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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Ohhhh… the Wall Street Journal explains direct medical care.

Ohhhhh… the Wall Street Journal explains direct medical care.

I am such a fan of direct medical care. Many of the 350 family medicine physicians that I trained in Kansas have opened direct medical care practices.

Here in the West, direct medical care has not caught on as much. Here I see more concierge practices, which are different.

Please read on. Consider finding a direct medical practice to join for your family (or your business!) and decrease your insurance payments drastically, increase your access to your physician, and decrease the payment to the insurance companies.

https://www.wsj.com/articles/cut-out-the-medical-middlemen-11558294424?emailToken=cef4438463c8eca7d47431adca8dffeeNJ7P3N0eQb8h3k0R5lulbzk5%2FZ+ng%2F4v1HO0if8fP%2FdclDqJx9bwzxowARF9Qo+DzeDQSexrHwt8FDEf%2F%2FFEhg%3D%3D&reflink=article_email_share

https://www.dpcare.org/

I hope this helps.

Posted in Uncategorized

Diabetes management

Diabetes management!  I recently attended a lecture on diabetes management.  Here are the  nuts and bolts…
There are three pillars of diabetes management…  It’s best to max out #1 and #2 or you and your physician will need to travel down the road of #3.

#1. Diet.  A key strategy is 45-60 grams of carbs per meal. Limit sweetened beverages and concentrated carbohydrates. Eat a “consistent carbohydrate diet.”
Mediterranean diet, DASH, plant based diets. To lose weight have a deficit of 500 to 750 kcal/day.

#2. Exercise. At least 150 minutes per week of moderate intensity aerobic, keeping heart rate at 50-70% of maximum heart rate. Strength training of 2-3 times per week is helpful for patients older than 50.Medications
Diabetes affects 8 different organ systems. For instance, pancreas is involved with insulin secretion and glucagon secretion, the brain is affected with appetite control, the kidney is affected by glucose reabsorption, the muscle has changes in glucose uptake.
The ADA has a new guideline December 2017 (see link at the bottom) which lets us know which medications to start depending on hemoglobin A1c. Metformin is the mainstay medication.

When should insulin be started?  If the patient is on 3 oral medications at the maximum dose AND still not at HbA1c goal, the patient is due for insulin.
#3 Medications.  And now the list of drug classes with their in-class medication names and the specifics.

Sulfonylureas. Decreases A1c by 1.5 % but it leads to progressive decline in beta-cell function. This has fallen out of favor due to this. Within 3 years more patients require second anti-diabetic medication.

Alpha-glucosidase inhibitors (brand names: Acarbose and Miglitol). Decreases A1c of 0.5 to 0.8%. This class of drug is not known to increase weight gain nor does it cause hypoglycemia. These medications help the patients decrease the speed of carbohydrate digestion. This may cause stomach cramping and feeling gassy.
Biguanides (metformin). This decreases GI glucose glucose absorption and reduces appetite and decreases liver glucose production. This helps bring the fasting glucose in the morning. Lowers A1c by 1.5% This is a safe drug for patients with good liver and kidney function. If patients get a CT scan, they should stop this medication 2 days before contrast use.
Meglitinides (brand names– Starlix and Prandin). Most physicians don’t use this drug class often. These medicines may cause hypoglycemia. May lower A1c by 1-1.5
Thiazolidinediones (TZD)–brand name: Actos and Avandia . Decrease A1c by 0.8 – 1%. Lower blood sugars without hypoglycemia. A few years ago, there was a bladder scare. This has been changed to show that bladder cancer patients were in smokers. This may increase central adiposity.
Dipeptidyl peptidase 4 inhibitors (DPP4s)–brand names: Januvia, Onglyza, Tradjenta. Lowers A1c from 0l.5 – 0.8%. Do not cause hypoglycemia often. Can be used in combination with other oral agents. May cause abdominal pain or headaches or sciatic nerve pain. Do not use this with GLP1 drugs. Tradjenta is dosed in one dose only and no adjustments are needed for renal failure patients.
Bile Acid Sequestrants (brand name: Welchol). Lowers A1c 0.5 – 0.6%. Lowers both A1c and LDL cholesterol.
Dopamine Agonist (brand name: Cycloset). Resets the biological clock and may. It does decrease A1c from 0.3 – 0.5%.
Sodium glucose Co-transporter 2 (SGLT2) brand names Invokana, Farxiga, Jardiance, Steglatro. Blocks the reabsorption of the glucose by the kidneys. Lowers A1c 0.7-1.0%. May also cause weight loss. There is a low risk of hypoglycemia. It may increase yeast infections in both women and uncircumcised males. SGLT2 may lead to reduction in bone formation. Invokana may increase rate of amputation. And, a rare side effect of this class of drug is Fournier’s gangrene. Jardiance may help decrease cardiovascular events.
Glucagon-like peptide-1 receptor agonist. GLP1 (Byetta and Victoza and Adlyxin and Bydureon and Trulicity and ozempic) is responsible for the incretin changes. It lowers A1c 0.6 – 1.4%. May cause nausea, vomiting, and a pounding temporal headaches. May cause weight loss and less chance of cardiovascular events. May use with metformin. Do not use with DPP4s. This may promote proliferation of beta cells and islet cells. Byetta is dosed twice a day. Victoza is dosed once a day. Adlyxin is new in 2016. Injection site may feel like a knot under the skin. This is normal and intended. Bydureon is dosed once a week. Trulicity is also dosed once a week. Ozempic was FDA approved in 2017 and is dosed once a week. This class is well tolerated.
Insulin. The goal is to start the patient on a therapeutic dose. 0.2 units/kg patient weight.
Rapid acting insulins work in 15 minutes and peak in 30-90 minutes and duration is 3-5 hours. This is matched with their food. Timing of insulin injection is important. Longer acting insuin (levemir and lantus) with onset 1-2 hours with peak at 3-9 hours with duration of up to 24 hours. Basaglar is biosimilar to lantus requires 25-50% more insulin than levemir and lantus. Toujeo is glargine U-300. Duration is 36 hours. Tresiba has a duration of 42 hours. This may be beneficial in patients who forget to take their daily insulin dose.

Have you heard about an inhaled insulin? It’s called Afrezza. This is not often prescribed, needs good lung functioning and can only be used in a nonsmoker.
Want to know more?  The best overall look is the American Diabetes Association 2017 guidelines. https://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf

 

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Vocal cord dysfunction

Vocal cord dysfunction.

What is this?  Feels like throat tightness, not lung/chest tightness.  Starts less than 5 minutes into exercise and recovers within 5-10 minutes from stopping exercise.  These patients do not benefit from beta-agonist (albuterol) challenge like those who have exercise-induced asthma do.  Predisposing factors: allergic symptoms, anxiety, reflux.  Most common patient is a type A teenage female.

How to evaluate?

  • A laryngoscope during exercise.  Yep, this is just like it sounds…This is when the patient rides a bike hard or runs on a treadmill fast and then a scope is introduced into the mouth and down the throat to look at the vocal cords.  The vocal cords SHUT instead of open (!) in vocal cord dysfunction.  This is counterintuitive as during exercise, the athlete needs MORE air.  This makes it difficult for the athlete to inhale as much air as their body would like.

Treatment:

  • Speech therapy!  This is really the mainstay of treatment to help the vocal cords from shutting when they should be open.,
  • treat reflux as if stomach acid comes up the esophagus, the vocal cords may shut in response to this acidic insult to the cords,
  • behavioral treatment to help decrease anxiety.img_2402
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Exercise Induced Bronchospasm

img_2193Exercise-induced bronchospasm, non-physicians may call this exercise-induced asthma.

What is this?

  • It is respiratory distress or wheezing that starts within 15 minutes of exercise onset.
  • Usually it resolves within 15-60 minutes after exercise stops.
  • This can occur in endurance athletes, swimming/pool athletes, ice rink athletes or athletes exposed to cold air.
  • Occurs in 5-10% of the general population without asthma.  EIB occurs in 90% of asthma patients.

Is it active training that causes EIB?  This is a theory in that when elite athletes stop training, most of them do not have EIB. Is it due to a loss of water from the airway that changes airway osmolality and epithelial cell changes?  Or is it thermal and there is a loss of heat from the airway and bronchoconstriction occurs?

What do we  physicians do?

  • Get a good history, is there a pattern of symptoms?  known triggers that bring on symptoms? Is there an asthma diagnosis in the past?
  • We will do an exam.
  • Objective testing then may be done with baseline spirometry and a bronchodilator challenge (the patient is given albuterol and then we see if symptoms resolve and if the spirometry numbers look better).

If testing is positive, then treatment should happen before exercise/ training episodes.

Treatment: Give short-acting beta agonist (albuterol), 15 minutes before exercise.  Tolerance can develop if given daily.  This may not completely help 15-20% of the population.  A second inhaled agent (a steroid) may also be needed.  Leukotriene-receptor antagonists (montelukast) may also be given when taken 2 hours before exercise.  Anything that can help?  pre-exercise warm up and wearing a loosely fitted mask when exercising in cold weather.

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How to coach patients to help them be successful in blood pressure management?

How to coach patients to help them be successful in blood pressure management?  Research shows that in one-year only 50% of patients take their blood pressure medication as prescribed.

One of my roles as a physician is to coach and motivate (!)  my patients.  I am not their mother, daughter, sister, or boss.  I give advice… and the patient has the option to adhere to my advice.  In this manner, I need to meet the patient, wherever they are psychologically.  Often treatments are not successful as they are not followed.  Then, my question to myself is why (?) did they not follow the treatment?

  • Was it too expensive?
  • Did they not understand the instructions?
  • Do they not believe that the treatment will help them?
  • Do they think there will be adverse side effects from it?
  • Did they try it and there were side effects?
  • How can I help?

Lifestyle changes, per the American Heart Association/American College of Cardiology for NON-pharmacologic control of blood pressure includes…

  • Limit sodium to 2400 mg a day.  Do not add additional salt.
  • Read labels on prepackaged foods to estimate sodium intake.
  • Stop using tobacco products.
  • Limit alcohol consumption to 2 drinks per day for men, 1 for women.
  • Measure blood pressure daily at different times of day.  Make a log.  Show your physician this log.
    • The rules to measure blood pressure are to rest for 3 minutes before checking blood pressure, measure blood pressure when arm is at the height of the heart.
  • Exercise 3-4 times per week, 40 minutes per session.
  • Eat a diet rich with vegetables, fruits, and whole grains.
  • Limit red meat and sweets.

There are also peer support programs which may help to promote and sustain healthy behavior.  Research

Let us physicians help you maintain better health.img_2006

 

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What are “red flag” symptoms for those with low back pain?

img_2327What are “red flag” symptoms for those with low back pain?  When a patient presents to the office or hospital with low back pain, we are looking for the “red flag” (or VERY concerning symptoms) because it reveals that there is a more ominous cause.

  • new inability to urinate,
  • progressive loss of strength in the lower legs,
  • urinary incontinence,
  • a recent invasive spinal procedure,
  • progressive sensory loss (of the anus or near genitals),
  • history of cancer,
  • fever.

If red flags are ABSENT, the guidelines are to NOT perform an MRI, CT or x rays within the first 6 weeks of onset of back pain.  Often back pain resolves spontaneously within 6 weeks, so this is the reason for waiting… unless a “red flag” is present.

I hope this helps.

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Social determinants of health. As a physician am I asking the right questions?

img_2255Social determinants of health.  As a physician, am I asking the right questions?  I recently went to a conference given by Aaron Dieringer MD who is also a Masters in Public Health candidate.  He showcased the ways that I can be aware of environmental differences in patient’s lives.  These issues need to be addressed differently than I have been doing before.

Examples of issues that are biased// juxtaposed to more appropriate questions…

  • “Do not take this medication on an empty stomach.”  //What if the patient does not have access to food regularly (or even daily)?
  • “Go outside to walk every day for exercise.”  //Do you have a safe nearby area to walk?
  • “Come back in the office in 4 weeks.”  //Is there a time or date that works best for your next appointment to help with transportation issues?
  • “See the specialist that I am sending you to.” //If you are unable to get to the specialist’s office due to transportation issues (not on a bus route) let the social worker in my office know and we will work with you to get this fixed.

How to help?

  • Consider immediate postpartum placement of long-acting reversible contraception.  50% of pregnancies are unintended.  The risks unintended pregnancies are that the patient may not be taking a prenatal vitamin or may be using alcohol or drugs.
  • Centering pregnancy.  This is a group prenatal visit.  The first few minutes are one-on-one with a physician and then the rest of the hour is a group learning session about a pregnancy issue.  This form of prenatal visits has decreased the disparity in pregnancy outcomes. https://www.centeringhealthcare.org/what-we-do/centering-pregnancy
  • Student Outreach Clinic.  The University of Nevada Reno has a free medical clinic available to the local underserved population.  One patient example given was a woman seen for asthma exacerbation who needs steroids to avoid worsening in her condition, necessitating an ER visit or a hospitalization.  One question to ask of all patients is  “If I prescribe you medication on the $4 Wal-Mart list, can you afford this?”  Some patients cannot afford this and there are social work workarounds…  Up to 60% of preventable mortality is attributable to social and economic circumstances. Want to know more about our UNR SOC?   med.unr.edu/soc/clinics
  • Project Upstream is a program which accompanies the UNR Student Outreach Clinic.  These Project Upstream volunteers help address the social determinants of health that may affect their treatment (transportation, $4 medications) so that the physician’s advice has a better chance to be adhered to with more optimal care outcomes.

I hope this helps.

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