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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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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FREE medical treatment!

May 7, 10, & 14: Student Outreach Clinics

UNR Med students will provide FREE medical services in Lovelock and Reno to Northern Nevadans who are uninsured, underinsured, or without a social security number at three events in the next two weeks.

  • Rural Outreach Clinic, Sunday, 9 a.m.—1 p.m., May 7: Lovelock Community Church, 1055 Dartmouth Ave., Lovelock, Nevada, 8941
  • General and Pediatrics Clinic, 6 p.m., Tuesday, May 10: University Health Building, 745 W. Moana Lane, Reno
  • Women’s Clinic, 8 a.m., Saturday, May 14: University Health Building, 745 W. Moana Lane, Reno
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Osteoporosis and menopause: What you should know…

Osteoporosis and menopause: What you should know…

femur (thigh bone) fracture
  • How common is osteoporosis?  Almost half of women older than 50 years will experience a fracture related to osteoporosis in their lifetimes.  These fractures often resulting in significant symptoms and impairment of function and quality of life.  Hip fractures may require surgery, a rehab stay or long-term nursing home.  Osteoporosis is substantially underdiagnosed and undertreated.  Ask your physician if a bone density (DEXA) test is right for you.
  • Estrogen deficiency at menopause is the primary cause of bone loss leading to osteoporosis.
  • Even with good nutrition and regular physical activity, osteoporosis progresses with advancing age unless treated.  There is no cure for osteoporosis so life-long management is required once the diagnosis has been made.
  • Hormone therapy is the most appropriate choice to prevent bone loss at the time of menopause for healthy women, particularly those who have menopause symptoms.
  • Bone mineral density measured while on treatment correlates with the patient’s current risk of fracture, providing justification for the use of the T-score at the hip as an appropriate clinical target. Therapy should be reviewed after each bone density test.
  • Although antiremodeling drugs such as bisphosphonates and denosumab are the drugs chosen to treat most patients with osteoporosis, a new paradigm of beginning treatment with a bone-building agent, followed by an antiremodeling agent, is recommended for women at very high risk of fracture.  Talk to your doctor about what may be right for you.
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Urinary complications of menopause

Urinary complications of menopause.

flickr.com/photos/ vinceandjoy/ 319681936/

Stress incontinence: leaking.

1.One nonsurgical intervention is an intravaginal pessary help give support to the bladder neck.

2.Surgical options: Mesh (the size of scotch tape) can form a hammock to keep the urethra upright.  The mesh is the best treatment that urogynecologists have.  The media does not like mesh and attorneys seem to love it

Overactive bladder: urge to urinate. 

  1. First steps: voiding diary.  24-hour diary (writing down how much she drinks and how much she urinates at every bathroom trip) as this gives insight as how well the bladder is functioning.
  2. 2. Pelvic floor muscle strength.  This is assessed during a pelvic exam. 
  3. 3. Common medications are in the family of anticholinergics. The medication limits bladder contractility which is good, but can also cause dry mouth and constipation.
  4. Other nonmedication treatments: PTNS percutaneous tibial (which is on the leg) nerve stimulation.  This is a treatment that can be done multiple times in a urology office.
  5. Intravesical botox.  Botox is inserted into the bladder at your urology office. This helps relax the bladder.
  6. Spinal stimulation with implantable pulse generator can also give long-lasting relief.

Urinary tract infections: UTIs are more frequent after menopause. 

1.The role of estrogen in the urologic system is to help to maintain a beneficial vaginal flora to help decrease infections.  Use of estrogen helps decrease UTIs by half.  Estrogen can be in the vaginal in the form of cream, pill, or ring.

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The sexual history questions your physician may ask…

The sexual history questions your physician may ask…

flickr.com/ photos/ tokaris/ 207335658

The Centers for Disease Control and Prevention (CDC) recently updated their “A Guide to Taking a Sexual History.”  The list is usually tailored to those questions that seem appropriate for the patient.

Any sexually active person, regardless of age, should be asked these questions. The STI rate in postmenopausal women increased 50% in the past decade. The most important predictor of STIs in older persons is the number of sexual partners they’ve had in the past year.

1. Partners: Are you currently having sex of any kind—oral, vaginal, or anal—with anyone? In recent months, how many sex partners have you had? What is the gender(s) of your partner(s)? Do you or your partner(s) currently have other sex partners?

2. Practices: What parts of your body are involved when you have sex? Do you have genital sex, anal sex, oral sex? Do you meet your partners online or through apps?

3. Protection: Do you and your partner(s) discuss prevention of STIs? If so, what kind of prevention tools do you use, and how often do you use it?

4. History of STIs: Have you been diagnosed with an STI in the past? When? Did you get treatment? Do you have any of those symptoms that return? Do you know the HIV status of your partner(s)?

5. Pregnancy intention: Do you think you would like to have [more] children at some point? When do you think that might be? How important is it to you to prevent pregnancy [until then]? Are you or your partner using contraception or practicing any form of birth control?

6. Experts recommended an “aspirational” question addressing pleasure, but has not been included in the guide: Are you satisfied with the sex that you are having?

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How to decrease your risk of getting breast cancer?

How to decrease your risk of getting breast cancer?

https:flickr.com/photos/seniwati/3179821198
flickr.com/photos/seniwati/3179821198

Breastfeed your babies!  It is also convenient, good for baby, and free.

Lose weight.  For postmenopausal women with obesity (BMI >30), there is a 20-40% INCREASED risk of breast cancer.  In premenopausal women who are obese and have breast cancer, there is an increased chance they will have a more-aggressive triple-negative breast cancer.  Obesity is associated with worse breast cancer outcomes for women of all ages (shorter time to recurrence and increased risk of death from breast cancer).  This may be due to adipose (fat cells) holding onto estrogen, causing inflammation and being associated with hyperinsulinemia.  These abnormalities can cause disrupted cellular mechanisms and downregulate immunity, letting cellular abnormalities (cancer cells) to go unchecked.

WHAT you eat is important.  High total fruit and vegetable consumption is associated with a reduced risk overall risk of breast cancer.  Starchy vegetables (corn, peas, potatoes) do not count, so avoid those. Whole grains are also helpful.

DO physical activity.  1 in 8 breast cancers can be prevented with physical activity.  The 2020 American cancer Society Guidelines for Diet and Physical Activity for Cancer Prevention recommend 150 to 300 minutes of moderate-intensity (or 75 minutes of vigorous) physical activity weekly.  Get active.

Avoid alcohol.  Alcohol is considered a carcinogen and is linked to seven types of major cancers, including breast cancer. Any amount of alcohol increases the risk of breast cancer.  More alcohol use is associated with higher risk. Alcohol causes systemic changes of increased acetaldehyde, interference with metabolizing folate, inflammation, and increased estradiol.

I hope this helps.

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How to decrease your chance of getting a blood clot while traveling?

How to decrease your chance of getting a blood clot while traveling?

Burning Man 2020

Asymptomatic blood clots, otherwise called deep venous thrombosis (DVT), is most common form, occurs in 2-4% of high-risk travelers.

What is a “high-risk” traveler?  Currently have cancer, recently given birth, obesity (BMI more than 30), long travel, recent surgery, hormone therapy, and previous history of a blood clot.

Do compression stockings help?  Yes! There was a recent study that looked at how well do compression stockings work in flights >5 hours to help patients NOT get a blood clot. The bottom line is that compression stockings ARE effective in asymptomatic DVTs in both high and low risk populations. The number needed to treat (NNT) is 37 in high-risk individuals.  This means that 37 people will wear compression stockings for ONE person to avoid getting a blood clot. But, that person to NOT get a blood clot could be you!  Overall, there is little harm in wearing compression stockings and they may help you. 

You can buy compression stockings online and are now available in lively patterns.

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Pertussis. Whooping cough. What you should know…

Pertussis.  Whooping cough.  What you should know…

Pertussis is also called whooping cough.  It continues to be a public health concern (with nearly 20 million infections worldwide yearly) despite there being an effective vaccine.  My husband got whooping cough years ago, we remember it well.

What are the symptoms of pertussis?  First, the patient has a runny nose, then coughs with a classic “whoop.”  A whoop is when you cough sooooo much that there is no more air in your lungs and you make a “whooping” sound while filling your lungs back up with air.  Then, the last stage of pertussis is a persistent cough. Overall, the uncontrolled coughing can last for MONTHS, even if you are treated with antibiotics. Antibiotics make you not contagious, it does not cure the cough. Additionally, studies have not shown any medications that decrease the pertussis-cough.

How to test for pertussis?  The diagnosis is made by a polymerase chain reaction test (PCR) using a nasopharyngeal swab with results coming back in 1-2 days. In the past we did cultures that took a week to result, but these are no longer done. 

How to avoid pertussis?  Get a Tdap vaccine, avoid sick people, and consider wearing a mask!  The Tdap vaccine is a combination tetanus AND pertussis vaccine. 

Who gets a Tdap vaccine?  Everyone should.  We give the vaccine to children (and it is required by most school districts to attend in-person school). The last scheduled dose is given to teens at age 11-12.  After age 12 a tetanus vaccine should be given every 10 years and ONE of the tetanus vaccines can be a TdaP (with pertussis) as an adult.  All pregnant women, regardless of the timing of their last Tdap, should receive a Tdap vaccine in their third trimester as this gives some immunity to the newborn.  More than 85% of pertussis deaths occur in infants too young to receive the pertussis vaccine.  Newborns get the pertussis vaccine at ages 2,4, and 6 months of age and are not thought to be immune to the infection until after their 6 month dose.  This is why it is important for those who have exposure to newborns (like grandparents) to get the Tdap vaccine if they have not had one as an adult.

How to treat pertussis?  We give antibiotics.  But, the antibiotics does not shorten the disease course or improve symptoms in the person infected.  Antibiotics DO prevent transmission of pertussis to others. Antibiotics should also be considered for those within 21 days of a known exposure to pertussis.  Azithromycin is the preferred antibiotic. 

I hope this helps…

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