Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you find 14.3.3 eta or vectra DA helpful in clinical practice?
These blood tests were developed to help diagnose and monitor rheumatoid arthritis.14-3-3 eta is an interesting protein that may have pro-inflammatory properties and could be helpful in diagnosing RA (Maksymowych et al., PMID 25128504), confirmed in a recent meta-analysis to have reasonable diagnost...
Would you recommend delaying left heart catheterization until development of ESKD in a patient with CKD Stage 5 and stable coronary artery disease given concern for contrast-induced nephropathy?
This is a complicated scenario and one in which there are more factors than just medical ones. I am far less concerned about contrast nephropathy (even arterial as in this case), compared to a decade ago. The more important question is whether a patient with stable CAD requires a cardiac cath. If th...
What treatment modalities have you had success with for treating sebaceous hyperplasia?
I have used light electrodesication with a blunt tip needle with good effective results without visible scarring for the vast majority of patients. I find that it is efficient and less expensive than laser modalities. The procedure is uncomfortable for my patients and typically I need to use topical...
Does the presence of diastolic dysfunction guide subsequent pharmacological, pacing and ablative therapies for atrial fibrillation?
For the majority of patients with atrial fibrillation, symptoms are generated by the elevated heart rates rather than the irregularity or the loss of the atrial contribution to ventricular filling. The exception to this is patients with heart failure with preserved ejection fraction (diastolic dysfu...
What is your approach to checking preoperative cardiac biomarkers such as troponin and BNP?
While now recommended as a means of risk stratification for those over 65 years with cardiac risk factors across all three guidelines (AHA/ACC, CCS, ESC), we mostly reserve the use of biomarkers preoperatively for patients in whom we are on the fence for obtaining additional cardiac workup. We view ...
Besides treadmill, what other exercises may be considered for post-exercise ABIs, and are their diagnostic parameters identical to standard post-exercise ABIs?
2 minutes of Toe-raises has been demonstrated to be an acceptable alternative to exercise ABI's.
What serologic biomarkers do you send to assess for sarcoidosis at baseline and/or during flares, in patients where it may correlate with disease activity?
Elevated ACE, dihydroxy vitamin D, and soluble IL2r levels have been shown to correlate with disease activity, but it is important to keep in mind that the sensitivity and specificity are variable and they should never be used in isolation to diagnosis or assess disease activity in sarcoidosis. The ...
How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?
As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD...
How would you manage cardiac sarcoid with intolerance/contraindications to methotrexate, azathioprine, and mycophenolate/mycophenolic acid and that has proven refractory to adalimumab and infliximab as determined by PET?
I think it would be important to know the doses of the medications 'failed'. Similarly to allopurinol dosing and gout prophylaxis 'failures', I find most patients I see for consultation with this story are not on high enough doses, need combo therapy, or are not on the medication long enough. Meth...
For those who don't have access to addiction medicine, have you considered using naltrexone for the treatment of stimulant use disorder in your primary care clinic?
I often reference the ASAM stimulant use disorder guidelines available online, which offer several off-label medications for both cocaine use disorders and amphetamine use disorders, respectively, given other concomitant conditions. Of note, the only gold standard and approved option for treatment o...