The sun rises over the San Joaquin Valley, California, today is Jul 17, 2020.
It feels good to talk about prevention when an effective and safe vaccine is actually available! This is the case for the Pneumococcal Conjugate Vaccine 13 (PCV13 or Prevnar 13®).
In November 2019, the CDC issued an update on PCV13 vaccination. PCV13 vaccination for ALL immunocompetent adults 65 years and older is NOT recommended. Instead, it is recommended to make a shared decision when these patients do NOT have an immunocompromising condition, CSF leak, or cochlear implant, and have not previously received PCV13.
Some candidates for PCV13 include patients residing in areas with low pediatric PCV13 uptake; those traveling to settings with no pediatric PCV13 program; those with chronic heart, lung, and/or liver disease, diabetes, or alcoholism; and those who smoke.
PCV13 is still recommended in a series with Pneumovax® (PPSV23) for all adults 19 years and older (including those 65 years and older) with immunocompromising conditions, CSF leaks, or cochlear implants. A single dose of Pneumovax® for ALL adults 65 years and older is still recommended (1,2).
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“Perfection is not attainable, but if we chase perfection we can catch excellence.” –Vince Lombardi
Perfection is a very complex concept. Have you seen a surgery that was performed perfectly? I have. Believe it or not, there are perfect surgeries. Some musicians can play a song perfectly. I think perfection in some areas may be attainable. Another example, I think a person can be perfectly punctual for a time. That’s perfection.
However, in most cases, perfection may not be attainable, but we should at least aim for excellence. And today, we have a resident who is in her pursuit of excellence, she is doing very good in her residency. Her voice may be familiar to you because she has recorded many of our introductions, and people have loved her voice. Welcome Dr Der Mugrdechian.
My name is Alyssa Der Mugrdechian, I am a 2nd-year resident in the Rio Bravo Family Medicine Program here in Bakersfield. I am a native to the Central Valley having grown up in Fresno, California. I am of Armenian descent and my family settled in California after surviving the Armenian Genocide in 1915. Coming from a family of mostly educators, I am the first to pursue Medicine.
I went to UC Irvine for undergrad and majored in Biological Sciences, and my journey to becoming an MD took me to Ross University on the beautiful island of Dominica.
Though I have traveled a lot during my schooling, I am happy to have the opportunity to have returned to the Central Valley to complete my residency training in an underserved community close to my family and friends.
For fun, I like to draw/paint, I also enjoy cooking, traveling, going to the beach and going to any Disney park as often as possible.
This month my rotation is Gynecology. I am generally seeing patients for gynecologic issues, OB follow ups and routine post-partum visits. During these appointments, a very important question that can often be overlooked is whether the patient is coping with post-partum depression. Furthermore, another important distinction to make is if it is in fact major depression vs. baby blues.
Post-partum Depression (PPD)
The post-partum period can encompass the first 12 months after giving birth, however there’s no set length that’s been agreed upon.
Major depression is not confined to the post-partum stage, it can also arise during pregnancy.
Factors that increase risk of developing Post-Partum Depression (PPD):
Other factors to take into consideration are home life, socioeconomic factors, previous or current abusive relationships/situations.
Edinburgh Postnatal Depression scale
The EPDS is a screening tool for postpartum depression. It consists of 10 questions. The test can usually be completed in less than 5 minutes. Responses are scored 0, 1, 2, or 3 according to increased severity of the symptom. Some items are reverse scored (i.e., 3, 2, 1, and 0). You add scores of each question to get a total score. Cut-off scores range from 9 to 13 points. It requires clinical judgment to determine the right timing for referral. For example, if a woman scores 9 or indicating any suicidal ideation, she most likely would benefit from immediate referral. “In women without a history of postpartum major depression, a score above 12 has a sensitivity of 86 percent and specificity of 78 percent for postpartum major depression. You can find the hand out at the end of this document.
Other screening methods include PHQ-9, and diagnosis is based on DSM-5.
Distinguishing Between “Baby Blues” and Postpartum Major Depression
| CHARACTERISTIC | BABY BLUES | POSTPARTUM MAJOR DEPRESSION |
| Duration | Less than 10 days | More than two weeks |
| Onset | Within two to three days postpartum | Often within first month; may be up to one year |
| Prevalence | 80 percent | 5 to 7 percent |
| Severity | Mild dysfunction | Moderate to severe dysfunction |
| Suicidal ideation | Not present | May be present |
Diagnosis and Treatment
Labs can also be considered, including TSH to rule out other causes of depressive symptoms
Treatment can include both pharmacologic and non-pharmacologic methods such as psychotherapy (interpersonal, cognitive behavioral therapy)
Selective serotonin reuptake inhibitors — SSRIs are widely prescribed in lactating women. Breastfeeding should not be discouraged during treatment with SSRIs.
| DRUG | STARTING DOSAGE | USUAL TREATMENT DOSAGE | MAXIMAL DOSAGE | ADVERSE EFFECTS |
| Selective serotonin reuptake inhibitors | ||||
| Citalopram (Celexa) | 10 mg | 20 to 40 mg | 60 mg | Headache, nausea, diarrhea, sedation, insomnia, tremor, nervousness, loss of libido, delayed orgasm |
| Escitalopram (Lexapro) | 5 mg | 10 to 20 mg | 20 mg | |
| Fluoxetine (Prozac) | 10 mg | 20 to 40 mg | 80 mg | |
| Paroxetine (Paxil) | 10 mg | 20 to 40 mg | 50 mg | |
| Sertraline (Zoloft) | 25 mg | 50 to 100 mg | 200 mg | |
| Serotonin-norepinephrine reuptake inhibitors | ||||
| Desvenlafaxine, extended release (Pristiq) | 50 mg | 50 mg | 100 mg | Headache, nausea, diarrhea, sedation, insomnia, tremor, nervousness, loss of libido, delayed orgasm, sustained hypertension |
| Duloxetine (Cymbalta) | 20 mg | 30 to 60 mg | 60 mg | Same as selective serotonin reuptake inhibitors |
| Venlafaxine, extended release (Effexor XR) | 37.5 mg | 75 to 300 mg | 300 mg | Same as desvenlafaxine |
Sometimes patients aren’t willing or open to discussing this topic. In other cases, it may not even be touched upon by providers following up with the patients. But especially with everything going on this year with the pandemic, mental health is vital to a patient’s overall well-being. It also affects maternal functioning, and ultimately the well-being of the child
It can lead to lack of breastfeeding, lack of maternal-infant bonding, problems with abnormal child development, problems with infants sleeping properly and also receiving the proper vaccinations. Suicide can also occur, however this rate is very low in the post-partum period
I got interested in the topic because of the patients I have seen in clinic. I consulted reliable sources such as UpToDate, our day-to-day companion in clinic; American Academy of Family Physician; and the United States Preventive Services Task Force, which is our main source of preventive services offered in Family Medicine.
An article by Dr Viguera about Postpartum depression in UpToDate, updated on 11/20/2018. I also consulted an article about safe infant exposure to antidepressants in UpToDate. AAFP has a very good source of information about Postpartum depression. See details below.
Edinburgh Postnatal Depression Scale
Edinburgh Postnatal Depression Scale. © 1987 The Royal College of Psychiatrists. The Edinbugh Postnatal Depression Scale may be photocopied by individual researchers or clinicians for their own use without seeking permission from the publishers. The scale must be copied in full and all copies must acknowledge the following source: Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786. Written permission must be obtained from the Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online or by any other medium). Translations of the scale, and guidance as to its use, may be found in Cox JL, Holden J. Perinatal Mental Health: A Guide to the Edinburgh Postnatal Depression Scale. London: Gaskell; 2003.
Speaking Medical: Borborygmus
by Max Uschuk, MS4
We all have been in a silent exam and your stomach decides to demonstrate the sound of a humpback whale mating call. That’s borborygmus. What is borborygmus besides an interesting word to say? Technically speaking it is peristaltic movement of gas and fluid through the intestines causing an audible sound that is loud enough to be heard by the naked ear.
When someone says their stomach is growling or rumbling, that is borborygmus or borborygmi (plural), not to be confused with bowel sound or peristaltic sounds which require a stethoscope to be heard.
Is it medically pertinent? Many things can cause borborygmus.
An empty stomach around 2 hours post prandial starts to signal the brain that it is fasting, it triggers peristaltic waves every 90-230 min, and contents are moved through the intestines and function to inhibit migration of bacteria from the large intestine to the small intestine. This movement can cause borborygmus. When someone swallows air while talking, eating or drinking it can increase borborygmus. Incomplete digestion of foods such as milk, gluten, fruits and vegetables, bean, legumes, and high fiber foods can increase borborygmus.
Now, this can be normal but when paired with bloating, pain, diarrhea or constipation it can be indicative of a pathological process. Some pathologies such as celiac disease, colitis due to infection or necrotizing colitis, diverticulitis, irritable bowel syndrome, carcinoid syndrome or basically anything that really irritates the intestines can cause borborygmus. From the Practical Medicine Series; General Surgery, “the presence of stormy peristalsis or borborygmus in the absence of fever may be considered pathognomonic to intestinal obstruction as it never occurs in adynamic ileus”
Thank you for listening and I hope you get to use the word borborygmus sometime soon. ____________________________
Espanish Por Favor: Spanish Last Names
by Dr Claudia Carranza
“Hola, me llamo Fernando Hernandez Guerrero Fernandez Guerrero.”That’s a fictional name from Fuller House, but sometimes that’s how Hispanic names sound like to English speakers.
Hi, this is Dr Carranza in our section Espanish por favor, today instead of bringing you a word of the week I wanted to discuss a topic with everyone. It’s the topic of last names! In the States, people usually have one last name, unless once married they chose to hyphenate their last name. Well, in the Hispanic culture we usually have 2 last names. The last names we have are first, our father’s last name, and our second, our mother’s last name.
So, for example, my name is Claudia Carranza, but the name given to me at birth was: Claudia Roxana Carranza Guzman. I don’t think I have ever met anyone in Peru (where I’m from) that only had one last name. Dr Arreaza brought up an interesting point, which is what if people in Latin American cultures have one last name? I’ll let him expand on this topic.
Dr Arreaza: Having only one last name may have a negative social connotation. When someone has one last name in Venezuela it usually means that you are a “natural son”, or illegitimate, or born from a single mother.
Dr Carranza: In Peru, at least what I saw growing up, if a child only had one parent then they took the full first and second last name of that parent. So, guys when you meet a Hispanic patient with two last names, remember that their 1st last name is the one they will usually go by, not the second. So, for my name Claudia Roxana Carranza Guzman, you would call me: Claudia Carranza, not Claudia Guzman. Hope this helps when you are trying to figure out what last name to use when you see a patient or have a coworker with 2 last names!
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For your Sanity:
by Steven Saito and Tana Parker
Doctor: I have bad news, and very bad news.
Patient: What's the bad news?
Doctor: You only have 24-hours to live
Patient: And the really bad news?
Doctor: I’ve been trying to contact you since yesterday.
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Now we conclude our episode number 20 “Baby Blues”. Dr Der Mugrdechian reminded us to screen for post-partum depression using the Edinburg Postnatal Depression Scale and make sure it is not “baby blues.” Max taught us the word borborygmus, just a fancy way to say “very loud stomach growling,” and Dr Carranza explained that the name you see at the end of a looooong Spanish name may not be the actual last name. The actual last name is the name before the last, I know it may be confusing, but it’s OK to ask your patients their preferred last name.
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 for this episode is Hector Arreaza, Alyssa Der Mugrdechian, Claudia Carranza, Lisa Manzanares, and Max Uschuk (pronounced Use-Chuck). Audio edition: Suraj Amrutia. See you soon!
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References: