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Dr. Arreaza: Welcome to another episode of Rio Bravo qWeek. Today we're talking about a condition that is common in primary care, usually easy to diagnose, but can be surprisingly painful and frustrating for patients: trigger finger. You know the patient—the finger clicks, catches, sometimes locks, and suddenly opening a jar becomes very difficult. Today we are going to talk about what causes trigger finger, how to recognize it, what else can look like it, and most importantly, how we treat it. Joining me today are two family medicine residents who will help us walk through the topic. Please introduce yourself. Dr. Awa: [Introduce yourself.] Dr. Dadzie: [Introduce yourself.] Dr. Arreaza: Excellent. Let's start with the basics. What exactly is trigger finger? Dr. Awa: Trigger finger, also called “stenosing flexor tenosynovitis,” is a mechanical problem involving the flexor tendon and the pulley system of the finger. The flexor tendon normally glides smoothly through a series of pulleys that keep the tendon close to the bone during finger movement. The important structure in trigger finger is the first annular pulley, or A1 pulley, located near the metacarpophalangeal, or MCP, joint. Dr. Dadzie: When the tendon and surrounding tissue become enlarged or the pulley becomes narrowed, the tendon has difficulty gliding through that space. It can catch as the finger flexes or extends. Dr. Arreaza: So essentially, the tendon is trying to pass through a space that has become too tight? Dr. Awa: Exactly. And that mechanical catching is what produces the characteristic clicking, snapping, or locking. Dr. Dadzie: The underlying histologic change is also interesting. The A1 pulley can develop changes in the fibers and cartilage, which contribute to narrowing of the canal. Dr. Arreaza: Trigger finger may be associated to several conditions, mostly inflammatory and metabolic disorders, right? Dr. Dadzie: Yes, but most cases are idiopathic. Patients often associate their symptoms with repetitive activity, but the evidence for repetitive occupational activity as a direct cause is controversial. Dr. Arreaza: Let’s describe a typical patient with trigger finger. Dr. Awa: It's common in adults, with a prevalence of roughly 2 percent in the general population. It is more common in women, particularly during the fifth and sixth decades of life. It can involve one finger or multiple fingers, and it can affect both hands. Dr. Arreaza: And what medical conditions should make us think about trigger finger? Dr. Dadzie: Diabetes mellitus is an important association. Trigger finger is also more common in patients with rheumatoid arthritis and in some systemic disorders, including amyloidosis. Dr. Arreaza: Let's move to the classic presentation. The classic story is clicking, catching, or locking of a finger during flexion or extension. Dr. Awa: Correct. Initially, the triggering may be painless. Over time, patients can develop pain, especially around the volar aspect of the MCP joint, and they may have difficulty extending the finger after it catches. Dr. Dadzie: Some patients notice symptoms particularly in the morning. They may wake up with a finger locked in the palm and then gradually regain movement as the day goes on. Dr. Arreaza: Some cases are mild, but we can also have a severe presentation. Dr. Dadzie: Yes, the finger can become locked in flexion and require passive manipulation to straighten it. That can be quite painful. If the patient avoids moving the finger because of pain or locking, they can eventually develop a secondary contracture, particularly at the proximal interphalangeal, or PIP, joint. Dr. Arreaza: Trigger finger is primarily a clinical diagnosis that does not require imaging. Dr. Awa: Yes, we can ask the patient to open and close the hand and try to reproduce the triggering. With the palms facing upward, we watch for catching, clicking, or locking. Dr. Dadzie: We can also palpate over the A1 pulley near the MCP joint. There may be tenderness or a palpable nodule caused by thickening of the tendon. Dr. Arreaza: So if we can reproduce the clicking and the patient is tender right over the A1 pulley, that's pretty easy. Have you read about the use of ultrasound for these patients? Dr. Dadzie: Ultrasound isn't required for most patients, but it can be useful when the diagnosis is uncertain or when we want to guide an injection. Dynamic ultrasound can demonstrate a thickened A1 pulley and can sometimes show the tendon catching as it moves beneath the pulley. Dr. Arreaza: That sounds neat. US are our new eyes. Dr. Dadzie: X-rays or MRI are generally not necessary for a straightforward case. Radiographs or CT may occasionally show calcification, while MRI can help identify alternative tendon or soft-tissue pathology, but MRI isn't particularly useful for directly evaluating the A1 pulley. Dr. Arreaza: Good. So, don’t order x-rays or MRI for trigger finger, but we can have some mimics. Let's talk about the differential diagnosis. A patient has a painful finger that doesn't move normally. What else should we consider? Dr. Awa: One important alternative is Dupuytren's contracture (dOOp-itrens). In trigger finger, the loss of motion is typically dynamic—the finger catches and releases. With Dupuytren's, the loss of extension is fixed and progressive, and there are usually nodules or cords in the palmar fascia. Dr. Arreaza: So dynamic versus fixed is an important distinction between trigger finger vs Dupuytren contracture. Dr. Awa: Exactly. Dr. Dadzie: Another possibility is diabetic cheiroarthropathy, or limited joint mobility associated with diabetes. This usually affects multiple fingers more symmetrically and causes difficulty flexing or extending the joints rather than the episodic catching seen with trigger finger. Dr. Arreaza: What if the patient had an injury, does it change our approach? Dr. Dadzie: Then we should think about an MCP joint sprain or another traumatic injury. A history of trauma and absence of triggering would point away from classic trigger finger. Dr. Arreaza: Infection is a differential we should not miss, especially because an infection in the hands may be an emergency. Dr. Awa: Absolutely. Infectious flexor tenosynovitis is an important diagnosis not to miss. It presents with severe pain, tenderness, swelling, erythema, and symptoms extending along the flexor tendon—especially after a puncture wound or bite—should raise concern for infection. Unlike uncomplicated trigger finger, infection can rapidly cause significant loss of function and tendon damage. Dr. Arreaza: Yes, an infection will require urgent evaluation and surgical consultation because a closed-space infection of the tendon sheath may require drainage. Excellent. Any other mimics? Dr. Dadzie: Calcific periarthritis or peritendinitis can cause severe pain and inflammation and may mimic infection, but it generally doesn't cause the characteristic triggering. Inflammatory tenosynovitis, such as that associated with rheumatoid or reactive arthritis, can also cause pain and swelling along the tendon. The distribution and underlying inflammatory disease help distinguish it from trigger finger. Dr. Arreaza: As a summary, differential diagnosis include: Dupuytren's contracture, diabetic cheiroarthropathy, trauma and infections. Now let's get to the part that our audience has been waiting for. After we diagnose a patient with trigger finger, and we ruled out other possible causes, how do we treat it? What's our first move? Dr. Awa: Start conservatively. Activity modification and splinting are reasonable initial treatments. The patient doesn't necessarily need to stop all activity, but they should avoid movements that aggravate the symptoms, particularly repetitive pinching or grasping. Dr. Arreaza: Tell us more about splinting? Dr. Dadzie: Splinting can reduce triggering by limiting motion of the affected digit. Different splint designs can be used depending on the patient's triggering pattern and preference. A typical trial is around six to ten weeks. For milder cases, buddy taping the affected finger to an adjacent finger can also be considered. Dr. Arreaza: The splint should be used 24 hours a day, and the splint that is best tolerated by patients is the MCP joint blocking orthosis, but you can also use a PIP joint blocking splint, which can actually be more effective for pain relieve and improvement of function. Splinting is especially useful when injection is relatively contraindicated—e.g., diabetics with poor glycemic control, given the risk of steroid-induced hyperglycemia, and children. And what about medications? Dr. Awa: NSAIDs can be used for short-term pain relief when appropriate. Typically, we would limit their use to about two to four weeks and consider contraindications such as gastrointestinal disease, kidney disease, or heart disease. Dr. Dadzie: It's important to remember that NSAIDs treat the pain; they don't necessarily correct the mechanical problem causing the triggering.   _____________________ References: Blazar PE, Aggarwal R. Trigger finger (stenosing flexor tenosynovitis). UpToDate. Topic 7755, Version 30.0. Literature review current through August 2026. Topic last updated August 5, 2026.Moore JS. Flexor tendon entrapment of the digits (trigger finger and trigger thumb). J Occup Environ Med. 2000;42:526.Saldana MJ. Trigger digits: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9:246.McAuliffe JA. Tendon disorders of the hand and wrist. J Hand Surg Am. 2010;35:846.Sbernardori MC, Bandiera P. Histopathology of the A1 pulley in adult trigger fingers. J Hand Surg Eur Vol. 2007;32:556.Katzman BM, Steinberg DR, Bozentka DJ, et al. Utility of obtaining radiographs in patients with trigger finger. Am J Orthop. 1999;28:703.Guerini H, Pessis E, Theumann N, et al. Sonographic appearance of trigger fingers. J Ultrasound Med. 2008;27:1407.Colbourn J, Heath N, Manary S, Pacifico D. Effec

INTRODUCTION: Fever of Unknown Origin, or FUO: We have all had a fever at some point—maybe from seasonal flu or a brief stomach bug—where the body turns up the heat, fights off the bug, and recovers in a couple of days. Fever is a very efficient defense mechanism to fight microorganisms by making your body a hostile environment where they cannot survive. But what happens when a fever lasts for weeks, standard tests come back normal, and usual fever reducing medications do not seem to work? We will talk about the surprising root causes, the latest imaging technology like PET scans, and what to do when a fever refuses to break. Whether you are a medical student, a healthcare professional, or simply curious about how our body's defense mechanisms work, this episode is for you. Let us get into it! Definition of Fever of Unknown Origin. A standard fever is like a smoke alarm going off when you burn toast—you quickly spot the cause, fix it, and the alarm stops. FUO is like an alarm ringing continuously for weeks, but despite searching every room, you cannot find the source of the fire.Clinical Criteria (Classic FUO):1. Temperature >38.3 C measured on multiple occasions. 2. Duration of at least 3 weeks.3.Unexplained after 1 week of intensive outpatient or inpatient evaluation (or three outpatient visits). Categories of FUO. 1.      Classic FUO: The traditional presentation described above. 2.      Nosocomial (Hospital-Acquired) FUO: Fevers in hospitalized patients without infection upon admission. 3.      Neutropenic FUO: Fevers in immunocompromised patients (e.g., undergoing chemotherapy) with low white blood cell counts. 4.      HIV-Associated FUO: Fevers lasting weeks in patients with HIV, often driven by opportunistic infections like Tuberculosis or CMV, that stands for cytomegalovirus. What a mouthful! The Big Four Causes are:Infections (~30–40%): Atypical presentations of common diseases (e.g., hidden abscesses, endocarditis, tuberculosis, or tick-borne illnesses). Our priority will be to determine if this patient is having an infection, unless we get clinical manifestations that would guide us in another direction. Autoimmune & Inflammatory Diseases (~20–30%): The immune system overreacting and attacking the body’s tissues (e.g., Adult-onset Still's disease, Temporal Arteritis/Giant Cell Arteritis, Lupus). Malignancies / Cancers (~10–20%): Blood cancers (Lymphoma, Leukemia) or solid tumors (Renal cell carcinoma). Infections, autoimmune/inflammatory diseases, and malignancies cover 60-90% of the causes of FUO. Miscellaneous / Drug Fevers (~10–15%): "Drug fever" caused by adverse reactions to common medications (e.g., antibiotics, anti-seizure meds), thyroid storm, or deep vein thrombosis (DVT). Modern Medicine: Advanced imaging (CT, MRI, PET scans) which have helped us diagnose cancers and abscesses much earlier. As a result, modern FUOs are increasingly driven by autoimmune conditions, non-infectious inflammatory disorders. Sometimes it feels like we solve one problem and uncover another one! Important: Some cases remain undiagnosed (up to 30–50%) and resolve without a specific label. Diagnostic Approach: Step 1: The "Detective Work" (History & Physical): ●     Detailed History: Travel history, animal exposure (ticks, pets), occupational hazards, social history, medication review (to exclude drug fevers), and family history. ●     Potential Diagnostic Clues: Looking for subtle signals (e.g., a new heart murmur, temporal tenderness, hidden skin rashes, or swollen lymph nodes). Step 2: Basic Tiered Testing: ●     Blood Work: CBC (complete blood count), inflammatory markers (ESR, CRP, Ferritin), comprehensive metabolic panel, blood cultures. ●     Targeted Serologies: HIV, viral panels, autoimmune antibodies (ANA, Rheumatoid Factor). ●     Initial Imaging: Chest X-ray, abdominal ultrasound. Step 3: Advanced Diagnostic Workup: FDG-PET/CT Imaging: One of the most significant updates in recent guidelines. FDG-PET/CT uses a radioactive sugar tracer to highlight areas of high metabolic activity (inflammation, infection, tumor) throughout the entire body in a single scan. FDG-PET is a functional nuclear-imaging technique that uses ¹⁸F-fluoro-deoxy-glucose (FDG) — a radioactive glucose analog — to map tissue glucose metabolism.Targeted Biopsies: Biopsying tissues guided by PET scan findings (e.g., lymph node, liver, or temporal artery)."Refractory" Fevers: Fever vs. Hyperthermia: Standard fevers are driven by the brain's hypothalamus resetting the body's thermostat upward (often mediated by prostaglandins).  ●     Antipyretics (acetaminophen, NSAIDs) block prostaglandin synthesis. ●     If a fever does not respond to antipyretics, it may indicate non-prostaglandin-mediated inflammation (e.g., severe cytokine storm, drug-induced hyperthermia, or central nervous system dysregulation). Empiric Treatment vs. Observation: ●     The "Hold Your Horses" Principle: Current guidelines strongly advise against starting empirical antibiotics or steroids right away in stable patients. Antibiotics can mask infections and produce false-negative culture results, while steroids can hide inflammatory signs or exacerbate hidden infections. ●     When to Treat Empirically: Reserved for hemodynamically unstable patients, neutropenic patients, or specific high-suspicion conditions (e.g., suspected Temporal Arteritis to prevent blindness). Diagnostic Trial: Naproxen Test (Historical & Clinical Pearl): A brief trial of naproxen can sometimes distinguish tumor fevers (which often drop sharply in response to NSAIDs) from infectious fevers, though it is used cautiously as a supportive diagnostic clue rather than a rule. So, if a patient responds to a trial of naproxen, then we can suspect a tumor as a cause of the patient’s fevers. But it is not a strong recommendation. A 2019 systematic review/meta-analysis (15 studies, 582 patients) found a 94.1% success rate for naproxen in treating confirmed neoplastic fever. The test is not specific and lacks validation, but I can see the importance of knowing this: Naproxen is effective against cancer fever. FUO evaluation is a marathon, not a sprint. Re-evaluating the patient daily in the hospital for new physical clues is often more valuable than ordering endless specialized tests. I would like to emphasize that modern tools PET/CT have transformed how quickly we locate hidden inflammation. Also, let us remember that a huge proportion of undiagnosed FUOs eventually resolve spontaneously with good long-term outcomes, provided serious conditions have been systematically ruled out. Take away messages: First, FUO is a diagnostic marathon, not a sprint. Finding the cause takes patient detective work, careful daily exams, and targeted testing rather than rushing into quick fixes. Second, modern imaging like FDG-PET scans has completely transformed how we spot hidden inflammation and infection long before standard blood work gives us an answer. And finally, 'refractory' fevers require caution. If a fever is not responding to standard antipyretics, starting antibiotics or steroids right away can hide the real culprit. In stable patients, holding off and continuing the search is often the safest path. __________________ Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! References: 1)      David AB, Quinlan JD. Fever of Unknown Origin in Adults. American Family Physician. 2022;105(2):137-143. 2)      Wright WF, Stelmash L, Betrains A, Mulders-Manders CM, Rovers CP, Vanderschueren S, Auwaerter PG; International Fever and Inflammation of Unknown Origin Research Working Group. Recommendations for Updating Fever and Inflammation of Unknown Origin From a Modified Delphi Consensus Panel. Open Forum Infectious Diseases. 2024;11(7):ofae298. 3)      Wright WF, Durso SC, Forry C, Rovers CP. Fever of unknown origin. BMJ. 2025;388:e080847. 4)      Wright WF, Auwaerter PG. Fever and fever of unknown origin: review, recent advances, and lingering dogma. Open Forum Infectious Diseases. 2020;7(5):ofaa132. 5)      Cunha BA, Lortholary O, Cunha CB. Fever of unknown origin: a clinical approach. The American Journal of Medicine. 2015;128(10):1138.e1-1138.e15. 6)      Nazar AH, Naswa N, Sharma P, et al. Spectrum of 18F-FDG PET/CT findings in patients presenting with fever of unknown origin. American Journal of Roentgenology. 2012;199(1):175-185 1)      Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 229: Is it Prostate Cancer? (Pidgin English).   Dr. Ozoemena and his colleagues Dr. Okojie and Dr. Nweke engage in a conversation about the difference between benign prostatic hyperplasia and prostate cancer.  Written by Dr. Michael Ozoemena. Comments by Dr. Ejodakeme Okojie and Dr. Kenechutwu Nweke. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice. Interview was unscripted. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References: Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Interview: Dr. Ozoemena: Welcome back to our community health podcast, where we discuss important health topics in ways everybody can understand. Today we will be talking about Heart Failure. Many people have heard this term before, but it often causes fear and confusion. Here to talk about this important topic is Dr. Ken Nweke, a resident at our program, and he will be discussing this topic in Pidgin English so that some people in our community can understand it. Dr. Nweke, welcome to the program.  Dr. Nweke: Thank you very much. I happy make we discuss dis very important mata today.  Dr. Ozoemena: Let's start with the basics. What exactly is heart failure?  Dr. Nweke: First make we understand one thing. The heart na our generator. Just like generator dey provide light for house, the heart dey pump blood carry oxygen and nutrients go every part of the body. Every organ for body depend on the heart to survive. When person get heart failure, e no mean say the heart don stop work. E mean say the heart no dey pump enough blood and oxygen reach the body the as e suppose. The generator still dey run, but e no get enough power again. That struggle fit make different parts of the body begin show signs say wahala dey.  Dr. Ozoemena: What are some of the common causes of heart failure?  Dr. Nweke: Many things fit cause heart failure. One common cause na high blood pressure wey person don get for long time. If blood pressure high for many years, the heart go dey work harder pass normal every day. After some time, the heart fit begin weak. Heart attack fit also damage the heart muscle. When blood no reach part of the heart muscle, dat part fit damage and the heart no go pump blood well again. Sugar disease wey oyibo dey call diabetes also fit cause am Kidney disease fit contribute too. Some people get heart valve problems. Some oda people fit get heart problems from when dem born dem. People wey dey drink alcohol like water or people wey dey smoke fit develop am. Certain yama yama disease or infections fit affect the heart muscle. And for some families, heart problems fit run from generation to generation.  Dr. Ozoemena: What symptoms should people watch out for?  Dr. Nweke: One big sign na shortness of breath. At first, person fit notice am when e dey walk fast, climb stairs, or do heavy work. As the condition worsen, breathing fit become difficult even when person just dey rest. Some people go wake up for night because dem no fit breathe well. Some people go need plenty pillows before dem fit sleep well. Leg, ankle and foot fit swell. Water fit gather for body. Some people go notice say dem gain weight because water don full for body. Person fit tire easily. Things wey dem fit do before without problem fit become difficult. Some people fit get cough wey no gree go. Others fit notice swelling for belle because fluid don gather. Heart fit dey beat fast or anyhow.  Dr. Ozoemena: When should someone seek medical attention?  Dr. Nweke: If person dey notice shortness of breath wey no dey improve, swelling for leg, tiredness wey no dey normal, cough wey no gree stop, or weight gain wey sudden, e dey very important make e go see doctor. If person suddenly no fit breathe, get serious chest pain, faint, or collapse, dat one fit be emergency. Make dem go hospital immediately.  Dr. Ozoemena: How do doctors find out if someone has heart failure?  Dr. Nweke: Doctor go first ask plenty questions make dem sabi wetin b d kasala - doctors dey call history taking. Doctor go examine the patient. Dem go check blood pressure. Dem fit listen to the heart and lungs with stethoscope. Dem fit check for swelling for leg and foot. Blood tests fit help. Some blood tests fit show whether the heart dey under stress. Chest X-ray fit show whether fluid don gather for the lungs. EKG fit help weda electricals for d heart dey ok. One very important test na echocardiogram. Na ultrasound of the heart. E fit show say d heart don weak as e dey pump blood. e dey also check weda d heart valves dey ok. Heart valves na small small doors wey dey for heart wey dey open or close as the heart dey pump. Sometimes doctor fit request other tests depending on the situation.  Dr. Ozoemena: Can heart failure be treated?  Dr. Nweke: Yes or Better treatment dey. Although some cases no fit cure completely, treatment fit help people make dem live longer and feel better. We get medicines wey fit help the heart work better. Some medicines help remove extra water from the body. Some medicines help reduce the work wey the heart dey do. Others fit help protect the heart make e no weak For some people, doctor fit recommend special devices or surgery depending on the cause. But medicine no be the only thing. Lifestyle changes important too.  Dr. Ozoemena: What lifestyle changes can help?  Dr. Nweke: Person wey get heart failure suppose reduce salt for food. Too much salt fit make water gather for body. Dem suppose take medicines exactly the way doctor prescribe. Regular exercise fit help if doctor say e safe. Make dem avoid smoking. Too much alcohol no good. Try maintain healthy body weight. And make person keep all clinic appointments so doctor fit monitor the condition.  Dr. Ozoemena: Can heart failure be prevented?  Dr. Nweke: For many people, yes. make we control high blood pressure - taking medication, go see your doctor regularly Control sugar disease/diabetes. Make we try dey exercise regularly. Make we dey eat healthy food. Reduce salt for food. Avoid smoking. Avoid too much alcohol. Keep healthy weight. And go for regular medical checkup. Many times, if we control these risk factors early, we fit reduce the chance of developing heart failure. Dr. Ozoemena: Before we close, what would you like everyone listening to remember?  Dr. Nweke: Remember say heart failure no mean say the heart don stop work. The heart still dey work, but e dey struggle. Think of am like generator wey still dey run but im light weak, e no dey carry wetin e dey carry before. If you notice shortness of breath, swelling for leg, unusual tiredness, cough wey no gree go, or sudden weight gain, make you go see doctor. No wait until the condition become serious.  Dr. Ozoemena: Thank you, Dr. Nweke. And thank you to everyone listening today. Remember, heart na our generator. Take care of am. Until next time, stay healthy and stay informed Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References: Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Interview: Dr. Ozoemena: Welcome to today’s podcast where we will be discussing an important health topic in a way that's easy to understand. I'm your host, Dr. Ozoemena. Today we're talking about Deep Vein Thrombosis, or DVT, a condition that affects thousands of people each year and can sometimes lead to serious complications if not recognized early. Joining us today is Dr. Okojie, a 3rd year Family Medicine Resident Physician. Thank you for being here today, Doctor. Dr. Okojie: Thank you for having me. I'm excited to discuss this important topic. What is DVT? Dr. Ozoemena: Let's start with the basics. What exactly is Deep Vein Thrombosis? Dr. Okojie: Deep Vein Thrombosis, or DVT, occurs when a blood clot forms in one of the deep veins of the body, most commonly in the legs. Normally, blood flows smoothly through our veins, but sometimes a clot can develop and block that flow. The biggest concern is that part of the clot can break off and travel to the lungs. This is called pulmonary embolism, which can be a medical emergency. Why Should People Know About DVT? Dr. Ozoemena: Why is it important for the public to be aware of DVT? Dr. Okojie: DVT is more common than many people realize. The symptoms can sometimes be mild or mistaken for other conditions. Early recognition is important because prompt treatment can prevent serious complications and improve outcomes. Many cases are preventable, especially when people understand the risk factors. Who Is at Risk? Dr. Ozoemena: Who is more likely to develop blood clots? Dr. Okojie: Several factors can increase the risk of DVT. These include: {Discuss Virchow triad: VEH - Venous stasis, Endothelial injury and Hypercoagulability} Being inactive for long periods, such as during long flights or car rides Recent surgery or hospitalization Cancer  Pregnancy and the weeks after childbirth Smoking Obesity A History of clotting disorders It's important to remember that having a risk factor doesn't mean someone will definitely develop a clot, but it does increase the chances. What Are the Symptoms? Dr. Ozoemena: What symptoms should people watch for? Dr. Okojie: The most common symptoms occur in one leg and may include: Swelling Pain or tenderness Warmth in the affected area Redness or discoloration of the skin Some people describe the pain as a cramp that doesn't go away. When Does It Become an Emergency? Dr. Ozoemena: You mentioned that a clot can travel to the lungs. What warning signs should prompt someone to seek emergency care? Dr. Okojie: That's a very important question. People should seek immediate medical attention if they experience: Sudden shortness of breath Chest pain, especially when taking a deep breath Rapid heartbeat Dizziness or fainting Coughing up blood These symptoms could indicate a pulmonary embolism, which requires urgent treatment. How Is DVT Diagnosed? Dr. Ozoemena: If someone visits their doctor with symptoms, how is DVT diagnosed? Dr. Okojie: The healthcare provider will first ask about symptoms and medical history. The most common test is the ultrasound of the leg. It's painless, noninvasive, and allows us to see whether blood flow is blocked by a clot. Sometimes a blood test called a D-dimer is also used to help determine whether further testing is needed. How Is DVT Treated? Dr. Ozoemena: Once a clot is diagnosed, what treatment options are available? Dr. Okojie: The primary treatment is medication known as anticoagulants for those with contraindications to anticoagulants, IVC filter is recommended These medications help prevent the clot from growing larger and reduce the risk of new clots forming. Treatment usually continues for at least several months, although the exact duration depends on the individual's situation and risk factors. Most patients do very well when treatment starts promptly. Can DVT Be Prevented? Dr. Ozoemena: That's encouraging. What can people do to reduce their risks? Dr. Okojie: There are several practical steps: Stay physically active Take walking breaks during long trips Stay well hydrated Maintain a healthy weight Avoid smoking Follow your healthcare provider's recommendations after surgery or hospitalization Common Misconceptions Dr. Ozoemena: Are there any common myths about DVT that you'd like to address? Dr. Okojie: One common misconception is that blood clots only affect older adults. While risk increases with age, DVT can occur in younger adults as well, especially if they have risk factors such as recent surgery, pregnancy, certain medications, or inherited clotting disorders. Another misconception is that leg swelling is always harmless. Persistent swelling, especially in one leg, should be evaluated by a healthcare professional. Key Take-Home Messages Dr. Ozoemena: Before we wrap up, what are the most important messages you'd like listeners to remember? Dr. Okojie: I'd emphasize three key points: First, know the symptoms—swelling, pain, warmth, and redness in one leg. Second, understand your personal risk factors, especially after surgery, hospitalization, long travel, or during pregnancy. And third, seek medical attention promptly if you have symptoms of DVT or signs of pulmonary embolism, such as sudden shortness of breath or chest pain. Early diagnosis and treatment can save lives. Dr. Okojie: Thank you for having me. I hope today's discussion helps listeners better understand DVT and recognize when to seek medical care. Dr. Ozoemena: And thank you to our listeners for joining us today. Remember, this podcast is intended for educational purposes and should not replace advice from your healthcare provider. Until next time, stay informed, stay healthy, and take care. This is Rio Bravo qWeek… signing off! Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!  References: American Academy of Family Physicians. Venous Thromboembolism: Diagnosis and Management.  UpToDate. Overview of the Treatment of Lower Extremity Deep Vein Thrombosis (DVT). Updated September 2025.  American College of Chest Physicians. Antithrombotic Therapy for VTE Disease.  American Society of Hematology. Guidelines for Management of Venous Thromboembolism. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Introduction Dr. Arreaza: Hello, everyone, today we continue with our series about sleep. I invite you to listen to Moira Wilson on Episodes 220 and 221 about the approach of insomnia and CBT-I in adults. Today we will discuss not only what to do, but also why it works. We frequently hear advice like ‘get more sleep,’ but we need to dig deeper into the physiology behind it. So, Dr. Kim and Dr. Carlisle are here to briefly explain the physiology of sleep and what we can do to support better sleep. But before we start, let’s welcome Dr. Carlisle, who recently matched to our program. He will start his residency soon, and Dr. Kim, who will soon become a PGY2, welcome doctors.  Dr. Carlisle: [Introduce yourself].  Dr. Kim: [Introduce yourself].  Dr. Arreaza: Let’s start simple. Why does sleep matter clinically? Why Sleep Matters Dr. Kim: Sleep is one of the most important biological processes we have. It’s not passive; it’s highly active and tightly regulated. It affects cognition, metabolism, immune function, cardiovascular health, and hormonal balance. When sleep is disrupted, you see downstream effects in almost every organ system. Dr. Carlisle: Yeah, and one thing I always emphasize is that sleep deprivation isn’t just about feeling tired. It actually puts you in a physiologic state that’s very similar to being intoxicated. There are studies showing that being awake for about 24 hours can impair cognitive performance to a level comparable to being above the legal driving limit for alcohol. Dr. Arreaza: That’s actually kind of scary when you think about it.  Dr. Carlisle: It really is. Another way to think about it is sleep deprivation doesn’t just make you slower; it actually changes how you make decisions. People become more impulsive and less risky. And in medicine, we see that translates into increased medical errors, decreased attention, and poor decision-making. So, from a clinical standpoint, sleep isn’t optional; it’s foundational. Dr. Kim: Delay caffeine (but not too late), avoid alcohol, and focus on behavioral strategies (put away your phone 1 hour before bedtime).  Dr. Carlisle: And sleep is the foundation of performance. If sleep is off, everything else is compensating. Dr. Kim: And even beyond cognition, even one night of poor sleep can impair immune function and shift hormones that regulate hunger, which is why people tend to crave more food when they’re sleep deprived. Dr. Arreaza: I think it’s wise to dispel the myth of the “Russian Sleep Experiment”, have you heard about it? Dr. Carlile-Dr Kim: [reaction] Dr. Arreaza: The “Russian Sleep Experiment” is an internet horror story claiming Soviet scientists kept prisoners awake for several weeks using a gas. They developed extreme paranoia, violence, and self-mutilation. Then, the experiment got out of control, the subjects became unrecognizable, they refused to sleep, continued to deteriorate, and went insane. Even though the story went viral in 2010, it is fictional (reaction), with no real evidence that it really happened. So, it is just a made-up horror story. But there are some real studies about sleep deprivation in humans.  Dr Kim: Yes, the most famous case was Randy Gardner (1964) who stayed awake for 11 days. He developed hallucinations, memory problems, and mood changes. He recovered after sleep (no permanent “madness”). Dr. Carlisle: Sure, but as I mentioned before, even one night without sleep significantly reduces performance and accuracy. Dr. Kim: Another myth we fall into is “catching up on sleep”. It is a myth! Sleep Architecture Dr. Arreaza: Sleeping is a state when you reset your brain and your energy, but what actually happens during sleep? Dr. Carlisle: Sleep cycles between non-REM and REM stages. Non-REM sleep, especially deep, slow-wave sleep, is where physical restoration happens. That’s when you get growth hormone release, tissue repair, and metabolic recovery. Dr. Kim: And one of the most fascinating things is what happens in the brain during that deep sleep. The space between brain cells actually expands, which allows cerebrospinal fluid to circulate and clear out metabolic waste. Dr. Carlisle: That’s the glymphatic system. And what’s interesting is that this clearance is most active during deep sleep (Stage 3, Delta waves). It clears neurotoxins like beta amyloid, which is one reason chronic sleep deprivation is linked to neurodegenerative diseases, such as Alzheimer’s disease.  Dr. Arreaza: So, your brain is basically cleaning itself while you sleep. The “glymphatic system” is relatively new. It was described in 2010, and it clears substances like beta-amyloid, which is linked to Alzheimer’s disease. Dr. Carlisle: Exactly. Then REM sleep is more focused on brain function. That’s where memory consolidation, emotional processing, and learning really happen. Dr. Kim: And REM sleep tends to occur more in the second half of the night. So, when people cut their sleep short, they lose a lot of that REM sleep, which affects mood, focus, and overall cognitive function. What Drives Sleep Dr. Arreaza: So, what actually makes us feel sleepy? Dr. Kim: There are two main processes. The first is the homeostatic drive, where adenosine builds up in the brain the longer you’re awake, creating sleep pressure.  Dr. Carlisle: And the second is your circadian rhythm, which is controlled by your brain’s internal clock and influenced mainly by light exposure. Dr. Arreaza: So, in summary, one process depends on how long you’ve been awake, and the other process depends on your body’s own timing.  Dr. Carlisle: Exactly. I think of it as pressure and timing. Adenosine builds pressure, and your circadian rhythm determines when that pressure gets released. Dr. Kim: And when those two systems are aligned, sleep happens naturally. When they’re out of sync, that’s when people start having issues.  Morning Routine Dr. Arreaza: Let’s talk about practical tips. The morning seems to be a key element in our sleep. What can we do in the mornings to help us sleep at night? Dr. Carlisle: Morning sunlight, without a doubt. Getting light exposure within the first 30 to 60 minutes of waking helps anchor your circadian rhythm. Dr. Kim: And outdoor light is much stronger than indoor light, even on cloudy days. Dr. Carlisle: The mechanism is that light activates specialized retinal cells that signal your brain’s clock. That sets the timing for cortisol release in the morning and melatonin release later at night. Dr. Kim: And it also increases dopamine early in the day, which helps with mood, motivation, and focus. Dr. Carlisle: So, you’re not just waking up; you’re setting up your entire day’s physiology. Caffeine and Hydration Dr. Arreaza: Light exposure; I like the idea. That’s why phototherapy works for any kind of depression, not only seasonal depression. What other suggestions can you give us about our morning routine?  Dr. Carlisle: Hydration first thing in the morning helps restore plasma volume and improve alertness since we’re mildly dehydrated overnight. Dr. Kim: It is also a good idea to add electrolytes to the water. And caffeine timing is huge. If you drink it right when you wake up, you’re interfering with your natural adenosine cycle. Dr. Carlisle: Exactly. Caffeine blocks adenosine receptors, but it doesn’t remove adenosine. So later in the day, when caffeine wears off, all that built-up adenosine hits at once, and that’s what causes the crash. And that’s why some people feel wired but still tired because the underlying sleep pressure is still there, just being masked by the caffeine.  Dr. Arreaza: So, what should people do instead? (I say people because I personally don’t drink coffee, and occasionally I drink caffeine) Dr. Kim: People should wait about 60 to 90 minutes before having caffeine.   Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References: 1. Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med 2000;57(10):649-655. 2. Xie L, Kang H, Xu Q, et al. Sleep drives metabolite clearance from the adult brain. Science. 2013;342(6156):373-377. 3. Walker MP. Why We Sleep: Unlocking the Power of Sleep and Dreams. Scribner; 2017. 4. McMorris T, Harris RC, Swain J, et al. Effect of creatine supplementation and sleep deprivation on cognitive performance. J Sports Sci. 2006;24(3):305-313. 5. Turner CE, Byblow WD, Gant N. Creatine supplementation enhances corticomotor excitability and cognitive performance during sleep deprivation. J Sleep Res. 2015;24(3):307-315. 6. Gordji-Nejad A, Matusch A, et al. Creatine supplementation and brain energy metabolism during sleep deprivation. Sci Rep. 2024;14:54249. 7.  Wienecke E, Nolden C, et al. Magnesium and sleep quality: systematic review. *Med Res Arch.2021. 8. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Dr. Arreaza: Hello, everyone, my name is Dr. Hector Arreaza, I am a family physician and an associate program director in the Clinica Sierra Vista – Rio Bravo Family Medicine Residency Program.  Today we’re discussing one of the most powerful predictors of health that many people rarely think about: geography. Where someone lives can influence everything from access to physicians and emergency care to chronic disease outcomes and life expectancy. Joining us today is Peyton, who will be taking a deeper look into the matter. Peyton, thank you for being here — can you start by introducing yourself, please? Peyton: Hello, thank you for having me. My name is Peyton, I am a 4th year medical student with Western Atlantic University, and I am from a very small town in South Dakota.  Dr. Arreaza: Peyton, you are on your last few days in your FM rotation, when are you graduation?  Peyton, you prepared this topic and it is great. When people hear the phrase “your ZIP code can determine your health,” what does that actually mean? Peyton: It basically means that where someone lives can significantly influence their health outcomes and even life expectancy. A person’s ZIP code can affect access to physicians, hospitals, transportation, emergency services, and preventative care. Arreaza: Talking about prevention. The American Heart Association agrees with you because Zip code is not part of the cardiovascular risk calculator called PREVENT. I invite everyone to take a look at this new calculator. I think a lot of people assume healthcare is equal as long as hospitals or clinics exist nearby, right? Peyton: Yes, patients may still struggle with overcrowded healthcare systems, which can lead to long wait times. In fact, a national physician appointment survey found that average wait times for new patient primary care appointments in major cities can exceed three weeks, with some cities reporting significantly longer delays depending on specialty access and provider availability. Dr. Arreaza: And when patients experience those kinds of delays, they may frequently switch between providers, which becomes much harder to establish consistent long-term care. Peyton: One of the biggest issues many patients face is continuity of care — having consistent follow-up with the same provider over time. Dr. Arreaza: And that continuity really matters in medicine, especially family medicine, it is one of our keywords: continuity of care. Peyton: Exactly. Preventative care and chronic disease management work best when patients have long-term relationships with healthcare providers. But in many underserved communities, patients may wait months for appointments, frequently change providers, or rely on emergency rooms instead of primary care clinics. Dr. Arreaza: And urgent care too. When care becomes fragmented, conditions like hypertension, diabetes, and chronic illnesses can become much harder to manage. Peyton: Exactly. Delayed screenings, missed follow-up appointments, and lack of preventative care often lead to patients presenting later with more advanced disease that could have been treated earlier. Dr. Arreaza: And urban communities may face some of the same challenges, but rural communities are at a different level of barriers to health care. Peyton: Absolutely. Rural communities often experience significant physician shortages. According to the Health Resources and Services Administration, over 100 million Americans live in primary care shortage areas, and nearly 65% of those shortage areas are located in rural regions. Peyton: I think one of the biggest solutions starts with strengthening primary care and investing more heavily in underserved communities, especially rural areas. Dr. Arreaza: And that includes increasing the number of physicians going into family medicine and primary care specialties.  Peyton: Here is an interesting fact: According to the Graham Center, Northeastern states receive high graduate medical education (GME) funding but produce relatively fewer primary care physicians. Northwestern states receive low GME funding but perform relatively better, producing slightly above the U.S. average (70.8 vs 69.8 primary care physicians per 100,000 people). However, even this remains far below Canada’s average of 119 primary care physicians per 100,000 people.  Right now, the United States is facing a growing physician shortage. According to the Association of American Medical Colleges, the country could face a shortage of up to 86,000 physicians by 2036, with primary care being one of the most affected areas. Arreaza: Another group that may help address the physician shortage is International Medical Graduates. We’ll cover this in more detail in a future episode, but it’s worth mentioning briefly here. We have highly trained physicians, including neurosurgeons, driving Uber. There is nothing wrong with that work, but their medical skills could be used to help more people. I’ll leave our listeners with that thought: IMGs can help. So, Peyton, are you interested in rural medicine? Peyton: I am very interested in Rural medicine, in fact my next few rotations will be back in South Dakota on the Pine Ridge Indian Reservation. Actually, the Pine Ridge Reservation is the poorest Indian Reservation in the country.  Peyton: The measure of any healthcare system is not how well it serves those closest to its centers of power, but how far its reach extends to those who need it most. If we are serious about health equity, the road forward must run through every small town, every county clinic, and every community that has been told to wait its turn. Their turn is now. References Association of American Medical Colleges (AAMC). The Complexities of Physician Supply and Demand: Projections From 2021 to 2036. https://www.aamc.org/workforce American Academy of Family Physicians (AAFP). Rural Practice and Physician Recruitment.https://www.aafp.org Centers for Disease Control and Prevention (CDC). Rural Americans at Higher Risk of Death from Five Leading Causes.https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html Cecil G. Sheps Center for Health Services Research. Rural Hospital Closures.https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/ Chetty R, Stepner M, Abraham S, et al. The Association Between Income and Life Expectancy in the United States, 2001–2014. JAMA. 2016;315(16):1750–1766. https://jamanetwork.com/journals/jama/fullarticle/2513561 Health Resources & Services Administration (HRSA). Health Professional Shortage Areas (HPSAs).https://data.hrsa.gov/topics/health-workforce/shortage-areas Rural Health Information Hub. Healthcare Access in Rural Communities.https://www.ruralhealthinfo.org/topics/healthcare-access Rural Health Information Hub. Transportation to Support Rural Healthcare.https://www.ruralhealthinfo.org/topics/transportation Rural Health Information Hub. Rural Residency Planning and Development. https://www.ruralhealthinfo.org/topics/rural-residency-programs Centers for Disease Control and Prevention (CDC). Health and Access to Care in Rural America.https://www.cdc.gov/ruralhealth/index.html Measure of America. A Portrait of Los Angeles County 2026. Social Science Research Council.https://ssrc-static.s3.amazonaws.com/moa/APortraitofLosAngelesCounty2026.pdf Merritt Hawkins. Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates.https://www.merritthawkins.com/news-and-insights/thought-leadership/survey/survey-of-physician-appointment-wait-times/ Fenster, T. L., MD, Park, J., PhD, Huffstetler, A. N., MD, & Topmiller, M., PhD (2026). Graduate Medical Education Funding Does Not Flow to Primary Care Physician Production. American family physician, 113(4), 321–322. https://pubmed.ncbi.nlm.nih.gov/42101593/ Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 224: Community Health Workers Dr. Arreaza: Today we will discuss a topic that, frankly, every single person listening, whether you're a medical student, a resident, a nurse, a family doctor, or any primary care provider, needs to really understand. We're talking about community health workers (CHWs). We are joined by our stellar medical student; you may be familiar with her voice from previous episodes about insomnia. Moira, welcome, please introduce yourself.  Moira: I want to be upfront about why Community Health Workers matter to you specifically. If you've ever felt frustrated that your patient with uncontrolled diabetes keeps missing appointments because they can't get a ride, or that your heart failure patient was readmitted because nobody checked whether they could afford their medications, then you already understand the problem that CHWs are designed to solve. Dr. Arreaza: We're going to give you the definition of a CHW, the evidence behind their effectiveness, how they fit into your care team, the return on investment, and practical steps for integrating them into your practice. We have pulled information from a lot of peer-reviewed sources, and we want to share them with you. So, Moira, let's start with the basics. What exactly is a community health worker? Moira: Great question, and it's one that even literature struggles with, because there are so many titles for this role. Community Health Worker is an umbrella term that encompasses more than 20 different titles including outreach workers, promotores or promotoras de salud, community health representatives, lay health workers, peer educators, patient navigators, and many more. The American Public Health Association defines CHWs as frontline public health workers who are trusted members of or have an unusually close understanding of the communities they serve. Arreaza: And that trust is so important in health care. CHWs are not physicians. They are not nurses. They do not diagnose or prescribe. But they are like a bridge connecting the medical environment, social services, and the community to reduce gaps in healthcare delivery.  Moira: Exactly. In the United States, the role was formally recognized in the 2010 Patient Protection and Affordable Care Act, which includes several sections highlighting the key roles CHWs play in achieving important goals of healthcare. ________________ References:  Aguerrebere, M., Rodríguez-Cuevas, F. G., Flores, H., Arrieta, J., & Raviola, G. (2019). Providing Mental Health Care in Primary Care Centers in LMICs. Innovations in Global Mental Health, 1–22. https://doi.org/10.1007/978-3-319-70134-9_95-1 Allen, L. N., Rasanathan, K., Mash, R., Uribe, M. V., Martinez-Bianchi, V., & Kidd, M. (2025). Models of Global Primary Care Post-2030. The Lancet Primary Care, 1(3), 100027. https://doi.org/10.1016/j.lanprc.2025.100027 Babagoli, M. A., Nieto-Martínez, R., González-Rivas, J. P., Sivaramakrishnan, K., & Mechanick, J. I. (2021). Roles for Community Health Workers in Diabetes Prevention and Management in Low- And Middle-Income Countries. Cadernos De Saúde Pública, 37(10). https://doi.org/10.1590/0102-311x00287120 Balasubramanya, B., Isaac, R., Philip, S., Prashanth, H. R., Abraham, P., Poobalan, A., Thomas, N., Jeyaseelan, L., Mammen, J., Devarasetty, P., & John, O. (2020). Task Shifting to Frontline Community Health Workers for Improved Diabetes Care in Low-Resource Settings in India: A Phase II Non-Randomized Controlled Clinical Trial. Journal of Global Health Reports, 4. https://doi.org/10.29392/001c.17609 Battaglia, T. A., Zhang, X., Dwyer, A. J., Rush, C. H., & Paskett, E. D. (2022). Change Agents in the Oncology Workforce: Let’s Be Clear About Community Health Workers and Patient Navigators. Cancer, 128(S13), 2664–2668. https://doi.org/10.1002/cncr.34194 Das, S., Grant, L., & Fernandes, G. (2023). Task Shifting Healthcare Services in the Post-Covid World: A Scoping Review. PLOS Global Public Health, 3(12), e0001712. https://doi.org/10.1371/journal.pgph.0001712 Dodd, R., Palagyi, A., Jan, S., Abdel-All, M., Nambiar, D., Madhira, P., Balane, C., Tian, M., Joshi, R., Abimbola, S., & Peiris, D. (2019). Organisation of Primary Health Care Systems in Low- And Middle-Income Countries: Review of Evidence on What Works and Why in the Asia-Pacific Region. BMJ Global Health, 4(Suppl 8), e001487. https://doi.org/10.1136/bmjgh-2019-001487 Huang, W., Long, H., Li, J., Tao, S., Zheng, P., Tang, S., & Abdullah, A. S. (2018). Delivery of Public Health Services by Community Health Workers (CHWs) in Primary Health Care Settings in China: A Systematic Review (1996–2016). Global Health Research and Policy, 3(1). https://doi.org/10.1186/s41256-018-0072-0 McCray, G. G., Haynes, B., Proeller, A., Ervin, C., & Williams-Livingston, A. (2020). Making the Case for Community Health Workers in Georgia. Journal of the Georgia Public Health Association, 8(1). https://doi.org/10.20429/jgpha.2020.080116 Mor, N., Ananth, B., Ambalam, V., Edassery, A., Meher, A., Tiwari, P., Sonawane, V., Mahajani, A., Mathur, K., Parekh, A., & Dharmaraju, R. (2023). Evolution of Community Health Workers: The Fourth Stage. Frontiers in Public Health, 11. https://doi.org/10.3389/fpubh.2023.1209673 Noel, L., Chen, Q., Petruzzi, L. J., Phillips, F., Garay, R., Valdez, C., Aranda, M. P., & Jones, B. (2022). Interprofessional Collaboration Between Social Workers and Community Health Workers to Address Health and Mental Health in the United States: A Systematised Review. Health &Amp; Social Care in the Community, 30(6). https://doi.org/10.1111/hsc.14061 None, N. (2022). Walking the Talk: Reimagining Primary Health Care After COVID-19. https://doi.org/10.1596/978-1-4648-1768-7 Orkin, A. M., McArthur, A., Venugopal, J., Kithulegoda, N., Martiniuk, A., Buchman, D. Z., Kouyoumdjian, F., Rachlis, B., Strike, C., & Upshur, R. (2019). Defining and Measuring Health Equity in Research on Task Shifting in High-Income Countries: A Systematic Review. SSM - Population Health, 7, 100366. https://doi.org/10.1016/j.ssmph.2019.100366 Pingel, E. S. (2022). Seeing Inside: How Stigma and Recognition Shape Community Health Worker Home Visits in São Paulo, Brazil. Community Health Equity Research &Amp; Policy, 44(3), 303–313. https://doi.org/10.1177/2752535x221137384 Rifkin, S. B., Fort, M., Patcharanarumol, W., & Tangcharoensathien, V. (2021). Primary Healthcare in the Time of COVID-19: Breaking the Silos of Healthcare Provision. BMJ Global Health, 6(11), e007721. https://doi.org/10.1136/bmjgh-2021-007721 Rohan, E. A., Townsend, J. S., Bermudez, A. T., Thompson, H. L., Holman, D. M., Reza, A., Tharpe, F. S., & Wennerstrom, A. (2024). Engaging Community Health Workers in Primary Care Practices. Journal of Ambulatory Care Management, 47(3), 154–167. https://doi.org/10.1097/jac.0000000000000501 Shommu, N. S., Ahmed, S., Rumana, N., Barron, G. R. S., McBrien, K. A., & Turin, T. C. (2016). What Is the Scope of Improving Immigrant and Ethnic Minority Healthcare Using Community Navigators: A Systematic Scoping Review. International Journal for Equity in Health, 15(1). https://doi.org/10.1186/s12939-016-0298-8 Sisson, N., & Starke, J. (2022). Promotores De Salud in Montana: An Analysis of a Rural Health Care Intervention Rooted in Catholic Social Teaching and Its Place in Medical Curricula. The Linacre Quarterly, 89(1), 21–35. https://doi.org/10.1177/00243639211059346 The Role and Impact of Female Health Workers on the Well-Being of Global South Communities: A Call for Gender-Transformative Action. (2022). Archives of Women Health and Care, 5(2). https://doi.org/10.31038/awhc.2022521 Williams-Livingston, A., Henry Akintobi, T., & Banerjee, A. (2020). Community-Based Participatory Research in Action: The Patient-Centered Medical Home and Neighborhood. Journal of Primary Care &Amp; Community Health, 11. https://doi.org/10.1177/2150132720968456 Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.   Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 223: Oncogenic Viruses Introduction Mehr: Hi everyone, welcome back to the Rio Bravo qweek podcast. Back by popular demand is Me, Mehr Boparai a third-year medical student at COMP-NW. Here with me is Jeremy Pan from COMP who is also a third-year medical student. How are you doing Jeremy? Jeremy: I’m doing great Mehr.Thanks for the kind intro; we had a fun time this morning doing street medicine and had some practice giving Toradol injections and wound dressings. So excited to be back for another podcast episode this afternoon! Mehr: This week, we are moving away from bacteria and antibiotics and diving deeper into cancer-causing viruses. Jeremy: Yes, and if you are interested at all in public health, this is one of those areas where medicine overlaps with public health in a really tangible way. I think one of the most underappreciated aspects of this topic is that we have vaccines that can prevent many of these cancers. If you told someone 50 years ago we’d be vaccinating against cancer, they probably wouldn’t believe you! It’s amazing to see how far medicine has come. How viruses cause cancer: Jeremy: Before jumping into specific viruses, I always think having a mechanism-based framework makes everything stick better. Mehr: Right, because they don’t all cause cancer the same way. Medicine can never be easy huh? Jeremy: Yea…this career really is just a lifetime of discovery. So just to start, in broad terms, we can think of three main buckets of how viruses can cause cancer: Direct oncogenesis where viral proteins interfere with tumor suppressors like P53 and Rb. We will go over their specific mechanisms a little later in the discussion. Mehr:  Chronic inflammation where viruses cause repeated injury through production of reactive oxygen species. They also increase the chance of mutation through repeated DNA replication, leading to cancer.  Jeremy: Immune evasion or suppression leads to decreased tumor surveillance. What this means essentially is that our immune system is constantly removing abnormal cells before they become cancerous. This is completed by CD8 T cells and natural killer, or NK, cells. CD8 T cells recognize abnormal peptides presented on Major Histocompatibility Complex, or MHC, class I molecules and induce apoptosis in those cells. Mehr: And NK cells step in when cells decide to stop expressing MHC I, which abnormal cells like to hide to avoid being caught. So just to reiterate, there are two layers to dissect here: if a cell looks suspicious with an abnormal MHC, CD8 T-cells kill them. If the abnormal cell decides to hide its MHC, then the NK cell will kill it instead. Jeremy: So, for the final big picture, we can think of oncogenic viruses as either disabling tumor suppression, causing chronic damage over time through inflammation, and weakening the immune system’s ability to catch cancer in time before it develops. HPV Mehr: Let’s start with one of the most common viruses afflicting our population – Human Papilloma Virus otherwise known as HPV.  Jeremy: Right, this notorious virus is probably the most clinically impactful oncogenic virus. The key players HPV utilizes are proteins E6 and E7. Mehr: Right! E6 binds to and inhibits p53, which normally acts to induce cell cycle arrest, and E7 inhibits Rb, which normally acts as a tumor suppressor gene that inhibits the G1 to S phase transition in a normal cell cycle. Jeremy: So essentially, we are losing both apoptosis and losing cell cycle control at the same time. What is interesting about HPV is that persistent infection, not just exposure to the virus, is what drives cancer risk.  Mehr: Exactly, most HPV infections clear on their own, but the ones that persist are the problem. Clinically, many end up being asymptomatic. However, for high-risk infections, we can see genital warts that can itch, feel tender, or cause abnormal vaginal bleeding and discharge. Patients are sometimes not able to have a vaginal delivery because of the warts that are present along their genital tract. We can also see warts on the hands and fingers or plantar surface of our feet. Jeremy: Another interesting point is that we are also seeing a shift where there are more cases of oropharyngeal cancers in younger, non-smoking patients. This is why if we see an abnormal neck lymph node or persistent sore throat after swallowing in a young patient, HPV should definitely be on the differential.  Mehr: Screening is very important as well! We typically discover high-risk HPV infections through routine Pap smears and other HPV specific tests through DNA PCR and RNA tests. We also encourage vaccination for effective prevention of both genital warts and high-risk HPV-related cancers. There was also a study in Scotland where there were zero cases of HPV in adults who received the vaccine between 12-13 years of age! Which is crazy!  EBV HBV & HCV Mehr: Now let’s shift to viruses that affect the liver, Hepatitis B virus and Hepatitis C virus. Jeremy: Both are strongly associated with hepatocellular carcinoma, but they actually get there in slightlydifferent ways. Mehr: Right. Hepatitis B is a DNA virus that can integrate directly into the host genome, which can disrupttumor suppressor genes and promote oncogenesis. Jeremy: Whereas Hepatitis C is an RNA virus, so it doesn’t integrate into the host genome. Instead, it causes chronic inflammation Over time, that leads to repeated cycles of hepatocyte injury and regeneration, along withoxidative stress from reactive oxygen species, which increases the risk of DNA mutations. Mehr: One really important clinical pearl is that Hep B can actually cause hepatocellular carcinoma evenwithout cirrhosis. Whereas with Hep C, the pathway is usually chronic inflammation → fibrosis → cirrhosis → dysplasia→ cancer.  Jeremy: So, screening becomes really important for both of these viruses. For high-risk patients—like those with chronic hepatitis or cirrhosis—we typically dosurveillance with liver ultrasound every 6 months, sometimes with alpha-fetoprotein levels to see if it is elevated. Mehr: From a prevention standpoint, the Hep B vaccine is a huge win. It significantly reduces the risk ofhepatocellular carcinoma. For Hep C, we don’t have a vaccine, but direct-acting antivirals can actually cure the infection andreduce long-term cancer risk, which is why we screen between ages 18-79  nowadays. Global Hep B and C account for 65% of all HCC cases! So, it makes sense that primary care itself is increasing the treatment of Hep C cases as well since it is easier to prescribe and that you want to be treated ASAP.  Jeremy: Yea, the ability to treat Hep C is so beneficial to population health. Now let’s say you have a patient who develops hepatocellular carcinoma, options can include surgicalresection, liver transplantation, local therapies, or systemic treatments depending on stage.  Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!  __________________________________ References: Barry H. C. (2024). Scottish Screening: No Cases of Invasive Cervical Cancer in Women Who Received at Least One Dose of Bivalent HPV Vaccine at 12 or 13 Years of Age. American family physician, 110(2), 201–202. https://pubmed.ncbi.nlm.nih.gov/39172683/ Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Arreaza: Welcome back tothe Rio Bravo qWeek Podcast! My name is Dr. Hector Arreaza, I am a family physician and faculty member in the Rio Bravo Family Medicine Residency Program. Today I am joined by two excellent medical students who will introduce themselves now, welcome, guys! Mehr: Thank you for the introduction! My name is Mehr Boparai, third year medical student at WesternU COMP-NW. Jeremy: And my name is Jeremy Pan, also a third-year medical student at WesternU COMP Pomona and we will be discussing a very prevalent topic today in the clinical world that is arguably becoming one of the biggest threats to modern medicine: antibiotic resistance. Mehr: That’s right! Imagine this scenario: a routine infection, something we’ve treated easily for decades, suddenly becomes life-threatening because the drugs we always thought we could rely on just don’t work anymore. You likely ran into this problem just last week with one of your patients! That’s not science fiction. That’s happening every day in hospitals across the world. Dr. Arreaza: I agree, antibiotic resistance must be taken seriously. I increased my awareness in 2023, when I attended a medical research conference in Carmel(which is a popular conference that takes place in that beautiful town). I heard Dr. David Gilbert, a famous and accomplished ID doctor who helped develop the Sanford Guide to Antimicrobial Therapy, he warned everyone about antibiotic resistance as one of the biggest threats for humanity, the other two were a nuclear bomb and an epidemic. Jeremy: Woah, comparing antibiotic resistance to a nuclear bomb is absolutely crazy, but likely very real!! Well today, we’re going to be focusing on five of the most common infections or “bugs” you’ll see in a hospital setting. We’ll talk about what typically causes them, what antibiotics we used to rely on, and what happens when resistance decides to enter the picture. Mehr: If you are a medical student (or resident), you understand that dreaded feeling when an attending asks “what antibiotics should we start?” But don’t worry, in this episode, we hope to address the decision-making process in a simple framework. What is Antibiotic Resistance? Dr. Arreaza:  Before we jump into specific common infections and pathogens, let’s cover our basics. Antibiotic resistance occurs when bacteria evolve to survive drugs designed to kill them. This can happen through genetic mutations or by getting resistance genes from other bacteria. Why does this matter? Jeremy: It matters because antibiotics play a huge role in modern medicine. Without them, surgeries, chemotherapy, organ transplants—even childbirth—become significantly more dangerous. Mehr: According to the CDC, in the U.S. alone, antibiotic-resistant infections affect over 2.8 million people each year and cause more than 35,000 deaths! So, when we talk about resistance, we’re not just talking about inconvenience for treatments. We’re talking about a fundamental threat to healthcare. Staph aureus Dr. Arreaza: So, if you have a patient who comes in with a skin infection or is maybe showing signs of pneumonia or bacteremia, what is one of the most common bugs that you should think about? Jeremy: Staph aureus! Typically to treat methicillin-sensitive strains (MSSA), we would utilize antibiotics like nafcillin, oxacillin, or cefazolin. But there is one strain in particular that is worrisome, Mehr? Mehr: yeap, that would have to be MRSA, one of the most well-known resistant organisms. MRSA is resistant to all beta-lactam antibiotics, which means we can say goodbye to all penicillin and most cephalosporins. Dr. Arreaza: And what is the first antibiotic that comes to mind if we see MRSA on a culture in the hospital? Mehr: Vancomycin! Alternative treatments include linezolid and daptomycin depending on the type of infection. But what is the problem that we are starting to see? Jeremy: You guessed it, cases of resistance to vancomycin are starting to appear—VRSA. These cases are still uncommon today, but these findings show a worrying trend, that we will eventually start running out of reliable options. Dr. Arreaza: Fortunately, VRSA infections are extremely rare, with only 14-16 documented cases in the United States. As of 2019, 52 VRSA strains have been identified in the United States, India, Iran, Pakistan, Brazil, and Portugal. Let’s keep an eye on VRSA in the future.  E. coli Dr. Arreaza: Alright, so let’s say you have a patient with dysuria, urinary frequency, maybe even a catheter in place. What’s the most common bug you’re thinking of? Mehr: That one’s a classic, we are thinking E. coli. Jeremy: Exactly. E. coli is the leading cause of urinary tract infections, especially in both community and hospital settings. Dr. Arreaza: So Jeremy, what are we using for uncomplicated UTIs? Jeremy: We usually think of trimethoprim-sulfamethoxazole, nitrofurantoin, or sometimes fosfomycin. And in more complicated cases, we might consider fluoroquinolones like ciprofloxacin. Mehr: But here’s where things get tricky. Resistance to TMP-SMX and fluoroquinolones has been increasing significantly. In some areas, resistance rates are over 20–30%, which really changes your empiric choices. Conclusion: Dr. Arreaza: So we’ve talked about five major organisms today: Staph aureus, E. coli, Klebsiella, Pseudomonas, and C. diff. What’s the overarching takeaway of the discussion? Jeremy: The main takeway is that antibiotic resistance is already here, and it’s affecting some of the most common infections we see in clinical practice on a day-to-day basis. Mehr: And as students and future physicians, it’s important to not just memorize antibiotics, but understand why we’re choosing them. Dr. Arreaza: Exactly. Always think: What organism am I targeting? What are the local resistance patterns? And can I narrow therapy once I have cultures? Jeremy: And maybe most importantly—don’t overuse antibiotics, especially in cases when they’re not needed. Mehr: Because the more we use them, the faster we lose them. Dr. Arreaza: I’d like to share the story I listed to in a RadioLab episode about Dr Steffanie A. Strathdee, one of the most influential ID doctors in the world and Co-Director at the Center for Innovative Phage Applications and Therapeutics (IPATH). She shared that her husband got infected by Acinetobacter baumannii, an opportunistic infection that can cause severe infection. After trying many antibiotics, he was treated with “phages”, “bacteriophages”. So, that’s part of “thinking out of the box”. Jeremy: Thank you all for tuning in to the Rio Bravo qWeek podcast series and thank you Dr. Arreaza for having Mehr and me on the podcast today! Stay informed, stay curious—and we’ll see you next time Mehr: Guys! I had so much fun! We hope this episode helped simplify antibiotic selection for the most common infections and bugs seen in a hospital setting and gave you a framework you can for initial treatments and cases of antibiotic resistance. Thanks for hanging out with us!  Dr. Arreaza: And remember, antibiotics are one of the most powerful tools we have in medicine. Let’s use them wisely. This is Dr. Arreaza, signing off.  _____________________ References: Radiolab. (2026, March 27). Antibiotic apocalypse. WNYC Studios. https://radiolab.org/podcast/antibiotic-apocalypse Metlay, J. P., Waterer, G. W., Long, A. C., et al. (2019). Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200(7), e45–e67. https://www.idsociety.org/practice-guideline/community-acquired-pneumonia-cap-in-adults/ Gilbert, D. N., Chambers, H. F., Saag, M. S., et al. (2026). The Sanford Guide to Antimicrobial Therapy (56th ed.). Antimicrobial Therapy, Inc. Centers for Disease Control and Prevention. (2025, September 17). Antibiotic stewardship resource bundles. https://www.cdc.gov/antibiotic-use/hcp/educational-resources/stewardship/index.html Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.   Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

ARREAZA: Today we will expand on other treatments for insomnia in adults. MOIRA: Yes, we spent some time explaining the assessment of insomnia and the first-line treatment, Cognitive Behavioral Therapy for Insomnia (CBT-I). We also mentioned sleep hygiene. You can listen to episode 220 if you want to learn more about that. Medication should be considered a secondary option. The American College of Physicians (ACP) recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add medication in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful.  In general, pharmacotherapy is associated with risks of dependence, tolerance, and poorer quality sleep, whereas evidence-based psychotherapies, like CBT-I, result in better long-term outcomes, no drug dependence or polypharmacy risk, and potential cost savings. ARREAZA: Yes, we will start this episode by talking about medications. If you practice primary care, I’m 100% sure that a patient has asked you for “sleeping pills” in clinic. Moira, I know our listeners want to hear about meds. What can you tell about meds to treat insomnia? Moira:We can really split pharmacotherapy for sleep into two categories, OTC, and prescription. And many folks reach for OTC sleep aids before talking to a clinician. When we say OTC sleep aids, we’re mostly talking about sedating antihistamines, like diphenhydramine and doxylamine, which are common in products marketed for occasional sleep difficulties. Melatonin is often marketed as a supplement rather than a drug, but it’s also widely used OTC in many places, though regulations and quality vary by country. ARREAZA: Exactly. Several studies describe widespread use of these agents among adults and especially older adults, who may face sleep problems related to comorbidities and polypharmacy. Many older adults use OTC sleep aids, often without consulting a healthcare professional or reading labels carefully. Moira: And there’s evidence that a substantial share of OTC sleep products contains diphenhydramine or doxylamine—first-gen antihistamines that carry anticholinergic burden, which is particularly relevant for older adults. Melatonin’s story is similarly mixed for efficacy. It can modestly affect sleep onset and duration in some populations, especially older adults or circadian rhythm–related sleep problems, but the overall clinical impact is small. What about on the prescription side? DR. ARREAZA: “Z-drugs” are nonbenzodiazepine sedative-hypnotics that enhance the effects of GABA (neurotransmitter). For example, Zolpidem, Zaleplon, eszopiclone. The risks of benzodiazepine use are significant.Benzodiazepine use is associated with increased fall risk across all age groups, and older adults are the highest risk group. That’s something we should mention to patients who are requesting a “sleeping pill”, “you may sleep a little better, but you may fall.” A meta-analysis of randomized trials in adults over 60 found that benzodiazepines (vs placebo) caused: 2.6× more psychomotor problems (like falls and car accidents), 3.8× more daytime sleepiness, 4.8× more cognitive impairment. Also, benzodiazepine use is associated with a 34% increased risk of hip fractures (RR 1.34) in older adults. MOIRA: Very significant. Benzodiazepine use is only recommended for four weeks or less due to unproven long-term efficacy and the risk of tolerance, dependence, and misuse. Psychological and physical dependence on benzodiazepines can develop within a few weeks of regular or repeated use. Long-term use is associated with multiple consequences, including dependence, and even increased risk of opioid use.  Dr ARREAZA: And the withdrawal symptoms are very uncomfortable for benzo dependent patients who try to stop benzos on their own. MOIRA: And with the Z-drugs you were mentioning, the FDA has required that all Z-drugs carry a Boxed Warning highlighting the risk of complex sleep behaviors such as sleepwalking and sleep-driving, which can result in serious injuries including death. Medications such as benzodiazepines and antidepressants should be avoided for the treatment of insomnia in older adults whenever possible. DR ARREAZA: There are other prescription options too. Let’s talk about low-dose doxepin has shown to have one of the best balances between efficacy and tolerability. When I hear “doxepin” the word “old” comes to my mind. And, yes, it was approved in 1969, it is a tricyclic antidepressant used to treat depression, anxiety, and insomnia. The recommended dose for insomnia is between 3-6 mg. It is not free of side effects, but lower doses seem to be better tolerated. Complex behaviors associated with doxepin: Doxepin may cause out of bed while not being fully awake and do an activity that you do not know you are doing. The next morning, you may not remember that you did anything during the night. You have a higher chance of doing these activities if you drink alcohol or take other medicines that make you sleepy with this medicine. Reported activities include: "sleep-driving", cooking and eating food, talking on the phone, having sex, or sleepwalking. Moira: Another group of medications is dual orexin receptor antagonists (DORAs) such as lemborexant are considered medications with good balance of efficacy and tolerability. No single medication is considered the "best" for all patients. Let’s remember that optimal medication depends on patient age, comorbidities, safety considerations, and the type of insomnia (sleep onset vs. maintenance.) MOIRA: Older adults deserve special attention. Although insomnia is not a normal part of the aging process, we do see its prevalence increases with age. CBT-I is effective in older adults and is associated with minimal side effects. We can’t talk about sleep meds and older adults without mentioning BEERS criteria, which is a guideline which aims to reduce adverse drug events and polypharmacy by highlighting drugs with risks outweighing benefits, urging safer alternative. In sleep medicine and insomnia management for older adults, Beers Criteria explicitly flag sedating antihistamines (e.g., diphenhydramine, doxylamine) as potentially inappropriate for elderly patients due to anticholinergic burden and adverse effects such as delirium, cognitive impairment, sedation, and falls risk. MOIRA: Yes! So again, I want to highlight that the first line treatment should always be CBT-I, but when this isn't working or isn't an option, then think about adding pharmacotherapy. We should really be sharing that OTC options should only be for occasional sleep trouble, not chronic insomnia. Also, be mindful of age-related risks. And consider melatonin with caveats, melatonin may be an option with generally small sleep-onset effects but again, short-term use and quality matters. To close, OTC sleep aids fill a real need for short-term relief, but they’re not a substitute for diagnosis and evidence-based treatment of insomnia, especially in older adults where safety is a particular concern. And our prescription options like benzos, z drugs, antidepressants, aren’t much better. DR. ARREAZA: Primum non nocere (“first, do no harm”) is a chief consideration in insomnia management. Sleep is foundational to health, and I hope this helps our colleagues feel more confident in addressing it.If you found this helpful, share it with a friend or colleague and rate us wherever you listen to us. This is Dr. Arreaza, signing off. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References: Morin, C. M., & Buysse, D. J. (2024). Management of Insomnia. The New England journal of medicine, 391(3), 247–258. https://doi.org/10.1056/NEJMcp2305655 Healy, W. J., Khayat, R. N., & Kwon, Y. (2024). Insomnia: Advancements and Limitations of Current Management Strategies. American family physician, 109(2), 107–108. https://pubmed.ncbi.nlm.nih.gov/38393789/ Drugs.com. (2025, August 6). Doxepin. Retrieved April 15, 2026, from https://www.drugs.com/doxepin.html Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 220: Approach of Insomnia in Adults     ARREAZA: Today we are going to talk about how to approach sleep issues in adults — from the initial assessment all the way through treatment. And I think what is going to surprise a lot of our listeners is the changes in management in recent years, especially what is recommended as first-line therapy. So, let's jump right in. MOIRA: Sleep is one of those topics that touches every specialty, but Primary Care in particular, so I'm excited to dig into this. ARREAZA: Let's start with the big picture–statistics. How common are sleep problems in adults? MOIRA: Incredibly common. Chronic insomnia affects roughly 10% of the general population, and that number has only grown in recent years . During the COVID-19 pandemic, for instance, prevalence rates of insomnia symptoms were reported globally at 20 to 45% (wow). And, importantly, those sleep problems did not simply resolve once infection rates dropped, insomnia symptoms and fatigue have continued even as mood improves in people recovering from COVID-19 infection.  ARREAZA: Incredible that we are in 2026 and still talking about COVID-19. And we clinicians need to understand that insomnia isn't just an annoyance. It has long-term consequences. Also, financially, insomnia causes direct and indirect costs of up to $100 billion each year. MOIRA: Exactly. Insomnia is both a risk factor for, and a symptom of, several psychiatric disorders, and it is a predictor of death by suicide, making it an important target for intervention. It's highly comorbid with medical and psychiatric disorders and is associated with significantly increased healthcare utilization and costs. People with insomnia also perform more poorly on complex cognitive tasks. So, we're talking about a condition that affects cognition, mental health, physical health, and quality of life. ARREAZA: And yet, it still gets overlooked in many clinical encounters. Let’s be honest, dealing with insomnia is not easy on patients… and doctors! MOIRA: That's the paradox. Primary care practitioners are often poorly informed about sleep disorders, which remain underdiagnosed and sub-optimally managed. In one Italian epidemiological survey, insomnia was reported by 64% of over 3,000 patients interviewed under general practitioners, with 20% reporting both nighttime and daytime symptoms. So, the patients are there, we're just not always asking the right questions or knowing what to do when they tell us about their sleep. ARREAZA: Great. Let's talk about assessment. In my experience, we need a full encounter to address sleeping issues. Patients tend to mention insomnia as you start walking out of the room. Let’s say a patient tells us, "Doctor, I can't sleep," how de we approach this? MOIRA: The first step is a comprehensive sleep and health history. Clinical assessment should describe the sleep disturbance and elicit etiological and exacerbating factors. You want to understand the nature of the complaint; is it difficulty to fall asleep, difficulty staying asleep, early morning awakening, or some combination? How long has it been going on? What's the impact on daytime functioning? ARREAZA: That’s why I think it should be addressed in a full encounter, if possible, because understanding the full extent of the problem requires time. We need to think about contributing factors too. MOIRA: Absolutely. Factors such as medications, medical disorders, and psychiatric disorders can all increase the risk for insomnia. You need to screen for comorbid conditions, depression, anxiety, PTSD, and chronic pain. Insomnia is actually both a risk factor for and a symptom of several psychiatric disorders. You also want to rule out other primary sleep disorders. Comorbid insomnia and sleep apnea, for example, is highly prevalent and debilitating. If someone has both insomnia and obstructive sleep apnea, treating only one without addressing the other may lead to suboptimal outcomes. ARREAZA: Now that you mention comorbid conditions, let’s mention nocturia. I feel like it’s very common with my older patients. MOIRA: Great point. Nocturia (waking from sleep at night to void) and chronic insomnia frequently co-exist in older adults, contributing synergistically to sleep disturbance. Treatments typically target either nocturia or insomnia rather than simultaneously addressing the shared mechanisms for these disorders. There's emerging work on integrated cognitive-behavioral treatment programs that address both conditions simultaneously, which is a promising direction. But at minimum, you should be asking about it, because if nocturia is driving the awakenings, you need to address that as part of the treatment plan. _____________________ References: Baglioni, C., Altena, E., Bjorvatn, B., Blom, K., Bothelius, K., Devoto, A., … & Riemann, D. (2019). The European Academy for Cognitive Behavioural Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment. Journal of Sleep Research, 29(2). https://doi.org/10.1111/jsr.12967 Becker, P. (2022). Overview of sleep management during COVID-19. Sleep Medicine, 91, 211-218. https://doi.org/10.1016/j.sleep.2021.04.024 Bramoweth, A., Germain, A., Youk, A., Rodriguez, K., & Chinman, M. (2018). A hybrid type I trial to increase Veterans’ access to insomnia care: study protocol for a randomized controlled trial. Trials, 19(1). https://doi.org/10.1186/s13063-017-2437-y Brewster, G., Riegel, B., & Gehrman, P. (2018). Insomnia in the Older Adult. Sleep Medicine Clinics, 13(1), 13-19. https://doi.org/10.1016/j.jsmc.2017.09.002 Conroy, D. and Ebben, M. (2015). Referral Practices for Cognitive Behavioral Therapy for Insomnia: A Survey Study. Behavioural Neurology, 2015, 1-4. https://doi.org/10.1155/2015/819402 Dzierzewski, J., Griffin, S., Ravyts, S., & Rybarczyk, B. (2018). Psychological Interventions for Late-Life Insomnia: Current and Emerging Science. Current Sleep Medicine Reports, 4(4), 268-277. https://doi.org/10.1007/s40675-018-0129-0 Fung, C., Huang, A., Markland, A., Schembri, M., Martin, J., Bliwise, D., … & Vaughan, C. (2024). A multisite feasibility study of integrated cognitive‐behavioral treatment for co‐existing nocturia and chronic insomnia. Journal of the American Geriatrics Society, 73(2), 558-565. https://doi.org/10.1111/jgs.19214 Gardner, D., Turner, J., Magalhaes, S., Rajda, M., & Murphy, A. (2024). Patient Self-Guided Interventions to Reduce Sedative Use and Improve Sleep. Jama Psychiatry, 81(12), 1187. https://doi.org/10.1001/jamapsychiatry.2024.2731 Garland, S., Vargas, I., Grandner, M., & Perlis, M. (2018). Treating insomnia in patients with comorbid psychiatric disorders: A focused review. Canadian Psychology/Psychologie Canadienne, 59(2), 176-186. https://doi.org/10.1037/cap0000141 Germain, A., Wolfson, M., Brock, M., O’Reilly, B., Hearn, H., Knowles, S., … & Wallace, M. (2023). Digital CBTI hubs as a treatment augmentation strategy in military clinics: study protocol for a pragmatic randomized clinical trial. Trials, 24(1). https://doi.org/10.1186/s13063-023-07686-2 Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Shivam: My name is Shivam Patel and I’m currently a 3rd year medical student from Western university and today we will be discussing Chronic Pain After Cancer with an emphasis on Improving functionality in cancer survivors and how it overlaps with musculoskeletal dysfunction. We will also talk about the management of pain in outpatient settings as well as the role acute rehab units can play in recovery. Arreaza: Before getting into specific considerations, let’s start with a framework most clinicians are familiar with, standard, guideline-based management of upper extremity pain. Typical approach of a patient with shoulder or upper extremity pain Shivam: The standard approach for any patient coming in with a musculoskeletal issue is stepwise and conservative first. Initial management includes activity modification, NSAIDs or acetaminophen for pain control, and early referral to physical therapy depending on severity and duration. If symptoms persist, we escalate. That may include imaging—usually starting with X-ray, then MRI if indicated, and consideration of corticosteroid injections, particularly for conditions like subacromial impingement or adhesive capsulitis which are commonly seen especially following breast cancer treatment. Arreaza: Most guidelines emphasize avoiding early imaging unless there are red flags like trauma, neurologic deficits, or suspicion for malignancy or infection. The reason behind this recommendation is that if you image the population of people older than 50 years old, about 40% of people show rotator cuff tears or damage.  Shivam: When I First heard about this statistic as a medical student, I was shocked and it opened my eyes to the potential downsides of overimaging. We also emphasize maintaining mobility. For example, in adhesive capsulitis, early range-of-motion exercises are key, not immobilization. Arreaza: Exactly. “Motion is lotion” (Dr. Uy’s mantra). Shivam: And pharmacologically, we’re moving toward a multimodal approach. NSAIDs are first line when tolerated. Topical agents like diclofenac can be useful. Neuropathic agents like gabapentin or duloxetine are only considered if there’s a neuropathic component. Arreaza: And a key element is that opioids are not first-line for chronic musculoskeletal pain. Shivam: Yes, that’s a key point. Current guidelines recommend minimizing opioid use, reserving them for severe, refractory cases, and even then, for short durations with clear treatment goals. Arreaza: Now, let’s transition this framework into cancer survivors.  Shivam: The challenge is that many of these patients present with similar complaints. In the upper extremities, for example, they present with shoulder pain, weakness, stiffness, but the underlying causes are more complex. Particularly in cancer survivors, upper extremity pain is often multifactorial. You still have mechanical issues but layered on top are treatment-related effects such as surgical disruption of anatomy, radiation-induced fibrosis, chemotherapy-induced neuropathy, and generalized deconditioning. Arreaza: Let’s take an example: THIs a 55-year-old female, s/p left mastectomy and chemoradiation, completed her cancer treatment 1 year ago and now she is presenting with shoulder pain. So, how do we approach this patient? Shivam: This was a specific case I had the pleasure of familiarizing myself with however it is important to acknowledge just how many patients in America share similar experiences due to the incidence of breast cancer. If we approach this as a typical rotator cuff issue, we might miss key contributors that have been seen in cancer survivors like pectoralis tightness from radiation, scapular dyskinesis from surgery, or even early lymphedema. Arreaza: Right, and that changes management. Because if you don’t address those underlying contributors, standard treatments may only provide partial or temporary relief. Shivam: Exactly. And this is where we start to see the limitations of a purely symptom-based approach. Let’s zoom out again. There are nearly 19 million cancer survivors in the U.S., and that number is increasing due to rapidly improving cancer treatment options. With that, we’re seeing more long-term sequelae—especially involving the musculoskeletal system. Arreaza: Some symptoms in cancer survivors are reduced mobility, persistent fatigue, weakness, and impaired return to activities of daily living. And this may lead to chronic pain and reduced quality of life.  Shivam: As a side note, we can also acknowledge the impact of mental and psychological aspects on patients who have cancer or any other chronic condition. If they are depressed or less motivated to be active, participate in therapy, the deconditioning effect can be exacerbated in these patients.  Arreaza: Great point, and also, this is a population that is often under-referred to rehabilitation services. We hope we can increase awareness today. Shivam: Yes, some sources state that only around 30% of those that qualify for acute rehab are referred to it. Which is surprising, because rehabilitation directly addresses many of these issues that cancer patients experience—strength deficits, mobility limitations, and functional decline. Arreaza: Let’s talk about pathophysiology for a moment. Why do these patients develop chronic pain? Shivam: A major factor is deconditioning. During cancer treatment, patients often reduce their activity levels significantly. That leads to loss of muscle mass, decreased endurance, and altered biomechanics. Arreaza: I see, sarcopenia plays a role in the development of pain in these patients.  Shivam: And once pain develops, it further limits activity, reinforcing that cycle—pain → inactivity → deconditioning → more pain. On top of that, structural changes, often caused by fibrosis from radiation, reduce tissue elasticity, limit range of motion, and contribute to stiffness and pain. Arreaza: And neuropathic pain from chemotherapy adds another layer—burning, tingling, or hypersensitivity—which requires a different treatment approach. So, given this complexity, how should we as clinicians adjust our assessment of pain in these patients? Shivam: I think it’s very important to start with a thorough history to ensure we don’t miss any past history of chronic conditions or intensive treatment for prior medical diagnoses. First, we need to broaden the differential. Don’t assume it’s a single pathology. Second, incorporate function into our assessment. Ask the patient: What can you do? What can’t you do?  Additionally, I think it’s very important to ask what your patient’s goals are for themselves and what they would like to accomplish.  _____________________ References:  Stubblefield, M, Upper Body Pain and Functional Disorders in Patients With Breast Cancer. PM&R, 2014; 6:170 - 183​. https://pubmed.ncbi.nlm.nih.gov/24360839/ Cohen, E, American Cancer Society Head and Neck Cancer Survivorship Care Guideline, Ca Cancer Journal Clin. 2016;0-36​. https://pubmed.ncbi.nlm.nih.gov/27002678/ Stubblefield, M, Radiation Fibrosis Syndrome: Neuromuscular and Musculoskeletal Complications in Cancer Survivors​. https://pubmed.ncbi.nlm.nih.gov/22108231/ Silver JK, Raj VS, Fu JB, Wisotzky EM, Smith SR, Kirch RA. Cancer rehabilitation and palliative care: Critical components in the delivery of high-quality oncology services. Support Care Cancer. 2015;(23):3633-43.​ https://pubmed.ncbi.nlm.nih.gov/26314705/ Cai, Z, Radiation-induced brachial plexopathy in patients with nasopharyngeal carcinoma: a retrospective study. MuscleNerve. 56; 2017: 1031–1040​. https://pmc.ncbi.nlm.nih.gov/articles/PMC4951337/ Silver, J. K., Baima, J., & Mayer, R. S. (2013). Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship. CA: a cancer journal for clinicians, 63(5), 295–317. https://doi.org/10.3322/caac.21186.  Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 218: Statin Therapy Fundamentals What are statins? Zohal: Statins are medications that lower cholesterol by inhibiting the enzyme HMG-CoA reductase, which prevents cholesterol synthesis in the liver. By doing so, statins decrease low-density lipoprotein cholesterol (LDL-C).  Why should we lower LDL? Zohal: There are four main lipoproteins that transport fats in blood, including chylomicrons, VLDL, LDL, and HDL. This is where we get our “bad cholesterol” vs. “good cholesterol”. Of these, LDL is most associated with an increased risk in cardiovascular disease, while a higher HDL is associated with lower risk. Thus, reducing LDL subsequently reduces the risk of cardiovascular disease.  Arreaza: The lowest LDL I’ve seen was 25, and the highest HDL was 60. HDL doesn’t really have a strict upper limit, but most people fall between 40 and 60. Extremely high HDL—above 100—may not always be protective and can sometimes signal underlying issues. Zohal: My HDL is 70! Statins are used for both primary prevention, meaning preventing cardiovascular disease before it occurs, and secondary prevention, meaning preventing disease progression in patients who already have cardiovascular disease. History of statins. Zohal: In the early 1900’s, researchers were studying the association between cholesterol and atherosclerosis, and at that time, they primarily used animal subjects. These studies were initially not taken seriously, because most believed cardiovascular disease in humans were simply due to aging and was not preventable.  It wasn’t until the middle of the century when researchers began observing that increased levels of LDL and decreased HDL was correlated with an increased rate of heart attacks. This finding prompted interest in determining the pathway of cholesterol synthesis in the human body.  Statins were first discovered in the 1970s when researchers identified compounds that inhibit a critical step in cholesterol synthesis. The first statin approved for clinical use was Lovastatin in 1987. Since then, multiple statins have been developed, including Atorvastatin, Rosuvastatin, Simvastatin, and Pravastatin. Further clinical trials in the 1990s and 2000s showed that statins significantly reduce myocardial infarction, stroke, and cardiovascular mortality. Why do Statins Matter in Primary Prevention Zohal: Cardiovascular disease is the most common cause of death worldwide. As previously mentioned, elevated LDL cholesterol contributes to the development of atherosclerotic plaques within arteries, which can lead to heart attack and stroke. By lowering LDL cholesterol and stabilizing plaque formation, statins implemented in a timely manner significantly reduce the risk of atherosclerotic cardiovascular disease. Arreaza: One of the things I love most about primary care is prevention. You’re working upstream, often quietly, humbly, helping people avoid disease before it starts. And the truth is—you rarely see the full impact of your actions. You don’t get a notification that says, “this patient didn’t have a heart attack because of you.” But every time you help someone control their blood pressure, quit smoking, improve their diet, or stay consistent with their medications, you’re shifting their tracks. You’re reducing risk in ways that may never be fully visible. That’s the paradox and the beauty of it: in primary care, your highest victories are often events that never happen.  Who Should Receive Statins for Primary Prevention? Zohal: Recommendations slightly differ depending on who you ask. We look to the U.S. Preventive Services Task Force, the American College of Cardiology, and the American Heart Association for their recommendations regarding statins for primary prevention. USPSTF on statins. The U.S. Preventive Services Task Force (or USPSTF for short) is an organization that works to improve the health of people nationwide by making evidence-based recommendations on effective ways to prevent disease & prolong life. They recommend statins for the primary prevention of cardiovascular disease in: Adults 40–75 years old With one or more cardiovascular risk factors such as dyslipidemia, diabetes, hypertension, or smoking AND a 10-year cardiovascular risk of 10% or greater Their recommendations are graded A, B, C, D, and I, depending on the strength of evidence and this is a Grade B recommendation. Arreaza: So, you have to meet all the criteria to receive a statin, according to USPSTF: 40-75, one CV risk factor and a high 10-y ASCVD score, by the way, the ASCVD risk calculator was introduced in 2013 by AHA/ACC. It is available online for free and many EHRs have integrated this tool into their software. For example, if you use EPIC, you can type .ascvd and get a score automatically. What about patients with a cardiovascular risk less than 10%? Zohal: For patients with a 7.5–10% risk, some may offer statin therapy on a case-by-case basis as this is a Grade C recommendation. But I’ll get more into this later. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References: Grundy SM, et.al, Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Jun 18;139(25):e1082-e1143. doi: 10.1161/CIR.0000000000000625. Epub 2018 Nov 10. Erratum in: Circulation. 2019 Jun 18;139(25):e1182-e1186. doi: 10.1161/CIR.0000000000000698. Erratum in: Circulation. 2023 Aug 15;148(7):e5. doi: 10.1161/CIR.0000000000001172. PMID: 30586774; PMCID: PMC7403606. https://pubmed.ncbi.nlm.nih.gov/30586774/ U.S. Preventive Services Task Force. (2022, August 23). Statin use for the primary prevention of cardiovascular disease in adults: Preventive medication.https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medicatio American College of Cardiology ASCVD Risk Estimator: https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/ Guideline Central. (2026, March). ACC/AHA dyslipidemia guideline spotlight (March 2026).https://www.guidelinecentral.com/insights/mar-2026-accaha-dyslipidemia-guideline-spotlight/ Endo A. A historical perspective on the discovery of statins. Proc Jpn Acad Ser B Phys Biol Sci. 2010;86(5):484-93. doi: 10.2183/pjab.86.484. PMID: 20467214; PMCID: PMC3108295. https://pubmed.ncbi.nlm.nih.gov/20467214/ Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 217: Testicular Cancer Dr. Arreaza: Welcome to Rio Bravo qWeek Podcast. Today we are discussing testicular cancer, a topic that may not appear frequently in primary care but is extremely important to recognize early. We are joined by Brandon Noorvash and Dr. Ebenezer Dadzie. Please introduce yourselves. Brandon: Thank you, Dr. Arreaza. My name is Brandon Noorvash. I am a third-year medical student at Western University of Health Sciences with a strong interest in urology. Ebenezer: Thank you for having us. My name is Dr. Ebenezer Dadzie, and I am a PGY-1 resident in the Clinica Sierra Vista Family Medicine Residency Program. Dr. Arreaza: Testicular cancer represents about 1-2% of cancers in men, but it is the most common cancer in men between the ages of 15 and 40. The good news is that it is also one of the most curable cancers in medicine, especially when detected early. Let’s start with a quick question for our listeners. If a 25-year-old man presents with a painless lump in his testicle, what diagnosis should immediately come to your mind? Ebenezer: Testicular cancer should always be high on the differential. While benign conditions can cause scrotal swelling, a painless testicular mass should be considered cancer until proven otherwise. Dr. Arreaza: I agree. Especially if we perform a physical exam and find that the mass is attached to the testicle. Why is this such an important diagnosis for primary care physicians to recognize, what do you think, Brandon? Brandon: Testicular cancer typically affects young, otherwise healthy men, and early detection dramatically improves outcomes. Patients may delay seeking care because the lump is painless or because they feel embarrassed discussing symptoms. However, when diagnosed early, the 5-year survival rate exceeds 95%, and in localized disease it approaches 99%. Dr. Arreaza: Exactly, the survival is incredible and it gets even better with early detection. How common is testicular cancer? Ebenezer: In the United States, approximately 10,000 new cases are diagnosed each year, with around 500 deaths annually. The relatively low mortality reflects how effective current treatments are, especially chemotherapy for germ cell tumors. Dr. Arreaza: Let’s talk about risk factors. What should clinicians know about risk factors for testicular cancer? Who is at risk? Brandon: The most important risk factor is cryptorchidism, or undescended testicle. Men with a history of cryptorchidism have about a 4-to-8-fold increased risk of developing testicular cancer. Ebenezer: Other risk factors include family history, personal history of testicular cancer, infertility, testicular atrophy, and certain genetic conditions such as Klinefelter syndrome. However, many patients who develop testicular cancer have no clear risk factors. Dr. Arreaza: Brandon, you recently saw a patient with testicular cancer during your rotation. Can you briefly tell us about that case? Protected health information is not being revealed, so patient confidentiality is being respected during this discussion. Dr. Arreaza: I think we all were pleasantly surprised to know that lung metastasis did not place the patient in a higher risk category. On the other hand, nonpulmonary visceral metastases (such as liver, bone, or brain) define poor-risk disease in nonseminoma and intermediate-risk disease in seminoma.  Dr. Arreaza: And of course, if the patient presents with sudden severe pain, we should always think about testicular torsion, which is a surgical emergency. What should clinicians focus on during the physical exam? Ebenezer: Testicular tumors typically feel firm, irregular, non-tender, and located within the testicle itself. Brandon: A helpful exam pearl is transillumination. Fluid-filled structures like hydroceles will transilluminate, whereas solid tumors do not. Dr. Arreaza: I have to admit I’ve never done a transillumination in a s*****m before.  Brandon/Ebenezer: I’ve done it. I had to clean my pen light afterwards. Arreaza: Once you suspect testicular cancer, what is the next step in evaluation? Ebenezer: The first diagnostic test is a scrotal ultrasound. Ultrasound is highly sensitive and can determine whether the mass is intratesticular, which is highly suspicious for malignancy. Dr. Arreaza: US and tumor markers. Let’s talk a bit more about tumor markers. Why are they useful in testicular cancer? Brandon: Tumor markers help with diagnosis, staging, and monitoring response to treatment. Ebenezer: Alpha-fetoprotein, or AFP, is typically elevated in non-seminomatous germ cell tumors, particularly yolk sac tumors. An important point is that pure seminomas do not produce AFP. Brandon: Beta-hCG can be elevated in both seminomas and non-seminomatous tumors, although the levels are often higher in the non-seminomatous types. Ebenezer: LDH is less specific but can reflect tumor burden and disease activity, so it’s useful for monitoring progression or response to treatment. Dr. Arreaza: So, tumor markers are not only diagnostic tools, but they also help guide staging and follow-up care. That’s an important board question. Why don’t we perform a biopsy in a testicular mass?  Ebenezer: Testicular masses suspicious of cancer are not biopsied because biopsy can disrupt lymphatic drainage and potentially spread tumor cells. Instead, the standard treatment is radical inguinal orchiectomy, which both removes the tumor and establishes the diagnosis. Dr. Arreaza: Brandon, can you briefly explain the two main categories of testicular cancer? Brandon: Let’s start with the germ cell tumors. They are broadly divided into seminomas and non-seminomatous germ cell tumors (NSGCT). Seminomas tend to grow more slowly and are highly sensitive to radiation therapy. Ebenezer: Non-seminomatous tumors include embryonal carcinoma, yolk sac tumor, choriocarcinoma, and teratoma. These tumors tend to be more aggressive but are still highly responsive to treatment. Dr. Arreaza: How are patients staged once the diagnosis is made? Ebenezer: Staging typically includes a CT scan of the chest, abdomen, and pelvis to evaluate for metastasis, especially to the retroperitoneal lymph nodes, which are the most common site of spread. Dr. Arreaza: And how is testicular cancer managed? Brandon: The initial step is almost always radical inguinal orchiectomy. Depending on staging and tumor type, treatment may include active surveillance, chemotherapy, radiation therapy, or retroperitoneal lymph node dissection. Ebenezer: One reason outcomes are so favorable is that germ cell tumors respond extremely well to cisplatin-based chemotherapy. Dr. Arreaza: Let’s talk about prognosis. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _________________________________________ References: Honda K, Kawai T, Taguchi S, Shiratori T, Miyakawa J, Nakamura Y, Kaneko T, Suzuki K, Suda S, Kamei J, Kakutani S, Niimi A, Yamada Y, Urakami S, Fukuhara H, Nakagawa T, Kume H. Impact and Risk Factors of Diagnostic Delay in Patients With Testicular Cancer: A Multicenter Retrospective Study. Int J Urol. 2025 Nov;32(11):1593-1601. doi: 10.1111/iju.70187. Epub 2025 Jul 28. PMID: 40726135; PMCID: PMC12586796. https://pubmed.ncbi.nlm.nih.gov/40726135/ Singla N, Bagrodia A, Baraban E, Fankhauser CD, Ged YMA. Testicular Germ Cell Tumors: A Review. JAMA. 2025;333(9):793–803. doi:10.1001/jama.2024.27122 https://jamanetwork.com/journals/jama/article-abstract/2829847?utm_source=openevidence&utm_medium=referral Chavarriaga J, Nappi L, Papachristofilou A, Conduit C, Hamilton RJ. Testicular cancer. Lancet. 2025 Jul 5;406(10498):76-90. doi: 10.1016/S0140-6736(25)00455-6. Epub 2025 May 29. PMID: 40451233. https://pubmed.ncbi.nlm.nih.gov/40451233/ Tateo V, Thompson ZJ, Gilbert SM, Cortessis VK, Daneshmand S, Masterson TA, Feldman DR, Pierorazio PM, Prakash G, Heidenreich A, Albers P, Necchi A, Spiess PE. Epidemiology and Risk Factors for Testicular Cancer: A Systematic Review. Eur Urol. 2025 Apr;87(4):427-441. doi: 10.1016/j.eururo.2024.10.023. Epub 2024 Nov 13. PMID: 39542769. https://pubmed.ncbi.nlm.nih.gov/39542769/ Langn RC, Puente MEE. Scrotal Masses. Am Fam Physician. 2022 Aug;106(2):184-189. PMID: 35977130. https://pubmed.ncbi.nlm.nih.gov/35977130/ Xu P, Wang J, Abudurexiti M, Jin S, Wu J, Shen Y, Ye D. Prognosis of Patients With Testicular Carcinoma Is Dependent on Metastatic Site. Front Oncol. 2020 Jan 10;9:1495. doi: 10.3389/fonc.2019.01495. PMID: 31998648; PMCID: PMC6966605. https://pubmed.ncbi.nlm.nih.gov/31998648/ Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!