[Music to start: Grieg’s Morning Mood (https://www.youtube.com/watch?v=-rh8gMvzPw0)
The sun rises over the San Joaquin Valley, California, today is August 28, 2020.
The Journal of the American Board of Family Medicine recently published the characteristics of primary care physicians (PCPs) associated with prescribing potentially inappropriate medication (PIM) for elderly patients. Medicare data from more than 100,000 PCPs was analyzed. The sample included specialists in family medicine, internal medicine, geriatrics and general practice. PCPs more likely to prescribe PIMs were on average older, male, DO, practicing in the South, and have a smaller Medicare patient panel. The study also found that PIM rates have been decreasing over time (1). So, don’t forget to review your Beers Criteria (2) when prescribing meds to your elderly patients.
Cancer and VTE normally means low molecular weight heparin, LMWH aka Lovenox®, right? But direct oral anticoagulants (DOACs) are being used more frequently in patients with acute venous thromboembolism (VTE) and active cancer. Studies comparing their safety and efficacy with LMWH are limited. In a recent, randomized trial of 1170 patients with cancer and VTE, the DOAC apixaban resulted in similar rates of recurrent VTE when compared with the LMWH dalteparin (Fragmin®) (5.6 versus 7.9 percent) without any impact on major bleeding events. Apixaban is now considered a suitable alternative to LMWH for treatment of VTE in patients with active cancer (3). So, good point for Eliquis®.
[Music mixes with country Chris Haugen - Cattleshire - Country & Folk https://www.youtube.com/watch?v=WiYqHkH4Tnc&list=PLYo1YtVKirP-LAZ3AjpIiJNW9KIe1MJLw&index=7]
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. [Music continues and fades…]
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“By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.” –Confucius
Spanish refrains don’t make sense, but here I have one to see if it makes sense: “Nobody learns on someone else’s brain”. It means, you learn better by experience. Dear residents, how do you want to learn wisdom? By reflection, by imitation or by experience?
This is Steven Saito. I am a former Navy doctor, having spent 6.5 years in the service primarily working out of a branch clinic having taken on a variety of additional duties including prior department head and senior medical officer.
I am also a recent graduate from RBFM and have come back as faculty
Tag line: I’m here to give you your weekly suppository of information. Relax and let it in.
What I actually encountered was a need for follow up from podcast #9 vaccine hesitancy. There were follow on questions for autisms and what we can be doing as primary care providers.
I’m going to start with some basics of autism.
Diagnostic Criteria
The current DSM criteria states that a child must have persistent deficits in 3 areas of social communication/interaction and at least 2 of 4 types of restricted/repetitive behaviors. It’s important to understand these criteria as not every child who has difficulty with eye contact falls on the spectrum.
A: Areas of social communication and interaction
B: Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
C: Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
D: Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
E: These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.
Hey. Hey you. The poor resident and or medical student that just sat through a bunch of raw criteria. I’m sorry.
A real quick aside, we have already covered some of the basics of epidemiology in a prior podcast (that’s Podcast #9 which dealt with vaccine hesitancy)
Let me expand that discussion a little bit, we know that boys are about 4x as likely as girls to have it, there does seem to be a genetic component as noted in twin studies. As far as impact it falls somewhere around 1 in 40 and 1 in 500 people. There may be environmental factors that act as a second hit, but again see our prior podcast- studies have shown time and again no significant correlation between vaccines and autism. There are some things which have been shown to cause a greater relative risk such as older parents, chromosomal abnormalities (such as fragile X), and certain medications taken during the prenatal period (such as valproic acid)
Symptoms can present prior to 18 months, but they are most typically fully noted at 18 to 24 months when symptoms exceed the capacities of the patient.
Let’s talk about something that you might need to wake up for. Wake up. Wake up. Wake up.
The role of Primary Care is not necessarily to make the diagnosis. Comprehensive evaluation by appropriate tools is still best left to specialists who are well trained in the field. Most commonly developmental pediatricians, pediatric psychologist/psychiatrists, or pediatric neurologist. However, it is very important that we recognize the signs and symptoms of autism and that we perform appropriate screening.
So, what constitutes appropriate screening?
For children who appear neurotypical in whom parents are not concerned, routine screening should be implemented at ages 18 and 24 months using any of the standardized tools.
The M-CHAT R/ F is validated as a first tier screening. It is available in multiple languages through their official website. Importantly for the primary care provider it can be completed in under 5 minutes and at least for the initial questionnaire can be completed by the parent before the visit eg either in the waiting room if given while awaiting or if the appropriate underlying electronic health record / email service is in place, the questionnaire can be given online prior to the visit. For F component of the M-CHAT R/F is a structured set of follow up questions that should be done prior to referral.
For example, the first question: “If you point at something across the room, does (your child) look at it?”
Prompts the question, what does your child typically do?
There is a list of 7 items that are typical examples. A child might still pass for example if he were to point at the object. A greater concern might be when the child ignores the parent or looks at the finger instead of the object.
Please note that there are other standardized questionnaires for example the Autism Spectrum Screening Questionnaire. Most still require additional studies or are potentially better at finding other issues (such as general intellectual disability)
Resources for parents
If the child is less than 3 years old, the Early Childhood Technical Assistance Center may be of use (especially if I am talking to people outside of my local jurisdiction) Their website located at ectacenter.org has a contact list for coordinators that may be connect parents with services.
Locally, we have the Kern Regional Center
For those 3 and older, you can contact the local public school system even for those not currently enrolled in school.
For those of us in California, the Lanterman Act is very important. The Lanterman act is the California law that gives people with developmental disabilities the right to the services and supports they need to live a more independent and normal life. In particular, your patient may be eligible for Medi-Cal even if they might otherwise not be eligible, and they may be entitled top additional services. Furthermore, it allows them to access for additional services through the Regional Center. As an example, their diagnosis may entitle the family to Respite services.
Now that we have identified the patient with autism, what are some of the ways that we can improve their care in our primary care.
First remember that these children still need routine primary care preventive services and screening. Anticipatory guidance may need to adapted to include some additional safety recommendations for example discussing elopement
Those with autism may have some difficulty with change, and so unfamiliar settings eg things that are not done everyday and per routine, may be more difficult. If the patient is already in ABA therapy they may already be getting social stories or a visual board to orient the child as to expectations. Allow additional time if possible (or manipulate your schedule to have easier / shorter appointments adjacent to this visit) to give more time to allow the patient to adapt.
As a general rule, I refer to multiple online sources like UpToDate to read articles and get suggestions for primary source citation. eg check the bibliography from UTD to see there sources and see if you agree with their evidence for your evidence-based medicine and primary sources.
However, for this talk I wanted to get some additional sources to discuss. My usual go to locations for additional broad information is to first start with important medical institutions including the Center for Disease Control, World Health Organization, and AAFP.
I used a variety of references. Primarily I used UpToDate, but I also used the DSM, as well as information from the Center for Disease Control and the World Health Organization
Rights Under the Lanterman Act https://www.disabilityrightsca.org/publications/rula-rights-under-the-lanterman-act-complete-manual Date of access 8/18/2020
Caldwell, Nicole. Going to the Doctor http://www.positivelyautism.com/downloads/DoctorVisit_Story.pdf
“Autism” Center for Disease Control, https://www.cdc.gov/ncbddd/autism/index.html Date of access 8/18/2020
American Psychiatric Association. Autism spectrum disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.50
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. www.who.int/classifications/icd/en/bluebook.pdf (Accessed on March 28, 2018).
Augustyn, Marilyn MD. “Autism spectrum disorder: Terminology, epidemiology, and pathogenesis” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-terminology-epidemiology-and-pathogenesis Date of access 8/18/2020
Weissman, Laura MD “Autism spectrum disorder in children and adolescents: Pharmacologic interverventions” UpToDate https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-pharmacologic-interventions Date of access 8/18/2020
Augustyn, Marilyn MD and von Hahn, L Erik MD. “Autism spectrum disorder: Clinical Features” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-clinical-features Date of access 8/18/2020
Augustyn, Marilyn MD. “Autism spectrum disorder in children and adolescents: Overview of management” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-managementDate of access 8/18/2020
Handleman, J.S., Harris, S., eds. Preschool Education Programs for Children with Autism (2nd ed). Austin, TX: Pro-Ed. 2000.
National Research Council. Educating Children with Autism. Washington, DC: National Academy Press, 2001.
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Speaking Medical: Anosognosia
by Cameron Anderson, MS4
When someone rejects a diagnosis of mental illness, it’s tempting to say that he's “in denial.” But someone with acute mental illness may not be thinking clearly enough to consciously choose denial. They may instead be experiencing “lack of insight” or “lack of awareness.” The formal medical term for this condition is anosognosia, from the Greek meaning “to not know a disease.”
As humans, we are consistently updating our reality and perception. Think about it this way: when you get a sunburn because you spent your weekend at the beach you expect yourself to look red when you look in the mirror. You have updated your perception of what your reality is. You now expect to appear more red. This update requires a functioning frontal lobe of the brain. When that is not working properly you can lose your ability to update what is real. Everyone else can tell you received a sunburn but you are unable to recognize you have one. In essence, this is anosognosia.
This lack of insight into the disease is fairly common in those with schizophrenia and bipolar disorder. When a person is in this state they become very difficult to treat because they believe their perceptions of reality are what we should be experiencing. These people frequently will stop taking their medications because in their mind there is no reason to continue them because there is no disease.
People with anosognosia often fluctuate with how aware they are of their disease. This can also cause a strain on their support system and relationships with friends and families. Since our perceptions feel accurate, we conclude that our loved ones are lying or making a mistake. If family and friends insist they're right, the person with an illness may get frustrated or angry, or begin to avoid them. When maintaining a relationship with a person with anosognosia, it is important to realize that their perception of reality is as real to them as our reality is to us.
Remember the word anosognosia.
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Espanish Por Favor: Cansancio
by Dr Claudia Carranza
Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is cansancio. Cansancio means tiredness or fatigue. The verb “cansar” comes from the Latin word “campsare” which means to deviate or bend from a path or trajectory. Interestingly, back in the day cansancio began to be used to describe taking a break from a trip, taking a break due to exhaustion, or to rest because you’re tired. Patients can come to you with the complaint: “Doctor, tengo cansancio” or “Doctor, estoy cansado” which means: “Doctor, I am tired” or “I feel tired”.
Cansancio is a very common complaint in clinic but it’s not very specific. So, the question “¿Se siente cansado?” “Are you feeling tired?” normally is answered with a yes, more so if you are a resident. Feeling tired may be physiologic, but feeling tired continually, with no relief after rest, and with no identifiable cause can lead you to start an investigation. Ask if this cansancio is new or chronic, think of differentials such as thyroid disease, anemia, sleep apnea, acute viral illness and continue with your work up.
Now you know the Spanish word of the week, cansancio.
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For your Sanity: Medical Jokes
by Dr RAVA
[SURAJ, PLEASE EDIT]
[Music to end: Jeremy Blake - Stardrive - Rock | Bright ]
Now we conclude our episode number 25 “Autism with Saito”. Dr Saito explained the key features of Autism Spectrum Disorder and reminded us to screen at 18 and 24 months by using M-CHAT. Health care of patients with ASD requires a multidisciplinary team, and you can be part of that team. For some reason, we decided to expand on the word anosognosia (explained in episode 14). Cameron explained that anosognosia (UH NO SO NOGSIA) may fluctuate in intensity causing difficulty in relationships with family and friends. Dr Carranza gave us a good explanation about cansancio, which means tiredness, a good word to describe how we feel after a busy shift like today. Tomorrow the sun will rise again over the San Joaquin Valley and we’ll continue to learn and grow.
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.
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Our podcast team is Hector Arreaza, Lisa Manzanares, Steven Saito, Roberto Velazquez, Audio edition: Suraj Amrutia. See you soon!
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References: