I helped write an article on NerdWallet.com Travel medical advice…

Posted on May 18, 2018 by drlesliegreenberg

I helped write an article on NerdWallet.com… Travel medical advice… https://www.nerdwallet.com/blog/travel/how-to-avoid-germs-on-planes/

 

 

 

 

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Does calcium and vitamin D help with community-dwelling older adults?

Posted on May 16, 2018 by drlesliegreenberg

Does calcium and vitamin D help with community-dwelling older adults?  JAMA put out a great article recently about calcium and vitamin D and its help to decrease fractures.

The low down on this study is that in this meta-analysis (meaning a compilation of many randomized clinical trials with over 51,000 patients) the use of supplements including calcium and vitamin D was NOT associated with a lower risk of fractures among community-dwelling older adults.

These findings do NOT support the routine use of these supplements in community-dwelling older people.

Want more information?  1252802383_d8582894a7_ohttps://www.doximity.com/newsfeed

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How can physicians help patients keep prescription cost down?

Posted on May 15, 2018 by drlesliegreenberg

How can physicians help patients keep prescription costs down? This is a very important and constantly changing problem.  Pharmaceutical companies have figured out how to get more money for their prescriptions.  Some ways to keep inflated prices are that there are limited alternatives to the medication (ex: lead poisoning treatment), older medications with few manufacturers (ex: EpiPen and colchicine), single manufacturer with no generic available (example: humalog insulin), “evergreening” or making slight changes to existing drugs to continue patent exclusivity (ex: ortho tri-cyclen or oxycontin).

It is the rare patient who is not plagued with high prescription drug costs.

How can your physician help manage high prescription drug costs?

  • Choose low-cost generic drugs first.  There are many drugs available for $4/month (which may be a long-term medication or for a short course for a specific ailment).  I am a fan of the Walmart $4/month medication list. http://www.walmart.com/cp/4-Prescriptions/1078664.  This list can help to decide which medications could be obtained at Walmart for $4/month.  Consider asking your favorite pharmacy to match their price.
  • Learn the costs of your medications.  Your physician may have you on a medication with no generic, but if there is a generic within that same medication class you can consider a switch.  If the generic is just as effective and without side effects, ask your doctor to change prescriptions. For example, there is a cholesterol-lowering medication called pitavastatin (not available in a generic form) for $3000 per year or a generic lovastatin available for $40 per year.
  • Do not assume that your insurance will help lower the costs of medications more than paying cash for your medications (as if you had no insurance).  A name-brand medication may cost MORE with insurance than a generic without. Or at times a generic medication may cost MORE with insurance than paying without your insurance.  ALSO, there are some over-the-counter medications like acne cream that are less expensive bought off the shelf than from the pharmacist.
  • If your physician’s office offers samples for a drug, consider that even though the samples are free… the medication (when you buy it from the pharmacy) may cost more than if you were started on a less-expensive medication.  When a pharmaceutical representative drops off samples at a physician’s office, those are most-often-than-not EXPENSIVE medications. Beware.

 

Did you know there are patient assistance programs?  NeedyMeds at www.needymeds.org or  RxAssist at www.rxassist.org help patients find assistance with drug costs.

 

Want to try a new medication?  Be wary. New medications may have unknown side effects or long-term complications AND are more likely to be expensive.  I understand that pharmaceutical companies need to recoup their research and development costs, but you can be a smart consumer and decide what you are willing to pay for your medications.  The relative safety, effectiveness, tolerability, price, and simplicity of new drugs are presented in the STEPS department in the American Family Physician (our family medicine go-to-journal) at www.aafp.org/afp/steps.

 

I have no relevant financial affiliations.

pills

flickr.com/ photos/masterslate/ 3003880273

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Hyperthroidism, an overactive gas pedal to our body…

Posted on May 8, 2018 by drlesliegreenberg

Hyperthyroidism.  This is when the thyroid gland (the gas pedal to our body) is working too hard.    The actual definition is an excessive concentration of thyroid hormones. This can be caused by the body making too many thyroid hormones or taking more thyroid hormone than is needed.  The most common causes of excessive production of thyroid hormones is toxic adenoma, toxic multinodular goiter and Graves disease. Excessive passive release of thyroid hormone can be painless thyroiditis.

 

Symptoms of hyperthyroidism are

  • heart palpitations or fast heart rate,
  • jitteriness,
  • weight loss despite increased appetite,
  • anxiety,
  • rapid or pressured speech,
  • insomnia or
  • even psychosis.
  • A late finding is exophthamos (where the eyes seem to “bug out”).

 

How to test for hyperthyroidism?  Your doctor will do a blood test. You do not need to fast for this test.  The test with the highest sensitivity and specificity for hyperthyroidism is the TSH (Thyroid stimulating hormone). If this value is LOW, then a free thyroxine (T4) and a total triiodothyronine (T3) level may also be checked.

There are other reasons the thyroid labs could look like hyperthyroidism without being hyperthyroidism.  Pregnancy. Estrogen therapy. Acute illnesses. Steroid or dopamine treatment.

Aren’t there imaging tests?  Yes. A radioactive iodine uptake test and thyroid scan can help determine the cause of hyperthyroidism.  The uptake is the percentage of an iodine I-123 tracer dose that is taken up by the thyroid gland. It should be 15-25% at 24 hours.  If the uptake is very low, like 0-2%, this could signal thyroiditis (where the thyroid is inflamed) and high in patients with Graves disease, a toxic adenoma, or toxic multinodular goiter.  If the tracer is homogeneously distributed, this can signal Graves disease and if it accumulates in certain spots this could signal a toxic adenoma or if in multiple areas, a toxic multinodular goiter.  Ultrasound is sometimes used as a cost-effective and safe alternative to radioactive iodine.

How to treat hyperthyroidism?

  • To control the symptoms. Propranolol is a beta blocker often used to slow the heart rate down to normal and decrease symptoms.
  • Otherwise, there are three treatment options to control hyperthyroidism long-term.
    • 1. Antithyroid medications (like methimazole or propylthiouracil)
    • 2. Radioactive iodine I-131 to ablate (burn out) the thyroid
    • 3. Or surgical removal of the thyroid gland.

I hope this helps.

rainbow

flickr.com/photos/ devilskebab/7355494132

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Summer travel is upon us: International travel and medication advice!

Posted on May 1, 2018 by drlesliegreenberg

International travel and medication advice.  As the summer travel season heats up, what should you know about medications and travel?

There are two great websites, the Centers for Disease Control and Prevention (CDC) and the Transportation Security Administration (TSA) to help delineate the rules on medications and international travel.

Travel tips:

  • Carry a legible updated medication list while traveling with brand (and generic name of the drug), dosage and dosage schedule and indication for the medication.
  • Carry copies of recent laboratory tests, electrocardiogram results, a list of chronic medical problems a recent medical history and physical examination results, and any pertinent recent hospital records (if applicable).
  • Keep essential medications with you in a carry-on bag.
  • It may save you distress to keep your medication in the original containers (even though in the US you are allowed to transfer medications to a pillbox) as this will also have the name of the prescribing physician and their phone number.
  • There are specific rules (current as of 4/2018) with TSA regarding liquids and syringes and needles.
    • You can travel with an excess of 3.4 ounces on airplanes, provided the traveler follows TSA’s rules.  “You may bring medically necessary liquids, medications and creams in excess of 3.4 ounces or 100 milliliters in your carry-on bag.”
    • Remove them from your carry-on bag to be screened separately from the rest of your belongings. You are not required to place your liquid medication in a plastic zip-top bag.”
    • “Also declare accessories associated with your liquid medication such as freezer packs, IV bags, pumps and syringes. Labeling these items can help facilitate the screening process.”  These supplies may need to undergo additional screening procedures. Consult with TSA before traveling!

 

Bringing breastmilk or formula?  TSA will allow more than 3.4 ounces of either liquid to be brought onto airplanes.  You are instructed to “inform the TSA officer at the beginning of the screening process that you carry formula, breastmilk, and juice in excess of 3.4 ounces in your carry-on bag.”  The liquids will undergo x-ray. You can request visual inspection instead.

Illegal medications in other countries:

  • Pseudoephedrine is illegal (even with a prescription) to be brought into Mexico.
  • Amphetamines (like Adderall) are illegal (do not bring into) in Japan.  Check the US Department of State to review if your medication can be brought in to your destination.

Differing brand names:

  • Be aware that your US medication may be named something else in another country.
  • Or the same sounding medication name in another country can be another kind of medication altogether elsewhere.

 

Buying medications overseas:

  • Quality control of overseas medications may not be as rigorous as the US.
  • The CDC estimates that medication sold in developing countries is counterfeit up to 30%.
  • If you do buy medication overseas, check that the medication is in its original packaging and that the printing on the package looks original.
  • Buy medications are reputable pharmacies and ask the pharmacist if the new medication has the same active ingredient as the medication it is replacing.

How to get help overseas.  Consider asking the US embassy for suggestions for medical services like reputable physicians, health care facilities and pharmacies.  To find an embassy www.usembassy.gov

I hope this helps.

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flickr.com/photos/n8kowald/1981964609/

 

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Do you need to safely dispose of medications? Saturday, April 28. Take back medicine day!

Posted on April 28, 2018 by drlesliegreenberg

Do you have extra medication at home that you no longer use or is expired?  Now is your time.  Saturday, April 26 is take-back-medicine-day!

Which medicine should you take back?

  • ANY you are no longer using or needing.
  • It is especially important to safely dispose of controlled pain (like opioids) or anxiety medicine. Often when a patient has surgery, they are prescribed pain prescription pain medicine.  If medication is left over, friends or family (your teenagers?!) have access to pain medicine that may lead to addiction.  Be responsible.  Dispose of the medication safely.

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    flickr.com/photos/j-ster/4431952048

Want more information in your area?  http://www.Takebackday.dea.gov

I hope this helps.

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Testosterone replacement. Do you (or your man) need it?

Posted on April 27, 2018 by drlesliegreenberg

Testosterone replacement.  Do you (or your man) need it? I recently attended a medical conference discussing the subject of testosterone deficiency (and replacement!),  risks and benefits.  I’d like to share what I learned…

Direct-to-consumer advertisements.  There are MANY ads to promote the vigor that testosterone gives men.  Of note, the quality of life and vigor from testosterone replacement is the least well-studied part of research.

What should we call this condition?!  One term, testosterone replacement therapy, is not be the most appropriate name in that “replacing” implies a deficit.  Other names for this are androgen deficiency therapy, symptomatic androgen deficiency, pathological androgen deficiency, and testosterone replacement therapy.  It is best called testosterone therapy.  Your physician may medically appropriately diagnose it as late-onset hypogonadism (LOH).  But, the real question is….Is the deficiency of testosterone causing a decrease in quality of life?

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flickr.com/photos/rossap/8283009697

Criteria for LOH.

  • total testosterone less than 300 ng/dl.
  • Or free testosterone concentration less than 5 mg/dl.
  • LH and FSH may be tested, but this is very uncommonly.
  • Sexual symptoms:
    • decreased libido,
    • lack of spontaneous erections,
    • erectile dysfunction.

What is NOT LOH criteria?  (what are the MARKETED symptoms…)

  • decreased energy, depressive symptoms,
  • poor concentration,
  • sleep disturbance,
  • reduced muscle mass,
  • increased body fat,
  • decreased physical or work performance.  These MARKETED symptoms are vague and testosterone may be prescribed at some offices WITHOUT ever getting labs.

Prevalence of LOH.  Based on sexual symptoms (the first 3– and only LOH-specific- symptoms) 20-40% prevalence by age 80.  The MARKETED symptoms are prevalent in 40-60% by age 80.  If lab is done, then there is only low testosterone in 6% (!) in those with sexual symptoms.    The prevalence of “low total testosterone” in men with obesity, insulin resistance, metabolic syndrome is 50% and these patients may need a free testosterone to appropriately diagnose LOH.

What % of men across the globe are prescribed testosterone?  Mexico 0.05%.  Denmark 0.1%.  UK 0.3%.  Australia 0.5%.  US  3.5%. Canada 13% (inflated due to internet prescriptions being sent out of the country, read this… sent to the US among other countries).

Marketing of Low testosterone.  There are questionnaires with high sensitivity, but low specificity.  This means that the questionnaire is SO inclusive that almost all men who have low testosterone are included, but also many men who do not have low testosterone are show positive also.  As a provider, I should look at two parameters: sexual symptoms and testosterone level.  Most above questionnaires rely on MARKETING symptoms.

LOH consequences.

  • frailty which increases fall risk,
  • reduced bone strength.
  • cardiovascular disease.
  • increased all-cause mortality  (we are unsure about the association versus causation.)  There is minimal evidence that replacement of testosterone decreases all-cause mortality (meaning you may not live longer than without testosterone replacement). Supplementation of testosterone may not decrease all-cause mortality rate by much.

Influences on Testosterone levels.  Testosterone levels vary daily and throughout the day.  So, have more than one testosterone level drawn.  Check on more than one day.  Labs should all be obtained in the morning (as up to 13% lower in the afternoon).  30% of abnormal afternoon tests may be normal in the morning. Should you get a total testosterone or a free testosterone.  60% of testosterone is bound to sex-hormone binding globulin (SHBG), 38% is bound to albumin.  2% is free.  So, if the total testosterone level is low and the patient is obese, then a free testosterone may be helpful, as it may really be at a normal level.

Benefits of testosterone therapy.

  • Slightly decreased depressive symptoms.
  • Slight increase in 6-minute walking distance.
  • Moderate benefit in improved sexual function (BUT this fades over time).
  • No change in vitality, overall function, quality of life.
  • No benefit to those who take testosterone in their muscle mass versus muscle strength and performance.

The testosterone trials.  https://clinicaltrials.gov/ct2/show/NCT00799617  The largest and longest clinical trial.  They screened 51,000 men to get 790 men to be in the study.  (This was 1.5% of those screened).  Total testosterone level to be in the study was less than 275 ng/dl and men had sexual side effects.  We know that Viagra (or similar medications) is better for erectile dysfunction.  Testosterone benefits waned over time  Increased estradiol levels may occur (especially is obese men who then noted breast development).

Risks of testosterone.

  • Mood disorders can occur with testosterone, just like it does with anabolic steroids.
  • Liver cancer can occur although this is avoided with transdermal of intramuscular administration of testosterone.
  • Increased red blood cells which may increase the risks of making blood clots.
  • Gynecomastia–men making breast tissue (from testosterone changing to estrogen within the body).
  • Sleep apnea.
  • Whereas, prior concerns of testosterone increasing prostate cancer is now disproven, this does not happen.

Benefits of testosterone.

  • May lower blood pressure.
  • May improve left ventricular heart function.
  • May increase blood pressure in obese men,
  • lowers good-cholesterol (HDL).
  • Increased red blood cells which may increase the risks of blood clots.

Contraindication to testosterone therapy.

  • Breast cancer.
  • Prostate cancer.
  • Severe lower urinary symptoms (like difficulty starting or stopping the stream of urine, getting up at night to urinate).
  • Sleep apnea risk increases or may worsens with testosterone.

Testosterone Preparations.

  • 85% of prescriptions for testosterone is by gel administration.  Gel 25-50mg/d.
  • The least expensive formulation of testosterone is an injection intramuscular

How to monitor testosterone therapy?

  • Baseline assessment:
    • Needs a digital prostate exam.
    • PSA lab work should be under 4 ng/ml.
    • Bone density test.
  • Monitoring of lab should be done every 3-6 months.
    • Total testosterone should be above 350-400 ng/dl.
    • Patient should fill out a symptom assessment.  If the patient does not FEEL better, then the testosterone may be discontinued.
    • Check red blood cell count.
    • Follow up rectal exam and PSA (if the PSA increases by more than 0.4 ng/ml/year that’s important).
    • Consider re-check bone density.

Overall.  There is no widespread screening recommended to check for testosterone level.  Treatment should be based on LOW testosterone levels ONLY if patients also have sexual symptoms.  Understand that free testosterone lab may be needed with those with obesity or diabetes.   The patient needs to have an informed consent as he needs to know the risks of treatment.  If the patient’s benefits go away, then stop the testosterone.

I hope this helps…

 

 

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Does acupunture help prevent migraines?

Posted on April 24, 2018 by drlesliegreenberg

Does acupuncture help prevent migraines?

Yes!  There is moderate-quality evidence showing that whole-body acupunture may help prevent migraines.   Research has shown that compared to “usual care” acupuncture decreased the frequency of migraines by at least 50% and that this result was maintained with follow-up research at 3 months.

The Institute for Clinical Systems Improvement recommends the use of acupuncture for prevention of episodic migraines.

sad

.flickr.com/ photos/ bahkubean/ 1287879564

Want more information?  Check out http://www.cochrane.org/CD001218

 

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How to balance work and life? How to perform conscious leadership?

Posted on April 20, 2018 by drlesliegreenberg

How to balance work and life?  How to perform conscious leadership.   I attended a lecture at University of Nevada Reno Medical School aimed to help balance self, family and work to “achieve success.”  Here are my take-home points…

Overview: This is the first year that more female matriculated to medical school (woot!  woot!).  Women only make up 39% of all US full-time faculty.   (UNR has 36%)  Women are more commonly the lower ranks of medical schools (meaning less of us are full professors).

Do female physicians make less than men?  Yes! Female doctors’ earnings were 28% lower than their male counterparts in 2017.  So, the gender pay gap for physicians is real and commensurate with other fields’ discrepancy. Women earn 10 to 30% less than men for the same work and it is getting worse for physicians.  This is a global problem and is published by the World Economic Forum in the Global Gender Gap Report.  https://www.weforum.org/reports/the-global-gender-gap-report-2017

Why should we care about diversity?  It is known that

  • Gender diversity leads to better performance.
  • Inclusivity strengthens employee retention.
  • Advancing women’s equality leads to economic growth.
  • Strong female leadership provides financial returns.
  • Diversity breeds innovation and discovery.

What are the barriers to women achieving gender equality?

  • Lack of female role models.
  • Lack of work-life integration (childcare and elder-care responsibilities).
  • Negotiation skills.
  • Unconscious bias.

How to achieve change?

  • Know where you stand.  Know where you are going.  Set goals!
  • Gather your tools and create safety.  What are our tools? What areas do we want to improve in?
  • Recognize our weaknesses.
  • Be authentic to yourself and others.  It’s not WHAT you do, it’s HOW you do it.   Take failures with grace.
  • Celebrate our achievements.  We are often in a rush and there is graceful self-promotion that can be done.

Work/Life Integration.

  • Integrate work and home life.  For example, every time you attend a medical conference, take one of your children.  Connect with that child.  (or Take-your-child-to-work-Day).
  • Delegate.  What can you let go of?  Decide what is worth my time.
    • We may do an activity inefficiently.  Take time to think about how to perform more efficiently.  Hypo-stress.  eu-stress.  Hyper-stress.  Distress.  In distress is where burnout happens.
    • Time Allocation.  divide this into sections.
      • When we are inefficient at a task, delegate it. Someone else may do this better. (example: making the work’s hospital call schedule)
      • When we feel competent at a task, we make take it on because we can complete the task fast. Consider delegating this. (example: cooking)
      • When we are an expert and others do not know how to do it, consider coaching someone and let them take it over.  (example: running a simulation lab)
      • What we are unique in, DO IT MORE!
      • AND…Don’t underestimate the value of doing nothing.

Build your network.

  • One mentor is no longer enough.  We each need our own “Board of Directors.”  Who is on this Board of Directors?
    • Mentors are people you go to for advice and feedback.
    • Family and friends give us social and emotional support.
    • Coaches help with self-discovery and challenge us to think in new ways.  Coaching is important for leaders in that we often do not take time to re-think our lives.  (They may help give us questions… what are OUR best and worse case scenarios?)
  • Negotiating skills.  It is all about your emotional quotient.  ASK and think BIG!  Women often do not apply for a job until they are a 90% match. (Men apply for a job with a 50% match). So, we should dream big.  Know what you want: inner self-awareness.  This helps with better negotiating skills.  Know the other side: social awareness.   Make your wish list, match your bosses list.  Prepare options for mutual gain: relationship management.
  • How can I make my goals match your superior’s goals? Listen carefully: self-management.  Listening helps you now what is important to other people.  We each like to be heard.  Know your BATNA (Best Alternative To Negotiated Agreement): External self-awareness.  Watch out if you push too far when you don’t have another position/opportunity.
  • Self-promotion is all about being graceful  Make a habit of recognizing and praising the accomplishments of others.  Self-promotion may not always mean telling everyone how great we are. View talking about yourself (or others) as educating or teaching others, rather than”selling.”  Report accomplishments and use social media.  Your research, when is on social media, is disseminated better.  This also helps to highlight what we are doing better.  Develop an interesting story around the facts.  Keep your boss in the information loop.  Take credit gracefully.  It is okay for people to know what you have done for them.  Always say thank you.

How can we collectively take action?  Start with self-care.  And, take care of others. Develop conscious leadership skills.  Support women in local and national professional development opportunities throughout the career life-cycle.  Empower women to support, mentor and sponsor each other.  Train both men and women to effectively mentor across genders.   Provide unconscious bias training for everyone.

Your word is a lamp to my feet… And a light to my path.  May we each be a light for one another.

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How to pick a probiotic?

Posted on April 17, 2018 by drlesliegreenberg
influenza bug

flickr.com/photos/ 53867930@N08/5091074915

How to pick a probiotic?

Did you know that in 2012 3.8 million adults and 300,000 children were known to be taking probiotics?!  This is a 400% increase in 5 years.

What does a probiotic do?  It transiently changes the microbiome of the intestine.  It can only be found in the gut microbiome in stool samples for one to two weeks.  This means that the health benefit of a probiotic only lasts for 1-2 weeks after your last ingestion of the probiotic.  This also means that probiotic foods, like yogurt, are as effective as a supplement.

Probiotics are considered a nutritional supplement per the Dietary Supplement Health and Education Act (DSHEA) so they are NOT regulated for clinical application as it is considered food and not a drug.  The DSHEA requires that dietary supplements meet current good manufacturing guidelines, but this does not necessarily mean that the products are effective.

How to buy a probiotic?  Consider buying a probiotic with an expiration date printed on the bottle and one that lists the number of viable colony-forming units at expiration–as this may give some assurance that the probiotic viability continues throughout the lifespan of the product.

The probiotic Saccharomyces boulardii is not eradicated by antibiotics and may help with gut health.  Probiotics have good evidence supporting their benefit in patients with irritable bowel or ulcerative colitis and may prevent antibiotic-associated diarrhea and Clostridium difficile-associated diarrhea.

When buying probiotics, I recommend a probiotic with the National Science Foundation’s certification of good manufacturing practice.  This website can help…   http://www.nsf.org/regulatory/regulator-nsf-certification

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