Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend life long aspirin 81 mg daily for non-specific T2 white matter hyper-intensities on MRI brain?
"Non-specific" means non-specific, indeed, and ASA risks of bleeding increase with age.
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...
For patients with microcytosis MCV 75-79 and normal Hb, low TIBC, and normal ferritin do you always rule out thalassemia?
Microcytosis is typical in thalassemia. With a normal ferritin and hemoglobin concentration, I would start screening by measuring HPLC, HbA2 levels that are high in beta-thalassemia carriers. (HbA2 can be normal with “mild” thalassemia alleles and for several other reasons.) Microcytosis without iro...
What is the target ferritin level for patients with hereditary hemochromatosis and signs of end-organ damage?
I believe the best marker to guide phlebotomy therapy for iron overload is the serum ferritin concentration. I use a target ferritin level of approximately 50 ng/ml. However, one could justify a ferritin level of <200 ng/ml from the literature of serum ferritin compared to body iron stores in HFE he...
Do you recommend the use of SGLT2 inhibitors to reduce the risk of liver cirrhosis in patients with Type 2 diabetes mellitus?
Metabolic dysfunction-associated steatotic liver disease (MASLD) can be found in about 30% of adults in the U.S. Diabetes is a significant co-morbidity and increases the risk of progression to metabolic dysfunction-associated steatohepatitis (MASH). I calculate a FIB-4 index in these patients to see...
How do you treat postpartum obsessive-compulsive disorder?
The ideal treatment for women who are breastfeeding is transcranial magnetic stimulation. TMS has a 50% response rate for OCD, higher if treatment is extended past the typical course of 30-36 treatments. This is similar to the response rates reported for SSRI treatment of OCD. Most women with post-p...
Would you consider using long-acting injectable cabotegravir/rilpivirine for pregnant women with HIV?
At this time, long-acting injectable cabotegravir/rilpivirine (CAB/RPV) is not generally recommended during pregnancy due to limited safety data and unknown effects on the developing fetus. So far, there have not been any reported safety concerns regarding harm to the fetus for either long-acting in...
How do you manage persistent insomnia despite ASV titration in patients with complex sleep apnea?
It is an excellent question, and I am not sure if I have a perfect answer. The first question I would have is if the insomnia pre-dated the treatment-emergent central sleep apnea. It is assumed if they are on adaptive servo-ventilation (ASV) that they already tried CPAP, had treatment-emergent centr...
Is there a role for the use of transient elastography (FibroScan) to monitor liver fibrosis in patients on long term methotrexate?
Liver elastography is a useful tool to use when assessing the potential hepatotoxicity of various drug therapies. Traditionally, methotrexate accounted for nearly all the hepatotoxicity issues that we faced; however, we can add many other drugs to that list. Virtually, every immune suppressive drug ...
How do you counsel patients who want to use vaping to quit smoking cigarettes?
My patient population is largely persons with severe opioid use disorder. Most use tobacco/ nicotine in some form - typically cigarettes and/or vaping. I have seen people minimize their use of cigarettes with vaping and feel very happy with their results. I don't see, however, a lot of patients stop...