Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you monitor safety, effectiveness, and adherence to therapy when using sedative hypnotics in patients with insomnia?
Generally looking at the average sleep length and quality monthly as described by the patient; side effects are always a concern; if there is any possibility of modifying overall sleep hygiene–that would be the way to go; strength of the medicine should be the lowest possible; definitely avoiding or...
Do you prefer celecoxib over a nonselective NSAID in patients with chronic kidney disease?
There are many potential advantages of celecoxib, as a "selective" COX-2 inhibitor, over non-selective NSAIDs. Because of the lesser inhibition of platelet function, it has potential advantages in the peri-operative period, in patients with bleeding disorders or taking anti-thrombotic or anti-coagul...
Do you pursue a cardiac evaluation in all patients with an excised cutaneous myxoma?
I'm a dermatopathologist, not a clinician, but would note the following data points: Many things are called myxomas. Those associated with Carney complex, in which atrial myxomas also occur, are a specific variant, superficial angiomyxomas. They usually have inactivation of protein kinase regulator...
Is ABI (Ankle Brachial index) lower limb arterial doppler not recommended if patient already has arterial stents in the legs, and if so, what other imaging modality would you consider as first-line?
ABI is still helpful in follow-up of patients with arterial stents but only gives a sense of global perfusion to the distal limb and may not be helpful in patients with calcified non-compressible vessels, (e.g. CKD, diabetics), so a better assessment is arterial duplex that can visualize the entire ...
Is there a role for 24 hour urine stone risk profiles in your patients with known recurrent struvite kidney stones?
It depends. Pure struvite stones are not a metabolic abnormality; they are the consequence of a urease-producing urinary infection that splits urea to ammonium, raising the urine pH into the high 7-8 range, which in turn precipitates magnesium ammonium phosphate, otherwise known as struvite. Pure st...
Which steroid-sparing agent do you prefer to treat multi-organ Sweet's syndrome?
I have used methotrexate in combination with cyclosporine with some success but am most impressed with the effect of anakinra to control disease and allow discontinuation of corticosteroids. I would also recommend them in that order.
How do you approach management of adult patients with CVID and sarcoid-like syndrome?
Common variable immunodeficiency syndrome (CVID) is the most common primary immunodeficiency, and is of course, characterized by recurrent infections. This can lead to bronchiectasis due to structural damage from these recurrent infections. However, patients can also have non-infectious manifestatio...
How often do you see bony erosions in patients with Lyme arthritis?
There are three ways that Lyme disease can result in joint involvement. The most common is diffuse arthralgias (not a true arthritis) associated with the acute infection. This is self-limited and does not harm the joint. The second is an inflammatory arthritis that is similar to other infected joint...
Given that high coronary calcium scores portend significantly increased cardiac mortality rates over 5-6 years, is there any data to support performing coronary angiography when the score is very high, e.g. over 1000, even in asymptomatic patients with no objective evidence of ischemia?
The question is; is coronary angiography necessary in asymptomatic folks with extensive CAD on EBCT? Will it tell us more than what we already know; that the patient has extensive CAD? Will it make an asymptomatic patient feel better? Will the information obtained from coronary angiography allow for...
How do you manage introduction of other seeds when the patient has never been exposed and has a sesame allergy?
Since there is considerable cross-reactivity between other seeds, but also with nuts and other foods, one needs to do allergy testing in a sesame seed allergic patient before introducing other seeds. That can be either with prick skin testing or in-vitro testing. However, if one is negative with one...