Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For male patients who strongly prefer to stop anticoagulation for unprovoked VTE, are there any tools or labs that you would use to guide your decision making?
This is a challenging situation as one of the more useful tools to predict risk of recurrence after unprovoked VTE, the HERDOO2 rule, suggests that even with an otherwise "perfect" score, men have a high enough risk of recurrence to recommend ongoing anticoagulation. As such, and given the generally...
What is your approach to immunosuppression in patients with preserved kidney function who are found to have nephrotic syndrome of unknown etiology and cannot safely undergo a kidney biopsy?
This is a difficult scenario. Would definitely try to get a biopsy at a Higher level of care perhaps by Interventional Nephrology. Would obtain a comprehensive laboratory workup including kidney function, serum albumin level, random and 24-hour urine collection for albuminuria and proteinuria, Hepat...
Is there a role for dual antibiotic treatment with ethambutol and macrolide only, as opposed to three-drug antibiotic therapy, in the treatment of treatment-naive pulmonary MAC without cavitary disease?
That is a great question, as the role of rifampin (or rifabutin) regarding its relative contribution to the treatment of MAC is not overly clear. Historic data that is a few decades old raised the possibility of better activity when a rifamycin is combined with ethambutol (at least in vitro and furt...
Do you use delayed-release budesonide over prednisone or methylprednisolone for the treatment of IgA nephropathy, considering the available safety and efficacy data?
The two agents (TRF-budesonide and systemic glucocorticoids, the latter of which include prednisone and methylprednisolone) have never been compared head-to-head, and so direct comparisons are unavailable. I try to present both options to patients, and in particular, I will focus on the side effect ...
Are recurrent UTIs a contraindication to SGLT2i use?
I don't view UTIs as a contraindication to SGLT2i use, but I make a risk and benefit analysis with each patient. Bacterial UTI as well as mycotic vaginal infections may be a sign that the patient has excessive glycosuria from hyperglycemia. In general, treating hyperglycemia should lessen the freque...
Do you recommend boric acid for patients with recurrent candida vulvovaginitis?
Yes, this will be effective at 600 mg bid for 2-4 weeks. However, with recurrence, it is important to obtain a fungal culture to document species and susceptibility.
Do you recommend discontinuing IVIG for a newly diagnosed HMGCR+ statin induced necrotizing myopathy who developed a recent brachial DVT?
Really, the issue is if the DVT was provoked or not. If possibly not provoked then would decrease the dose of IVIG or give it over a long time frame. For example, if the patient is on 2 gm/kg over 2 days, I would do 2 gm/kg over 4 days. Or reduce the dose to 1 gm/kg over 2 days.
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
How do you approach weakly positive PL-7 antibody in a patient who initially presented with muscle weakness, rhabdomyolysis and non specific muscular edema on MRI that resolved with IV fluids?
During an episode of rhabdomyolysis, muscle MRI isn't reliable since it would be positive regardless of the underlying cause. So, monitoring the trajectory of CPK levels and serial muscle exams to evaluate for weakness would offer a more reliable assessment for true myositis. Positive antibody resul...
What are alternate approaches to medical therapy and/or interventions to consider in patients with refractory, severe coronary vasospasm despite short-acting nitrates, calcium channel blockers, L-arginine, and clonidine?
Angina caused by coronary vasospasm is relatively rare. I have come across very few cases of severe coronary vasospasm in my 15 years of career. The most common thread seems to be smoking and drug abuse (amphetamines, cocaine). Smoking cessation and stopping drug abuse are the most important interve...