Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you consider using disulfiram in patients with alcohol use disorder?
Yes, there is a select population who benefit greatly from Antabuse: motivated professionals, monitoring programs for impaired professionals, and court-mandated cases. Informed consent would include complete disclosure related to dietary limitations/risks for severe drug interaction up to 2 weeks po...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
What is your preferred first line management of alcohol use disorder with concomitant depression?
The presence of comorbid depression doesn't significantly change the way I think about pharmacotherapy for AUD. I would still consider disulfiram, naltrexone (PO and IM), and acamprosate as equivalent first-line agents. It's worth noting that distinguishing between major depressive disorder and subs...
What is your preferred first line management of alcohol use disorder with concomitant depression?
The presence of comorbid depression doesn't significantly change the way I think about pharmacotherapy for AUD. I would still consider disulfiram, naltrexone (PO and IM), and acamprosate as equivalent first-line agents. It's worth noting that distinguishing between major depressive disorder and subs...
How do you approach screening for occult cardiac or tracheal involvement in a patient with relapsing polychondritis?
Hello! Dynamic CT and echo, if you have suspicion of vasculitis (physical exam, sx), a CTA can help. Happy to discuss your case.
When would you consider long-term cardiac monitoring to look for atrial fibrillation in patients with mitral stenosis given their baseline elevated risk for atrial fibrillation and thrombosis?
This is a thought-provoking question. Not only is Afib a risk factor for strokes but these strokes can be particularly devastating. While screening for subclinical Afib in large populations is described, there is little data to show that this leads to clinical benefits (1, 2). The benefit of detecti...
Is asymptomatic long QT syndrome a contraindication for starting AIT?
No.
What is the rationale/evidence to support doing 4 puffs of albuterol vs. 2 puffs for a reversibility study?
The rationale per ATS in 2005 is that 4 puffs of albuterol is higher on the dose-response curve and thus would potentially avoid getting a suboptimal (< 12%, < 200 mL) response from 2 puffs. Having said that, there was a study of this issue in 240 pediatric patients showing non-inferiority of 2 puff...
How do you approach rising PSA following radical prostatectomy and early salvage radiation therapy?
There are several factors that I will take into consideration, including the patient's overall health, the interval from treatment to relapse, the PSA doubling time (rather than a PSA threshold), whether or not they're castrate resistant and whether or not they now have overt metastatic disease. Pat...
What do you think about chronic suppressive therapy for HSV-2 in a patient with positive antibodies but no prior clinical outbreak?
The first challenge is often the reliability of the test result. HSV-2 serologies and their interpretation can be challenging. A strongly positive result for HSV2, i.e., an EIA or similar index value well above the minimal cut-off, usually is reliable. Lesser values often are false positives, even t...