April 13, 2007 Archives - Page 2 of 8 - Clinical Advisor

Print Issue: April 13, 2007

COST-EFFECTIVE SARCOIDOSIS WORKUP

What is the most cost-effective approach to diagnosing sarcoidosis?—Melissa Magliocco, MD, Plainsboro, N.J. The American Thoracic Society (ATS) says that diagnosis requires a compatible clinical picture and histologic evidence of noncaseating granulomas. Moreover, other diseases capable of producing a similar histologic or clinical picture must be excluded (Am J Respir Crit Care Med. 1999;160:736-755). If…

PUTTING A TRACE ON “TRACE” PROTEIN

What workup is warranted following a report of “trace” protein in the urine of an apparently healthy individual?—Stephen Parker, DO, Roselle Park, N.J. The discovery of “trace” proteinuria in healthy individuals is surprisingly common. Transient proteinuria may, in fact, occur in up to 4% of men and 7% of women on a single examination. This…

RISK OF LACTIC ACIDOSIS WHILE TAKING METFORMIN

A 58-year-old woman who has adult-onset diabetes mellitus, hypertension, and hyperlipidemia was taking simvastatin (Zocor) 40 mg, glyburide (Diabeta) 20 mg, metformin (Glucophage) 850 mg t.i.d., pioglitazone (Actos) 45 mg, losartan (Cozaar) 100 mg, verapamil (Calan SR) one-half a 240-mg tablet daily, clonidine (Catapres) 0.3 mg at bedtime, furosemide (Lasix) 40 mg, and potassium chloride…

MI RESPONSE: SPEED VS. DISTANCE

.Is it better for an MI patient who needs percutaneous coronary intervention (PCI) to have fibrinolytic therapy at a nearby hospital or to go to a larger hospital 20 miles away that offers PCI?—Leroy Schaffner, MD, Henrietta, Tex. It depends on several factors, but the goal of either strategy is to keep the total ischemic…

WHICH FORMS OF STREP SHOULD BE TREATED?

New York State mandates that we send all strep A-negative throat cultures to be confirmed. Frequently, this result is positive for other strains (e.g., B, C, G, and even F). While I treat only strep G, some local physicians treat all strains. Do you recommend treating forms of strep other than A and G?—Richard Brooks,…

INFREQUENT TB TESTING

As a family practitioner in a solo practice, I am occasionally asked to do TB screening tests. The requests are so infrequent that it is difficult for me to rationalize intradermal purified protein derivative (PPD) testing because the multidose vial expires within 30 days of using the first dose. I’d like to use tine testing…

SCREENING SIBLINGS OF A CANCER PATIENT

What is the appropriate screening for the male and female siblings of a man with germ-cell testicular cancer diagnosed as stage 3 at age 22? The family history includes a paternal history of colon cancer at age 45 and a paternal aunt with thyroid cancer. —Michael T. Vest, DO, Columbus, Ga. The familial incidence of…

Timing of antibiotics for nail removal

In the case of a severely infected great-toe paronychia, does it matter whether or not you start antibiotics before you perform partial nail removal?—Gregory H. Tuttle, MD, Chapel Hill, N.C. Paronychia is an often tender infection or inflammation around the base of the nail fold. It can start suddenly (acute paronychia) or gradually (chronic paronychia).…

WHEN TO START AN ALZHEIMER’S DRUG

How low a diagnostic threshold should one have for prescribing drugs for Alzheimer’s disease (AD)? Is it appropriate to prescribe a trial course for a concerned patient if you believe she has benign senescent forgetfulness rather than early AD?—Melissa Raue, PA-C, Pound Ridge, N.Y. Not all forgetfulness is a result of AD, so it is…

COMBINING SILDENAFIL WITH OTHER MEDICATIONS

Would using l-arginine capsules (to provide nitric oxide) in combination with sildenafil and grapefruit juice allow patients with erectile dysfunction to reduce the dose of sildenafil?—Alberto Saenz, MD, Columbia, S.C. A double-blind, placebo-controlled study of high-dose l-arginine (5 g/day) done in 50 patients, aged 50-75, over six weeks showed no difference on the Brief Male…

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