Episode 22 Salty and Sweet: Hypertension and Diabetes

The sun rises over the San Joaquin Valley, California, today is August 7, 2020.

Have you heard any news about COVID-19? You surely have, who hasn’t? But above all the negativity surrounding this disease, including political issues, there is hope for the future. Have you heard of, for example, mRNA 1273?(1) Could this be the vaccine we have been waiting for? We don’t know yet, but there are more than 21 vaccines being tested right now around the world. If an effective vaccine is found, you’ll certainly hear about it in this podcast.

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”― Viktor E. Frankl

Part I: Primary Aldosteronism with Roberto Velazquez Amador, MD, Rio Bravo Family Medicine Residency Program

1. Who are you?

I am Dr Velazquez Amador, I am originally from Jalisco, Mexico where I was born and race. I completed my medical studies at the Universidad of Guadalajara, and now I on the third year of FM residency.

1. What did you learn this week?

I learned about a patient whom had an incomplete work up for adrenal insufficiency but still treated. He ended up showing signs of Cushing’s syndrome and resistant hypertension. I want to talk about secondary hypertension and Primary Aldosteronism.

Why that knowledge important for you and your patients?

It is important because it reminds me that secondary causes of hypertension are often under diagnosed. 

How did you get that knowledge?

Reading upon new cases, specially from the inpatient population, it often leads me to find new differentials and new testing modalities. 

Where did that knowledge come from?

First line review data place for me is Uptodate now that I am in residency. But the initial knowledge came while on Medical school. Reading physiology and physiopathology books. The book that I like to consult a lot is Kelly’s Essentials for Internal Medicine, this book chapters encompass anatomy, physiology and the pathology aspect beside diagnoses and treatment. It is very complete. While in residency, also my reference is the AAFM articles. 

Primary Aldosteronism

The evaluation of a patient with hypertension depends upon the likely cause and the degree of difficulty in achieving acceptable blood pressure control since many forms of secondary hypertension lead to "treatment-resistant" hypertension. Because it is not cost effective to perform a complete evaluation for secondary hypertension in every hypertensive patient, it is important to be aware of the clinical clues that suggest secondary hypertension. There are a number of general clinical clues that, in isolation or in combination, are suggestive of secondary hypertension. Primary aldosteronism is  a hormonal disorder that leads to high blood pressure. It occurs when your adrenal glands produce too much of a hormone called aldosterone. 

The classic presenting signs of primary aldosteronism are hypertension and hypokalemia, but potassium levels are frequently normal in modern-day series of primary aldosteronism. The presence of primary mineralocorticoid excess should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. However, most patients with primary mineralocorticoid excess are normokalemic and, rarely, some are hypokalemic but normotensive (primarily in young adult females).

The most common subtypes of primary aldosteronism are:

1. Aldosterone-producing adenomas (APA)
2. Bilateral idiopathic hyperaldosteronism (IHA; bilateral adrenal hyperplasia)

The presence of primary mineralocorticoid excess should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. 

In patients diagnosed with primary aldosteronism, treatment of the mineralocorticoid excess results in reversal or improvement of the hypertension and resolution of the increased cardiovascular risk.

Who should be tested?

Test for primary aldosteronism in the following patients: 

●Hypertension and spontaneous or low-dose, diuretic-induced hypokalemia

The following patients should undergo testing even if they are normokalemic:

●Severe hypertension (>150 mmHg systolic or >100 mmHg diastolic) or drug-resistant hypertension (defined as suboptimally controlled hypertension on a three-drug program that includes an adrenergic inhibitor, vasodilator, and diuretic)

●Hypertension with adrenal incidentaloma

●Hypertension with sleep apnea

●Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (<40 years)

●All hypertensive first-degree relatives of patients with primary aldosteronism

Case-detection testing with measurement of plasma aldosterone concentration (PAC) and renin (plasma renin activity [PRA] or plasma renin concentration [PRC])

The test is performed by measuring a morning (preferably 8 AM), ambulatory, paired, random PAC and PRA or PRC.

The PRA and PRC are typically very low (due in part to the associated mild volume expansion) in patients with primary aldosteronism.

The PAC is usually >15 ng/dL (416 pmol/L), but may be as low as 10 ng/dL (277 pmol/L).

Some clinicians calculate a PAC/PRA ratio as part of the case detection strategy, but we prefer to use the paired random PAC and PRA (or PRC). The mean value for the PAC/PRA ratio in normal subjects and patients with primary hypertension (formerly called "essential" hypertension) is 4 to 10, compared with more than 30 to 50 in most patients with primary aldosteronism 

In general, a PAC/PRA ratio greater than 20 (depending upon the laboratory normals) is considered suspicious for primary aldosteronism, although others use a cutoff criterion of 30. 

Part II: Continuous Glucose Monitoring with Denise Le DeWhitt, MS3, Ross University School of Medicine 

1. What is a CGM?
2. A continuous glucose monitor is a special type of device that allows for continuous measurement of glucose levels from the interstitial fluid rather than the blood. 
3. Depending upon the device, glucose levels are measured every 5-15 minutes. 
4. CGM allows for a measurement of a trend in a patient’s glucose levels as compared to a measurement of a glucose level at a single point in time, commonly known as traditional finger prick testing.

1. How is it used?
2. A CGM works by placing a small sensor under the patient’s skin, commonly located on the abdomen or under the arm. 
3. The glucose readings are sent to a monitor via a transmitter. 
4. Depending upon which CGM brand is used, the monitor maybe attached to an insulin pump, which can be easily placed in a patient’s pocket or purse for convenience. 
5. Alternatively, some CGM devices may even send the glucose readings directly to a smartphone, or other smart device, if the patient has the app.

1. Why should we prescribe CGM instead of traditional glucometer?
2. Allows patients to take active control of their Diabetes.
3. It gives patients a better idea on how their sugar levels can fluctuate in a day (visually can see hypoglycemic and hyperglycemic level trends).
4. Decreased incidence of having hypoglycemic emergencies.
5. Some devices come with an alarm that can alert the patient when their glucose levels are too high or too low.
6. Reduced finger stick pricks.
7.  
8. Most popular brand names, or just focus on Free Style Libre (cheapest)
9. Free Style Libre (APPROVED by Medicare lowest cost and widest inaccuracy in low glucose range)
10. It is a CGM system that automatically measures the blood glucose levels of the person wearing it.
11. Apply the sensor with the provided applicator, and a glucose sensing filament is inserted just below the skin.  
12. The sensor measures glucose in the interstitial fluid.
13. By waving the digital reader above the sensor, it records the amount of glucose in the wearer’s system at the moment and stores the data in the digital reader.
14. It allows for immediate access to glucose levels and to trend hypoglycemia and hyperglycemia. 
15. It allows for ease of checking glucose in public discreetly. 
16. The system makes it easy for health care providers to have access to the stored glucose logs by connecting the reader to a computer.
17. Dexcom G6: (Medicare approved, costly sensors and transmitters)
18. Senseonics Eversense CGM (NOT approved by Medicare)
19. Medtronic Guardian 3: Impacted by Acetaminophen use, provides real time alerts for highs and lows

1. Medi-Cal and Medicare Coverage 
2. Medicare covers therapeutic continuous glucose monitors (CGMs) and related supplies instead of blood sugar monitors for making diabetes treatment decisions, like changes in diet and insulin dosage. 
3. For these individuals, coverage of diabetes drugs and technology dramatically increases their chances of living a life free of complications. Despite this, however, continuous glucose monitors (CGM) are not covered by Medi-Cal. 
4. CGMs are covered under California Children’s Services (CCS), a state program for children with certain diseases or health problems, this is limited only to children with multiple co-morbidities and children who are disabled.
5. Not currently covered under Medi-cal insurance.

1. How to set up for patient and for our office
2. Falls under the category of Durable Medical Equipment covered under Medicare
3. In order to be eligible these are the conditions that must be met:
4. Physician must prescribe the equipment for home use, and it must be medically necessary.
5. Physician prescribing the monitoring system, as well as the supplier, must be enrolled in Medicare and accept Medicare assignment.
6. Medicare recipient must have diabetes and must be using a blood glucose monitor to test levels 4 or more times daily. They must also be taking 3 or more daily insulin injections.
7. With Medicare Part B, Medicare covers 80 percent of the approved amount. Medicare recipients are responsible for paying 20 percent of the final, approved cost, and the Part B deductible will apply. 

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Speaking Medical: Xanthochromia
by Isabelo Bustamante, MS3

Have you seen the word xanthochromia in a Cerebrospinal Fluid (CSF) study result? Xanthochromia has a Greek origin combining “yellow” (xantho) and “color” (chromia). Xanthochromia basically meansyellowish-colored CSF that can be seen with the naked eye. CSF is normally crystal clear. Xanthochromia can be found after several hours of bleeding into the subarachnoid space. This is because of the degradation of red blood cells after Subarachnoid Hemorrhage or SAH. Now you know the medical word of the week, xathochromia. Have a nice week.  

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Espanish Por Favor: Azúcar
by Dr Claudia Carranza

Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is azúcar.  The word azúcar  was made popular by the famous Cuban singer Celia Cruz; she used it as an expression of happiness and joy “AZÚCAR!”

Azúcar is a sweet crystalline substance derived from many plants such as sugar cane and sugar beet. You guessed it! Azúcar means sugar in Spanish. Azúcar is a substance that is part of us as humans and it literally runs through our veins. 

Azúcar comes from the Hispanic Arabic assúkkar. Azúcar is a vital word to use when talking to patients with diabetes and obesity. Most people will understand blood glucose if you say just azúcar, but if you see a weird look in your patient you may be more specific with the phrase azúcar en la sangre. 

Azúcar alta means high sugar (hyperglycemia), and azúcar baja means low sugar (hypoglycemia). 

Now you know the Espanish word of the week, “AZÚCAR”, I hope you have a sweet day full of joy and happiness! Until next time!

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Now we conclude our episode number 22 “Salty and Sweet: Hypertension and Diabetes”. We covered the basics on Primary Aldosteronism with Dr Velazquez, the salty part: sodium and potassium; and Continuous Glucose Monitoring with Denise, the sweet part: sugar. Isabello explained xanthochromia, which is yellowish cerebrospinal fluid, and, to put the cherry on this salty and sweet cake, Dr Carranza taught that sugar in Spanish is azúcar.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. 

Our podcast team is Hector Arreaza, Gina Cha, Claudia Carranza, Roberto Velazquez, and the special participation of our medical students Isabelo Lucho Bustamante and Denise Le DeWhitt. Audio edition: Suraj Amrutia. See you soon! 

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References:

1. mRNA-1273 Approval Status, Reviewed by Judith Stewart, BPharm. Last updated on Jul 27, 2020. https://www.drugs.com/history/mrna-1273.html
2. University of Southern California - Health Sciences. “Significantly less addictive opioid may slow progression of osteoarthritis while easing pain.” ScienceDaily, 13 July 2020. www.sciencedaily.com/releases/2020/07/200713120014.htm, accessed on Jul 30, 2020.