Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you determine if a pyoderma gangrenosum lesion is “burned out"?
The first sign is it becomes much less exudative.
How do you reduce the risk of contralateral fracture in a patient with atypical femur fracture from prolonged bisphosphonate use?
While there are no published clinical trials treating AFF with anabolics, we have considerable experience taking care of AFF's. Between myself and two ANP's doing strictly bone health with a large group of orthos who manage a large percentage of fractures in the Phoenix valley, we unfortunately stil...
Do you correct the synovial fluid white blood cell count for red blood cells, and if so, is there a rough approximation/equation you use?
In a rheumatology practice, under most circumstances, there is no need to make a correction of the synovial fluid white blood cell count. The fluid is either translucent, transparent, or opaque and the count will help to establish the presence or absence of an infectious or inflammatory process and ...
Do you avoid potassium citrate due to concerns with increasing the urine pH in patients with recurrent struvite nephrolithiasis who also have hypocitraturia?
Thanks for asking! My answer is: In general, "No", but it depends... Struvite stones can only form at un-physiologically high urine pHs. This situation occurs when urease-producing bacteria cause urinary infection. Urease splits normally occurring urinary urea to ammonium, raising the urine pH >7.0 ...
Do you prefer cinacalcet or etelcalcetide for patients with hyperparathyroidism in the setting of kidney disease?
In a group of vintage ESKD patients, assuming compliance is not an issue and hypocalcemia handled and Parsabiv utilized when approved, PTH still not controlled often. Over few thousands. The main reason is that the parathyroid hyperplasia turns to be nodular and encapsulated. And it’s time for surgi...
Are adults with IDD at increased risk for adverse events like NMS or central anticholinergic syndrome?
Thanks so much for your question. There is no doubt that individuals with IDD may often exhibit aberrant behaviors including those with autism. The use of various psychopharmacologics is very prevalent. The risks of side effects and particular complications is certainly higher in this cohort. Check ...
Would you use romosozumab in a patient with a cardiovascular event more than 2 years prior?
Frankly, knowing the data fairly well, I think the decision is a matter of style. Recall that the enhanced cardiovascular risk was only seen in the ARCH trial when romosozumab was compared to alendronate (leaving open the interpretation that alendronate reduces CV events, rather than romo increasing...
How would you interpret a temporal artery biopsy demonstrating focal chronic inflammation in the adventitia associated with small adventitial vessels and nerves without inflammation of the intima and media and without giant cells?
Peri-adventitial inflammation seen in temporal artery biopsies is generally a non-specific finding. This was demonstrated nicely in a recent histopathological study from Mayo Clinic evaluating temporal artery samples from autopsy cases. Over 40% of temporal arteries from older individuals (with no h...
How do you manage eyebrow and eyelash involvement in patients with alopecia areata?
The possible options are bimatoprost (either Latisse or the eyedrops) twice a day and compounded tofacitinib 2% solution twice a day. ILK 2.5 mg/ml every 6 weeks for eyebrows.
At what point is a skin biopsy indicated in patients with neuropathy?
Skin biopsy is indicated when small fiber neuropathy is suspected- that is, a patient with usually painful paresthesias- positive sensory symptoms, and less often negative sensory symptoms alone, and normal EMG/NCS. Clinical exam usually, but not always, will show some signs of small fiber involveme...