Alcohol Withdrawal syndrome. Can this be managed as an outpatient?

Posted on January 4, 2022 by drlesliegreenberg
Photo by Charlotte May on Pexels.com

Alcohol Withdrawal syndrome.  Can this be managed as an outpatient?

Half of patients with alcohol use disorder who abruptly reduce or stop their alcohol intake develop signs or symptoms of alcohol withdrawal syndrome.

Why does alcohol withdrawal syndrome occur?  The central and autonomic nervous system are revved up and overactive and this can lead to insomnia, nausea, vomiting, tremors, hallucinations, agitation and anxiety.

What can occur if alcohol withdrawal is not treated?  Seizures, delirium tremens and occasionally death can occur. 

Who can be treated as an outpatient (not staying overnight in the hospital)?  Patients with mild to moderate withdrawal symptoms (without additional risk factors) can be treated as outpatients.  Mild symptoms can be treated with carbamazepine or gabapentin.  For more severe symptoms, benzodiazepines are first-line therapy.  Patients will need to be seen by their physician daily for up to 5 days after their last drink to monitor symptom improvement and evaluate the need for additional therapy.  

What else can help?  A 12-step program, like Alcoholics Anonymous, are more effective at helping patients remain abstinent up to 3 years than other forms of therapy.

Why should patients do inpatient withdrawal treatment?  –Unstable home situation or absence of caregiver support. — Other psychiatric conditions.  —Previous drinking more than 8 alcoholic drinks per day. —History of severe alcohol withdrawal symptoms less than 1 year ago. —Dependence on other addictive medications. —Unstable transportation situation.

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Home blood pressure monitoring. Do you need it? How to do it?

Posted on December 21, 2021 by drlesliegreenberg
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Home blood pressure monitoring. Do you need it?  How to do it?

Blood pressure is an important vital sign.  Blood pressures should routinely run less than 135/85.  Some patients only have high blood pressure in physician or dental offices.  This is called “white coat hypertension.”

How to best monitor your blood pressure? I urge patients to do home blood pressure monitoring.  This entails using an appropriately fitting upper-arm cuff on a bare arm, emptying the bladder, avoiding caffeinated beverages for 30 minutes before taking the measurement, resting for five minutes before taking the measurement., keeping both feet on the floor, uncross your legs while sitting, keep the arm supported, with the bp cuff at heart level, do not talk during the blood pressure test.

How many readings to take?  Ideally, take two bp readings in the morning and in the evening.  Separate the two bp readings by at least one minute.  Do this once a week and record the average of the top number and the average of the bottom number. 

Why do home blood pressure monitoring?  I tell patients that they live in their homes, not my office.  So, if the bp is only high in my office… that’s okay.  Home blood pressure readings can confirm the diagnosis of hypertension after an elevated office blood pressure reading.  

How to pick a good bp machine?  It should be validated and fully automated.  Choose an appropriately sized upper arm cuff.  Have bp machine store measurements.  To get a validated machine, look at https://www.validatebp.org   Wrist cuffs are less accurate and positioning of the cuff over the radial artery may be difficult. 

Will my insurance pay for my blood pressure monitor?  Maybe.  Ask your physician to write you a prescription, then call your insurance to find out if it is a covered benefit.

Ambulatory blood pressure monitoring is another way to check blood pressures.  This involves wearing a monitoring device for 24 to 48 hours.  The bp is measured at regular intervals while the patient is doing normal activities.  This method of monitoring is more thorough, but is not widely available outside of academic medical centers. 

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The risks of pregnant women taking opioids…

Posted on December 14, 2021 by drlesliegreenberg

On hospital call I frequently care for infants who are withdrawing from opiates.  This is called “neonatal abstinence syndrome” (NAS). 

What is NAS? It is a constellation of symptoms including high-pitched cries, tremors, hyperactive reflexes, poor feeding, poor weight gain, mottling of the skin, inability to keep temperature in a good range, vomiting, diarrhea and tremors.  It occurs in 50-80% of infants exposed to opioids in utero. 

All pregnant women should be screened for opioid use disorder and offered methadone or buprenorphine, which are safer for both mom and baby than opiates. 

Guidelines state that all newborn born to mothers who use opioids need to stay in the hospital for 5 days after birth to watch for the symptoms of withdrawal.  The infant’s behavior is scored.  If the score exceeds a threshold, treatment for neonatal abstinence syndrome is started. 

Initial treatment is having the newborn in a low-stimulation environment, swaddling, rocking the infant, feeding on-demand.  Skin-to-skin contact helps comfort the infant.  Breastfeeding may help decrease the need to give the infant opioids.  If the infant’s symptoms do not improve with supportive care, the infant is given morphine or methadone with phenobarbital or clonidine.  The dose of intravenous medication to the infant is weaned slowly.  Often NAS infants are in the hospital for a month before they are successfully weaned off of medications and sent home.  This gives the mother an opportunity for a fresh start. 

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Abnormal cholesterol labs. What to do with elevated triglycerides?

Posted on September 22, 2021 by drlesliegreenberg
flickr.com/photos/divine_harvester/2287243509

You see your physician and get a routine cholesterol panel.  The results show that your triglycerides are high.  What should you do?

Fasting lab work should show that your triglycerides should be less than 150. When triglycerides are higher than 150, it increases your risk of cardiovascular (CV) disease. If the levels are severely elevated (500 mg per dL or higher) add the risk of pancreatitis to the risk of CV disease.

What are risk factors for high triglycerides?

  • Metabolic syndrome
  • Type 2 diabetes
  • Obesity

What should you do if your triglycerides are between 150-500.  We suggest “lifestyle modification” as this decreases the 3 risk factors contributing to high triglycerides.  Sometimes I have patients list off to me what they are currently doing… and yet your body needs more healthful changes than you are currently doing.  This means that what you are currently doing is not enough to maintain good triglycerides and decrease your risk long-term of cardiovascular issues.  Decrease intake of carbohydrates, especially refined carbohydrates and increase physical activity.  Aim to have 30 minutes a day of moderate-to-high intensity physical activity.  Increase omega-3 fatty acid intake and increase protein intake.  These lifestyle changes will help improve exercise capacity and overall health. 

If your ASCVD risk (the risk of having a cardiovascular event in 10 years) is borderline or intermediate, then you and your physician can consider starting on a statin drug.  Here is an ASCVD risk calculator.

If you continue to have elevated triglycerides despite lifestyle changes and statins, high-dose icosapent, fibrates, omega-3 fatty acids or niacin can be considered. 

If you are admitted to the hospital with acute pancreatitis from hypertriglyceridemia, your physician may start an insulin infusion or do plasmapheresis.  The goal is to head this off at the pass. 

I hope this helps.

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Long covid or “post-acute sequelae of SARS-CoV-2

Posted on September 15, 2021 by drlesliegreenberg

Oh my! Patients who have had the covid infection are often finding that they do not “bounce back” fast. In fact, a significant number of covid patients have lingering side effects

flickr.com/photos/rypscl26/50765612453

The World Health Organization report found that up to 10% with COVID-19 still have symptoms 12 weeks (!) later.

  • What are the symptoms?
    • Excessive fatigue
    • Cough
    • Chest pain
    • Shortness of breath
    • Brain fogginess with difficulty concentrating and with memory

The persistence of these symptoms may lead people to leave their jobs and it is known that prolonged absence from a person’s workplace is detrimental to physical, social, mental and financial well-being.

Ask your physician if she can write for appropriate workplace accommodations and adjustments.  Maybe your job or work environment can be tweaked for a few weeks to help your symptoms improve. 

Primary care physicians and occupational medicine physicians can help advise human resources or management leaders on return-to-work strategies.

The long-term health effects from SARS-CoV-2 infection are unknown.  Ask your physician for help.

Better yet, if you are unvaccinated, get vaccinated.  The vaccine greatly decreases your risk of contracting covid-19 and thereby decreasing your chance of long covid. 

Take care of yourself.

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Acne treatment for teens

Posted on September 9, 2021 by drlesliegreenberg

Being a teenager is difficult enough… even without acne. Acne treatments for teens are available over the counter and from the pharmacy. Here is my overall treatment plan with ingredients that can all be bought over the counter.

I want a treatment that the teen can do. This means it should not be expensive and should be able to be incorporated into their overall skin care regimen. Easy and inexpensive; that’s my plan.

Depending on your acne (is it whiteheads? blackheads? cystic? scarring?) your treatment may need to be individualized. The following acne treatment for teens is a good place to start.

What are you doing now for your skin? Is it working? Are you diligent and do it daily? What has worked in the past? Are you a female and acne is worse before your menstrual period? If so, oral contraceptives may help your skin greatly. See your physician for contraceptive prescription.

Back to your skin, the facial skin does not like to be roughed up. So, I urge patients to start with washing morning and night with a facial cleanser. Inexpensive ones are Dove, Basis, or Cetaphil. Then, pat the face dry. No roughing it up with a buff-puff or abrasive sponge.

Benzoyl peroxide (BP) is available over the counter in 2.5%, 5%, and 10%. The stronger it is the more likely your skin will turn red, dry, and scaly before it becomes accustomed to it. BP helps kill the bacteria on your skin that causes acne. BP also helps your skin not become resistant to other topical medications for acne. BP can bleach your hair, clothing, towels, and bedding: so be aware of that. Often skin is sensitive to BP (and gets red, dry, and scaly), so consider using it every other day or every third day for a few weeks, until your skin is used to it and then you can increase the frequency to every day.

A topical retinoic acid derivative, adapalene, is also available over the counter. This can be used nightly (after your face is washed and patted dry). I suggest you use adapalene every other night and BP the nights you do not use adapalene.

Acne treatment for teens is great, but also it is important to wear sunscreen. Acne treatments can make the face more sensitive to light and more likely to burn. Pick a noncomedogenic sunscreen that is meant for the face. Neutrogena and Eucerin make a facial sunscreen that feels and smells good (and is also available without a prescription!).

Your teenager may be seeing acne advertisements. Most of these contain the ingredients above, but in a much more expensive format.

As always, see your physician for more individualized skin care help. Most primary care physicians can easily take care of acne. There are 1000 ways to help acne, this is just my routine first step: easy and inexpensive.

I hope this helps.

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Contraception decreases unwanted pregnancies. Get your birth control under control.

Posted on September 1, 2021 by drlesliegreenberg

Watch this short, compelling video by a fellow physician…

-what are your contraceptive choices?

-how to ask your physician for what you need?

-Will your insurance pay for a year of birth control at a time?

-What are options of emergency contraception?

-Recent legal setbacks of Roe v Wade

-How to get involved…

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Should you have a carotid artery ultrasound?

Posted on July 13, 2021 by drlesliegreenberg

Should you have a carotid artery ultrasound?

Some concierge physicians offer carotid artery ultrasound with their “executive physical.”  This is NOT a suggested test for most patients.  The general adult population should NOT get a carotid ultrasound to rule out carotid artery stenosis.

Do not screen for carotid artery stenosis.  The *USPSTF found that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. Insignificant problems can be found that did not need to be found and then procedures (that have risk) may be done on patients who do not benefit from them. Just because a test is available does not mean that you should have it.

Who should get a carotid artery ultrasound?  Patients with neurological signs of symptoms from possible carotid artery stenosis or patients with history of transient ischemic attacks (TIA) or strokes.

What would you do if you had carotid artery stenosis?  Possibly surgery called carotid endarterectomy (reaming out the artery).  Less invasive interventions are to start on statin medication, antiplatelet medications, manage hypertension and diabetes, and lifestyle modifications. 

*The USPSTF (US Preventive Services Task Force) is an organization that researches what testing has been shown to have benefit, is neutral, and which causes harm.

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Should you get a carotid artery ultrasound?

Posted on July 6, 2021 by drlesliegreenberg

Should you have a carotid artery ultrasound?

Some concierge physicians offer carotid artery ultrasound with their “executive physical.”  This is not a suggested test for most patients.  The general adult population should NOT get a carotid ultrasound to rule out carotid artery stenosis.

Do not screen for carotid artery stenosis.  The *USPSTF found that the harms of screening for asymptomatic carotid artery stenosis outweigh the benefits. 

Who should get a carotid artery ultrasound?  Patients with neurological signs of symptoms from possible carotid artery stenosis or patients with history of transient ischemic attacks (TIA) or strokes.

What would you do if you had carotid artery stenosis?  Possibly surgery called carotid endarterectomy (like reaming out the artery).  Start on statins, antiplatelet medications, manage hypertension and diabetes, and lifestyle modifications. 

*The USPSTF (US Preventive Services Task Force) is an organization that researches what testing has been shown to have benefit, is neutral, and which causes harm.

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Hypothyroidism. What is it? Why is it important?

Posted on June 29, 2021 by drlesliegreenberg
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Hypothyroidism is when the thyroid gland produces inadequate thyroid hormone production. 

Why is this important?  I consider the thyroid the gas pedal of the body.  The body needs get-up-and-go to function well.

How prevalent is hypothyroidism?  It affects one in 300 people in the US.

Who is at risk for hypothyroidism?  Women (7 times more than men), those with autoimmune issues, and older patients

What are the symptoms? Fatigue. Weight gain. Constipation. Dry skin. Intolerance to cold. Voice changes.

Should you be screened for hypothyroidism?  If you feel fine, the guidelines are to NOT to check thyroid labs. 

What happens to hypothyroid pregnant patients?  Women who are pregnant need to have their thyroid labs checked.  Pregnant women often need their weekly dosage increased by 30%.

How to replace thyroid hormones?  It’s easy!  Take a pill daily.  It is best to take the pill on an empty stomach and no food within 30 minutes of medication ingestion.

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