Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
What is your approach to monitoring for hepatic fibrosis in chronic methotrexate use?
Historically, in lower-risk patients (e.g. rheumatoid arthritis patients who are less likely to have metabolic syndrome and are treated with lower doses), guidance has been to proceed with liver biopsy if repeated tests show elevated liver enzymes or hypoalbuminemia. In higher risk patients, (e.g. p...
What is your experience with using 5 alpha reductase inhibitors in females of childbearing age for androgenetic alopecia?
I have avoided finasteride in young women with pattern alopecia, though low dose oral minoxidil has been safe/effective in several instances over the past year (for both pattern alopecia and chronic telogen effluvium in women of childbearing age).
Should patients with hypothyroidism hold their morning levothyroxine dose before going to the lab to check free T4/TSH?
There exists a lack of consensus regarding the optimal timing for thyroid blood tests in relation to levothyroxine administration. Given the 7-9 days half-life of T4 and the approximately 4-5 half-lives required for clearance from the system, the timing of levothyroxine intake doesn't significantly ...
When and for whom should we consider adding bempedoic acid to the lipid lowering regimen?
Bemepedoic acid is approved in the US for use as an adjunct to statin therapy in patients with established ASCVD (secondary prevention) or those with heterozygous Familial Hypercholesterolemia who require additional LDL- cholesterol reduction. More recently it has also been approved for primary prev...
After corticosteroids, what second line agent do you select to treat drug induced hypersensitivity syndrome (also known as DRESS syndrome)?
see reference
How do you medically manage uncontrolled Graves' disease in a patient awaiting surgery who is intolerant to methimazole and PTU and refusing RAI?
Although this seems like a difficult situation, one must remember that in the past, patients were prepared for surgery with beta-blockers + KI, with excellent outcomes.Feek et al., PMID 6892650Therefore, I do not think you need to treat this patient with lithium, risking lithium toxicity, to prepare...
Do you repeat a lumbar puncture in a patient living with HIV diagnosed with and treated for neurosyphilis and if so, when?
This is a complex issue, and there isn't a one-size-fits-all approach. There are no hard and fast guidelines in place. If the initial CSF abnormalities include only reactive CSF VDRL, along with modest protein elevation and mononuclear pleocytosis (both of which are consistent with HIV infection), a...