Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage recurrent migratory lower extremity thrombophlebitis that occurs despite being on therapeutic apixaban?
The differential diagnosis of Trousseau syndrome (migratory superficial thrombophlebitis) is relatively broad and includes both inflammatory states and undetected proximal DVTs. So I think the short answer about venogram is "maybe," based on how clear is the view by ultrasound. This isn't a typical ...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
What is your preferred first-line agent to treat anxiety in patients with Parkinson's disease?
Any standard SSRI/SNRI can be tried. I like to try the SNRIs duloxetine or venlafaxine. If comorbid insomnia is a problem, mirtazapine may be a good choice. Think about talk therapy too. It is important to make sure episodic anxiety is not a non-motor symptom fluctuation related to levodopa or oth...
What is your approach to monitoring patients referred for high titer +RF and +CCP but without active symptoms of inflammatory arthritis?
It has been well described that patients with a +RF and + CCP autoantibody may develop clinically active RA up to two decades or more (potentially lifelong) after the detection of these autoantibodies in a patient. It is now thought that there is a preclinical phase of autoimmune diseases including ...
Do you modify dosing or use of bupropion to mitigate seizure risk in patients without eating disorder who are restricting calories to lose weight?
No. The risk of seizures with bupropion is 0.1% with daily doses below 300 mg and 0.4% with doses up to 450 mg daily. The increased risk of seizures in eating disorders is due to higher risk of severe electrolyte disturbances that result from disordered eating, induced vomiting, and laxative abuse. ...
Is there evidence to suggest there is a withdrawal syndrome from muscle relaxants such as tizanidine?
The answer is yes, there is evidence in published literature supporting withdrawal manifestations from sudden discontinuation of alpha-2 agonists including tizanidine (references below), primarily due to catecholamine surge causing a sympathetic overdrive, affecting the patient's physiological state...
How do you treat depression symptoms in patients with Parkinson's disease?
The management of PD-related depression can be a little complicated, but there are several proposed algorithms out there based on varying degrees of evidence. Personally, I like this reference (Pontone and Mills, PMID 33648830) as a place to start. It makes 3 key points: Distinguishing between PD an...
What is your approach to helping parents manage sleep disturbances in patients with autism spectrum disorder?
At our center, we start with sleep hygiene education, using tools such as the Autism Speaks sleep toolkit which has a printable PDF that is free for parental and clinical use. We also try to do therapy on sleep hygiene and our therapists will often try to find out what factors may exist in the home ...
What is your approach to evaluating amiodarone induced interstitial pneumonitis?
There are no definitive histopathological or radiological findings of amiodarone toxicity. For example, foamy lipid laden macrophages are reported but this reflects exposure, not injury, and these findings are present without interstitial lung disease related to amiodarone. High HUs have been report...
Do you refer all patients with a Beighton score over 5 to genetics for further assessment?
Our genetics clinic does not accept these patients for genetic testing anymore because they are inundated with such requests from patients with plain benign joint hypermobility syndrome. They reject these requests for genetic testing. They accept doing genetic testing only for patients with vascular...