Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients on vaping cessation as compared to smoking cessation?
Presently, evidence-based approaches to vaping cessation are not well-developed. Thus, one should approach nicotine vaping cessation in a similar way to tobacco smoking cessation using a stepped care approach. Motivation to quit (versus reduce) use should be assessed and motivational counselling tec...
What treatment modalities have you had success with for treating recalcitrant warts?
More than digital warts, I find plantar warts challenging to treat. This is my usual approach: Paring down warts on feet. Multiple rounds of cryotherapy every 4-6 weeks. Between cryotherapy sessions- use of topical 5-FU with 40-70% salicylic acid After 3 rounds of cryo- if still persistent- IL Cand...
How do you approach restarting cDMARDS/bDMARDS in a patient with active RA after incidence of disseminated CNS VZV infection while on tofacitinib?
This is a complex problem for which any response clearly is not data-driven. Disseminated VZV is a profound illness and is linked to JAKi exposure. While the majority of VZV is 'mild' all complications are increased in this setting and dissemination is among the most serious and potentially fatal co...
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
Under what circumstances do you recommend targeting a systolic blood pressure of less than 120 mmHg in a patient with CKD?
I am going to deviate a bit from the KDIGO recommendations here, and will try to document my reasons. The SPRINT trial, which was the largest BP target trial for individuals with CKD, did not enroll individuals with an eGFR < 20. The automated office BP measurement used in SPRINT is still not standa...
Would you accept the diagnosis of SLE on the basis of an AVISE CTD panel where the results just showed a positive EC4d or BC4d, positive ANA>1/80 + one clinical criteria such as multiple tender joints but did otherwise not fulfill criteria for SLE?
The answer is "Yes and No."@Dr. First Last: I am so glad you asked this question. I once observed a speaker give incorrect information on this topic with an answer of "yes."The quick answer, is that the AVISE Lupus Test (which uses EC4d and BC4d) result does NOT give a "yes" or "no" answer for someo...
When do you restart antiplatelet therapy in patients with hemorrhagic conversion of stroke?
This is a great question and not an uncommon clinical encounter for stroke neurologists. Indeed there is no one right answer. First, you may want to make sure that the observed ICH is true transformation of an ischemic lesion. Second, the degree of hemorrhagic transformation matters, I totally agree...
Would you change treatment approach for rectal cancer with an associated intussusception?
If the patient has obstruction, I probably would favor surgery first. If not, then I'd treat it as usual. It's a judgment call though.
When do you incorporate Lyrica into the treatment strategy for patients with restless leg syndrome?
When it comes to treating RLS, my go-to medication is gabapentin. I rarely (and possibly could say never) prescribe dopamine agonists. Once you've treated one patient with augmentation and have seen the overwhelming discomfort it can cause a patient, you would likely feel how I feel about the dopami...
After completing 12 months romosozumab, what is the next best treatment option for patients with severe osteoporosis, high risk for fracture, and normal kidney function?
Zoledronic acid is my clear-cut first choice in this setting.