Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to de-escalation of asthma therapy if patients have remained clinically stable on triple inhaler therapy and a biologic agent?
Since the reason most folks need biologics is prednisone and considering the side effects, getting patients down to the lowest dose is beneficial.
How do you treat CTD-associated organizing pneumonia?
The approach to CTD-associated organizing pneumonia is similar to that of CTD-associated NSIP and involves treatment with glucocorticoids and steroid-sparing agents. The evidence for the choice of steroid-sparing agents is extrapolated from clinical trial and observational data from systemic scleros...
What is the typical timeline for remission of autoimmune hypoglycemia?
Insulin autoimmune syndrome (IAS) or Hirata disease is a rare disorder characterized by hypoglycemic episodes due to the presence of high titers of insulin autoantibodies (IAA). The disease was first described in 1970. Because of its rarity, large clinical experiences with this disorder are limited....
How do you counsel patients with ALS on the benefits of enteral nutrition?
I agree with Drs. @Dr. First Last and @Dr. First Last but what I find frequently is that patients are reluctant to have PEG because of a number of psychological factors; fear of the surgery, fear of having a tube, fear of disease progression, fear that it will keep them alive indefinitely as in the ...
When do you recommend genetic testing in patients with neuropathy?
I would do genetic testing in any chronic progressive polyneuropathy that defies explanation after routine lab testing and is associated with at least one of the following features: positive family history early onset (<35-40) abnormal foot appearance-pes cavus, hammertoes motor predominant symptom...
What workup do you recommend on patients with suspected ischemic cranial nerve six palsy?
The conventional wisdom is that 90% of isolated ischemic (or "vasculopathic") 6th nerve palsies recover in 6 months or less. Diagnostic certainty of this etiology is increased if the patient is hypertensive, diabetic, or maybe has hyperlipidemia or tobacco use. The real problem for the non-ophthalmi...
How would you manage cognitive changes in a patient with memory impairment and significant brain atrophy with no diagnostic testing consistent with Alzheimer's disease?
It would depend on the clinical history, pattern of atrophy, and diagnostic biomarkers. If I had a patient with a typical clinical history of AD with progressive episodic memory loss substantiated by neuropsychological testing, IADL impairment, and hippocampal atrophy on imaging, I probably would no...
When do you screen for pulmonary hypertension in ILD patients?
Pulmonary hypertension (PH) is a frequent finding in patients with advanced interstitial lung disease (ILD) and its presence is associated with worse morbidity and mortality. The prevalence of PH will depend on the severity of ILD, ranging from around 10% at diagnosis and about 60% of patients with ...
When would you consider biopsy for an incidentally noted, PET negative, solid, solitary pulmonary nodule that is >8mm in size?
No, probably not. The whole point of a PET scan is to use it for its negative predictive value (which is very high for a nodule that is solid, and large enough). I'd like to know just how large it is because smaller nodules (e.g. just at or above the 8 mm size threshold we all perseverate on) can be...
What would be the main indications for opting for biosimilars over an original biologic, outside of insurance barriers?
A timely question, as we head to 2023! The only reason to use biosimilars is for the broad purpose of resource stewardship. There isn't a medical reason to prefer a biosimilar over a reference product (or vice versa), because if a product were found to have a significantly different therapeutic effe...