Hello Reno Families!

2021 Leslie Greenberg headshot croppedHello, I am  Leslie Greenberg.  I am a family physician in Reno, Nevada.  I attended Northwestern University in Chicago, then University of Nevada School of Medicine.  I 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 400 + family medicine residents (and countless medical students), over nearly 25 years.  I currently teach at the family medicine residency program in Reno and also see private patients.  I care for newborns through elderly patients in both the hospital and office.  I love to do procedures: skin biopsies, circumcisions, IUD insertion/removals, paps, colposocopies, and toenail removals. I invite you to read my blog.  If you would like to become a patient, please call 775-982-1000.

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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How to prevent delirium:

How to prevent delirium:

Delirium is an acute confusional state.  There’s an alteration of consciousness with decreased ability to focus, sustain or shift attention.  Delirium usually develops over hours to days and may fluctuate during the course of the day. 

To prevent delirium:

  1. Stay hydrated
  2. Get good nutrition
  3. Maintain oxygenation
  4. Avoid constipation
  5. If in the hospital, avoid tubes (monitors, foley catheters, intravenous lines)
  6. Keep mobile.  Walk.
  7. Keep senses aware: Use eyeglasses, hearing aids, mobility devices).
  8. Prevent infections
  9. Limit medications that are psychoactive (sleep or anxiety medications)
  10. Manage pain with nonsedating medications like ibuprofen or acetaminophen
  11. Have familiar people around (family and caregivers)
  12. Visualize clocks and calendars.
  13. Get reoriented by family and staff to location and time, as needed.
  14. Avoid nighttime disturbances
  15. Reduce noise at night.

I hope this helps…

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What are red flag signs for headache?

What are red flag signs for headache?

Red flags are concerning symptoms that need further investigation.  See your physician if you have any red flag signs.

Headache red flags:

Systemic symptoms: fever, chills, immunocompromised condition, infection, muscle aches, night sweats, weight loss, pregnancy, postpartum, cancer

Neurologic symptoms: double vision, impaired consciousness, pulsatile ringing in the ears, seizures, confusion.

Onset: occurs intensely within a few minutes like a “thunderclap” headache.

Older:  Headaches starting after age 50

Progression:  If there is a change in headache features, pattern or severity over time.

Precipitated by bearing down (like with a bowel movement or sit-ups)

Worse with lying down.

Swelling of the optic nerve with headache (seen by eye doctor)

Headaches worsen with exercise

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Toenail fungus. How to treat? How to avoid it?

Toenail fungus. How to treat?  How to avoid it?

Onychomycosis is a chronic fungal infection of the fingernail or toenail bed. This leads to brittle, discolored, unsightly, and thickened nails.

Untreated, onychomycosis can cause pain, discomfort and may negatively impact quality of life.

Your doctor can do a test on your nail to confirm that it is indeed a fungal infection so that the correct treatment is started.

What is effective treatment?  Oral terbinafine is markedly more effective than topical therapy than topical therapy.  Let your doctor know what other medications you are on as terbinafine can interfere with other medications. Topical medications include ciclopirox 8%, efinaconazole 10% and tavaborole 5% but all are less effective than oral agents.  Topical agents can be used to treat mild to moderate onychomycosis and it has fewer drug-drug interactions than the oral treatment. 

What else can you do to help?  Trim nails and file the nail to keep the nail thickness less.

How to prevent recurrence?  Avoiding walking barefoot in public places, wearing socks, and disinfecting shoes is thought to decrease relapse rate by 25%.

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Can physical activity decrease depression?

Can physical activity decrease depression?

A combined meta-analysis of 49 unique prospective studies with nearly 267,000 patients were followed up for 1,837,794 person-years. 

Results:  Both the high intensity interval training patients and the moderate continuous training program participants showed significantly less depressive symptoms compared to those who did no exercise. 

Take home point: Work in some exercise to your life and feel better physically and mentally.

Want more information? https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2018.17111194

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HPV. What you should know…

HPV.  What you should know…

There are more than 200 types of human papillomavirus (HPV) that cause infections of the skin and mucosa.  HPV is the most common sexually transmitted infection in the US.

Most HPV infections are transient, some lead to warts or cancer.

The most common subtypes of HPV that cause cancer are HPV16 and 18.

What types of cancers are HPV-related?  Anal, cervical, oropharyngeal (mouth and throat), penile, vaginal and vulvar cancers.

What increases the risk of HPV infections?  Multiple sexual partners. Initiation of sexual activity at an early age. Not using condoms. Other STDs (including HIV). An immunocompromised state. Alcohol use. Smoking.

How to avoid HPV? Use condoms or dental dams. Get the HPV vaccine.

Details about the HPV vaccine.  It is ideally administered at 11 or 12 years of age (irrespective of gender of the patient).  If first HPV vaccine given before age 15 it is a series of 2 vaccines.  If started at 15 or after, then it is 3 vaccines. The HPV vaccine is approved through age 45.  HPV vaccination of people older than 26 may not be covered by insurance.

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Facts about pregnancy and covid

The vaccine is safe for mom (are you a future mom?!) and baby.

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Acute Achilles tendon rupture. Ouch! What to do now?

Acute Achilles tendon rupture.  Ouch! What to do now?

Photo by Pixabay on Pexels.com

What is the optimal treatment of acute achilles tendon rupture? The options are to let the tendon scar over time (and not have surgery) OR to have an operation to sew the two parts of the Achilles tendon together.

Outcome: Nonsurgical management had 7% complication rate and had 4 time more chance of re-rupture rate compared to those who had surgery. 

In comparison, for those who had surgery the re-rupture rate was only 3.6% (it was 12% re-rupture rate with non-operative management). Surgical treatment has fewer re-ruptures, but more complications. 

If you have surgery, is there a way to decrease risk and increase benefit?  Yes.  Minimally invasive surgery has fewer complications than an open surgical approach.  There is no difference in re-rupture rate with minimally invasive surgery compared to open surgery . 

So, if you have an achilles tendon rupture, ask your orthopaedic surgeon if they can perform the reattachment with minimally invasive surgery.

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Physical INACTIVITY is associated with a higher risk for severe covid 19 bad outcomes!

Physical INACTIVITY is associated with a higher risk for severe covid 19 bad outcomes!

What is the research?  There was a recent study done with 50,000 patients.  This research was at Kaiser where exercise is considered a vital sign, which explains why there is such robust data on this. 

They took into consideration the patients other medical conditions (gender, diabetes, hypertension, smoking, etc). 

What are the risks? 

Inactive group was 2.25 times more likely to be hospitalized compared to those who exercised 150 minutes per week.

The physically inactive were 2.5 times more likely to DIE compared to those who exercised 150 minutes per week. 

Take home point: Exercise 150 minutes a week can truly save your life.

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How to avoid ACL injury?

The anterior cruciate ligament (ACL) helps stabilize the knee. It is a common ligament that gets torn. My daughter tore her ACL a few years ago, requiring operative management, AND months and months of physical therapy.

How to avoid an ACL injury? 

  1. Age (the earlier you start strengthening muscles the better).
  2. Use good biomechanics.

●     Stretch before any exercise or athletic activity.

●     Practice proper landing skills. These should include: Land with knees bent but the legs (thighs, knees, and lower legs) kept in a straight line. Land on the balls of the feet instead of the entire foot or heel

●    Maintain proper body posture throughout the landing.

●    Ensure both feet land simultaneously. (No one-footed landings.)

●    Practice proper pivoting. Women tend to remain more erect when turning, which can stress the ACL. One exercise is practicing pivoting in a slightly crouched position with the hips and knees slightly bent.

●    Increase agility by practicing running, stopping, pivoting, and running in another direction while maintaining the proper body position.

3. Compliance. This means… keep it up! Make it a routine of yours.

4.How much is useful?  Any amount, but research shows that 20 minutes daily is best.

5. Exercise variety (do not do a singular sport). The body needs varied feedback.

6. Perform specific exercises to help stabilize the muscles around the knee.

● Walking Lunges – Lunges help strengthen thigh muscles (quadriceps).
● Hamstring Leans – These strengthen the muscles in the back of the thigh.
● Single Toe Raises – You use your toes (not one toe) while the other leg is raised by bending the knee. This strengthens calf muscles (back of the lower leg) and improves overall balance.
● Squats – Whether traditional or wall squat, these exercises strengthen the quadriceps and hamstring muscles while improving balance.
● Split Jumps – Several studies have shown these to be one of the best ACL injury prevention exercises. This can be a difficult exercise to perform correctly, but it is important to gradually increase the duration and intensity of split jumps to ensure the best results. They should only be done for as long as the strength and stamina are available to perform them perfectly.

I hope this helps.

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What is physician burnout? Why should it be important to you?

What is physician burnout?  It’s not a disease but a syndrome highlighted by exhaustion, cynicism, and decreased sense of efficacy.  This is job-related.  In contrast, depression is across work and home environments.

Why is physician burnout important to you?  After YEARS of training, your physician may leave their career and leave you as their patient.  Your physician may have less empathy for you due to their overwhelming feeling of burnout. 

Burnout can be measured: Maslach burnout (emotional exhaustion where work makes us feel tired). This is different from depression.  When you have burnout, you may be happy when NOT at work.  There are additional features: Depersonalization (callous). Lack of personal accomplishment (need to feel that work is worthwhile) and Mini-Z (10 questions). 

What most contributes to physician burnout?  Too many bureaucratic tasks. Toxic work culture. Lack of control over schedule. Burnout is often not a money issue.

How to we cope?  Exercise. Isolating from others (we need people to “see us.”)   Not reaching out is a red flag.

How do we mitigate it? Physician burnout is a system issue, not an individual issue.  Fix the underlying problem.  Less bureaucratic. Less paperwork.

It is time to not hold physicians independently responsible for their burnout.  There is no amount of exercise or yoga that will battle physician burnout.  It is moral injury to be unable to help patients due to bureaucratic load. Insurance companies are piling on the administrative duties like requiring prior authorizations, peer-to-peer consultations.

Suicide rate is 2.3X for physicians versus 1.4X in the general population.

How to get to the bottom of what is individually important?  What is our carrot (versus stick)?  And, what is our goal? Do the choices that we are make honor our values?

What would help most to reduce your burnout?  Better be able to negotiate schedule.

How to create a culture of wellness?  Create a work environment with a set or normative values, attitudes, and behaviors that promote self-care.  Be efficient in your patient charting/paperwork.  Personal resilience.

How do we keep happy?

  • Build relationships! 
  • Work on family, fitness, fatigue. We often work in reverse order and do the least-enjoyable aspects of our life first.  There are no do-overs.
  • Learn to say no. 
  • Schedule family vacations a year in advance.
  • Eat dinner with your family 5 times per week. 
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