Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you recommend initially starting twice-weekly outpatient hemodialysis with close lab monitoring for nonoliguric AKI patients?
It is unusual in my experience to initiate dialysis for AKI as an outpatient. More often, patients with prolonged dialysis-requiring AKI may need to be transitioned from an inpatient setting to outpatient dialysis while awaiting improvement in kidney function. The question of when to initiate dialys...
Should IVIG dosing in patients with autoimmune disease (i.e., dermatomyositis) who become pregnant continue to be based on actual weight at the time of each infusion, or should it be limited to pre-pregnancy weight?
This is a very interesting and incredibly pragmatic question, but not one with an easy answer.By way of background:The treatment of pregnant DM patients is understandably complicated by the need to balance adequately treating disease activity against the maternal/fetal toxicity of medications. In ad...
How do you determine if a positive thimerosal patch test isn't a false positive?
Thimerosal is commonly positive on patch testing and frequently not relevant. In fact, it was voted (non) Allergen of the Year by the American Contact Dermatitis Society. While small amounts are used in some influenzae vaccines, there is not much else that contains this. At one time, it was a preser...
How would you manage a patient with nonspecific clinical symptoms and pathology consistent with spongiotic and psoriasiform dermatitis other than oral JAK inhibitors?
Vast majority of these patients will not have any diagnosable underlying cause (like 99% in a non-academic setting) and the longer and more you look before you treat, the longer and worse they suffer. Take your best guess if more psoriasiform or more eczematous. If guess psoriasiform give them sampl...
What is your approach to managing sicca symptoms in patients not responding or not tolerating conservative measures, pilocarpine, and cevimeline?
Try lower doses of pilocarpine with just 1/4 tablet at a time. Very slowly go up on the dose as tolerated. The patient's job is to find the maximum tolerated dose. I recommend this pill splitter: Mix capsule of cevimeline in water, just drink a tiny bit at a time tid and go up on dose as tolerated...
What treatments would you recommend for patients with chronic urticaria who have minimal improvement with anithistamines and Xolair?
Cyclosporine, no question about it. I start at about 3 mg/kg/d of modified cyclosporine if omalizumab been failed, then try to taper once it is well controlled. I also want to give glucosamine at about 25 mg/kg/d - which has been shown in a randomized double-blind placebo-controlled clinical trial t...
How do you evaluate livedo reticularis (not livideo racemosa)?
Livedo reticularis appears as an interrupted vascular network on the lower limbs. One does not need to warm up the affected area in order to make this diagnosis. The response to heat usually occurs in cutis marmorata that is found in children. Livedo reticularis when it is acquired in teenage and la...
How do you treat patients with Linear IgA that are deficient in G6PD?
Quite a unique clinical situation! One in which the diagnosis is rather rare, but with an added wrinkle where the most classic textbook therapy, dapsone, cannot be used.A few case reports have shown that omalizumab and dupilumab have been reported to effectively treat LABD: Almuhanna et al., PMID 37...
For isolated and very high lipoprotein (a) levels (LDL of > 140, has an Lp(a) > 100) in a patient with no cardiac symptoms or risk factors, would you start lipid lowering treatment, such as with a PCSK9i if they develop statin intolerance?
There are a number of trials going on for reduction of Lp(a) with both IM and PO meds. We know that lifestyle modification does not help for reduction of this very atherogenic protein. If calc scores are high, I would look into entering one of the trials. If the score is low (unlikely), I would wait...
How do you use baby tam, low dose tamoxifen, in your practice?
At SABCS 2022, we heard additional follow up results from Dr. DeCensi for TAM-01 (previous publication), which randomized patients with DCIS, LCIS, or atypia to low dose tamoxifen (5 mg daily) or placebo for 3 years. Similar to the prior full dose tamoxifen prevention trials, this resulted in about ...