Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you navigate PAP approval for patients with tracheobronchomalacia or excessive dynamic airway collapse who do not have OSA?
Since there is no insurance pathway for PAP for tracheobronchomalacia, we basically perform a sleep study and hope there is a small amount of OSA to treat. Otherwise, we find ways to get a machine for the patient at low cost. While there is theoretical benefit to using PAP for TBM there isn't much e...
What is your initial treatment of choice in patients with RA and associated interstitial lung disease?
Because of the nature of the disease and to avoid unnecessary ILD treatment, it would not be appropriate to provide the 'direct answer' first. But the direct answer will appear in bold at the bottom. Of note, there is little data on therapeutics in RA-ILD. This is an important question because it hi...
What is the clinical importance of differentiating between impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) states?
IGT and IFG are different phenotypes of prediabetes. Clinical studies* suggest that IGT may be associated with higher cardiovascular risk than IFG. The molecular mechanisms and the treatments are thus different. IGT, which is due to impairments of beta cell insulin release, can be treated with reduc...
How do you approach the use of hydroxychloroquine in patients with a history of visual field defect from another cause such as macular degeneration or diabetic retinopathy?
As Dr. @Dr. First Last noted, close collaboration with an ophthalmologist is critical, as the findings of HCQ-toxicity on advanced imaging with modalities such as an OCT can often be distinguished from other causes, and hence there is not an absolute contraindication in most cases. A few considerati...
How do you approach CV risk assessment in RA patients when RA itself is associated with some degree of increased CV risk at baseline?
I try to screen for the CV risk factors, present or absent. If present, I use the CV risk calculator, as an example the online Framingham risk calculator, and multiply the risk by a factor of 1.5-2 as proposed by EULAR, depending on whether the RA is active or inactive. Once you have a good assessme...
How do you advise patients with recurrent nephrolithiasis who also have chronic mild hyponatremia for which they limit daily fluid intake?
Depending on the cause of hyponatremia, as you implied, our usual recommendation for recurrent stone formers to drink more fluid may be inappropriate or contraindicated. First, I would like to know the kidney stone composition. For example, if it is uric acid, we could prevent new stone formation an...
Would you prescribe a thiazide diuretic for patients with recurrent nephrolithiasis attributed to hypercalciuria in the setting of excess dietary sodium or animal protein intake who fail or are unwilling to adhere to recommended dietary changes?
Yes. Difficulty with dietary compliance is common, but there is no sense in being punitive about non-compliance. I would use what other treatments are available. Caveat emptor! A high sodium diet coupled with a thiazide diuretic often equals hypokalemia. Potassium supplementation might be in order, ...
Do you have patients with recurrent calcium oxalate kidney stones stop taking supplements containing vitamin C if their 24 hour urine oxalate excretion is normal?
No. I am not aware of data that suggests Vitamin C would aggravate kidney stone formation in this situation. Stephen B. Erickson, MD
What is the ideal period to wait until curative surgery for patients with acute pulmonary embolism and solid malignancy?
This is a very important and practical question. As with most clinical circumstances, there is no evidence-based recommendation. The approach will vary with individual situations. For example: 1) Incidentally discovered subsegmental PE: my bias would be to proceed with curative surgery after one mon...
How would you approach a fit older (>70 years) with grade I-II, bulky, follicular lymphoma causing ureteral obstruction and renal failure?
You could also consider focal radiotherapy as we know follicular lymphoma is often very radiosensitive (and can respond quickly to RT). Depending on the trajectory of the AKI and dysfunction, I would discuss with my urology colleagues to see if there is any role for ureteral stenting to see if kidne...