Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend EMG/NCS in all patients with clinical findings of carpal tunnel syndrome?
In my experience as a neurophysiologist, a typical Carpal Tunnel Syndrome (with all the classical signs and symptoms) can be diagnosed with high certainty by examination and history alone. My recommendation would be that when the symptoms are mild and the presentation is typical, conservative treatm...
Would it be prudent to complete long term cardiac monitoring (ie. 30 day) in a patient with a new typical appearing lacunar type thalamic infarct and history of hypertension?
This is a really good question. Until this year, I probably would have said that looking for AF in patients with a clear lacunar stroke is not needed. But the recent results from the STROKE AF trial (Bernstein et al., PMID 34061145.) suggest that long term monitors (implanted monitors, so a little d...
What conditions do you screen for in patients with hyperacusis?
Hyperacusis is a non-specific complaint and can be related to a number of different, unrelated pathologies. Screening for specific conditions is largely dictated by other associated signs and symptoms and whether the hyperacusis is unilateral or bilateral. Common conditions include 7th cranial nerve...
What strategy do you use to determine the appropriate timing to resume osteoporosis therapy after a drug holiday?
A drug holiday (drug sabbatical) is given to reduce the likelihood of an atypical femur fracture. Such fractures have characteristic x-ray appearances and are found from below the lesser trochanter to the supracondylar flare of the distal femur. While the overall incidence of these fractures is low,...
Do you ever consider treatment outside of the peripartum period in a patient with a history of obstetric APS?
I agree with Dr. @Dr. First Last that the patient should be treated with prophylactic low molecular weight heparin and low dose aspirin in any future pregnancies. Dr. Broder makes the very important point that modifiable cardiovascular risk factors should be particularly attended to in persons with ...
Do you hold tocilizumab for patients who are diagnosed with Covid and are with mild to moderate symptoms or non-hospitalized?
I generally hold all immune suppressive medications, once a patient is diagnosed with COVID19 to allow for faster clearance of the infection. Inhibition of IL-6 and other immune modulating interventions should be reserved only for hospitalized severely ill patients where the immune system hyper-acti...
How do you approach a potential drug holiday in a patient with osteoporosis who has had improvement in BMD after several years of denosumab therapy?
If a patient on denosumab has achieved BMD of the spine and hip that are in the high osteopenia range or normal BMDs (T score above -1), and the patient has not fractured and is not on glucocorticoids or hormone depleting agents for breast or prostate cancer, can have denosumab stopped. However, at ...
Are there any known contraindications for IL-23 use in patients with psoriatic arthritis and CKD or ESRD?
There are no contraindications in the use of IL-23 inhibitors in the treatment of psoriatic arthritis. The package insert suggests no dosage adjustments for CKD. Clearance of a monoclonal ab is through degradation to small peptides and amino acids in a fashion similar to endogenous IgG. My only conc...
How would you work up focal periventricular leukomalacia presenting in adulthood?
This depends on the location, appearance, size, and PMH of the patient. However, I usually start with giving contrast (aware it is encephalomalacia) and as known, most won't enhance. What is the age of this adult patient? Is there any previous history to suggest MS? If ischemic, why did it happen? D...
What has been your experience using apremilast to treat mild to moderate psoriatic arthritis not controlled with NSAIDs?
Overall, my experience has been good with apremilast when the correct patient is targeted for therapy. The best patient generally falls into a niche of milder disease. Mild to moderate psoriasis and milder and less aggressive MSK manifestations. Patients need to realize that they are trading speed o...