Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What patient characteristics would lead you to opt for triple therapy versus double therapy in newly diagnosed PAH?
When treating patients with PAH it is essential to assess their mortality risk. Risk assessment is done using 2 tools that include the a) European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines (Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hyp...
Would you generalize the data from the CHANCE-2 trial to a broader clinic population given that the study was specific to Han Chinese patients?
I would not generalize to a broader population at this time but it is probably relevant in slow metabolizers of any ethnicity.
Do you routinely provide GI protection in the form of a PPI or histamine blocker for patients with immunobullous disease initiated on high doses of oral corticosteroids?
I honestly don’t unless a patient brings up GI symptoms during the visit. However, the literature does have clear recommendations. A recent JAAD CME stated that on any dose of prednisone for 3 months or greater, GI prophylaxis is needed for those who must be on a concomitant NSAID. It also recommend...
What workup do you do for patients who have PL-7 elevation when screening for myopathy?
In the literature, the PL-7 antibody has been associated with the antisynthetase syndrome and aside from myositis, interstitial lung disease (ILD). Patients with PL-7 autoantibodies are at high risk of ILD. Referral to pulmonary should be considered. One would also consider assessing pulmonary funct...
How do you interpret a mildly positive NT5C1A lab test in patients with hyperCKemia?
Seropositivity, in general, ought to support the clinical features of the given disease in the patient. In this instance, the patient should have selective medial forearm flexor weakness, quadriceps atrophy/weakness, and dysphagia (if in later stages). In the rare case that the phenotype has not yet...
How do you mitigate the risk of renal crisis from corticosteroids in a patient with UCTD?
I assume that this patient with UCTD has some scleroderma features (like a scleroderma-specific antibody) that are raising the concern for a renal crisis. If the patient is in the scleroderma spectrum, there probably is some risk, albeit probably low unless they have high-risk features (early, diffu...
Does the overall conclusion of the CHANCE-2 trial make ticagrelor + ASA a worthwhile transition given the data showing cumulative hazard of stroke diverged during the first week and was subsequently similar, which suggests the benefit of ticagrelor over clopidogrel is seen predominantly soon after stroke?
Given the fact that clopidogrel costs 11 cents a day and ticagrelor costs almost $8/day and the fact that most patients will not be tested for slow CYP2c19 metabolizer (or have the results back in a timely fashion), it seems that the combination of ASA plus clopidogrel is the best option from a publ...
In a patient with a bleeding disorder, how would one approach anticoagulation during active COVID infection?
This is very dependent on what the bleeding disorder is, how severe it is, and what you think is the risk of clotting with this COVID infection in this individual. For example, if this is a mild-moderate type I VWD with very infrequent bleeding with a need for treatment, you could probably handle th...
How do you work up patients who present with elevated myoglobin in the setting of normal creatinine kinase and exercise intolerance?
Myoglobin may originate either from cardiac or skeletal muscle; therefore, I would first try pinpointing the origin with troponins and CK fractions. I would work up the exercise intolerance with a non-ischemic forearm test to determine whether a flat lactate curve is present. In that case, I’d typic...
How do you evaluate asymptomatic patients referred for benign intracranial hypertension?
"Benign intracranial hypertension" is not really the preferred term for pseudotumor cerebri or idiopathic intracranial hypertension (IIH) anymore, as the phenomenon can lead to permanent vision loss and thus cannot be considered truly benign. Having said that, if the patient has no symptoms (no blur...