Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Have you applied the POET trial to clinical practice?
I do transition to oral therapy after clinical stability, resolution of systemic inflammatory response and blood culture negativity have been achieved. I have long operated on the principle that it doesn’t matter how (IV or oral administration) the antibiotic gets into the bloodstream as long as it ...
Given recent data for use of doxycycline as post-exposure STD prophylaxis, how have you applied its use in clinical practice?
Doxycycline as POST-exposure prophylaxis for bacterial STI prevention is the hottest thing in STI prevention. It's good at preventing syphilis and chlamydia (approximately 80%) and okay at preventing gonorrhea (approximately 50% depending on background resistance). Here is the landmark study:Luetkem...
Would you recommend genetic testing to determine if there is a potential underlying primary process in a patient with congenital solitary kidney who is presumed to have secondary FSGS?
I do recommend genetic testing more frequently especially at our institution in which the cost to the patient is minimal to none. I would imagine very rarely one finds a positive genetic test result but one never knows what we find until we do the testing.
Is febuxostat a safe alternative for patients who are HLA-B*58:01 positive and of Han Chinese descent?
Cutaneous reactions to allopurinol range from the mild to the very severe and life-threatening such as Stevens-Johnson's Syndrome (SJS) and toxic epidermal necrolysis. The association of these reactions is so strong as to have its own acronym, AHS, for the allopurinol hypersensitivity syndrome.These...
When do you re-image patients with a diagnosis of venous sinus thrombosis?
My practice is to perform early reimaging, typically at around 2 weeks, before transitioning from parenteral anticoagulation to oral anticoagulation. This early reassessment is important as recanalization processes begin early and are linked to clinical outcomes. Subsequent imaging at 6 months is al...
Do you generally recommend low dose aspirin for patients with giant cell arteritis?
I generally do not use aspirin routinely in patients with GCA. While several retrospective series suggested a benefit to ASA for preventing ischemic complications in GCA (e.g. Nesher et al., PMID 15077317), this data is limited by its retrospective nature, small numbers, and significant confounding....
What is your approach to patients with recurrent nephrolithiasis and hypercalciuria who take daily calcium supplements?
Calcium-based stone disease and osteopenia/porosis commonly occur together in postmenopausal women. Calcium supplements are the basic treatment for osteopenia/porosis but may aggravate stone disease in hypercalciuric patients. My approach is first to ask our Stone Clinic dietitian to estimate the pa...
What is your approach to management of chronic recurrent parotitis in patients with Sjogren's Syndrome?
Uncommon, however, I consider chronic infection/reinfection, especially in setting of significant immunocompromise or severe dental/periodontal disease. Secretion from stensen duct os can be cultured.Salivary duct stones can be detected by ultrasound if ~ >2mm, and duct dilation seen.Especially if c...
Should fasting C-peptide levels be used to guide T2DM management?
For most patients, it is not necessary to measure C-peptide to make treatment decisions. However, it is important to remember that ~5% of adults with new-onset diabetes actually have type 1 diabetes (sometimes called LADA in adults) and not type 2 diabetes. If there are concerns that type 1 diabetes...
What is your approach to a patient on long-term denosumab who now requires multiple invasive dental procedures?
This is an important issue and one our practice faces routinely. We have close to 2,000 patients on Prolia. When we initiate Prolia we discuss the concern about rapid bone loss associated with discontinuation. We advise that if they need a dental extraction we hope they can get it done before initia...