Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to managing patients with recurrent calcium oxalate nephrolithiasis since childhood who are found to be gene carriers for mutations in genes associated with primary hyperoxaluria?
Thank you for this question. In general, there is no good evidence that patients with a carrier of 1 of the 3 primary hyperoxaluria genes (AGXT, GR/HPR or HOGA1) has any phenotype consistent with primary hyperoxaluria, or that these genes are enriched in the general stone forming population. That be...
What disease activity measures do you find helpful in clinical practice for psoriatic arthritis/peripheral spondyloarthritis?
Treat to target strategy has been shown to improve patient outcomes in patients with PsA (TICOPA study). Therefore, it is important to set treatment targets and measure disease activity in clinical practice in PsA. Measuring disease activity in this disease is, however, challenging due to heterogene...
Do you use any urinary staining techniques when performing urine microscopy for patients with acute kidney injury?
No. Not at this time. At one point, about 10 years ago, we did have Wright stain to stain for eosinophilluria but it seemed too labor-intensive and not that helpful, so we stopped using it.
Do you recommend Alpha Lipoic Acid to patients with diabetic polyneuropathy?
Recommend is a strong word. I mention it to my patients as there's some 'evidence' supporting it. It has minimal side effects and virtually no risk, so it's worth a try. However, it's important to note that very few of my patients report any benefit from it.
What clinical sign or symptom do you consider to be the most specific for Cushing syndrome?
Cushing's syndrome is a rare disease. The following symptoms and signs are suggestive. Symptoms: weight gain, especially in the middle, muscle weakness, and easy bruising Signs: Moon facies Central obesity with relatively thin arms and legs Pad of fat behind the neck (Buffalo hump), thin skin, pur...
How do you manage patients with bullous pemphigoid who have IgE autoantibodies to BP180?
40% of patients with BP can have IgE class autoantibodies directed against BP. Treatment does not have to differ from patients without IgE class autoantibodies: for mild or localized disease or in patients who cannot tolerate immunosuppression, doxycycline and high potency topical steroids can be us...
What are your strategies for preventive migraine therapy in breastfeeding patients?
Transfer to milk depends on how highly a medication is protein-bound. Measurable concentrations occur for drugs <70% bound. >85% bound is not expected to have a measurable concentration in infants. Propranolol, amitriptyline, and Depakote are >90% protein-bound so I consider them first. Botox is not...
Which patient population would most benefit from inhaled insulin (Afrezza)?
Afrezza has the fastest onset of action and peak and shortest duration of action of any of the “ultra-rapid” prandial insulins. Its peak effect is 45 minutes vs 2 hours for the fastest injected insulin. Its duration of action is 2-3 hours vs 5-8 hours for injected mealtime insulins. A recent study s...
Any concern for lupus flare in patients undergoing laser hair removal?
Great question - no there is little concern for this because LHR wavelengths are not in the ultraviolet spectrum which is known to spark SLE flares. Even narrow-band UVB (phototherapy) has been used in SLE patients without much issue, however, this is controversial and some feel that depending on th...
What recommendations do you provide to patients with sensitive skin that can not tolerate retinoids more than a few times per week?
Our studies showed sensitive skin is mostly the result of a compromised stratum corneum. Microfissures provide channels allowing access to the underlying vulnerable epidermal epithelium. In the past, these patients were very difficult. Low doses of tretinoin partially encapsulated in microsponges we...