Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?
I am unaware of any published data to guide the decision-making for this topic. Empirically, I recommend low-dose aspirin in patients >50 who have to get long-term IVIG especially if there are a lot of underlying risk factors for thrombosis like diabetes, immobility, etc. Again, this is not an evide...
What criteria do you use to decide when to perform a BAL in hypersensitivity pneumonitis?
Short answer: When the vibes are right. I know that's a flippant answer, but that's an honest-to-God real answer. Long answer: This is really complicated and personally, I'm frustrated by our guidelines and the level of evidence we have for diagnosing HP. To answer the question, it's worth delineati...
Are there any varying treatment considerations to make when managing patients with carbonate apatite versus hydroxyapatite kidney stones?
Both of these stone types require a relatively alkaline urine to crystallize. Not surprisingly, they are often found in combination within the same stone. My diagnostic and treatment considerations do not depend on which mineral composition predominates. Stephen B Erickson, MD
How do you use CD4% in clinical practice in management of patients living with HIV?
Perhaps a slightly different perspective: The CD4 percentage is invaluable in specific scenarios. Since the absolute CD4 count depends on the total WBC count and the lymphocyte percentage, the CD4 count can vary widely based on context, while the CD4 percentage is typically the more stable and relia...
How do you utilize cytokine panels in your clinical practice?
It's become easier to order cytokine panels that get processed locally in my hospital. However, I think we're still far from knowing how to interpret these or make clinical changes as a result. While it's tempting to think, "If TNF is elevated, I will give the patient a TNF inhibitor, which will mak...
Is it better to give dose 2 of the mRNA 2024-2025 Covid-19 vaccine at month 2 or month 6 after dose 1 in moderately immunocompromised patients?
This is a complicated question and unfortunately, we have no clear answer for it based upon clinical outcome data. The COVID-19 pandemic has changed dramatically since its inception over 4 years ago. Based on a combination of favorable viral evolution of diminishing pathogenic potential continuing t...
What dosing range of spironolactone do you prescribe for hormonal acne?
I most commonly prescribe 50-100mg daily, but I may titrate up to 150mg occasionally as needed. I prefer QAM dosing to minimize diuresis in the evening. I find that starting at 25mg and up-titrating by 25mg weekly leads to better tolerability, especially when it comes to orthostasis and dizziness.
Do you make any changes to surveillance imaging frequency, 24 hour urine stone risk collection frequency, and stone preventative medication approaches for patients with recurrent nephrolithiasis who become pregnant?
Pregnancy is a lithogenic state. Stone passages peak in the second trimester. I avoid imaging that involves radiation. I monitor with ultrasound. I prefer to withdraw prescription medication and manage stone disease with diet and fluid therapy. Certainly, there are exceptions to this rule. Encouragi...
What additional treatment strategies would you recommend for a patient with a Mycobacterium chelonae and Mycobacterium abscessus infection following bilateral prophylactic mastectomies and implant insertion, who has undergone multiple surgeries and an extended course of IV antibiotics selected based on sensitivities?
I assume the implants have been removed. I have had no success trying to treat with retention of the implants (because the patients all want a trial of antibiotics first at the suggestion of the surgeon). If the implants are out, all you can do is continue long courses of antibiotics based on sensit...
Do you follow LFTs in patients on tamoxifen as suggested in the prescribing guidelines?
I check LFTs about every 6-9 months for patients on tamoxifen. In my practice, most patients with an LFT abnormality will have a G1 AST or ALT abnormality when it is discovered. Therefore, this seems to be frequent enough. If LFTs are abnormal, then I hold tamoxifen, and LFTs usually improve or norm...