https://youtu.be/dqAxY3UjV8o
Grand Rounds at Sutter Santa Rosa Regional Hospital
Sponsored by the Santa Rosa Family Medicine Residency and Sutter Medical Group of the Redwoods
Integrative Approach to Anxiety and Depression (Brown, 10/30/2024)
A recording of this presentation is available HERE.
Many thanks to Dr. Andrew Brown, who gave an excellent Grand Rounds presentation this week on Integrative Approach to Anxiety and Depression. Anyone in primary care knows that we do a lot of management of psychiatric disorders in the primary care setting, often with very little specialty support. Many patients are interested in pursuing not just standard medical therapy (SSRI + cognitive behavioral therapy), but also integrative modalities.
Dr. Brown laid out the evidence for a wide range of non-pharmaceutical and non-psychotherapy treatments for anxiety and depression. The bottom line is that there are many, many, many integrative options with a range of small to moderate to strong evidence for the management of anxiety/depression. Put your seatbelts on. And don't use too many at once!
Integrative modalities, for the purpose of this talk include
- lifestyle/behavioral
- nutrition
- supplements and
- physical practices
Lifestyle/behavioral
Exercise works! The USPSTF recommends 2.5 hours/week of aerobic exercise for overall improved health. And good news, exercise can improved depression! Some exercise modalities may be better than others, including: include walking/jogging/yoga/strength training. The more "intense" the better. However, in a 2023 review article, ANY regular exercise, regardless of type, setting, or supervision decreased depression scores by 5-7 points.
There is not much evidence for exercise in anxiety, with a different review paper finding a benefit of exercise for anxiety in 7 of 25 studies and no benefit in the remaining 18.
It should come as no surprise that substance use and substance use disorders are frequent comorbidities with anxiety and depression. Note in the chart below:
- 16% of people with anxiety disorder also have SUD
- 16% of people with an adjustment disorder also have SUD
- 16% of people with depression also have SUD
- Kava Kava (Piper methysticum): 50-70mg TID, mixed evidence, some concern for hepatoxicity
- St. John's Wort (Hypericum perforatum): strong evidence in depression, 500-1800mg/day. A 2017 Meta-analysis found it to be equivalent to SSRIs (of note, not safe to take at same time as SSRIs)
- Saffron (Crocus sativus): 30-200mg/day, strong evidence for depression and anxiety, $$ cost can be an issue, also concerns regarding first trimester SAB in early pregnancy
- Lavender (Lavandula angustifolia): "a few drops", moderate evidence, compared to lorazepam in a trial of preoperative patients was found to be "equivalent". SE: gynecomastia
- Vitamin D: stronger evidence in depression (than anxiety)
- B Complex, found in dark/green/leafy veggies, may be good adjunct
- Zinc: dose response benefit in depression and anxiety
- Magnesium: strong evidence as either monotherapy OR adjunct, depression more than anxiety, change of 4 points on GAD7 or PHQ9, so may be good choice for mild-mod depression/anxiety
- Acupuncture: 2024 Meta-analysis found that acupuncture was BETTER than SSRIs for depression, particularly if electro-acupuncture techniques are used. Most studies indicate that a combination of SSRI and acupuncture decreases rates of remission. There is less evidence for acupuncture in anxiety.
- Acupressure: no evidence for durable benefit, but may be good for episodic symptoms (and can be self-done)
- Progressive Muscle Relaxation: strong evidence in pre-procedural anxiety and symptoms report for patients. There are a wide range of muscle relaxation techniques, many can be taught in just a few minutes in the office setting
- Breathwork: Once again, there are many different breath practices. Two easy ones to teach in the office are: Box, 4-7-8 (see images below). Both have been shown to help with symptom management
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Farmworkers’ experiences working during wildfires and impacts on health (Hyland and Gordon, 10/16/24)
This week, in commemoration of the 2017 Tubbs Fire, which destroyed over 5,000 homes in Santa Rosa, we had a really special presentation by two researchers from the Berkeley School of Public Health and Berkeley Law School on the impact of the Ag Pass program and wildfire smoke on Sonoma County farm worker health.
If you can, please watch their presentation. A recording is available HERE.
- AB1103: California law that established a "Livestock pass" in 2021, work authorization program, allowing workers back into evacuation zones during natural disasters
- Counties have interpreted this law as permitting them to allow workers into evacuation zones
- Unfortunately, no occupational health analysis (by Cal-OSHA) was done in the passing of this law
- From 2017-2022, such passes were handed out in an Ad-Hoc manner by the Ag Commissioner, often based on personal contacts and phone calls
- 25% increase in ED visits for respiratory symptoms
- 33% increase in hospitalizations for respiratory illnesses
- 18.7% increase in asthma prescriptions
- Disparities based on race and SES
Recruited local farm workers and trusted figures
- 75% reported having worked during wildfire
- 64% received some protective equipment from employer
- many had to reuse
- many given surgical mask (rather than N95)
- 70% reported short term health impacts
- 36% who had health impacts indicated they lingered over time
- Mental health impacts
- >50% reported no health insurance
- 39% difficult to get appointment at clinic (hours, days open, etc)
- There is no process to communicate with individuals who are reentering an evacuation zone.
- Currently employers are responsible to ensure workers leave in time
- The sheriff could request the information but no system at the county level to ensure this happens safely for workers.
- No method for county agencies to communicate directly with pass holders. All communication is via employers.
- Recommending consolidating the AgPass application under one department (e.g. under Ag Commissioner) to make process more clear, streamlined, address concerns identified with signing up via the Sheriff's office (considering largely undocumented workforce)
- Support additional research: survey H2A workers inside evacuation zones, specific needs of indigenous language speakers in the county (current offerings only available in Eng/Spanish), understanding air pollutant exposures (increased monitoring), financial literacy needs (long-term planning in changing climate and extreme weather, likelihood this will only get worse)
- Health focused recommendations to SoCo BOS:
- Public Health and Health officials should be included in decisions to activate the Ag Pass, specifically tracking air quality and heat levels inside evacuation zones
- Increased air monitors across the county (hyper-local info needed in rural areas)
- Increase collaboration and support with Sonoma County Community Organizations Active in Disaster (COAD), 80 organizations across the county who have infrastructure to provider training and information to farm workers
- $$ support for health and safety training
- PPE to COAD that could be distributed BEFORE fire season in places that are comfortable
- Safety kids: N95, info about wildfire smoke, Cal-OSHA
- Training for employers and how to protect self and
- Require sufficient stockpile of N95 for workers
- Increase hours of FQHCs across the county, expanded mobile health services, expanded monitoring
- FQHC collecting farmworker employment
- Health focus recommendations for State of CA
- Update Cal-OSHA smoke standards (AQI >150, PPE needs to be available but not mandatory until AQI >500, no level which is considered unsafe to work)
- Need more monitoring of AQI levels during fire event
- Need requirements employers to communicate AQI levels
- Decrease barriers to reporting concerns to Cal OSHA
- Recommendation for Safety
- Use current active SoCo Alert system, require Ag Pass holders to sign up for these alerts, sign up all farm workers for these alerts
- Develop new alerts: e.g. Ag Pass activated, Deactivated, AQI levels
- Recommendations for economic improvements
- Interconnection of health/economic security
- Comprehensive disaster pay program; create meaningful choice for workers (e.g. hazard pay, disaster insurance, unemployment, paid sick leave)
- Enforcement of retaliation protection so workers don't lose job after choosing not to work for health and safety reasons
Inpatient End of Life Care (Selby, 10/9/24)
A recording of this presentation on Inpatient End of Life Care is available HERE.
***
We are so lucky in the hospital to have a talented and knowledgeable hospice liaison, Kristi Selby RN, who very much guides us through the process of transitioning patients onto hospice in the hospital. Most of those patients then discharge to home or the community, but occasionally we get to be witness to death of patient in the hospital. I am personally grateful for Kristi's attentive care of a patient with shared this past week.
I am also grateful to her for an excellent presentation she gave this week outlining the basics of hospice definitions, eligibility, services, and philosophy. Please watch the above link for the whole presentation. If you just want my notes, here they are:
Hospice is a level of care, not a place. Hospice offers expert medical care, pain management, emotional and spiritual support that is tailored to each patient (not to the disease). It includes facility support, bereavement for up to 18 months, and a focus on caring, not curing. It takes into account important aspects like anticipatory grief.
Just like many people these days have birth plans, hospice can help people have the death they want -- a death plan, of sorts.
In order to be eligible for hospice, you need to have:
- terminal illness
- <6 months prognosis
- no curative treatment desired
- cultural/death taboo
- many people are unaware of hospice and hospice services
- family or providers don't want to take away hope
- there is a misunderstanding of what hospice is (it's not just give me morphine and kill me)
- death is really hard to talk about!
- Routine (multidisciplinary team with many visits/week in the home, SNF, etc)
- Continuous care (8 hours shifts, generally by RN)
- Respite care (short term, up to 5 days at a SNF for caregivers)
- General inpatient (GIP), in which a patient who is not stable to receive routine hospice care at home and/or needs up titration of medications can receive that level of care in the hospital
The Dobbs Crisis: A Family Medicine Response (Pfeifer, 10/2/24)
A recording of this presentation is available HERE.
A written summary will be forthcoming.
Empiric Antibiotics and SSRRH Antibiogram (Patel, 9/25/24)
Many thanks to Omi Patel, PharmD and head of our SSRRH pharmacy for an excellent and important talk on Empiric Antibiotics and the SSRRH Antibiogram. A recording of her presentation is available HERE.
My notes:
Empiric antibiotics should be chosen based on many different factors:
- patient characteristics (age, comorbidities, recent hospitalization, etc)
- site of infection
- pharmacokinetics
- evidence-based guidelines (e.g. IDSA, John's Hopkins, Sanford guide)
- facility specific guidelines (CPMC, UCSF)
- clinical pathways (most recent possible)
- local antibiogram (which is what this talk focused on)
Gram Negative Organisms at SSRRH |
Last year, at SSRRH 64% of Gram Negative Organisms were E Coli. Other more commonly isolated organisms include Klebsiella, Pseudomonas, Proteus and Enterobacter.
- Despite common practice, ceftriaxone does not concentrate well in the urine as cefoxitin. Ceftriaxone should not be first line for UTI treatment
- Once culture results return, use the specific data to drive antibiotic treatment moving forward
- If a patient has had a recent history-- meaning in the last 120 days) of infection at the same site, use that information (and NOT the antibiogram) to drive your empiric antibiotic choice
- ESBL is a form of resistance that presents in gram negative bacteria.
- The CTX-M gene (aka Ceftriaxone resistance) is a surrogate marker for ESBL
- Sutter labs will not specifically report out an ESBL organism, so LOOK for ceftriaxone resistance as a surrogate marker for ESBL organisms
- If you suspect an ESBL organism, do NOT use Zosyn, any cephalosporin for empiric treatment. Your best choice is a carbapenem
- For pseudomonas aeruginosa, the only oral abx for this organism locally is ciprofloxacin, and based on 2023 antibiogram, it is currently only 83% sensitive
- do NOT use levofloxacin (77% sensitive)
- MRSA resistance to clindamycin has been consistently high since 2017 (around 59%)
- do NOT use clindamycin for MRSA coverage
- Resistance to TMP-SMX is increasing in Santa Rosa (>16% resistance rate)
- Doxycycline sensitivity (currently 95%) is significantly higher than tetracycline (68%).
- Tetracycline is NOT a good surrogate marker for doxy against MRSA. Therefore, susceptibilities should be reported separately.
- Doxycycline is a good local choice for empiric MRSA coverage
Empiric Group B Strep (GBS)
- Local GBS is resistant to clindamycin 50% of the time, GAS is resistant 25% of the time
- Clindamycin should never be used to empirically cover GBS in a pregnant woman without sensitivities
- Unless sensitivity is known, linezolid is preferred over clindamycin to inhibit toxin production (usually just 3 days duration)
Restricted Antibiotics
Barriers to Fertility Care (Orozco-Llamas, 9/18/2024)
Many thanks to Dr. Orozco-Llamas for an excellent, thought-provoking presentation this week on Barriers to Fertility Care. A recording of her presentation is available HERE.
My notes:
2020 American Society for Reproductive Medicine definition for infertility:
Inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing or any combination of those factors.
Need for medical intervention to achieve a successful pregnancy either as an individual or with a partner
In patients having regular, unprotected vaginal-penile intercourse, evaluation should be initiated at
- 12 months when the female is under 35 years of age
- 6 months when female is 35 - 40 years
- Immediate evaluation may be warranted in female >40 years
Consult $280
US done in-house $275 (even if done already at outside facility)
Blood work $350 (often needs repeating)
IUI $400 per cycle
IVF $10,000-$15,000 per cycle
Ovulation stimulating medication is relatively low-cost for our Medi-Cal and uninsured patients (~$18 for a course of clomiphene and/or letrozole), but there is currently no in clinic IUI offered at our community health centers. Patients can be counseled on doing home insemination, which has a lower success rate.
All non-white racial and ethnic groups (black, other race, and Hispanic) are significantly more likely to experience infertility than whites.
Both high school dropouts and high school graduates are significantly more likely to experience infertility than four-year college graduates.
Women who are not white and women who are of lower SES are significantly less likely to report ever having received infertility treatment.
Talk to your patients about fertility!
Refer to WHPC or GYN clinic at Vista SRCH
Education on infertility and ovulation cycle
Mental health resources
Diet and lifestyle modifications
Guidance on when to refer and providing financial information
- Bill Status - SB-729 Health Care Coverage: Treatment for Infertility and Fertility Services. leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202320240SB729.
- Figà-Talamanca, Irene. “Occupational risk factors and reproductive health of women.” Occupational medicine (Oxford, England) vol. 56,8 (2006): 521-31. doi:10.1093/occmed/kql114
- Fuortes, L et al. “Association between female infertility and agricultural work history.” American journal of industrial medicine vol. 31,4 (1997): 445-51.
- Gaskins, Audrey J, and Jorge E Chavarro. “Diet and fertility: a review.” American journal of obstetrics and gynecology vol. 218,4 (2018): 379-389. doi:10.1016/j.ajog.2017.08.010
- “Infertility: An Overview Patient Education Booklet.” Infertility: An Overview Patient Education Booklet | ReproductiveFacts.Org, American Society for Reproductive Medicine, www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/infertility-an-overview-booklet/.
- Infertility Workup for the Women’s Health Specialist: ACOG Committee Opinion, Number 781. Obstetrics & Gynecology 133(6):p e377-e384, June 2019. | DOI: 10.1097/AOG.0000000000003271
- Katz, Patricia et al. “Costs of infertility treatment: results from an 18-month prospective cohort study.” Fertility and sterility vol. 95,3 (2011): 915-21.
- Mays, Mackenzie. “A Bay Area Cancer Patient Froze Her Eggs in Hopes of Having Children. She Can’t Afford to Finish IVF - Los Angeles Times.” Los Angeles Times, 9 Apr. 2024, www.latimes.com/california/story/2024-03-31/ivf-isnt-covered-by-insurance-in-california-hopeful-parents-are-struggling-to-afford-fertility-care.
- Phillips, Kiwita, et al. “Infertility: Evaluation and Management.” AAFP, 15 June 2023, www.aafp.org/pubs/afp/issues/2023/0600/infertility.html.
- Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org. “Definitions of infertility and recurrent pregnancy loss: a committee opinion.” Fertility and sterility vol. 113,3 (2020): 533-535. doi:10.1016/j.fertnstert.2019.11.025
- Weigel, Gabriela, et al. “Coverage and Use of Fertility Services in the U.S. | KFF.” KFF, 15 Sept. 2020, www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s.
Methadone in Hospitalized Patients (Bowen & Aguilar 11/6/2025)
https://youtu.be/dqAxY3UjV8o
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