Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For a patient interested in home dialysis modalities, what are some key points that you discuss with them to help them make a decision on peritoneal dialysis versus home hemodialysis?
1. Dialysis access: a major difference between the 2 modalities is dialysis access. Discussion with the patient should include detailed education with photos, videos, or physical examples of a PD catheter in situ and AVF/AVG/catheter. Some patients have strong feelings regarding the issue of needle ...
What is your approach to treating premenopausal woman with OI with a new compression fracture?
Young women with idiopathic premenopausal osteoporosis likely have low bone formation. I was not told her BMD but I will assume it is low. An antiresorptive does not make much sense because she is producing enough estrogen to keep her cycles going. There has been some published data with the use o...
How do you approach patients with malignant melanoma who are disease free on immunotherapy for over 3 years?
The prognosis of metastatic melanoma patients treated with immunotherapy has improved considerably. Based on the 6.5-yr update to the CHECKMATE-067 study (presented at ASCO 2021 meeting), the OS for patients treated with ipi/nivo is 49%, 42% for nivo alone, and 23% for ipi alone. If the patient has ...
How do you decide when to try stopping hydroxychloroquine in patients with erosive osteoarthritis?
As we lack any peer-reviewed evidence that hydroxychloroquine (HCQ) effectively and significantly helps with erosive osteoarthritis, I would stop the drug if there was no relief within 2 months (if I had started it for a patient). While HCQ (and other DMARDs) are often used empirically with these er...
For an asymptomatic patient discovered during workup for elevated PT/PTT to have mild prothrombin deficiency, would you suggest any preoperative prophylaxis?
In someone with normal liver function otherwise, who was found on preoperative screening to have both mildly prolonged PT and PTT, AND the only abnormality found was a factor II (2, prothrombin) level >60%, I would not administer preoperative prophylaxis. However, I find the question confusing as it...
How should one approach an incidentally found T-cell gene arrangement?
When I see an incidental T-cell clonal rearrangement without any manifestation, my first question is how was this being measured? Many PCR-based methods have a difficult time distinguishing oligoclonal versus monoclonal T-cell populations. My favored test here is looking by flow cytometry at the T-c...
Would you treat a hemochromatosis carrier with IV iron if they have iron deficiency anemia in conjunction with elevated ferritin?
This scenario, with numbers like these, suggests another underlying issue. A carrier of hemochromatosis cannot typically have a ferritin level of >900 due to hemochromatosis. The TSAT of <10% corroborates this statement. If this patient is real, they likely have an underlying inflammatory disorder ...
What is your approach to monitoring patients with cardiac sarcoid while tapering immunosuppression?
Monitoring of patients with cardiac sarcoidosis (CS) is critical to optimizing therapy and improving outcomes. Once a decision has been made to institute immunosuppressive therapy, it is important that the efficacy of therapy is demonstrated and that the duration of therapy is guided by the response...
Is there a role for systemic therapy for a patient with scleroderma sine sclerosis, with esophageal strictures and Raynaud’s syndrome, but no pulmonary involvement?
We don't have any evidence that immunosuppression (assuming that is what you are referring to) would play a role in the treatment of the esophageal disease or the Raynaud phenomenon. Also, we don't have any data to suggest that this would have any overall long-term "disease-modifying" effects. So in...
Do you start aspirin for patients with incidentally found intracranial vertebral stenosis?
I'm not aware of any clinical trial evidence, but in this scenario, I would probably start with baby aspirin.