Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider adding or switching to pirfenidone for a patient with progressing UIP (based on imaging and PFTs) who is currently on nintedanib?
Yes, I would consider it. There's some recent literature addressing this, which indicates switching may be associated with disease amelioration. Why might it work? Not super clear, perhaps biologic differences or maybe driven by better compliance. Smarter people than me could probably speak to the r...
Do you recommend bedtime administration of antihypertensives in patients who exhibit nondipping on ambulatory blood pressure monitoring?
Most of the effective anti-hypertensive medications are long-acting, with therapeutic levels maintained for up to 72 hours between doses. From a pharmacokinetic perspective, dosing these meds (like amlodipine and chlorthalidone) at night would not make a difference. Data supporting nocturnal dosing ...
Do you perform routine interval screening for renal angiomyolipomas in patients with sporadic LAM?
The occurrence of angiomyolipomas (AMLs) in sporadic lymphangioleiomyomatosis (S-LAM) is less common compared to tuberous sclerosis complex-related LAM (TSC-LAM). One study showed that up to 50% of patients with S-LAM developed AMLs, whereas 100% of TSC-LAM patients were affected (Yeoh et al., PMID ...
Does evidence support extending the duration of intravenous iron dextran (INFeD) infusion in pregnant patients?
No, there has never been evidence with any of the four formulations supporting a longer rate of infusion (above the minimum recommended) as a harbinger of either benefit or safety. LMW ID (INFeD) should be given as 1000 mg in 250 ml of normal saline over one hour. My gut tells me 45 minutes is OK bu...
In patients with sicca symptoms and positive SSA/SSB how often do you perform other diagnostic testing such as salivary gland ultrasound, biopsy, Shirmers, ocular staining, stimulated salivary flow, etc?
In patients with sicca symptoms and positive SSA antibodies, I always try to confirm that they have objective evidence of dryness/gland involvement. This is because patients can say they have dry eye and/or dry mouth yet not have this bear out on objective testing (Bezzina et al., PMID 27992710, Rip...
What is your approach to monitoring patients with the indeterminate form of Chagas disease?
Once the diagnosis of Chagas is confirmed (by at least two different serological tests), we routinely evaluate the patient for symptoms or signs of cardiac or GI complications. We also obtain an EKG with 30-second rhythm strip and schedule a transthoracic echocardiogram with contrast (because some p...
How can hepatic venous pressure gradients in patients with cirrhosis be used to differentiate between cardiac cirrhosis and portopulmonary hypertension?
HVPG is a measure that quantifies the increase in sinusoidal resistance to blood flow and can be obtained in a minimally invasive way compared to portal venous sampling directly which may be more invasive. HVPG is the pressure difference between hepatic vein wedge pressure (HVWP) & hepatic vein free...
When cinacalcet is used to treat hypercalcemia in primary hyperparathyroidism, does it also normalize low serum phosphorus levels?
Cinacalcet can be used for treating primary hyperparathyroidism especially in patients who are unable to tolerate the surgery. Lowering the PTH cinacalcet will not only decrease serum calcium levels but will also increase serum phosphate levels. See Peacock et al., PMID 19837909.
What is the importance of finding a positive titer for TS-HDS and what treatment would be advised for these patients?
TS-HDS antibodies were first described by investigators from Washington University in St. Louis (2003) in five patients with painful sensory axonal neuropathy [1]. Further studies by the same group indicated that TS-HDS antibodies were associated with prominent neuropathic pain in the upper extremit...
What methods have you found successful in getting young children to use nasal sprays?
Intranasal corticosteroid nasal sprays (INCS) are beneficial in controlling symptoms in children with allergic rhinitis but acceptance is often a barrier to use. I advise parents first start with a gentle nasal saline spray to help their child accept the sensation of liquid in the nose. Parents can ...