Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to the management of patients with isolated cervical adenopathy related to sarcoidosis?
Establishing a diagnosis of sarcoidosis solely on the basis of isolated cervical adenopathy can present a challenge. Although thoracic adenopathy—alone or in combination with other extra-nodal clinical features—is part of the classic illness script for sarcoidosis, peripheral adenopathy as the exclu...
What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?
This is by far the hardest task assigned for a practicing rheumatologist. Inheriting a patient on a regimen you did not develop and are uncomfortable continuing poses a daunting challenge: you are challenging the patient’s relationship with the previous rheumatologist, the control of the patient’s d...
How do you approach a persistently elevated mean platelet volume and immature platelet fraction in an otherwise healthy patient with a normal platelet count?
I am trying to understand the circumstances where this question might arise. Nowadays, when patients can readily see CBC results before their clinicians, they might notice the H or L designations and ask. In general, I would not think twice about "slightly out of range" CBC parameters in a single me...
For patients undergoing TNT for rectal cancer with planned operative management, what is the optimal sequencing and timing of workup imaging and procedures?
I think the question that is posed does not really make sense as written. One should not be making decisions about management (i.e. TNT) before the staging evaluation is complete. If a patient presents with a newly diagnosed rectal cancer, the first thing to do is to stage to find out whether the pr...
What is your preferred method for diagnosing adenine phosphoribosyltransferase (APRT) deficiency in a patient with recurrent kidney stones and abnormal crystalluria?
Genetic testing using a panel that includes APRT is the most reliable and straightforward thing to do. There is not a laboratory in the United States currently that can measure urinary or blood dihydroxy adenine. You can send a blood spot to the University of California San Diego lab for enzymatic a...
What is your approach to pacemaker lead thromboses in terms of threshold for lead extraction and initiation of systemic anticoagulation?
This is a question that often comes up. In general, most thrombi found on chronic pacing leads incidentally noted on an echo in our experience are not problematic. However, the bigger question is whether the mass noted is indeed a thrombus versus some vegetation related to an infection. In one publi...
Are there any non-beta-lactam antibiotic options for treatment of neurosyphilis in non-pregnant adults?
Doxycycline is a consideration. There are no conclusive data, but a few anecdotal reports are supportive -- the most recent (in a brief PubMed search) cited below. On the other hand, there is at least one case report (also cited) of a patient treated with doxycycline who subsequently re-presented wi...
How do you time PET/CT surveillance and COVID boosters?
I have not changed the timing of PET surveillance imaging around vaccinations but 1) is a frequent question from patients, and 2) I have seen a fair amount of false positive FDG avid axillary adenopathy post-vaccination. Think this tends to be too unpredictable in the duration of these imaging findi...
How reliable is an exercise stress echo in the diagnosis of exercise-induced heart failure with preserved ejection fraction?
This is my understanding of HFpEF. It is a clinical diagnosis of exertional Dyspnea in patients with risk factors such as HTN, atherosclerosis and Hyperlipidemia, increased BMI, and inactivity. A new classification means stage A only risk factors, stage B has some organ dysfunction such as LVH, left...
How long do you anticoagulate for cirrhosis patients who have portal vein thrombosis extending to the mesenteric veins?
I recommend indefinite anticoagulation for most patients with portal vein thrombosis, and at least 3-6 months if there are risk factors for bleeding. Once they complete anticoagulation for the first 6 months, I re-evaluate their risk of recurrent thrombosis vs bleeding, and if there is an underlying...