Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach in differentiating IPAF (interstitial pneumonia with autoimmune features) versus "CTD ILD" in patients with serologic abnormalities but do not fulfill criteria for autoimmune disease?
Even for those of us who work in ILD clinics, this can be a challenging issue. The concept of IPAF (interstitial pneumonia with autoimmune features) was developed in 2015 jointly by the ATS and the ERS for study purposes and as such is somewhat helpful in the clinic. Much like classification criteri...
What is your approach to weight loss interventions for patients with recurrent nephrolithiasis and obesity?
Obesity tends to be a little more common in stone formers. Integrating weight loss with stone prevention features can be tricky. We are fortunate to have a dietitian dedicated to our Stone Clinic and I rely heavily upon her expertise. More fluid, preferably water, and a diet tailored to the patient’...
What do you do if a patient with ADHD on dexamfetamine for many years develops Alzheimer's disease?
The issue with the diagnosis of ADHD is that adult-onset ADHD particularly, in my opinion, has major validity problems including a wide differential diagnosis, with no biomarkers. Also, it is now thought that Alzheimer's disease has a long prodrome (15-20 years) from being asymptomatic to having pro...
Do you consider late latent syphilis adequately treated if a patient receives a 10-14 day course of IV ceftriaxone for another indication?
This is a great question and not uncommon scenario. First, I would emphasize the importance of accurately staging the patient as 'late latent' and be sure there are no current signs or symptoms concerning for neurosyphilis, ocular, or otic (even before the IV CTX was given). Having said that, the bo...
What infectious prophylaxis do you use for patients with newly diagnosed multiple myeloma?
Excellent question for sure. In order of controversial nature/lack of evidence/lack of consensus around evidence: 1) Antiviral prophylaxis - I don't think there's any controversy around this, particularly in patients on PIs and/or a CD38 mAb. We do use acyclovir even in patients who have received th...
How do you approach antidepressant choices for patients with generalized anxiety disorder when the patient reports excessive sedation on low doses of SSRIs?
We forget that bupropion, despite systemic misconceptions, has a very good anxiolytic effect. It is the darling of the centers treating refractory anxiety disorders.
How do you approach the use of metformin in the management of prediabetes for patients who are neither obese nor have a family history of diabetes?
When considering the approach to a patient with a diagnosis of pre-diabetes, I think it is important to be sure the patient actually meets criteria. Most of us screen patients at risk with A1C levels because it is so much easier. However, A1C levels do not fully correspond to glucose levels and may ...
When do you recommend using trabecular bone score (TBS) for managing osteoporosis?
Trabecular bone score is a valuable tool in the evaluation of osteoporosis and risk of fracture. It is an indirect indicator of bone microarchitecture. Although TBS predicts fracture risk, it should not be used alone but in conjunction with BMD for deciding whether to treat the osteoporosis and if s...
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
How do you approach follow up of young patients with isolated +ANA, but no current clinical signs or symptoms of SLE?
An old study showed that ANA can be positive in patients who develop lupus up to 9 years (average 3 years) before the onset of clinical disease but it was not necessarily isolated ANA as Ro and La antibodies could also be detected long before the onset of the disease (Arbuckle et al., PMID 14561795)...