Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you address mental health and online presence with teenage patients?
There are four variables that I talk to parents/teens about: Volume of screen exposure; low vs high. There is some data that pure volume is a risk factor, but not uniformly so. Psychiatric vulnerability; low vs high. Some kids are more vulnerable (e.g., social and generalized anxiety disorder and d...
How do you interpret DXA results in cases where there is discordance between normal hip and spine BMD with abnormal one-third radius BMD?
This is an interesting question. To my knowledge, there are no fracture prediction models based only on forearm bone density values so my response is my opinion and not evidence-based. Firstly, we always rule out hyperparathyroidism when there is forearm bone discordance compared to spine and hips s...
How do you approach therapy for severe osteoporosis after an initial 12 months of romosozumab?
After 12 months of romosozumab, most likely the patient will still need additional therapy. If you can get a bone mineral density, that can guide you into what the best next medication can be. If the patient still has significant osteoporosis or fracture during the treatment with romosozumab, I woul...
What monitoring do you routinely perform on lifelong EDS for epilepsy syndromes?
One of the complications inherent in using AEDs in anybody with epilepsy syndrome or neurotypical people with seizures is bone loss. It is especially important to look at their early loss of bone mass. I check for vitamin D levels even in very young patients. I might even do DEXA scans. I'm very pro...
What therapies have you found most effective in treating teenagers with recurrent CARP?
I have found CARP to be uniformly responsive to minocycline. In my experience, the incidence of recurrence is low and normally responds to minocycline.
Are there instances when you dose sodium zirconium cyclosilicate more than once daily for long term therapy for patients with end stage kidney disease and hyperkalemia?
Not for long-term therapy. I definitely use it more than once daily to lower serum potassium levels acutely, in patients who have clotted their access and are unable to dialyze for 1-2 days until they get decloted, etc. I would imagine that it would be safe to use long-term more than once daily exce...
What approaches do you take to prevent worsening kidney function for patients with chronic kidney disease who have an upcoming outpatient CT scan with iodinated contrast?
If CT is really necessary, if not very high risk just encourage moderate oral hydration before and after. May hold diuretics if this can be done safely. If very high risk try to get IV saline for a few hours prior.
Given recent data from the REPRIEVE trial, how will you adapt your practice with regards to prescribing statins to patients living with HIV?
This randomized controlled trial (Randomized Trial to Prevent Vascular Events) found that, for people living with HIV between the ages of 40 and 75 years who were taking pitavastatin calcium, the risk of major adverse cardiovascular events was lowered by 35% and the risk of cardiovascular death was ...
Given recent data from the REPRIEVE trial, how will you adapt your practice with regards to prescribing statins to patients living with HIV?
This randomized controlled trial (Randomized Trial to Prevent Vascular Events) found that, for people living with HIV between the ages of 40 and 75 years who were taking pitavastatin calcium, the risk of major adverse cardiovascular events was lowered by 35% and the risk of cardiovascular death was ...
How do you counsel someone about metformin use for type 2 diabetes mellitus who is also on a GLP-1 agonist and achieved goal HbA1c, but prefers not to be on metformin anymore?
I am all for this! I realize metformin is still "first line" technically, but so many patients are having a robust response to GLP-1as that I think this may change. Given that GLP-1as have a lower risk of hypoglycemia plus the cardiovascular benefits, I think monotherapy is very appropriate. Also, A...