Free vasectomies at UNR
What picture did you expect?

Free vasectomies at UNR. Yep! You read that right.

The University if Nevada Reno School of Medicine (UNRSOM) is offering men (over 18 years old) who want permanent sterilization a free vasectomy.

UNRSOM is known for offering free clinic days through the Student Outreach Clinic (SOC). The SOC has medical students seeing patients with the oversight of full-fledged physicians. The free vasectomies will be done by a licensed physician with UNRSOM medical students observing and assisting.

A vasectomy is a minor outpatient procedure that blocks the sperm from reaching the semen. Vasectomies take between 15 and 45 minutes to perform and often costs $500 to $3000. Vasectomies are a highly effective birth control option (99% effective) that is permanent, takes less than an hour, and (in this case) free!

I’d say that is a win-win for local men who desire permanent sterility.

What should men expect after a vasectomy?

  • They should have a driver and someone who can help with tasks (driving and heavy lifting).
  • I suggest resting for the next 2-3 days.
  • Apply an ice pack intermittently on top of the underwear helps decrease swelling and therefore discomfort.
  • Do not bathe for 24 to 48 hours after the procedure to let the small incision sites heal.
  • Intercourse can be resumed after a week, but expect to use birth control until the semen analysis done at 3 months (and about 20 ejaculations after the vasectomy to clear the ducts of sperm) after the procedure shows NO sperm. No live sperm and no dead sperm (because were the dead sperm actually alive immediately after ejaculation?!).

When sex is resumed, the male should feel no differently than before. Vasectomies do not affect libido. There is no link between vasectomy and prostate or testicular cancer or heart disease. There will be ejaculate, just no sperm in the seminal fluid. Again, a win-win.

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Death certificates

Death certificates.  What are they?  What information is on these?  As much as physicians want to preserve life, death certificates are also a bread-and-butter duty of physicians, especially family physicians.

There is a great deal of information on the death certificate.  It records the cause and manner of the person’s death.  These circumstances are used in many ways.  This information is sent to federal agencies, like the CDC.  This information is collated and this helps decide which medical conditions receive research and development fundal, helps  set public health goals, helps measure health status (at local, state, federal, and international levels.)

What is the pathway for this death certificate?  Indeed many people help fill out this document.  First, the death occurs, then the funeral home initiates a death certificate, then they send this to the certifier (often the physician, although sometimes a nurse practitioner or the coroner), then to the registrar for finalization.

What is the “cause of death?”  It is the physician’s best medical opinion.  This must be filled out (in Nevada) within 48 hours of receipt of the death certificate.

What is on the certificate?

  • date of death.
  • time of death.
  • social security number,
  • cause of death,
  • death due to a communicable disease?
  • did tobacco use contribute to the death?
  • If a female (age 5-75), there is additional information like whether they were pregnant within the past year.

The Nevada program is called the EDRS. Electronic Death Registry System.

Cause of Death.  If it is pending, then a coroner will fill this out.
“Immediate cause” is the final cause (example: pneumonia).  “Due to a consequence of”  (example: a bedridden patient).  So, for the example above, a bedridden patient contracted pneumonia and pneumonia was the final cause of death.  Was an autopsy performed?  Did tobacco use contribute to death?  Was the patient pregnancy (and, if so, when?)

  • NOT ACCEPTABLE CAUSES OF DEATH: Cardiac arrest, cardiopulmonary arrest, respiratory arrest, failure to thrive, multiple organ system failure, respiratory failure.

Manner of Death.

  • Often this is “natural causes.”
  • If it is not a natural cause, the coroner may need to address manner of death.
  • Injury is another manner of death (For example:  a fall may cause a hemorrhage and the blood loss causes death).

I hope I addressed all the questions you had about Nevada death certificates.

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Cholesterol.  I attended a lecture recently from a well-known local cardiologist specializing in cholesterol.  Here are the “pearls” from the talk.

What is cholesterol?  Cholesterol are lipids that are carried on particles.  A cholesterol panel estimates what kinds of particles are circulating in a patient’s blood, as cholesterol can be small or large or dense.  Hint: you would like your cholesterol large and buoyant.

The LDL is the bad cholesterol that is found in a plaque.  Plaque is what accumulates on the walls of the blood vessel that decreases the blood able to flow through that blood vessel.  VLDL are triglyceride-rich particles that are also found in plaque.

The LPLa (lipoprotein a) is a good thing, it’s a molecule that helps to break down cholesterol.  LPLa is down-regulated (this is bad) in obese patients.

LDL-c is the concentration of LDL.  A Direct LDLc can be asked for at the lab.  A lipid panel is meant to tell us physicians, what are the chances that you have atherosclerosis which is what leads to an athlerosclerotic cardiovascular disease event (ASCVD).

What can we do? First, we treat cardiovascular risk!

  • Lifestyle modification is first line therapy: decrease saturated fats, increase dietary intake of fats from fish, increased dietary and supplemental fiber, increase soy protein, increase nuts, weight loss, exercise.
  • Use the risk calculator.  There are separate treatment pathways for primary and secondary prevention.
  • “Risk enhancers” should be considered… including coronary calcium scores.
  • Emphasize rechecking lipids after starting therapy.
  • Consider non-statin therapies like ezetimibe and psck9i-medications.

How to decrease triglycerides?

  • consume  low carbohydrate and low sugar diet.
  • Avoid excess fat in diet.
  • Add omega-3 supplements.

How to raise HDL?

  • Exercise.
  • Stop smoking.
  • Moderate alcohol intake (1-2 glasses of red wine/day).

When to start a statin?

  1. Known ASCVD (atherosclerotic cardiovascular disease).  This is a patient with known vascular disease, a history of stroke or heart attack or peripheral vascular disease.
  2. LDL more than 190, in a patient more than 21 years old.
  3. In a patient without an ASCVD event, but has diabetes, is aged 40-75, and has an LDL between 70-190.
  4. In a patient with an ASCVD-event risk of 7.5% in 10 years or more.
    1. Want to know your ASCVD risk score?!/calculate/estimate/

Who should get a coronary calcium score?

  • If a patient is resistant to starting on a statin despite the labs showing that statins are suggested, a coronary calcium score is a test that can give us more information.  If the coronary calcium score is zero, then the chance of a ASCVD risk in the next 10years is low, so maybe no statin is needed.

Do statins help?  Yes!

  • It is know that statins help decrease ASCVD events by 30-60%!  That is fantastic!

What are the drawbacks?

  • 5-10% of patients complain of muscle pain.
  • It may lead to new-onset diabetes, but most of these patients are already at risk for diabetes (risk factors for diabetes are a BMI of more than 30, fasting blood sugar is already more than 100 or in a patient with hemoglobin A1c of more than 6%).
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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.

I hope this helps.

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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.


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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.


  • 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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