Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...
How do you approach management of bone marrow involvement in sarcoidosis?
Monoclonal TNF inhibition would be an option as it is less likely to cause cytopenias and has shown some effectiveness in extrapulmonary Sarcoid. I have 2 patients who have anecdotally who have done well in the past.
When would you pursue genetic testing for severe recalcitrant atopic dermatitis?
Not an easy question to answer, but severe and treatment-refractory AD, especially if early onset, is concerning for immune dysregulation and should warrant immune evaluation early. By treatment-refractory, I do not just mean topical therapies, but attempts to control the Th2 pathway that fail repea...
Is it safe to continue azathioprine in a patient with severe bilateral panuveitis (thought to be related to sarcoidosis) and benign ethnic neutropenia, given worsening neutropenia since starting the medication, or should an alternative immunosuppressive agent be considered?
In this case, I would consider stopping azathioprine and switching to an alternative medication, such as an anti-TNF agent. Although not a large drop in the PMN, azathioprine is known to cause leukopenia, and in a patient with known neutropenia, extra precaution should be taken. In the case of uveit...
How do you discuss harms of MGUS screening with other medical providers?
I understand the intent of the question, but - as always - real life is more complicated. I agree that the evidence for screening completely healthy patients for MGUS does not currently exist. But, for patients with unexplained pertinent lab/imaging findings or symptoms, it's not unreasonable. In th...
How do you discuss harms of MGUS screening with other medical providers?
I understand the intent of the question, but - as always - real life is more complicated. I agree that the evidence for screening completely healthy patients for MGUS does not currently exist. But, for patients with unexplained pertinent lab/imaging findings or symptoms, it's not unreasonable. In th...
What considerations do you take in starting stimulant medications for the management of adult ADHD?
Adult stimulant prescriptions for ADHD and The Journal of the American College of Cardiology in particular have published several articles in the last few years investigating the cardiovascular risk of long-term use of these medications. There have been three already in 2024 and data remains mixed.I...
What agent and for how long would you treat a patient with asymptomatic azole-resistant C auris candiduria who is planning to undergo a urological procedure?
I would be cautious here. If there are reasonable MICs to fluconazole (SDD but achievable), this would be preferred. Intravesical amphotericin is a good option. But, if this were impossible to achieve, I would be reluctant to use IV amphotericin in any formulation, since there's a risk of harm, and ...
Which imaging modalities and schedule do you use to follow stage I-II follicular lymphoma that was treated with radiotherapy alone?
PET has been demonstrated to be more sensitive and specific in staging for FL as well as a strong independent predictor of outcome after treatment. Patients also have ~50% risk of developing recurrence outside the RT volume - and PET allows for whole-body imaging. PET is therefore the imaging modali...
How long would you continue chronic transfusion therapy for adult sickle cell patients who have had a stroke?
There is no high-level evidence to inform the decision of how long to continue chronic transfusion in this scenario. Decisions on whether to continue indefinitely are affected by multiple factors like the presence of RBC alloimmunization, whether the patient was on hydroxyurea at MTD or not at the t...