Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In your practice, when do you opt to treat unilateral primary hyperaldosteronism medically rather than surgically?
There should be a good reason for not pursuing surgery in a patient with unilateral primary aldosteronism. The surgery is more cost-effective. Some but not all data suggest a faster decrease in cardiovascular morbidity, a lower risk of atrial fibrillation, arterial stiffness, left ventricular mass, ...
Do you prefer still over carbonated water for your patients with recurrent nephrolithiasis who have chronically low urine volumes?
My main concern is hydration. Stone formers tend to be un-thirsty folks, and it is hard to get them to drink anything, let alone my minimum of 2L daily. Generally I recommend plain water; old research found no difference between hard and soft water. To the extent that carbonated water alkalinizes u...
Do you recommend routine use of Evusheld for pre-exposure prophylaxis for patients on immunosuppression?
The use of monoclonal antibodies as passive immunity for pre-exposure prophylaxis is an exciting development for vulnerable patients, including immunosuppressed patients (either primary or through medications such as for autoimmune diseases), cancer patients, and organ transplant recipients. Evushel...
Do you recommend daily topical exit site antibiotic use for patients with a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
No. When PD catheters are being accessed only once weekly for flushes, we keep the exit site under a sterile dressing with a chlorhexidine-gluconate-impregnated disc surrounding the exit site. The catheter is accessed only by the PD nurse at the time of flushing, and we do not have the patient perfo...
How do you counsel and manage patients who meet criteria for sleep apnea based on 3% but not 4% desaturation?
It depends on the patient's symptoms. If they have symptoms attributable to sleep apnea then I tell them they have sleep apnea. If they don't have symptoms then I don't diagnose them with sleep apnea. If the patient has an insurance plan that only accepts 4% desaturations and yet they clearly have s...
Do you transition patients with recurrent nephrolithiasis and hypercalciuria off of hydrochlorothiazide in favor of an alternative thiazide diuretic?
No. Assuming the patient tolerates HCTZ well, and it is effective in lowering hypercalciuria, I continue it. Most of the thiazide research has been done using this agent. Stephen B. Erickson, MD
What is your approach to managing acidic urine in patients with recurrent uric acid nephrolithiasis who have normal urinary citrate levels?
After appropriate dietary advice from our Stone Clinic dietitian, I preferentially prescribe sodium bicarbonate tablets, teaching the patient how to adjust the dose using pH strip testing to reach the desired urinary pH. pH testing should be done frequently, as urine pH is in part dietary dependent ...
What is the optimal anti androgen dose of spironolactone when treating female hirsutism?
My experience with this issue has primarily been in treating women with PCOS who have hirsutism and so these comments are limited to that condition. First, it is important to establish normal renal function and electrolytes before starting. It is also important to know if the patient is on an ACE-I ...
For how long do you recommend treatment for latent tuberculosis prior to initiation of anti-TNF therapy?
Some recommendations call for completing a course of treatment for latent TB prior to starting a biologic but I find most patients and referring specialists are intolerant of that strategy. This reference: Yeo et al., European Respiratory Journal 2014 is a good example of data supporting a shorter w...
Under what circumstances would you test for hypercortisolism in a patient with insulin resistance?
The American Diabetes Association meeting that just finished up featured the CATALYST study that found hypercortisolism by an abnormal dexamethasone suppression test was present in 24% of patients with difficult-to-control type 2 diabetes. For insulin resistance alone, I suspect the prevalence would...