Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend the use of GLP 1 R agonist therapy for obese women with PCOS who are actively trying to conceive?
This is a very relevant question. GLP 1 RA therapy is recommended by the recently published International Consensus Guideline in Management of PCOS for assistance with weight loss in combination with lifestyle modification (Teede et al., PMID 37580314). The guideline states that this should be done ...
Have you seen drug induced SCLE from IL-17 inhibitors?
Fortunately, drug-induced subacute cutaneous lupus erythematosus (diSCLE) induced by IL-17 inhibitors is rare. I have never seen a case, but there are at least 3-4 cases in the medical literature (from brodalumab, ustekinumab, and secukinumab: Ang et al., PMID 33511692, Tierney et al., PMID 30891478...
How do you manage patients with hand dermatitis recalcitrant to potent topical steroids?
Strictly dorsal/interdigital = irritant contact derm Purely palmar = atopic (should not be using the term "dyshidrosis" any longer Both palmar and dorsal = allergic contact derm If irritant, most important things, according to data from Covid, are: Washing hands in cold water Avoiding soap and wa...
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
In patients undergoing MRI evaluation for inflammatory back pain, how long do you recommend they hold NSAIDs prior to imaging?
The other issue regarding NSAIDs and MRI is whether these agents will suppress the bone marrow edema signal which has been demonstrated in some patients. Therefore, it is recommended to hold NSAIDs for at least 3 days prior to the MRI.
Would you recommend a neck soft collar after a cervical internal carotid artery dissection?
I would sincerely doubt that would have any benefit. Avoiding more strenuous or sudden trauma would be more appropriate.
Would you recommend a CT venogram or MR venogram in patients with concern for venous sinus thrombosis?
Either modality is suitable for assessing CVST. However, I typically prefer CTV. It's easier to obtain and has a quick scan time, which reduces the chances of motion artifacts. MRV provides better resolution, but it requires a screening form and has a longer scan time, which may lead to motion artif...
Do you recommend any particular type of contraceptive use in young patients with strokes of unclear etiology?
The safest choice would be a progesterone-only method. If a combination must be used, the lowest estrogen option.
What workup do you perform for elevated B12 levels in an adult who is not taking supplements?
There is no convincing evidence of the harmful effects of elevated serum B12 per se, so I have not vigorously pursued this lab finding. If excessive supplements are consumed, B12 is innocuously excreted in the urine once tissue receptors are saturated. Nonetheless, this question raises some interest...
Is there a correlation between spleen size and degree of thrombocytopenia?
In a normal individual, approximately 1/3 of total body platelets are sequestered in the spleen at any given time. As the size of the spleen increases, so too does the proportion of platelets in the spleen increase. This is due to the total volume of the spleen, not just longitudinal measurement. It...