Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to treating osteoporosis in patients post bariatric surgery?
While there is no guidance from the bariatric surgeons, I tend to avoid oral bisphosphonates in all patients with prior bariatric surgery. I am worried about the pill getting stuck independent of the type of surgery. Since we have IV bisphosphonates and denosumab I have good alternatives to oral bis...
How do you manage cases of levodopa intolerance due to nausea or drowsiness?
This is a great question. Side effects from levodopa can be challenging to manage. First, when you start carbidopa-levodopa, ensure you uptitrate it slowly to limit side effects. Carbidopa is most effective in reducing side effects when it is at least 75 mg total daily dose, thus, the 10-100 tablet ...
What are some strategies to help teach patients transitioning from pediatric to adult care to become more independent with respect to their care and less dependent on their caregivers?
A framework that has been helpful is Got Transition® that provides a structure for the approach in implementing a transition process. It is divided into areas to help health care providers, youth and young adults, parents and caregivers. Numerous resources are available for all stakeholders that inc...
Is there a maximum dose of potassium citrate you would use for patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia?
I don’t think there is a maximum dose of potassium citrate. Hyperkalemia can occur, especially if GFR is impaired, and monitoring for that is important. In my experience, diarrhea is the most common dose limiting effect. Taste fatigue is common; fortunately there are multiple preparations available ...
What is your approach to managing patients with recurrent calcium oxalate nephrolithiasis since childhood who are found to be gene carriers for mutations in genes associated with primary hyperoxaluria?
Thank you for this question. In general, there is no good evidence that patients with a carrier of 1 of the 3 primary hyperoxaluria genes (AGXT, GR/HPR or HOGA1) has any phenotype consistent with primary hyperoxaluria, or that these genes are enriched in the general stone forming population. That be...
What disease activity measures do you find helpful in clinical practice for psoriatic arthritis/peripheral spondyloarthritis?
Treat to target strategy has been shown to improve patient outcomes in patients with PsA (TICOPA study). Therefore, it is important to set treatment targets and measure disease activity in clinical practice in PsA. Measuring disease activity in this disease is, however, challenging due to heterogene...
Do you use any urinary staining techniques when performing urine microscopy for patients with acute kidney injury?
No. Not at this time. At one point, about 10 years ago, we did have Wright stain to stain for eosinophilluria but it seemed too labor-intensive and not that helpful, so we stopped using it.
Do you recommend Alpha Lipoic Acid to patients with diabetic polyneuropathy?
Recommend is a strong word. I mention it to my patients as there's some 'evidence' supporting it. It has minimal side effects and virtually no risk, so it's worth a try. However, it's important to note that very few of my patients report any benefit from it.
What clinical sign or symptom do you consider to be the most specific for Cushing syndrome?
Cushing's syndrome is a rare disease. The following symptoms and signs are suggestive. Symptoms: weight gain, especially in the middle, muscle weakness, and easy bruising Signs: Moon facies Central obesity with relatively thin arms and legs Pad of fat behind the neck (Buffalo hump), thin skin, pur...
How do you manage patients with bullous pemphigoid who have IgE autoantibodies to BP180?
40% of patients with BP can have IgE class autoantibodies directed against BP. Treatment does not have to differ from patients without IgE class autoantibodies: for mild or localized disease or in patients who cannot tolerate immunosuppression, doxycycline and high potency topical steroids can be us...