Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you stop current immunosuppressive therapy or delay starting immunosuppressive therapy in a patient with aplastic anemia who has been infected with COVID-19?
Not much is known yet about this specific situation—but our growing experience here in New York City suggests it may be safe. We have had several post-BMT patients who were on immune suppression for GVHD become COVID positive who have not had significant problems. Also, we have now treated 8-10 pat...
How do you reassure families that no allergy testing is needed for urticaria?
I explain to them that it is an immunologic phenomenon (inside job) and not allergic (outside job).
What are the current official guidelines regarding managing patients during COVID-19?
Here are some guidelines and FAQ from professional societies: NCCN: https://www.nccn.org/covid-19/default.aspx ASTRO FAQ: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/COVID-19-FAQs ASCO Coronavirus Resources: https://www.asco.org/asco-coronavirus-information
What is your response to the question, "Is this terminal?"
Thanks for this question, it's really important. This question comes up in two distinct scenarios: when a person is first diagnosed and when a person is nearing the end of her life. Let's talk about them in sequence. 1). At diagnosis: When a person is first diagnosed, this question is part of "getti...
Do you seek pathologic confirmation before proceeding with empiric immunosuppressive therapy in symptomatic patients with radiographic NSIP?
In general, getting lung biopsies is needed in a minority of people who have clear evidence of NSIP on HRCT. If there is any evidence to suggest a concomitant ARD, a biopsy will not typically be needed. In our combined ILD-Rheumatology clinic, we see these patients all the time and I can think of on...
How do you present the trade off between a small chance of a sustained response for a new drug at the expense of potential worsening quality of life?
Since we now have an increasing number of treatments at our disposal, this becomes an ever more frequent conversation in oncology. This question gets at several Shared Decision Making (SDM) model steps. Usually in this scenario, there are not routine standard of care options and highlighting the pat...
How do you approach the workup of pauci-immune glomerulonephritis?
When a kidney biopsy reveals a pauci-immune GN, the Ddx must extend well beyond classic AAV and infective endocarditis. For instance, anti-GBM disease should remain high on the list, as up to 25% of these patients present with a "dual-positive" ANCA, and the characteristic linear IgG staining on IF ...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
Can you use bisphosphonates in a patient with osteoporosis who has had prior avascular necrosis of TMJ due to steroid use?
Due to the rarity of medication-related osteonecrosis of the jaw (MRONJ) and significantly high fracture risk from osteoporosis, prior history of osteonecrosis is not considered an absolute contraindication for bisphosphonate use. The clinical picture is important in weighing this decision. If the p...
In older adults with mild cognitive impairment, do you ever prescribe cholinesterase inhibitors and/or memantine?
This is a great question, and of course, "do you ever" will get you in trouble every time! Let me start by saying that, in general, I do not prescribe these drugs for MCI. Cholinesterase inhibitors are clearly indicated for the mild-moderate stage of some kinds of dementia (some people would include...