Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to anal pap screening among MSM with HIV, and if routinely recommend, starting at what age (assuming access to HRA)?
We taught our nurses and patients how to do self-collection, which cut down on the amount of time it takes. Multiple guidelines for HPV have been revised in the past few months based on more recent studies (although the emotional reaction to having multiple of my patients diagnosed with anal cancer ...
Would you check ANCA titers in a patient with a history of PR-3-ANCA glomerulonephritis in remission and a stable creatinine but with recurrent microscopic hematuria?
Not sure there is an easy answer to this. A patient in remission should not get a recurrence of glomerular hematuria unless the disease is active. A new onset glomerular hematuria would certainly make me worried about a relapse, some of which may be subtle, indicating "grumbling disease". The data o...
Would you recommend waiting for a low Vitamin D level to correct to goal prior to giving a scheduled Prolia injection when transitioning a patient from Zolendronic acid to Prolia therapy for worsening osteoporosis?
When ZA is in its early days patients had to have a D level of 15ng/ml. To be on the safe side most of us want a 25 ng/ml level which is easy to obtain.
What is your experience with using anabolic therapy for treatment of osteoporosis in patients with EtOH cirrhosis and is one agent preferred over another (PTH analogue vs Evenity)?
The approach that has been recommended may be reasonable. It is important to recognize that a bone density score consistent with osteoporosis does not necessarily mean that the patient has osteoporosis i.e. loss of mineral and matrix. Osteomalacia, a mineralization defect of the collagen elastin mat...
Are SGLT2 inhibitors contraindicated in patients with osteoporosis and history of vertebral and hip fractures?
In ovariectomized mice, the GLP-1 agonists were found to improve bone density by reducing the inflammation in the bone marrow so there is no contra-indication for a patient with osteoporosis and vertebral fractures to take this class of medications. It is the first weight loss therapy that is not as...
If a patient has potential arrhythmic-sounding syncope and a noninducible type 2 or 3 Brugada ECG pattern, have we excluded Brugada syndrome as the etiology for their syncope?
This is a complex question with a few nuanced components. The first component is qualifying an arrhythmic versus non arrhythmic cause of syncope. I would stress that this is based on generalization as there are no features that will provide absolute certainty for the nature of a single syncopal even...
How do you treat a patient with moderate dementia who experiences a recurrence of depression?
When I get a patient with moderate dementia and depression, I make sure the basic potential reversible medical contributors have been looked into and corrected (i.e., B12/D3 deficiency, OSA, etc). If the patient is on medications that could contribute to depression, I discuss with PCP and family if ...
In what clinical situation would you consider using benzodiazepines in patients with dementia?
I would avoid long-term benzodiazepines treatment if someone has full-blown dementia syndrome or frontal lobe syndrome due to the potential of paradoxical disinhibitions along with amnestic and ataxic side effects. However, I would consider clonazepam for RBD and related REM sleep issues in dementia...
Would you recommend changing a patient from the pill form of levothyroxine to Tirosint-SOL if they are started on a proton pump inhibitor?
While it is true that PPI's may lead to a decrease in levothyroxine absorption due to decreased tablet dissolution in the stomach (Guzman-Prado et al., PMID 33469743), and that liquid formulations are not susceptible to this effect (Seng Yue et al., PMID 38554774), the decrease in levothyroxine abso...
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, ...