Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach transaminase elevations with use of allopurinol in gout?
This is quite rare in my practice of the use of allopurinol. That may be because I discourage NSAID concomitant use in people with gout, given their concomitant hypertension, and NSAID-associated GI, renal, and liver toxicity. 1. If mild transaminitis happens, I would approach it as I do for any pat...
What sort of telehealth approaches do you pursue for a newly diagnosed end stage kidney disease patient starting peritoneal dialysis or home hemodialysis?
All new patients to home dialysis should be seen in person for at least three months. The first three months of home dialysis is a time by which you can make sure that the patient is stable. The patients are always adjusting to home dialysis both physically but also emotionally. After the first thre...
What is your approach to management of persistent painless salivary gland swelling/sialadenitis in patients with Sjogren's?
This is a common problem in this patient population, and we had Rheumatologist send to worry about physical findings that we are having trouble explaining. In this particular situation, the printable concern would be for sites of damage. Unfortunately, there are no known immunologic interventions th...
How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?
Very good question. Disclaimer 1st - I am not a nephrologist or nephropathologist so this really requires putting many heads together! Thrombotic microangiopathies (TMA) are clinical syndromes defined by the presence of hemolytic anemia, thrombocytopenia, and organ damage from micro thrombosis in ca...
What is your approach to monitoring a patient with SLE who has persistent hypocomplementemia on hydroxychloroquine, but clinically has resolution of cutaneous symptoms and no other internal organ manifestations of disease?
Per the subtitle under your question, an undetectable C4 with low C3 makes me wonder about the possibility of a homozygous C4 deficiency, of whom 75-80% of patients have SLE with a high occurrence of lupus nephritis (Yang et al., PMID 15294999). You can consider genetic testing (primarily for geneti...
Is there a role for repeat surveillance blood cultures in patients with prosthetic valve endocarditis without associated cardiac abscess after a 6 week course of antibiotic treatment without surgical intervention?
Compared to NVE, PVE is associated with high morbidity and in-hospital mortality (10-30%). Patients with PVIE who are medically managed have either no surgical indication or have surgical contraindications. 2023 ESC guidelines supported repeating the blood cultures within the first week of finishing...
Is there any role for additional antiviral therapy during rebound from COVID-19 infection after a course of Paxlovid?
Guidelines treat rebound mostly as an infection control issue requiring additional isolation. Treatment is not routinely recommended. Anecdotally, both in the literature and in my practice, I have encountered patients, mostly immunocompromised hosts with severe or very symptomatic rebounds who have ...
How do you approach management of patients with inflammatory arthritis who are asymptomatic but develop radiographic progression?
Radiographic disease progression remains the gold standard test for assessing disease activity in patients with RA. Therefore, any time one notes progression of radiographic change, this finding needs to be taken seriously. Since plain radiographs may take many months or years to demonstrate such ch...
What kinds of dental work do you particularly worry about and try to avoid in patients on bisphosphonates?
Firstly, the incidence of BRONJ (bisphosphonate-related osteonecrosis of the jaw) is very low with all drugs of this class. However, many patients and dentists are concerned about the possibility of this problem. Generally, BRONJ occurs after an extraction and subsequent poor healing at the extracti...
What indicators do you use to determine whether a patient is having a favorable or unfavorable response to nintedanib?
Unfortunately, there probably isn't a way to do this. It might be helpful to step back and see what nintedanib buys you: as compared to placebo, the nintedanib group suffered less FVC decline by ~110mL/year. Real-world data suggest there's probably a mortality benefit if you have your patients on it...