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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Burning Man. Musings from the playa

Burning Man. Musings from the playa.

As I biked around Black Rock City during the 2019 Burning Man Event, I came across so many poignant signs. One that I was especially drawn to was a bright pink lounge with a quote “Love more, fear less. Float more. Steer less.” This may be my mantra from this year’s Event.

Picture courtesy of Dr. Greenberg while biking along the Burning Man Esplanade.  The “steer less” was cut off…

I have always loved with my whole heart and have not been fearful. So, that part of the phrase was not as meaningful to me. But, I am a woman who steers like there is no tomorrow.

As a forward-thinking professional I have always worked a to-do list with an end-goal in mind: Doing well at Northwestern to position myself well to get into medical school, master new physician skills to perform better patient care, schedule the births of my first two children (our third child was just an unexpected blessing!), orchestrate a move back to our hometown to practice medicine.

Now that I am nearing my 50th birthday and my teenagers are “leaving the nest” I am waxing poetic on the whys and pace of life. I indeed would like to float more and steer less. I would like the future to unfold and for me to orchestrate less. This is emotionally freeing. I urge you to find a mantra that speaks to you and explore it.

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Burning Man Physician.

Burning Man Physician. I recently worked at the Burning Man event. What an experience! I doctored in the main medical tent on the main Esplanade.

It was a refreshing experience as the patients were thankful and had varied medical ailments and the paperwork side of doctoring was minimal. To make the experience even better the medical care (including physician care, x-rays, tetanus vaccines, and medications) were given free!

The medical tent was staffed with both family medicine and emergency medicine attending physicians, resident physicians, and a few medical students. There was always a full time pharmacist and x ray technician. Nurses and EMTs started many IVs to help patients receive IV fluids and medications. Many of the first-aid workers at the outlying minor medical tents were physicians themselves in other states and gave excellent care “in the field/playa.”

I worked four 12-hour shifts at Burning Man and I was known as “Dr. Leslie.” I went from cot to cot treating abscesses, dehydration, corneal abrasions, fractures as well as routine medical issues that any town of 70,000 people would have. It was an excellent experience for all involved. The patients frequently thanked all the members of the medical tent for providing their services. And, I think they also appreciated the clean and cool environment as a respite from the austere Black Rock Desert with the associated heat and dust storms.

I definitely enjoyed my first Burn.

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The male exam.

The male exam. What is the purpose of the male exam? It should incorporate evidenced-based guidelines, focus on prevention and health care promotion, ask about substance abuse, sexually transmitted diseases, diet, exercise, safety and depression screen.

Men aged 50-74 are doing poorer health wise than in the past. This is often due to self-imposed factors: substance abuse (tobacco, alcohol, or drugs) and not being safe.

Your physician should be a support system for you and should help with depression intervention.

In fact, well men often do not come in to see a physician. So, a physician’s should address possible depression.

What screenings should be done?

1. Blood pressure. The bp goal is less than 135/85,

2. Cholesterol screen (if older than 35),

3. Abdominal aortic aneurysm. An ultrasound of the abdomen is warranted for men aged 65-75 if they have ever (!) smoked.

4. Prostate cancer. Should you have PSA screening? There is insufficient evidence to screen for prostate cancer with a PSA lab test. You and your doctor should talk about should YOU be tested. If the patient has BPH with increasing symptoms or a strong family history of prostate cancer, this may be a warranted lab test. We also have to consider how good are the treatments?

5. Colon cancer. Should you have colorectal screening? Yes! If you are between 50 and 75 years of age. Colonoscopy is the gold standard (meaning the best test).

6. Lung cancer. Low dose CT scan of lung, if you have a 30 pack year history of smoking and you are between the ages of 55-80.

We no longer screen for testicular cancer and COPD. Although, patients should know their bodies… if they feel a lump on their testicle or have lung issues, tell your physician for an appropriate work up.

Physicians should Ask about safety issues: helmet use (motorcycle and bicycle and horseback riding), gun use (store guns and ammunition separately in locked safes), risky behavior including drugs, tobacco and alcohol.

And, obesity. 35% of men older than 50 are obese. Obesity is considered a BMI > 30. Want to know your BMI? https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Alcohol intake should take in 2 drinks or less per day to maintain health. When binge drinking men should drink 4 or less drinks at a time.

Make sure you have age-appropriate vaccinations. We suggest the influenza vaccine every fall. Tdap vaccines should be given once as an adult (or if you have exposure to infants) and even though it is a needed vaccine, your insurance may not pay for it. Td should be given every 10 years. Shingrix (2 vaccines) should be given after age 50 and be prepared for needing to be on a waitlist at your pharmacy to get this. Two pneumonia vaccines should be given: one vaccine at age 65 and one at 66. Your vaccine schedule may differ from the above if you have specific risk factors. Talk to your physician.

Statistics: 48% of men do not exercise regularly. 33% are obese. 32% have 5+ alcoholic drinks at least once. 31% have hypertension. 22% of men smoke. 20% of those under age 65 do not have insurance (How do they get routine medical care?). 12% of males rate their health as “poor.”

How to be healthier?

1. Drink less than 14 drinks per week.

2. Address depression.

3. Eat a healthy diet (4 helpings of veggies, decrease sodium and saturated fat and cholesterol and sugar).

4. Decrease lifestyle risks. Exercise 30 minutes most days of the week (The goal is 150 minutes or more). Cross-training is helpful. As we age, our muscle mass decreases and so strength training is important. Balance training over the age of 70 will help you not fall (and break a hip or have a head injury.)

I hope this helps…

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Here’s a great easy read. Two easy steps to slash health care costs by 75%. And, it’s not (!) Medicare for all.

Here’s a great easy read. Two easy steps to slash health care costs by 75%. And, it’s not (!) Medicare for all.

I love the sentence reading “…all of that bickering and chicanery goes away.”

https://www.marketwatch.com/story/the-us-can-slash-health-care-costs-75-with-2-fundamental-changes-and-without-medicare-for-all-2019-08-15

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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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