Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you think that home INR monitoring is a feasible option for elderly, frail patients with atrial fibrillation on VKA treatment, given variations in socioeconomic status and access to care?
Whenever possible, I prescribe home INR monitoring with appropriate equipment. This allows me to monitor my patients on a weekly basis, rather than on a monthly basis at best. Unfortunately, insurance reimbursement is not standard for this equipment, and many patients are unable to obtain it. The ab...
How do you interpret CSF pleocytosis in the context of significant leukocytosis on CBC?
There is no correction factor as there would be for CSF vs serum glucose, for example. A patient with leukocytosis in peripheral blood, for example, due to urosepsis would not always have elevated CSF WBC unless there were concomitant meningoencephalitis. I would consider 100 WBC abnormal for CSF re...
How do you counsel male patients with Androgenetic Alopecia who are trying to conceive about using oral or topical minoxidil?
No specific counseling. There is little evidence that it affects fertility.
How would you manage a patient with highly active ankylosing spondylitis, iritis and Crohn’s, controlled with weekly adalimumab with co-morbid IgG4RD and intolerance of azathioprine due to elevated LFTs?
There is not a known association between IgG4-RD and IBD or spondyloarthritis. Given that these are rare diseases, it is important to ensure diagnostic accuracy, as the combination of these diseases would be unusual, though not impossible. There are two types of autoimmune pancreatitis: type 1 (IgG4...
How do you approach severe anemia and thrombocytopenia in an elderly patient whose bone marrow biopsy shows hypercellular marrow with mild dysplasia in erythroid and megakaryocytic lineage but normal cytogenetics and a negative NGS panel?
This is a really interesting case! Few things to consider: The presence of a small PNH clone suggests marrow injury however, the marrow is usually hypo rather than hypercellular in this scenario. It may be worthwhile to send HLA typing. The presence of HLA-B14:02, HLA-B40:02, and HLA-B07:02 alleles...
Would you order a fibroscan to screen for MASLD in patients with insulin resistance but normal LFTs?
Suggest that you check the FIB-4 score first.
In patients with diffuse scleroderma and symptomatic lower extremity venous insufficiency, would you recommend treatment with endovenous laser/ablation?
It all depends on the severity of scleroderma and the severity of the venous insufficiency. No one can give an answer to that without knowing those two things.
Is there any benefit to supervised PAD exercise programs in the presence of collaterals seen on angiography for patients with severe claudication and significant lesions?
Yes, exercise benefits for claudication are more about muscle training and metabolism and general physical conditioning than building of collateral circulation.
What is your approach to the use of Paxlovid for patients with risk factors for severe Covid-19 infection but who have received SARS-CoV-2 vaccines in light of the EPIC-SR trial findings?
Although EPIC-SR Trial may not have shown a significant benefit of paxlovid in standard-risk patients regardless of vaccination status, EPIC HR and real-world evidence have shown benefits in high-risk populations. Shared decision-making with the patient is always the best policy.Disclosure: I have r...
Would you favor stopping low-dose aspirin and continuing OAC alone in a patient with atrial fibrillation and mild coronary artery calcification seen on routine chest imaging?
Absolutely, most of the patients that I would treat with dual-antithrombotics (as opposed to dual antiplatelet plus/minus anticoagulant), have had clinical events. Most commonly MI and/ or stent plus atrial fibrillation. Your patient has one clinical event (AF) and another "subclinical" condition.