Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you screen adults in your practice with sickle cell disease for silent cerebral infarcts?
The details of the ASH guidelines regarding adults are complex. It was not my practice to screen all patients. More than 50% of adults have silent infarction. Screening requires MRI and this, according to the guidelines, needs careful attention to many details before it is reliable. There are no pro...
Would you restart prophylactic anticoagulation in a patient with a history of unprovoked PE who received short term anticoagulation with a prior physician?
The decision on duration of anticoagulation should balance the risk of hemorrhage vs risk of recurrent VTE. The annual risk of recurrence with unprovoked venous thromboembolism (VTE) is definitely higher than provoked VTE and seems to be higher in males than females.According to one study (Rodger et...
Do you recommend a kidney biopsy for patients who develop acute kidney injury after starting sacituzumab?
For all novel agents, I think that it is prudent - if there are no contraindications to the renal biopsy - to proceed with a biopsy. A renal biopsy is helpful in clarifying the etiology of the AKI and may have implications regarding whether the medication can be safely continued - depending on what ...
What alternative antibiotics or other therapies do you recommend for patients with papulopustular rosacea and a tetracycline allergy?
PO Ivermectin and PO Niacinamide can be helpful. However, for antibiotics, anything works/is anti-inflammatory, but usually, I’ll do azithromycin.
How do you treat Raynaud's in patients with baseline low blood pressure?
These can be very challenging patients. I tend to try 2.5 mg amlodipine at night which they can often tolerate. If there is a component of anxiety or stress/emotion to the Raynaud's, particularly in primary Raynaud's, fluoxetine can be useful. Some patients can tolerate half-dose sildenafil (10mg TI...
How do you approach the diagnosis of erythronychia?
Erythronychia has a broad differential including inflammatory diseases (lichen planus), infectious diseases (verruca), and benign (onychopapilloma, glomus tumor), and malignant tumors (SCC, amelanotic melanoma). I approach erythronychia with history and physical examination including measuring width...
Are there concerns with using sulfasalazine in SLE?
A very practical question:1. Yes, there is a concern theoretically; but you can use SSZ in lupus patients in certain circumstances.Sulfonamides are divided up into antibiotic (abx) sulfonamides (like trimethoprim-sulfamethoxazole, TMP-SMX) and non-abx sulfonamides (e.g. furosemide, hydrochlorothiazi...
How do you re-stratify patients with a primary prevention ICD in need of a generator change if their LVEF has improved to >40% and they have not previously required any device therapies?
This is an important question on which there remains a lack of consensus. We had tried to address this through an observational study which was published a few years back:(Appropriateness of primary prevention implantable cardioverter-defibrillators at the time of generator replacement: are indicati...
How do you approach the workup of transverse myelitis without any abnormality on spine MRI?
If you are highly suspecting TM on clinical features, and other etiologies seem unlikely, then consider LP, checking labs (autoimmune, demyelinating, infectious, metabolic, etc), starting immunotherapy (if infection is unlikely, maybe check with Infectious Disease on that decision), and then in a fe...
How often do you monitor labs in patients taking methotrexate?
Lab monitoring for patients taking MTX should be based on a few key principles. It should be done at least on a quarterly basis, ie every 3 months, if the patient is prescribed a stable dose and does not belong to one of the higher risk categories for the development of toxicities. These risk factor...