Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In patients who are on 3 of the 4 pillars of HF therapy for HFrEF, would you add the 4th pillar if they are no longer in symptomatic HF and LVEF normalizes?
This is a great question, and a data-free zone. The way I see it, the LV recovered with 3 pillars, and assuming the EF is normal and patient asymptomatic, I'm not sure what benefit is derived from the fourth pillar. I would not add it as there is no data that in patients with HFimpEF already on 3 pi...
What is your approach to radiographically suspicious lung nodules for which initial biopsy was negative for malignancy?
It depends on how suspicious the nodule is for malignancy clinically and on the biopsy. The following criteria play into my decision-making: If the kinetics (steady growth over multiple scans) and morphology (solid and spiculated) on CT as well as hypermetabolism on PET-CT are highly suggestive of ...
What is your preferred protocol for squaric acid (SADBE) treatments for alopecia areata/totalis?
Based on a few series published showing that sensitization is not necessary for contact immunotherapy, I tend to do one of two things: Start patients at squaric acid 0.001% solution every other day at home and increase the concentration by 10 (0.01%, then 0.1%, then 0.5%) monthly if not reacting. ...
How long would you wait before performing a kidney biopsy in a patient with possible AIN whose creatinine has plateaued, but not improved, after discontinuing the suspected offending agent?
If the kidney function has not resolved one week after withdrawal of the suspected offending agent, I would request a biopsy.
What is your preferred prophylactic agent in idiopathic angioedema?
I start them on Zyrtec and titrate up to 4x daily dosing as I would in chronic urticaria.
How do you approach treatment of depression in Graves' Disease?
Though depression is often associated with hypothyroidism, it has also been found to be associated with hyperthyroid states and depression itself can impact thyroid function levels (1, 2). It is important to normalize thyroid function as psychiatric symptoms physiologically stemming from hyperthyro...
Do you use direct oral anticoagulants to treat port-a-cath related VTE in patients with an active malignancy?
The initial trials that established DOACs as effective and safe in most patients with cancer-associated thrombosis (Agnelli et al., PMID 32223112, Planquette et al., PMID 34627853) only included patients with lower-extremity DVT or PE but clearly showed equivalence to low-molecular weight heparin (w...
What is your treatment algorithm for managing scalp vitiligo?
It is reasonable, safe, and effective to start with topical steroids and topical calcineurin inhibitors.
How would you manage a patient with progressive/refractory molluscum contagiosum who is well controlled on methotrexate for seropositive rheumatoid arthritis?
Molluscum can be more challenging to treat when a pt is taking any immunosuppressive. In treating that patient, I would attempt to use cimetidine 400 mg TID along with a topical retinoid such as Retin A 0.1% bid to each individual molluscum. If there are only a few remaining, recalcitrant lesions, I...
Do you screen for VWD in all women with menorrhagia severe enough to cause iron deficiency anemia?
Yes, testing vWF is needed in this situation of severe menometrorrhagia. Excessive menstrual bleeding, especially when severe enough to cause anemia, is a common presenting symptom of vWD in women. The testing should be done as part of a comprehensive workup for gynecologic etiologies and other coag...