Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In people who have had a single detected episode of atrial fibrillation, but none documented subsequently, is there any consideration for increased thrombolembolic risk just from altered atrial architecture, impaired contractility?
Clarification, impaired left atrial contractility
Do you always aspirate effusions in patients with knee osteoarthritis prior to injecting hyaluronic acid?
There is strong biologic plausibility that one should always aspirate an effusion before injecting hyaluronic acid. Even a mildly inflammatory effusion will have an excess of white cells. White cells produce hyaluronidase. Hyaluronidase catalyzes the degradation of hyaluronic acid and renders it ina...
Is there risk for local recurrence if thymoma received CT guided biopsy transgressing the capsule prior to surgery?
I polled two board-certified thoracic surgeons in our institution and here is the compilation of their responses: "The data associating tumor spread with biopsy are, in general, anecdotal and outdated. Pleural spread is a common route of metastasis but there are no clear data to link it to biopsy. W...
Do you avoid ESAs in patients with end stage kidney disease who also have heart failure due to increased risk of stroke?
If the question is whether I avoid ESAs in patients with ESKD who also have heart failure, the answer is no for several reasons. The warning in the ESA package insert regarding using ESAs with caution in patients with heart failure (HF) comes from the CHOIR study (Singh, et al., PMID 17108343) of no...
Do you give a short-acting antihypertensive before starting outpatient hemodialysis on an asymptomatic ESKD patient with a predialysis blood pressure of more than 200/100?
I rarely use short-acting antihypertensive agents. I usually give long-acting calcium channel blockers, b-blockers or ace inhibitors if the blood pressure is very high. Ultimately the best option would be to remove more and more fluid slowly over time if patient can tolerate it. However, I find flui...
How do you manage a patient with severe RA or SLE that worsens after stopping immunosuppressants due to having chronic foot ulceration?
Fear the foot ulcer! These portals of entry for microorganisms can wreak havoc in immune-compromised patients. Rheumatologists must ensure that these lesions are being properly managed. Since healing can often be prolonged in some of our patients, the decision of whether and when to resume immune su...
What is your approach to management of recurrent nephrolithiasis in patients with mixed composition uric acid and calcium phosphate stones?
Likely the urine pH is more typically low in such patients, since the uric acid components will dissolve during periods of higher pH. Consequently, the appearance of uric acid crystals in the stone suggests that the urine pH is more typically low. Drinking more fluid to cause more dilute urine alway...
What is your approach to treating crowned dens syndrome?
Crowned dens syndrome is said to account for as much as 2% of acute neck pain. The diagnosis is mostly clinical. The patient will present with acute neck pain, elevated acute phase reactants, calcific deposits overlying the dens on x-ray or CT scan, and the lack of an alternative diagnosis. In >40 y...
Are there patients with recurrent nephrolithiasis for who you recommend magnesium supplementation to reduce stone risk?
While magnesium supplementation may be justified on theoretical grounds, I have never used magnesium supplements as a treatment exclusively for kidney stones. I have only ever seen or used magnesium supplementation in stone patients that had concurrent hypomagnesemia.
What topical therapies do you find are most effective for treating inverse psoriasis in areas of the body with thinner skin?
I have had excellent results from 1% LCD in 2.5% hydrocortisone cream or 1% LCD in 0.1% TAC. Irwin Braverman