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It’s August! A perfect time for sitting on the dock of the bay, watching the clouds roll away and a great time to look back on summer memories. Adrian and Kris take a stroll down medical memory lane and talk about their most memorable summer medicine. Then they highlight our August segment on managing HIV in primary care to summarize the key take-aways from this.
Neda is joined by her UC RAP friends Miz, Matt, and Matt for a conversation about how primary care clinicians are the unsung heroes of medicine
Study the prevalence of PE among patients presenting to the ED with syncope.
Chagas disease is on the rise in the United States and becoming more widespread. Why? How do these patients present, and how do we make the diagnosis and then treat them appropriately? How can we prevent further transmission? In this segment, Drs. Mizuho Morrison and Neda Frayha review the ins and outs of Chagas disease, one of five neglected parasitic infections in the U.S. according to the CDC.
What do we usually do when a female patient comes to us with recurrent UTIs? And should we be doing this? Our Things I Do But Should I duo, Vanessa and Adrien, are here to share pearls for the prophylaxis and management of recurrent UTIs.
To determine if immediate cardioversion in recent-onset atrial fibrillation is necessary compared to a wait-and-see approach.
Neda and Michael discuss the spectrum of outpatient tobacco cessation treatment including FDA approved pharmacotherapy, innovative strategies, and alternative/complementary treatments.
Can HIV be managed in the primary care setting? With today’s advances in antiretroviral therapy, the answer is yes. Infectious Diseases physician Dr. Devang Patel sits down with Miz and Neda for a conversation about the latest developments in HIV treatment.
To validate a specific diagnostic algorithm in pregnant women with suspected PE.
Pediatric cardiologist Pierangelo Renella discusses with Sol how to distinguish between innocent and pathologic heart murmurs
To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives.
Usually the words “chronic” and “pain” together can feel defeating. Especially when it’s an entity that’s been as poorly understood as chronic pelvic pain. Aisha and Neda are here to shed light on this pain syndrome and provide us with management tips and tricks to help our patients.
Patient complaints may reveal medical errors and may escalate to litigation. Be sure whatever process you have in place has been developed in conjunction with your risk management department or insurance carrier. This allows for an “early warning” system to be in place for your malpractice insurance company when litigation is possible.
To assess whether a specific pregnancy-adapted algorithm can be safely used to avoid unnecessary diagnostic imaging in suspected PE.
With the start of the new season of medicine (medical students to resident, residents to fellows, fellows to attendings), it a great time to talk about how PAs fit into this training of model for our physician colleagues. Our host discuss their experiences at teaching institutions and highlight a May 2019 article in the Journal for the American Academy of Physician Assistants. Then, Adrian and Kris tell you a story on how storytelling is important in medicine.
To review the phenomenon of missing or misused DEA numbers and what to do if it happens to you.
Lisa Patel and Andi Marmor discuss how new advances in genetic testing and personalized medicine raise ethical issues for providers and families.
To evaluate whether adjunctive intermittent pneumatic compression in critically ill patients receiving pharmacologic thromboprophylaxis would result in lower incidence of deep-vein thrombosis than pharmacologic thromboprophylaxis alone.
Vaginal bleeding in the first trimester of pregnancy is one of those topics that seems straightforward but is actually pretty complex. Dr. Jenny Beck-Esmay speaks with our own Dr. Neda Frayha about how to approach first-trimester bleeding in a logical, organized, evidence-based way that’s easy to understand.
To determine if nonspecific symptoms and fever affect probability of acute bacterial infection in older patients.
Ever wondered if your patient is just a little too obsessive? You might be right: patients with obsessive compulsive disorder (OCD) and related disorders often present to general health care settings rather than a psychiatrist’s office. Dr. Shawn Hersevoort is back with us, sharing lots of OCD pearls and management tips with our own Dr. Mizuho Morrison.
Why does storytelling in medicine matter? How can it impact our lives, and the care we provide our patients, for the better? In this segment, Neda sits down with Dr. Emily Silverman, academic hospitalist at the Zuckerberg San Francisco General Hospital and creator and host of The Nocturnists, to learn more about the role of narrative medicine in our work and wellbeing.
To determine the association between delirium and 30-day readmission.
Paul Simmons brings us another helpful, algorithmic approach to treating a common primary care condition - this time, migraines. Do you know the POUND mnemonic? Or a simple, 5-step approach to treating migraines? After listening to this piece, you will.
Assess changes in nighttime disruptions and patient experience through EHR changes and interprofessional education initiatives.
When an international expert in obesity medicine is (a) a fun, great teacher and (b) happy to talk to Hippo about how we can help our patients lose weight effectively, we jump at the chance to interview her. In this segment, Dr. Kim Gudzune from Johns Hopkins University School of Medicine reviews the commercial weight loss programs our patients may be asking about.
Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or patient safety.
Do you remember what was covered in the segments from the AAPA Primary Care Podcast over the past few months? Have you reviewed the specific segments that could influence your practice? Our hosts review the key points that spoke to them in a challenge bowl style format to utilize spaced repetition to enhance retention. Then listen in as Kris and Adrian take a second July madcap adventure that many of us have been on- the adventure of navigating obesity treatment!
One of our listeners wrote in asking about updates in fatty liver, so Aisha and Neda discuss this common primary condition in the introduction to our June 2019 episode.
Our favorite hospitalist Dr. Maj Cina is back, this time with a lightning round of common inpatient scenarios and the latest evidence to support or refute our common practices in these situations, which span the fields of GI, ID, Pulmonology, and Nephrology.
There is uncertainty around the effect of medication compared with placebo. Larger RCTs are needed to resolve the uncertainty around efficacy of medications for knee osteoarthritis.
Our Things I Do But Should I? duo brings us another great discussion on the use of oral codeine for acute cough. We tend to prescribe this for our patients at their wits’ end with cough, but should we? Listen to this segment to find out.
E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support.
We probably know on a gut level that cannabis use in pregnancy is not ideal, but what do the data show? How can we quantify the risks and best advise our pregnant patients who may be regular cannabis users? In this segment, Dr. Erin Lurie sits down with Neda to review the specific risks of cannabis use in pregnancy and breastfeeding, as well as approaches we can use in managing these patients.
Compounded pain creams were not better than placebo for treatment of chronic pain.
When an international expert in obesity medicine is (a) a fun, great teacher and (b) happy to talk to Hippo about how we can help our patients lose weight effectively, we jump at the chance to interview her. In this segment, Dr. Kim Gudzune from Johns Hopkins University School of Medicine reviews the best evidence behind successful weight loss and how we can best advise our patients to achieve this goal. This is the first of a 3-part series on diet and weight loss.
The price of alirocumab would have to be reduced considerably to be cost-effective.
In this segment, Dr. Sandra Quezada teaches Tom and Neda about the importance of specific health maintenance components in the care of patients with inflammatory bowel disease. We primary care providers can feel empowered to take great care of these patients without sending them back to their gastroenterologists for true primary care needs.
Andi and Miz sit down with PEM doc Ilene Claudius to sort out high yield and “can’t miss” pediatric foot and ankle injuries.
Aerobic exercise speeds recovery and may reduce incidence of delayed recovery in adolescents with sports related concussions.
When our listener Brianne asked us to do a segment on informed consent (because how we do ever know if we’re doing it right?), we jumped at the chance to brush up our informed consent knowledge and skills. Neda speaks with Dr. Mara Gordon, a Family Medicine physician at Georgetown and a writer for the NPR Health Desk, to get the scoop on informed consent and how we can apply it to our daily clinical practice.
Our PA hosts discuss the US News and World Report that lists the PA profession as the #1 best health job in 2019 and what this can mean for the future of the profession, the projected growth of PAs, and the impact on PA programs. Then, Kris and Adrian reflect on clinical reasoning and decision making. Yes, it gets pretty meta!
Our Primary Care RAP mailbag is bursting at the seams! Paul and Neda tackle more of our listeners’ great questions in this lightning round of Q&A.
Ever struggled with how to prescribe lancets, test strips, or insulin pen needles? Or wondered which syringe length or gauge to order? In this mind-blowingly practical, helpful segment, endocrinologist and clinician educator Dr. Rana Malek teaches Miz and Neda the basics of what to order for our diabetic patients, along with tips for injection techniques, common prescribing pitfalls to avoid, attention to insulin pricing, and the new continuous glucose monitor that primary care providers will be prescribing. This segment will change your practice.
Stethoscopes in the ICU carry complex polymicrobial colonies, reflecting important bacterial species that can cause healthcare-associated infections, including Staph. Cleaning practices reduce contamination but are only partially successful.
Polycythemia vera is a relatively rare myeloproliferative disorder characterized by increased RBC production. In this segment, our own Matt DeClerck interviews Hematology guru Dr. Tom Deloughery on the in’s and out’s of PV. Clinical suspicion for PV should occur in any patient with elevated RBC mass, elevated Hgb/Hct, aquagenic pruritus, erythromelalgia, and/or systemic thrombi (MI, stroke, DVT, etc). Diagnosis is confirmed by presence of the JAK2 gene mutation. Treatment is focused on decreasing RBCs with phlebotomy and/or cytoreductive therapy; symptom control; and treatment/prevention of arterial or venous thrombi.
Mizuho Morrison and Sol Behar how to diagnose croup, and help sort out what does and does not work in the management of acute croup.
Among patients initiating oral anticoagulant therapy, incidence of UGIB was highest in patients prescribed rivaroxaban and lowest for patients prescribed apixaban. The incidence of hospitalization for UGIB was lower among patients who were receiving PPI cotherapy.
General practitioners manage a wide variety of OB questions and concerns from their patients. In this segment, Dr. Megan Jones and Neda Frayha tackle a potpourri of OB topics for the general practitioner: vaginal bleeding in the pregnant patient, nausea and vomiting in pregnancy, management pearls for twin pregnancies, and preterm contractions vs labor.
Supplementation with vitamin D did not result in lower incidence of invasive cancer or cardiovascular events than placebo.
Mizuho Morrison and Rick Pescatore discuss the data surrounding the use of probiotics alongside antibiotics for the prevention of antibiotic-associated diarrhea (AAD) and Clostridium Difficile colitis. They review the most up to date literature on this natural supplement.
How often do we groan when we find incidental lung nodules on imaging? How do we know what counts as high-risk and when to re-image different patients? In this segment, Tom Robertson and Neda Frayha explore this all-too-common dilemma and share guideline-based recommendations on what to do for lung nodules and when.
Anemia after hospitalization increased in parallel with decreased RBC transfusion. There was no accompanying increase in RBC use, rehospitalization, or mortality 6 months post-discharge. This longitudinal study supports the safety of current practice recommendations to limit RBC transfusions.
In this segment, Brandon Grove reviews the literature on wandering in patients with dementia and some innovative strategies to help keep these patients safe.
We all make clinical decisions all the time, hundreds of times per day. But how do we make these decisions? What reasoning skills are we using that we may not even be aware of? And how can we get better at this? Dr. Sandra Oza, Assistant Professor of Medicine at the Albert Einstein College of Medicine and director of their Introduction to Clinical Medicine course, walks us through systems of thinking and decision making so we can be our best clinical selves.
Pioglitazone did not reduce the occurrence of cardiovascular events in patients with mild DM and previous MI.
Our PA hosts look into post graduate residency programs for PAs and discuss some of the reasons for choosing to apply to one and some of the reasons individuals go right into practice without completing residencies. After the Primary Care RAP segments, Adrian and Kris reflect on tick bites, Lyme disease and indications for using doxycycline in specific scenarios and populations.
Listeners, you are writing in with topic requests at record speed! In this introduction to the April 2019 episode, Neda and Paul tackle a smorgasbord of your questions.
We all advocate for our patients on a regular basis, but how many of us have blown the whistle on a massive public health crisis? In this segment, Neda interviews Dr. Mona Hanna-Attisha, the Flint, MI pediatrician who opened the world’s eyes to lead in the water that was poisoning Flint’s citizens. They talk about how to become a more effective patient advocate, and how to face situations that feel scary but ultimately benefit our patients.
To investigate whether ultrasound-based pictorial information about subclinical carotid atherosclerosis, targeting both primary care physicians and individuals, improves prevention.
Our Things I Do But Should I duo is on a myth-busting streak! In this segment, they explore whether or not we really need to avoid doxycycline for Lyme prophylaxis in kids under the age of 8.
Introduce the concept of the patient experience and how the focus is different from patient satisfaction/press ganey measures. Discuss actionable items on things clinicians can do to improve the pt experience.
To evaluate a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers.
Urinary incontinence in women is a common problem that we can diagnose and treat almost entirely in a primary care setting. In this segment, Drs. Molly Heublein and Neda Frayha go all in on the bladder and bring us management pearls to help our patients.
Andi and Parul review the new CDC and AAP pediatric concussion guidelines with Sports Medicine doctor Tracy Zaslow, director of the Children’s Hospital Los Angeles Concussion clinic.
To evaluate the non-inferiority of NO prophylaxis compared to guidelines recommended prophylaxis in preventing contrast induced nephropathy.
Acute rhinosinusitis is one of the most common conditions we see in primary care. In this segment, Dr. Jacob Anderson gives us a helpful primer on the presentation, diagnosis, and treatment of acute rhinosinusitis, whether viral or bacterial in origin.
How often do we just go through the motions of the physical exam, without really knowing which maneuvers can give us superpowers? Or which ones are worthless? In this segment, Paul Simmons teaches Neda how to become a master diagnostician with the evidence-based physical exam.
To compare the rate of moderate to severe exacerbations between triple therapy and dual or monotherapy in patients with COPD.
In acute superficial bursitis, aspiration can be both therapeutic and diagnostic. In this segment, Brandon Grove takes us on a tour of olecranon and pre-patellar bursitis, and how to approach aspiration and treatment.
What do you do when you find an adrenal incidentaloma? In this mini-segment, Neda asks endocrinologist and adrenal gland aficionado Dr. Kashif Munir how we should approach the adrenal incidentaloma.
To determine if alirocumab (a human monoclonal antibody to PCSK9) would improve cardiovascular outcomes after an acute coronary syndrome in patients receiving high-intensity statin therapy.
Adrian and Kris discuss PAEA’s response to the current administration's report on reforming America’s healthcare system and how this federal support can improve the access patients can have to PAs across the country. This is another huge step in the right direction for PAs! Since both Kris and Adrian are educators, what better segment to discuss then learner feedback. They breakdown the segment with Dr. Neda Freya and Dr. Nikki Southall on providing quality feedback to learners and why you shouldn't “feed them a sandwich.”
Interstitial cystitis can be a tricky disease to diagnose and treat. The good news is that primary care providers can make a huge difference here, without needing to refer these patients to specialists. In this segment, Aisha and Neda review the diagnosis and treatment of IC.
To discuss the epidemiology and identification of sepsis, identify areas of increased focus in sepsis management, discuss three recent large trials about early goal-directed therapy, and delineate how we may improve our processes of care.
To evaluate if a novel antibiotic Zoliflodacin is effective in treatment of uncomplicated gonorrhea.
Jason Woods digs deep into the diagnosis, complications, and management of nephrotic syndrome with pediatric nephrology doctor Danielle Sorrano.
How much do we really know about the pharmacologic treatment of alcohol use disorder? After this segment with Dr. Michael Baca-Atlas and our own Neda Frayha, the answer will be, a whole lot.
To evaluate the efficacy of rivaroxaban alone or in combination with aspirin for secondary prevention of CV disease.
What is the deal with aspirin for primary prevention of cardiovascular disease? In this segment, Tom and Steve break down some of the most recent, headline-grabbing articles on this exact subject.
To present official recommendations for the medical management of opioid-induced constipation.
Miz and Matt Delaney sit down with Rick Pescatore to discuss a common condition: balanoposthitis. They discuss causes, differential diagnosis and treatment. They discuss the typical disease course, as well as what to do with cases not responding to first line therapy.
Following Shawn Hersevoort’s helpful primer on all the personality disorders, our own Aisha Lofters and Neda Frayha bring us a segment specifically on how best to manage patients with borderline personality disorder in the primary care setting.
To evaluate urinary biomarkers of kidney damage in patients with intensive vs standard BP control (as opposed to looking at GFR as marker of kidney damage) using patients from the SPRINT trial.
Ever tried to give feedback to a learner only to have the whole interaction feel awkward and unproductive? We are starting a series of conversations to help us all become better medical educators, and in this segment, Dr. Nikki Southall and our own Neda Frayha share some strategies and pearls for becoming pros at the feedback discussion.
To determine the incidence of infectious and noninfectious patient-reported complications associated with the indwelling urethral catheter.
In this episode, Kris & Adrian discuss the 2018 legislature that (finally) included PA’s in the management of their patients referred to hospice care. This is a huge win for AAPA and their lobbying team, to recognize the work that PAs do in managing end-of-life-care for hospice patients.
A listener wrote us and asked for a segment on alopecia in women. This is a highly distressing concern for most patients, with a straightforward, algorithmic approach to workup and treatment. In this segment, our own Mizuho Spangler and Neda Frayha look to the scalp and provide an overview of how to diagnose and manage female alopecia.
BOTTOM LINE: In patients with left-sided endocarditis in stable condition, changing to oral antibiotics was noninferior to continued intravenous antibiotics.
When a patient comes into your practice with blood pressures of 180/100 but they feel totally fine, what should you do? How much evaluation should they undergo? Should they be treated in the office? Or should they be referred to the ED? In this segment, Dr. Joseph Martinez chats with our own Mizuho Morrison and Matt DeLaney about the outpatient management of severe asymptomatic hypertension.
The ever-fantastic Dr. Shawn Hersevoort is back for another installment of Psychiatry Files! In this segment, he and Mizuho Spangler discuss a practical approach to understanding and managing patients with different personality disorders.
BOTTOM LINE: Remote telemedical interventions reduced hospital admission days and all-cause mortality.
What to do when you notice incidental eosinophilia in a patient? In this segment, Tom walks Neda through a fascinating case of peripheral eosinophilia, what it means, and how to work it up in the most strategic, effective way.
BOTTOM LINE: Among nonpregnant adults with subclinical hypothyroidism, the use of thyroid hormone therapy was not associated with improvements in general quality of life or thyroid-related symptoms. These findings do not support the routine use of thyroid hormone therapy in adults with subclinical hypothyroidism
In January 2019, we featured two segments on creative approaches to the problem of clinician burnout. In this segment, Aisha and Neda continue this conversation and discuss specific organizational strategies our health systems, hospitals, and clinics can adopt to prevent - and cope with - the epidemic of burnout.
BOTTOM LINE: Statin treatment was associated with reductions in the incidnece of atheroscleortic CVD and all cause mortality in elderly adults age 75-84 with diabetes. In adults age > 74 without diabetes or adults >85 with diabetes, statin treatment was not associated with a reduction in CVD or all cause mortality.
Continuing the recent discussion between Matt DeClerck and Dr. Tom Deloughery on the direct oral anticoagulants (DOACs), this month we bring you a segment on reversing these DOACs with Matt, Neda, and Dr. Tarlan Hedayati. What are the agents currently on the market, including the newest kid on the block, andexanet alfa? What does the evidence show about their safety and efficacy?
Listeners have been asking for lots of segments on oral contraceptive pills, especially on how to choose an agent when prescribing OCPs to a patient for the first time. In this segment, Molly and Neda build on our Things I Do But Should I duo’s recent OCP myth-busting and go through a systematic, stepwise approach to understanding and prescribing OCPs.
BOTTOM LINE: Galcanezumab monthly injections provided clinical benefits and improved functioning in terms of reduced headache days per month, reduced use of acute migraine meds and improved patient symptom scores, with low incidence of adverse effects.
Matt Delaney interviews Jeff Holmes MD to discuss polymyalgia rheumatica. PMR should be suspected in patients over 50 with symptoms involving aching and stiffness about the upper arms, posterior neck, pelvic girdle, and/or lumbar region (all worse upon arising in morning). Jeff and Matt discuss pathophysiology, diagnosis and treatment of this condition.
2019 is here and the AAPA Primary Care RAP team is ready to help you face it like a new year champ! In this episode, we cover the latest changes to the NCCPA blueprint, both content and question style to keep you prepared and informed on all things C in your PA-C! We also reflect on (read: gush-over) the insightful segments hosted by Dr. Neda Fraya where she talks with former Pixar CFO, Lawrence Levy as well as internist and educator, Dr. Todd Cassesse about the challenges that health care providers face.
When a listener asked us about the adverse effects of proton pump inhibitors and whether (and how) we should deprescribe these drugs, Neda and Rob jumped all over it. In this segment, they’ll review the major categories of adverse effects described in the literature and figure out what it all means.
In this Things I Do But Should I segment, Adrien and Vanessa tackle some commonly held misconceptions about oral contraceptive pills. It’s one segment of an ongoing series on OCPs, inspired by questions from our listeners.
BOTTOM LINE: Single-dose baloxavir was without evident safety concerns, was superior to placebo in alleviating influenza symptoms, and was superior to both oseltamivir and placebo in reducing the viral load 1 day after initiation of the trial regimen in patients with uncomplicated influenza. Evidence for the development of decreased susceptibility to baloxavir after treatment was also observed.
What does the former CFO of Pixar have to do with physician burnout and the culture of medicine? We find out in this segment. Neda interviews Dr. Todd Cassese and Lawrence Levy, who helped build Pixar into the company it is today. Together they talk about changing professional cultures, the narrative of medicine being out of sync with the reality of medicine, perfectionism, emotional intelligence, and how Eastern philosophy’s The Middle Way can apply to all of our lives.
BOTTOM LINE: The provision of procalcitonin assay results, along with instructions on their interpretation, to emergency department and hospital-based clinicians did not result in less use of antibiotics than did usual care among patients with suspected lower respiratory tract infection.
When we last heard from reproductive endocrinologist and fertility specialist Dr. Lauren Roth, she took us through the workup and treatment algorithm of patients with infertility. In this segment, Dr. Roth walks us through the basics of egg freezing and genetic screening.
What does the former CFO of Pixar have to do with physician burnout and the culture of medicine? We find out in this segment. Neda interviews Dr. Todd Cassese and Lawrence Levy, who helped build Pixar into the company it is today. Together they talk about the need for continuous self-care rather than “checkbox meditation,” and how to change the system while also working on ourselves to find joy in our work.
BOTTOM LINE: Among patients with E coli or K pneumoniae bloodstream infection and ceftriaxone resistance, definitive treatment with piperacillin-tazobactam compared with meropenem did not result in a noninferior 30-day mortality. These findings do not support use of piperacillin-tazobactam in this setting.
Amal Mattu discusses two large branches of pitfalls in patients being evaluated for ACS: EKG pitfalls and HISTORY red flags. We discuss pitfalls and red flags relating to medical legal risks when dealing with chest pain.
Additional talking points:
ECG: 25-50 % misses, look closer, nonspecific and normal aren’t to be dismissed, repeat ECG’s, compare with old ones,
Hx: don’t be deterred to workup bc of age, women (gender bias)
Acute kidney injury in hospitalized patients is a big deal, with significant morbidity and morality. In this segment, Neda asks hospitalist and Med Peds physician Dr. Nidhi Goel and clinical pharmacist Dr. Asha Tata how to prevent AKI in our hospitalized patients.
BOTTOM LINE: Increased cancer detection at lower positivity thresholds is counterbalanced by substantial increases in positive tests. Tailored thresholds may provide screening benefits that are more equal among different demographic groups, depending on local resources.
Miz and Jenny discuss current diagnosis, workup and management of GERD. Jenny highlights the step-up approach to treatment when lifestyle modifications alone are insufficient.
Imagine waking up and suddenly being A&O x 1. You know who you are, but not anything about your surroundings or what day or time it is. Transient global amnesia is a diagnosis that often presents to the primary care office and can be totally alarming for everyone involved. Is it linked to a risk of stroke or TIA? How long does it take to resolve? Can it happen again? In this segment, Tom Robertson and Neda Frayha help us become more A&O to this fascinating diagnosis.
BOTTOM LINE: Treatment of carefully selected patients with acute PE and low risk by PESI < 86, echocardiography, and CUS without inpatient hospitalization is safe and acceptable to patients. Results must be viewed with caution because of the small sample size relative to the end point and the generalizability surrounding availability of emergent echocardiography.
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