Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should CT coronary calcium score be avoided in dialysis patients in light of presumed high prevalence of CAC in this population?
The incidence of coronary calcifications in patients on dialysis exceeds 80% and is between 50-80% in patients with CKD. In addition, dialysis and ESRD cause two types of vascular calcification - in the medial and intimal layers, the latter being the one that correlates best with atherosclerotic pla...
What is your approach to isolated alkaline phosphatase without other laboratory abnormalities?
Assuming none of the other LFTs are abnormal, I would get a GGT. If GGT is elevated --> likely a hepatobiliary issue. Would consider age, medical history, and risk factors. If persistently elevated, could consider RUQ US + MRCP. Conditions like PSC or PBC are frequently discovered due to asymptomati...
How do you address mental health and online presence with teenage patients?
There are four variables that I talk to parents/teens about: Volume of screen exposure; low vs high. There is some data that pure volume is a risk factor, but not uniformly so. Psychiatric vulnerability; low vs high. Some kids are more vulnerable (e.g., social and generalized anxiety disorder and d...
Are there data to support full-dose anticoagulation added to an antiplatelet in recurrent peripheral arterial thrombosis requiring revascularization and stenting?
This question comes up frequently at our institution. I previously consulted with our vascular surgery team who referred me to this trial of Edoxaban with SAPT, trying to avert what may be limb loss if the bypass graft/stent fails. We've often promoted rivaroxaban 2.5 mg po BID per VOYAGER PAD if we...
How do you interpret DXA results in cases where there is discordance between normal hip and spine BMD with abnormal one-third radius BMD?
This is an interesting question. To my knowledge, there are no fracture prediction models based only on forearm bone density values so my response is my opinion and not evidence-based. Firstly, we always rule out hyperparathyroidism when there is forearm bone discordance compared to spine and hips s...
How do you approach therapy for severe osteoporosis after an initial 12 months of romosozumab?
After 12 months of romosozumab, most likely the patient will still need additional therapy. If you can get a bone mineral density, that can guide you into what the best next medication can be. If the patient still has significant osteoporosis or fracture during the treatment with romosozumab, I woul...
What monitoring do you routinely perform on lifelong EDS for epilepsy syndromes?
One of the complications inherent in using AEDs in anybody with epilepsy syndrome or neurotypical people with seizures is bone loss. It is especially important to look at their early loss of bone mass. I check for vitamin D levels even in very young patients. I might even do DEXA scans. I'm very pro...
What therapies have you found most effective in treating teenagers with recurrent CARP?
I have found CARP to be uniformly responsive to minocycline. In my experience, the incidence of recurrence is low and normally responds to minocycline.
Are there instances when you dose sodium zirconium cyclosilicate more than once daily for long term therapy for patients with end stage kidney disease and hyperkalemia?
Not for long-term therapy. I definitely use it more than once daily to lower serum potassium levels acutely, in patients who have clotted their access and are unable to dialyze for 1-2 days until they get decloted, etc. I would imagine that it would be safe to use long-term more than once daily exce...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...