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.
The American College of Rheumatology and Arthritis Foundation have put out new practice guidelines on how to manage osteoarthritis (OA).
Arthritis affects over 300 million people worldwide. The most common joints affected are knees, hips, and hands.
Lose weight! …even a 5% weight loss helps.
Tibio-femoral knee braces may help decrease knee pain and increase walking speed.
Acupunture and heat or cold interventions may help
NSAIDs (ibuprofen and naproxen) oral or topical (cream) provide temporary improvement
Corticosteroid injections into the joints help knee and hip OA.
What has been shown to not help? Transcutaneous electrical nerve stimulation (TENS units) does not improve knee OA. Bisphosphonates, methotrexate, and hydroxychloroquine do not improve pain or function. Platelet-rich plasma, stem cells, and hyaluronic acid have failed to demonstrate clinical benefit in trials.
Difficulty swallowing is a common problem. I have had countless patients with this… and also two family members with this in the past few months.
Swallowing is a complex process. Breathing must be coordinated with swallowing. Food is chewed (and mixed with saliva) and forms into a bolus such that with the initiating of swallowing the food passes the upper esophageal sphincter and into the esophagus. While in the esophagus peristalsis occurs to get this bolus of food through the relaxed lower esophageal sphincter and into the stomach.
Neuromuscular conditions: ALS (Lou Gehrig’s), myasthenia gravis, multiple sclerosis
Structural issues: head and neck cancers, radiation, thyroid enlargement
Oral causes: poor dentition or dentures, dry mouth
Reflux (this is the most common!)
What is the work up for difficulty swallowing? First, see your physician. You need a good physical exam with a head and neck exam, observation of a swallow, abdominal inspection and palpation, cranial nerve exam, and discussion of nutritional status and fitness.
From there daily reflux medication may be prescribed, or a swallowing study may be ordered, or a referral to a GI physician for esophagogastroduodenoscopy (EGD).
In the meanwhile, diet modifications is helpful. Eat mindfully. Avoid foods that cause problems. Chew carefully. Cut food into smaller pieces. Drink liquids during the meal. Eat upright. Chin-tuck with swallowing.
Just in the US 1.6 million groin hernias are diagnosed every year. The lifetime prevalence of groin hernias is higher in men (27%!) compared to women at 3%. Most of the time hernias are only on one side of the groin, but in 20% of patients they are on both sides.
What is a hernia? It is a weak spot or a tear in the abdominal wall. Most patients complain of a bulge in the groin that gets larger over time. There may be pain or discomfort (or pulling or burning) at the site, but nearly 1/3 of patients have no symptoms.
What is the best way to diagnose a hernia? In men, the diagnosis may be obvious on physical exam. Women often need an ultrasound to confirm a hernia. Ultrasound is also a good imaging tool in patients with surgical complications after a hernia repair, recurrent hernias or other causes of groin pain. If the ultrasound appears normal, some patients need an MRI to diagnose occult hernias.
If you have a hernia, there is a risk that the intestines will slip through the abdominal wall defect, fill with air, and then not be able to slip back in. This increases the risk of bowel perforation, abdominal infections which could lead to death.
Surgical consultation is the key to managing hernias. The surgeon will review with you what the options are… most of the time this will mean you will need a surgery to keep the bowel inside the abdomen, and stitching or mesh to fill the abdominal wall defect. Watchful waiting is NOT suggested if you have symptoms or are a nonpregnant female.
When to go to the hospital? Intractable abdominal pain needs immediate attention.
Night sweats are a nonspecific symptom that could be from many, diverse causes.
Night sweats occur more often in the middle-aged and older patients. Sweating decreases the body’s core temperature and is controlled by complex feedback mechanisms.
What should your physician be considering? It is best to rule out the worst things first: malignancies or infections. But, most often night sweats are associated with benign conditions: reflux, hyperthyroidism, obesity, menopause, and anxiety. Bring a list of your medications as some can cause night sweats: SSRIs, ARBs, steroids, thyroid supplements.
You should see your primary care physician for a history and physical exam. If these do not reveal the problem, a systematic strategy would be helpful. Here’s a start: lab work with complete blood count, HIV, thyroid labs, CRP (shows inflammation in the body) as well as a tuberculosis skin test and chest x-ray. If these are all negative there are more costly and invasive tests that may be warranted (like a bone marrow biopsy, CT scan and sleep study).
Why are night sweats important? It could be a symptom of a problem that needs addressed, but it also decreases quality of life to not get proper rest.
Pregnancy tips from a family physician (and mom of 3)
I delivered babies for over 23 years and continue to see women of childbearing-age daily. What advice would I like to give you?
Take a prenatal vitamin throughout childbearing years as 50% of pregnancies are unplanned. Generic vitamin is okay as long as it has 400 micrograms of folic acid (also called folate), 30 mg of elemental iron, and 600 IU of vitamin D. This helps the fetus with spinal growth and musculoskeletal development.
Weight gain suggestions. This is based on your pre-pregnancy weight. If you are underweight, consider gaining 28 to 40 pounds. If you are a normal weight (BMI 20-25), gain 25 to 35 pounds. If you are overweight (BMI 25-30) gain 15 to 25 pounds or if you are obese (BMI > 30) gain 11 to 20 pounds. Need to calculate your BMI? https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
What should you eat while pregnant? Aim for a well-balanced diet, rich in omega-3 fatty acids. Avoid unpasteurized foods (like soft cheeses) and lunchmeats as this can cause listeriosis. Also avoid artificial sweeteners, and alcohol and marijuana.
Marijuana. Sometimes patients tell me they use marijuana to help with nausea of pregnancy. There are MUCH BETTER WAYS to stop nausea that will not harm the fetus. Ask your physician for help and stop using marijuana.
Can you drink coffee (caffeine)? Yes, but limit yourself to 200 mg per day which is two small cups of coffee.
Exercise is also encouraged. 30 minutes most days of the week is good although avoid contact sports, activities with high risk of falling, hot yoga, scuba diving, or sky diving). Sex can continue throughout an uncomplicated pregnancy.
Bring all your pre-conception and pregnancy questions to your doctor, they can address all your concerns.
What is appendicitis? It is when the appendix (a little vestige/outpouching/diverticulum of the intestine where the small and large intestine attach) gets inflamed.
What is the lifetime risk of appendicitis? 10%
What are the classic symptoms: abdominal pain near the belly button which then migrates to the right lower quadrant, loss of appetite, vomiting, nausea, fever, and elevated white blood cell count.
Why is appendicitis important? If your appendix is inflamed it can rupture and spew stool and bacteria into your abdomen. This can cause sepsis and death.
What are your options? If you have abdominal pain that worsens and does not let up, you should go to the emergency department (not urgent care). Serial physical exams will be performed which lets the physician know if your symptoms are easing up or worsening.
What is the imaging that may be done? There was a compilation of studies that totaled more than 10,000 patients. CT scan is a good screening test with 95% sensitivity (missing 5% of the cases) and 94% specificity(so if the CT shows you have appendicitis there is a VERY good chance you actually have it). Unenhanced, standard-dose CT scan was a little less likely to show appendicitis compared to standard-dose CT WITH rectal, intravenous or oral contrast enhancement. Because of these findings the American College of Radiology Appropriateness Criteria for right lower quadrant pain with suspected appendicitis gives abdominal and pelvic CT with IV contrast the highest rating and abdominal and pelvic CT without IV contrast the middle rating.
What is a POLST? POLST stands for Provider Order for Life-Sustaining Treatment form. Nevada defines “provider” as either a physician, APRN (advanced practice registered nurse) or PA (Physician Assistant). A POLST is both a legal document and a portal medical order. It allows you to express your wishes for current and future medical care, even when you no longer possess mental “capacity.” Capacity is determined by their provider at the time of the completion of the POLST and is their ability to understand and communicate their health care preferences for options in this medical order. If the patient is able to express their wishes, the POLST is not necessary and yet I believe that we each could become incapacitated (think traumatic accident or heart arrhythmia) at anytime. The POLST is what medical procedures (CPR, antibiotics, etc) the patient would want if they were incapacitated now.
Who should have a POLST? Anyone. Old age is not a requirement for a POLST, although the majority of POLSTs are completed for the elderly. If the patient’s physician would not be surprised should the patient die within one year. Patients who are terminally ill or frail would greatly benefit from a POLST.
When to fill out a POLST? Anytime. The POLST is filled out by the patient and their physician. The physician must sign the form in order for it to be legal. If the patient lacks capacity, then the Durable Power of Attorney/ legal guardian can fill out and sign the POLST. The POLST is best done when the patient has mental capacity to communicate their wishes for medical care. The document can be updated by the patient/guardian as wishes change.
Where to keep your POLST? Carry it with you…Or place it on your fridge (this is a common place EMS workers look if you are found down in your home). If you are in a care facility, they should have a copy.
Why is a POLST important? Medical professionals want to do what you want us to do. If we do not know your wishes, EVERYTHING is done. The treatments may not be what you want. The POLST avoids this by determining if you want aggressive treatment, specific intermediate measures or comfort-focused care. The POLST allows patients to communicate their desired health care treatment currently and in the future in the event they no longer have the ability to do so on their own.
POLST vs. DNR (Do Not Resuscitate) vs. AD (Advanced Directive): A POLST is a medical order that is valid in any setting. A DNR order is only valid in a healthcare facility. An AD is a legal document, not a medical order, so it cannot be followed by healthcare personnel such as EMS unless a provider writes a medical order to stop resuscitation. EMS must initiate CPR even in the presence of an AD stating the patient does not want CPR because an AD is not a medical order, it is a legal document.
DNR orders are used in circumstances when a patient has lost their pulse, is not breathing or is near death and can no longer communicate.
The POLST is much more than just a DNR order. It guides health care providers which treatments the patient wants. These decisions can include, but are not limited to the use of IV fluids, antibiotics, feeding tubes, intubation and placement on ventilators, or even whether or not a patient wants to be hospitalized or placed into the ICU (intensive care unit).
I encourage my patients to have a DPOA and to let all their loved ones know who is their DPOA. Then each of them needs to know what the patient’s wishes are if they are found down. Do you want CPR? Do you want a ventilator to help you breathe? What is the manner in which you would like to live? (walk? talk? eat independently? think well?) What if those cannot be met? Do you want your DPOA to withdraw care?
Let us do what you want us to do. If you do not express your wishes everything will be done and that may be against your wishes. Be proactive. A POLST is an easy, fast document that begins a conversation between you and your loved ones.
Intermittent fasting is a style of eating in which you have periods of eating and periods of fasting. There are not strict rules about which foods to eat, but rather when you should eat them.
You already fast every day, while you sleep. Intermittent fasting can be as simple as extending that fast a little longer. You can do this by skipping breakfast and then eating your first meal at noon and finishing your last meal at 8 pm. That way, you’re technically fasting for 16 hours every day, and restricting eating to an 8-hour eating window. This is the most popular form of intermittent fasting, known as the 16/8 method. Benefits have also been shown using a 12 hour fast and 12 hour eating window, but 16 hours of fasting is better if you can do it. Other people do a 5/2 method where they eat normally during 5 days of the week and fast completely for 2 days (24 hour period) per week.
Although this may be different from your normal habits in modern culture, intermittent fasting is fairly easy to do. Many people report feeling better and having more energy eating this way. Hunger in the fasting window is usually not that big of an issue, although it can be bothersome in the beginning while your body is getting used to not eating for extended periods of time. Most people find they don’t mind waiting until later in the day to eat.. and most fully adjust within 1 month.
No food is allowed during the fasting period, but you can drink sugarless beverages such as water, black coffee, plain tea, carbonated water, or other non-caloric beverages.
What are the benefits?
According to an article in the New England Journal of Medicine by Rafael de Cabo, Ph.D., and Mark P. Mattson, Ph.D published in December 2019, the benefits include:
Improved glucose (blood sugar) regulation
Increased stress resistance
Suppression or reduction of inflammation
Blood pressure and heart rate reduction
Significant effects decreasing Obesity, Diabetes, Heart disease, Arthritis, and Neurodegenerative brain diseases like Alzheimer’s and Parkinson’s
Improved mental and physical performance
Increased life span
Protection against cancer and positive effects on pre-existing tumor growth and response to chemotherapy
Here are physicians you may be interested in looking up who promote this style of eating
Dr. Jason Fung at thefastingmethod.com
Dr. Michael Mosley at thefast800.com
Dr. Clark-Ganheart at thefastingdoctor.com
How to get started…
Make a plan. Decide how you are going to proceed, when to start, and what you will do if you are feeling like quitting.
Find sugar-free beverages you enjoy. Flavorful herbal tea? or zero-calorie sparkling water? Or black coffee?
Ask your partner, friend, or adult child to be your accountability partner.
Track your progress. Take note of how you feel, how your body changes, and any weight you lose to feel motivated to continue.
2020 Colorectal Cancer Screening Recommendations, per the American College of Physicians consensus statement
Why is this so important? Colorectal cancer (CRC) is the second leading cause of cancer death in the US. There is a 65% overall five-year survival. Removal of adenomas can prevent cancer.
What does screening mean? Screening are baseline tests. This means that the CRC patient is asymptomatic (no rectal bleeding, no change in bowel habits, and no abdominal pain) AND has no increased risk (no history of polyps or no family history of colon cancer). These consensus statements are NOT generalized to people at elevated CRC risk.
Who to screen? The BMJ/MAGIC Group recommends calculating a patient’s CRC risk. https://qcancer.org/15yr/colorectal/ If the 15 year risk of CRC is less than 3% no screening for CRC is recommended. Routine recommendations are to perform CRC screening to average-risk asymptomatic adults from aged 50 to 79 with at least 15 years of life expectancy.
Methods of screening? Colonoscopy reduces incidence of premalignant adenomas by 34% because the GI doctor can remove polyps during a colonoscopy. Patients who have noninvasive tests like FIT tests of guaiac fecal occult blood testing cannot remove polyps with the testing.
Guidelines/Timelines for screening for CRC by method…
-Colonoscopy. Every 10 years. Benefits: may be fully paid by your insurance as it is a considered a screening test. Physician can remove polyps at the time of scope. Drawbacks: need to do a bowel prep.
-FIT. Every 2 years. Benefits: no bowel prep needed. Submit a single stool sample to the lab. No dietary restrictions. Drawbacks: If positive, you need a colonoscopy. Insurance, then, may code your colonoscopy as a diagnostic test and you may have a big insurance bill.
When to stop screening? CRC screening is not recommended after 75 years of age or when life expectancy is less than 10 years.