Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you select an SSRI and dosing strategy for older adults newly being treated for depression?
SSRIs are preferred based on tolerability, drug interaction potential, and comorbidities. Start at low doses (e.g., sertraline 25 mg daily) and titrate gradually to therapeutic levels over 1–2 weeks, monitoring closely for adverse effects. Among SSRIs, sertraline and escitalopram are particularly r...
How would you approach treatment of latent TB for patients who cannot tolerate rifamycins or isoniazid due to allergy, intolerance, or drug-drug interactions?
Levofloxacin or moxifloxacin. Duration is 6-9 months.
For patients with acute renal failure and possible urinary retention, do you obtain a bedside bladder POCUS exam before ordering renal imaging or placing a Foley catheter?
Bedside Bladder Ultrasound has a strong role in the evaluation of acute urinary retention (AUR) as a possible cause for acute renal failure. Practice varies, as does the evidence base, but most POCUS experts recommend ultrasounding both the bladder (to assess for post-void residual volume) and both ...
Are there any special considerations when treating patients with recurrent nephrolithiasis who also have medullary sponge kidney?
Sponge kidney patients present a very challenging therapeutic situation. Anatomically speaking, a sponge kidney is often a congenital, although occasionally acquired, dilation of the renal collecting ducts, which in turn causes the inability to acidify urine. Urine pH is typically unusually alkaline...
Do you integrate firearm violence prevention into your annual wellness visits?
What factors should be considered when deciding whether to omit radiation in pediatric/AYA patients receiving N+AVD, particularly regarding long-term outcomes and second malignancy risks?
Based on the early data from S1826, it appears that radiation can be omitted if end-of-therapy scans (after 6 cycles of therapy) show metabolic remission of disease. The ability to limit RT to 1% of patients is encouraging for potential reduction in late effects such as cardiovascular disease and SM...
In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?
There is a difference between high-normal and unsuppressed ACTH. If ACTH is high-normal, this is ACTH-dependent Cushing. However, you can have mild adrenal Cushing without fully suppressed ACTH (e.g., ACTH in the 10-20 pg/ml range and sometimes even above 20). I don't think you can rely on DHEAS in ...
How do you approach managing intolerable vivid dreams as a side effect of SSRIs?
Given that the dreams are described as intolerable, I would transition to an agent more favorable in terms of sleep architecture, such as vilazodone (Viibryd).
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...
How would you approach a patient with a recent MI s/p DES who is being considered for neoadjuvant chemotherapy for TNBC?
This is mostly opinion as there is not data specific to this situation. First, I would coordinate closely with the cardiologist, preferably someone with knowledge of cardio-oncology. Presumably the patient is already on cardioprotective medications, such as beta blocker and ACE inhibitor, but if not...