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February 2, 2020
We have been waiting and waiting and waiting for the new community acquired guidelines. And here they are! Infectious Diseases expert Dr. Devang Patel, MD joins Matt DeLaney, MD, FACEP, FAAEM and Neda Frayha, MD for a conversation on CAP in general and the new guidelines in specific. For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year.  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.
January 30, 2020
In this Hippo Education Short, Infectious Diseases specialist Dr. Devang Patel sits down with our own Dr. Neda Frayha to discuss what we know so far about the new 2019-n-CoV coronavirus outbreak and what front-line clinicians can do if we suspect a patient of ours might have this viral illness.  References: Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med, 24 Jan 2020. DOI: 10.1056/NEJMoa2001017.  Munster VJ, Koopmans M, van Doremalen M, et al. A novel coronavirus emerging in China - key questions for impact assessment. N Engl J Med, 24 Jan 2020. DOI: 10.1056/NEJMp2000929 Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 24 Jan 2020. https://doi.org/10.1016/ S0140-6736(20)30183-5    Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet, 24 Jan 2020. https://doi.org/10.1016/S0140-6736(20)30154-9 Phan LT, Nguyen TV, Luong QC, et al. Importation and human-to-human transmission of a novel coronavirus in Vietnam. N Engl J Med, 28 Jan 2020. DOI: 10.1056/NEJMc2001272 Wuhan Coronavirus - 2019-n-CoV. Infectious Diseases Society of America. https://www.idsociety.org/public-health/wuhan-coronavirus/. Accessed 29 Jan 2020 2019 Novel Coronavirus (2019-n-CoV), Wuhan, China. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/summary.html. Accessed 29 Jan 2020. Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-n-CoV) in Wuhan, China. Centers for Disease Control and Prevention. https://emergency.cdc.gov/han/han00426.asp. Accessed 29 Jan 2020.   Resource: Centers for Disease Control and Prevention 2019-n-CoV PUI Case Investigation Form: https://www.cdc.gov/coronavirus/2019-ncov/downloads/pui-form.pdfpdf icon
January 1, 2020
Primary Care RAP has covered the start-screening-mammos-at-age-50 perspective in the past. Today, we’ll explore the other side of the coin: why women’s health focused organizations recommend beginning annual screening mammography at age 40. Neda Frayha, MD sat down with Dr. Alison Chetlen, DO a breast imaging expert and Associate Professor and Vice Chair of Education in the Department of Radiology at Penn State Health and Hershey Medical Center, for a deeper dive into the evidence we don’t always hear about in primary care. 
December 2, 2019
Hoarseness is a common complaint in the primary care setting. Our ENT colleague, Dr. Elizabeth Guardiani, sits down with Drs. Matt DeLaney and Neda Frayha to discuss how we can approach this in primary care as well as when to refer to a specialist.  For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and you'll stay up-to-date on all the latest with your favorite Primary Care RAP hosts and contributors.
November 2, 2019
We all know what to do in pre-op visits for non-cardiac surgery. But guidelines on the pre-op management of cardiac surgery patients are hard to find. Neda Frayha, MD sat down with Dr. Michael Grant, a cardiac anesthesiologist at the Johns Hopkins University School of Medicine, to learn what we need to worry about (and what our pre-op evaluations should include) when our patients go off to cardiac surgery. For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year. 
October 1, 2019
 It all started when Paul and Neda researched porphyria to answer a mailbag question. Paul couldn’t get the song ‘Ophelia’ by the Lumineers out of his head. So he did what any self-respecting lyrical genius would do and wrote a different version of the song. Hippo Education’s own Melinda Hershey brought her vocal talent to the collaboration, and voila - ‘Oh, Porphyria!’ was born.   For more incredible education like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year.   
October 1, 2019
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 Dr. Salim Rezaie of Rebel EM for an invigorating conversation about this controversial topic and what the literature actually tells us about it.    For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year.   
September 18, 2019
Given the recent spike of VAPI (vaping associated pulmonary injury) cases, our HIPPO medical editorial team review the clinical presentation and latest management recommendations for this lung disease. Mizuho Morrison and Sol Behar discuss a recent case, and review the hot-off-the-press published CDC health alert. Take a listen! Pearls: There has been a recent explosion in vape associated pulmonary injury, with serious morbidity and mortality. VAPI has been more commonly associated with THC-containing products ,although a wide variety of nicotine containing products and devices have been reported. Symptoms:  Constitutional symptoms (100%) Respiratory distress and cough (98%) GI symptoms: nausea, vomiting, diarrhea (80%) Fever (30%) Diagnosis: Vaping in past 90 days, bilateral pulmonary infiltrates on imaging, Ground-glass appearance noted on CT chest. Absence of detectable bacterial/viral infection.  Treatment:  Respiratory support Steroids may be beneficial Antibiotics alone do not appear to help as this is not an infectious process, rather an inflammatory one. However given initial mixed presentation, it is not unreasonable to initiate antibiotics until pneumonia is ruled out and diagnosis is confirmed.    References:  Layden JE1,Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report. N Engl J Med. 2019 Sep 6.  https://www.cdc.gov/media/releases/2019/p0906-vaping-related-illness.html https://emcrit.org/ibcc/vaping-associated-pulmonary-injury/  https://health.ny.gov/press/releases/2019/2019-09-05_vaping.htm   How would you like to listen to 6 months of full episodes for free? For the month of September, when you refer a friend to sign up for Primary Care RAP,  you'll get 6 free months of Primary Care RAP for yourself--on top of the $25 Amazon gift card you get for every friend who signs up! Start sharing below!  Refer a friend
September 1, 2019
We see “ALL: PCN” all the time. But how often is it true? And why does it matter? Our own Dr.Neda Frayha sits down with Dr. Torie Grant, a Med/Peds Allergist and Immunologist at Johns Hopkins, to learn all about the risks attached to a penicillin allergy label and some easy approaches to debunking this allergy in the primary care setting.  Thanks for listening to Primary Care RAP on iTunes. We hope you've learned some fantastic pearls so far from the free chapter segments.  How would you like to listen to 6 months of full episodes for free? For the month of September, when you refer a friend to sign up for Primary Care RAP,  you'll get 6 free months of Primary Care RAP for yourself--on top of the $25 Amazon gift card you get for every friend who signs up! Start sharing below!   Refer a friend
August 1, 2019
Can HIV be managed in the primary care setting? With today’s advances in antiretroviral therapy, the answer is yes. Infectious Disease expert Dr. Devang Patel sits down with Mizuho Morrison, DO and Neda Frayha, MD for a conversation about the latest developments in HIV treatment.  For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year.   
July 1, 2019
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 well-being.    Subscribe today for more incredible storytelling and 3.5 hours of CME each month.  
June 2, 2019
In this segment, Dr. Sandra Quezada teaches Tom Robertson, MD, and Neda Frayha, MD 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. For more incredible education like this, subscribe to PC:RAP today.You'll never miss a moment of the program and earn 42 hours of CME per year. 
May 2, 2019
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 Mizuho Morrison, DO, and Neda Frayha, MD 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.   For more incredible podcasts like this, subscribe to PC:RAP today.You'll never miss a moment of the program and earn 42 hours of CME per year. 
April 2, 2019
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.   Subscribe today for more incredible storytelling and 3.5 hours of CME each month.
March 2, 2019
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.   Subscribe today to hear the rest of this months episode
February 2, 2019
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.
January 2, 2019
What does the former CFO of Pixar have to do with physician burnout and the culture of medicine? We find out in this segment. Dr. Neda Freyha 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. To hear the rest of this episode and many more - Subscribe Today!  
December 2, 2018
There are four main types of hypertensive disorders in pregnancy, and there are nuances to how each should be managed differently. In this segment, Drs. Megan Jones and Neda Frayha walk us through these four categories, how to tell them apart from one another and how to manage them, including when to consider early delivery.
November 1, 2018
Dr. 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.
October 1, 2018
Dr. Paul Offit 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 and Neda Frayha 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.
September 4, 2018
Infertility affects 1 in 8 couples in the U.S., and patients often present first to their primary care providers. In this segment, reproductive endocrinologist and fertility specialist Dr. Lauren Roth takes us through the workup and treatment algorithm of patients with infertility, including treatment risks and success rates.
August 28, 2018
Are you a fan of your annual physicals, or are you moving away from them in your practice? In this segment, Neda and our new PC RAP contributor Aisha Lofters debate the merits and drawbacks of the annual physical. Spoiler alert: Aisha wins!
August 28, 2018
There are over 140 different types of interstitial lung disease, all with their own acronym. This adds up to a complex alphabet soup that can be hard to keep straight in our daily practice. In this segment, pulmonologist and medical educator Dr. Nirav Shah provides us with a broad framework for understanding ILD and how to approach the workup and early supportive treatment.
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