Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach pain management needs for patients well-established on buprenorphine/naloxone?
Buprenorphine has high affinity but low activity at mu receptors, and as a result, buprenorphine provides limited analgesia and will not likely provide adequate relief of severe pain in most patients.Continue suboxone treatment. In case of acute pain, consider oxycodone 5 mg tabs, 1-2 q 4 hours as n...
What is the preferred treatment regimen for cardiovascular syphilis, specifically syphilitic ostial coronary artery disease?
The standard treatment with benzathine pen G 2.4 MU IM, 1-3 doses at weekly intervals, depending on likely duration of syphilis, should be sufficient. Most likely there is no need for especially high dose penicillin therapy. I can understand a theoretical rationale for it, for urgent or potentially ...
What type of visual disturbance qualifies as a visual aura?
Visual aura should be a time-limited neurologic event (5 minutes to 60 minutes) with or without migraine headache. It can contain positive (e.g., flashes of light) and/or negative (e.g., scotoma) visual phenomena. It is often toward one side of the visual field but is binocular (comes from both eyes...
Do you typically obtain an EEG in patients undergoing workup for cognitive dysfunction?
I do not obtain an EEG unless something in the patient's history leads me to suspect seizures.
How do you transition patients between different long-acting injectable antipsychotics?
When it is time for the next dose of LAI #1, administer LAI #2 instead. Use an equivalent dose to produce equivalent dopamine receptor activity. To determine the equivalent dose, consider the maximum recommended dose of #1 to be equivalent to the maximum recommended dose of #2. With all the sophisti...
How often should lupus anticoagulant be checked in patients with SLE if prior was negative or if prior was positive?
The key question when considering retesting for any laboratory test, including antiphospholipid antibodies (aPL), is: How would a positive or negative result change the patient's management or prognosis? This question helps guide the decision-making process by focusing on the potential clinical impl...
Is narrow-band ultraviolet B (nbUVB) phototherapy contraindicated or recommended with caution in patients with a personal history of melanoma?
Although it is challenging to be definitive, our current literature suggests that nbUVB does not increase the risk of melanoma or nonmelanoma skin cancer.Previous studies suggesting a possible increased risk with nbUVB included patients with a history of PUVA, which has been shown to increase risk. ...
How do you approach RA management in a patient who develops a new solid tumor while on therapy?
Risk-benefit ratios need to be individually assessed. There are several aspects to take into account: Choice of DMARD - Data on impact of various DMARDS on cancer recurrence or progression is scarce, especially for patients with active cancer. In general, there are few concerns for conventional DMA...
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
Which medications do you deem necessary to stop prior to measuring plasma renin and plasma aldosterone when evaluating a patient for possible primary aldosteronism?
The most important medications to stop before checking renin and aldo levels are spironolactone, amiloride, triamterene, finerenone, and eplerenone. Ideally, patients should be off these meds for at least 6 weeks before testing. A pathologic primary aldo can be detected while taking beta blockers or...