The sun rises over the San Joaquin Valley, California, today is June 19, 2020.
This week we welcomed a new group of residents who started on June 15, 2020. Welcome aboard, Drs. Amodio, Civelli, Grewal, Lorenzo, Lundquist, Martinez, Nwosu, and Viamontes. We are excited for you and all the experiences you will have in the next 3 years.
On Jun 9, the USPSTF recommended to screen for unhealthy drug use all adults age 18 years or older. This a Grade B recommendation (moderate to substantial benefit). Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Screening in this case refers to asking questions about unhealthy drug use, not testing biological specimens(1).
The search for the miraculous antiviral drug against COVID-19 continues. We previously mentioned remdesivir, which was granted Emergency Use Authorization (EUA) by the FDA on May 1, 2020 in the US. Another drug you should be aware of is avifavir. Avifavir is based on Favipiravir, originally sold in Japan as an antiviral medication to treat influenza. Avifavir has been approved to be used in Russia, and is being tested in the US and the UK as well. Let’s keep avifavir on our radar, if it works, we’ll surely know about it.
Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.
The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve.
Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.
“[Feedback], like rain, should be gentle enough to nourish a man’s growth without destroying his roots.” – inspired by Frank A. Clark
Being corrected is not easy. It takes a lot of courage to accept that we may be wrong sometimes, and trying to fix our mistake requires diligence. Remember that your attendings are not trying to humiliate you (or at least the attending I know), but they are correcting you to help you succeed in your career. Today we have a resident who is excited to talk about his topic. Welcome, Dr Brito.
1. Question Number 1: Who are you?
I was born and raised in the center of the Cuban island. I had the opportunity to study and practice Medicine in my native country. After graduating from medical school, I completed my social service year in an underserved area on the beautiful north coast. Most of my patients were farm workers or fishermen. I also worked in the ER for 6 years before emigrating to the United States. Once in the US, and after years of preparation, I was accepted into the UCLA IMG Program in 2018, and the following year I matched in the Rio Bravo program.
I like fish keeping, outdoor sports such as running, sports in general, my favorite Movie director is Pedro Almodovar. I also love jazz music, Miles Davis, and Chucho Valdes.
2. Question number 2: What did you learn this week?
I learned about the treatment of Tension-type Headache (TTH).
PREVENTIVE THERAPY
Prophylactic therapy ranges from drugs to nonpharmacologic therapies such as behavioral and cognitive interventions. Prophylactic treatment is indicated if headaches are frequent, long-lasting, or account for a significant amount of total disability. Such as, frequent episodic subtype (1 to 14 headache-days a month) and chronic subtype (>15 headache-days a month)
Preventive therapy may be also indicated when acute therapy (such as acetaminophen and NSAIDs) fails or is inappropriate because of inadequate response, adverse events, overuse, or contraindications.
Pharmacologic preventive therapies: Evidence of efficacy is limited and inconsistent, but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. Other medications - mirtazapine and venlafaxine, topiramate, gabapentin, tizanidine have limited data. Trigger point injections require more research. In contrast, SSRIs are not effective.
Dosing and duration of therapy: Start the drug at the lowest dose, and increase the dose gradually until therapeutic benefit is achieved. Benefit is often first noted only after four to six weeks of therapy. Avoid overuse of analgesic medication, in fact eliminate it, or preventive therapy will likely be ineffective. Measure the effectiveness of therapy by use of a patient headache diary. For example, amitriptyline at 10-12.5 mg nightly, and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated, maximum dose of 100 to 125 mg. TCA are associated with cardiac conduction abnormalities and arrhythmias. Before initiating treatment, patient should be screened, 40 years and older with EKG, younger than 40 can be screened by history for evidence of cardiac disease.
Behavioral therapies: Regulation of sleep, exercise, and meals. CBT, relaxation, biofeedback—These therapies may be suited for patients who prefer no pharmacologic treatment; those who have insufficient response to, or poor tolerance to pharmacologic treatments; pregnant, nursing, excessive use of analgesics; those who have significant stress or deficient stress-coping skills.
Studies suggest treatment using biofeedback combined with relation therapy rather than other behavioral therapy options.
Biofeedback: Electrical sensors connected to a monitor are hooked up to your body. The sensors measure one or more signs of stress. This can include heart rate, muscle tension, or body temperature. The measurements provide feedback about how your body responds to different stimuli. Patients learn to interpret those signals and control them.
Other no pharmacologic therapies such as acupuncture which suggests any benefit is likely to be modest and Physical therapies with unproven benefits.
ACUTE TREATMENT
The acute or abortive therapy of TTH ranges from nonpharmacologic therapies to simple and combination analgesic medications. In most cases, the treatment of TTH is largely self-directed using OTC medications without any input from a medical provider.
Nonpharmacologic treatments include heat, ice, massage, rest, and biofeedback.
Precipitating factors include of TTH: Stress and mental tension are reported to be the most common precipitants. Other precipitants anxiety, major depression, overwork, Lack of sleep, Incorrect posture, etc. Controlling these triggers may help in the acute treatment of TTH.
Medications: Given the available data, the recommended treatment is with simple analgesics such as NSAIDs or aspirin for patients with pure episodic TTH. Acetaminophen 1000 mg is probably less effective than NSAIDs or aspirin.
Reasonable choices include ibuprofen (200-400), naproxen (220 or 550 mg) or aspirin (650 to 1000). For failing, diclofenac (25 to 100 mg). For those who cannot tolerate NSAIDs or aspirin, acetaminophen 1000 mg is the preferred choice.
How to judge the success of acute treatment
Reasonable goals:
- Is the patient pain-free and functioning normally in two to four hours after treatment?
- Does the treatment work consistently without routine headache recurrence?
- Is the patient able to plan his or her day? (disability)
- Is it tolerable?
The treatment should be considered ineffective if two or more of these criteria are consistently not met.
What to do in case of treatment failure
Other acute interventions: Combination analgesics containing caffeine (recommended in suboptimal response), butalbital and codeine (not recommended as initial therapy), Parenteral (chlorpromazine, metoclopramide (limited evidence), Ketorolac, Muscle relaxant (not recommended)
3. Question number 3: Why is that knowledge important for you and your patients?
Tension-type headache is the most prevalent headache in the general population and the second-most prevalent disorder in the world. Yearly, prevalence rates for episodic TTH are approximately 80 % in men and women. Understanding the pathophysiology and clinical aspects of TTH is important for accurate diagnosis and optimum treatment. However, TTH is a relatively featureless HA, making it the least distinct of all the primary HA phenotypes. In addition, it is the least studied of all the primary HA disorders, despite having a high socioeconomic impact.
Societal impact: The prevalence of TTH is greater than migraine and the overall cost of TTH is high. In one population study, persons with episodic TTH reported a mean of nine lost workdays and five reduced- effectiveness days, while persons with chronic TTH reported a mean of 27 lost workdays and 20 reduced-effectiveness days.
4. Question number 4: How did you get that knowledge?
That knowledge came first from medical school, and second, after years of practicing Medicine. During those years, we as doctors, evaluate and manage a large number of patients with one of the most common medical complaints, headache.
In terms of finding out more of what to do with patients, how to make them feel better, I had to look some stuff up. My trusty sources in clinic are 1) Up to Date, 2) Faculty, 3) Review/Journal articles. Not necessarily in that order.
5. Question number 5: Where did that knowledge come from?
The information comes from multiple reliable medical sources such as “Frequent Headaches: Evaluation and Management” by Anne Walling, downloaded from the AAFP website, and “Tension-type headache in adults: Preventive treatment and Acute Treatment” in Up-to-Date.
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Speaking Medical: Choluria
Hi this is Harjinder Sidhu, I’m a 3rd-year medical student. I’m here to present the medical word of the week: Choluria. Has your patient ever inform you their urine color is brown (Coca-Cola color)? Choluria has 2 roots, “chol” and “uria.” “Chol” is the combination of bile and gallbladder. “Uria” is the presence of something in urine that should not be present. So choluria is the presence of bile in the urine. What causes the urine to become brownish in color? The presence of bile in urine is caused by an underlying liver disease such as cirrhosis, hepatitis and/or hemolysis. Choluria usually manifests when the serum levels of bilirubin are above 1.5mg/dl. Now that you understand what choluria is, in the future you can look out for our patients by asking any changes in urine as a sign of potential liver problems. Stay tuned for next week’s word of the week!
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Espanish Por Favor: Señale con un dedo
Hi this is Dr Carranza on our section Espanish por favor. This week I wanted to share a tool for a follow-up question. Not too long ago we learned that DOLOR means pain, and we learned about body parts like “cabeza” head, “rodilla” knee, “pecho” chest, etc.
Next you will probably want to ask where the “dolor” exactly is, and to simplify things we can ask the patient to point with one finger to where it hurts. We can do this by saying “dónde” which means where, followed by “señale con un dedo”, which means point with one finger. “Señalar” means to point, and “dedo” means finger.
I hope you can use this in your practice, “señale con un dedo”, and you can always ask nicely and add “por favor” which means please.
Have a great week!
Now we conclude our episode number 17 “Tension Headache”. Dr Brito briefly explained the treatment of tension headache. Lifestyle modifications are key in the treatment, and many non-pharmacological options are available with different degrees of evidence. Thinking about prophylaxis of tension headaches? Amitriptyline is likely a good choice, but remember the side effects as well. Dr Carranza taught us how to ask about location of pain with the phrase “señale con un dedo”, and then we remembered the word choluria, which is bilirubin in the urine. Stay tuned for more next week.
This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.
If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice.
Our podcast team is Hector Arreaza, Ariel Brito, Claudia Carranza, and Harjinder Sidhu. Audio edition: Suraj Amrutia. See you soon!
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