This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/PCRAPPOD Paul Offit, MD is a world-renowned expert on the safety and efficacy of vaccines. He has authored over 160 articles, co-invented the rotavirus vaccine, and been featured on shows like “60 Minutes,” “The Daily Show,” and “The Colbert Report,” among many others. In this segment, Sol Behar, MD, and Neda Frayha,  MD pick Dr. Offit’s brain about why our patients may be skeptical about vaccines and how best to communicate with them for the safety and wellbeing of all our patients. Pearls: It is understandable that parents are questioning vaccines now given that they do not encounter the effects of these infections in their day to day life. The role of the clinician is to make the consequences of vaccine preventable diseases real for parents so that they can understand how truly scary they are.   Why might parents be skeptical of vaccines? Parents are no longer scared of the diseases that vaccines aim to protect children from. In comparison to the twenties and thirties, when children were dying from diphtheria or becoming disabled from polio, this generation of parents have not seen firsthand the effects of these infections. As practitioners, we are asking parents to vaccinate their children against 14 different diseases in the first year of life to prevent diseases that most people do not see, using biological fluids that most people do not understand. With these facts in mind, Dr. Offit underscores is reasonable it is for parents to be skeptical. What can practitioners do when faced with a vaccine skeptical parent? The first thing to do when you see someone who is hesitant about vaccines is to ask them what they are scared of. If there is a specific issue, be it autism, diabetes or multiple sclerosis, there likely will be data to answer those questions. As the clinician, you try to present the data in a compelling, passionate, and compassionate way. As Dr. Offit says, science alone is not good enough. It is also important to make people realize that the choice not to vaccinate is not a risk free choice. By referring to parent activist groups like Families Fighting Flu or National Meningitis Association, you can provide parents with examples of the very serious risk associated with not vaccinating. What is Dr. Offit’s approach to dealing with a parent that is unsure about vaccines? The way that Dr. Offit goes about it is as follows: he finds out what the parent is worried about, tries to go through how one would answer those question, he talks about what has been done to answer those questions and ends by emphasizing why it is important to vaccinate. He makes it personal, making sure that the parent knows that he has his own children that are fully vaccinated and says that vaccinating is a matter of loving the child. He tells parents that by not vaccinating their child, the parent is asking him to practice substandard care. Why might parents continue to believe that autism is linked to the MMR vaccine? As Dr. Offit explains, if you are a parent of a child that suffers from autism, you want to try and figure out why. What Andrew Wakefield offered was a reason why; in his explanation it was the vaccine that caused the development of autism. With this explanation, parents were allowed some control over the disease. For example, parents believed that they could control whether or not their future children developed autism but choosing not to vaccinate them. As practitioners we can say things like vaccines are good and vaccine protect against preventable disease but what we still cannot say is what causes autism and parents want that explanation. How can practitioners advocate for their patients? Say something. It is important for clinicians to speak up when they see misinformation being presented because these false claims are devaluing the truth of science. 

Primary Care RAP

Communicating with Vaccine Skeptics

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/PCRAPPOD   Rana Awdish, MD a pulmonary and critical care physician in Detroit, Michigan, wrote an incredibly powerful, bestselling memoir (In Shock) about her own experiences as a critical care patient. In this segment, she sits down with Neda Frayha, MD to talk about healing, the ways the giant medical education industrial complex contributes to provider burnout, and the redemptive power of connection. Pearls: Dr. Rana Awdish shares her story and takeaways from her experience as a patient that have changed how she practices medicine. A summary won’t do this justice - it’s a must listen!   Dr. Awdish’s medical story: She was in the final days of her training in pulmonary/critical care when she developed acute-onset abdominal pain while being 7 months pregnant. They assumed she had HELLP because her liver enzymes were in the 10,000’s, platelets were 15 and she was in hemorrhagic shock. It turns out that she had a ruptured hepatic adenoma, ended up losing the pregnancy, and went  into multiorgan failure in the surgical ICU. Some of her takeaways from that experience: She needed to be seen as a patient navigating an illness and having emotions about it Individual medical providers can have a profound impact on a patient’s experience during illness, both negatively and positively Providers often lose sight of the person immediately in front of us, caught up in things that are less patient-centric (ie: how many patients you have to see that day) Providers come in with an agenda without understanding what is important to the patient The medical education complex has a way of taking really idealistic and compassionate young people and often turns them into jaded cynics Part of this may be from a lack of modeling joy in work and a sense of purpose We often avoid hard conversations and leaning into the discomfort for the short-term benefit at the detriment of missing the long-term benefit Getting to know patients and tailoring your recommendations to their values is liberating as a provider Give yourself the permission to be the kind of providers our patients actually want us to be   References: Awdish R. In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope. New York, New York: St. Martin’s Press; 2017.        

In Shock

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/PCRAPPOD Post-contrast AKI (or contrast induced nephropathy as it used to be called) is one of those hot-button issues in modern medicine. Is it really a thing? Was it ever, really? Neda Frayha, MD sits down with Salim Rezaie, MD of Rebel EM for an invigorating conversation about this controversial topic and what the literature actually tells us about it.    Pearls: The term contrast-induced nephropathy has fallen out of favor to post-contrast AKI because the debate about contrast’s role in kidney injury rages on. Much of the recent literature has not shown a difference in AKI for those who receive a CT with contrast. Earlier studies were based on contrasts of higher volume and osmolarity given arterially that are not routinely used today. Remember that studies excluded those who had a renal transplant, GFR4.   Terminology: contrast-induced nephropathy has fallen out of favor to post-contrast AKI because we aren’t sure if contrast is really the culprit Issues with the literature: Many studies involved high volume, high osmolar contrast given arterially, not venous, low volume or low osmolar contrast Early studies used 15,000 milliosmole contrast whereas today we are using 320-800 milliosmoles or even iso-osmolar contrast Shown that route does make a difference. People receiving arterial contrast (ie: coronary angiography) are more at risk of AKI Studies are observational so you cannot get to causation, just association Other potential risk factors: comorbid conditions (diabetes, heart failure, hypertension), volume depletion, concurrent medications (vancomycin, NSAIDs, diuretics) Are outcomes clinical or patient-oriented (ie: dialysis, death, increased length of stay) or a lab value change? New literature: 1. Annals of EM 2017 (Hinson et. al) Single center Retrospective cohort study 17,000 patients who underwent CT with contrast, without contrast or no CT at all Excluded if Cr > 4mg/dL or renal transplant Bottomline: no difference in patient-oriented outcomes (dialysis, mortality) 2. Annals of EM 2017 (Aycock et. al) Meta-analysis 28 articles with 100,000 patients Bottomline: no difference in patient-oriented outcomes (dialysis, mortality) 3. Lancet 2017 (AMACING trial) Randomized control trial (three parallel group, open label, non-inferiority) Excluded if GFR

Post-Contrast AKI

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at  hippoed.com/PCRAPPOD We have been waiting and waiting and waiting for the new community acquired guidelines. And here they are! Infectious Diseases expert Devang Patel,MD joins Matt DeLaney, MD and Neda Frayha, MD for a conversation on CAP in general and the new guidelines in specific. Pearls: The latest guidelines for community acquired pneumonia now includes amoxicillin or doxycycline for 5-7 days as first-line treatment given the rising rates of macrolide resistance and less emphasis on coverage of atypical pneumonia pathogens.   Review of pathophysiology: Lower respiratory tract often preceded by an upper respiratory tract infection, that inhibits ability to clear mucus and pathogens invade the lungs Other risk factors: Smoking Elderly Immune compromise (ie: infection, steroids, cancer) Pathogens: Typical - strep pneumo, haemophilus, staph aureus Atypical (more common) - influenza, parainfluenza, mycoplasma, chlamydia pneumoniae, legionella, coccidioidomycosis (in the southwest) EPIC Study (2015) - study to determine pneumonia pathogens using all the tools we have available (culture, PCR) 62% no pathogen detected 22% viral - most were rhinovirus which does not cause lower respiratory tract infections but predisposes to pneumonia Strep pneumonia was the number one bacterial pathogen Bottomline: we still don’t know what causes most pneumonias but just that our patients get better with antibiotics Differentiating between typical v. atypical pneumonias - there’s no good way to know viral versus bacterial → default is to treat as bacterial pneumonia with antibiotics Diagnosis: Clinical features (cough, fever, sputum production, pleuritic chest pain, crackles) Guidelines recommend a chest x-ray For outpatient uncomplicated pneumonia, don’t get blood or sputum cultures For severe cases (those with risk factors for multidrug resistance, MRSA, or pseudomonas) you still want to get blood and sputum cultures Pearls: No more healthcare-associated pneumonia Emphasis on CURB-65 to assess severity of who does NOT need to be admitted Procalcitonin is NOT endorsed as a way to determine who gets antibiotics and who doesn’t Treatment: Increasing strep pneumo resistance to macrolides so no more monotherapy with macrolide (azithromycin) unless resistance is less than 20% in the area First-line in non-hospitalized adult is amoxicillin or doxycycline for 5-7 days Steroids recommended not use but may be considered in septic shock Commentary from Dr. Patel (ID specialist): Not a major change in practice other than to consider not covering atypicals in an otherwise healthy person   REFERENCES: Metlay JP, Waterer GW, Long AC, et al on behalf of the American Thoracic Society and Infectious Diseases Society of America. Diagnosis and Treatment of Adults with Community-Acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST. https://www.atsjournals.org/doi/10.1164/rccm.201908-1581ST  Jain S, Self WH, Wunderink RG, et al for the CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med 2015; 373:415-427. Postma DF, van Werkhoven CH, van Elden LJR, et al for the CAP-START Study Group. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med 2015; 372:1312-1323. 

Community Acquired Pneumonia Guideline Update

A cough lasting longer than 8 weeks can be a major frustration for our patients (and everyone around them). In this segment, pulmonologist and cough expert Dr. Kathryn Robinett walks Neda Frayha, MD, and Paul Simmons, MD through a real-world approach to chronic cough and drops tons of beautiful, shimmery knowledge pearls along the way. To view the references and show notes for this segment CLICK HERE   

Chronic Cough

In this Hippo Education bonus conversation, Drs. Jay-Sheree Allen and Neda Frayha sit down with noted health disparities researcher Dr. Utibe Essien, an Assistant Professor of Medicine at the University of Pittsburgh School of Medicine and Core Investigator for the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System. They explore reasons for disparities in the health care outcomes of our patients, disparities in the diversity of our medical profession, and the crucial bridge that connects these two. They close with three concrete steps we all can take to improve our clinical practice and reduce health disparities in our patient communities. CLICK HERE To view the references and join our thriving community of clinicians

Health Disparities with Dr. Utibe Essien

Got time? A lot of our resident listeners have been asking for tips and tools for time management in the clinic. Dr. Nikki Southall joins Paul Simmons, MD, and Neda Frayha, MD for a conversation about typical time sinks, some great time management tips, and strategies for becoming more efficient at work.  Click here to view references and show notes

Efficiency & Time Management in Clinic

Race and health are inextricably linked to each other. Pediatricians Nathan Chomilo and Michael Cosimini break down the AAP Policy Statement on the health effects of racism on children. To view the references for this segment Click Here

Racism and Child Health

 In recent weeks, many of our medical organizations have released official statements declaring racism to be a public health crisis. In this introduction to Hippo Education’s new Race and Medicine audio series, Dr. Jay-Sheree Allen sits down with Primary Care RAP host Dr. Neda Frayha for a candid conversation exploring the definition and types of racism, the historical and present-day manifestations of racism in medicine, and potential strategies we all can incorporate into our daily practices to go beyond the hashtag and become true allies. To View the references from this segment: Click Here 

Race and Medicine - An Introduction

Do you automatically refer to a urologist when a patient asks about a vasectomy? Have you ever considered that this procedure can actually be done in the primary care office? Our own Paul Simmons, MD discusses this with Lyrad Riley, MD in the first installment of a new series on procedural tips and tricks called: “Proceed with Confidence.”  To view the references and show notes from this segment Click Here

Proceed with Confidence: Vasectomies

Drs. Brian Lin and Mike Weinstock discuss alterations to our usual practice patterns of laceration repair in the setting of the COVID pandemic, which include increasing patient throughput through faster closure techniques, reducing total points of contact with the healthcare system by using techniques to obviate the need for a return visit, and habit changes during closure to minimize exposure risk during face-to-face contact.   To view the references and show notes from this podcast Click here

Laceration Repair in the Time of COVID

How are you coping with all of the death around us these days? In this Hippo Education update, Primary Care RAP host Dr. Neda Frayha interviews Dr. BJ Miller, a hospice and palliative care specialist at the University of California, San Francisco whose TED talk on what really matters at the end of life has been viewed over 10 million times. Along with Shoshana Berger, Dr. Miller is the co-author of the book, A Beginner’s Guide to the End: Practical Advice for Living Life and Facing Death and founder of the Center for Dying and Living. In this conversation, he helps us come to terms with our own mortality and provide better support to our patients at the end of life.    To view the references and show notes from this podcast Click here

Facing Death in the Time of COVID-19 with Dr. BJ Miller

Dr. Mizuho Morrison & Dr.Jenny Beck Esmay both having had covid themselves, briefly discuss the clinical course and what presence of IgM vs. IgG signifies. They discuss what we currently know about antibody testing (national availability, reliability, sensitivity) as well as convalescent plasma transfusion (CPT) and criteria for donation vs. recipient.   To view the references and show notes from this podcast Click here

COVID Antibodies and Immunity

*Editor's note: As of June 4, 2020, The Lancet article by Mehra MR et al has been retracted. (https://www.thelancet.com/lancet/article/s0140673620313246) In this Hippo Education short, Dr.Salim Rezaie from REBEL EM and Lit Matters critically appraises two papers published on Friday May 22nd, 2020.  He discusses what the evidence shows for both remdesivir & hydroxychloroquine/chloroquine as effective treatment or prophylaxis for COVID-19.   To view the references and show notes from this podcast Click here

*UPDATED* - The Saga Continues with Remdesivir and Hydroxychloroquine

COVID-19 causes STEMI’s, arrhythmias and myocarditis?!? Emergency medicine and cardiology guru Amal Mattu, MD chats with Mizuho Morrison, DO on the cardiovascular effects of COVID-19. They discuss: the known pathophysiology of how viral infections affect the heart; Review the new consensus statement from the Society of Cardiovascular Angiography and interventions (SCAI), American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) on how to manage STEMIs; and lastly discuss how cardiac arrest management differs in this COVID era.    To view the references and show notes from this podcast Click here

COVID CARDIOLOGY

Your work is hard; staying current shouldn’t be. Keep your practice ahead of the curve with entertaining, engaging and concise primary care and family medicine topics from world-class educators. This iTunes segment is just one monthly free segment of the full Primary Care RAP show. Get 3 hours of fresh podcast episodes per month and 42 AMA PRA Category 1 credit(s)™ per year when you sign up for the full podcast at hippoed.com. Don’t forget to download the Primary Care RAP app in the app store for even more streamlined listening.

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