Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are you using the microbial cell-free DNA “Karius” test to aid in the diagnosis of an atypical pulmonary infection such as PJP or NTM?
No, not at this time. Intriguing, but not sure we know enough yet.
How would you manage a middle-aged patient with Paget's disease who received one dose of zolendronic acid 2 years ago, currently suppressed CTX, normal bone-specific Alkaline phos, and a recent hairline fracture in the thoracic spine?
Parathyroid hormone analogs are, of course, contraindicated in patients with Paget's disease and I am not aware of any data regarding the use of romosozumab in patients with this condition. Paget's disease is primarily considered to be an osteoclast-related disorder and bisphosphonates, particularly...
How would you approach treating a patient with active rheumatoid arthritis and a history of treated lymphoma that is currently in remission?
I would individualize treatment in each patient depending on degree of RA activity, type of lymphoma and length of time of remission with shared decision-making between myself, patient and oncologist. For moderate to high degree of activity of RA, in general, rituximab in keeping with the ACR 2021 g...
How do you interpret the results of oligoclonal bands ordered to evaluate for demyelinating disease in patients with brain MRI lesions of unclear etiology?
While the presence of oligoclonal bands (OCBs) has been incorporated in the updated diagnostic criteria as a surrogate for dissemination in time, OCBs should not be used in isolation to make the diagnosis of multiple sclerosis. There are several systemic and peripheral immune diseases, including inf...
Do you obtain spot urine protein or 24 hour urine protein quantification studies in pregnant patients who are found to have proteinuria on a standard urinalysis test?
If a patient has a positive dipstick for protein, I would do a 24-hour collection, just to get the most accurate answer to the question of whether there is truly abnormal proteinuria or not, and taking into account the physiologic protein increase that happens during pregnancy. I generally check a b...
How do you approach patients with RA and severe bronchiectasis with associated findings of UIP?
Usual Interstitial Pneumonia or UIP is among the most serious forms of RA-associated lung disease. Clinical studies have demonstrated that its prognosis is similar to idiopathic pulmonary fibrosis (IPF). UIP is extremely challenging to treat and we have learned from experience that our DMARDs and bi...
How do you approach patients with onychomycosis that does not respond to terbinafine and prolonged courses of fluconazole?
Terbinafine is usually effective in the treatment of the most common nail infections. Failure of treatment with terbinafine and fluconazole should make us consider bacterial co-infection or other non-dermatophyte organisms (i.e., aspergillus or non-C albicans). Fungal cultures are often falsely nega...
How do you manage patients with a prior intracerebral hemorrhage from probable cerebral amyloid angiopathy who develop new small vessel ischemic infarcts?
In this situation, I would consider using cilostazol since it has both antihypertensive and antiplatelet properties. However, the safety profile is unclear in patients with amyloid angiopathy.
What is your approach to postpartum screening and cardiovascular risk assessment in patients with a prior history of preeclampsia?
Hypertensive disorders during pregnancy, including preeclampsia and gestational hypertension, elevate a woman's long-term risk of cardiovascular disease. The American College of Cardiology (ACC) and the American Heart Association (AHA) now recognize preeclampsia as a risk-enhancing factor for heart ...
When do you consider immunosuppression in patients with Sjogren's neuropathy?
Only when disease activity is moderate-severe, impairing QoL, or rapidly progressive, ie mononeuritis multiplex/vasculitis, with significant risk of end-organ/tissue damage. Occasionally, autonomic neuropathy in SjD can be so debilitating to patient, and all other supportive treatments have failed, ...