Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?
Pulmonary hypertension (PH) associated with sarcoidosis presents a complex clinical challenge. The decision to use corticosteroids in sarcoidosis-associated pulmonary hypertension depends on several factors: Underlying Cause of PH: It's crucial to determine whether the pulmonary hypertension is dir...
How have you adjusted your practice for treatment of syphilis in light of the penicillin G benzathine shortage?
Theoretically, there should be an ample supply of penicillin G benzathine. Per the CDC: "June 10, 2024: Pfizer noted that they currently have an available supply of 2.4 million Units/4 milliliter Bicillin." https://www.cdc.gov/std/treatment/drug-notices.htm If by chance for whatever reason there is ...
When would you add a third antibacterial agent in addition to macrolide and ethambutol for treatment of a patient with HIV and disseminated MAC?
Add 3rd agent for patients failing or not on ART regimen when diagnosed with disseminated MAC Optimize failing ART. For treatment-naïve or not on ART, start ART ASAP after MAC therapy All our samples are sent to National Jewish Health in Denver, CO, right away for drug resistance testing If no clin...
Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?
Combination therapy is often required in patients with sarcoidosis. Combination of adalimumab with other immunosuppressants, such as methotrexate, leflunomide, azathioprine, or mycophenolate, can be used, with close monitoring of labs (CBC, CMP) and for infections.
How is transferrin saturation a reliable indicator for any parameter if serum iron is not reliable?
The question is a very good question. The Fe/TIBC must be drawn on an overnight fast including any vitamin pills containing iron. Otherwise, the serum iron is speciously elevated which in turn speciously elevates the TSAT. If those conditions are met, the TSAT is as good as the transferrin receptor ...
How reliable is the FRAX score for assessing risk of osteoporotic fractures?
FRAX model predictions are moderately good. One commonly used measure of a prediction tool's robustness is the C-statistic, which is a generalized analogue of the area under the curve. No predictive value yields C = 0.5, while perfect prediction yields c = 1.0. There are different FRAX models for di...
Should dopamine agonist treatment stop in pregnant patients with recurrent prolactinoma despite prior surgery?
That depends on the size of the residual adenoma, the distance from the optic chiasm, and on the responsiveness of the adenoma to cabergoline. If patient had surgery, I am assuming that was poorly responsive to DA. Sometimes it is prudent to stop during the first trimester, and re-start after organo...
Should oral combined contraceptives be held prior to overnight dexamethasone suppression test to rule out Cushings?
Yes, they should be stopped for one month due to an increase in cortisol levels secondary to oral estrogen-increasing CBG. However, many women will still suppress while on OCP. Therefore, an alternative approach is to do the test while on OCP and to repeat it off OCP if the test is abnormal.
How would you treat a patient with combined pre- and post-capillary pulmonary hypertension after successfully optimizing post-capillary pressures through a valvular intervention?
No good data here. First, if I'm contemplating treating this group with pulmonary vasodilators at all, I would like to see repeat RHC demonstrating precapillary pulmonary hypertension with a low wedge. Fixing the valvular disease may help with left-sided function, but many of these patients have dev...
What work-up do you recommend in patients with early-onset dementia?
After a thorough history (especially drugs, alcohol and Family Hx) - would do: imaging study, TSH, B12 level and consider genetic labs and CSF for early onset dementia.