Regardless of age, the majority of patients with chest pain do not have cardiac ischemia. But providers are wary of missing this important diagnosis, so most err on the side of caution when they encounter it. The American Heart Association (AHA) and European Society of Cardiology (ESC) have recently published objective guidance on evaluating chest pain that is applicable in a clinic setting. We've condensed the recommendations into 4 practical steps that provide an evidence- and guideline-based tool for assessing chest pain. Given the litigious and consequential nature of missing cardiac ischemia, many low-risk patients are referred for expensive and unnecessary workups. The steps below can help alleviate the anxiety and excessive testing associated with these patients. more
When absorbed intestinally, testosterone undergoes the first-pass effect in the liver, rendering it inactive. To avoid this, drug manufacturers have developed products that are injected or absorbed through the skin, nose, and oral mucosa. In the past year, two testosterone capsules, Jatenzo and Tlando, have become available. They contain testosterone undecanoate, whose lipophilic properties facilitate its absorption by the intestinal lymphatic system, allowing it to avoid the first-pass effect. Links to information on both products are provided below, along with our review of male hypogonadism.
Acute mountain sickness (AMS), also called altitude sickness, can develop when someone rapidly ascends from near sea level to more than 3000 meters. Symptoms include headache, lightheadedness, nausea, insomnia, and fatigue. AMS is believed to occur from hypoxia-induced respiratory alkalosis. The carbonic anhydrase inhibitor acetazolamide, which promotes renal bicarbonate loss, has been prescribed for years to people who are planning a high-altitude trip. Two recently published studies compared acetazolamide to placebo for the prevention of AMS; Study one enrolled healthy adults, and Study two involved patients with COPD. Acetazolamide was effective in both studies, although subgroup analyses showed that women saw a much greater benefit.
Patients are often sent to primary care providers to be "cleared" for surgery. The provider is then tasked with determining what testing is necessary to declare a patient fit for their procedure. This can be a daunting task given that patients often have undiagnosed conditions (e.g. CAD, CHF) that increase their risk of perioperative mortality. Professional guidance does exist, but much of it is fragmented, inconsistent, nonspecific, and based on expert opinion and observational data. We pooled the best information available and put it on our new Preoperative Evaluation Page. Cardiac testing, pulmonary testing, and recommended laboratories are covered, along with medication management.
The meniscus is a cartilage pad in the knee that serves as a cushion between the femur and tibia bones. It may become torn through acute trauma or normal wear-and-tear. Meniscal tears can cause pain and mechanical symptoms described as popping, locking, and catching. To address these symptoms, orthopedic surgeons often perform arthroscopic surgery, where they attempt to suture or remove the torn meniscus. Because of blood supply and tear patterns, less than 10% of meniscal tears can be sewn back together (repair), and the rest are treated with excision of the damaged cartilage (meniscectomy). more
Primary care providers are often asked to manage antithrombotics around procedures. Balancing the risk between thromboembolism and surgical bleeding can be intimidating, and it doesn't help that recommendations from professional organizations are sometimes contradictory. To make matters worse, no guidance exists for certain scenarios, and in some cases, recent studies do not support current recommendations. To help alleviate some of the confusion, we revamped our periprocedural antithrombotic recommendations page so that guidelines are grouped by indication and therapy. Important studies are also covered, along with complicated topics like bridging therapy.
Vtama® (tapinarof) cream - novel drug class (aryl hydrocarbon receptor agonist) for treating psoriasis
Vivjao® (oteseconazole) - new azole antifungal approved for recurrent yeast infections
Quviviq® (daridorexant) - third orexin receptor antagonist approved to treat insomnia
Tlando® (testosterone undecanoate) capsule - new oral testosterone replacement product
Cibinqo® (abrocitinib) - new janus kinase inhibitor approved for atopic dermatitis
Tirzepatide (Mounjaro®) - novel GLP-1/GIP receptor agonist for type 2 diabetes
Obstructive sleep apnea (OSA) awareness has increased dramatically over the past 10 years, to the point that patients frequently come in requesting sleep studies - oftentimes a significant other has noticed symptoms, or the patient is concerned about daytime fatigue. Sleep medicine has become such a big part of healthcare that a quick Google search of "sleep study" brings up over 20 sleep centers within a 15-mile radius of my location, Austin, Texas. Insurance companies reimburse overnight sleep studies at a rate of $650 - $1200, and the average CPAP machine costs $500 - $800, not including maintenance. more
Adolescent obesity has become a significant health issue, with 22% of children aged 12 - 19 years being obese. Diet and exercise interventions are important, but it's clear that they do not work in many cases. When parents turn to providers for help, there are a limited number of options. Until recently, only liraglutide (Saxenda®) and orlistat (Xenical®) were FDA-approved to treat obesity in children 12 years and older. Liraglutide is expensive and requires once-daily injections, and orlistat has some uncomfortable side effects (e.g. oily rectal spotting, flatus) that may be unacceptable in this age group. Thankfully, another option is now available. more
Opioid addiction has become a national health crisis, with more than 130 people dying daily from opioid-related overdoses. Given this frightening statistic, it's important that providers are aware of the treatments available for opiate addiction. Our new Opioid Use Disorder page gives concise information on treating patients with buprenorphine, methadone, and naltrexone. Important details on therapy initiation are covered, along with relevant topics like assessing withdrawal, managing acute pain, and urine drug screening. As always, comprehensive drug information (e.g. side effects, precautions, interactions) is included. See opioid use disorder for more.
Janus kinase (JAK) is an intracellular enzyme that transmits signals from surface membrane cytokine receptors. JAK signaling stimulates immune cell activation by influencing gene expression. JAK inhibitors block JAK signaling and therefore suppress immune activation. Ruxolitinib (Jakafi) was the first JAK inhibitor approved in the U.S. in 2011, and with the recent approval of abrocitinib (Cibinqo), there are now 6 JAK inhibitors currently available. The drugs differ in their affinity for JAK enzyme subtypes (JAK1, JAK2, JAK3); the clinical relevance of these differences is currently unknown. more
Steroid joint injections remain a popular treatment for joint pain even though studies have found they have no clear benefit. Injecting the hip joint is technically more difficult and typically only performed by orthopedic surgeons or sports medicine doctors. A study published in the British Medical Journal looked at the effects of steroid hip injections in patients with hip osteoarthritis (OA) The study enrolled 199 patients with hip OA and moderate to severe pain for at least 6 weeks. Patients were randomized to one of three groups: more
HIV pre-exposure prophylaxis (PrEP) with Truvada, Descovy, and just recently, Apretude is becoming more common as access and awareness have increased. The CDC issues specific guidelines on whom to treat and how therapy should be managed. Our new HIV prophylaxis page covers all the details in a concise and easy-to-navigate format. Recommendations for nonoccupational post-exposure prophylaxis (NPEP) are also included, along with information on drug precautions, interactions, efficacy, and side effects. HIV prophylaxis page
A study published in the Annals of Internal Medicine compared results from an array of diagnostic tests (e.g. labs, PFTs, ECHO) between COVID long-haulers and control subjects with no history of COVID. The study found no significant differences between the two groups on any of the testing.
A Longitudinal Study of COVID-19 Sequelae and Immunity: Baseline Findings, Annals of IM (2022)
Tirzepatide (Mounjaro®) is a new diabetes drug from Lilly that is a first-in-class dual GLP-1/GIP receptor agonist. GLP-1 and GIP are hormones secreted by the small intestine, whose actions include stimulating insulin release and suppressing hunger. GLP-1 receptor agonists have been available since 2005, and tirzepatide is the first drug to target both GLP-1 and GIP receptors. more
GERD is boring, and many patients self-treat, but the American College of Gastroenterology (ACG) recently published GERD guidelines, so it's worth reviewing certain nuances of the disease. Our new GERD page covers ACG recommendations for diagnosis and treatment, along with a review of proton pump inhibitors, which are consumed every day by millions of people. See the Straight Healthcare GERD page for more.