Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to monitoring patients referred for high titer +RF and +CCP but without active symptoms of inflammatory arthritis?
It has been well described that patients with a +RF and + CCP autoantibody may develop clinically active RA up to two decades or more (potentially lifelong) after the detection of these autoantibodies in a patient. It is now thought that there is a preclinical phase of autoimmune diseases including ...
Do you modify dosing or use of bupropion to mitigate seizure risk in patients without eating disorder who are restricting calories to lose weight?
No. The risk of seizures with bupropion is 0.1% with daily doses below 300 mg and 0.4% with doses up to 450 mg daily. The increased risk of seizures in eating disorders is due to higher risk of severe electrolyte disturbances that result from disordered eating, induced vomiting, and laxative abuse. ...
Is there evidence to suggest there is a withdrawal syndrome from muscle relaxants such as tizanidine?
The answer is yes, there is evidence in published literature supporting withdrawal manifestations from sudden discontinuation of alpha-2 agonists including tizanidine (references below), primarily due to catecholamine surge causing a sympathetic overdrive, affecting the patient's physiological state...
What is your approach to helping parents manage sleep disturbances in patients with autism spectrum disorder?
At our center, we start with sleep hygiene education, using tools such as the Autism Speaks sleep toolkit which has a printable PDF that is free for parental and clinical use. We also try to do therapy on sleep hygiene and our therapists will often try to find out what factors may exist in the home ...
What is your approach to evaluating amiodarone induced interstitial pneumonitis?
There are no definitive histopathological or radiological findings of amiodarone toxicity. For example, foamy lipid laden macrophages are reported but this reflects exposure, not injury, and these findings are present without interstitial lung disease related to amiodarone. High HUs have been report...
Do you refer all patients with a Beighton score over 5 to genetics for further assessment?
Our genetics clinic does not accept these patients for genetic testing anymore because they are inundated with such requests from patients with plain benign joint hypermobility syndrome. They reject these requests for genetic testing. They accept doing genetic testing only for patients with vascular...
Would you switch a patient with glucocorticoid induced osteoporosis to romosozumab if a patient sustained a fragility fracture 1 year into treatment with teriparatide?
This is an interesting question for which there is no evidence-based medicine. It would be important to know what bone was broken. If it was a vertebral fracture I would likely suggest a change to romosozumab because vertebral fractures are usually not traumatic and are the purest osteoporotic fract...
How soon after radioactive iodine therapy for hyperthyroidism should Methimazole be resumed?
In patients pretreated with methimazole, there is a risk of recurrent hyperthyroidism following radioiodine (RAI) administration, with possible adverse cardiac effects, especially in older persons or in those with cardiac disease (reviewed in Walter et al., PMID 17309884). However, resumption of met...
What is the utility of checking reverse T3 in clinical practice?
I have never routinely ordered it, only when forced to by certain rare patients who are reading Dr. Google or other information they find. They think it will change their plan, it never does.
In patients with active IBD and rectal cancer, do you take any precautions before starting TNT?
First, I would be sure that the patient really needs TNT. If a patient has active inflammatory bowel disease, they will not tolerate TNT very well. If a patient has inactive IBD, there is not likely to be much added morbidity. I would be very hesitant to use TNT if someone has really active IBD. The...