Is the answer always syphilis? (Le, 2021)

Thanks to Dr. Jimmy Le for an excellent Grand Rounds presentation this week on Syphilis. Rates of syphilis have been on the rise in the US and in Sonoma County for the last decade.

A recording of his excellent presentation is available HERE.

For those of you who want the notes, here are my notes:

Epidemiology:

• Before 2013, cases of syphilis in the US were generally concentrated in men who have sex with men (MSM) 
• From 2013-2018, there has been increase of 170% primary and secondary syphilis diagnosis in women AND rising rates in black/Latinx populations
• There is a high rate of co-infection w/HIV (42% MSM with syphilis also have HIV)
• In 2019, 129K cases of syphilis in the US (MSM and MSMW), 1870 cases reported of congenital syphilis (unfortunately more common in BIPOC mothers)
• In SoCo, as well, rates have been increasing, similarly transitioning from primarily a disease in MSM to a wider category of folks, including more women, homeless, persons who inject drugs

What is syphilis?

• A spirochete infection caused by treponema pallidum
• Multiple stages of syphilis can be confusing (see graphic below from Emory)
• The incubation period 9 days-3 months (can be asymptomatic)
• Neurosyphilis, ocular syphilis and otic syphilis can happen at ANY time during infection (should have low threshold to test for these)

Primary syphilis: 3-90 days after exposure, painless chancre, round and firm, can appear anywhere, generally 3 weeks after infection, heal on own in days/weeks, place where chancre appears is where exposure occurred (e.g. anus, vagina, penis). Gets missed, people don't notice because it doesn't hurt!

Secondary syphilis: 3-6 months after initial infection: "bigger rashes", more widespread (hands, feet, trunk, tongue, hair loss)

Tertiary syphilis: years to decades after exposure, "the great imitator", can show up in any tissues: cardiovascular, skin, bone, etc

Early latent: asymptomatic, <12 months of exposure

Late latent: asymptomatic  infection >12 months of exposure, "syphilis of unknown duration"

Neurosyphilis: CNS infection (meningitis), general paresis, tabes dorsalis

Ocular syphilis: vision loss, blurry vision, eye pain, redness

Otic syphilis: sensorineural hearing loss, tinnitus, vertigo

Transmission:

• Primary syphilis is VERY transmittable (lots of treponemes in primary chancres-- any surface is vulnerable), likelihood of transmission is ~30%
• As you move through stages, you become less and less infectious, can definitely still transmit but less than primary
• Syphilis is also one of TORCHES infections, the spirochete crosses the placenta very readily

Diagnosis:

• Two types of tests:
• Non-treponemal test: tests for cardiolipin cholesterol-lecithin antigen (RPR, VDRL), always presented as titers
• Treponemal test: detection of Ab against Ag. once positive, will always test positive (FTA-ABS, TPPA)
• Two methods for testing, decision which algorithm to use is based on prevalence. Generally thought higher prevalence area should use reverse testing algorithm 
• Traditional (see image) starts with RPR, reflex to TPPA confirmation
• Reverse (see image), do the opposite (start with TPPA), if that tests positive, reflexes to RPR)
• Once a patient is positive, Treponemal tests will ALWAYS be positive, so you always need RPR and titers
• Do note, you can have false negative RPR in latent period and upon appearance of chancre 1-3 weeks (e.g. if you are testing "too early", if you see a chancre, treat treat treat)
• Dx of neurosyphilis requires high clinical suspicion and low threshold for doing LP and getting CSF: test for protein, WBC, CSF-VDRL (which has poor sensitivity, 70% can test negative)

Treatment

Penicillin is ALWAYS the treatment (see chart above for details)

• Don't forget to get an RPR on the day of treatment (to get baseline)
• If a patient reports contact with anyone with syphilis in the last 90 days, treat empirically! 
• including partner treatment!
• www.dontspreadit.com (anonymous texting about exposure)
• Primary, secondary, early latent (<12 months): PCN 2.4 million units IMx 1
• Late latent (>12 months), unknown duration of tertiary with normal CSF: need to be treated with IM injections x 3 (one week apart)
• Neuro/ocular/otic syphilis: treatment is IV PCN 10-14 days (usually initial hospitalization)
• If a patient has PCN allergy, desensitization and treatment with PCN is still recommended (JAMA article on PCN desensitization available HERE)
• Follow-up testing is KEY: 
• for primary/secondary, early latent, retest with RPR at 6, 12 month (looking for 4x decrease in titer)
• for late latent, unknown, you should retest at 6, 12, and 24 months
• RPR baseline will be your guideline to determine if someone has been reinfected (4x increase demonstrates reinfection)

Questions about staging/treatment, can always call: Team Vida 707-583-8823 or SoCo Health Department 707-565-4566

Congenital Syphilis:

• complex diagnosis and treatment algorithms (see diagram from California DPH below)
• steady rise of congenital syphilis since 2012, 400% increase since 2012
• syphilis readily crosses placenta or via contact with chancre during delivery
• can affect ALL organs of the body, can lead to infant death and miscarriage
• wide clinical presentation: < 2 year old, usually presents by 5w-3 months of age, 60-90% will be symptomatic
• sx include hepatomegaly, jaundice, rhinitis ("snuffles"=white discharge, more severe than common cold, mucous discharge VERY infectious because lots of treponemes in them), rash, generalized LAD, skeletal abnormalities
• Treatment: IV PCN 50K units/kg q8 hours x 1 week, then q12 hours OR PCM IM x daily x 10 days
• Evaluation: neurodevelopmental, hearing, eye, serologic testing with RPR until negative or 4x decrease (usually non-reactive by 6 months)

https://californiaptc.com/in-the-news/new-tool-for-clinicians-unveiled-to-ensure-appropriate-treatment-of-congenital-syphilis/

Screen for STIs!

Screen all sexually active patients for HIV, RPR, GC/CT (including swabbing every site they use to have sex, including mouth, vagina, rectal)

Other STIs predict HIV risk (see infographic)

Offer partner treatment always

https://californiaptc.com/wp-content/uploads/2017/03/Slide7.jpg

Vomiting in Children (Mueller, 4/21/2021)

Many thanks to Dr. Claudia Mueller, Stanford and CPMC pediatric surgeon, for an excellent presentation on Vomiting in Children-- her lens, unsurprisingly, was on the surgical causes of vomiting in children. 

As a family medicine physician, I don't typically consider vomiting in children a "surgical" problem, but it was sure a good reminder that sometimes it is! It's a hearty crew of clinicians who want to assemble at 7:30am to talk about vomit-- but hey-I have to tell you-- her presentation was excellent!  AND the best part was that Dr. Mueller gave us a number to call if we ever run into problems. 

To watch Dr. Mueller's excellent presentation click HERE.

For the Cliff's notes version, here you go:

• Surgical causes of vomiting in children can rapidly progress to be life threatening
• Ask yourself How sick is this kid? Do they have fever, tachycardia, moist music membranes, lethargy? Can I get them to stand for the KUB?
• Presence of vomiting and ABSENCE of diarrhea is a concerning sign 
• This makes sense; most vomiting in kids is related to acute viral gastroenteritis or food poisoning, both of which should be accompanied by diarrhea. The absence of diarrhea is a sign that surgical causes of vomiting should be on your ddx
• The color of the vomit is key: color gives you some indication of the level the vomit is coming from (I know, I know, who wants to talk about the color of vomit) 
• this is particularly true in infants
• yellow/green (bilious) emesis in children <1 year is an "alarm bell that should be rung through the streets of any city" as it could be a surgical emergency (cardinal hallmark of a midgut volvulus that you do NOT want to miss)
• most children will vomit food and other particulate matter, if they vomit long enough, they will eventually vomit bile, so prolonged vomiting leading to bilious vomiting may be less concerning than it starting out bilious

• The intestine is a tube: in addition to the color of the vomit, what is coming out the bottom gives us a lot of information. If a child is having something out the bottom, they are much less likely to have true obstruction
• Passing gas is best indication (more even than bowel movements)

SBO

• Previous abdominal surgery is #1 cause of of adhesions causing SBO in children
• traumatic surgeries (e.g. trauma ex-lap) are more likely to lead to adhesions
• laparoscopic surgery maybe less risky (eg. laparoscopic appy) 
• Farting is a good sign-- air doesn't just hang out in the colon; a child that is passing gas, even if there is an obstruction, it is at least partial
• Be aware: not all kids with SBO get abdominal distention
• An UPRIGHT KUB is the imaging modality of choice to evaluate for SBO in a child
• want to be able to visualize: diaphragm, rectal gas
• UPRIGHT is super important: air goes to top, liquid down to the bottom
• air-fluid levels (straight lines) in SBO (can see in ileus, but more common in SBO)
• a sick child who cannot stand up for KUB is concerning
• CT scans can show more detail, e.g. the "point of the obstruction" but generally try to avoid CT scans in children <10 due to radiation
• if you do CT scan, should do IV contrast; used to always require oral contrast (and can be more helpful), but should be done carefully due to risk of aspiration 

Upright KUB showing SBO

• Initial treatment: NGT for decompression 
• NGT should be adequate size (if it's too small, won't work as well). An NGT an actually treat SBO by relieving the pressure
• Babies, size 10-12
• Toddlers, size 12-14
• age >7 years, size 14
• teenagers/adults, minimum size 14, better >16
• NGT has to be flushed, or it will get clogged
• If NGT is working, as evidenced by the amount coming out of NGT decreases, and child starts feeling better, you may be able to avoid surgery
• Another option after NGT: small bowel follow-through with gastrograffin (or ominpaque) can be diagnostic AND therapeutic
• 25-50cc, repeat KUB 6-12 hours after administration: decreases hospital stay either because quicker to OR vs. able to discharge home
• Hydration and serial abdominal exams are important in SBO

Midgut volvulus is the most urgent cause of bilious vomiting, usually in children <1 year old (85% before 6 months, 95% before 1 year)

• A true emergency is caused because mesenteric vein and artery get twisted, no blood flow to the entire small bowel (colon and first/second part of duodenum have their own blood supply)
• Can be life threatening in a few hours
• Perfectly healthy baby totally fine, suddenly starts throwing up yellow/green, call a surgeon!
• Imaging: UGI shows cutoff; x-ray may show just a stomach bubble (no other gas)
• Consequence so dire: lose entire small intestine, may never be able to survive not on TPN

Pyloric Stenosis typically thickening/hypertrophy of pyloric muscle fibers

• No one know why it happens
• Usually age 2 weeks to 2 months, classically first-born males
• Non-bilious (breastmilk or formula), progressive and persistent
• Imaging: ultrasound
• Surgery: cut open hypertrophic fibers, outer layer and spread it (pyloromyotomy)
• Typically does not recur

Appendicitis

• n/v, abdominal pain, umbilical down to RLQ
• renewed interest in conservative management with antibiotics only
• 95% of cases can be treated with antibiotics only, but 20% will recur in 1 year, 30% in 5 years
• fecolith has VERY high recurrence, should be operated lap appendectomy

Ileocolic intussusception

• generally age 6-36 months
• small part of small intestine gets stuck in large intestine
• usually due to laxity, lead point usually a lymph node, can be seen after enteritis OR after immunization (e.g. rotavirus vaccine)
• Imaging: ultrasound, "target sign"
• Reduction via radiology (air or contrast from anus into rectum, pushes the intussusception , reduces the small intestine), works large majority of time in kids without ischemia
• 10% recurrence rate-->  to OR
• Older kids need work up, lead point (e.g. lymphoma)

Hernias

• bilious vomiting, if incarcerated
• remember to take off vomiting baby's diaper to look for non-reduceable hernia

Dental Care for Primary Care (Gonzalez, 4/14/2021)

Great thanks and Happy Birthday to our Grand Rounds speaker this week, Gina Gonzalez, DDS for a comprehensive review of what primary care doctors should know about dental care: Oral Health for the Primary Care Provider. Dr. Gonzalez took us from the cradle to the grave (or crib to casket, so to speak) and motivated me to schedule a dental preventive visit ASAP! 

She reminded us that the mouth is an important part of the body, and when medical providers are seeing patients, we should definitely be examining their mouths, giving them preventive dental care recommendations, and screening for oral cancers. 

For those of you who missed it, a link to the video recording can be found HERE. For those of you who prefer the summary, here are my summary notes:

Tooth decay and periodontal disease are 100% preventable

• 92% of US adult have dental disease, 50% have gum disease, 5% of adults are edentulous
• 42% of US children have early childhood cavities (i.e. in baby teeth)
• Fluoride reduced decay by 50%

Pediatrics:

Prevention

• Cavities are an infectious disease! Strep mutans is the oral bacteria transmitted from adults' mouths to babies' mouths Pro tip: don't kiss babies on the mouth (you'll give them your bacteria)
• A baby's first visit to the dentist should be as soon as baby has its first tooth (parental education: how to care for the mouth, fluoride-- remember, in Sonoma County, we don't have fluoridated water, so parents need to use fluoride supplement or a fluoride containing toothpaste)
• To get a good look in a baby's mouth during your exam, try doing a knee-to-knee exam (see photo), in which the baby straddles parent and head is in examiner's lap 

  

  knee to knee dental exam position

  
  
• Kids should NOT use toothpaste unless they know to spit OR parents can put about 1/4 size of pea (can wipe away, is not harmful)
• Breastmilk (and formula ) both have a lot of carbs--> don't forget to wipe down baby's mouth after they feed
• Fruits and veggies that contain fluoride include: grapes, spinach, oatmeal and carrots
• Brush baby's teeth every day!
• Early childhood caries can be prevented: no fall asleep after nursing/bottle without wiping the teeth, only water in the bottle, clean
• No soda!

Pathology

• Rarely, infants are born with a neonatal tooth (often rudimentary root), which be easily extracted, particularly if they are making problems with breastfeeding
• Silver diamide fluoride is treatment for ECC (it may be ugly but STOPS the decay and avoids general anesthesia, capping, etc.)
• When a child is getting their adult teeth, two rows of teeth is normal, usually teeth come out on the own, don't worry!
• If a child's tooth comes out due to trauma, put the tooth back in child's mouth while you seek care; if you are worried they cannot safely do so, put the tooth in your own mouth (saliva is good for preserving the root). A third choice is to put it in milk (not water, which is dehydrating)
• In children, purulent abscess can form due to trauma or decay; if you see one, they critically need treatment 

Adults

Prevention

• Advise adults to floss their teeth before they brush: fluoride goes into cleaner space
• Power brushes can remove more plaque than traditional toothbrush
• Tongue hygiene brush is a good idea
• Drink water that is similar to pH of saliva (6.-7.6), bubbly water is acidic, saliva lubricates and bathes your teeth

Pathology

• Tooth decay is a result of poor hygiene, poor diet, genetics, prescription medications (e.g. SSRI, BP meds can cause a lot of dry mouth, leading to cervical decay--> add fluoride, brushing)
• soda is bad! 46gm sugar, very low pH
• Periodontitis is irreversible gum disease; it requires urgent and imperative tooth care
• As teeth decay and become abscess, infection can go through the bone, full of pus, hard to numb 
• As patients age, elders tend to drop out of routine care (transportation); don't forget to talk about how they are accessing dental care at well check visits
• Edentulism is a travesty! When teeth removed, you lose proprioception, start chewing funny, lose pressure to eat, get jaw collapse--> poor appetite, failure to thrive. Dental implants (with dentures attached) are superior!

Oral cancer screening is important and quick!

• grab a gauze, pull the tongue out!
• All you need: 2x2 gauze, tongue depressor and flashlight
• high risk locations for oral cancer: floor of the mouth, lateral borders of the tongue, junction of the hard and soft palate, and posterior oropharynx
• to do a cancer exam:
• look at skin of face, scaling, irregular and dark changes, particular attention to ear
• palpate back of neck, clavicular nodes, SCM, submandibular and sublingual glands
• eyes: Movement, melanoma, sclera
• look in nose
• look at vermillion border of mouth
• palpate bimanually to feel for anything fixed, parotid gland (tenderness occlusion), check joints (pops/clicks, jaw deviation)
  
• lateral border of tongue, floor of mouth, symmetry, gums/bones/teeth
• palpate inside mouth, junction of hard/soft palate
• look for symmetry!
• can be done in 3 minutes!
• oral cancer risks: tobacco, alcohol, vaping

Okay, now for a quiz: are these oral lesions benign or cancerous? Name these abnormalies (answers below)

A.

B.

C. 

D.

E.

F.

G.

H.

I.

J.

K.

A. black hairy tongue (benign) B. oral lichen planus C. Pyogenic granulomas (aka "pregnancy tumors") (benign) D. fordyce granules (benign) E. Geographic tongue (benign) F. Labial HSV G. Oral HPV H. Squamous cell cancer I. Squamous cell cancer  J. verrucous carcinoma K. precancerous lesion from snuff

Human Trafficking (Lisa Fatu, 4/7/2021)

Thanks to Lisa Fatu, director of Youth Crisis Services at Social Advocates for Youth (SAY), who spoke to us this week about Human Trafficking. A video recording of her presentation is available HERE. 

Human trafficking is the use of force, fraud or coercion to obtain some type of labor or commercial sex act; it is a multi-billion dollar international industry. Human trafficking can occur in any industry, including agriculture, construction, domestic service (housekeeper, nanny), restaurants, salons, commercial sex work, massage parlors, and small businesses. 

Between 2011 and 2018, the Sonoma County District Attorney pursued over 200 cases of human trafficking-- it is certain that many more were events were not reported. SAY provides crisis intervention, food, shelter, trauma-informed counseling, and much more. 

Lisa's goal for Grand Rounds was to teach health care providers how to keep our eyes out for victims of human trafficking-- recognizing that health care settings may be the only outside place where victims are allowed to be seen by their perpetrators. 

Things to look out for that may be indicative of a human trafficking situation:

• 80% of people trafficked are under 23 years old; average age 14
• Most victims are women, but men can also be trafficked
• Be suspicious if you see a young person with another female/male companion who is doing all the talking
• A trafficking victim may have their head down, make poor eye contact, make minimal interaction
• They may not know there address or have a PO Box (many traffickers take victims to clinics away from their home)
• They may not agree to be seen alone, don't want to be left in a room alone
• They may have bruises, burn markings, small cuts on the inner arm/feet (not generally visible without a full exam)
• They may have "branding tattoos" (e.g. behind ear, on neck)
• A victim may be coming only for a vaginal exam, but merit further questioning e.g. "Are you eating?"
• Victims may be particularly scare of needles

Lisa acknowledged that many of these "red flags" have overlap with insecure youth, youth who are inflicting their own self harm, a young person with poor self esteem, mail away brides, etc. Providers must use your judgement if you suspect the situation is not right, and take the next steps.

Things to consider:

• Educate your front desk employees (they are most likely to see who a patient arrives with, notice that they do not know their address, act oddly, etc)
• Always ask for a few moments alone with the patient, have their companion leave the room
• Consider having the patient leave a urine sample so you can see the patient away from the people that accompany him/her
• Have a game plan if you identify someone who you think is being trafficked
• Make relationships with local law enforcement (SRPD, SoCo sheriff's)
• Always make a follow-up appointment to give victim another chance to be offered services
• Consider having "nail cards" that have fake nail ad on them but actually have a phone # where help can be available

Aftercare

Unfortunately, 40% of human trafficking victims will return to their trafficker without intense intervention. Victims need therapy, safe living situations, wraparound services, money (they are used to having things paid for) and family education/services (consistency, monitoring relationships, internet activity, clothing)

Did you know SoCo has a multidisciplinary Human Trafficking Task Force?

For more information, contact lisa at: 707-546-3432 or lfatu@saysc.org

Or see SAY's website: https://www.saysc.org/

Nursing leadership at Sutter Santa Rosa Regional Hospital are currently working on a program to educate employees on Human Trafficking in our community. Let me know if you have questions/ideas. Thanks!

What a Pain! Tales of Adult Arthritides (Ramirez, 3/31/2021)

Thank you to Dr. Vanessa Ramirez for her review of two very important inflammatory arthritides at Grand Rounds this week: psoriatic arthritis and gout.  I gleaned so many important pearls from her presentation. For those of you interested in seeing the full recording, it is available here. My summary notes are below:

Inflammatory arthritides

• infectious (septic)
• crystal induced (gout, pseudogout)
• immune related (RA, SLE, psoriatic arthritis, dermatomyositis, Sjogren's)
• reactive

Psoriatic arthritis (PsA) 

• PsA affects about 20% of people with psoriasis 
• skin changes can precede arthritis sx for years-- even up to 12 years
• skin changes and PsA flares are not necessarily temporally related, nor is disease severity necessarily correlated
• typically asymmetric arthritis (in one, several or multiple joints), sacroiliitis (30-78%) 
• historic definition of PsA: serological negative (i.e. negative rheumatoid factor) polyarticular arthritis in someone with psoriasis skin manifestations
• classification Criteria for Psoriatic Arthritis (CASPAR) (2006) may be helpful in making this clinical diagnosis (see image below)
• early identification and treatment prevents joint destruction
• anti-CCP may be elevated (usually mild) in 12% of patients with PsA
• more likely in higher numbers of involved joints
• Risk factors for PsA
• scalp psoriasis 4x risk, intergluteal/perianal 2.3x risk, nail involvement
• earlier age at dx with psoriasis, >3 body sites affected, family hx of PsA (first degree)
• ESR is superior to CRP as a marker of damage progression and mortality
• Treatment for PSA includes lifestyle modification (diet, smoking cessation, exercise), followed by symptomatic treatments (NSAID, steroids, injections) and then TNF alphas
• see images below from the 2018 ACR Guidelines
• also see AAFP image, which includes cost of these treatments

2018 ACR Guidelines for Treatment of PsA

https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf

https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf

AAFP Psoriasis (Am Family Physician 2013)

https://www.aafp.org/afp/2013/0501/p626.html

Gout 

• Gout is caused by deposition of monosodium urate crystals in the joint space, periarticular structures and soft tissues
• associated with obesity, htn, hyperlipidemia, DM, CKD, heart failure, thiazide diuretic 
• ACR online tool Clinical prediction (see image)

• 

  https://www.aafp.org/afp/2020/1101/p533.html

  
  
  
• Treatment Acute
• 2020 ACR Guidelines for Treatment of Gout Flare
• Naproxen 500 mg BID OR indomethacin 50 mg TID, ibuprofen 800mg TID
• Colchicine (low dose) 1.2mg PO, then 0.6mg 1 hour later, then BID until flare resolves
• Oral prednisone 0.5mg/kg (5-10 days full dose then stop OR 2-5 days full dose and then taper over 7-10 days)
• Treatment Chronic
• all patients with tophi, radiographic evidence or damage or 2+ flares/year
• goal is symptom relief AND maintenance of urate levels (<6)
• we should be titrating allopurinol based on checking uric acid levels
• Allopurinol is treatment of choice, lower doses preferred to start
• if on thiazide for BP, switch to losartan

Ecology and the Physician: Therapeutic Considerations for your Patients AND the Environment (Bacon, Fetke 3/24/2021)

Many thanks to Drs. Bacon and Fetke for their presentation. 

A recording of their presentation can be found here: https://youtu.be/gtypRTzS2e8 

A written summary will be added later this week.

Radiology Potpourri (Kujala, 3/17/2021)

Many thanks to Dr. Nick Kujala, Sutter Radiologist and mid-West Scrubs and hockey fan, who gave an entertaining and informative presentation this week, covering a range of topics in radiology: from the history of the first radiograph to the risk of radiation exposure to the invention of the CT scanner. The video recording is available HERE.

Here are a few summary points from his presentation:

1) Radiation Exposure: Many patients (and clinicians) have concerns about the risks of radiation exposure with imaging studies. It may be helpful to note that living on earth gives us daily background radiation exposure, and certain jobs/situations (e.g. working as flight attendant or pilot) increase the amount of that exposure over time. Of note,  exposure from one chest x-ray is the equivalent of  ~10 days of background radiation, whereas at CT of the chest is equivalent to ~2 years. 

Information on radiation exposure for patients is available at this website:  https://www.radiologyinfo.org/en/info.cfm?pg=safety-xray

Also, remember that MRI and ultrasound are alternative imaging modalities that offer ZERO radiation exposure.

2) Breastfeeding and contrast: Women who are breastfeeding can safely receive contrast (iodinated and gadolinium-based) for imaging studies without concern. The dose absorbed by an infant is exceedingly low. There is no need to pump and dump, but ultimately the decision should be left to the lactating mother.

3) ACR Appropriateness Criteria: The American College of Radiology (ACR) has an excellent, information-packed website to help clinicians make the correct choice about imaging studies. Everything you want to know about radiology imaging (indications, risks/benefits, radiation exposure, alternatives) can be found here: https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria

An excerpted example of these ACR criteria for abnormal uterine bleeding is pictured below.

4) MRI and Gadolinium: Gadolinium has been used as contrast in MRI for over 30 years. There is a known phenomenon of gadolinium deposition in some tissues (bone, kidney, brain); however, there has been no consistent evidence to suggest that these deposits are associated with neurotoxicity. However, as recent as 2016, some scientists have suggested a condition called Gadolinium Deposition Disease, linking these deposits with a constellation of neurological symptoms and signs.  While Dr. Kujala and the ACR  support the safety profile of gadolinium, it is not recommended during pregnancy

5) More IS Better! Give your radiologist as MUCH clinical information as possible when ordering an imaging study-- you will get more clear results back. And if you have a question, call your local radiologist sitting in his dark reading room (or at home) at x-44551.

Extras:

Roentgen's first ever radiograph of his wife's hand (1895) 

Hounsfield's invention: the CT Scanner (he shared the 1979 Nobel Prize in Medicine)

And finally, what is an Aunt Minnie? The origins of the term "Aunt Minnie" are a bit hazy, but it's believed to have been coined in the 1940s by Dr. Ben Felson, a radiologist at the University of Cincinnati. He used it to describe "a case with radiologic findings so specific and compelling that no realistic differential diagnosis exists."

Can you name the Aunt Minnie below?

Answer: Tension Pneumothorax

End of Life Care: Cultural Values in the Latinx Community (Panameño, 3/3/2021)

Dr. Karla Panemeño gave thought-provoking and important Grand Rounds this week on End of Life Care: Cultural Values in the Latinx Community. You can watch a recording of her presentation here: video to be uploaded.

Dr. Panemeño began her presentation with a brief history of hospice, and she pointed out that hospice is very much a "western phenomenon" with much of Latin America is still lacking the concepts of hospice and palliative care principles embedded in their own healthcare systems. She also reminded us that the Latinx community is the fastest growing ethnic minority group in the US, and that the COVID-19 Pandemic has disproportionately affected Latinx in our country (3x the hospitalization rate) and our own local community (while Latinos make up 27% of our SoCo population, they comprise 67% of our cases).

There is mixed evidence on Latinx use of end of life services, but generally the Latinx community tends to be less likely to have an advanced care plan and less likely to take advantage of hospice service. There are many reasons why this may be true, including: language barriers, financial barriers (many immigrants are not eligible for Medicare), knowledge about the resources, and cultural values.

Dr. Panameno then spent a good percentage of her remaining time describing key Latinx cultural values that may influence the interactions of Latinx patients with end of life care. She encouraged us that recognizing these cultural values may help us give better care. She reminded us, however, to be careful not to generalize, as the Latinx population in the US is itself a diverse group of people. Also, being aware of an immigrant patient's level of acculturation is important in understanding how these values shape their decisions

• Familismo (family unit)
• Personalismo (personal interactions)
• Respeto (respect)
• Confianza (trust)
• Fatalismo (fatalism)
• Dignidad (dignity)

For me, exploring these cultural values and how to integrate them into the care of acutely and chronically ill and dying patients is such an important take home message.

Here are a few pearls:

Familismo is a family centered model of decision-making highly valued in the Latinx community, may be valued more than autonomy (whereas medical system often values autonomy over all else), involves broad networks of support that extend beyond the nuclear family 

• this may be seen in medical decisions being made as a family unit, rather than by an individual
• also family members very much see themselves as caretakers and often have a strong sense of duty to care for their dying family member
• How do we navigate familismo in the care of patients?
• identify the family spokesperson
• actively engage family members in decisions
• educate and support the whole family

Respeto is a notion that relationships are based in common humanity, and one must establish respect as part of that relationship

• this may be seen in hierarchy within families as to who is designated spokesperson
• patient and family may not be assertive in expressing their concerns, disagreements with clinicians

Personalismo is a value that places an emphasis on your personal interactions, rapport is built on warmth and regard

• pleasant and agreeable conversations with healthcare provider (even when they disagree)
• may not want to disclose poor prognosis to the patient
• How do we navigate personalismo and respecto in the care of patients?
• Be respectful (in the language you use, who you address, etc)
• Respect the familial hierarchy
• Give families time to process
• Take time to know each member of the family -- don't underestimate the value of family 

Confianza is trust in a person with the belief that the other person in the relationship has your best interests in mind.

• many Latinx patients have experienced discrimination based on race, language, etc in the healthcare setting
• How do we navigate confianza?
• follow up on promises, spend additional time with patient/family, make small talk, have open dialogue about prejudice, discrimination, language barriers
• use important key community members (e.g. pastor)

Dignidad: feeling worthy and valued

• may manifest as anxiety at time of death, fear/anger around dying, 
• How to navigate? Open conversation with family members, be curious about the feelings in the room

Fatalismo: a belief ones future is not in your own hands, not in your own control

• patients may seek care late in their illness
• may express hope for a miracle
• How to navigate? Explore thoughts/feelings/values, validate the role of others' control

I encourage all of us who take care of Latinx patients to consider how these cultural values may influence our patients' interactions with us and with the healthcare system, and not to overgeneralize but rather apply this lens humbly in how we care for patients.

2020 Year in Review (Jimenez, Green 2/24/2021)

Great thanks to Dr. Douglas Jimenez and Dr. Cherie Green for their Grand Rounds 2020 Year in Review. Much of the presentation focused on-- you guessed it-- COVID (that is basically what ALL our lives revolve around these days), with select bonus points on a few other hot topics. Dr. DJ covered the latest and greatest on COVID in OB and Dr. Green did a potpourri of COVID in kids. 

The COVID literature is evolving literally day by day, so please take this summary as a point in time update. Our understanding of the disease will continue to evolve as we get more data/studies/literature on these topics. For a video recording of this presentation, click here: VIDEO.

Here are my summary points from this presentation:

COVID OB Management in 2020:

• Pregnant women appear to be at higher risk for severe COVID illness and death
• 5-6% of pregnant women with COVID are hospitalized
• 3x risk ICU, 2.9x risk intubation, 1.7x risk of death

• Pregnant women with severe/critical COVID disease also appear to be at increased risk for preterm birth and pregnancy loss
• 10-25% preterm delivery (induced + spontaneous)
• 60% preterm delivery in critical illness
• Per SMFM, a history of COVID disease is NOT itself an indication for antenatal testing
• use routine indications for antenatal testing
• however, a 32 week growth ultrasound may be considered
• Is COVID an indication for delivery?
• asymptomatic/mild infection: COVID is not an indication for delivery, though can consider delivery if >39 weeks
• severe/critical illness: it is reasonable to consider delivery but mechanical ventilation alone is not an indication for delivery
• if EGA< 32 weeks and considering delivery, also consider proning, ECMO, etc
• Is COVID vaccination recommended in pregnancy?
• Due to lack of data in vaccine trials, the WHO has been "lukewarm" about recommending COVID vaccine, recently adjusting their recommendation to recommend vaccinating women at high risk (e.g. healthcare workers) and those with comorbidities that put them aat increase risk for severe illness (e.g. diabetes, obesity).
• However, it is important to note that the Maternal Immunizations Task Force (which includes many large and reputable organizations including: ACOG, AAFP, IDSA, AAFP) specifically recommend that COVID-19 vaccine be made available to all pregnant women
• they say it is unethical to not offer vaccine knowing that pregnancy is a risk factor for more severe COVID illness
• this should be a shared decision-making conversation with provider on risk vs, lack of safety data
• What about Breastfeeding and COVID?
• CDC recommends ALL women with active COVID continue to breastfeed-- no evidence of COVID in breast milk, benefits>>risks
• should use face mask and hand hygiene with every feed
• Labor support and COVID
• Policies surrounding limitation of support people in labor disproportionately harm women of low SES and women of color, who are also disproportionately affected by COVID-19
• less labor support--> more operative delivery, longer labors, etc
• We should be mindful of these policies and do our best to weigh risks/benefits in our advocacy work

Bonus Pearl: Alcohol in pregnancy. Dr. DJ reviewed a paper from Australia  (Association of Perinatal Alcohol Exposure with Psychological, Behavioral, and Neurodevelopmental Outcomes in Children from the ABCD Study, American Journal of Psychiatry  2020), which found a dose-dependent correlation between ANY alcohol use in pregnancy and psychological/emotional problems and behavioral problems. 

• 25% increased likelihood of an ADHD in children exposed to heavier levels of alcohol (approximately 36 drinks) in the first 6-7 weeks of pregnancy.
• Heavier alcohol use during early pregnancy also associated with rule breaking behavior and aggression, 30% higher risk of the child being diagnosed with oppositional defiant disorder

COVID + kids 2020:

Dr. Green reviewed several studies on the impact of COVID on our children. Here are her pearls:

• 2020 study out of China, 123,000 children looking at myopic changes with a 5 month lock down
• in children ages 6-8 years, significant number of children had a clinically significant myopic shift (-0.3 diopters) with higher prevalence of myopia in children compared to previous years
• this was not true in older children (ages 9-12)
• conclusion: home confinement seemed to have a significant effect on vision and myopia rates in children ages 6-8, perhaps because this is a more critical developmental period for this problem
• Clinical pearl: every 20 minutes, have children look up and way from the screen for at least 20 seconds, 20 feet away
• Mental health in children during the Pandemic
• Clark County, Nevada: 19 deaths by suicide
• Riley Hospital, Philadelphia: 250% increase in hospitalization for childhood suicide attempts
• CHO: double rate of childhood suicide attempts compared to 1 year ago
• CDC reports increase in mental health ED visits, sustained since March 2020 (see image)
• 25% increase in children 5-11, 31% in children 12-17, compared to the same period one year prior
• Clinical pearl: Ask ALL children how there mental health is doing during the pandemic. Particularly for teens, consider the use of APPS: including CALM, headspace, COVID coach
• 
• The Safety of School Reopening 

• SARS-CoV-2 infection and transmission in educational settings: a prospective, cross-sectional analysis of infection clusters and outbreaks in England Ismail et al, Lancet December

• prospective study, strict infection control precautions, small groups, low community prevalence
• 1,000,000 students, 500K staff--> 343 total cases of COVID (130 in children, 213 in staff)
• 55 total outbreaks (outbreak defined as more than 1 person, most involved just 2), probable staff to staff in 26 of those outbreaks
• no children hospitalized, 3 adults hospitalized, 1 adult died (contracted from home)
• Summary: SARS-CoV-2 infections and outbreaks were uncommon in educational settings during the summer half-term in England. The strong association with regional COVID-19 incidence emphasises the importance of controlling community transmission to protect educational settings. Interventions should focus on reducing transmission in and among staff”

• Incidence and Secondary Transmission of SARS-CoV-2 Infections in Schools

  Zimmerman et al, Pediatrics 2021
• 11 districts in North Carolina, 100K students x 9 weeks
• 32 additional cases of COVID via school transmission
• No instances of child to adult transmission
• Summary:

• In the first 9 weeks of in-person instruction in NC schools, secondary transmission of SARS-CoV-2 was extremely low overall, and only involved staff to staff transmission. “Our data support the concept that schools can stay open safely in communities with widespread community transmission.”

With mitigation in place (distancing, handwashing, ventilation) schools do not appear to be contributing widely to the spread of COVID in the community. They CAN be reopened safely and prevent some of the unfortunate other unsafe conditions for children, particularly our most vulnerable children.

Interrupting Racial Trauma: Strategies & Tools to Assist Health Care Professionals to Do No Harm (Washington, 2/17/2021)

A HUGE thanks to Dr. Sharon Washington for her wisdom on interrupting bias in the health care setting. Engaging in anti-racism is hard work. We know that every institution in this nation is struggling now to confront the recognition that race and racism are a fundamental part of who we are as a nation, as a society, and as a community. Healthcare is no different. I will add a summary of this Grand Rounds in the near future. Better yet: watch it yourself here: https://youtu.be/YpjNkCTNpxY

Benzodiazepine-Sparing Alcohol Withdrawal (Maldonado, 2/10/2021)

Great thanks to Dr. Jose Maldonado, a Stanford psychiatrist and neuropsychiatrist, who literally wrote the benzodiazepine-sparing alcohol withdrawal protocols that we have been utilizing at SSRRH for the last few years. He gave us a deep dive into the science behind them this week! If you want to see the whole presentation, it is archived here: VIDEO: Benzo Sparing Alcohol Withdrawal 

For those of you who prefer the written word, here is Dr. Maldonado's paper, and for those who prefer an abbreviated version, here are my notes from Grand Rounds:

Alcohol Use Disorder is extremely common in our society, particularly among hospitalized patients: 20-42%of hospitalized medical patients; ~7% are identified by physician. Check out these numbers:

• 40% of ED patients
• 43-81% surgical and head and neck patients
• 42% of hospitalized veterans 
• 59-67% of trauma patients
• up to 44% elderly patients admitted to acute geriatric units

Remember that legal driving limit is a blood alcohol concentration (BAC) of 0.08. Alcohol follows zero order kinetic metabolism, which means there is nothing we can do to slow down or speed up its rate of metabolism.  Ethanol is metabolized at rate of 0.015% per hour,which means a  person with BAC of 0.15 (twice the legal driving limit) will have no measurable alcohol in the bloodstream after 10 hours. 

Alcohol Withdrawal Syndromes

This is something I did not really know before this presentation: alcohol withdrawal CAN present even if BAC is still quite elevated. In fact, signs and symptoms of withdrawal occur once a person's BAC drops by 30% from their usual level; this means that you don't have to be at a BAC of zero to have symptoms of alcohol withdrawal. In fact, you can be in DTs even with an extremely elevated BAC, if it is just lower than where you normally live.

Here is another pearl: 80% of patients withdrawing from alcohol do NOT require aggressive medical treatment; supportive management is enough. If we treat everyone who walks through the door for alcohol withdrawal, we will definitely over treat--> leading to respiratory depression, toxicity, falls, oversedation, etc.

There are FOUR unique alcohol withdrawal syndromes: 2 are dangerous/complicated, 2 are not

1. Uncomplicated Alcohol Withdrawal ("The Shakes")
• 80% of all patients
• tremor, usually fine (but can be coarse)
• GI distress, anxiety, difficulty sleeping/insomnia, violent and unpleasant dreams, mild sx of autonomic instability
• sx decrease usually by day 5, more severe symptoms last 10-14 days
2. Alcohol Withdrawal Seizures ("Rum Fits")--> complicated 
• 5-15% of all patients
• peaks quite early: 12-48 hours (much earlier than DTs)\
• the greater the amount of alcohol consumed, the greater the risk of seizure
3. Alcoholic Hallucinosis  ("The Horrors")
• up to 30% of all patients
• onset: ~8 hours, peak 24-96 hours
• related to length and amount of alcohol exposure
• auditory, visual, tactile hallucinations in context of CLEAR sensorium, stable VS
4. Delirium Tremens ("DTs")--> complicated
• ~5% of all patients
• peak can be relatively late, up to 7 days after stopping alcohol
• "autonomic storm"
• 1% mortality in healthy person, but can be as high as 20% if elderly and multiple medical issues

What is the problem with benzodiazepines?  Well, you and I know that there are too many things to count. . . here are a few:

1. Benzos have serious abuse liability; plus there is 29-76% concurrent alcohol and benzo use
2. Benzo use may increase craving, early relapse to alcohol use, and increased alcohol consumption
3. Benzos are CNS depressants and really prolong withdrawal rather than treat it
4. Benzos cause psychomotor retardation, cognitive blunting, ataxia, poor balance, and decreased mobility
5. Benzos disrupt circadian rhythms of melatonin release, interfering with sleep
6. Benzos disrupt thalamic gating
7. Benzos are associated with an increased risk of delirium (40% of the time)

The Neurotransmitter-imbalances of Alcohol Withdrawal

Alcohol withdrawal is a complicated cascade of neurotransmitter imbalances involving all kinds of brain chemistry (this takes me way back to my neuroscience degree from undergrad). For the purposes of the algorithm, key imbalances include: excess of norepinephrine (NE), glutamate, dopamine, as well as a defective GABA-ergic system

The very imbalances of these neurotransmitters is what is being addressed in the benzo-sparing protocol, aimed at evening things out.

1) Alpha 2 agonists are the basis of the benzo sparing protocol: taking you way back to pharmacology 101, the alpha 2 agonists work at the presynaptic receptor, preventing the release of massive amounts of NE and Glutamate that occurs in alcohol withdrawal--> this, in essence treats, rather than masks (in contrast, Beta blockers mask alcohol withdrawal (post synaptic), but patient will still seize)

There are three alpha-2 agonists (in order of efficacy)

• clonidine: cheap, easy, readily available, comes in PO/IV/patch
• dexmedetomidine (precedex): highly selective alpha 2>alpha 1: offers more anxiolysis, less hypotension and bradycardia. BUT it is only IV, and has to be administered in ICU/monitored bed (there are not great papers, but lots of good anecdotal evidence, intensivists use it all the time at SSRRH)
• guanfacine: more highly selective than even dexmedetomidine, but has long half life (takes a bit to kick in)

There are at least 11 studies showing a benefit of alpha-2 agonists OVER  benzos (better in terms of withdrawal, anxiety, agitation, progression to DTs), Dr. Maldonado says these agents overall are about 3x better than benzos.

2) The other major component of the benzo-sparing protocol are the Antiglutamatergic agents/calcium channel modulators. These include carbamazepine, valproic acid (VPA), gabapentin, and pregabalin to name a few. Dr. Maldonado prefers pregabalin>gabapentin>VPA.

• 13 studies: head to head, cbz, VPA are equal to or superior to benzos without all the problems benzos have
• VPA (available PO/IV)
• Gabapentin multiple studies showing equal to or superior to benzo
• Pregabalin: same mechanism of action, but gabapentin only absorbed in small intestine, more gabapentin you give, the less you absorb. Pregabalin absorbed throughout entire GI tract, peak plasma concentration 1 hour (compared to 3-4 for gabapentin),

How do we distinguish which patients who will go through withdrawal need treatment?

To distinguish those 80% who only need supportive care from those who needs medical management, you can use the PAWSS Score, close to sens 100%, spec 100% to predict alcohol withdrawal

• PAWSS<4, pt might withdraw but will not have complicated withdrawal
• PAWSS>4: pt WILL have severe or complicated withdrawal
• if already withdrawing, treat
• if not, ppx arm

Summary of Stanford Benzo Sparing Protocol

A. Alpha 1 agonist: 0.1mg clonidine patch x 2 (#1 removed day 4, #2 removed day 7) PLUS 0.1mg PO/IV q 8 hours x 3 doses 
B. IF vital signs unable to tolerate alpha 2 effect OR patient has excess anxiety--> you can instead use high dose gabapentin (1200mg loading, 800mg TID w/taper) OR high dose pregabalin 150 mg loading (see here for protocol) OR VPA 250mg PO/IV BID + 500mg QHS

• IF patients at extremely high risk for AWS (PASS>7 or BAL>300 on admission) USE both A+B
• For adjunct medication: melatonin 10 mg PO qhs, hydroxyzine prn anxiety, doxylamine prn insomnia
• benzos (PO lorazepam) should only be used if high breakthrough sx despite adequate treatment with A+ B (e.g. CIWA>15 or >20) 

Random pearls:

• Electrolyte abnormalities are particularly common in patients with alcohol use disorder and alcohol withdrawal: watch K+ (QT prolongation), Mg
• of note, hypomagnesemia is #1 electrolyte abnormality that predicts seizure in patients with withdrawal
• Thiamine deficiency is also endemic patients with alcohol use disorder: all patients with AUD should get thiamine 500 mg IV/PO/Im TID x 3-5 days
• Dr Maldonado says that they do discharge folks from their ER to home on these regimens with outpatient follow-up

In summary, per Dr. Maldonado, using a benzo-sparing protocol is safe and effective, decreases the risk of delirium as well as other adverse effects of benzodiazepines, decreases LOS, and ultimately hopefully helps the patient in the long-run. Go forth and get folks off their alcohol.