Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For which patients or under which circumstances do you recommend a 9-month over a 6-month course of isoniazid for treatment of LTBI?
The preferred regimens now for the treatment of latent TB infection are shorter rifamycin-based regimens. We have options of 3 months of isoniazid and rifapentine given once weekly, or 4 months of rifampin given daily, or 3 months of isoniazid and rifampin given daily. Isoniazid-only regimens are no...
How would you counsel a female to male transgender patient regarding VTE risk with testosterone therapy, who has additional mild-moderate risk factors for thrombosis?
If physiologic concentrations of testosterone are not exceeded and the hematocrit is monitored to avoid a pathologic level of erythrocytosis, the risk for thrombosis from testosterone GAHT does not appear to in excess of the general population. I would refer you to the following two articles that pr...
What scented alternatives do you recommend patients with fragrance allergies try to replace perfumes/colognes?
My approach is to initially advise for the first 3 months a strict personal care “product elimination diet” free of fragrances, botanicals, and essential oils for patients who test positive to fragrance-related allergens. “Product elimination diet” is a term coined by expert Canadian dermatologist S...
What is your approach to symptomatic superficial thrombosis of the pelvic veins occurring in the immediate postpartum period?
I would strongly consider anticoagulation in this scenario given the high risk of thrombosis in the postpartum period.Generally, there is a low threshold to place patients on prophylactic dose anticoagulation for six weeks postpartum (personal history of thrombosis, inherited thrombophilia) given th...
How would you approach the workup and management of isolated inflammatory subglottic stenosis in a young previously healthy patient that is steroid responsive with a completely negative serologic autoimmune workup?
This is a relatively unusual situation in that idiopathic subglottic stenosis is typically not managed with systemic immunosuppression. The typical therapies are endoscopic and include dilatation (+/- intralesional corticosteroids), endoscopic resection, and cricotracheal resection. A recent large t...
How do you counsel patients with mild congenital myopathy about exercise limitations?
There are many reasons why all patients with muscle disorders should exercise. Many studies have shown improvements in aerobic capacity and some have shown improvements in functional capacity (i.e., 6MWT). Furthermore, many patients with neuromuscular disorders tend to avoid exercise and this is a c...
How can I maximize my efficiency in the clinic?
I have found that my time is better spent if I: 1. Get in an ~hour before official work schedule time period. 2. See all my OTVs on Mondays (or Tuesdays for holidays). I found that seeing them on Thursday or Fridays allows for more visits on the following Monday because of weekend issues. No simulat...
What work up do you recommend for persistent subclinical hyperthyroidism with decreased RAI uptake and negative thyroid antibody tests?
If the RAIU is very low, then this may be subacute thyroiditis. Lymphocytic or silent has no biochemical confirmatory tests. If there is pain, this suggest pseudogranulomatis subacute thyroiditis associated with a high URI and a recent viral infection. The other choice is they have some nodular thyr...
What are the implications of immunosuppressive therapy in a chronic asymptomatic T cell lymphopenic adult undergoing lung transplant evaluation?
The details of T cell lymphopenia are not mentioned for this patient. Idiopathic CD4 T cell lymphopenia is a recognized clinical syndrome which has been studied extensively (Lisco et al., PMID 37133586). The need for lung transplant is not detailed and raises the question if the two are related. It ...
Do you recommend holding ACE inhibitors, ARBs, and SGLT2 inhibitors for patients with chronic kidney disease and malignancy who are about to start high-dose intravenous methotrexate?
This is obviously an opinion-based question since there are no clinical data on this topic. If a patient has risk factors for AKI (underlying CKD, advanced age, low body mass) then it may be reasonable to hold RAAS blockers prior to treatment and resume following the completion of that cycle of high...