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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Should you increase your antidepressant after beginning on a starting dose?

Should you increase your antidepressant after beginning on a starting dose?  Not necessarily.  Research has shown that new-generation antidepressants like SSRIs may not need to be increased from the starting dose.  This means that your first dose, may be all that you need to ease your mood. Patients are urged to see their physician at 6 to 8 weeks after starting medication to assess clinical improvement.  Before increasing the dose or changing the medication, talk to your physician.  In short, research showed no benefit to automatically increase the dose. 

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Does a short course of antibiotics work?

Does a short course of antibiotics work to fight infection? It depends.  The American College of Physicians recommends FIVE days of antibiotics for pneumonia (when it’s community acquired—not hospital or nursing home acquired).  Five days is also recommended for COPD exacerbation when a bacterial component is suspected.  Those with uncomplicated kidney infection need 5 to 7 days of antibiotics. Although, those with an uncomplicated bladder infection may be completely treated with only THREE days! We, physicians, used to prescribe longer courses of antibiotics. But, we know more now!

Of course, if there is no clinical improvement additional (or different) antibiotics may be needed.

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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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