Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there a role for cinacalcet suppression testing when evaluating patients for suspected primary hyperparathyroidism who also have recurrent calcium containing kidney stone disease?
I understand the physiology upon which the cinacalcet suppression test is based. However, I have not used it in my practice. Once I see a discordant result between a parathyroid hormone level and its main determinants: serum calcium, phosphorus, and vitamin D (or 1, 25-vitamin-D), I use a sestamibi ...
Is intracranial hemorrhage a contraindication for valproic acid?
The short answer is no. Valproic Acid (VPA) can cause bone marrow suppression leading to thrombocytopenia, as well has hypofibrinogenemia. Through these mechanisms, and possibly others, platelet aggregation is reduced, which may place one at risk for hemorrhagic expansion, but in my experience, and ...
Can TPO agonists, like avatrombopag or lusutrombopag, be used for patients with chronic thrombocytopenia and new acute portal vein thrombosis?
A caveat before answering - these tend to be very difficult clinical situations in a population that often has cirrhosis and has a very difficult-to-predict hemostatic picture (whether they are prohemorrhagic or prothrombotic from the underlying liver disease).I would refer you to some of the excell...
When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?
My simple answer is “rarely, if ever” (but it can get much more complicated). Related to hepcidin changes, patients with chronic liver disease frequently have elevated serum ferritin and transferrin saturation, more so with alcoholic liver disease and non-alcoholic fatty liver disease. It is far fro...
How would you decide between conservative management vs. ILR or pacemaker for asymptomatic nocturnal bradycardia/pauses (as an example rates in the 30s, pauses ranging 4-12 seconds) in the absence of bradyarrhythmias during the day and ECG with normal intervals, and not otherwise on medications to slow down HR?
The guidelines are clear in stating that patients with symptomatic bradycardia or higher degree heart block during waking hours would benefit from pacing, but determining symptom-rhythm correlation is not always easy. In sinus node dysfunction, there is no established minimal HR or length of pause t...
Is there a risk of increased skin toxicity with combined radiation and doxycycline?
No reports that I am aware of. Tetracyclines have an absorption wavelength of ~300-350 nm and can be pushed into an excited energy state by primarily UVA (320-400 nm) waves. Relaxation back to base state leads to chemical reactions that generate photoproducts that serve as antigens in a cutaneous al...
How has the recently FDA-approved topical cantharidin altered your molluscum treatment algorithm?
I recommend the use of topical cantharidin on a limited number of lesions, since the blistering can be painful especially in young children. Moreover, by treating a few lesions you may trigger an immunologic reaction that results in spontaneous resolution of untreated lesions as well. Moreover, we p...
What is your approach to managing osteoporosis in patients with end stage kidney disease?
I don't believe you can make a diagnosis of osteoporosis in patients with ESRD. They have to be treated based on the disorders associated with CKD-MBD and not solely based on the results of a bone density scan. In some patients with documented low turnover disease and mineralization defect, some may...
When do you consider stopping anti-seizure medications in seizure-free pediatric epilepsy patients?
Prior to 1988, we would never dare take a patient off seizure medicine if the patient was seizure-free.Callaghan's paper published in the New England Journal of Medicine (Callaghan et al., PMID 3127710) clearly showed that patients who were seizure-free on Tegretol for 3 years had a 90% chance of be...
Would you expect cinacalcet to lower calcium levels in a patient with Familial Hypocalciuric Hypercalcemia (FHH)?
The hypercalcemia in FHH is not primarily driven by overactive PTH secretion, so targeting the CaSR pharmacologically would not address the underlying pathophysiology. However, I suppose inducing hypoparathyroidism with Cinacalcet would induce calciuria, though at the expense of hypocalcemia.