Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In patients with sicca symptoms and positive SSA/SSB how often do you perform other diagnostic testing such as salivary gland ultrasound, biopsy, Shirmers, ocular staining, stimulated salivary flow, etc?
In patients with sicca symptoms and positive SSA antibodies, I always try to confirm that they have objective evidence of dryness/gland involvement. This is because patients can say they have dry eye and/or dry mouth yet not have this bear out on objective testing (Bezzina et al., PMID 27992710, Rip...
What is your approach to monitoring patients with the indeterminate form of Chagas disease?
Once the diagnosis of Chagas is confirmed (by at least two different serological tests), we routinely evaluate the patient for symptoms or signs of cardiac or GI complications. We also obtain an EKG with 30-second rhythm strip and schedule a transthoracic echocardiogram with contrast (because some p...
How can hepatic venous pressure gradients in patients with cirrhosis be used to differentiate between cardiac cirrhosis and portopulmonary hypertension?
HVPG is a measure that quantifies the increase in sinusoidal resistance to blood flow and can be obtained in a minimally invasive way compared to portal venous sampling directly which may be more invasive. HVPG is the pressure difference between hepatic vein wedge pressure (HVWP) & hepatic vein free...
When cinacalcet is used to treat hypercalcemia in primary hyperparathyroidism, does it also normalize low serum phosphorus levels?
Cinacalcet can be used for treating primary hyperparathyroidism especially in patients who are unable to tolerate the surgery. Lowering the PTH cinacalcet will not only decrease serum calcium levels but will also increase serum phosphate levels. See Peacock et al., PMID 19837909.
What is the importance of finding a positive titer for TS-HDS and what treatment would be advised for these patients?
TS-HDS antibodies were first described by investigators from Washington University in St. Louis (2003) in five patients with painful sensory axonal neuropathy [1]. Further studies by the same group indicated that TS-HDS antibodies were associated with prominent neuropathic pain in the upper extremit...
What methods have you found successful in getting young children to use nasal sprays?
Intranasal corticosteroid nasal sprays (INCS) are beneficial in controlling symptoms in children with allergic rhinitis but acceptance is often a barrier to use. I advise parents first start with a gentle nasal saline spray to help their child accept the sensation of liquid in the nose. Parents can ...
Would you add an additional alkali medication for patients with recurrent uric acid nephrolithiasis who are on high doses of potassium citrate and continue to have acidic urine?
Maybe. My first concern is poor compliance with potassium citrate. I would like to see the patients home pH records. I strongly encourage patients on alkali therapy to test urine pH periodically, and more frequently if a dose adjustment appears to be needed. I prefer potassium citrate to sodium bica...
For patients with kidney stone disease and chronic kidney disease, is there an eGFR threshold at which you no longer recommend pursing 24 hour urine stone risk studies?
While I agree with Dr. Erickson's comments in general, though, I have encountered patients that newly presented for stone disease at late stages of CKD and even on dialysis. The critical consideration is whether there is evidence of ongoing stone formation/growth. We must be aware that a stone passa...
How do you approach hematuria in a patient with diabetic nephropathy?
This is a difficult question to answer. If young, no risk factors for GU malignancy and only microscopic hematuria would generally not pursue but make patient aware of small risk and make sure PCP also knows. Helpful to know if red cells are dysmorphic and if there is also proteinuria. Gross hematur...
Would you transition from denosumab to anabolic agents in patients who are in urgent need for extensive dental work?
From my experience, this is a catch-22. If you stop the Denosumab you will markedly increase osteoclastic activity throughout the entire skeleton which is why it is recommended that you not stop the medication without some other intervention. I have had several patients with either osteonecrosis of ...