Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What are some of the biggest challenges you run into when patients transition from pediatric to adult care?
Expectations – the pediatric health care system tends to have more resources readily available to assist patients (e.g., social work, child life, psychology, pharmacy) and appointment times tend to be longer. In the adult world, resources may be less readily available and appointment times shorter....
When would be your threshold to consider obtaining an exercise RHC for undifferentiated dyspnea to help diagnose HFpEF?
When to Consider Exercise Right Heart Catheterization (RHC) for Diagnosing HFpEF in Patients with Undifferentiated Dyspnea: Persistent, Unexplained Dyspnea: Clinical Context: Exercise RHC is indicated in patients with persistent dyspnea not explained by common conditions such as chronic obstructiv...
What is the recommendation for women with migraine with aura who are planning to undergo IVF hormone therapy?
I would not change my migraine management approach. With pregnancy planning, I would avoid medications that are not recommended in pregnancy. I would counsel on the safety of different acute and preventative treatments in pregnancy.
In light of the NOAH-AFNET6 and ARTESiA trials, how would you approach the decision regarding anticoagulation for patients with incidentally-detected AF <24 hrs on pacemakers/defibrillators?
Finding the right answer for subclinical atrial fibrillation is sometimes hard to tease out the subtleties. The 2023 ACC/AHA/HRS atrial fibrillation guidelines were published in Jan 2024 (Joglar et al., PMID 38033089) and a section (6.4.1) is dedicated to patients with CIED without prior atrial fibr...
How do you manage significant asymptomatic indirect hyperbilirubinemia in patients with hemolytic diseases (SCD, HS, etc.)?
Hello, Indirect bilirubin is from hemolysis, not cholestasis (a few exceptions from rare syndromes), so not associated with stones, and would not expect ursodiol to help. It's a marker of how bad the sickling is - along with LDH, reticulocyte count, and MCHC (which measures cell density, i.e., irrev...
What is your approach to the workup for an underlying systemic condition in a patient presenting with retinal vasculitis?
Retinal vasculitis is a frequently misunderstood condition. My colleagues and I have written about it on several occasions such as in Current Opinion in Rheumatology, 2016. Retinal vasculitis is often diagnosed by an ophthalmologist on the basis of vascular leakage in a test called a fluorescein ang...
Should all kidney transplant patients be started on statin therapy post operatively given their increased risk of CVD?
A kidney transplant is not an indication for statin therapy per se. The 2018 cholesterol guidelines list CKD (but not ESRD or Transplant) as a risk-enhancing factor. I would guide the decision to use statin therapy based on the patient's risk as assessed for non-transplant patients. Having said that...
What lab markers are helpful for monitoring polymyalgia rheumatica patients on tocilizumab?
Based on the evidence supporting the use of tocilizumab (TOC) for the treatment of GCA, a number of small clinical trials have presented early data regarding its use for the treatment of PMR. Before we all jump on this bandwagon, we should carefully review the rationale for using TOC to treat PMR.Fi...
Do you recommend a daily B complex multivitamin for patients with end stage kidney disease who are receiving peritoneal dialysis?
When it comes to Vitamin management in my dialysis patients I defer to my RD, Diane Mettler, who has decades of experience and knows this material better than I ever will. Diane says “I recommend a daily renal vitamin on PD, due to the losses of B-vitamins with dialysis. That being said, if the pati...
What patients with food allergies do you screen for EoE?
If a patient has symptoms of esophageal dysfunction, they should be screened for EoE. Because symptoms can be ill-defined in children, this may be more challenging. Growth failure, unexplained abdominal pain, or vomiting are indications for GI referral with consideration for endoscopy. Indiscriminat...