Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Have you been able to safely use other bisphosphonates in patients who developed an allergic reaction (angioedema) to fosamax?
Hypersensitivity with urticaria in someone on alendronate is quite rare. I am not aware of any publications showing another bisphosphonate safely used in this setting. Although there are significant chemical differences between the various oral and IV bisphosphonates, I personally would avoid the en...
Is there any indication for monitoring for renal medullary carcinoma in patients with sickle cell trait?
Hematuria occurs episodically in approximately 5% of people with sickle cell trait. Although often recurrent and sometimes producing anemia, the causes of hematuria are usually benign and it is self-limited. Medullary carcinoma of the kidney is a rare highly aggressive tumor that occurs almost exclu...
Do you recommend shingles vaccine to all immunosuppressed patients under the age of 50 y.o.?
This is an interesting question. Clearly, patients with autoimmune or immune-mediated diseases because of their immunosuppressed status are at an increased risk of H. zoster, regardless of age. Presently, the recommendations from the CDC, different professional societies, etc., are to immunize patie...
At what serum bicarbonate level do you initiate alkali therapy for patients with chronic kidney disease?
I find that there is a lot of variability between different laboratories in their serum CO2 levels. As such, I don't think this is a one-size-fits-all all situation. At my lab, which tends to have higher CO2 levels, I start bicarbonate therapy once the serum CO2 level is at or below 20 mEq/L.
What nutritional supplements do you recommend for patients with hair loss?
Protein 30-40 grams a day. These skinny dieters who only eat fish aren't getting enough. I do check iron and ferritin and get ferritin to at least 50, even 60-70 for shedding hair. I really like untangled by foundation skincare.
Do you treat Candida spp isolated from a bronchoalveolar lavage?
I would only treat if there was evidence of Candida infection from another source/location (at the same time).
Are there patients who can forgo anticoagulation with asymptomatic, incidentally discovered subsegmental pulmonary embolism?
Of note, there are two ongoing clinical trials that should hopefully provide further data on the definitive management of SSPE (NCT01455818, NCT04263038).
How do you approach evaluation and management of a patient with recurrent monoarticular inflammatory arthritis of unclear etiology?
Routine testing will not identify Lyme disease although the WBC count is higher than usual. If the antibiotic does not target B burgdorferi recurrence might mean inappropriate therapy previously. WBC count WAAAY too high for mere trauma or internal derangement. Anything else to suggest psoriasis? Lo...
How do you approach mild prolactin elevations (20-80) in women with galactorrhea on nipple stimulation but regular menses and no plans for pregnancy?
I get baseline MRI of the sella and then monitor prolactin every 6-12 months. I don't treat unless the patient develops symptoms.
What is your approach to transitioning an SLE patient from a pregnancy incompatible regimen to pregnancy compatible regimen?
There are no clear data on how to do this. One study (Fischer-Betz et al., PMID 23382355) transitioned patients by reducing the MMF by 500mg/d dosing every four weeks and then stopping MMFo once the patient is down to MMF 500mg/d and adding azathioprine 2mg/kg. In my clinical practice, I taper faste...