Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach prevention of kidney stones in patients with an ileal diversion and recurrent nephrolithiasis?
My first step, is to perform a kidney stone analysis. Kidney stones are not a "monolithic" disorder; rather they are "symptoms" of a diverse group of renal mineral metabolism and acid-base disorders. my next step in this case would be to obtain a 24-hour urine supersaturation study. I would be parti...
How do you approach treatment of a patient with active RA and a history of Lynch Syndrome?
The presence of hereditary polyposis coli and its predisposition to colon cancer should have little effect on the management of RA. Available data indicate that methotrexate has at best a neutral effect on predisposition to malignancy. There are data to suggest that the combination of methotrexate a...
Do you discontinue IL-17A, IL-17A/F, or IL-23 blockade in pregnant patients with psoriasis?
I always give my patients the option of discontinuing but put it in perspective. For the most part, my patients do end up stopping, with the plan to restart after delivery. We discuss a few topics: Pregnancy doesn't tend to worsen psoriasis in general, in fact in many patients, it gets better. It i...
How often would you perform an upper endoscopy on an individual with chronic gastritis and previously eradicated H pylori with respect to risk of gastric malignancy?
Endoscopic surveillance of patients with chronic gastritis and previously eradicated Helicobacter pylori (H. pylori) would primarily hinge on endoscopic/histologic features on index endoscopy.Endoscopically and histologically, the presence and extent/distribution of gastric pre-neoplastic lesions no...
Do you recommend genetic screening for FMF in asymptomatic first-degree relatives with a strong family history (multiple family members, severe/refractory disease)?
In the absence of FMF symptoms, it is not necessary to obtain genetics in first-degree relatives of patients with FMF. More critical than genetics is to screen for systemic inflammation and amyloidosis, which I would consider doing. I would check inflammatory markers and urinalysis with urine protei...
What is your approach to maintenance of sotalol in terms of drug monitoring and duration of therapy for outpatients who remain in normal sinus rhythm?
I have a healthy respect for the proarrhythmic potential of sotalol. I routinely load and increase the dose in the hospital setting. Not too dissimilar to dofetilide. I avoid as much as possible other drugs that prolong the QT interval and I use caution with other drugs that slow the HR. I monitor E...
What or where is the best reference guide for managing patients with bipolar disorder who are on meds and want to become pregnant?
Great question! There are a few resources that I find particularly helpful for both patients and providers. The MGH Center for Women's Mental Health Website, https://womensmentalhealth.org/, is a great resource for both patients and clinicians alike. There are speciality specific pages, including o...
Would you ever consider oral doxycycline for treatment of either gram-negative or gram-positive uncomplicated bacteremia?
I would not consider this a first or even second-line option due to the poor serum levels that are achieved. I supposed that this could be used for "mop up" therapy, but in such cases, it's almost as if you are using the doxy to treat yourself rather than the patient.
Do you recommend genetic testing for patients with a family history of polycystic kidney disease and who meet the imaging criteria, but the specific genetic variant in the family is unknown?
This is an interesting and evolving area. I think this is somewhat dependent on a patient's own interest after discussing the following things: In some cases, even with family history and imaging criteria, a genetic diagnosis may not be available from testing (due to inability to detect or perhaps i...
How does your approach to subsegmental PE differ from segmental PE both diagnostically and therapeutically?
My approach to subsegmental PE and segmental PE generally tends to be very similar. I am aware of the CHEST guidelines which indicate patients can safely be observed with subsegmental PE, but like a recent study showed (Rouleau et al., PMID 37531107), uptake of these guidelines is slow and many pati...