Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there a reason to repeat HMGCR antibody level for monitoring disease activity once documented positive in patients with IMNM?
HMGCR antibody persists even when the disease is quiescent, and levels of the antibody correlate with the log of the CPK levels. Therefore, it is not a very sensitive marker for disease activity, so it is not a useful marker to follow longitudinally. Instead, CPK is a cheaper and more sensitive mark...
Do you typically screen patients for antiphospholipid antibodies in autoimmune diseases besides lupus in the absence of a clotting event?
I would check antiphospholipid antibodies (APLAs) in a few situations in the absence of thrombotic events: 1. In someone with other APS manifestations: Obstetrical complications (especially) APL nephropathy noted on renal bx Unexplained adrenal hemorrhage/microthrombosis Non-infectious endocardial v...
How would you counsel a patient who is interested in using supplements (such as fish oil or turmeric) as an adjunct to treatment of inflammatory arthritis?
Drs. @Dr. First Last and @Dr. First Last expertly raise the key difficulty rheumatologists face with herbal medications: imparting a healthy respect for the potential risk:benefit (and limited data) about these agents against allowing patients to erroneously characterize their physician as close-min...
What is the current recommendation for using thiazide diuretics in patients with calcium oxalate stone disease, given the negative results of the NOSTONE trial?
This trial will have no effect on my practice. Seven of 10 previous studies of thiazides for stones were positive, as was a meta-analysis. My preference is for the longer-acting drugs indapamide and chlorthalidone; I haven't used HCTZ which is probably a twice-a-day drug, for some years. Note that t...
If you have a patient with isolated CN VII palsy (Bell's Palsy), and straightforward symptoms with no red flags (such as concern for carcinomatous meningitis), do you routinely get an MRI brain or do you just make a clinical diagnosis?
In my practice, I do not order a brain MRI if there are no red flags. I treat with a course of steroids; 60 mg of prednisone for four days, 40 mg for four days, 20 mg for four days and then stop. I see the patient back in six weeks. If they have not made a complete recovery, I perform MRI imaging wi...
Do you recommend taking any unique approaches to managing patients with persistent hypertension following bilateral renal artery stenting?
Yes, I will be more aggressive with lipid management, sometimes using PCSK9-INH in addition to a statin, if the cause of the renal artery stenosis was atherosclerotic-related. Also, I typically get yearly ultrasounds to evaluate the patency of the renal artery stents. From a management perspective, ...
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
What is your approach to counseling a patient with stable but severe multivessel coronary disease if the patient does not wish to undergo bypass surgery?
The question assumes that a stable patient with multivessel disease would do better with bypass surgery. If the ejection fraction is less than 35% then the long-term outcome from the STITCH trial showed a reduction in mortality. There is no comparable data for angioplasty. If the patient refuses sur...
What is a reasonable way to treat statin-induced myalgia and what statin substitute would you consider using in the event the myalgia is not resolved?
Qunol co administration Vytorin - lower doses PCSK9
What are your next steps when managing patients with suspected Gitelman syndrome for whom genetic testing reveals variants of uncertain significance or novel mutations not well characterized?
If the patient had a clinical syndrome that fit the Gitelman phenotype I would totally treating as such.