Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you decide between CT and ultrasound imaging tests for surveillance imaging for patients with recurrent nephrolithiasis?
I much prefer non-contrast renal CT scanning compared to ultrasound to determine metabolic stone activity (an increase in size or number of stones from previous imaging). Although more expensive, radiation exposure is low and sensitivity is high. Determining metabolic activity is important; if activ...
What approaches do you take for your patients with nephrolithiasis who undergo intermittent fasting for cultural, religious, or personal reasons?
Assuming "fasting" does not prohibit the intake of water, I encourage my patients to continue drinking water frequently, ideally at least 2 L daily, as that is the minimum amount shown in previous studies to decrease kidney stone passage. If fasting is intermittent and includes all fluids, I encoura...
What instances will you start outpatient steroids in patients with nephrotic syndrome of unknown etiology prior to obtaining a kidney biopsy?
It is Friday, your patient presents with classic acute nephrotic syndrome, your biopsy Friday won't have results (if not longer if you need EMs which you need for MCD) until Tuesday. I never think a few days of steroids is a big deal, so I can see doing it.
Are there instances when you recommend femoral vein dialysis catheter placement in patients newly started on hemodialysis in an effort to preserve upper extremity future fistula options?
I do not recommend tunneled femoral lines for patients who will need dialysis through the catheter for more than a week or so. Temporary femoral catheters are useful at times if unable to place tunneled line expeditiously.
How do you monitor patients with cutaneous lupus for progression to SLE?
I think it is prudent to check patients with a new diagnosis of cutaneous lupus for any signs of SLE, typically with CBC, CMP, UA, complement levels, and ANA by IFA. If negative, I just screen with review of systems and check labs if something comes up.
How are you navigating approval of CPAP for patients with a high suspicion for OSA on chronic oxygen who are unable to complete an in-lab PSG?
This is a challenging situation for both patient and healthcare provider. The physician is to be applauded for making efforts to get this patient appropriate care despite the very difficult situation to navigate. Of course, the best outcome will occur if we can find a way to get this patient in for ...
What is your approach to use of D-mannose for prevention of recurrent uncomplicated cystitis?
Unfortunately, in light of Hayward et al., PMID 38587819, I think there is a very limited role for the use of D-mannose for the prevention of recurrent uncomplicated cystitis. Our evidence-based options for the prevention of recurrent uncomplicated cystitis in postmenopausal women without catheters ...
What is your approach to determining which patients with ESKD and pruritis should be started on difelikefalin?
Since difelikefalin is a restricted formulary item at my dialysis units, I am required to reserve its use for patients who have failed antihistamines and neuroleptics. If the patient doesn't have traditional Medicare, there may be issues with difelikefalin reimbursement by Medicare Advantage and com...
In patients with Afib on anticoagulation and concurrent intracranial atherosclerotic disease, would you consider adding an anti-platelet to anticoagulation if there are recurrent events that could be related to the ICAD?
This is a difficult clinical situation. If the new stroke was clearly in the vascular territory related to the ICAD, I would consider adding low-dose aspirin to the anticoagulant. I would also consider using the 2.5 mg dose of apixaban as the anticoagulant to reduce the risk of major bleeding associ...
How should we address the questions about the use of hormone replacement therapy in post-menopausal women who have concerns about its relation to breast cancer?
I am presuming that we are referring to woman that does not have breast cancer. Overall, long term estrogen replacement, especially combined with a progestin, is used much less these days since the Women's Health Initiative trials found an increases in coronary heart disease (CHD), breast cancer, pu...