Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach for disease activity monitoring in patients with sarcoidosis?
Disease activity monitoring is useful in managing therapy and prognostication in sarcoidosis. Since the disease activity can vary across different organ systems, it can be a challenge. Broadly, good bio-markers of overall disease activity are lacking in this disease.ACE level lacks the sensitivity b...
Do you recommend dietary changes to your patients with recurrent kidney stone disease who consume coffee and low oxalate teas daily?
Thank you for your question. Many patients get tired of drinking water and would prefer coffee, low-oxalate tea, or other beverages instead. Studies have shown no difference in whether the water is hard or soft. Coffee and low oxalate tea do not seem to increase stone passage either. There is some d...
Is it safe to continue administering Prolia per schedule for osteoporosis treatment shortly after a patient has undergone extensive spinal surgery?
There is no evidence that spine surgery is a contraindication to receiving Prolia. If the bone was incised, Prolia could help healing.
What have you found to be effective for keratosis pilaris?
The best treatment for KP is time. With age KP improves on the face, forearms and legs during and after puberty. Natural oil production on the face is likely the reason for improvement in this area. Natural terminal hair growth on the legs/forearms likely improves KP in these areas. Posterior upper ...
What are reasonable next steps in the work-up of suspected ATTR amyloidosis if the PYP scan is equivocal, in light of the potential risks of endomyocardial biopsy?
Before addressing the next move after an equivocal PYP scan, some comments on PYP scan reporting are in order. Unfortunately, despite the relative simplicity of obtaining a high quality PYP scam, around 10 -20% of the ones that we see done at outside institutions (including teaching institutions) ar...
What is your approach to maintenance treatment in a patient with Sjogren's who received rituximab for mononeuritis multiplex?
The data supporting the use of maintenance DMARDs, in this scenario, is limited. On the other hand, there is some evidence that relapse is common. Therefore, agents such as Azathioprine, MFM or maintenance Rituximab, should be considered, akin to the management approach for ANCA vasculitis. Managing...
What is your strategy for treating headaches in patients with history of brain tumor?
Not all headaches in patients with brain tumors arise in the context of elevated ICP, but there are other mechanisms (dural irritation, traction on blood vessels, post-craniotomy pain, for example) by which they can be related. If the headache otherwise seems migrainous, I would treat it as migraine...
What patient-specific factors would influence your decision to initiate semaglutide therapy in patients with HIV-associated lipohypertrophy?
I would consider it if the patient had diabetes. But there is not much data on this question.
Is it possible for certain individuals with osteoporosis to be a denosumab "non-responder"?
As far as I know, there are non-responders to every drug. There are 2 considerations that you should particularly consider, and which you could address. First, does the patient have an unrecognized secondary cause for low bone mass or fracture? It is really important to reevaluate a patient who is n...
How do you manage incidentally identified pituitary lesions on brain imaging?
Pituitary lesions are among the most common incidentalomas seen on brain MRIs. Various studies cite numbers as high as 10- >30% for pituitary lesions found incidentally on brain imaging, with the higher incidence rates emerging in the era of high-resolution MRIs. In pediatric neurology/neuro-oncolog...