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Breast cancer screening has long been a cornerstone of women's healthcare. With 1 in 8 women diagnosed with breast cancer in their lifetime1, the United States Preventive Services Task Force (USPSTF) has developed screening recommendations to help detect early-stage cancer. Notably in 2023, the USPSTF revised the recommended age for biennial mammogram screenings for women with average risk to start at age 40 instead of 502, estimated to result in 19% more lives being saved3 by starting screening earlier. While initiating screening at an earlier age offers advantages to a wide demographic, concerns about the potential of over-screening prompted research into the feasibility of identifying women with lower breast cancer risk who could safely delay mammograms. While guidelines address high-risk individuals, a notable gap exists in providing recommendations tailored to those at lower risk. To gain insight into a patient's risk level, physicians are able to utilize genetic testing to understand an individual's genetic makeup, providing precise insights into their predisposition to various health conditions, including breast cancer. Armed with this genetic information, healthcare providers could craft tailored screening strategies that align with an individual’s specific risk profile. This genetic risk-based approach underscores the value of genetics in individualizing the onset of screening to help avoid over-screening and its associated costs. Surprisingly, genetic information is not currently being widely utilized to identify women at risk of breast cancer or other diseases in clinical practice, despite its potential to make a significant positive impact for patients. A recent retrospective analysis of 25,591 women from the Healthy Nevada Project4 sheds light on the potential benefits of this genetic risk-based approach. The study classified 2,338 (9.1%) of these women as having a low genetic risk for breast cancer. What's remarkable is that these women exhibited a significantly lower and later onset of breast cancer compared to their average or high-risk counterparts. This finding suggests that it might be safe for low-risk women to delay mammogram screening by 5 to 10 years without compromising their health.

Read More About Optimizing Mammogram Screenings: A Genetic Approach to a Personalized Screening Schedule

Dr. Shipra Singh, a Pediatric Pulmonologist, outlines the challenges of diagnosing asthma in children due to symptoms resembling other respiratory issues. It's particularly difficult to identify in infants and young children, who may not clearly exhibit breathing difficulties. Asthma, often confused with bronchitis, croup, or allergies, is a significant chronic illness causing school absenteeism, as per the CDC. Risk factors include prenatal smoking and family history of allergies or asthma. Infants and toddlers are more susceptible due to smaller airways and respiratory viruses, which can exacerbate conditions like colds and bronchitis. How can I tell if my child has asthma? Unfortunately small children are unable to describe their symptoms, making asthma difficult to diagnose. Your child may even be active, playing and smiling, although they are experiencing chest tightness or labored breathing. Observe your child and let the child’s doctor know if: Your child’s breathing behavior has changed (coughing, wheezing, rapid breathing) Your child’s breathing pattern changes (day vs. night, with rest or activity, inside vs. outside) You have a family history of asthma or allergies Your child’s breathing is triggered by any foods or allergies With your help, your child’s doctor can make the best diagnosis to determine if your child has asthma. A pediatric pulmonologist (lung specialist) or pediatric allergist may also have to be consulted for special testing. Tests may include lung function testing, allergy tests, blood tests and X-rays for an accurate diagnosis. What is the treatment for infants and toddlers? Young children can use many of the same medications as older children and adults, although the way they take them and the dosage will differ. A nebulizer (or breathing machine) creating a medicated mist for your child to breathe through a mask may be used. An inhaler with a small spacer tube connected to a mask is also common to help your child breath medication into their lungs. Either of these options are effective. Asthma in children is treated with both fast-acting and long-term medicines to open up airways quickly for easy breathing and also to lessen asthma symptoms over time. Communicate with your child’s medical providers to create a personalized asthma management plan for them. How can I manage my child’s asthma? Recognize your child’s breathing habits and be aware of worsening symptoms. Consult with your child’s doctor on a daily asthma action plan to recognize worsening symptoms and track medications. Here’s an example of an asthma action plan provided by the U.S. Department of Health and Human Services’ National Institutes of Health). Be consistent with the plan and talk to your doctor before changing it. Have an emergency plan in case of a serious asthma attack. Know where the closest ER is and know who can take care of your other children. Also know what the medical treatment coverage is under your insurance plan. Dr. Singh explains, "Discussing asthma with your child may be difficult. Some kids find the subject frightening or confusing. Others, especially the older kids, may resent the treatment and may not be interested in doing it. Talk to your doctor about advice to build an open and trusting relationship regarding your child's asthma care."

Read More About Understanding and Managing Childhood Asthma

February is American Heart Month. While cardiac care is crucial every time of year – especially as heart disease stays the number one killer in the United States – American Heart Month serves as a great reminder to stay on top of your heart health. We spoke with Malina Ruiz, a cardiology nurse practitioner at Renown Health, on three key ways to embrace heart-healthy living and how genetic screening can help inform you of certain genetic risks that can play a role on the cardiac life stage.  1.  Invest in a heart-healthy diet. Eating a diet that is rich in fruits, vegetables, whole grains and healthy fats (including monounsaturated fats such as avocados and polyunsaturated fats such as sunflower oil) is a key defense in protecting your cardiac health, according to Malina. While you are filling your plate with these nutritious foods, remember to keep an eye on your saturated and trans-fat intake, and try limiting foods that are high in those fats.   “No matter what age we are, maintaining a heart-healthy diet will always be important,” said Malina.    Need help finding cardiac-friendly meals? The National Heart, Lung and Blood Institute makes it easy with heart-healthy recipes and tips from experts.  2.  Do an exercise audit. “Keeping an active lifestyle during our younger years is one of the most important factors that affect heart health in future years,” said Malina. Maintaining a regular exercise regimen that allows you to raise your heart rate and break a sweat can help prevent future cardiac events.     A good rule of thumb is to aim for 150 minutes a week of moderate-intensity exercise, which averages out to 30 minutes a day on 5 days out of the week.    It’s never too late to start a regular exercise routine! Exercise doesn’t have to be something you dread – leverage American Heart Month to find activities that you enjoy. The American Heart Association can help you discover new ways to move your body. At the end of the day, as Malina emphasizes, “any movement is better than nothing!”  3. Don't skip those check-ups. Regular preventative visits with your primary care provider can help you identify possible risk factors for heart conditions before they start actively affecting your life. “Check-ups become even more important as we age, along with being aware of the signs and symptoms of heart disease, heart attack and stroke,” added Malina.     There’s no time better than the present – call our expert scheduling team today at 775-982-5000 to request a preventative check-up with your primary care provider.

Read More About Staying Heart-Healthy with Genetic Screening

Being admitted to the hospital is never easy. Being admitted for a traumatic injury can be even harder. Whether it's learning how to walk again or powering through a new speech therapy routine, recovering from an injury that may affect the course of your life can be daunting.  But it doesn’t have to be, thanks to the Acute Care Rehab Therapy team at Renown Health.  The smiling faces of the Acute Care Rehab Therapy team at both Renown Regional Medical Center and Renown South Meadows Medical Center will make you see that there is a light at the end of the tunnel. Your dedicated physical therapists, occupational therapists and speech language pathologists are here to serve you and place you back on the right path to recovery and function.  The Role of Acute Inpatient Therapy  The Acute Care Rehab Therapy team comes in at a critical juncture in a patient’s care process after hospital admission. As one of the primary rehabilitation partners on a care team, these dedicated therapists are here to maximize every patient’s safe and independent living before they set off back home – all while reducing the risk of hospital readmission.  “As physical therapists, we address musculoskeletal deficits and assess a patient’s current function after acute injury or illness from their baseline and develop a plan for functional recovery,” said Kristie Eide-Hughes, Physical Therapist at Renown Regional. “We also use our clinical expertise to assist with the discharge process and make sure each patient has the best durable medical equipment the first time around, removing the guesswork.”   “On the occupational therapy side, we work with patients to facilitate their independence with basic life skills, such as dressing, bathing and using the restroom,” added Jeanne Clinesmith, Occupational Therapist at Renown Regional.  “In the pediatric setting, we help babies and kids get back to what they were doing before they came into the hospital,” continued Rhonda Yeager, Pediatric Occupational Therapist at Renown Regional. “In the NICU specifically, we support the development of babies, trying to prevent problems from worsening. It’s nice to be a source of positivity in an otherwise intimidating situation.”  The role of therapy in this setting reaches all ages, from babies in the neonatal intensive care unit (NICU) to adults approaching end-of-life care. Every therapeutic approach is tailored specifically to each patient.  “Therapy is more of a habilitative approach for infants in the NICU, while it is more of a rehabilitative approach for kids and adults following injury or illness,” said Sara Carolla, Physical Therapist at Renown Regional.   Each team member in the Acute Care Rehab Therapy department is dedicated to each patient, helping them make progress from start to finish and giving them the tools to succeed along the way.  “I enjoy the variety of the patients we get to see and the ability to see them make gains from the wonderful treatment they get in the hospital from my team,” said Kelly Schwarz, Occupational Therapist at Renown South Meadows.  “We provide education as each patient’s acute issues evolve,” added Nicole Leeton, Speech Language Pathologist at Renown Regional. “One of my favorite parts of my work is the patient and family education aspect, and that includes other healthcare provider education as well. It’s a moving picture.”  Moreover, every team member gives each patient tools to learn how to be themselves again and empowers them to continue striving for the best possible result of their therapy  “We get the opportunity to make a person’s bad experience in life better even by spending one session with them, giving them the keys to unlock something that they didn’t think they had the ability to do,” said Dana Robinson, Occupational Therapist at Renown Regional.  On the Road to Independence  Our dedicated therapists in the Acute Care Rehab Therapy team set the stage for a patient’s recovery process after trauma, showing them their potential for independence. With a multitude of patients coming into the hospital with many degrees of medical complexity, each day is different while the end goal is always the same: to optimize function as early as possible while overcoming any barriers and paving the way for a comfortable and effective quality of life.  “Early intervention is a big piece,” said Nicole Leeton. “Us seeing patients early can get them recovered and independent more quickly and help prevent future illness and injuries. For example, in speech therapy, getting in early and facilitating communication skills for patients with impaired speech can make a huge difference.”  Acute Care Rehab therapists dig deeply to see the whole picture of each patient’s situation to foster their independence – their history, social skills, support system and more.  “Sometimes, we are the difference between independence and dependence,” said Dana Robinson. “We are the eyes and ears because we have so much time with the patients. Our team is extremely collaborative and develops a great rapport with patients, so they feel comfortable telling us everything going on with them.”  “For kids, we teach parents ways they can help their kids by setting up their homes and the equipment they need to succeed,” added Rhonda Yeager.  According to the team, one of the biggest keys to independence is repetition. A continual flow of getting up and trying again is crucial for recovery.  “Repetition helps people regain their quality of life back sooner and control their recovery process,” said Megan Hough, Physical Therapist at Renown Health.  “Helping people continue to get stronger and more independent makes my job so rewarding,” added Sam Brown, Physical Therapist at Renown Regional.  Knowing that they have made a difference and help shape a patient’s overall development inspires each therapist to never give up, regardless of how difficult an injury presents. There is no set schedule for recovery, and the therapists are always in the patient’s corner.  “This team has the most passionate, caring and dedicated individuals that I know,” said Kendra Webber, Manager of Acute Inpatient Rehab Therapy Services at Renown Regional. They give 110 percent to every patient every time to ensure they have what they need to regain function and independence.”  “By tailoring therapy to the individual, the bounds are virtually limitless for what we can accomplish,” added Dana Robinson.  It Takes a Village  Since acute inpatient therapy is never a one-size-fits-all approach, it truly takes a village for this team to move the mountains they do for patients every day. These teams are fact-finding masters, gathering all the necessary information from the patient, their family and their care team to figure out their precise needs.  “We are a consistent presence for our patients, identifying a lot of different needs and meeting those needs to help patients grow in their treatment process,” said Kelly Schwarz. “By collaborating with each patient’s diverse care team, we are able to employ the clinical judgment to help patients overcome physical, emotional and environmental struggles and set them up with the proper resources once they leave our setting.”  “Our team has steady communication with physicians, nurses, acute care technicians, respiratory staff, physician assistants, case managers and more to ensure the best possible care,” added Jet Manzi, Physical Therapist at Renown Regional.  Constant communication and collaboration are also necessary beyond the acute treatment process. These skills are vital in order to facilitate discharge planning, and the Acute Care Rehab therapists are an essential resource in the discharge process alongside our Hospital Care Management team.  “Often times, a patient’s family needs a lot of guidance in helping their loved ones determine the next level, and we help them navigate those steps and the resources available to them,” said Mark Stumpf, Occupational Therapist at Renown Regional. “And it’s all a team effort.”  “Our therapists are the most committed, generous, hardworking people,” added Courtney Phillips-Shoda, Supervisor of Rehab Therapy Services at Renown Regional. “Despite being short-staffed, we come to work every single day and give everything to our patients. They are the priority.”  If you take away one thing, know this for certain: Renown’s Acute Care Rehab occupational, speech and physical therapists will always be there to help patients continue on a positive trajectory to physical, mental and emotional recovery.  “Whether you are a patient or a provider, if there is a problem, never hesitate to reach out to us,” said Nicole Leeton. “We are always receptive to anyone seeking our help.”  With the Acute Care Inpatient Therapy team on their side, a patient’s journey to recovery is only just beginning.

Read More About Department Spotlight: Acute Care Rehab Therapy

As we enter the holiday season, many of us are beginning to plan and partake in festivities such as shopping, cooking, baking, holiday parties and family gatherings. While the holidays often bring joy and cheer, the hustle and bustle can also lead to fatigue, stress, anxiety and sometimes depression. To avoid holiday burnout, it’s important to find ways to care for yourself mentally and physically. Galen Gorelangton, Renown's Spiritual Center Volunteer, discusses how yoga and meditation can benefit you. What is yoga and meditation?  Yoga is defined as performing a series of postures and controlled breathing exercises to promote a more flexible body and a calm mind. As you move through poses that require balance and concentration, you're encouraged to focus less on your busy day and more on the moment. Meditation involves focusing or clearing your mind using a combination of mental and physical techniques. While there are many different types of meditation and yoga practices, they both share similar benefits including: Reduced stress Lower blood pressure Decreased anxiety and depression Increased energy Better sleep Lower inflammation and pain levels Improved strength, balance and flexibility  Better focus and concentration  And much more!

Read More About Meditation: Give Yourself the Gift of Inner Peace

Reviewed by: Jessica Blauenstein, a Board-Certified Specialist in Oncology Nutrition and Registered Dietitian at Renown Health. As the temperatures continue to rise around northern Nevada, our farmer’s markets and home gardens are bursting with produce – making this the perfect time to prepare a fresh summer salad for you and your family. American salads have come a long way. No longer must we settle for iceberg lettuce topped with pale tomatoes and store-bought salad dressing. Fresh fruits, exotic vegetables and aromatic herbs are proudly taking up residence as entrees on menus around the globe. These refreshing Pritikin salad recipes are chocked full of phytonutrients – plant compounds that provide a host of anti-bacterial and anti-inflammatory benefits while supporting the body’s natural detoxification process. When it comes to ingredients, freshness counts! Try to use local and unsprayed produce in your salads whenever possible for added nutritional value. Already thinking of ways you can put your own personal touch on these recipes? Andria Herron, dietary educator with Renown’s Healthy Heart Program, encourages you to experiment. “Salads are the perfect recipes to substitute, omit and add in additional ingredients based on your personal preferences,” said Andria.

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Renaissance Don   The Sterling Silver Club is honored to have thousands of members who’ve led and continue to lead incredibly vibrant and diverse lives. And we’re absolutely thrilled when those members volunteer to share their stories and experiences so we can all appreciate and learn from them.   This issue’s featured member is no exception. From his love of cooking, travel and music to his drive to learn new languages, take on new hobbies and keep himself active and fit, Don is an aspiring Renaissance man who may already be deserving of the title.    Revolutionary Family Roots   Don’s father, who was born in Beijing, China, earned a master’s degree in metallurgical engineering from the University of California, Berkeley and was working on his PhD there on a full scholarship from his home country when the Chinese Communist Revolution occurred. In order to stay in the United States and avoid potentially being thrown into prison by the new communist regime (a fate that befell some of his family members), his father married Don’s mother, who was a U.S. citizen and also a student at Berkeley. Together, they started a family.   “My father met my mother in a class and received his green card by marrying her,” says Don. “They proceeded to have six kids in nine years, I was number three. Dad never finished his PhD, but clearly earned what we like to call his “PSK” degree – Papa with Six Kids.”  Proud (of) Papa: Don’s father was a professor of metallurgy and a brilliant research scientist who was responsible for virtually every breakthrough in the development of titanium in the 1960s.

Read More About Meet Multifaceted Member Don Chang

What exactly is the relationship between genetics and disease? Powered by Renown Health, the Healthy Nevada Project is one of the most visible genomic studies in the United States. They are recruiting participants here in northern Nevada to understand the relationship between genetics and nonalcoholic liver disease. Joseph Grzymski, Principal Investigator at the Healthy Nevada Project and Chief Scientific Officer at Renown Health, shares why this study is so important and who should take part. Many people are aware that heavy drinking can lead to liver disease. Yet they are unaware that other types of liver disease are not caused by alcohol consumption. These types of liver disease are more difficult to diagnose but are equally dangerous. What is NASH? A build-up of fat causes nonalcoholic Fatty Liver Disease (NAFLD) in the liver. The most dangerous form is called Nonalcoholic Steatohepatitis (NASH). It causes inflammation and damages liver cells, leading to fibrosis, scarring of the liver, and decreased liver function. If NASH goes untreated, irreversible liver damage can occur, leading to cirrhosis, cancer, or liver failure. These conditions can be fatal. What’s most concerning about NASH is that the symptoms don’t typically cause pain and aren’t noticeable. The good news is that a new local study is raising awareness about this disease by recruiting at-risk people for NASH. Am I at risk for developing NASH? The following factors put you at risk: Obesity Type 2 diabetes Metabolic syndrome High blood lipids, such as cholesterol and triglycerides Does having a family member with nonalcoholic liver disease increase my risk? We do not know a lot about inheriting NASH, although a lot risk factors run in families. One goal of this study is to better understand the genetic component of NASH. There are certainly other risks too, such as environmental and behavioral risk factors. However, we don’t yet have a good grasp on how these impact NASH risk. How is NASH diagnosed? Diagnosis is traditionally done with either a liver ultrasound or biopsy. However, both procedures are expensive and the invasive biopsy has risks. Therefore doctors often use risk factors or less invasive blood tests for diagnosis. This NASH study will include a new blood test called the enhanced liver function (ELF) test. Doctors and researchers have data suggesting that the ELF test is a better diagnostic test for NASH risk. Conducting this cutting-edge test with study participants allows them to share results with their doctors to ensure the best care. What can I do to reduce my NASH risk? Limiting exposure to the risk factors of NASH often lowers risk. Eating a healthy diet, maintaining a recommended weight and exercising regularly can proactively lower your risk.

Read More About Nonalcoholic Liver Disease and Genetics: Is There a Link?

The Healthy Nevada Project (HNP) is one of the most visible genomic studies in the United States, and guess what? Renown Health powers it! The Healthy Nevada Project (HNP) aligns with Renown's goal to do the best for our patients. The genomic study is at no-cost for Nevadans and gives participants insight into different genetic traits, including results on three prevalent and serious health conditions known as CDC Tier 1 conditions. CDC Tier 1 Conditions Include: Hereditary Breast and Ovarian Cancer Syndrome (HBOC) Lynch Syndrome Familial Hypercholesterolemia (FH) Not only does HNP give participants insights into their genetic background, but it also facilitates Renown's ability to study population health. Research lays the foundation for the future of medicine, and Renown's HNP is on the cutting edge of genetic research. We do this by providing skilled researchers access to studies for the diseases that currently have limited treatment, including nonalcoholic steatohepatitis liver disease or NASH. For example, the observational NASH study helps researchers understand genetic links to the disease. Make an Appointment to Get Screened If you haven't already, join the over 55,000 HNP participants and make an appointment to have yourself screened. You can schedule a screening appointment through MyChart. Click “Schedule an Appointment" and select Research Appointment - Genetic Screening. Prior to your appointment, please complete e-Check-in and complete your consent form.

Read More About What is the Healthy Nevada Project?

Colorectal cancer is the number two cancer killer in Nevada, only second to lung cancer, yet it is also one of the most preventable. Still, in 2020, 20.7% of Nevadans said they had never been screened for this deadly disease, according to the Nevada Cancer Coalition. At the start of the COVID-19 pandemic, unfortunately many healthcare services were halted, including colorectal cancer screenings. Those delays in screenings can lead to delays in diagnoses of colorectal cancer, resulting in poorer outcomes. Per the American Cancer Society, if colorectal cancer can be found early the relative 5-year survival rate is approximately 90%. Screening is key, and it is important to engage in preventative care. Even if you have no personal or family history of colorectal cancer, ask your doctor about colorectal risk factors and when to start screening, and if you’re up to date on your screenings, talk to loved ones and make sure they are too. According to the American Cancer Society, most colorectal cancer cases are found in those without a family history. This month let us help raise awareness for colorectal cancer and the importance of routine, life-saving screenings. To learn more, we spoke to Renown Health oncology nurse Christina Alsop, APRN. What is Colorectal Cancer Colorectal cancer is a disease in which the cells in the colon or rectum grow out of control. It usually forms from precancerous polyps, or abnormal growths, in the colon or rectum, which can become malignant without presenting any symptoms. How do Screenings Work Screening tests like stool tests, colonoscopies and others can detect these precancerous polyps, so they can be removed by a physician before turning into cancer. Screening tests can also find colorectal cancer early, resulting in better treatment outcomes. As of 2021, the U.S. Preventative Services Task Force recommends adults begin colorectal cancer screenings beginning at age 45, through 75. Screening methods include a blood stool test, which needs to take place every year or a colonoscopy, which takes place every 5-10 years. Healthy Habits Can Help Stave Off Risk Routine screenings are the only way to determine colorectal health, yet some healthy habits may reduce your risk for colorectal cancer. These factors include maintaining a healthy weight, being physically active, eating a diet rich in fresh fruits, vegetables and whole grains, limiting alcohol intake and not smoking.

Read More About Early Detection is Key to Surviving Colorectal Cancer

Often, when we think of Italian dishes, we think of pasta. In fact, there are more than 600 different pasta shapes, each holding the task of delivering Italy’s flavors.  While we all crave pasta, according to the U.S. Department of Agriculture (USDA), a cup of pasta shells contains about 166 calories, 6 grams of protein and 32 grams of carbohydrates. When you add all the other comforting ingredients that comes with cooking Italian, it’s nearly impossible to keep it healthy.  Caitlin Bus, Registered Dietitian with the Renown Healthy Heart Program shares a healthier version of an Italian favorite –deconstructed manicotti using zucchini as a substitute for noodles. If you’re looking for a healthier Italian dish and wondering how to use a spiralizer to turn vegetables into noodles, this recipe is for you.

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Millions of people across the west live in areas where air pollution can cause serious health problems. In addition, local air quality can affect our daily lives.  Who is Affected? Kouros Farro, MD, a physician with Renown Urgent Care, advises that certain people are more likely to be affected when fine particle pollution reaches an unhealthy level. People who have asthma or other breathing conditions like chronic obstructive pulmonary disease (COPD). People who have heart disease or high blood pressure. Children and older adults. People of all ages who are doing extended or heavy physical activity like playing sports or working outdoors. “Everyone should take precautions when the air quality is unhealthy. Air pollution can aggravate heart and cardiovascular disease as well as lung diseases like asthma and COPD. When the air quality is unhealthy, people with these conditions may experience symptoms like chest pain, shortness of breath, wheezing, coughing, or fatigue. If you are experiencing any of these symptoms, use your inhalers as directed and contact your health care provider,” says Dr. Farro, who is board certified in family medicine and practices at Renown Urgent Care at 975 Ryland St. in Reno. “If you do not have a health care provider, there is a Renown Urgent Care office on almost every corner, with providers ready to see you.” Dr. Farro advises the following: Take it easy and listen to your body. Limit, change or postpone your physical activity level. If possible, stay away from local sources of air pollution like busy roads and wood fires. If you have asthma or other breathing conditions like COPD, make sure you have your relief/rescue inhaler with you. People with asthma should review and follow the direction in their written asthma action plan. Make an appointment to see your health provider to be sure you have an asthma action plan. Getting Same-Day Care Renown Urgent Care provides same-day treatment for a wide range of minor injuries, illnesses and medical concerns that are urgent but not life-threatening. Avoid the long wait times and high emergency room prices at 11 convenient sites, including Reno, Sparks, Carson City, USA Parkway, Fallon and Fernley. You can walk in or book ahead online. Make an Urgent Care Appointment Community Health Resources The Washoe County Health District offers online health information on its Smoke Smart website, including fire information, daily air quality information, fire and smoke maps and how to protect yourself. In addition, an online subscription page allows you to sign up for EnviroFlash, notifying you about air quality.

Read More About Tips for Coping with Smoke-Related Health Problems