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.
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.
Should women under 50 add a screening breast ultrasound to their screening mammogram yearly?
No. A study looked at IF adding a breast ultrasound to a screening mammogram for women less than 50 years old (regardless of their breast cancer risk) HELPED detect breast cancers.
Breast cancer was detected at a similar rate across the groups (those with only screening mammogram and those with BOTH screening mammograms and ultrasounds). 5.4 versus 5.5 per 1,000 screens. So, the additional screening test did not find more breast cancers than screening mammogram alone.
The downside to getting screening ultrasounds in addition to mammogram are unnecessary breast biopsies. The breast biopsy rate was TWICE as high for the combination screening imaging compared to women who only received screening mammograms.
Hemorrhoids. What are they? What can you/we do to make them better?
Hemorrhoids are when the veins near the anus are filled with blood. Hemorrhoids are the most common benign condition that causes anal bleeding. You do need to see your physician for diagnosis. And you may need a work up for other causes of bleeding like anal fissures (a tear in the anal sphincter) or colon cancer.
What is the initial treatment? Add water and fiber! Take 25 to 35 grams of insoluble fiber (like OTC psyllium). Increase water intake to 64 ounces per day. If you are dehydrated, the stool is also dehydrated and this makes it more difficult to pass. Straining with a bowel movement sends more blood into those already engorged anal blood vessels. The goal is to pass a daily soft stool, with no straining. Sitz baths, sitting in lukewarm bathwater, also helps hemorrhoids. Topical treatments (steroids, antiseptics and analgesics) are often used, but the research does not show overwhelming success.
What if the pain is excruciating and you cannot sit down? Call your physician. You may have an acute thrombosed hemorrhoid and this needs medical attention. The pressure within the hemorrhoid is the uncomfortable part and your physician can incise (cut) the hemorrhoid and take out the blood clot within the hemorrhoid. This gives most patients instant relief.
What if all of the above does not work? Then I would send you to a surgeon. They may perform an office procedure like rubber band ligation to get rid of the problem blood vessel, or they may inject sclerotherapy into the problem blood vessel. A small number of patients need to be taken to the operating room for an excisional hemorrhoidectomy.
How to avoid hemorrhoids? Eat insoluble fiber (vegetable and fruit peels and whole grains) and adequate water intake. Do not strain with bowel movements. For occasional constipation, add OTC fiber or polyethylene glycol to your diet.
I recently attended a lecture on HIV in Nevada. Nevada is way ahead of the nation (read this: we are risky!) HIV Incidence rate is 20 people per 100,000. The national average is 12. Nevada has one of the highest rates of HIV in the country.
Many people who live with HIV do NOT know that they have it. 40% of new infections are transmitted by people who do not know that they have the virus. This is why widespread screening should be done.
HIV and STIs go hand-in-hand. In addition to high HIV rates, Nevada has one of the highest rates of syphilis and chlamydia infections. Infections are often without symptoms, get tested!
There is a national HIV/AIDS strategy for the USA. This was started in 2010. There are 3 overarching goals:
Reduce new HIV infections
Improve health outcomes for those living with HIV
Reduce HIV-related disparities
“Continuum of care” in HIV reveals our goals with HIV patients. Once a person is diagnosed with HIV, the patient is encouraged to receive HIV care, retain them in HIV care, prescribing antiretroviral therapies, achieving viral suppression.
How are Nevadans doing? Not well. Nevada’s continuum of care shows that of those diagnosed in Nevada with HIV only 81% were “linked to care.” This means 19% of HIV patients do not see a healthcare provider. Of the 81% who initially saw a physician, only 28% of patients retain their healthcare relationship. This means only 28% of patients are getting viral loads and medication. 26% of those with HIV in Nevada have reached viral suppression. When the virus is suppressed, this decreases the risk of viral transmission to others. So, viral suppression is the goal!
How can we end the HIV epidemic?
U = U. Undetectable = Untransmissable. The data is incredible relating to this. Thousands of sex acts have been studied and those HIV positive patients on effective HIV treatment with undetectable viral loads will not pass HIV on with sex.
Treatment as Prevention. Patients need access to testing and treatment. Support needs to be available to maintain viral suppression as this will help retention. Need access to viral load monitoring. This needs resources.
PrEP. Pre-Exposure Prophylaxis. This is for patients who are HIV negative which means patients need to know their HIV status. They take one pill a day. Two medications are in this one pill and there are two brands of pills with different doses of the two active medications. It is 99% effective. PrEP use in HIV-negative-Nevada is only 1% of the population, many don’t know that there is a VERY effective pill. Truvada or Descovy
nPEP. Non-occupation Post exposure Prophylaxis. (This is NOT a healthcare worker who has a needlestick). This must be started within 72 hours of exposure. 28 day treatment (Truvada plus Raltegravir). Highly effective. Minimal side effects. Does this patient want to start on PrEP after their 28 day treatment to decrease their risk of contracting HIV in the future?
STI (sexually transmitted infections). Those with STIs are more at risk for HIV. What body parts should be tested? 3 site testing: oral, rectal, urine-based. Because different body parts are being used to have sex, all 3 need to be tested. Oral and rectal swabs can be done very effectively by the patient. We miss 95% of gonorrhea and 73% of chlamydia because we often do not do 3 site testing.
Why is the way sex is performed important? There are different risks of contracting HIV from a partner depending on the manner of sex. Receptive anal sex has 1.4% risk per episode which is remarkably higher than any other manner. Insertive anal sex is 0.06 to 0.62%. Receptive vaginal sex is 0.08%.
It depends. If you have chronic migraines with more than 15 (!) headache days per month and at least 8 of those headaches being a migraine, YES! It will help you. If you have fewer than 15 headache days per month, it may not help decrease your pain-free days.
In one study botox was shown to reduce the number of migraine days per month by two days compared with placebo (sugar pills). Botox is FDA approved for treatment of chronic migraines. This approval may give you a better chance at your insurance paying for this treatment, but of course, that is never guaranteed.
There was a metaanalysis (a bunch of research studies with the results collated together) with nearly 4200 patients which showed that botox reduced the number of migraine days per month for 3.1 days in patients with chronic migraines.
What are the drawbacks to botox? Botox is delivered by injections which inherently has some discomfort. But, otherwise no serious adverse effects were noted. Mild symptoms were arm muscle weakness, eyelid drooping, neck pain, and injection site pain.
Many years ago, when I first considered pursuing a career in medicine, I thought long and hard before going down that road because I knew it would involve sacrifice. My dad was a surgeon, so, as much as any child can understand, I did. I understood the lifestyle of being called away, of working nights and weekends, of having healthcare decisions weigh on my mind. When I finally made the decision, I knew right away there were certain things I was signing up for. But medicine was my calling. I felt it what I was meant to do so whatever it took it was worth it.
I knew even then that I was signing up for a lot of nights studying instead of socializing or relaxing. I signed up for difficult classes and long nights. I signed up for volunteering in a hospital throughout college and stressing about grades and spending the summer studying for the MCAT. But I didn’t sign up for this.
When I got accepted to medical school I knew what I was signing up for. I willingly signed up for even more, even longer nights studying. I signed up for dissecting cadavers, high pressure tests, and losing touch with some of my best friends from college. I signed up for being at the hospital at 6 AM, losing 15 lbs during surgery rotation because I never had time to eat, and talking to friends on the phone to make sure they didn’t fall asleep driving home after a call shift. But I didn’t sign up for this.
When I entered Family Medicine Residency I signed up for moving halfway across the country (Kansas!). I signed up for working 80+ hour weeks, 30 hour shifts, and not sleeping in my own bed. I pushed my boundaries for what I felt comfortable doing: I worked as the solo physician in a small-town ER for 60-hour shifts so that those doctors can recharge. I signed up for spending my birthday on call and making an average of about $4 an hour. I am a good re-framer: I was on obstetrical call one birthday and felt blessed that I could welcome newborns to share my birthday. I signed up for stressed out patients and the responsibility of their health in my hands. But I didn’t sign up for this.
I followed my husband to rural Indiana while he completed his specialized medical training. I got a job teaching at the local medical school’s rural training site for family medicine and realized my love of academic medicine, for welcoming the new physician into my field. I put off having our first child until we had a more reasonable work schedule. But I didn’t sign up for this.
I didn’t sign up for spending more time with my computer than with my patients. I didn’t sign up for insurance companies dictating what tests and medications my patient can and cannot receive. I sure as hell didn’t sign up for a government official who doesn’t know a stethoscope from a horoscope telling me how often my patient needs to be in the hospital or cutting my reimbursement because someone was angry I didn’t refill their narcotic prescription early. I didn’t sign up for being told I’m not allowed to use the appropriate personal protective equipment in order to keep my immunocompromised patients, my colleagues, and myself safe because there’s not enough to go around.
I educate the new residents about how to become more efficient, how to work within the current cumbersome system. I encourage them to feel joy in everyday and to appreciate small accomplishments. I don’t want the next generation of physicians to throw in the towel, to not care for patients.
I knew what I was signing up for. I didn’t sign up for this.
Why are there pneumonia vaccines? Streptococcus pneumonia infection is the most common cause of bacterial pneumonia. We know that older people often need hospitalization or they die from this type of bacterial pneumonia. We added a pneumococcal conjugate vaccine to the childhood immunization schedules in 2000. This led to herd immunity and a NINE-FOLD decrease in invasive pneumococcal disease in adults 65 and older. Wow!
Timeline of 13-valent pneumococcal conjugate vaccine for older adults…
In 2014 the Advisory Committee on Immunization Practices (ACIP) expanded their recommendation for us to give the 13-valent pneumococcal conjugate vaccine (also known as PCV13 or Prevnar 13) to ALL patients older than 65, regardless if they had any risk factors.
Between 2014 and 2018 we have kept watch and despite 47% of Medicare patients older than 65 receiving PCV13 there has been no further decrease in noninvasive or invasive pneumococcal disease and no decrease in mortality from pneumonia.
ACIP met in 2019 and reviewed that information. Now instead of suggesting PCV13 to ALL people older than 65 ACIP suggests that the patient and physician discuss IF this vaccine is appropriate for them. Those at higher or highest risk for streptococcus pneumonia are still advised to get PCV13.
What are the risk factors that may lead to more dangerous infections due to streptococcus pneumonia?
The highest-risk group should still get PCV13 regardless of age. Chronic diseases (renal failure, nephrotic syndrome, chronic cerebral spinal fluid leak), treatment with immunosuppressant medications, B and T cell lymphocyte deficiency, HIV infection, phagocytic disorders, cancers of any type, leukemia, lymphoma, radiation therapy, anatomic or functional splenia, sickle cell disease, cochlear implants, multiple myeloma, solid organ transplant.
The group with higher risk (compared to the routine population) should consider shared decision-making with the patient’s physician. What are the higher risk conditions? Chronic heart, liver or lung disease, those living in a group situation (nursing home, assisted living facilities, jails, and shelters), prior pneumonia, those living near a high-rate of non-vaccinators, and substance abusers.
The vaccine is safe and effective at an individual level. But, because of the decreased burden of pneumococcal disease from the monumental success of childhood vaccination, it decreases the benefit of the PCV-13 in older, well adults.
If a well 65 year old patient chooses to get the PCV13 vaccine, it should be given at age 65 and then the “other” pneumonia vaccine, PPSV23, is given a year later. Medicare currently pays for the PCV13 vaccine. If in the future Medicare denies financial coverage for the PCV13 vaccine, it may cost the patient about $200.
See your physician once a year for a well visit. This is the perfect time to discuss screening tests and vaccines.