Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is there any evidence for amyloid/amyloidosis causing a spurious/false PSA reading?
This is an excellent question.Our group has been involved with amyloid/radiation effects in patients with Alzheimer’s disease Turn our initial run-up and through our most recent reviews, I have not seen any significant publications nor have I seen clinical situations that this addresses, although am...
Below what eGFR would you consider discontinuing lithium in a bipolar disorder patient with chronic kidney disease?
It seems nowadays we have other effective therapy besides lithium for the treatment of bipolar disorder. I tend to stop lithium as soon as I get a sense that there is a decline in kidney function as to avoid further damage. Of course, all of this depends on the specific situation and other possible ...
What is your approach for patients with a history of nephrolithiasis who are being evaluated for living kidney donation?
We have a protocol that guides us on the work-up in this situation. If they have a remote history of stones, then we do a Litholink and if they have a urinary milieu that is risky for stone disease they are counseled on fluid intake and dietary changes. If they have symptomatic stones, they are rule...
How often do you screen for cerebral aneurysms in patients with autosomal dominant polycystic kidney disease who do not have a family history of intracranial aneurysms or for whom the family history is unknown?
We recently wrote an editorial about this topic. Our conclusion was as follows: "considering the potential for morbidity and mortality in this unique population at risk for ICAs with possibly higher-than-average risk of rupture, we believe that presymptomatic screening for ICA in all individuals wit...
What is your approach to de-escalation of asthma inhaler therapy in the setting of negative bronchoprovocation testing when patients are averse to deprescribing?
I discuss the reason we are doing the bronchoprovacation test and what the results would mean. This makes it easier for patients to de-escalate therapy and seek an alternative diagnosis for their symptoms.
How do you treat benign fasciculation syndrome?
Reassurance. Just telling the patient that it isn’t ALS and it’s a benign and common condition will often suffice. If it doesn’t suffice: Address anxiety with psychotherapy, medications, or both. Reduce caffeine intake, and ensure the patient gets adequate sleep. If the first and second options don...
How do you approach medication management in biopsy-proven pulmonary sarcoidosis with disease stable for over 2 years on hydroxychloroquine and low dose prednisone?
Epidemiologic studies in sarcoidosis show that the majority of sarcoid cases are benign. Some patients can have disease remission, and therefore are able to come off of therapy. Most of this data is in pulmonary sarcoidosis and the data is less clear when there is other organ involvement. The diseas...
What is your approach to prescribing RIPE for 6 month vs rifapentine/moxifloxacin for 4 months in the treatment of drug sensitive TB in the US?
There are many things that have to be taken into consideration before deciding on using the rifapentine-moxifloxacin regimen instead of the standard RIPE regimen for drug-susceptible TB. The regimen is only recommended for people with pulmonary TB at this time. People with extra pulmonary TB were no...
Do you usually recommend a modified diet for Clostridioides difficile infection (CDI)?
Post-infection IBS is common after C. diff infection, and some of these patients have dietary intolerances. Other than avoiding foods that exacerbate these symptoms, I do not recommend any particular diet. I also do not recommend probiotics, in keeping with society guidelines.
What laboratory workup do you perform in patients with symptoms consistent with erythromelalgia?
The usual CBC with differential, as well as CRP, ANA, ESR, and Rheumatoid Factor.