Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How soon after starting treatment for Takayasu arteritis do you decide on the need for any vascular interventions to manage chronic damage?
To answer this question, several elements need to be considered. As a rule of thumb, in TAK and large vessel vasculitis in general, it is recommended to perform vascular surgery at the time of disease remission to prevent complications during the surgical procedure and in the immediate postoperative...
Do you recommend checking both TSI and TBII antibodies for Graves' disease diagnosis and monitoring?
The two assays correlate with one another to a great degree, but they are not identical. The TRAb or TBII test measures all antibodies directed against the TSH receptor that could be stimulatory, neutral, or blocking. The TSI test only measures stimulatory antibodies, and is therefore clinically mor...
What is the likelihood of recovery of parathyroid gland function for patients who underwent total thyroidectomy, found to have embedded parathyroid glands intra-operatively and then subsequently had them re-implanted into neck muscle?
Recovery of parathyroid function after total thyroidectomy in which parathyroid tissue was found embedded in the thyroid depends upon many factors. How many glands were found in the thyroid? Was the surgery extensive, and thus perhaps led to compromise of the vascular supply of the parathyroid gland...
How do you counsel patients on the use of compounded weight loss medications?
It is a difficult question that is being asked more frequently, recently, because of the shortage of these drugs. I handle it the same way that I used to handle when patients asked about the use of herbs as food supplements. The important fact is that we don't know the reliability of these products....
How do you explain progression free survival to patients?
This is a really, really important question. I'd argue we often greatly undervalue the importance of communication with our patients and the impact the quality of our communication has on what they understand about their illness. I remember once having a long conversation with a patient where I outl...
Do you have any pearls for how to manage OSA with CPAP in older adults with cognitive impairment?
I try to involve a partner or other family member in the process, including getting a sleep study in the first place. If the study shows moderate or severe sleep apnea, especially with substantial oxygen desaturation, I remind the patient and partner that use of CPAP will help the patient's memory. ...
How do you counsel older adults regarding the use of melatonin (dose and timing) for sleep-related problems?
Melatonin has a weak hypnotic (i.e., sleep-inducing) effect. It helps people to fall asleep but not to stay asleep. It is not effective in people with chronic insomnia, but it is perfectly safe in low doses (i.e., below 10 mg) and can be helpful for occasional problems with falling asleep. For sleep...
In an older adults with dementia-related behavioral symptoms refractory to nonpharmacological management in whom you are starting SSRI, do you ever consider a short course of antipsychotic medication to overlap with the initiation of SSRI while waiting for therapeutic effect?
The American Geriatric Society recommends that antipsychotics may be considered when behaviors do not respond to non-pharmacological management and the patient is at risk of harming themselves or others. Thereby, it may be reasonable to overlap short-term antipsychotic with SSRI initiation in older ...
When would you consider genetic screening of first-degree relatives in patients with bicuspid aortic valves?
We commonly screen first degree relatives with echo and offer the BAV patient genetic screening. If the patient was found to have a genetic mutation, we would further offer genetic family screening.
Which patients with mild cognitive impairment do you consider referring for amyloid-targeted therapy?
This is an important question, as clearly, not everyone with MCI is appropriate or interested in Amyloid-Targeted Therapy. In general, I would say that the TrailBlazer trial did not change my approach to patient selection much, but it did provide more evidence that this class of drugs have a place i...