Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What treatment would you use in a patient with osteoporosis on denosumab for 10 years who develops ONJ at a site of an old implant?
A bone formative agent as teriparatide.
When do you consider stopping denosumab when a patient with osteoporosis is otherwise tolerating it without issues?
This is a matter of "style" more than anything. I continue Prolia and have many patients now exceeding 10 years - up to12 years, without any apparent safety issues. I realize we are in a "data-free" zone after 10 years, but as rheumatologists, we are frequently giving monoclonal antibodies for perio...
For a patient obtaining significant benefit and no side effects from pentoxifylline/Vitamin E for radiation-induced vulvovaginal fibrosis, do you continue treatment longer than 6-7 months or discontinue?
I reassess these patients at 3 and 6 months, regardless of site (gyn or breast). If the patient is benefitting from the trental/vitamin E but still has significant fibrosis, I continue these meds for up to 2 years.
What is your threshold to start triple therapy in mild to moderate asthma/COPD overlap with minimal functional limitation?
The question is vague as it does not define functional limitations. If the patient has frequent exacerbations (not defined by the question), Triple therapy would be recommended. If she just has minimal SOB for instance an exercise induced type picture SABA/LAMA prn with LABA ICS (w/o LAMA) would be ...
How would you manage a patient with erythrocytosis of unknown cause in pregnancy?
Pregnancy invokes changes in the blood volume and erythropoiesis: the plasma volume expands, erythropoietin production falls, and the hematocrit (don't use the hemoglobin level) declines (the hydremia of pregnancy) until the last trimester. So that by the third trimester, the hematocrit varies betwe...
How would you approach a low to moderate titer of one of the APLS antibodies in a patient with a strong family history but no personal history of thrombosis?
I would repeat these tests in about 12 weeks or so. Certain infections can transiently induce positive antiphospholipid antibodies, usually non-pathogenic, with certain exceptions.
What are some explanations for the persistent renal outcome disparity gaps affecting certain minority groups of patients with pediatric SLE despite improvement in overall renal outcomes?
There are likely some genetic causes, for example, Blazer et al., PMID 33461980 have shown in a Ghanian cohort of patients with SLE that apolipoprotein 1 risk variants are associated with progressive renal failure. However, it is undeniable that in the US, children in minoritized groups are dispropo...
What dose do you provide of folic acid in pregnant patients with epilepsy?
I recommend all people of child-bearing potential take 1mg folic acid. If they are taking a prenatal vitamin, are really opposed to taking another vitamin and are not actively trying to become pregnant, I'm ok with the 800mcg included in most standard PNVs. Once they are trying to conceive, however,...
What treatment do you recommend for patients with meralgia paresthetica?
I recommend the following: Weight loss. Better control of sugar if the patient is diabetic. Avoid wearing tight belts or clothing. Sleep on the other side. Rule out inguinal hernia or focal gynecologic problems. Consider using a Lidocaine patch or, if not covered by insurance, a cream. Nerve blocks...
Do you recommend prophylactic anticoagulation to pregnant women undergoing chemotherapy for breast cancer?
It is a very interesting thought but no, to my knowledge, there is no data to support anticoagulation of pregnant women receiving chemotherapy for breast cancer, and it is not a standard practice nor is it part of the guidelines around treating breast cancer in pregnancy.