Hello Reno Families!

This is Leslie Greenberg.  I am a family physician in Reno, Nevada.  I attended University of Nevada School of Medicine and relocated back to my hometown in 2015.  I trained and practiced medicine in the Midwest (Indiana and Kansas) for 20 years before moving back West.  I consider myself a teacher and educator.  I  have  taught family medicine residents for 20 years.  I currently teach at the family medicine residency program in Reno and also see private patients.  I invite you to read my blog.  If you would like to become a patient, please call 775-682-8200.

Medical Disclaimer

Please remember that medical information provided by myself, in the absence of a visit with a health care professional, must be considered an educational service only.  This blog should not be relied upon as a medical judgement and does not replace a physician’s independent judgement about the appropriateness or risks of a procedure or condition for a given patient.  I will do my best to provide you with information that may help you make your own health care decisions.

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Do you really need that pap? See the updated cervical cancer screening guidelines.

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Updated cervical cancer screening guidelines.  Do you really need that pap?

Why test for cervical cancer?  4000 patients still die annually from cervical cancer.  This is dramatically decreased compared to the 1950s, but racial and socioeconomic disparities continue to contribute to this number as our undocumented and uninsured may not have routine preventive care.

What is the best screening test? In 2018 the US Preventive Services Task Force (USPSTF) recommended testing for human papillomavirus WITHOUT cytology (meaning without a pap) as an option for cervical cancer screening for women 25 years and older.   Despite this recommendation, physicians often still perform a pap with HPV testing every 3 to 5 years, depending on the woman’s age.

What about women who have had the HPV vaccines?  In vaccinated patients, abnormal pap results are usually caused by HPV types with a low cancer risk.  The HPV vaccines are meant to vaccinate against the subtypes of HPV that are known to cause cells on the cervix to change from normal cells to cancerous ones.

When to stop doing paps?  If a patient has had a normal pap smear before, women can stop having paps at age 65.  Testing beyond age 65 in previously screened patients adds little benefit or life expectancy.  If the woman had been diagnosed with grade 2 or greater cervical dysplasia within the past 25 years and has had a normal pap within the past 10 years, she too does not need another pap after age 65.

I urge that you see your physician yearly for a well adult visit and you two can have a conversation about which test would be best for you.

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Mobility devices. WHICH is best for WHOM?

Mobility devices are used by nearly 30% of adults 65 years and older when OUTside the home and 26% use them INside the home. These devices often help decrease the risk and the fear of falling in older adults. Assistive devices can improve balance, increase mobility and confidence, reduce pain and decrease the risk of falls. When a fall causes a hip fracture, this is especially harmful in that hospitalization, surgery, rehab and possibly long-term nursing home care may ensue. The patient may never return to independent living.

Canes: improve standing tolerance and help walking by off-loading a weak or painful leg. Canes are the least stable of all assistive devices. Cane-users must have sufficient upper body strength, balance and dexterity to use them safely.
Standard cane: Should only be used for minimal weight-bearing.
Offset cane: More supportive than a standard cane. Handgrip more comfortable than standard cane.
Quadripod/ 4-pronged cane: Larger base, stands on its own slightly heavier than other canes, may not fit on stairs.

Crutches: Not used much in older adults due to the upper body strength that is needed to appropriately use them.

Walkers: MANY older patients use walkers to help people with poor balance or those who cannot bear full weight on their legs. There are a few different kinds of walkers.
Two-wheel rolling walker: Easier to maneuver than a walk with no wheels.
Four-wheel rolling walker: Also called rollator. Best for those who need rest breaks due to lung or heart endurance issues. Least stable type of walker so patients need to NOT need to fully off-load their weight from a limb.

Wheelchairs: Best for those who lack the lower body strength, endurance, or balance for walking. Need to be properly sized and the patient educated to help avoid skin breakdown, pressure ulcers.
Manual wheelchairs: Patients need sufficient upper body strength and coordination to move and maneuver it.
Power chairs: For those who cannot operate a manual wheelchair. These may be hard for insurance to pay for.

I hope this helps.

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New test for inflammatory bowel disease!

New test for inflammatory bowel disease!

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Fecal calprotectin is a protein expressed by neutrophils (white blood cells).  The presence of fecal calprotectin is a sensitive indicator that the gastrointestinal tract is inflamed.  Conversely, the absence of fecal calprotectin is a good indicator that the bowel is not significantly inflamed. The US Food and Drug Administration (FDA) approved the use of testing for fecal calprotectin to help physicians diagnose inflammatory bowel disease in both children and adults.

Who should get tested?  Patients with gastrointestinal symptoms of pain, bloating, diarrhea, mucus in the stool in the past may have only had the option to have a colonoscopy with biopsies to diagnose Crohn’s disease or ulcerative colitis.  Now fecal calprotectin testing can be done.  If the test is negative, patients may not need a colonoscopy because the diagnosis of inflammatory bowel disease is unlikely (but not zero).

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Does melatonin help older adults sleep?

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Does melatonin help older adults sleep?

Melatonin does (!) help older adults sleep.  It has been shown that melatonin preparations help people fall asleep faster, increase total sleep time, and slightly improve sleep efficiency.  Prolonged-release melatonin like ramelteon is thought to be helpful AND it does not increase traumatic accidents (head injuries, falls or motor vehicle crashes).

What are the guidelines?  American Academy of Sleep Medicine and the Choosing Wisely campaign both state that cognitive behavior therapy should be the primary treatment for chronic insomnia in adults.  This includes winding down before bed, only having sex or sleep in the bed, no blue lights or tv 30 minutes before bed.  The 2017 ASM guidelines gave a weak recommendation for starting ramelteon 8 mg nightly to help with chronic sleep-onset insomnia that did not respond well to cognitive behavior therapy.  Medications like Lunesta and ambien should be tried as a last resort.

I hope this helps.

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Alcohol Withdrawal syndrome. Can this be managed as an outpatient?

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Alcohol Withdrawal syndrome.  Can this be managed as an outpatient?

Half of patients with alcohol use disorder who abruptly reduce or stop their alcohol intake develop signs or symptoms of alcohol withdrawal syndrome.

Why does alcohol withdrawal syndrome occur?  The central and autonomic nervous system are revved up and overactive and this can lead to insomnia, nausea, vomiting, tremors, hallucinations, agitation and anxiety.

What can occur if alcohol withdrawal is not treated?  Seizures, delirium tremens and occasionally death can occur. 

Who can be treated as an outpatient (not staying overnight in the hospital)?  Patients with mild to moderate withdrawal symptoms (without additional risk factors) can be treated as outpatients.  Mild symptoms can be treated with carbamazepine or gabapentin.  For more severe symptoms, benzodiazepines are first-line therapy.  Patients will need to be seen by their physician daily for up to 5 days after their last drink to monitor symptom improvement and evaluate the need for additional therapy.  

What else can help?  A 12-step program, like Alcoholics Anonymous, are more effective at helping patients remain abstinent up to 3 years than other forms of therapy.

Why should patients do inpatient withdrawal treatment?  –Unstable home situation or absence of caregiver support. — Other psychiatric conditions.  —Previous drinking more than 8 alcoholic drinks per day. —History of severe alcohol withdrawal symptoms less than 1 year ago. —Dependence on other addictive medications. —Unstable transportation situation.

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Home blood pressure monitoring. Do you need it? How to do it?


Home blood pressure monitoring. Do you need it?  How to do it?

Blood pressure is an important vital sign.  Blood pressures should routinely run less than 135/85.  Some patients only have high blood pressure in physician or dental offices.  This is called “white coat hypertension.”

How to best monitor your blood pressure? I urge patients to do home blood pressure monitoring.  This entails using an appropriately fitting upper-arm cuff on a bare arm, emptying the bladder, avoiding caffeinated beverages for 30 minutes before taking the measurement, resting for five minutes before taking the measurement., keeping both feet on the floor, uncross your legs while sitting, keep the arm supported, with the bp cuff at heart level, do not talk during the blood pressure test.

How many readings to take?  Ideally, take two bp readings in the morning and in the evening.  Separate the two bp readings by at least one minute.  Do this once a week and record the average of the top number and the average of the bottom number. 

Why do home blood pressure monitoring?  I tell patients that they live in their homes, not my office.  So, if the bp is only high in my office… that’s okay.  Home blood pressure readings can confirm the diagnosis of hypertension after an elevated office blood pressure reading.  

How to pick a good bp machine?  It should be validated and fully automated.  Choose an appropriately sized upper arm cuff.  Have bp machine store measurements.  To get a validated machine, look at https://www.validatebp.org   Wrist cuffs are less accurate and positioning of the cuff over the radial artery may be difficult. 

Will my insurance pay for my blood pressure monitor?  Maybe.  Ask your physician to write you a prescription, then call your insurance to find out if it is a covered benefit.

Ambulatory blood pressure monitoring is another way to check blood pressures.  This involves wearing a monitoring device for 24 to 48 hours.  The bp is measured at regular intervals while the patient is doing normal activities.  This method of monitoring is more thorough, but is not widely available outside of academic medical centers. 

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The risks of pregnant women taking opioids…

On hospital call I frequently care for infants who are withdrawing from opiates.  This is called “neonatal abstinence syndrome” (NAS). 

What is NAS? It is a constellation of symptoms including high-pitched cries, tremors, hyperactive reflexes, poor feeding, poor weight gain, mottling of the skin, inability to keep temperature in a good range, vomiting, diarrhea and tremors.  It occurs in 50-80% of infants exposed to opioids in utero. 

All pregnant women should be screened for opioid use disorder and offered methadone or buprenorphine, which are safer for both mom and baby than opiates. 

Guidelines state that all newborn born to mothers who use opioids need to stay in the hospital for 5 days after birth to watch for the symptoms of withdrawal.  The infant’s behavior is scored.  If the score exceeds a threshold, treatment for neonatal abstinence syndrome is started. 

Initial treatment is having the newborn in a low-stimulation environment, swaddling, rocking the infant, feeding on-demand.  Skin-to-skin contact helps comfort the infant.  Breastfeeding may help decrease the need to give the infant opioids.  If the infant’s symptoms do not improve with supportive care, the infant is given morphine or methadone with phenobarbital or clonidine.  The dose of intravenous medication to the infant is weaned slowly.  Often NAS infants are in the hospital for a month before they are successfully weaned off of medications and sent home.  This gives the mother an opportunity for a fresh start. 

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Abnormal cholesterol labs. What to do with elevated triglycerides?


You see your physician and get a routine cholesterol panel.  The results show that your triglycerides are high.  What should you do?

Fasting lab work should show that your triglycerides should be less than 150. When triglycerides are higher than 150, it increases your risk of cardiovascular (CV) disease. If the levels are severely elevated (500 mg per dL or higher) add the risk of pancreatitis to the risk of CV disease.

What are risk factors for high triglycerides?

  • Metabolic syndrome
  • Type 2 diabetes
  • Obesity

What should you do if your triglycerides are between 150-500.  We suggest “lifestyle modification” as this decreases the 3 risk factors contributing to high triglycerides.  Sometimes I have patients list off to me what they are currently doing… and yet your body needs more healthful changes than you are currently doing.  This means that what you are currently doing is not enough to maintain good triglycerides and decrease your risk long-term of cardiovascular issues.  Decrease intake of carbohydrates, especially refined carbohydrates and increase physical activity.  Aim to have 30 minutes a day of moderate-to-high intensity physical activity.  Increase omega-3 fatty acid intake and increase protein intake.  These lifestyle changes will help improve exercise capacity and overall health. 

If your ASCVD risk (the risk of having a cardiovascular event in 10 years) is borderline or intermediate, then you and your physician can consider starting on a statin drug.  Here is an ASCVD risk calculator.

If you continue to have elevated triglycerides despite lifestyle changes and statins, high-dose icosapent, fibrates, omega-3 fatty acids or niacin can be considered. 

If you are admitted to the hospital with acute pancreatitis from hypertriglyceridemia, your physician may start an insulin infusion or do plasmapheresis.  The goal is to head this off at the pass. 

I hope this helps.

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Long covid or “post-acute sequelae of SARS-CoV-2

Oh my! Patients who have had the covid infection are often finding that they do not “bounce back” fast. In fact, a significant number of covid patients have lingering side effects


The World Health Organization report found that up to 10% with COVID-19 still have symptoms 12 weeks (!) later.

  • What are the symptoms?
    • Excessive fatigue
    • Cough
    • Chest pain
    • Shortness of breath
    • Brain fogginess with difficulty concentrating and with memory

The persistence of these symptoms may lead people to leave their jobs and it is known that prolonged absence from a person’s workplace is detrimental to physical, social, mental and financial well-being.

Ask your physician if she can write for appropriate workplace accommodations and adjustments.  Maybe your job or work environment can be tweaked for a few weeks to help your symptoms improve. 

Primary care physicians and occupational medicine physicians can help advise human resources or management leaders on return-to-work strategies.

The long-term health effects from SARS-CoV-2 infection are unknown.  Ask your physician for help.

Better yet, if you are unvaccinated, get vaccinated.  The vaccine greatly decreases your risk of contracting covid-19 and thereby decreasing your chance of long covid. 

Take care of yourself.

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Acne treatment for teens

Being a teenager is difficult enough… even without acne. Acne treatments for teens are available over the counter and from the pharmacy. Here is my overall treatment plan with ingredients that can all be bought over the counter.

I want a treatment that the teen can do. This means it should not be expensive and should be able to be incorporated into their overall skin care regimen. Easy and inexpensive; that’s my plan.

Depending on your acne (is it whiteheads? blackheads? cystic? scarring?) your treatment may need to be individualized. The following acne treatment for teens is a good place to start.

What are you doing now for your skin? Is it working? Are you diligent and do it daily? What has worked in the past? Are you a female and acne is worse before your menstrual period? If so, oral contraceptives may help your skin greatly. See your physician for contraceptive prescription.

Back to your skin, the facial skin does not like to be roughed up. So, I urge patients to start with washing morning and night with a facial cleanser. Inexpensive ones are Dove, Basis, or Cetaphil. Then, pat the face dry. No roughing it up with a buff-puff or abrasive sponge.

Benzoyl peroxide (BP) is available over the counter in 2.5%, 5%, and 10%. The stronger it is the more likely your skin will turn red, dry, and scaly before it becomes accustomed to it. BP helps kill the bacteria on your skin that causes acne. BP also helps your skin not become resistant to other topical medications for acne. BP can bleach your hair, clothing, towels, and bedding: so be aware of that. Often skin is sensitive to BP (and gets red, dry, and scaly), so consider using it every other day or every third day for a few weeks, until your skin is used to it and then you can increase the frequency to every day.

A topical retinoic acid derivative, adapalene, is also available over the counter. This can be used nightly (after your face is washed and patted dry). I suggest you use adapalene every other night and BP the nights you do not use adapalene.

Acne treatment for teens is great, but also it is important to wear sunscreen. Acne treatments can make the face more sensitive to light and more likely to burn. Pick a noncomedogenic sunscreen that is meant for the face. Neutrogena and Eucerin make a facial sunscreen that feels and smells good (and is also available without a prescription!).

Your teenager may be seeing acne advertisements. Most of these contain the ingredients above, but in a much more expensive format.

As always, see your physician for more individualized skin care help. Most primary care physicians can easily take care of acne. There are 1000 ways to help acne, this is just my routine first step: easy and inexpensive.

I hope this helps.

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