Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What steps do you recommend to ensure continued viral suppression and prevent drug resistance in an HIV patient on injectable cabotegravir and rilpivirine who misses their scheduled injection appointment by two weeks?
When the patient returns to clinic, I would check an HIV VL and CD4 count and simply restart the same ART (cabaneuva). If the VL comes back high then resistance testing should be performed and the ART can be adjusted.
What additional studies would you obtain for a patient with end stage kidney disease on hemodialysis who has persistent hypercalcemia and low PTH?
No studies or measures until I got the patient off Vit D, sensipar, and possibly Ca-based binders, and watched for a couple of months to see if PTH came up and hypercalcemia resolved. This is typical adynamic bone disease until proven otherwise.
What is your approach to management of radiation-induced bullous pemphigoid?
Bullous Pemphigoid (BP) is a pruritic autoimmune blistering disease characterized by tense bullae that is rarely caused by radiotherapy. There have been >30 reports in the literature related to RT with most being localized to the radiated location, with rare reports of BP at non-irradiated sites or ...
How do you interpret negative HMGCR antibody test results in a patient with necrotizing myopathy who has already been on treatment with steroids and whose CK has normalized?
HMGCR antibodies tend to remain present over time, even during periods of disease remission. Only recently have we began observing negative results in patients undergoing long-term treatment. Therefore, considering the patient received steroids for only a brief period, it's reasonable to suspect tha...
What is your management strategy for patients with positive lymph nodes after radical prostatectomy?
There is a good retrospective study from Milan that shows considerable benefit to postoperative radiation therapy for node postive patients. DaPozza et al published this in "European Urology 55 (2009) 1003–1011". Their conclusions state: "Our data showed excellent long-term outcome for node-positi...
Which patients would benefit most from teplizumab therapy to delay the onset of T1DM?
First, for full disclosure, I am an adult endocrinologist and I have not prescribed teplizumab so what I will say is what I have distilled from reading the literature and discussing this topic with colleagues.Teplizumab was approved for use in a very narrow category of patients with a relatively sma...
How early do you involve palliative care in the management of a CKD Stage 5 patient who does not wish to pursue renal replacement therapy?
I tend to refer as soon as they are clear that they do not want to pursue renal replacement therapy for a couple of reasons: (1) By CKD 5, even if they do not have uremic symptoms, it is nice to establish longitudinal care with palliative care so that there is a strong relationship with trust when p...
What are common indications for ordering NGS of peripheral blood?
I am delighted that someone posed this question because, in my experience as a consultant hematologist, it appears that advances in DNA sequencing technology have outstripped the knowledge base of many practitioners. This is not due to lack of interest or due diligence on their part, but rather beca...
How significant are the cardiovascular side effects, such as hypertension, associated with valproate?
I do not routinely think of cardiovascular side effects, especially HTN, as being a major factor with valproate. I think of things like cardiac conduction changes are associated with sodium channel blockers much more frequently, such as lacosamide.However, as a result of this question, I found this ...
Is history of GBS a contraindication for all future flu vaccines?
In my opinion, the answer is no. Numerous studies have been published about this topic. Based on a recent review (see below): The additional risk for GBS attributed to influenza vaccination is 1-2 cases per million of vaccinated individuals. The risk of GBS following influenza INFECTION is several o...