Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are there instances when you would recommend obtaining a 24 hour urine protein measurement in place of spot urine protein studies in patients with acute kidney injury and proteinuria?
I would look at the urinalysis and if there was dipstick proteinuria, I would get a spot protein creatinine ratio (PCR) and a simultaneous albumin creatinine ratio (ACR), just to get some idea if I am dealing with a glomerular or tubular cause of AKI. These tests are not reliable from a quantity sta...
Do you caution against starting biologics for psoriasis if patient has hepatitis A antibodies?
No
What is the diagnostic utility of ordering an "Early Sjogren's Syndrome Profile", which tests novel autoantibodies, to support a diagnosis of Sjogren's syndrome in patients who test negative for SSA/SSB?
Currently, there is not much diagnostic utility to ordering these novel autoantibodies in patients who are negative for SSA/SSB as it is unclear how to interpret the results. In a mouse model for Sjogren's (Shen et al., PMID 23123440), these novel autoantibodies appeared earlier in the course of dis...
Does aspirin dose (81 mg vs 325 mg) matter for secondary stroke prevention?
This topic has been debated extensively. There are two camps in this debate: Aspirin with a dose of 81 mg is adequate for platelet inhibition in the general population. Aspirin with a dose of 325 mg may be needed for individuals who weigh more (>70 kg) to achieve appropriate platelet inhibition. T...
When do you consider discontinuing Pegloticase in a patient with tophaceous gout who has had excellent response to therapy?
This is an important question to clinicians who use pegloticase for their severely afflicted gout patients. There are no studies that provide guidance to answer this question but there is a good rational approach to knowing when to stop treatment.To recap, pegloticase therapy is indicated for patien...
Is there any indication for hydroxyurea in patients with sickle cell trait?
No. Of course, be sure it is the correct diagnosis and not HgA + HgS (beta+) which, as you know, shows HgA and HgS on electrophoresis and can/will be called trait if not looked at by someone experienced to note if A> S or if S > A. If MCV is low. If HgA2 is up. HgF up etc... If indirect Bili/LDH/AST...
Would you start anticoagulation in a patient with provoked blood clot in the past now with labs done for rheumatological reasons showing triple positive APLA?
The short answer is that I would probably not anticoagulate this patient as a history of prior thrombosis is hard to connect to the currently positive APL antibodies. I would certainly obtain a second set for future risk stratification. However, there are several variables that could influence the ...
Do you recommend patients discontinue spironolactone after a certain number of years?
In general, I think Spironolactone is a fabulous treatment for women with hormonal/stress-induced acne. I am cautious in women with reproductive potential. I also have been careful in prescribing it to women with a history of breast cancer.
How do you manage acne relapses after isotretinoin?
This is a good question, and the answer depends on several factors, the most notable of which is the severity of the relapse. Oftentimes, the relapse is not as severe as the original outbreak for which the original isotretinoin course of therapy was prescribed. When this is the case, I start with co...
In your experience, what has been the most effective form of field therapy for your patients with higher burdens of actinic keratoses?
For severe field disease in patients who have had multiple squamous cells, we typically use calcipitrione combined with 5 FU mixed one to one twice daily for 7 days on the face and 10 days on the scalp, hands, and arms. We give patients a portal to phone in photos on day 3 day 5 and day 7. When we u...