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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Posted in Uncategorized

Vaccine updates per American Family Physician magazine

Do you need an HPV vaccine? Maybe.

HPV Vaccine

First up was a vote to recommend that HPV vaccination be based on shared clinical decision-making for patients ages 27-45 who have not been adequately vaccinated.

The question arose after the FDA in October approved the use of Gardasil 9 vaccine for the first time in this age group.(www.fda.gov)

STORY HIGHLIGHTS
  • During the June 26-27 meeting of the CDC’s Advisory Committee on Immunization Practices, the group voted to update its recommendations for the nine-valent HPV and 13-valent pneumococcal conjugate vaccines.
  • Other topics considered during the meeting included recommendations for a catch-up schedule for children and adolescents ages 2-18 who hadn’t previously received hepatitis A vaccine and guidance for serogroup B meningococcal vaccination boosters for those with special conditions/circumstances.
  • During the ACIP’s upcoming meeting in October, the recently formed dengue vaccine workgroup will present its findings in preparation for a voting on a vaccine recommendation.

Rockwell said ACIP members discussed at length what guidance would need to be offered to help physicians with decision-making if indeed the recommendation to expand the age range for HPV vaccination was made.

As to the benefits of the expanded recommendation, “It helps those folks who missed out on getting vaccinated as adolescents, as the HPV vaccine wasn’t around when they were of that age,” Rockwell said.

“I believe clinicians are able to individually understand which patients may be helped by this vaccine,” she added. “For example, a 35- or 40-year-old newly divorced woman who had only one previous sexual partner and no history of abnormal Pap smears and who is now going back into the dating world is someone easily identified as one who would benefit from HPV vaccination.”

Next, the ACIP voted unanimously to recommend harmonizing the upper age for catch-up HPV vaccination across genders; now, all males ages 21-26 are recommended for catch-up HPV vaccination regardless of risk factors.

“Now, you don’t have to think about gender,” she said. “It’s recommended for all through age 26 for catch-up. Ideally, it’s recommended for patients ages 11-12 and for those as young as 9.”

Do you need two pneumonia vaccines? PCV13 Vaccine (Prevnar)

The ACIP also voted to recommend shared clinical decision-making on the PCV13 vaccine for people 65 and older who aren’t immunocompromised and who haven’t previously received PCV13. All those 65 and older are still recommended to receive a dose of 23-valent pneumococcal polysaccharide vaccine.

“This recommendation has been downgraded from an absolute recommendation for those 65 and older in immunocompetent adults down to shared clinical decision-making that they can get the vaccine at age 65 or older,” Rockwell said.

Rockwell said there was debate about how this change in recommendation might prove cumbersome when updating EHRs with protocols for giving vaccines.

“Now, clinicians are going to have to decide if their patient needs a PCV13 in addition to PPSV23 or whether their patient only needs PPSV23 and not PCV13,” she said. “The fear is that people who have COPD and compromised lungs, for instance, who are not recommended to receive PCV13 by this new decision may potentially be harmed by this recommendation if physicians decide not to offer PCV13 first followed by PPSV23, using shared clinical decision-making.”

Rockwell acknowledged that this type of change is hard to effect in real-time practice and can be confusing to physicians who don’t have time to review all the reasoning behind the recommendation.

“When the ACIP originally made this recommendation, they said they would go back in four years and review the data to see if the recommendation should be held,” she said. “It took five years, but they did that review and found that herd immunity from the little kids getting PCV13 starting in 2010 has made more of an impact than giving only adults the vaccine.”

Additional Notes

For the HepA vaccine, in addition to voting to recommend a catch-up schedule for patients ages 2-18 who were not previously vaccinated, the ACIP voted to recommend HepA vaccination for all patients with HIV who are age 1 or older and removing those with clotting disorders from the list of groups at high risk for HepA infection.

Many clinicians were already catching kids up on HepA vaccination, but now the recommendation supports their efforts, she added.

“The data shows that in the past 20 years, the improvements in screening for disease in the infusions that people with clotting disorders need to receive have basically made their risk for getting hepatitis the same as anybody else in the community,” Rockwell specified about removing clotting disorders from the high-risk list.

As for the serogroup B meningococcal vaccine, the ACIP said that because immunity wanes within one to two years after vaccination, it recommended booster vaccination for patients 10 and older who are at increased risk for MenB disease due to one of the following conditions or circumstances:

  • persistent complement component deficiency,
  • complement inhibitor use,
  • anatomic or functional asplenia (sickle cell), or
  • microbiologists at risk of exposure to meningococcus.

The ACIP recommends that the MenB booster dose for these groups be given one year after completing the primary series, followed by an additional booster dose every two to three years thereafter for as long as the increased risk remains.

Up Next

For the ACIP’s upcoming meeting in October, Rockwell said the recently formed Dengue Vaccine Work Group will present its findings in preparation for voting on a vaccine recommendation.

At this most recent meeting, Sanofi presented its new vaccine, Dengvaxia, which prevents infection caused by all four dengue virus serotypes in people ages 9-16 who have laboratory-confirmed previous dengue infection and who live in an endemic area. Risk for severe disease increases with subsequent infection.

In May, the FDA approved a three-dose schedule for the vaccine,(www.fda.gov) with doses given at zero, six and 12 months. The workgroup’s recommendations will be for the use of safe and effective dengue vaccines in the United States and its tropical territories.

Although the rabies vaccine was on the schedule for the June meeting, the ACIP ran out of time to discuss it, so it will be included for discussion at the October meeting, Rockwell said.

And finally, Rockwell said the group will vote on recommendations for the influenza vaccine for the next flu season in October, but she anticipates the guidance will be the same as it was for this past season.

Related AAFP News Coverage
ACIP Updates Japanese Encephalitis, Anthrax Vaccine Guidance
Group Considers Data on Various Other Immunization Topics

(3/6/2019)

CDC, AAFP Release 2019 Immunization Schedules
Updates Include Changes for LAIV, Hep A Vaccine

(2/11/2019)

ACIP Recommends Hep A Vaccine for Homeless Patients
Group Discusses Pneumococcal Vaccine Coverage, Redesigns Immunization Schedules
(10/31/2018)

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Free vasectomies at UNR

https://www.flickr.com/photos/pdamsten/32394407201
What picture did you expect?

Free vasectomies at UNR. Yep! You read that right.

The University if Nevada Reno School of Medicine (UNRSOM) is offering men (over 18 years old) who want permanent sterilization a free vasectomy.

UNRSOM is known for offering free clinic days through the Student Outreach Clinic (SOC). The SOC has medical students seeing patients with the oversight of full-fledged physicians. The free vasectomies will be done by a licensed physician with UNRSOM medical students observing and assisting.

A vasectomy is a minor outpatient procedure that blocks the sperm from reaching the semen. Vasectomies take between 15 and 45 minutes to perform and often costs $500 to $3000. Vasectomies are a highly effective birth control option (99% effective) that is permanent, takes less than an hour, and (in this case) free!

I’d say that is a win-win for local men who desire permanent sterility.

What should men expect after a vasectomy?

  • They should have a driver and someone who can help with tasks (driving and heavy lifting).
  • I suggest resting for the next 2-3 days.
  • Apply an ice pack intermittently on top of the underwear helps decrease swelling and therefore discomfort.
  • Do not bathe for 24 to 48 hours after the procedure to let the small incision sites heal.
  • Intercourse can be resumed after a week, but expect to use birth control until the semen analysis done at 3 months (and about 20 ejaculations after the vasectomy to clear the ducts of sperm) after the procedure shows NO sperm. No live sperm and no dead sperm (because were the dead sperm actually alive immediately after ejaculation?!).

When sex is resumed, the male should feel no differently than before. Vasectomies do not affect libido. There is no link between vasectomy and prostate or testicular cancer or heart disease. There will be ejaculate, just no sperm in the seminal fluid. Again, a win-win.

Want more information? http://www.plannedparenthood.org or http://www.vasectomy-information.com

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Death certificates

Death certificates.  What are they?  What information is on these?  As much as physicians want to preserve life, death certificates are also a bread-and-butter duty of physicians, especially family physicians.

There is a great deal of information on the death certificate.  It records the cause and manner of the person’s death.  These circumstances are used in many ways.  This information is sent to federal agencies, like the CDC.  This information is collated and this helps decide which medical conditions receive research and development fundal, helps  set public health goals, helps measure health status (at local, state, federal, and international levels.)

What is the pathway for this death certificate?  Indeed many people help fill out this document.  First, the death occurs, then the funeral home initiates a death certificate, then they send this to the certifier (often the physician, although sometimes a nurse practitioner or the coroner), then to the registrar for finalization.

What is the “cause of death?”  It is the physician’s best medical opinion.  This must be filled out (in Nevada) within 48 hours of receipt of the death certificate.

What is on the certificate?

  • date of death.
  • time of death.
  • social security number,
  • cause of death,
  • death due to a communicable disease?
  • did tobacco use contribute to the death?
  • If a female (age 5-75), there is additional information like whether they were pregnant within the past year.

The Nevada program is called the EDRS. Electronic Death Registry System.

Cause of Death.  If it is pending, then a coroner will fill this out.
“Immediate cause” is the final cause (example: pneumonia).  “Due to a consequence of”  (example: a bedridden patient).  So, for the example above, a bedridden patient contracted pneumonia and pneumonia was the final cause of death.  Was an autopsy performed?  Did tobacco use contribute to death?  Was the patient pregnancy (and, if so, when?)

  • NOT ACCEPTABLE CAUSES OF DEATH: Cardiac arrest, cardiopulmonary arrest, respiratory arrest, failure to thrive, multiple organ system failure, respiratory failure.

Manner of Death.

  • Often this is “natural causes.”
  • If it is not a natural cause, the coroner may need to address manner of death.
  • Injury is another manner of death (For example:  a fall may cause a hemorrhage and the blood loss causes death).

I hope I addressed all the questions you had about Nevada death certificates.

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Cholesterol

Cholesterol.  I attended a lecture recently from a well-known local cardiologist specializing in cholesterol.  Here are the “pearls” from the talk.

What is cholesterol?  Cholesterol are lipids that are carried on particles.  A cholesterol panel estimates what kinds of particles are circulating in a patient’s blood, as cholesterol can be small or large or dense.  Hint: you would like your cholesterol large and buoyant.

The LDL is the bad cholesterol that is found in a plaque.  Plaque is what accumulates on the walls of the blood vessel that decreases the blood able to flow through that blood vessel.  VLDL are triglyceride-rich particles that are also found in plaque.

The LPLa (lipoprotein a) is a good thing, it’s a molecule that helps to break down cholesterol.  LPLa is down-regulated (this is bad) in obese patients.

LDL-c is the concentration of LDL.  A Direct LDLc can be asked for at the lab.  A lipid panel is meant to tell us physicians, what are the chances that you have atherosclerosis which is what leads to an athlerosclerotic cardiovascular disease event (ASCVD).

What can we do? First, we treat cardiovascular risk!

  • Lifestyle modification is first line therapy: decrease saturated fats, increase dietary intake of fats from fish, increased dietary and supplemental fiber, increase soy protein, increase nuts, weight loss, exercise.
  • Use the risk calculator.  There are separate treatment pathways for primary and secondary prevention.
  • “Risk enhancers” should be considered… including coronary calcium scores.
  • Emphasize rechecking lipids after starting therapy.
  • Consider non-statin therapies like ezetimibe and psck9i-medications.

How to decrease triglycerides?

  • consume  low carbohydrate and low sugar diet.
  • Avoid excess fat in diet.
  • Add omega-3 supplements.

How to raise HDL?

  • Exercise.
  • Stop smoking.
  • Moderate alcohol intake (1-2 glasses of red wine/day).

When to start a statin?

  1. Known ASCVD (atherosclerotic cardiovascular disease).  This is a patient with known vascular disease, a history of stroke or heart attack or peripheral vascular disease.
  2. LDL more than 190, in a patient more than 21 years old.
  3. In a patient without an ASCVD event, but has diabetes, is aged 40-75, and has an LDL between 70-190.
  4. In a patient with an ASCVD-event risk of 7.5% in 10 years or more.
    1. Want to know your ASCVD risk score? http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/

Who should get a coronary calcium score?

  • If a patient is resistant to starting on a statin despite the labs showing that statins are suggested, a coronary calcium score is a test that can give us more information.  If the coronary calcium score is zero, then the chance of a ASCVD risk in the next 10years is low, so maybe no statin is needed.

Do statins help?  Yes!

  • It is know that statins help decrease ASCVD events by 30-60%!  That is fantastic!

What are the drawbacks?

  • 5-10% of patients complain of muscle pain.
  • It may lead to new-onset diabetes, but most of these patients are already at risk for diabetes (risk factors for diabetes are a BMI of more than 30, fasting blood sugar is already more than 100 or in a patient with hemoglobin A1c of more than 6%).
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Ohhhh… the Wall Street Journal explains direct medical care.

Ohhhhh… the Wall Street Journal explains direct medical care.

I am such a fan of direct medical care. Many of the 350 family medicine physicians that I trained in Kansas have opened direct medical care practices.

Here in the West, direct medical care has not caught on as much. Here I see more concierge practices, which are different.

Please read on. Consider finding a direct medical practice to join for your family (or your business!) and decrease your insurance payments drastically, increase your access to your physician, and decrease the payment to the insurance companies.

https://www.wsj.com/articles/cut-out-the-medical-middlemen-11558294424?emailToken=cef4438463c8eca7d47431adca8dffeeNJ7P3N0eQb8h3k0R5lulbzk5%2FZ+ng%2F4v1HO0if8fP%2FdclDqJx9bwzxowARF9Qo+DzeDQSexrHwt8FDEf%2F%2FFEhg%3D%3D&reflink=article_email_share

https://www.dpcare.org/

I hope this helps.

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Diabetes management

Diabetes management!  I recently attended a lecture on diabetes management.  Here are the  nuts and bolts…
There are three pillars of diabetes management…  It’s best to max out #1 and #2 or you and your physician will need to travel down the road of #3.

#1. Diet.  A key strategy is 45-60 grams of carbs per meal. Limit sweetened beverages and concentrated carbohydrates. Eat a “consistent carbohydrate diet.”
Mediterranean diet, DASH, plant based diets. To lose weight have a deficit of 500 to 750 kcal/day.

#2. Exercise. At least 150 minutes per week of moderate intensity aerobic, keeping heart rate at 50-70% of maximum heart rate. Strength training of 2-3 times per week is helpful for patients older than 50.Medications
Diabetes affects 8 different organ systems. For instance, pancreas is involved with insulin secretion and glucagon secretion, the brain is affected with appetite control, the kidney is affected by glucose reabsorption, the muscle has changes in glucose uptake.
The ADA has a new guideline December 2017 (see link at the bottom) which lets us know which medications to start depending on hemoglobin A1c. Metformin is the mainstay medication.

When should insulin be started?  If the patient is on 3 oral medications at the maximum dose AND still not at HbA1c goal, the patient is due for insulin.
#3 Medications.  And now the list of drug classes with their in-class medication names and the specifics.

Sulfonylureas. Decreases A1c by 1.5 % but it leads to progressive decline in beta-cell function. This has fallen out of favor due to this. Within 3 years more patients require second anti-diabetic medication.

Alpha-glucosidase inhibitors (brand names: Acarbose and Miglitol). Decreases A1c of 0.5 to 0.8%. This class of drug is not known to increase weight gain nor does it cause hypoglycemia. These medications help the patients decrease the speed of carbohydrate digestion. This may cause stomach cramping and feeling gassy.
Biguanides (metformin). This decreases GI glucose glucose absorption and reduces appetite and decreases liver glucose production. This helps bring the fasting glucose in the morning. Lowers A1c by 1.5% This is a safe drug for patients with good liver and kidney function. If patients get a CT scan, they should stop this medication 2 days before contrast use.
Meglitinides (brand names– Starlix and Prandin). Most physicians don’t use this drug class often. These medicines may cause hypoglycemia. May lower A1c by 1-1.5
Thiazolidinediones (TZD)–brand name: Actos and Avandia . Decrease A1c by 0.8 – 1%. Lower blood sugars without hypoglycemia. A few years ago, there was a bladder scare. This has been changed to show that bladder cancer patients were in smokers. This may increase central adiposity.
Dipeptidyl peptidase 4 inhibitors (DPP4s)–brand names: Januvia, Onglyza, Tradjenta. Lowers A1c from 0l.5 – 0.8%. Do not cause hypoglycemia often. Can be used in combination with other oral agents. May cause abdominal pain or headaches or sciatic nerve pain. Do not use this with GLP1 drugs. Tradjenta is dosed in one dose only and no adjustments are needed for renal failure patients.
Bile Acid Sequestrants (brand name: Welchol). Lowers A1c 0.5 – 0.6%. Lowers both A1c and LDL cholesterol.
Dopamine Agonist (brand name: Cycloset). Resets the biological clock and may. It does decrease A1c from 0.3 – 0.5%.
Sodium glucose Co-transporter 2 (SGLT2) brand names Invokana, Farxiga, Jardiance, Steglatro. Blocks the reabsorption of the glucose by the kidneys. Lowers A1c 0.7-1.0%. May also cause weight loss. There is a low risk of hypoglycemia. It may increase yeast infections in both women and uncircumcised males. SGLT2 may lead to reduction in bone formation. Invokana may increase rate of amputation. And, a rare side effect of this class of drug is Fournier’s gangrene. Jardiance may help decrease cardiovascular events.
Glucagon-like peptide-1 receptor agonist. GLP1 (Byetta and Victoza and Adlyxin and Bydureon and Trulicity and ozempic) is responsible for the incretin changes. It lowers A1c 0.6 – 1.4%. May cause nausea, vomiting, and a pounding temporal headaches. May cause weight loss and less chance of cardiovascular events. May use with metformin. Do not use with DPP4s. This may promote proliferation of beta cells and islet cells. Byetta is dosed twice a day. Victoza is dosed once a day. Adlyxin is new in 2016. Injection site may feel like a knot under the skin. This is normal and intended. Bydureon is dosed once a week. Trulicity is also dosed once a week. Ozempic was FDA approved in 2017 and is dosed once a week. This class is well tolerated.
Insulin. The goal is to start the patient on a therapeutic dose. 0.2 units/kg patient weight.
Rapid acting insulins work in 15 minutes and peak in 30-90 minutes and duration is 3-5 hours. This is matched with their food. Timing of insulin injection is important. Longer acting insuin (levemir and lantus) with onset 1-2 hours with peak at 3-9 hours with duration of up to 24 hours. Basaglar is biosimilar to lantus requires 25-50% more insulin than levemir and lantus. Toujeo is glargine U-300. Duration is 36 hours. Tresiba has a duration of 42 hours. This may be beneficial in patients who forget to take their daily insulin dose.

Have you heard about an inhaled insulin? It’s called Afrezza. This is not often prescribed, needs good lung functioning and can only be used in a nonsmoker.
Want to know more?  The best overall look is the American Diabetes Association 2017 guidelines. https://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf

 

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Vocal cord dysfunction

Vocal cord dysfunction.

What is this?  Feels like throat tightness, not lung/chest tightness.  Starts less than 5 minutes into exercise and recovers within 5-10 minutes from stopping exercise.  These patients do not benefit from beta-agonist (albuterol) challenge like those who have exercise-induced asthma do.  Predisposing factors: allergic symptoms, anxiety, reflux.  Most common patient is a type A teenage female.

How to evaluate?

  • A laryngoscope during exercise.  Yep, this is just like it sounds…This is when the patient rides a bike hard or runs on a treadmill fast and then a scope is introduced into the mouth and down the throat to look at the vocal cords.  The vocal cords SHUT instead of open (!) in vocal cord dysfunction.  This is counterintuitive as during exercise, the athlete needs MORE air.  This makes it difficult for the athlete to inhale as much air as their body would like.

Treatment:

  • Speech therapy!  This is really the mainstay of treatment to help the vocal cords from shutting when they should be open.,
  • treat reflux as if stomach acid comes up the esophagus, the vocal cords may shut in response to this acidic insult to the cords,
  • behavioral treatment to help decrease anxiety.img_2402
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