Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you recommend initiation of cinacalcet in a patient with hypercalcemia and recurrent nephrolithiasis attributed to an atypical presentation of familial hypocalciuric hypercalcemia?
I would really like to know the level of the patient’s parathyroid hormone. If it is low, cinacalcet would probably not be helpful. Stephen B Erickson, MD
Do you recommend restricting alcohol use in patients with recurrent nephrolithiasis?
No. Clearly excess alcohol use is to be avoided. I much prefer water or citrate containing beverages for stone prevention. Beer has some oxalate content and is better avoided. Stephen B. Erickson, MD
How frequently should outpatient mobile cardiac telemetry be ordered following resolution of post-CABG-related atrial fibrillation for patients off anticoagulation?
I am not a big user of MCOTs in general so I would say that I rarely use them in the postoperative setting. I very much like MCOT monitors but the struggle with reimbursement often makes it a challenge. we do routinely get atrial fibrillation burden with our standard event monitor which certainly im...
What is your approach to risk stratification of asymptomatic patients with pre-excitation syndrome?
When addressing pre-excitation on EKG, some good references include: ACC online expert analysis 2012 PACES/HRS expert consensus statement Editorial on the 2012 PACES guidelines about the challenges of being more aggressive In general, I agree with Dr. @Dr. First Last and the ACC expert analysis that...
Based on findings of the INCREASE trial, are you routinely prescribing inhaled treprostinil to patients with group 3 pulmonary hypertension secondary to interstitial lung disease?
As a brief background, the INCREASE trial (Waxman et al., PMID 33440084) was a randomized trial in patients with pulmonary hypertension due to interstitial lung disease (PH-ILD) assessing the effect of inhaled treprostinil versus placebo on change in 6-minute walk distance at 16 weeks. The study enr...
What antidepressants are recommended for management of depression or anxiety in patients with spinal cord injuries?
Some general considerations first: Acute or chronic injury? Associated TBI? Is uncomplicated depression/anxiety the main feature or significant anger and agitation? Is some cognitive rehabilitation needed? Is some motor system rehabilitation needed? On a vent? Difficult to wean? Acute? Think about a...
How do you approach an asymptomatic patient with evidence of intense radiotracer activity at the left sternoclavicular joint on bone scan with a history of SAPHO syndrome on Humira?
Any other area light up? Bone scans are sometimes challenging to read as they can light up with degenerative changes or prior damage and do not always represent active disease. Can consider an MRI of the joint to better determine whether there's disease activity or only prior damage. If it's really ...
How do you choose between the different vitamin D analogs for patients with CKD, an elevated PTH, and a normal 25-hydroxy vitamin D level?
In patients with pre dialysis CKD and elevated PTH, I would recommend using ER Calcifediol, which is a 25 D compound. It has been shown to be more effective than Vit D and it does not result in hypercalcemia, hyperphosphatemia, or FGF23 as is seen with VDRAs, calcitriol, paricalcitol, or doxercalcif...
What are your preferred strategies to manage mild to moderate rectal ulceration causing tenesmus and discomfort after chemoradiation for rectal adenocarcinoma?
Radiation-induced proctitis or tenesmus -- important to determine if the cause is external or internal to anal verge. Also important to rule out rectal fissures as this typically requires a different approach (Analpram cream and high fiber diet, +/- GI evaluation). If the cause is internal to anal v...
What is the appropriate interval to obtain a hydroxychloroquine level after making a dosage adjustment?
Hydroxychloroquine has an initial whole-blood half-life of around 5 days, while its terminal half-life is around 40 days (Costedeau-Chalumeau et al., PMID 27745934). The former is relevant to evaluating whole blood levels after a dose change.This was confirmed in the PLUS study (see figure 2 in Cost...