Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What are reasonable alternatives to invasive angiography for CAV surveillance in patients who are a few years out from cardiac transplant with impaired renal function?
In our practice, we move to PET-CT on Year 3 if the prior 2 angiograms with IVUS did not show accelerating disease. The issue with CAV is that there is not much to do about it reactively. The best you can do, is switch to an mTORi regimen early and optimize lipids. IVUS is useful for that reason. Be...
How do you manage nephrotic range proteinuria in a pregnant patient with a known history of diabetic nephropathy prior to pregnancy?
Interesting question. Part of this depends on what one thinks of the etiology of the nephrotic syndrome. With a history of diabetic nephropathy, the odds are this is a continuation/natural worsening of the underlying diabetes, and hence there is no specific therapy exists. Hence, a renal biopsy woul...
Which class(es) of antihypertensives do you recommend for first-line therapy for hypertension in severe aortic stenosis?
Most beneficial data on ACE inhibitors.B blockers are to be avoided if associated AR but prior apparent contradiction is no longer valid and some benefit in outcomes based on their effects. Exact Aortic Stenosis substrate and comorbidities to determine which drugs to benefit. ARB's role is probably ...
What treatment would you offer a patient with extensive lymphangioma circumscriptum intermittently covering the entire abdomen?
I would consider sirolimus (rapamycin) to shrink the lesion to a size that could be surgically excised.
What is your approach to differentiating diabetes insipidus from primary polydipsia in the outpatient setting?
I usually do overnight dehydration tests for 12 hours and if fasting AM urine osmolality is >600 DI is less likely. If urine osmolality is low with high serum sodium it indicates DI, whereas with primary polydipsia the serum sodium is low with low urine osmolality.
What is your approach for severe SCLE in patients unable to tolerate HCQ?
30% of subacute cutaneous lupus erythematosus (SCLE) is worsened by or caused by drugs, especially PPIs, calcium channel blockers (CCBs), thiazides, minocycline, and anti-fungal meds. Very different from other drug-induced disorders, the culprit drug could have been started months to years (as long...
What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?
I am unaware of any published data to guide the decision-making for this topic. Empirically, I recommend low-dose aspirin in patients >50 who have to get long-term IVIG especially if there are a lot of underlying risk factors for thrombosis like diabetes, immobility, etc. Again, this is not an evide...
Are there any varying treatment considerations to make when managing patients with carbonate apatite versus hydroxyapatite kidney stones?
Both of these stone types require a relatively alkaline urine to crystallize. Not surprisingly, they are often found in combination within the same stone. My diagnostic and treatment considerations do not depend on which mineral composition predominates. Stephen B Erickson, MD
How do you use CD4% in clinical practice in management of patients living with HIV?
Perhaps a slightly different perspective: The CD4 percentage is invaluable in specific scenarios. Since the absolute CD4 count depends on the total WBC count and the lymphocyte percentage, the CD4 count can vary widely based on context, while the CD4 percentage is typically the more stable and relia...
How do you utilize cytokine panels in your clinical practice?
It's become easier to order cytokine panels that get processed locally in my hospital. However, I think we're still far from knowing how to interpret these or make clinical changes as a result. While it's tempting to think, "If TNF is elevated, I will give the patient a TNF inhibitor, which will mak...