Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the best treatment for treatment resistant restless leg syndrome?
It can take time to respond. I’ll get a good dietary history and screen for eating disorders as well as overtraining. I usually bridge them with gabapentin while repleting iron. For malnourished patients, I’ll counsel them about eating a whole-food diet. Often, I’m recommending MVI and magnesium as ...
How long should T3 be continued in hypothyroid patients who received no symptomatic benefit after starting T3/T4 combination therapy?
I stop at next visit and increase T4 replacement accordingly.
What duration of therapy do you recommend for patients with a vascular graft infection in which the graft has been removed and another graft placed in the infected space?
The duration of antibiotics would also depend on whether the patient had positive blood cultures. At the time that a new graft is placed, graft site cultures should be obtained. This is because the patient may have received antibiotics prior to the procedure for a period of time. It is helpful to ha...
What therapies have you found most helpful for recalcitrant non-infectious cases of folliculitis?
In my experience, noninfectious folliculitis can be complicated by superficial infections with skin organisms, herpes, or fungi so treatment will include a topical anti-microbial. The folliculitis can be triggered by fragrances in laundry products, irritation by coarse fabrics or occlusion. The prim...
Does the presence of osteoporosis change the extent of workup that should be performed for an older patient with otherwise serologically low-risk MGUS?
In brief - no, it shouldn't. While some previous studies have suggested that patients with MGUS are more likely to develop osteoporosis than those who don't, this is often related to confounders when MGUS is picked up clinically - in other words, patients with comorbidities that prompt a doctor to l...
Would elevated bone mineral density/T-score be enough to make a diagnosis of osteopetrosis?
You should not make the diagnosis of osteopetrosis based on a high bone density. There are several causes for high bone density including the autosomal recessive genetic disorder sclerostosis which is caused by mutations in the STOST gene which prevents the production of functional sclerostin.
What is the therapeutic role and blood glucose lowering capability of bromocriptine and cholestyramine for the treatment of Type 2 diabetes?
In the 15 or so years since bromocriptine and cholestyramine were approved for the treatment of hyperglycemia in T2DM, I have never prescribed them for this indication. I also have very rarely used other FDA-approved glucose-lowering agents including meglitinides, alpha-glucosidase inhibitors and am...
How do you manage insomnia in cancer patients that is refractory to traditional sleep aides?
Insomnia and other sleep disturbances are very common in individuals diagnosed with cancer, and it is often helpful for patients to hear this. A good history of other contributors to sleep disturbance can be helpful as well. Often, depression, anxiety, and pain, as well as other stimulant medication...
How do you monitor patients with incidentally found high titer anti-smooth muscle antibodies without stigmata of liver disease?
I have quite a few SLE patients with ASMA who do not have any signs of hepatic disease (though I did not do bxs in those with normal hepatic transaminases). They are very common in the general population. I have down in my notes a prevalence of 16%. However, there are studies showing prevalences as...
What treatments have you found most effective for cholestatic pruritus?
My experience is mainly in Sjogren's or Sjogren's with PBC, ursodiol has been effective. Occasionally, I have used hydroxyzine or H1+H2 blockers. In Sjogren's where the skin biopsy has shown significant lymphocytic infiltration, mycophenolate or a calcineurin inhibitor trial has lead to the resoluti...