Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
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.