Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach management of patients with active RA and recurrent non-severe C.diff?
I think the question here is why the patient is experiencing recurrent C.diff. Is it true recurrence or it never fully clears? Any IgA deficiency? CVID? I would do an immune deficiency work up- complements, immunoglobulines and flowcytometry, response to pneumococcal vaccine. In parallel to the wo...
When do you recommend testing for APOL1 variants in patients with proteinuric chronic kidney disease?
As yet, despite APOL1 being a clear risk factor for kidney disease and ESKD, there are no clear guidelines to assist in decision-making regarding genetic testing. This is mainly due to the fact that there are (as yet) no specific drugs for APOL1-mediated kidney disease. There is an RCT for inaxaplin...
Would you anticoagulate a patient with splenic infarctions in the setting of CMV viremia?
Based on my general knowledge/experience, I would consider CMV viremia as temporary, short-lived risk factor for a thrombotic event on a part of other inflammatory conditions, and outside of other indications for anticoagulation (e.g., atrial fibrillation, etc), my inclination would be to conclude ...
How frequently do you check CK in patients with Becker's muscular dystrophy?
I do NOT check CK regularly in Becker or other muscular dystrophies after the initial diagnosis. The question is why should we check it regularly when there is no disease-modifying treatment currently FDA approved for the vast majority of muscular dystrophies, and there is no correlation of the leve...
How often do you check carnitine levels in your patients with end stage kidney disease on hemodialysis?
About 10 years ago I used to check carnitine levels in ESRD patients with intradialytic hypotension commonly. If low then I would treat with levocarnitine. At some point I gave up on the practice not because it was not working but because it was hard to determine if it was working or not. I am aware...
Is there enough evidence now to use injectable semaglutide as a foundational therapy for symptomatic heart failure with preserved ejection fraction in the setting of overweight or obesity?
While the evidence for using injectable semaglutide in the setting of heart failure with preserved ejection fraction (HFpEF) and overweight/obesity is promising, it's still considered emerging! STEP-HFpEF trial: This large, well-designed study showed that semaglutide significantly improved symptoms,...
What form of surveillance do you recommend for esophageal adenocarcinoma s/p NACRT and resection at what frequency?
We pretty much follow the NCCN guidelines. H&P every 3 months x 2 years, every 4-6 months out to five years, and our thoracic surgeons tend to continue annual follow-up after that. CBC and chemistries at each visit. NCCN points out that the value of CEA is unknown, but we tend to check them. Imaging...
How would you manage asymptomatic osseous sarcoidosis of the lumbar spine without any other systemic involvement?
Some patients with sarcoidosis are found to have bone-related abnormalities. These are frequently incidental findings often detected as a phantom abnormality on PET or MR scan without corresponding X-ray or CT abnormality; this suggests they are foci of inflammation localized within bone marrow and ...
Do you avoid the use of hydroxychloroquine in patients with psoriasis and/or psoriatic arthritis?
There are many effective medications for PsA out there now that don't have the risk of making their skin disease worse as is the case with HCQ. Patients are also less compliant with daily pills. To me, 1 in 10 is an unacceptably high number to flare their skin.When viewing through a historical lens,...
Do you routinely prescribe acetazolamide for patients with cystinuria who do not have significant urinary alkalinization or are intolerant to citrate therapy?
I have not used acetazolamide in this situation, although it makes good physiological sense, as urinary alkalinization increases urine cystine solubility. Sodium bicarbonate would be a bad idea because natriuresis increases cystinuria. I have used potassium citrate historically, and it is generally ...