Episode 42 - Baker's Cyst - a podcast by Rio Bravo Family Medicine Residency Program

Episode 42: Baker’s Cyst.

What is a Baker’s cyst and how to treat it? Alzheimer’s disease may be linked to sleeping pills, polyarthalgia question. 

Today is March 1, 2021.

Arreaza: Spring season is here! A renewal of life and a renewal of hope in the future, and for some, a renewal of allergies. But we will not talk about allergies in our intro today, we will talk about dementia.

Civelli: Research is increasingly showing that poor sleep correlates to dementia[1]. In 2019, an article was published by the Alzheimer’s Association International Conference (AAIC) which highlighted several links between sleep medication, sleep disorders and dementia, while also showing us what we still don’t know.  

Arreaza: Investigators at Utah State University (go Aggies! – my wife told me to say that) found interesting sex-related differences: For Men who reported using sleep medication for sleep issues, there was a 3-fold risk of developing Alzheimer’s disease than men who did not use sleep medications. Women however had different results. For Women who did NOT report having any sleep disturbance but still used sleep meds, the risk of Alzheimer’s disease was nearly 4x’s greater. However, in Women who DID self-report sleep disturbances at baseline, but also took sleeping pills, there was actually a 33% reduction in risk for Alzheimer’s disease. 

Civelli: Another study by investigators at University of California, San Francisco (UCSF) did not echo these findings. They found no sex-related differences, and they adjusted for a variety of genetic and lifestyle confounders. In this UCSF research, frequent sleep meds and later dementia were strongly correlated – but only in Caucasian adults. The specific sleep medications were not identified however, some meds such as benzos, antihistamines, antidepressants, or others were included. 

Arreaza: At the University of East Anglia in Norwich, England, in 2018 it was found that long-term exposure to anticholinergic drugs, some antidepressants and antihistamines were specifically associated with a higher risk of dementia, while use of benzodiazepines were not.

Civelli: Meanwhile in pursuit of physical proof: 337 brains from the U.K. brain bank were examined. 17% and 21% had known benzodiazepines and anticholinergic chronic exposures. Slight signals in neuronal loss in the nucleus basalis of Meynert were identified. Whether benzodiazepine exposure relates to dementia remains controversial.

Arreaza: Suvorexant (Belsomra), the only orexin receptor antagonist that regulates wakefulness, is being tested in Alzheimer’s disease. This targeted therapy decreases sleep fragmentation and increases total sleep time. It may be the future. We will see.

Civelli: Lastly, although not a magic bullet, trazodone, has been shown to increase total sleep time in patients with Alzheimer’s disease without affecting next-day cognitive performance, and even slowing down cognitive decline in patients who complained of sleep disturbance. According to Dr. Karageorgiou of UCSF “You’re not going to see long-term cognitive benefits if it’s not improving your sleep, So, whether trazodone improves sleep or not in a patient after a few months can be an early indicator for the clinician to continue using it or suspend it”. More prospective research is needed. 

Arreaza: The bottom line is: Dementias are associated with serious circadian rhythm disturbances. Physicians are encouraged to focus on improving sleep to help patients with, or at risk for, dementia by consolidating their sleep rhythms. So, what will you do to help your patients sleep better today? 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

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Question of the Month: Polyarthralgia
by Ikenna Nwosu 

A 49-year-old female comes to clinic reporting bilateral wrist and ankle pain for 1 month. The pain is worse with movement and responds well to ibuprofen. She denies joint swelling, warmth, or morning stiffness. She reports feeling more fatigued than usual this past month. You note on her chart that she was diagnosed with COVID-19 approximately 6 weeks ago for which she did not need to be hospitalized.  She denies history of diabetes, thyroid disease, lupus, rheumatoid arthritis, trauma, or anemia. She denies fecal, urinary, or vaginal bleeding, no headaches, no chest pain, no SOB or dizziness. Exam is remarkable for a “tired look” and tenderness to palpation at bilateral wrist and ankles. No signs of inflammation on joints are noted. What do you think is the etiology of this patient’s symptoms and what workup would you order (if any)? 

Let’s repeat the question: What do you think is the etiology of the symptoms in a 49-year-old female who complains of symmetrical POLYARTHRALGIA and fatigue for 1 month, and what workup would you order (if any)? Clue: Listen carefully to the history of the patient. Send us your answer to rbresidency@clinicasierravista.org before March 22, 2021. The winner will be announced and will receive a prize.

Quote: “Coming together is a beginning; keeping together is progress; working together is success.”
—Edward Everett Hale 

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Popliteal (Baker’s) Cyst

Introduction: Baker’s cyst is named for William Morrant Baker, a 19th-century surgeon who first described the condition. It presents as swelling in popliteal fossa due to enlargement of gastrocnemius-semimembranosus bursa. It is often due to degenerative inflammatory joint disease or injury. It usually communicates with the adjacent knee joint space. The Prevalence increases with age. It is often Accompanied by OA.

Clinical Features: Posterior knee pain, stiffness, swelling, and other symptoms related to OA.
Complications: Enlarging, dissection and/or rupture, leading to compressing of adjacent structures and signs resembling thrombophlebitis.

Diagnosis: Clinically, there is a medial popliteal mass most prominent with standing and knee fully extended. Swelling softens or disappears with flexion to 45 degrees (Foucher’s sign). Imaging, usually plain radiography and US, performed if diagnosis is uncertain or another condition suspected. Differentials include DVT, other cystic masses, tumors, or popliteal aneurysms.

Management:

Treat underlying joint disorder: Such OA, RA, or meniscal injury which may be causing increased synovial fluid. Initial therapy: Arthrocentesis of knee and intraarticular injection with glucocorticoids (40mg triamcinolone). Decrease in size of cyst and/or discomfort observed in approx. 2/3 of patients within 2 days to 1 week from time of injection.

Glucocorticoid injections into joint space can also be effective in patients with cysts but without joint effusion. 

In refractory cases: initial diagnosis of a Baker's cyst should be re-evaluated. In patients who do not respond to intraarticular injection, ultrasound-guided direct aspiration of popliteal cysts, followed by injection of glucocorticoids, can be performed by clinicians experienced in this procedure. 

Generally, surgical excision should be reserved only for those cases where more conservative interventions have failed and where there is significant functional impairment that can be ascribed to the cysts.

Overall good prognosis:   Most popliteal cysts do not cause symptoms or complications. Some cysts resolve without any intervention, and most respond to treatment of associated disorders of the knee joint.

Arreaza:

After we turned off the mics, we always come up with good topics of conversation. So, after I turned off the mics, Dr McGill reminded me of an important principle in medicine. What’s true today, may be not true tomorrow. We remembered when enlarged tonsils were treated successfully with Nasopharyngeal Radium Irradiation[2] for more than 20 years, until the late 1960s. Those practices were discontinued because of improved treatments were created and because of concerns with carcinogenesis. During this COVID-19 pandemic I feel we have woken up every day with a new recommendation in favor or against multiple clinical practices, too many to count. One of them is the use of face masks. At the beginning, it was not recommended, later it was recommended, most recently double masking is showing some evidence of effectiveness. My message is, make sure you stay on top of the updates, especially during this era of “information”, which some may later be called “the era of misinformation” or “the era of fake news”.  

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For your Sanity: ***
by “AJ” Arash Farzan, MS3

A patient goes to the doctor and after a full discussion on diets the doctor says: “I guess you need to cut carbs”. The patient got very excited and asked: “Should I cut the with a fork or a knife?”

Now we conclude our episode number 42 “Baker’s Cyst”, a common complaint in patients who have any kind of joint effusion such as ACL tears, meniscal tears, rheumatoid arthritis, but especially osteoarthritis. Remember our question for this month. What is the etiology of polyarthralgia in a 49-year-old female with increased fatigue for 1 month? What workup would you order (if any)? Clue: Listen carefully to the history of the patient. Send us your answer by email before March 22, 2021. Remember, even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Valerie Civelli, Terrance McGill, Ikenna Nwosu, and “AJ” Arash Farzan. Audio edition: Suraj Amrutia. See you next week!

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References:

Smith Jennies, Sleep aids and dementia: Studies find both risks and benefits, MDedge News, August 7, 2019, https://www.mdedge.com/chestphysician/article/206002/alzheimers-cognition/sleep-aids-and-dementia-studies-find-both-risks?sso=true.

NRI: General Information, Centers for Disease Control and Prevention, https://www.cdc.gov/nceh/radiation/nri/default.htm

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