Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
Do you use potassium phosphate for patients with recurrent nephrolithiasis to acidify the urine and prevent certain types of stones?
Short answer: No. That study was done about 40 years ago, I think by the Kaiser group, and was negative. That said, they used a suboptimal dose of 250 mg bid and measured success by stone passages rather than stone growth. However, studies using neutral phosphates (K Phos Neutral) were done by my me...
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...