Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What duration of therapy do you use for treatment of Legionella pneumonia in an immunocompetent host without associated empyema or extrapulmonary infection?
We have little experience of legionellosis, especially in immunocompetent patients. Based on the available information and the published recommendations (these follow), I would generally treat patients for 5-7 days, depending on clinical response.A recent review: Viasus et al., PMID 35505000IDSA/ATS...
Do you avoid ESAs in patients with anemia and chronic kidney disease who also have Factor V Leiden?
I personally do not. I think it is better to get the hemoglobin in the 10-11 g/dL range and avoid having to give blood transfusions potentially than the slightly increased risk of hypercoagulability.
What is your approach to determining the need for continued isolation in the dialysis unit for an ESKD patient who had a positive hepatitis B surface antigen one year ago but who now has a negative HbsAg in the absence of treatment?
I have not encountered this situation before. Assuming that both checks are accurate and not the result of vaccination, then I would continue to isolate for another 6 months, repeat Hep BsAg and viral load. If still negative would take off isolation.
Do you consider hyperuricemia as a potential etiology of an anion gap metabolic acidosis in patients with elevated uric acid levels and no other readily explainable causes of acidosis?
Urate has a molecular weight of ~166 mg/mmole and the valence of the anion is -1. Hence, let us say we have severe hyperuricemia with 16 mg/dl. That will provide an "anion gape" of only 1! So, by itself, urate cannot increase the anion gap. Could hyperuricemia be a "biomarker" of other causes of met...
How would you manage a patient with radiation pneumonitis who remains symptomatic on steroids?
Engage your Pulmonology colleagues to assist in these difficult cases. Important to rule out other causes of persistent symptoms including infectious processes. Rebronch can be helpful for infectious work up and/or determining the nature of the inflammatory process that is ongoing (for example, the ...
Do you continue to use Botox to treat chronic migraine in a patient who becomes pregnant?
First of all, my use of botulinum toxin for the preventive treatment of chronic migraine has dramatically decreased since I started working with the CGRP antibodies in the context of clinical trial research in 2012. I find them to be much more effective than botulinum toxin, equally well if not bett...
When (if ever) do you check for anti-platelet antibodies for workup of thrombocytopenia?
Routinely available anti-platelet antibody tests have a sensitivity too high and specificity too low to be of much clinical use. A patient's response to first line therapy (steroids or IVIg) is most telling and if there is no response, a bone marrow is warranted as it would be atypical for ITP. Ther...
Have you found success in managing refractory hidradenitis suppurativa with ertapenem?
Ertapenem is the magic bullet for HS. It is the one therapy that you can count on to shut down the disease, even in the most severe cases. So, why isn't it our first-line therapy? It only works while the patient is on therapy, and it can't be continued indefinitely owing to the risks associated with...
Do you avoid SSRIs in patients with a history of RCVS?
SSRIs are on a long list of medications associated with RCVS. The condition is relatively rare, and a very low percentage of patients have recurrences. If there is a strong indication for antidepressants, I would treat them with appropriate warnings.
How do you evaluate patients with suspected pseudo-dementia?
I am very careful about diagnosing a functional cause for cognitive impairment. I typically get vitamin B12 and TSH levels, and also get a neuropsychological evaluation. They are usually able to pick up underlying behavioral disorders or poor effort. If unrevealing, and there are no obvious risk fac...