Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In what clinical scenarios should we use the 2-day 2mg DST instead of the 1mg overnight DST for screening of Cushing syndrome?
The 2-day low-dose DST may be of some value in patients suspected to have nonneoplastic hypercortisolism (normal cortisol <1.4-1.8 ug/dL). The Dex/CRH test performs better in such patients, but the CRH is not available.
Do you routinely perform in-office urine microscopy for your patients with recurrent nephrolithiasis?
Yes and no. We have a dedicated laboratory at Mayo Clinic that specializes in urinalysis and is expert in recognizing crystals. I do not do office microscopy myself. I think it is important for my stone patients to have a urinalysis when I see them. I am looking for hematuria suggesting surgical sto...
What are some considerations to make when managing patients with recurrent nephrolithiasis who are found to have nephrocalcinosis on imaging?
Nephrocalcinosis is generally defined as calcification of the renal parenchyma, especially the medulla and papillary tips, as opposed to nephrolithiasis which refers to calcification in the urinary space. The two often coexist. Nephrocalcinosis, and its accompanying nephrolithiasis, are typically pr...
Are there certain subsets of ANCA vasculitis patients for whom you would consider life long maintenance therapy?
Overall the field is moving towards longer, and sometimes indefinite maintenance therapy. This is because multiple studies have demonstrated that relapse risk increases when maintenance therapy is stopped. I consider indefinite maintenance therapy for the following patients: 1. Frequent relapsers - ...
What is your preferred therapy to raise urinary citrate in a patient with recurrent calcium based stone disease and hypocitraturia?
I prefer potassium citrate tablets. For those who have trouble swallowing tablets, it also comes in liquid form. There used to be a powder packet that you could tear open and mix in liquid, but it is my understanding that is no longer available. These products require a prescription. For those on a ...
What duration of therapy do you use for treatment of Legionella pneumonia in an immunocompetent host without associated empyema or extrapulmonary infection?
We have little experience of legionellosis, especially in immunocompetent patients. Based on the available information and the published recommendations (these follow), I would generally treat patients for 5-7 days, depending on clinical response.A recent review: Viasus et al., PMID 35505000IDSA/ATS...
Do you avoid ESAs in patients with anemia and chronic kidney disease who also have Factor V Leiden?
I personally do not. I think it is better to get the hemoglobin in the 10-11 g/dL range and avoid having to give blood transfusions potentially than the slightly increased risk of hypercoagulability.
What is your approach to determining the need for continued isolation in the dialysis unit for an ESKD patient who had a positive hepatitis B surface antigen one year ago but who now has a negative HbsAg in the absence of treatment?
I have not encountered this situation before. Assuming that both checks are accurate and not the result of vaccination, then I would continue to isolate for another 6 months, repeat Hep BsAg and viral load. If still negative would take off isolation.
Do you consider hyperuricemia as a potential etiology of an anion gap metabolic acidosis in patients with elevated uric acid levels and no other readily explainable causes of acidosis?
Urate has a molecular weight of ~166 mg/mmole and the valence of the anion is -1. Hence, let us say we have severe hyperuricemia with 16 mg/dl. That will provide an "anion gape" of only 1! So, by itself, urate cannot increase the anion gap. Could hyperuricemia be a "biomarker" of other causes of met...
How would you manage a patient with radiation pneumonitis who remains symptomatic on steroids?
Engage your Pulmonology colleagues to assist in these difficult cases. Important to rule out other causes of persistent symptoms including infectious processes. Rebronch can be helpful for infectious work up and/or determining the nature of the inflammatory process that is ongoing (for example, the ...