Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?
I have checked M-M-R, Td, and pneumococcal titers in patients with hx of infection and low Ig levels to see if they are making an immunological response. If any of these immune titers are low or the immunization is “due” by routine schedules, I recommend immunization and repeat testing in 6 weeks. T...
What would be the utility of calcium scoring for the evaluation of low-flow low-gradient aortic stenosis, and what cut-off values typically fall within the severe range?
Echo findings can be equivocal in as many as 40% of patients. Multiple studies have demonstrated a good correlation of calcium score and the severity of AS. A calcium score of 1300 in females and 2000 in men are defined cutoffs. In low flow low gradient AS with diminished EF a dobutamine echo should...
Do you recommend chlorhexidine mouth rinse for prophylaxis against oral complications in patients undergoing dental work who are immunosuppressed?
I have not, but would defer to dental/oral medicine colleague involved in patient care.Specifically in Sjogren's, I do not recommend chlorhexidine (CH). CH (antimicrobial) is indicated for gingivitis and periodontitis. Many of the formulations contain alcohol and dye, which are irritating for dry mo...
Are there any concerns regarding side effects in changing from denosumab to zolendronic acid or vice versa?
In patients with advanced solid tumors and bone metastases, the anti-resorptive agents, zoledronic acid (ZA) or denosumab (D) are administered to prevent skeletal related events (SREs). The key toxicity of concern is medication-related osteonecrosis of the jaw (MRONJ). While patient and oral health ...
Is there utility of modifying DMARD treatment in a seropositive rheumatoid arthritis patient with recurrent pleural effusions and RA nodules without other signs of active disease?
Modifying DMARD treatment in a seropositive RA patient without active articular disease may be useful when the patient has symptomatic noninfectious recurrent pleural effusions that are exudative requiring repetitive thoracentesis, frequent courses of systemic or intrapleural corticosteroids. Rheuma...
Does phosphatidylserine antibody play a role in the diagnosis of antiphospholipid antibody syndrome?
While additional APLAs such as aPS/PT are being investigated for clinical relevance, to date, they are not established markers for disease. I would interpret the aforementioned paper with caution, as these antibodies were tested in individuals with known and diagnosed APS. Their role in establishing...
When should I consider anticoagulation in an unprovoked upper extremity superficial venous thrombosis?
I would consider anticoagulation when there are significant risk factors for extension to the deep vein system such as proximity to the deep veins, underlying thrombophilia (cancer in particular), symptoms, and large clot burden.
How would you approach a non-healing wound following lumpectomy for recurrent disease in a patient who underwent breast conservation therapy with radiation 10 years prior?
Can try HBO and plastic surgery closure at some point.
What are your recommendations for adult sickle cell patients who end up being admitted several times a year for pain crises despite hydroxyurea, crizanlizumab, voxelotor, etc?
This is the problem that vexes all people treating sickle cell disease. First, is to be sure that drug dosing is optimized. Both voxelotor and crizanlizumab can be added to hydroxyurea. All three drugs could be used together. Perhaps equally important as drug therapy is to cope as best as possible w...
What is your approach to abbreviated DAPT in post-PCI patients (ACS and non-ACS) with high bleeding risk?
Current guidelines suggest dual antiplatelet therapy (DAPT) for a minimum of 6 months after PCI for patients undergoing PCI for stable CAD (non-ACS) and 1 year of DAPT after PCI for patients undergoing PCI for ACS. Patients at higher bleeding risk (HBR) after PCI, however, may not be able to tolerat...