Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How long do you treat retroperitoneal fibrosis with immunosuppression?
I normally treat for 9 months to a year depending on response. I have found PET CT useful in determining if there is active ongoing inflammation.
How would you approach secondary stroke prevention in an adult with Hemoglobin SC disease?
Stroke is less common in HbSC disease than it is in HbS homozygotes (Ohene-Frempong et al., PMID 9414296). Thus, there are no studies focused on primary or secondary stroke prevention in HbSC disease. Recent guidelines for stroke management were “silent” on stroke in HbSC disease (DeBaun et al., PMI...
What is your approach for steroid dosing for patients with ANCA vasculitis on induction treatment with rituximab, avacopan, and glucocorticoid therapy?
I do not personally have a one-size-fits-all approach. Remember that ADVOCATE had a screening window of up to 2 weeks where many patients got steroids before they were randomized. At the time of randomization, patients had to be on less than 20mg of prednisone which was tapered over 4 weeks.In addit...
What is your approach to de-escalation of asthma therapy if patients have remained clinically stable on triple inhaler therapy and a biologic agent?
Since the reason most folks need biologics is prednisone and considering the side effects, getting patients down to the lowest dose is beneficial.
How do you treat CTD-associated organizing pneumonia?
The approach to CTD-associated organizing pneumonia is similar to that of CTD-associated NSIP and involves treatment with glucocorticoids and steroid-sparing agents. The evidence for the choice of steroid-sparing agents is extrapolated from clinical trial and observational data from systemic scleros...
What is the typical timeline for remission of autoimmune hypoglycemia?
Insulin autoimmune syndrome (IAS) or Hirata disease is a rare disorder characterized by hypoglycemic episodes due to the presence of high titers of insulin autoantibodies (IAA). The disease was first described in 1970. Because of its rarity, large clinical experiences with this disorder are limited....
How do you counsel patients with ALS on the benefits of enteral nutrition?
I agree with Drs. @Dr. First Last and @Dr. First Last but what I find frequently is that patients are reluctant to have PEG because of a number of psychological factors; fear of the surgery, fear of having a tube, fear of disease progression, fear that it will keep them alive indefinitely as in the ...
What is your approach to GDMT uptitration (particularly dosing for ARBs/ARNIs/MRA) if there is further evidence of renal dysfunction, especially in situations with worsening AKI on CKD?
Titration of RAAS inhibitors in the setting of AKI on CKD is challenging. First, look at the patient: if they have an increase in Cr after an increase in the RAAS inhibitor but no/stable HF symptoms and appear euvolemic on examination, then I will decrease diuretic therapy and see if the Cr improves...
When do you recommend genetic testing in patients with neuropathy?
I would do genetic testing in any chronic progressive polyneuropathy that defies explanation after routine lab testing and is associated with at least one of the following features: positive family history early onset (<35-40) abnormal foot appearance-pes cavus, hammertoes motor predominant symptom...
What imaging do you recommend for patients with suspected CSF leak?
I recommend getting an MRI brain.