Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What patient factors prompt you to consider starting dupilumab in patients with COPD?
The factors I consider are recurrent exacerbations, symptoms despite triple therapy, and an eosinophil count that is greater than 300. What is unclear is the decision regarding chronic azithromycin and/or roflumilast versus dupilumab. It looks like roflumilast was not allowed in the study, and appar...
Do you grade severity of OSA by AHI or RDI?
We recently changed, per AASM guidelines, to reporting both AHI3a and AHI4. Since most sleep-disordered breathing events will qualify with the 3a decision, as it includes arousals, we have stopped reporting an RDI. If there are events that don't meet the 3a hypopnea definition, we might comment on i...
How do you manage psoriasis in pregnant patients?
This really depends on the severity of the disease and the treatment resources available. I always would consider the use of topical corticosteroids if possible, of course. If this is not appropriate, a reasonable next choice would likely be UVB (broadband or narrowband) therapy, if that is accessib...
Do you think that home INR monitoring is a feasible option for elderly, frail patients with atrial fibrillation on VKA treatment, given variations in socioeconomic status and access to care?
Whenever possible, I prescribe home INR monitoring with appropriate equipment. This allows me to monitor my patients on a weekly basis, rather than on a monthly basis at best. Unfortunately, insurance reimbursement is not standard for this equipment, and many patients are unable to obtain it. The ab...
Would you recommend statin initiation in a young adult patient (age < 40) with type 1 diabetes mellitus and LDL cholesterol levels greater than 100 without any cardiovascular risk factors?
The recommendations are to start statins in young adults with type 1 DM if duration of diabetes is over 20 years.
How do you interpret CSF pleocytosis in the context of significant leukocytosis on CBC?
There is no correction factor as there would be for CSF vs serum glucose, for example. A patient with leukocytosis in peripheral blood, for example, due to urosepsis would not always have elevated CSF WBC unless there were concomitant meningoencephalitis. I would consider 100 WBC abnormal for CSF re...
How do you counsel male patients with Androgenetic Alopecia who are trying to conceive about using oral or topical minoxidil?
No specific counseling. There is little evidence that it affects fertility.
What is a reasonable surveillance strategy in terms of preferred imaging modality and frequency of monitoring for suspected AV bioprosthetic stenosis in patients status post SAVR?
Echocardiography is the best way to monitor the valve. Obtain baseline images in the first year after implantation. If baseline function is normal and access to care is good, it is not necessary to image every year in the first 5-7 years. The exception to this would be young individuals in whom the ...
How would you manage a patient with highly active ankylosing spondylitis, iritis and Crohn’s, controlled with weekly adalimumab with co-morbid IgG4RD and intolerance of azathioprine due to elevated LFTs?
There is not a known association between IgG4-RD and IBD or spondyloarthritis. Given that these are rare diseases, it is important to ensure diagnostic accuracy, as the combination of these diseases would be unusual, though not impossible. There are two types of autoimmune pancreatitis: type 1 (IgG4...
How do you approach severe anemia and thrombocytopenia in an elderly patient whose bone marrow biopsy shows hypercellular marrow with mild dysplasia in erythroid and megakaryocytic lineage but normal cytogenetics and a negative NGS panel?
This is a really interesting case! Few things to consider: The presence of a small PNH clone suggests marrow injury however, the marrow is usually hypo rather than hypercellular in this scenario. It may be worthwhile to send HLA typing. The presence of HLA-B14:02, HLA-B40:02, and HLA-B07:02 alleles...