confirmation in symptomatic scenarios can be a risk, especially during rapid glucose changes.Chris:Conclusion[***] Continuous glucose monitors have reshaped the way we manage diabetes, offering unprecedented insight into glucose trends, diet responses, and insulin timing. While CGMs are not flawless, the technology continues to evolve. Will: If your patient is on insulin or struggling with glucose variability, consider whether CGM is right for your patient. For those not using insulin, consider newer OTC options like FreeStyle Libre or Dexcom Stelo, which offer accessible entry points without the need for prescriptions. As AI integration, longer sensor life, and non-invasive monitoring enter the market, CGM will only become more useful.Dr Arreaza: Personal experience with CGMs. I do not have diabetes, but I have a strong family history of diabetes (including father, 2 grandmas, and about 15 uncles, aunts, and cousins.)I wanted to try it so I could teach my patients about CGM. My first experience was with Freestyle Libre 2: Pros: Painless placement, easy to use, scanning with phone was easier than fingersticks.Cons: Required some assembling to be placed, mild discomfort at night, and nighttime alarms.Dexcom G7:Pros: No need for scanning, feels more stable in your armCons: High readings (had to calibrate for a more accurate reading)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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________

Episode 196: Bipolar Disorder.     Learn about the diagnosis and management of bipolar disorder, presented by medical students Jennifer, Targol, and Tyler. Written by Jennifer Burnham, OMS III; Targol Mehrazar, OMS III; and Tyler Richins, OMS III. Western University of Health Sciences. 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.

Episode 195: Case of headache.     Future doctors Ibrahim and Redden explain the most common causes of headaches and explain the features of a serious cause of headache. Dr. Arreaza highlights the importance of diagnosis migraines.   Written by Michael Ibrahim, MSIV, and Jordan Redden, MSIV, Ross University School of Medicine. Edits and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Dr. Arreaza: Our topic today is one every doctor will commonly see in their practice: headaches. Headache is one of the most common neurological complaints encountered in clinical practice and affects people of all ages and backgrounds. I have learned that a headache can be “the noise of a working brain” or it can be a cue to a more serious condition. So, let’s start at the beginning: Michael, give us the big picture: how should clinicians think about headaches?Michael:Sure thing, Dr. Arreaza. So, at its core, a headache is pain that’s felt in the head, scalp, or neck. But that’s just the surface. Clinically, we break headaches into two broad categories: primary and secondary. Primary headaches are their own condition: things like migraines, tension-type headaches, or cluster headaches. Secondary headaches, on the other hand, are a symptom of something else: an infection, trauma, vascular event, or even a brain tumor.The challenge for us as clinicians is distinguishing between the two. Because while most headaches are benign, some can signal something much more serious. That’s why a detailed clinical history and a careful neurologic exam are absolutely essential.Jordan:Exactly. We were taught that while not every headache needs imaging, every headache needs a detailed history. Understanding the timeline, triggers, and associated symptoms can really point you in the right direction.Dr. Arreaza:Great points. Let's move into a real-world scenario. Michael, tell us about the patient case you brought to the podcast.Michael:Right. Our patient is a 32-year-old woman, Ms. A., who’s had six months of intermittent, throbbing headaches. They’re mostly on the right side, and they come with nausea, sensitivity to light and sound. She notices they’re often triggered by stress, poor sleep, or skipping meals. Her neuro exam is normal, but she’s anxious; she fears it might be a brain tumor.Jordan:That’s such a common scenario. Even when the clinical picture strongly suggests migraine, patients often fear the worst. And honestly, given how disabling migraine attacks can be, their concern is totally valid.Dr. Arreaza: Exactly. We should never downplay the patient’s fear. And in Ms. A’s case, the symptoms: unilateral throbbing, photophobia, nausea; these really do fit the classic migraine profile. Let’s review the major types of headaches.Michael:So, we break headaches down into primary and secondary. Under primary headaches, you’ve got migraines (with or without aura), tension-type headaches, which are the most common, and cluster headaches, which are rarer but incredibly distinctive.Jordan:When it comes to secondary headaches, we must think broadly. There are infectious causes like meningitis or encephalitis, vascular emergencies like subarachnoid hemorrhage, temporal arteritis in older adults, tumors, trauma, and even medication overuse.Dr. Arreaza:Let’s pause on that one: medication overuse. That’s a headache many patients don’t expect. They’re trying to manage their pain, but if they use analgesics too frequently (especially things like triptans, combination pain meds, or opioids) they can actually perpetuate the cycle of pain.Michael:It’s a vicious loop. Patients take more meds to control their headaches, but the rebound from those meds keeps the headache going. That’s why we always ask, how often are you taking something for your headache?Dr. Arreaza:That’s right. What are the clinical clues that would help us figure out the type of headache we’re dealing with?Michael:Well, migraines typically present with a combination of features: moderate to severe pain, often unilateral and throbbing, worsened by activity, and associated with nausea or vomiting and light or sound sensitivity. If there's an aura: visual changes, sensory symptoms, or speech disturbance, that can help confirm the diagnosis.Dr. Arreaza: Let’s remember the POUND mnemonics. Pulsating, throbbing, or varying the heartbeat. One to three days (4-72 h in duration). Unilateral location, usually frontotemporal. In children, it is often bilateral and switches to unilateral in adolescence. Nausea/Vomiting AND/OR Photophobia/Phonophobia. Disabling intensity: moderate to severe in intensity and it get worse with movement. Migraines hate movement! According to AFO Journal, “In a primary care setting, the probability of a migraine is 92% in patients who report at least four of the five POUND symptoms. The probability decreases to 64% in patients with three of the symptoms, and 17% in patients with 2 or fewer symptoms.”Jordan:Now, cluster headaches have previously been referred to as “suicide headaches” because the pain is so intense. They’re usually one-sided, come in cycles or “clusters,” and are associated with autonomic features like tearing, nasal congestion, even ptosis or miosis, which could mimic Horner’s syndrome.Michael:Tension-type headaches, on the other hand, feel more like a tight band around the head. They're bilateral, pressing rather than pulsating, and usually not accompanied by nausea or sensory sensitivity.Jordan:And then we always keep red flags in mind. That’s where the SNOOP mnemonic helps: Systemic symptoms, Neurologic signs, Onset sudden, older age, and Pattern change. These mnemonics have been updated, and several items have been added. It has two Ns, 2 Os, and 10 Ps. For example, one of the Ns that is added is neoplasia history, and some of the Ps are Pregnancy/Postpartum, Papilledema, and Pain killer overuse. You can find the updated version in the American Family Physician journal, April 2025. Dr. Arreaza:Exactly. Any of those should raise alarm bells. “Thunderclap headaches” especially! Those need immediate evaluation. I learned it in med school as “a lightning flashing in a blue sky” (Hispanics drama is real, folks [joke]).Michael:If we’re worried about secondary causes, that’s when labs and imaging come in. We might check CBC for infection, ESR for temporal arteritis, or even a toxicology screen if substances are a concern.Jordan:And imaging! Non-contrast CT is great for acute or sudden-onset headaches. But for chronic or worsening symptoms, we lean toward MRI. If vascular causes are on the table, we might add MRV or CTA. And don’t forget lumbar puncture if we’re thinking about meningitis or subarachnoid hemorrhage.Dr. Arreaza:Very good. The key is to tailor the workup to clinical suspicion. Not every headache needs a CT, but some definitely do. It’s not just about getting tests, it’s about getting the right tests based on the story. Let’s talk about management. How do we approach treatment?Michael:For acute migraine attacks, NSAIDs are a good first-line. Triptans are also effective, especially if given early. And adding an anti-emetic like metoclopramide can help with both nausea and improve absorption of oral meds.Jordan:And for tension-type, it’s usually NSAIDs, sometimes acetaminophen. But non-pharmacologic measures are key too, things like stress reduction, sleep hygiene, posture correction, etc.Michael:Cluster headaches are a different beast. The go-to is high-flow oxygen, 15 L via non-rebreather mask, and subcutaneous sumatriptan, because oral meds are too slow.Jordan:An even bigger challenge is treatment when headaches become chronic, especially with medication overuse. And there’s often comorbidity with depression or anxiety, which complicates management.Michael:Fortunately, most people with headaches don’t have chronic headaches. Some risk factors for chronic headaches include family history, female sex, poor sleep, stress, and hormonal shifts. Triggers like caffeine, dehydration, and irregular meals are also common.Dr. Arreaza:Those elements are important to ask about during the visit, not just the headache itself, but what might be feeding into it.Jordan:For patients with frequent headaches, preventive therapy is a game-changer. Think things like beta-blockers, topiramate, amitriptyline, or CGRP inhibitors. Gepants and ditans are newer medications, supported by evidence as second-line agents. Unlike triptans and ergot alkaloids, gepants and ditans do not have vascular contraindications. Their use may be limited by cost.Michael:And we can’t forget lifestyle modifications. Encouraging regular sleep, hydration, and stress reduction often makes an enormous difference.Dr. Arreaza:To wrap it up: headaches are complex, but with a structured approach, we can distinguish benign from dangerous. Michael, any final takeaway?Michael:Yes! Start with a good history and physical, then build your differential. Most headaches are manageable, but don’t ignore red flags.Jordan:And always validate the patient’s concerns. Even if it’s “just a migraine,” it can be disabling, and we need to treat it seriously. Dr Arreaza:Thanks for listening! Stay tuned for our next episode!_______________________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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________ References: International Headache Society. (2018). The International Classification of Headache Disorders, 3rd edition (ICHD-3). Retrieved f

Episode 194: Acute low back pain.  Future Dr. Ibrahim presents a clinical case to explain the essential points in the evaluation of back pain.  Future Dr. Redden adds information about differentiating between a back strain and more serious diseases such as cancer, and Dr. Arreaza shares information about returning to work after back strain.Written by Michael Ibrahim, MSIV. Editing and comments by Jordan Redden, MSIV, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Dr. Arreaza:Welcome back, everyone. Today’s topic is one that every primary care provider, emergency doctor, and even specialist sees routinely: low back pain. It's so common that studies estimate up to 80% of adults will experience it at some point in their lives. But despite how frequent it is, the challenge is to identify which cases are benign and which demand urgent attention.Jordan:Exactly. Low back pain is usually self-limiting and mechanical in nature, but we always need to keep an eye out for the rare but serious causes: things like infection, malignancy, or neurological compromise. That’s why a good history and physical exam are our best tools right out of the gate.Michael:And to ground this in a real example, let me introduce a patient we saw recently. John is a 45-year-old warehouse worker who came in with two weeks of lower back pain that started after lifting a 50-lb box. He describes it as a dull, aching pain that radiates from his lower back down the posterior left thigh into the calf. He says it gets worse with bending or coughing, but he feels better when lying flat. He also mentioned some numbness in his left foot, but he denies any bowel or bladder issues. His vitals are completely normal. On exam, he had lumbar paraspinal tenderness, a positive straight leg-raise at 40 degrees on the left and decreased sensation in the L5 dermatome, though reflexes were still intact.Dr. Arreaza:That’s a great case. Let’s take a minute and talk about the straight leg raise test. This is a bedside tool we use to assess for lumbar nerve root irritation often caused by a herniated disc. ***Here's how it works: the patient lies supine, and you slowly raise their straight leg. If pain radiates below the knee between 30° and 70°, that suggests radiculopathy, especially involving the L5 or S1 nerve roots. Pain at higher angles is more likely due to hamstring tightness or mechanical strain.Michael:Right. So, stepping back: what do we mean by "low back pain"? Broadly, it's any pain localized to the lumbar spine, but it’s often classified by type or cause:Mechanical (like muscle strain or degenerative disc disease), Radicular (nerve root involvement), Referred pain (like from pelvic or abdominal organs), Inflammatory (AS), and Systemic or serious causes like infection or malignancy. Jordan:In John’s case, we’re thinking radicular pain, most likely from a herniated disc compressing the L5 nerve root. That’s supported by the dermatomal numbness, the leg pain, and that positive straight leg test.Dr. Arreaza:Good reasoning. Now, anytime we see back pain, our brains should run a checklist for red flags. These help us pick up more serious causes that require urgent attention. Let’s run through the red flags.Michael:Sure. For fracture, we think about major trauma or even minor trauma in the elderly, especially those with osteoporosis or on chronic steroids. Also, anyone over 70 years old.Jordan:Then we have infections, which could include things like discitis, vertebral osteomyelitis, or epidural abscess. Red flags include fever, IV drug use, recent surgery, or immunosuppression.Michael:Malignancy is another critical one, especially if there’s a history of breast, prostate, lung, kidney, or thyroid cancer. Clues include unexplained weight loss, night pain, or constant pain not relieved by rest.Jordan:And don’t forget about inflammatory back pain, like ankylosing spondylitis, which is often seen in younger patients with morning stiffness that lasts more than 30 minutes and improves with activity.Dr. Arreaza:And of course, we always rule out cauda equina syndrome: a surgical emergency. That’s urinary retention or incontinence, saddle anesthesia, bilateral leg weakness, or fecal incontinence. Missing this diagnosis can be catastrophic.Michael:Thankfully, in John's case, we don’t see any red flags. His presentation is classic for uncomplicated lumbar radiculopathy. But we must stay vigilant, because sometimes patients don’t offer up key symptoms unless we ask directly.Jordan:And that’s where associated symptoms help guide us. For example:Radicular symptoms like numbness or weakness follow dermatomal patterns. Constitutional symptoms like fever or weight loss raise red flags. Bladder/bowel changes or saddle anesthesia raise alarms for cauda equina. Pain that wakes patients up at night might point to malignancy. Dr. Arreaza:So when do we order labs or imaging?Michael:Not right away. For most patients with acute low back pain, imaging is not needed unless they have red flags. If infection is suspected, we’d get CBC, ESR, and CRP. For cancer, maybe PSA or serum protein electrophoresis. And if inflammatory back disease is suspected, HLA-B27 can be helpful.Jordan:Yes, imaging should be delayed for at least six weeks unless red flags or significant neurologic deficits are present. When we do image, MRI is our go-to especially for suspected radiculopathy or cauda equina. X-rays can help if we’re thinking about fractures, but they won’t show soft tissue or nerve root issues.Michael:In the example from our case, since the patient doesn’t have red flags, we’d go with conservative management: start NSAIDs and recommend activity modification. As this is the acute setting, physical therapy would not be recommended.Jordan:For the acute phase, research shows no serious difference between those with PT and those without in the long term. However, physical therapy is really the cornerstone of management for chronic back pain. It’s not just movement: it’s education, body mechanics, and teaching patients how to move safely. And PT can actually reduce opioid use, imaging, and injections down the line for patient struggling with long term back pain.Dr. Arreaza:Yes, and PT is not one-size-fits-all. PT might include McKenzie exercises, manual therapy, postural retraining, or even neuromuscular re-education. The goal is always to build core stability, promote healthy movement patterns, and reduce fear of motion.Jordan:Let’s take a minute to talk about the McKenzie Method, a physical therapy approach used to treat lumbar disc herniation by identifying a specific movement, (often spinal extension) that reduces or centralizes pain. A common exercise is the prone press-up, (cobra pose for yoga fans) where the patient lies face down and pushes the upper body upward while keeping the hips on the floor to relieve pressure on the disc. These exercises should be done carefully, ideally under professional guidance, and discontinued if symptoms worsen.Michael:For our case patient, our working diagnosis is mechanical low back pain with L5 radiculopathy. No imaging needed now, no red flags. We’ll treat conservatively and educate him about proper lifting, staying active, and recovery expectations.Jordan:We also emphasized to him that bed rest isn’t helpful. In fact, bed rest can make things worse. Keeping active while avoiding heavy lifting for now is key.Dr. Arreaza:Return-to-work recommendations should be individualized. For example, an office worker, positioning while working, or work hours may be able to return to work promptly. However, those with physically demanding jobs may need light duty or be off work.Ice: no evidence of benefit. Heat: may reduce pain and disability in pain of less than 3 months, although the benefit was small and short.And we should always teach safe lifting techniques: bend at the knees, keep the load close, avoid twisting. It's basic knowledge, but it is very effective in preventing recurrence.Jordan:Now, if a patient fails to improve after 6 weeks of conservative therapy, or if they develop new neurologic deficits, that’s when we think about referral to spine specialists or surgical consultation.Michael:And as previously mentioned: in cases where back pain becomes chronic (lasting more than 12 weeks) a multidisciplinary approach works best. That can include:Physical therapy, Cognitive behavioral therapy (CBT) And sometimes pain management interventions. Jordan:We can’t forget the psychological toll either. Chronic back pain is associated with depression, anxiety, and opioid dependence. Increased risk factors include obesity, smoking, sedentary lifestyle, and previous back injuries.Dr. Arreaza:Well said. So, let’s summarize. Michael?Michael:Sure! Low back pain is common, and most cases are benign. But we have to know the red flags that point to serious pathology. A focused history and physical exam are more powerful than many people realize. And the first step in treatment is almost always conservative, with a strong emphasis on maintaining physical activity.Jordan:And don’t underestimate the value of patient education. Helping patients understand their pain, set realistic expectations, and stay active is often just as important as the medications or therapies we offer.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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Shekelle, P

Episode 193: Gestational Diabetes IntroJesica Mendoza (OMSIII) describes the pathophysiology of gestational diabetes and the right timing and method of screening for it. Dr. Arreaza adds insight into the need for culturally-appropriate foods, such as vegetables in Mexican cuisine.    Written by Jesica Mendoza, OMSIII, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.DefinitionGestational diabetes mellitus (GDM) is a condition that occurs to previously non-diabetic pregnant women, caused by glucose intolerance at around the 24th week of gestation. PathophysiologyGDM arises due to an underlying pancreatic beta cell dysfunction in the mother which leads to a decrease in the amount of insulin produced and thus leads to higher blood sugar levels during pregnancy. The placenta of the fetus will produce hPL (human placental lactogen) to ensure a steady supply of sugars to the fetus, creating an anti-insulin effect. However, hPL readily crosses the placental barrier causing the mothers insulin requirement to increase, when the mother’s pancreas cannot increase production of insulin to that level needed to counter the effect of hPL they become diabetic, and this leads to gestational diabetes. So, basically the placenta is asking for more glucose for the baby and the mother’s pancreas struggles to keep the glucose level within normal limits in the body of the mother. If left untreated, high levels of glucose in the mother can cause glucotoxicity in the mother.“Glucotoxicity” refers to the toxic effect of glucose. Glucose is the main fuel for cell functions, but when it is high in the bloodstream, it causes toxicity to organs. Prevalence of GDM.The CDC reports mean prevenance of GDM is 6.9%. In U.S. mothers the prevenance increased from 6.0% in 2016 to 8.3% in 2021. Many different factors have played a role in increasing gestational diabetes in American mothers, some of those being the ongoing obesity epidemic with excess body weight being a known risk factor for insulin resistance. Another being advanced maternal age (AMA) as more American women have children later in life their body becomes less sensitive to insulin and requires a higher insulin output on top of the insulin that is required for the fetus. The “American diet” is also something that has a big effect in diabetes development. With the increase of high-carb foods that are readily available, the diet of Americans has declined and is affecting the metabolic health of mothers as they carry and deliver their children. Despite ongoing awareness of GDM, 6% to 9% of pregnant women in the United States are diagnosed with gestational diabetes, and the prevalence continues to increase worldwide. It is estimated that in 2017 18.4 million pregnancies were affected by GDM in the world, which then continued to increase to 1 in 6 births to women with GDM in 2019. It was also found that women living in low-income communities were disproportionately affected due to limited healthcare access. Additionally, women with GDM had a 1.4-fold increase in likelihood of undergoing a c-section, with 15% increase in risk of requiring blood transfusion. Screening for GDMGestational diabetes is screened between the 24th to 28th week of gestation in all women without known pregestational diabetes. In women who have high-risk for GDM the screening occurs during the first trimester, these women usually have at least one of the following: BMI > 30, prior history of GDM, known impaired glucose metabolism, and/or a strong family history of diabetes. The screening during the first trimester is to detect “pregestational diabetes” because we have to keep a good glycemic control to improve outcomes of pregnancy. So, if it’s positive, you start treatment immediately. If these women are found to have a normal glucose, they repeat the testing again as done normally, at 24-28 weeks of gestation. How do we screen?The screening itself consists of two types of approaches. The two-step approach includes a 50-gram oral glucose tolerance test (OGTT), where blood glucose is measured in an hour and if it is below 140 they are considered to not have GDM, however if the reading is greater than 140 they must then do a 3-hour, 100g oral glucose tolerance test. The 3-hour OGTT includes measuring the blood sugars at Fasting which should be less than 95, at 1 hour at less than 180, at 2 hours at less than 155, and at 3 hours at less than 140. If 2 or more of these values exceed the threshold the patient is diagnosed with gestational diabetes mellitus. The one-step approach includes 75g after an overnight fast. Blood glucose is measured while fasting which should be less than 92, at 1 hour less than 180 and at 2 hours less than 153. If any one of these values is exceeded, the patient is diagnosed with GDM.If the mother is found to be GDM positive during pregnancy she will also need continued screening post-partum to monitor for any development of overt diabetes. The testing is usually 75g 2-hour OGTT at 6-12 weeks postpartum. If this testing is normal, then they are tested using HbA1c every 3 years. If the post-partum testing shows pre-diabetes, annual testing is recommended using HbA1c measurements. Maternal complications Women with GDM are at an increased risk for future cardiovascular disease, T2DM, and chronic kidney disease. GDM is also associated with increased likelihood of developing pre-eclampsia following delivery. Pre-eclampsia is a complication seen in pregnancy characterized by high blood pressure, proteinuria, vision changes, and liver involvement (high LFTs). Pre-eclampsia can then progress to eclampsia or HELLP syndrome, both of which can include end organ damage. Additionally, she can develop polyhydramnios which leads to overstretching of the uterus and can induce pre-term labor, placental abruption, and or uterine atony, all of which additionally put the mother at increased risk for c-section. All of these maternal complications that stem from GDM lead to complications and extended hospitalization. Child’s complications Although there is an increased set of risks for the mother, the neonate can also develop a variety of risks due to the increased glucose while in utero. While the fetus is growing, the placenta is the source of nutrition for the fetus. As the levels of glucose in the mother increase so does the amount of glucose filtered through the placenta and into the fetal circulation. Over time the glucose leads to oxidative stress and inflammation with activation of TGF-b which leads to fibroblast activation and fibrosis of the placenta. This fibrosis decreases the nutrient and oxygen exchange for the fetus. As the fetus attempts to grow in this restrictive environment its development is affected. The fetus can develop IUGR (intrauterine growth restriction) leading to a small for gestation age newborn which can then lead to another set of complications. The low oxygen environment can lead to increased EPO production and polycythemia at birth which can then lead to increased clotting that can travel to the newborn brain. Newborns can also be born with fetal acidosis due to the anerobic metabolism and lactic acid buildup in fetal tissues which can cause fetal encephalopathy leading to cerebral palsy and developmental delay. And the most severe of newborn complications to gestational diabetes can lead to fetal demise. Furthermore, the increase of glucose can also lead to macrosomia in the infant which can often lead to a traumatic delivery and delivery complications such as shoulder dystocia and brachial plexus injury. Brachial plexus injury sometimes resolves without sequela, but other times can lead to permanent weakness or paralysis of the affected arm. The baby can be born too small or too big.Additionally, once the fetus is born the cutting of the umbilical cord leads to a rapid deceleration in blood glucose in the fetal circulation and hypoglycemic episodes can occur, that often lead to NICU admission. The insulin that is created by the fetus in utero to accommodate the large quantities of glucose is known to affect lung maturation as well. The insulin produced inhibits surfactant production in the fetus. Upon birth some of the newborns also have to be placed on PEEP for ventilation and some children require treatment with surfactant to prevent alveolar collapse and/or progression to NRDS created by the low surfactant levels. Additionally, neonates who are macrosomic, which is usually seen in GDM mothers, are larger and stronger and when put on PEEP to help increase ventilation the newborn’s stronger respiratory effort can lead to higher pulmonary pressures and barotrauma such as neonatal pneumothorax.Long term complications to the child of a mother with GDM also occur. As the child grows, they are also at an increased risk for developing early onset obesity because of the increased adipose storage triggered by the increase in insulin in response to the high glucose in utero. This then can lead to a higher chance of developing type 2 diabetes mellitus in the child. With diabetes, also comes an increase in cardiovascular risk as the child ages and becomes an adult. The effects of GDM go beyond the fetal life but continue through adulthood.What can be done?Gestational Diabetes Mellitus has many severe and lifelong consequences for both the mother and the child and prevention of GDM would help enhance the quality of life of both. Many of the ways to prevent GDM complications include patient education and dietary modifications with a diet rich in who

Episode 192: ADHD Treatment.  Jordan Redden (MSIV) explains the treatment of ADHD. Dr. Bustamante adds input about pharmacologic and non-pharmacologic treatments. Dr. Arreaza shares the how stimulants were discovered as the treatment for ADHD. Written by Jordan Redden, MSIV, Ross University School of Medicine. Comments and edits by Isabelo Bustamante, MD, and Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.ADHD is a chronic neurodevelopmental condition characterized by inattention, impulsivity, and/or hyperactivity. While it’s often diagnosed in childhood, symptoms can persist well in adulthood. The treatment for ADHD is multifaceted. It often includes medication, behavioral therapy, environmental modifications, and sometimes educational interventions which are especially effective in younger patients. Ongoing evaluation is needed during treatment. Treatment needs adjustments over time.Starting with medications: Stimulants are the most well-studied and effective pharmacologic treatment for ADHD. These include methylphenidate-based medications such as Ritalin, Concerta, and Focalin, and amphetamine-based options, like Adderall, Vyvanse, and Dexedrine. Discovery of stimulants for ADHD> Dr. Charles Bradley discovered stimulants as the treatment for ADHD around 1937. ADHD did not have a name at that time, but it was known that some children had behavioral problems related to poor attention and inability to control their impulses, but they were still intelligent. Dr. Bradley was a psychiatrist who was working in the Bradley Hospital (Rhode Island), he was studying these children and, as part of his experiments, they developed severe headaches. He gave “Benzedrine” (a decongestant) to his pediatric patients to treat severe headaches, and he discovered that Benzedrine improved academic performance and interest in school and improved disruptive behavior in some children.How do stimulants work.Stimulants work primarily by increasing dopamine and norepinephrine levels in the brain, which helps improve focus, attention span, and impulse control. They typically show a rapid onset of action and can lead to noticeable improvements within the first few days of use. Dosing is individualized and should start low with gradual titration. Side effects can include reduced appetite, insomnia, headaches, increased heart rate, and emotional lability.Types of stimulants. Stimulants come as short acting and long acting. They can come as a tablet, liquid, patch, or orally disintegrating tablet. After the discovery of Benzedrine as a possible treatment for ADHD, more research was done over the years, and Ritalin became the first FDA-approved medication for ADHD (1955). The list of medications may seem overwhelming, but there are only two types of stimulants used to treat ADHD: methylphenidate and amphetamine. Long-acting stimulant medications are often preferred for their consistent symptom control and lower potential for misuse. Vyvanse (lis-dexa-mfetamine) is a widely used long-acting amphetamine-based option. As a prodrug, it remains inactive until metabolized in the body, which results in a smoother onset and offset of action and may reduce the risk of abuse. This extended duration of effect can help patients maintain focus and regulate impulses throughout the day without the peaks and crashes sometimes seen with shorter-acting formulations. Of note, Vyvanse is also approved for Binge Eating Disorder. Many of these medications are Schedule II controlled substances, so to prescribe them you need a DEA license. Other long-acting options include Concerta, an extended-release methylphenidate, as well as extended-release versions of Adderall and Focalin. These are especially helpful for school-aged children who benefit from once-daily dosing, and for adults who need sustained attention during work or academic activities. The choice between short- and long-acting stimulants depends on individual response, side effect tolerance, and daily routine.For patients who cannot tolerate stimulants, or for those with contraindications such as a history of substance misuse or certain cardiac conditions, non-stimulant medications are an alternative. One of the most used is atomoxetine, which inhibits the presynaptic norepinephrine transporter (NET). This leads to increased levels of norepinephrine (and to a lesser extent dopamine). Guanfacine or clonidine are alpha-2A adrenergic receptor agonists that lead to reduced sympathetic outflow and enhanced prefrontal cortical function, improving attention and impulse control. These alpha agonists are particularly useful in younger children with significant hyperactivity or sleep disturbances.Non-pharmacologic treatments.Behavioral therapy before age 6 is the first choice, after that, medications are more effective than BH only, and as adults again you use CBT.Medication is often just one part of a broader treatment plan. Behavioral therapy, especially in children, plays a critical role. Parent-training programs, positive reinforcement systems, and structured routines can significantly improve functioning. And for adolescents and adults, cognitive-behavioral therapy (CBT) is particularly helpful. CBT can address issues like procrastination, time management, emotional regulation, and self-esteem which are areas that medication doesn’t always touch.Using medications for ADHD can be faced with resistance by parents, and even children. There is stigma and misconceptions about mental health, there may be concerns about side effects, fear of addiction, negative past experiences, and some parents prefer to treat ADHD the “natural” way without medications or only with supplements. All those concerns are valid. Starting a medication for ADHD is the first line of treatment in children who are 6 years and older, but it requires a shared decision with parents and patients. Cardiac side effects are possible with stimulants. EKG may be needed before starting stimulants, but it is not required. Get a personal and family cardiac history, including a solid ROS. Benefits include control of current condition and treating comorbid conditions.The presentation of ADHD changes as the person goes through different stages of life. For example, you may have severe hyperactivity in your school years, but that hyperactivity improves during adolescence and impulsivity worsens. It varies among sexes too. Women tend to present as inattentive, and men tend to be more hyperactive. ADHD is often underdiagnosed in adults, yet it can significantly impact job performance, relationships, and mental health. In adults, we often use long-acting stimulants to minimize the potential for misuse. And psychotherapy, particularly CBT or executive functioning coaching, can be life-changing when combined with pharmacologic treatment. There are several populations where treatment must be tailored carefully such as pregnant patients, individuals with co-occurring anxiety or depression, and those with a history of substance use. For example, atomoxetine may be preferred in patients with a history of substance misuse. And in children with coexisting oppositional defiant disorder, combined behavioral and pharmacologic therapy is usually more effective than either approach alone.Comorbid conditions.Depression and anxiety can be comorbid, and they can also mimic ADHD. Consult your DSM-5 to clarify what you are treating, ADHD vs depression/anxiety.Treatment goes beyond the clinic. For school-aged children, we often work closely with schools to implement 504 plans or Individualized Education Programs (IEPs) that provide classroom accommodations. Adults may also benefit from workplace strategies like structured schedules, noise-reducing headphones, or even coaching support. Ongoing monitoring is absolutely essential. We assess side effects of medication, adherence, and symptom control. ***In children, we also monitor growth and sleep patterns. We often use validated rating scales, like the Vanderbilt questionnaire for children 6–12 (collect answers from two settings) or Conners questionnaires (collect from clinician, parents and teachers), to track progress. And shared decision-making with patients and families is key throughout the treatment process.To summarize, ADHD is a chronic but manageable condition. Effective treatment usually involves a combination of medication and behavioral interventions, tailored to the individual’s needs. And early diagnosis and treatment can significantly improve quality of life academically, socially, and emotionally.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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text rev. (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022. CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder). Understanding ADHD. Accessed May 2025. https://chadd.org National Institute for Health and Care Excellence (NICE). Attention Deficit Hyperactivity Disorder: Diagnosis and Management. NICE guideline [NG87]. Updated March 2018. Accessed May 2025. https://www.nice.org.uk/guidance/ng87 Pliszka SR; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894–921. doi:10.1097/chi.0b

Episode 191: Diagnosis of ADHDFuture Dr. Granat explains how to diagnose Attention Deficit Hyperactivity Disorder. She explained the influence of social media in increasing awareness of ADHD. Dr. Arreaza added input about the validated tools for ADHD diagnosis and highlighted the importance of expert evaluation for the diagnosis of this disorder.  Written by Yen Stephanie Granat, MSIV. Ross University School of Medicine. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Steph: I love podcasts—many of us do—and if you, like me, spend any amount of your leisure time listening to podcasts, perusing the news, or scrolling social media; you’ve likely noticed an alarming trend in the number of discussions we seem to be having about ADHD. It has grown into a very hot topic over the past couple of years, and for some of us, it seems to have even begun sneaking into our “recommended videos” and across our news feeds! Naturally, for the average person this can spur questions like:“Do I have ADHD? Do we all have it? How can I be certain either way, and what do I do if I find myself relating to most of the symptoms that I’m seeing discussed?”Granted that there is a whirlpool of information circulating around this hot topic, I was hoping to spend a bit of time clearly outlining the disorder for anyone finding themselves curious. I believe that can best be achieved through outlining a clear, concise, and easy-to-understand definition of what ADHD is; outlining what it is not; and helping people sift through the fact and the fiction. As with many important things we see discussed on the internet, we’re seeing is that there is much more fiction than fact. Arreaza: I’m so glad you chose this topic! I think it is challenging to find reliable information about complex topics like ADHD. Tik Tok, Instagram and Facebook are great social media platforms, but we have to admit that fake news have spread like a fire in recent years. So, if you, listener, are looking for reliable information about ADHD, you are in the right place. With ADHD, there aren’t any obvious indicators, or rapid tests someone can take at home to give themselves a reliable “yes” or “no” test result. People’s concerns with ADHD are valid, and important to address, so we will discuss the steps to identify some of signs and symptoms they are seeing on TikTok or their favorite podcaster. Steph: Healthcare anxiety is a vital factor to consider when it comes to large cultural conversations around our minds and bodies; so, I hope to sweep away some of the misconceptions and misinformation floating around about ADHD. In doing so, I want to help alleviate any stress or confusion for anyone finding themselves wondering if ADHD is impacting their lives! We might even be able to more accurately navigate these kinds of “viral topics” (for lack of a better term) next time we see them popping up on our news feeds.Arreaza: The first thing I want to say about ADHD is “the crumpled paper sign.”Steph: What is that?Arreaza: It is an undescribed sign of ADHD, I have noticed it, and it is anecdotal, not evidence based. When I walk into a room to see a pediatric patient, I have noticed that when the paper that covers the examination table is crumpled, most of the times it is because the pediatric patient is very active. Then I proceed to ask questions about ADHD and I have been right many times about the diagnosis. So, just an anecdote, remember the crumpled paper sign.  Steph: When you have patients coming to you asking for stimulants because they think they have ADHD, hopefully, after today, you can be better prepared to help those patients. So, for the average person—anyone wanting to be sure if this diagnosis applies to them—how can we really know?”Arreaza: So, let’s talk about diagnosis.Steph: Yes, the clearest information we have is the DSM-5, which defines these disorders, as well as outlines the specific criteria (or “checkpoints”) one needs to meet to be able to have a formal diagnosis. However, this manual is best utilized by a trained professional—in this case, a physician—who can properly assess your signs and symptoms and give you a clear answer. Steph: ADHD stands for Attention Deficit Hyperactivity Disorder. It is among the most common neurodevelopmental disorders of childhood. That is not to say it does not affect adult—it does—and because it can be easy to miss, it’s very possible for someone to have ADHD without knowing. Arreaza: I recently learned that ADD is an outdated term. Some people with ADHD do not have hyperactivity but the term still applies to them. Steph: Yes, there are multiple types that I will explain in just a bit. But overall the disorder is most simply characterized by a significant degree of difficulty in paying attention, controlling impulsive behaviors, or in being overly active in a way that the individual finds very difficult to control. (CDC)Arreaza: How common is ADHD?Steph: The most recently published data from The CDC estimates that 7 million (11.4%) of U.S. children between the ages of 3 and 17 have been diagnosed with ADHD. For adults, it is estimated that there are 15.5 million (6%) individuals in the U.S. who currently have ADHD. Arreaza: I suspected it would be more than that. [Anecdote about Boy Scout camp]. Steph: I totally agree. With short videos on TikTok, or paying high subscription fees to skip ads, it feels like as a society we all have a shorter attention span. Arreaza: Even churches are adapting to the new generation of believers: Shorter sermons and shorter lessons.Steph: When it comes to better understanding these numbers, it's also important to know that there are three distinct presentations of ADHD recognized by The CDC and The World Health Organization. Arreaza: The DSM-5 TR no longer uses the word “subtypes” for ADHD. Instead, it uses the word "presentation" to describe the different ways that ADHD may manifest in a person. That reminded me to update my old DSM-5 manual and I ordered it while reading today about ADHD. This means people with ADHD are no longer diagnosed as having a “subtype”. Instead, they are diagnosed with ADHD and a certain “presentation” of symptoms.Steph: These presentations are:Inattentive TypePeople often have difficulty planning or completing tasksThey find themselves easily distracted (especially when it comes to longer, focus-oriented tasks)They can often forget details and specifics, even with things that are part of their daily routineThis used to be referred to as “ADD” (you’ll notice the absence of an “H”, segue).Hyperactive-Impulsive TypePeople often have a sense of intense “restlessness”, noticeable even in calm environments.They tend to be noticeably more talkative, and might often be seen interrupting others, or finishing their sentences.They find significant difficulty in being still for extended periods. Because of this, they are often unable to sit through a movie or class time, without fidgeting or getting up and moving around.With this category of ADHD, we often see an impulsiveness that unwittingly leads to risky behavior. Because of this, accidents and bodily injury are more common in individuals with this type of ADHD.Combined TypeThese are individuals who exhibit symptoms from both “Inattentive” and “Hyperactive-Impulsive” ADHD equally.Some listeners might have noticed that the categories are quite different, meaning that ADHD presents in different ways depending on the person! Two people who have ADHD can be in the same room and have vastly different presentations, whilst still having many of the same types of challenges. You also might have noticed what makes the discussion so interesting to the general public, which is also the thing that makes speaking to a professional to get formally tested so important:The diagnostic criteria rely heavily on patterns of behavior, or external variables; rather than on how a person might feel, or certain measurements taken from lab tests.Arreaza: Diagnosing ADHD requires evaluation by a professional who is properly trained for this. Fortunately, we have tools to assist with the diagnosis. The attention deficit must be noted in more than one major setting (e.g., social, academic, or occupational), that’s why the information should be gathered from multiple sources, including parents, teachers, and other caregivers, using validated tools, such as:The Neuropsychiatric EEG-Based ADHD Assessment Aid (NEBA), recommended by the American Academy of NeurologyThe Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) and the Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS), recommended by the Society for Developmental and Behavioral Pediatrics.For adults: The validated rating scales include the Adult ADHD Self-Report Scale (ASRS) and the Conners Adult ADHD Rating Scales (CAARS).Steph: This is important because nearly everyone alive has experienced several, if not most, of these behavioral patterns at least once. Whether or not an individual has ADHD, I’m certain we could all think of moments we’ve had great difficulty focusing or sitting still. Perhaps some of us are incredibly forgetful, or act more impulsively than the average person might find typical. Getting a professional diagnosis is important because it is in skillfully assessing “the bigger picture” of a person’s life, or their patterns of behavior, that a skilled physician, who understands the nuances and complexities in these disorders, can properly tell each of us whether we have ADHD, or not.Essentially, most of us could stand to use a bit more focus these days, but far fewer of us would meaningfully benefi

Episode 190: Measles BasicsFuture Dr. Kapur explained the basics of measles, including the pathophysiology, diagnosis and management of this disease. Dr. Schlaerth added information about SPPE and told interesting stories of measles. Dr. Arreaza explained some statistics and histed the episode.  Written by Ashna Kapur MS4 Ross University School of Medicine. Comments by Katherine Schlaerth, MD, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.According to the CDC, as of April 24, 2025, a total of 884 confirmed measles cases were reported by 30 states, including California, and notably Texas. This is already three times more cases than 2024. There are 3 confirmed deaths so far in the US. What is measles?Measles is a disease that’s been around for centuries, nearly eradicated, yet still lingers in parts of the world due to declining vaccination rates. Let's refresh our knowledge about its epidemiology, clinical features, diagnosis, management, and most importantly — prevention.Definition.Measles, also known as rubeola, is an acute viral respiratory illness caused by the measles virus. It’s a single-stranded, negative-sense RNA virus belonging to the Paramyxoviridae family. It’s extremely contagious with a transmission rate of up to 90% among non-immune individuals when exposed to an infected person.EpidemiologyBefore the introduction of the measles vaccine in 1963, nearly every child got measles by the time they were 15 years old. With the introduction of vaccination, cases and deaths caused by measles significantly declined. For example, in 2018, over 140,000 deaths were reported in the whole world, mostly among children under the age of 5.Measles is still a common disease in many countries, including in Europe, the Middle East, Asia, and Africa. Measles outbreaks have been reported recently in the UK, Israel, India, Thailand, Vietnam, Japan, Ukraine, the Philippines, and more recently in the US. So, let’s take prevention seriously to avoid the spread of this disease here at home and abroad. How do we get measles, Ashna?Mode of Transmission:● Air: Spread primarily through respiratory droplets.● Surfaces: The virus remains viable on surfaces or in the air for up to 2 hours. (so, if a person with measles was in a room and you enter the same room within 2 hours, you may still get measles)● Other people: Patients are contagious from 4 days before until 4 days after the rash appears.PathophysiologyThe measles virus first infects the respiratory epithelium, replicates, and then disseminates to the lymphatic system.It leads to transient but profound immunosuppression, which is why secondary infections are common. It affects the skin, respiratory tract, and sometimes the brain, leading to complications like pneumonia or encephalitis.Clinical PresentationThe classic presentation of measles can be remembered in three C’s:● Cough● Coryza (runny nose)● ConjunctivitisCourse of Disease (3 Phases):1. Prodromal Phase (2-4 days)○ High fever (can peak at 104°F or 40°C)○ The 3 C’s○ Koplik spots: Small white lesions on the buccal mucosa.2. Exanthem Phase○ Maculopapular rash begins on the face (especially around the hairline), then spreads from head to toe. The rash typically combines into 1 big mass as it spreads, and the fever often persists during the rash.3. Recovery Phase○ Rash fades in the same order it appeared.○ Patients remain at risk for complications during and after rash resolution.Complications:● Pneumonia (most common cause of death in children)● Otitis media (most common overall complication)● Encephalitis (can lead to permanent neurologic sequelae)● Subacute sclerosing panencephalitis (SSPE): A rare, fatal, degenerative CNS disease that can occur years after measles infection.High-risk groups for severe disease include:● Infants and young children● Pregnant women● Immunocompromised individualsDiagnosisClinical diagnosis is sufficient if classic symptoms are present, especially in outbreak settings.Ashna: Laboratory confirmation:● Measles-specific IgM antibodies detected by serology.● RT-PCR from nasopharyngeal, throat, or urine samples.Notify public health authorities immediately upon suspicion or diagnosis of measles to limit spread. ManagementThere is no specific antiviral treatment for measles. Management is supportive:● Hydration (by mouth and only IV in case of severe dehydration)● Antipyretics (e.g., acetaminophen) for fever● Oxygen if hypoxicVitamin A supplementation:● Recommended for all children with acute measles, particularly in areas with high vitamin A deficiency. It has shown to reduce morbidity and mortality.Hospitalization may be necessary for:● Severe respiratory compromise● Dehydration● Neurologic complicationsPrevention: We live in perilous times and vaccination is under scrutiny right now. Before the measles vaccine, about 48,000 people were hospitalized and 400–500 people died in the United States every year. Measles was declared eradicated in the US in 2000, but the vaccination coverage is no longer 95%. How do we prevent measles?Vaccination is the cornerstone of prevention.● MMR vaccine (Measles, Mumps, Rubella):○ First dose at 12-15 months of age.○ Second dose at 4-6 years of age.○ 97% effective after 2 doses.The Advisory Committee on Immunization Practices (ACIP) has noted that febrile seizures typically occur 7 to 12 days after vaccination with MMR, with an estimated incidence of 3.3 to 8.7 per 10,000 doses. The Centers for Disease Control and Prevention (CDC) states that febrile seizures following MMR vaccination are rare and not associated with any long-term effects. The risk of febrile seizures is higher when the MMR vaccine is administered as part of the combined MMRV (measles, mumps, rubella, and varicella) vaccine compared to the MMR vaccine alone.Post-exposure prophylaxis:● MMR vaccine within 72 hours of exposure (if possible).● Immunoglobulin within 6 days for high-risk individuals (e.g., infants, pregnant women, immunocompromised).Herd immunity requires at least 95% vaccination coverage to prevent outbreaks.Key Takeaways● Measles is a highly contagious viral illness that can lead to severe complications.● Diagnosis is often clinical, but lab confirmation helps with public health tracking.● Treatment is mainly supportive, with Vitamin A playing a critical role in reducing complications.● Vaccination remains the most effective tool to eliminate measles worldwide.While measles might seem like a disease of the past, it can make a dangerous comeback without continued vigilance and vaccination efforts.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Centers for Disease Control and Prevention (CDC). Measles (Rubeola), Clinical Overview, July 15, 2024. Accessed on May 1, 2025. https://www.cdc.gov/measles/hcp/clinical-overview/index.html.World Health Organization (WHO). Measles, November 14, 2024. https://www.who.int/news-room/fact-sheets/detail/measlesGans, Hayley and Yvonne A. Maldonado, Measles: Clinical manifestations, diagnosis, treatment, and prevention, UpToDate, January 15, 2025. Accessed on May 1, 2025. https://www.uptodate.com/contents/measles-clinical-manifestations-diagnosis-treatment-and-preventionTheme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 189: Intermittent Fasting (Religious and Sports)Future Doctors Carlisle and Kim give recommendations about patients who are fasting for religious reasons, such as Ramadan. They also explain the benefits and risks of fasting for athletes and also debunked some myths about fasting. Dr. Arreaza add input about the side effects of fasting and ways to address them.    Written by Cameron Carlisle, MSIV (RUSM) and Kyung Kim, MSIV (AUC). Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: In the last episode on fasting (#179), we explored how intermittent fasting (IF) can help manage type 2 diabetes by improving insulin sensitivity, promoting weight loss, and lowering inflammation. We discussed the benefits of methods like 16:8 time-restricted eating and the 5:2 meal plan, and even compared IF to medications like metformin. Today, we’re bringing that science into real life. We’ll talk about how people fast for religious reasons, like during Ramadan, how athletes use IF to stay in shape, and how we can use IF as a tool in family medicine to support community health and A1c control.Intermittent Fasting in Religious PracticeRamadan just ended on 3/30/25, but this is a great time to talk about the broader role of fasting in religion and health. Many faiths incorporate fasting into spiritual practice and understanding this can help us better support our patients.Islam (Ramadan): Ramadan is a month where Muslims fast from dawn to sunset, focusing on spiritual reflection and self-control. No food or drink is consumed during daylight hours. Despite this, studies have shown that with good planning, fasting during Ramadan does not significantly impair physical performance or metabolic health.Key health tips for patients observing Ramadan:Hydrate well between iftar (sunset) and suhoor (pre-dawn).Break the fast with dates and water to gently replenish energy and electrolytes.Eat balanced meals with complex carbs, protein, and healthy fatsAvoid greasy, heavy foods right after fastingLight exercise (such as a walk) after iftar is beneficialReview medications with a healthcare provider, especially for those on insulin or sulfonylureas.For example: Metformin should be taken when you break your fast and then again before dawn. If its an extended-release metformin, take it at night. Metformin does not cause significant hypoglycemia and can be continued during Ramadan. Basal insulin is advised to be given at Iftar, and the dose should be reduced by 25-35% if the patient is not well managed. And regarding the fast-acting insulin, it requires a little more reading, so you can look it up and learn about it. Judaism: In Judaism, fasting is practiced on days like Yom Kippur and Tisha B’Av, typically lasting 25 hours without food or water. These fasts are spiritual and reflective, and patients with medical conditions may seek guidance on how to participate safely.Christianity: Many Christians fast during Lent, either by abstaining from certain foods or limiting meal frequency. Some practice partial-day fasts or water-only fasts for spiritual renewal.A branch of Christianity known as The Church of Jesus Christ of Latter-day Saintsoften observe a 24-hour fast on the first Sunday of each month, known as Fast Sunday, where they abstain from food and drink and donate the cost of meals to charity. This practice is both spiritual and communal.Cameron: Fasting for religious reasons, when done safely, can align with IF protocols and be culturally sensitive for diverse patients in family medicine.IF in Athletes and PerformanceIntermittent fasting is gaining popularity in the sports world. Athletes are using IF to improve body composition, increase fat oxidation, and enhance metabolic flexibility. A recent study, known as the DRIFT trial and published in Annals of Internal Medicine, found that fasting three non-consecutive days a week led to more weight loss than daily calorie restriction. Participants lost an average of 6.37 pounds more over 12 months.Why? Better adherence. People found the 3-day fasting schedule easier to stick to than counting calories every day.Benefits of IF for athletes:Encourages fat burning (via AMPK activation and GLUT4 upregulation, listen to ep. 179).Helps maintain lean muscle while reducing fat.No major drop in performance when meals and workouts are timed properly.What are some practical tips?Schedule workouts during or just before eating windows.Eat protein-rich meals post-workout.Avoid intense training during long fasts unless adapted.Stay hydrated, especially in hot environments or endurance sports.Broader Applications and Myths Around IFHormonal Effects of IF: In addition to improving insulin sensitivity, IF also affects hormones such as ghrelin (which stimulates hunger, remember it as growling) and leptin (which signals fullness). Over time, IF may help the body regulate appetite better and reduce cravings. IF can also decrease morning cortisol levels, the stress hormone. That’s why it's important to monitor sleep, hydration, and stress levels when recommending IF.Circadian Rhythm Alignment: Emerging research shows that aligning eating times with natural light/dark cycles—eating during the day and fasting at night—can improve metabolic outcomes. This practice, known as early time-restricted eating (eTRE), has been shown to lower blood glucose, reduce insulin levels, and improve energy use. Patients who eat earlier in the day tend to have better results than those who eat late at night.Myths and Clarifications on IF:-“Fasting slows metabolism” In fact, short-term fasting may boost metabolism slightly due to increased norepinephrine. -“You can’t exercise while fasting.” Many people can safely train during fasted states, especially for moderate cardio or strength training. -“Skipping breakfast is bad.” For some, skipping breakfast is a useful IF strategy—as long as total nutrition is maintained. You can break your fast at 2:00 pm, it does have to be at 7:00 AM.What to Eat When Breaking a FastBreaking a fast properly is just as important as fasting itself. Whether it’s after a Ramadan fast or a 16-hour fast, the goal is to replenish energy gently and restore nutrients.Ideal foods to break a fast:Dates and water: provide quick energy, potassium, and fiberSoups: lentil or broth-based soups are gentle on digestionComplex carbs: whole grains like brown rice or oatsLean proteins: chicken, fish, eggs, legumesFruits and vegetables: hydrate and provide fiberHealthy fats: nuts, avocado, olive oilProbiotics: yogurt or kefir for gut supportBalanced meals with carbs, protein, and healthy fats help the body transition smoothly back to a fed state.Using IF in Family Medicine and Community HealthIntermittent fasting can be a practical, cost-effective strategy in family medicine. In areas with high rates of obesity and diabetes, like Kern County, IF offers a lifestyle-based tool to improve metabolic health, especially in underserved populations. IF is free!How IF can help in family medicine:Lower A1c levels: improves insulin sensitivity and glucose controlPromote weight loss: decreases insulin resistance and inflammationReduce medication dependence: fewer meds needed over time for some patientsEncourage patient engagement: flexible and easier to follow than strict calorie countingFit diverse lifestyles: aligns with religious and cultural practicesAddress food insecurity: structured eating windows can help patients stretch limited food resourcesHow to apply IF in clinic:Start the conversation by asking if the patient has heard of IFRecommend simple starting points: 12:12 or 14:10Emphasize hydration and nutrient-dense mealsMonitor labs and symptoms, especially in diabetic patientsAdjust medications to avoid hypoglycemiaProvide follow-up and patient education handouts if possibleWhat if a patient isn't ready to try fasting?For those not ready to commit to intermittent fasting, one effective alternative is walking after meals. A simple 10–20 minute walk post-meal can help stimulate GLUT4 receptors in skeletal muscle, promoting glucose uptake independent of insulin. This reduces the demand on pancreatic beta cells and may help improve blood sugar control over time. This strategy is particularly useful for patients with insulin resistance or early-stage type 2 diabetes.Conclusion: Intermittent fasting is not one-size-fits-all, but it can be a powerful tool for both individual and community health. From Ramadan to race day, IF has a place in family medicine when used thoughtfully. Encourage patients to work with their healthcare providers to find an approach that fits their lifestyle, medical needs, and personal values. IF is a cost-effective toolEven 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 RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Academy of Family Physicians. (2022). "Intermittent Fasting: A Promising Treatment for Diabetes." AAFP Community Blog. https://www.aafp.org/pubs/afp/afp-community-blog/entry/intermittent-fasting-a-promising-treatment-for-diabetes.htmlHealthline. (2023). "What Breaks a Fast? Foods, Drinks, and Supplements." https://www.healthline.com/nutrition/what-breaks-a-fast.Sarri KO, Tzanakis NE, Linardakis MK, Mamalakis GD, Kafatos AG. Effects of Greek Orthodox Christian Church fasting on serum lipids and obesity. BMC Public Health. 2003 May 16;3:16. doi: 10.1186/1471-2458-3-16. PMID: 12753698; PMCID: PMC156653. https://pmc.ncbi.nlm.nih.gov/a

Episode 188: RSV Management and PreventionDr. Sandhu and future Dr. Mohamed summarize the management of RSV and describe how to prevent it with chemoprophylaxis and vaccines. Dr Arreaza adds some comments about RSV vaccines.Written by Abdolhakim Mohamed, MSIV, Ross University School of Medicine. Comments by Ranbir Sandhu, MD, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is RSV? -The Respiratory syncytial Virus (RSV) is an enveloped, negative-sense, single-stranded RNA virus of the Orthopneumovirus genus within the Pneumoviridae family. -RSV is a major cause of acute respiratory tract infections, particularly bronchiolitis and pneumonia, in infants and young children, and it also significantly affects older adults and immunocompromised individuals. -RSV infections cause an estimated 58,000–80,000 hospitalizations among children younger than 5 years and 60,000–160,000 hospitalizations among adults older than 65 years each year.-RSV is highly contagious and spreads through respiratory droplets and direct contact with contaminated surfaces. The virus typically causes seasonal epidemics, peaking in the winter months in temperate climates and during the rainy season in tropical regions. -Virtually all children are infected with RSV by the age of two, and reinfections can occur throughout life, often with milder symptoms.-Per the 2014 Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis, from the American Academy of Pediatrics, the most common etiology of bronchiolitis is RSV. -About 97% of children are infected with RSV in the first 2 years of life, about 40% will experience lower respiratory tract infection during the initial infection. Other viruses that cause bronchiolitis include human rhinovirus, human metapneumovirus, influenza, adenovirus, coronavirus, and parainfluenza viruses.When is RSV season?-Classically, the highest incidence of infection occurs between December and March in North America. Per CDC, there were typical prepandemic RSV season patterns, but the COVID-19 pandemic disrupted RSV seasonality during 2020–2022. -Before we dive into the seasonality patterns, for context, in order to describe RSV seasonality in the US, data was gathered and analyzed from polymerase chain reaction (PCR) test results reported to the National Respiratory and Enteric Virus Surveillance System (NREVSS) during July 2017–February 2023. -Seasonal RSV epidemics were defined as the weeks during which the percentage of PCR test results that were positive for RSV was ≥3%. Per 2017–2020 data, RSV epidemics in the United States typically follow seasonal patterns, that began in October, peaked in December or January, and ended in April. -However, during 2020–21, the typical winter RSV epidemic did not occur. The 2021–22 season began in May, peaked in July, and ended in January. -The 2022–23 season started (June) and peaked (November) later than the 2021–22 season, but earlier than prepandemic seasons. CDC notes that the timing of the 2022–23 season suggests that seasonal patterns are returning toward those observed in prepandemic years, however, warn that clinicians should be aware that off-season RSV circulation might continue.Treatment of RSVSome key points of the 2014 pediatric guidelines from the American Academy of Pediatrics.-AAP strongly do not recommend beta agonists or steroids for viral associated bronchiolitis because of no significant improved outcomes. “Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).”-Epinephrine is not recommended for infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation).-Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department (Evidence Quality: B; Recommendation Strength: Moderate Recommendation), but hypertonic saline may be administered when they are hospitalized (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings]).-Chest physiotherapy should not be used in infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).-Antibiotics should not be administered in bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one (Evidence Quality: B; Recommendation Strength: Strong Recommendation).-Oxygen therapy may not be administered if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low level evidence and reasoning from first principles]).-Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally (Evidence Quality: X; Recommendation Strength: Strong Recommendation).How do we prevent RSV?Infant Immuno-prophylaxis:A clinical trial in 2022 demonstrated that a single injection of nirsevimab (Beyfortus®), administered before the RSV season, protected healthy late-preterm and term infants from RSV-associated lower respiratory tract that required medical treatment. Nirsevimab is a monoclonal antibody to the RSV fusion protein that has an extended half-life.Additionally, on August 3, 2023, the Advisory Committee on Immunization Practices (ACIP) recommended nirsevimab for all infants younger than 8 months who are born during or entering their first RSV season and for infants and children between 8-19 months who are at increased risk for severe RSV disease and are entering their second RSV season. On the basis of pre-COVID-19 pandemic patterns, nirsevimab could be administered in most of the continental United States from October through the end of March.Maternal Vaccination: The CDC recommends the administration of the RSVPreF vaccine to pregnant women between 32 0/7 and 36 6/7 weeks of gestation. This vaccination aims to reduce the risk of RSV-associated lower respiratory tract infection in infants during the first 6 months of life.At this time, if a pregnant woman has already received a maternal RSV vaccine during any previous pregnancy, CDC does not recommend another dose of RSV vaccine during subsequent pregnancies.Older individuals: -Each year in the U.S., it is estimated that between 60,000 and 160,000 older adults are hospitalized and between 6,000 and 10,000 die due to RSV infection-ABRYSVO’s approval will help offer older adults protection in the RSV season.-On June 26, 2024, ACIP voted to give these recommendations: all adults older than 75 years and adults between 60–74 years who are at increased risk for severe RSV disease should receive a single dose of RSV vaccine (Abrysvo®).Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Hamid S, Winn A, Parikh R, et al. Seasonality of Respiratory Syncytial Virus — United States, 2017–2023. MMWR Morb Mortal Wkly Rep 2023;72:355–361. DOI: http://dx.doi.org/10.15585/mmwr.mm7214a1Hammitt LL, Dagan R, Yuan Y, Baca Cots M, Bosheva M, Madhi SA, Muller WJ, Zar HJ, Brooks D, Grenham A, Wählby Hamrén U, Mankad VS, Ren P, Takas T, Abram ME, Leach A, Griffin MP, Villafana T; MELODY Study Group. Nirsevimab for Prevention of RSV in Healthy Late-Preterm and Term Infants. N Engl J Med. 2022 Mar 3;386(9):837-846. doi: 10.1056/NEJMoa2110275. PMID: 35235726.Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502. doi: 10.1542/peds.2014-2742. Erratum in: Pediatrics. 2015 Oct;136(4):782. doi: 10.1542/peds.2015-2862. PMID: 25349312.CDC, per their published article Seasonality of Respiratory Syncytial Virus — United States for 2017–2023, in the United StatesWhat U.S. Obstetricians Need to Know About Respiratory Syncytial Virus.Debessai H, Jones JM, Meaney-Delman D, Rasmussen SA. Obstetrics and Gynecology. 2024;143(3):e54-e62. doi:10.1097/AOG.0000000000005492.Maternal Respiratory Syncytial Virus Vaccination and Receipt of Respiratory Syncytial Virus Antibody (Nirsevimab) by Infants Aged <8 Months - United States, April 2024.Razzaghi H, Garacci E, Kahn KE, et al. MMWR. Morbidity and Mortality Weekly Report. 2024;73(38):837-843. doi:10.15585/mmwr.mm7338a2. Use of Nirsevimab for the Prevention of Respiratory Syncytial Virus Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices - United States, 2023.Jones JM, Fleming-Dutra KE, Prill MM, et al. MMWR. Morbidity and Mortality Weekly Report. 2023;72(34):920-925. doi:10.15585/mmwr.mm7234a4.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 187: Autism FundamentalsFuture Dr. Ayyagari explains the recommended screenings for autism, how to diagnose it and sheds some light on the management. Dr. Arreaza mentions the Savant Syndrome and the need to recognize ASD as a spectrum and not a “black or white” condition.Written by Tejasvi Ayyagari, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction:Autism, or Autism Spectrum Disorder (ASD), is a neurodevelopmental disorder that affects how a person thinks, interacts with others, and experiences the world. It is characterized by deficits in social communication and interaction and restricted and/or repetitive behavior patterns, interests, and activities. Autism is considered a "spectrum" disorder because it encompasses a wide range of symptoms, skills, and levels of functioning, including Asperger’s, Auditory processing disorder, Rett syndrome, etc. The exact causes of autism are not fully understood, but many question genetic and environmental factors at play.  What are some of the main characteristics of autism?1. Social difficulties: Individuals with autism may experience trouble understanding social cues or body language, leading to difficulty forming meaningful relationships. Children may display little interest in playing with others or engage in limited imaginative play (doll playing, pretend playing).2. Repetitive behaviors and interests: People with autism may engage in repetitive movements with their arms or hands and focus intensely on specific topics or activities. They may become distressed when routines are disrupted.3. Overstimulation: Individuals with autism may find multiple stimuli too overwhelming and gravitate towards either minimal stimulation or certain appealing stimulations best suited for their needs. 4. Intellectual variation: People with autism can have varying intellectual abilities, from severe mental disabilities to those who excel in specific disciplines, such as accounting or history (savants). Savant syndrome. It is a syndrome popularized by movies, TV shows and social media. The Good Doctor is a good example of it. Savant syndrome manifests by having a superior specific set of skills in a developmentally disabled person. Savants are like human supercomputers—while the rest of us are buffering, they can recall in 4K. We must not assume all people with autism are savants, unless we are particularly told about their exceptional talent.Another famous person with Savant syndrome was Kim Peek, portrayed by Dustin Hoffman in the 1988 movie The Rain Man. Kim Peek was later diagnosed with the FG syndrome and not autism spectrum disorder.What is the prevalence of autism?Worldwide, it is estimated that about 1 in 100 to 1 in 150 children are diagnosed with autism, though this number can vary based on the country and diagnostic practices. In the United States, according to the CDC, as of 2023, approximately 1 in 36 children are diagnosed with autism.  Some studies even claim that boys are 4x more likely to be diagnosed with autism than girls.It is a very prevalent condition, and we have some recommendations about screenings. I feel like most parents have a “feeling” that something may be wrong with their kid, but I think most parents may feel that way, especially when they have their first baby.The American Academy of Pediatrics recommends that all children should be screened for autism at 18 months and 24 months of age during routine well-child visits, using standardized tools like the Modified Checklist for Autism in Toddlers (M-CHAT) or other validated autism screening tools.   MCHAT is a two-step screening that requires a second visit if the first test shows moderate risk. Also, we must continue to follow up the development of kids in well child visits and be on the lookout for signs of autism, even outside of the recommended screening ages. How is autism diagnosed?Autism is typically diagnosed between the ages of 2 and 3, but it is often identified in early childhood. According to the DSM-5, there are two main clusters of symptoms for autism.- Cluster A: Involves social communication and interaction impairments in various settings.- Cluster B: Involves repetitive behavioral patterns, limited areas of interest, and atypical sensory behaviors/experiences.According to the DSM-5-TR criteria, a diagnosis of ASD requires that the following criteria are met:All three of the following Cluster A symptoms:- Social-emotional reciprocity: Difficulty engaging in mutually enjoyable conversations or interactions due to a lack of shared interests or understanding of others' thoughts and feelings.- Nonverbal communicative behaviors to socialize, such as using aspects with eye contact, facial expressions, gestures, and tone of voice, which makes communication more difficult.- Difficulty developing, understanding, and maintaining relationships: This could manifest as difficulty adjusting behavior to social settings, an inability to show expected social behaviors, a lack of interest in socializing, or difficulty making friends despite wanting to.Two or more of the following Cluster B symptoms:- Stereotyped or repetitive movements, use of objects, or speech: Echolalia or flapping the hands repeatedly.- Persistent sameness, where patients require adherence to routines or ritualized patterns of behavior, such as difficulty with transitions or a need to eat the same food each day.- Highly restricted, fixated interests: This may include an intense focus on specific objects (trains) or topics (such as dinosaurs or natural disasters).- Sensory response variations, including heightened or diminished responses to sensory input, such as adverse reactions to sounds, indifference to temperature, or excessive touching/smelling of objects.Additionally, the symptoms must:- Significantly impair social, academic/occupational, and daily functioning,- Not be better explained by intellectual disability or global developmental delay, and- Be present in early childhood. (However, symptoms may only become apparent when social demands exceed the child's capacity; in later life, they may be masked by learned strategies.)How can we go about managing autism?There is no "cure" for Autism. However, various therapies can help manage the condition. Treatment tailors to the individual's age, strengths, and weaknesses. Our main goal is to maximize function, encourage independence, and improve the patient's overall quality of life.During office visits as primary care doctors, we have to use different strategies to make the visits more focused on individual needs, making sure the caregivers are involved as well as the patient. We communicate with caregivers before and during the visit to optimize patient compliance, allow enough time for the family/caregiver to talk about the patient's history, allow the patient to play with instruments/materials provided, and use simple instructions. Sometimes, the physical exam can be the most challenging aspect of the exam because it is so overstimulating for the patient. Hence, allowing enough time for the patient to be comfortable is key.This is a multidisciplinary management that includes, family med, pediatricians, social workers, behavioral health, etc.Personal experiences interacting and managing patients with autism in the clinic or in the hospital:Dr. Arreaza: I have seen a lot of adult patients with autism.I see a challenge commonly found is agitation and the use of medications. I prefer to defer any prescriptions to psychiatry, if needed, but behavioral concerns can be successfully managed by behavioral health with participation of family, caregivers, and especial education.TJ:  Personal story with Auditory Processing Disorder (APD).Conclusions: Dr. Arreaza: Autism is a spectrum, not all persons with ASD are the same. They are not all geniuses, and they are not all developmentally delayed, they are not just black or white, but there are several shades of gray in between. TJ:  Not one doctor or one family will take care all responsibility, it requires a multifaceted approach.People with autism can live a long and meaningful lives.Thank you for listening to this week’s episode on Autism. We will see you next time.  Have a nice day.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Centers for Disease Control and Prevention. Data and statistics on autism spectrum disorder. CDC.gov. Accessed on March 13, 2025. https://www.cdc.gov/autism/data-research/index.htmlWeissman Hale, Laura, “Autism spectrum disorder in children and adolescents: Overview of management and prognosis,” UpToDate, accessed on March 13, 2025. https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-management-and-prognosis.Volkers, N. (2016). Early Signs. The ASHA Leader.https://doi.org/10.1044/leader.ftr1.21042016.44Urquhart-White, Alaina, “'The Good Doctor' Puts The Spotlight On A Rare, Mysterious Syndrome,” Bustle, September 25, 2017. https://www.bustle.com/p/whats-real-about-savant-syndrome-is-something-the-good-doctor-should-explore-2439405Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. 

Episode 186: Exercise PrescriptionsDr. Sandhu and future Dr. Daoud explain the way to prescribe exercise, what are the general guidelines for exercise and how to overcome barriers to exercise. Dr. Arreaza emphasized the importance to screen our patients before exercise and using the term “physical activity” to improve receptivity by patients.  Written by Wessam Daoud, MSIV, Ross University School of Medicine. Edits and comments by Ranbir Sandhu, MD, and Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: I’m Dr. Arreaza, and today, we will talk about a topic that is both simple and powerful: exercise. Previous episodes: 158, 100 (sexercise), 95, We all know exercise is good for us, but how do we prescribe it like we do medications? How can we tailor exercise recommendations to our patients' needs and lifestyles? To help us unpack this, I’m joined today by Dr. Ranbir Sandhu, and Medical Student, Wessam Daoud, who has a passion for preventive medicine. Welcome to the show!Ranbir: Thanks, Dr. Arreaza! We’re excited to be here and to discuss something so fundamental to health.Segment 1: Understanding Exercise PrescriptionArreaza: Let’s start with the basics. In medicine, we prescribe medications with precise instructions—dosage, frequency, duration. But how do we apply this concept to exercise?Ranbir: Great question! Before we prescribe exercise, we have to make sure that it is not contraindicated. We can use a system to stratify our patients based on risk factors, such as older age, smoking, baseline level of activity, etc. For example, a patient who had a heart attack within the last 6 weeks should not exercise yet, a person with heart failure exacerbation, asthma exacerbation, uncontrolled heart arrhythmia, etc. Wes: Exercise prescription follows a structured approach, similar to medications. We use the FITTE mnemonics to guide recommendations: Frequency – How often?Intensity – How hard should the patient work?Time – How long should each session last?Type – What kind of exercise is best?Enjoyment – Does the patient enjoy this activity?By adjusting these components, we can tailor exercise to each patient’s needs, whether it’s improving cardiovascular health, managing chronic disease, or building strength.Segment 2: How Much Exercise Do Adults Need?Arreaza: Now, when we talk about exercise, there’s a lot of conflicting advice out there. What do the official guidelines say about how much adults should exercise?Ranbir: The American College of Sports Medicine (ACSM) and CDC provide clear guidelines:Aerobic Exercise: At least 150 to 300 minutes of moderate-intensity exercise per week, OR 75 to 150 minutes of vigorous-intensity exercise (or a mix of both).Muscle Strengthening: At least two days per week of resistance training targeting major muscle groups.Balance & Flexibility: Particularly important for older adults to reduce fall risk.These guidelines are adaptable, meaning patients can break them into shorter sessions throughout the week.Arreaza: For weight regain, you may need to exercise a little bit more, about 300 minutes/week, and >2 days of resistance activity.Segment 3: Choosing the Right Type of ExerciseArreaza: With so many options—cardio, strength training, yoga—how do you guide patients in choosing the right type of exercise for them?Wes: It depends on the patient’s goals, health conditions, and personal preferences. Here’s how we might break it down:For cardiovascular health: Activities like brisk walking, jogging, cycling, or swimming.For strength and bone health: Resistance exercises, bodyweight exercises, or weightlifting.Ranbir: For flexibility and balance: Yoga, Pilates, or tai chi, especially for older adults.For chronic disease management: Customized plans—e.g., low-impact options for arthritis or supervised exercise for heart disease.The key is finding something they enjoy, because sustainability is the most important factor.Arreaza: We can use our physical therapy friends to design an appropriate plan for our patients.Segment 4: Overcoming Common Barriers to ExerciseArreaza: I hear this all the time in the clinic—patients want to exercise but struggle to stay consistent. What are the biggest barriers, and how do we help patients overcome those barriers?Wes: Absolutely. Some common barriers include:Lack of time: Patients think they need hours at the gym, but even short bouts of 10 minutes throughout the day add up.Low motivation: Encouraging goal setting and accountability, such as a workout buddy or an activity tracker, helps.Arreaza: Instagram post from Ranbir: Go to the gym even if you don’t want to go. Wes: Pain or chronic illness: We can adapt exercises—low-impact options like swimming or chair exercises work well.No access to a gym: Many exercises require no equipment—walking, stair climbing, bodyweight exercises.Ranbir: As physicians, we need to normalize movement as part of daily life rather than an all-or-nothing approach.Segment 5: The Role of Healthcare Providers in Exercise CounselingArreaza: We often focus on medications and procedures, but exercise is one of the best treatments we have. What role should physicians play in promoting physical activity?Ranbir: Our role is critical! Exercise is preventive medicine and can reduce the risk of heart disease, diabetes, obesity, and even depression. As physicians, we can:-Ask about exercise levels at routine visits.-Provide specific, personalized exercise prescriptions rather than just saying 'you should exercise more.'-Address patient concerns by modifying recommendations to their abilities.-Follow up and reinforce progress like we would with any other treatment.-Even a brief conversation about physical activity can significantly impact patient motivation and adherence.Arreaza: Exercise vs physical activity. Ask your patients as a routine. Closing Thoughts & Call to ActionArreaza: Ranbir andWessam, this has been a fantastic discussion. Any final thoughts for our listeners?Ranbir: My biggest takeaway is that any movement is better than none. Exercise doesn’t have to be perfect—it just has to be consistent. Start small, find an activity you enjoy, and build from there!Arreaza: Any take-home message, Wes?Wes: Same for me, find an activity you enjoy, start where you are, and keep moving!Arreaza: Great advice! If you found this episode helpful, share it with your colleagues and patients. Ranbir: Until next time—stay active and stay healthy!Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________Sources:Some information in this podcast was inspired by conferences from the Obesity Medicine Association, https://obesitymedicine.org/.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 185: Aging 101.  Dr. Schlaerth explained the physiology, how to slow down and how to prevent aging. Dr. Ayyagari inquired about how to fight ageism in our clinic and in our society. Dr. Arreaza highlights the importance of treating elderly patients with dignity and empathy. A new book written by Dr. Schlaerth is introduced (“The Ways our Bodies Age.”)  Written by Katherine Schlaerth, MD (Clinica Sierra Vista). Edits and comments by Hector Arreaza, MD (Clinica Sierra Vista), and Tejasvi Ayyagari, MSIV (Ross University School of Medicine.)You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.InterviewArreaza: Question 1: What are some early signs that may indicate that your body is aging? (Pain? Memory? Weight loss?)Schlaerth: Maximum bone mass, muscle strength and mass and general strength and endurance generally peak in the third and early fourth decades of life. However, genetics and environment play a big role in aging for each of us. People can have problems with visual accommodation in their early forties, if not before. Many people feel that a realization of the possibility of aging begins when they must have magnification to read very small print.  Women often complain of menopause as a benchmark for aging. Men don’t really have such a well demarcated event in their lives. Arreaza: Sure, men do not have a specific event, but I think an undeniable sign of aging in men is urinary frequency. I normally tell my patients that the nose, the ears, and the prostate are organs that tend to grow with age. So, if a male patient complains that they must use the bathroom more frequently, that may be a sign that their prostate is growing, after ruling out other conditions, if needed, we can reassure the patient that this can be a normal sign with aging. We will not neglect the patient because “it is normal” but we must offer interventions when needed.Schlaerth: The bottom line may be that aging is multifactorial, involves everything from the demands of one’s employment, through genetics, diet, and exercise right up to how many friends one has. It is also a stealth process, and all our body parts may even age at different rates! One individual may have great kidneys but an erratic thyroid, and another a shrinking liver but a superb array of teeth.Arreaza: (Humor) Plastic surgery and cosmetics can hide some signs of aging (not all). A wise woman said that you can hide your age, but your hands and neck will surely reveal it.Schlaerth: Many of us use external clues to measure aging. Teenage daughters accuse us of being behind the times, or new wrinkles and white streaks in our hair bring the reality of time passing to us. So, the realization of aging may be rather subjective, or it may be signaled by reduced energy, a falling off of the athletic skills we once had, or weight gain when we eat the same exact quantity and type of food we did at a younger age without gaining weight. So subjective aging mirrors incompletely the aging we are undergoing at a cellular and subcellular level.TJ: Question 2:How can we slow down aging?Schlaerth: One unpopular way would be to increase the age at which people are eligible for social security if in good health. WHY would this help? Because work adds a valuable dimension to the daily lives of seniors. It provides socialization, intellectual challenges, exercise and allows people to continue giving the results of their valuable life experience to others. Now there are issues here. Positions may have to change to accompany the changes of aging. People may choose different occupations from those held in adulthood. Part time work may compel employers to decrease salaries and to make accommodating changes in the workplace. Arreaza: I see your point. As you stay active, your aging slows down. Schlaerth: On the opposite side of the equation, social security may be saved from being turned into a funding responsibility of the federal government, raising taxes on younger workers and making them even less likely to be able to afford housing and even children. TJ: [In your experience Dr. Schlaerth, are professions, especially healthcare, moving in that direction to provide appropriate accommodations for aging workforce?] Schlaerth: There are variability. Schlaerth: To continue about slowing down aging, as an alternative, acquire a new skill or hobby that allows you to grow instead of vegetating in front of a TV or other screen, and brings you into contact with others, young and older, who share your interest.More popular ideas would include expanding opportunities to exercise and socialize within one’s own community, with local initiatives geared to the specifics of the community’s location and interests. But in the long run, education and motivation will be the biggest interventions. People need to know more about their bodies over time, because preparing for aging takes knowledge and starts in one’s thirties or forties. This means establishing an exercise habit which will endure for decades and is consistent with one’s responsibilities to one’s family and one’s job. It must work and be doable over time. Arreaza: So, we must develop an exercise routine that we enjoy, it’s challenging, and sustainable over decades. Brain exercise also works (new ways to go to work, learning a new language, etc.)Schlaerth: -Eating habits must be changed, which will involve less eating out and more home cooking. TJ: [As much as I enjoy a good In-N-Out burger, nothing beats a home cooked meal. Aside from controlling the ingredients for individualized diets/spice levels, cooking for me is therapeutic and helps relieve stress, especially when I cook Indian food (my specialty).] Schlaerth: Choosing the right lifelong partner and staying married is a big help. That may also require a bit of education, starting in childhood! All studies show that being married prolongs life!Tongue in cheek, I would suggest choosing the right location to settle down. Los Angeles and New York City don’t currently look like stress free places to live. That may change though.Arreaza: I guess if you have a good social support in those cities, it may work. What else can we recommend our patients?Schlaerth: People who are happy and optimistic and have lots of friends and family statistically do well. Join your local church, synagogue, temple, mosque, etc. Living according to your code of ethics and beliefs with others who share these is always reinforcing and offers support in times of trouble. One recently widowed octogenarian who had had a very strong and fulfilling marriage knew that she had to reinvent purpose in her life. So, she became the neighborhood unofficial social worker. Did a friend’s child need a place to stay until he or she got their own apartment? Come on over, there’s an extra bedroom. Was a trip to the doctor needed by someone who couldn’t drive? Let’s go! Another widow opened her home to students at a university, charging rent and becoming a “mother hen” to her student lodgers.A man who loved aeronautics served as a docent for a local museum and became a fount of information about the intricacies of World War II planes right down to structural details. All of these and similar strategies kept people interested and interesting, promoted exercise and took a bit of creativity and yes, energy.Arreaza: So, to slow down aging, stay physically, spiritually, and mentally active. Question 3:Why are people so afraid of aging? (TJ: There are some concepts we can introduce for discussion: -Gerascophobia is an abnormal or incessant fear of growing older or ageing. -Gerontophobia is the hatred or fear of the elderly. -Ageism refers to age discrimination) Schlaerth: There are very personal and idiosyncratic reasons for a fear of aging. One gentleman saw his wife die a painful death from cancer and this triggered his fear.Another saw his grandparents age and had to help care for them. Sometimes this kind of experience can engender love and respect for one’s older family members, and sometimes the opposite. -One’s teeth leave, food is no longer palatable, balanced precludes getting a kid’s ball off your roof, constipation and aches are a daily struggle, even the TV shows you loved are now old reruns. You no longer feel welcome in this new world. And anyway, you can’t drive at night, and you can’t hear well enough in a crowd to join in a restaurant conversation.-But probably the biggest reasons include a loss of function and autonomy (the Bible even alludes to this fear!), loss of employment and loneliness when one’s friends and especially one’s lifelong partner are no longer there.-Cultural change can also be a factor. The community one grew up in no longer exists. Communication is by computer or cell phone and much too complicated to learn. The old lot where baseball was played so long ago is now a derelict and abandoned shopping center! -You don’t look beautiful anymore.-A strong religious faith often mitigates a lot of these fears. TJ: Question 4:How can we fight age discrimination (ageism) in our clinics, hospitals, and society?Schlaerth: The humanity of each person needs to be recognized. It is said that people feel about 20 years younger than their chronologic age. This may not be true for children, teenagers, or young adults though. When interacting with older folk, the need for environmental issues like good illumination, comfort, clear and low-pitched speech, the absence of extraneous noise, eye contact should be addressed to facilitate communication. If a younger person accompanies the older person, address at least some comments specifically to the older person. Allow time for a slower gait or respon

Episode 184: Multiple Myeloma BasicsSub-Interns and future Drs. Di Tran and Jessica Avila explain the symptoms, work up and treatment of multiple myeloma. Written by Di Tran, MSIV, Ross University School of Medicine; Xiyuan Yang, MSIV, American University of the Caribbean. Comments by Jessica Avila, MSIV, American University of the Caribbean. Edits by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Di: Hi everyone, this is Di Tran, 4th year medical student from Ross university.  It’s a pleasure to be back.  To be honest, this project is a part of teamwork of two medical students, myself and another 4th year, her name is XiYuan.  She came from the AUC. Unfortunately, due to personal matters she was unable to make it to the recording today which makes me feel really sad. Jessica: My name is Jessica Avila, MSIV, American University of the Caribbean.Di: The topic we will present today is Multiple Myeloma. Multiple myeloma is typically a rare disease and it’s actually a type of blood cancer that affects plasma cells in the bone marrow.Jessica: Let’s start with a case: A 66-year-old male comes to his family doctor for an annual health checkup. He is not in any acute distress but he reports that he has been feeling tired and weaker than usual for the last 3 months. He also noticed that he tends to bruise easily. He has a history of arthritis and chronic joint pain, but he thinks his back pain has gotten worse in the last couple of months. Upon checking his lab values, his family doctor found that he has a calcium level of 10.8 and a creatinine level of 1.2, which has increased from his baseline. Given all that information, what do you think his family doctor is suspecting? And what kind of tests she can order for further evaluation?Di: Those symptoms sound awfully familiar – are we talking about the CRAB? You know, the diagnostic criteria for Multiple Myeloma.Jessica: Exactly! Those are called “myeloma-defining events.” Do you remember what those are?Di: CRAB criteria comes in 4 flavors.  It’s HYPERCALCEMIA with >1mg/dL, RENAL INSUFFICIENCY with serum creatinine >2mg/dL, ANEMIA with hemoglobin value <10 g/dL, or more than 2g/dL below normal, and BONE LESION, with one or more osteolytic lesions seen in imaging, be it CT or PET/CT scans.Jessica: You’re correct about the CRAB criteria! If our patient meets those conditions, myeloma is highly suspected.  Other than the CRAB, there’s something else that has to be met before we can diagnose multiple myeloma.  Patients must undergo a bone marrow biopsy and if there are > 10% plasma cells, PLUS any one or more of the CRAB features, we can make the official diagnosis of multiple myeloma. Di:  Before we go deeper, let’s back up a little bit and do a little background.  So, what do we know about the immunoglobulins, also known as antibodies? Back from years of studying from medical school, we know that the plasma cells are the ones that producing the antibodies that help fight infections.  There  are various kinds that come with various functions.  Each antibody is made up of 2 heavy chains and 2 light chains.  For heavy chains, we have A, D, E, G, M and for light chains we have Kappa and Lambda.Jessica: Usually, the 5 possible types of immunoglobulins for heavy chains would be written as IgG, IgA, IgD, IgE, and IgM.  And the most common type in the bloodstream is nonetheless the IgG. Di: What is multiple myeloma? In myeloma, all the abnormal plasma cells make the same type of antibody, the monoclonal antibody.  The cause of myeloma is unknown, but there are lots of studies and evidence that show a number of potential etiologies, including viral, genetic, and exposure to toxic chemicals, especially the Agent Orange, which is a chemical used as herbicide and defoliant. It was used as a chemical warfare by the U.S. military during the Vietnam War from 1961 to 1971.Jessica: We need to order some specific blood tests to see if there is elevated monoclonal proteins in the blood or urine. So, to begin with we’ll need to take a very thorough history and physical exam. Next, we’ll do labs, such as CBC, basic metabolic panel, calcium, serum beta-2 microglobulin, LDH, total protein, and some not so common tests: serum protein electrophoresis (SPEP), immunofixation of blood or urine (IFE), quantitative immunoglobulins (QIg), serum free light chain assay, and serum heavy/light chain ratio assay.If any of the results is abnormal, we should consider referring our patient to an oncologist.Di: Interesting! I read that Multiple Myeloma symptoms vary in different patients.  In fact, about 10-20% of patients with newly diagnosed myeloma do not have any symptoms at all.   Otherwise, classic symptomatic presentations are weakness, fatigue, increased bruising under the skin, reduced urine output, weakened bones that is likely prone to fractures, etc. And if multiple myeloma is highly suspected, a Bone Marrow biopsy should be done with testing for flow cytometry and fluorescent in situ hybridization (FISH). Actually, if any of the “Biomarkers of malignancy (SLIM)” is met we can also diagnose multiple myeloma even without the CRAB criteria. Jessica: The diagnosis is made if one or more of the following is found: >= 60% of clonal plasma cells on bone marrow biopsy, > 1 lytic bone lesion on MRI that is at least 5mm in size, or a biopsy confirmed plasmacytoma. Di: Imaging comes in at the final step especially if we able to find one or more sites of osteolytic bone destruction > 5mm on an MRI scan.Jessica: What if the bone marrow biopsy returns > 10% of monoclonal plasma cells, but our patient doesn't have either the CRAB or the Biomarker criteria? Di: That’s actually a very good question, since Multiple Myeloma is part of a spectrum of plasma cell disorders. That’s when smoldering myeloma comes into play. It is a precursor of active multiple myeloma. Smoldering myeloma is further categorized as high-risk or low-risk based on specific criteria.A less severe form is called Monoclonal Gammopathy of Undetermined Significance, or simply MGUS, with < 10% bone marrow involvement. Those are diagnoses we give once we rule out actual multiple myeloma, which are defined by the amount of M-protein in the serum.Jessica:  When to get started on treatment? Multiple Myeloma is on a spectrum of plasma cells proliferative disorders, starting from MGUS to Smoldering Myeloma, to Multiple Myeloma and to  Plasma Cell Leukemia.  Close supervision/active watching is enough for MGUS and low risk Smoldering Myeloma. But once it has progressed to high-risk smoldering myeloma or to active Multiple Myeloma, chemotherapy is usually required. Some situations may require emergent treatment to improve renal function, reduce hypercalcemia, and to prevent potential infections.Di: As of 2024, treatment of Multiple Myeloma comprises the Standard-of-Care approved by the FDA. In fact, the quadruple therapy is a combination of 4 different class of drugs that include a monoclonal antibody, a proteasome inhibitor, an immunomodulatory drug, and a steroid. Jessica: They are Darzalex (daratumumab), Velcade (bortezomib), Revlimid (lenalidomide) and dexamethasone.  Other treatment plans for Multiple Myeloma include chemotherapy, immunotherapy, radiation therapy (for plasmacytomas) and stem cell transplants. The patient will also be on prophylaxis acyclovir and Bactrim while on chemotherapy. Sometimes anticoagulants are also considered because the chemo increases the risk of venous thromboembolic events.Di: Although the disease is incurable, but with the advancing of novel therapies and clinical trials patients with multiple myeloma are able to live longer.  Problem is the majority of patients diagnosed with Multiple Myeloma are older adults (>65), the risk of falling is adding to multiple complications of the disease itself, such as bone density loss, pain, neurological compromises, distress and weakness.  Palliative care may come in help at any point in time throughout the course of treatment but is most often needed at the very end of the course. Jessica, can you give us a conclusion for this episode?Jessica: Multiple Myeloma may not be the most common cancer, but we have to be aware of the symptoms and keep it in our differential diagnosis for patients with bone pain, easy bruising, persistent severe headaches, unexplained renal dysfunction, and remember the CRAB: HyperCalcemia, Renal impairment, Anemia and Bone lesions.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:International Myeloma Foundation. (n.d.). International Myeloma Working Group (IMWG) criteria for the diagnosis of multiple myeloma. https://www.myeloma.org/international-myeloma-working-group-imwg-criteria-diagnosis-multiple-myeloma Laubach, J. P. (2024, August 28). Patient education: Multiple myeloma symptoms, diagnosis, and staging (Beyond the Basics). UpToDate. https://www.uptodate.com/contents/multiple-myeloma-symptoms-diagnosis-and-staging-beyond-the-basics.University of California San Francisco. (n.d.). About multiple myeloma. UCSF Helen Diller Family Comprehensive Cancer Center. https://cancer.ucsf.edu/research/multiple-myeloma/about Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.