Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you routinely use cefdinir for the treatment of common infections diagnosed in the outpatient setting such as CAP, uncomplicated UTIs?
Not routinely. More expensive than equally effective alternatives.
What is your preferred method for latent tuberculosis screening prior to outpatient hemodialysis initiation for a patient with new dialysis requirements?
Definitely Quantiferon testing. It can be done at the same time as the hepatitis B blood test. The patient does not have to come back and have it read a couple of days later.
What is your general approach to an immunocompetent patient with chronic, non-infectious diarrhea?
If the diarrhea has lasted more than a few weeks and all infectious workup is negative, then I'll send serologies for IBD/celiac, especially if there is any weight loss. Where we practice in New York City, these patients almost always end up getting an EGD/colonoscopy.
Are drug challenges after serum sickness-like reactions useful in delabeling the allergy?
Too unpredictable each time.
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...
Do you have to extend treatment for acute Lyme disease if a patient is on high dose steroids for another indication?
I am unaware of any evidence to support longer-term therapy in such a setting. I am quite sure no such study has ever been done. Standard therapy for early Lyme disease is 10 days of appropriate antibiotics. Extending to 20 days would likely do no harm to the patient, but may not be necessary, and t...
Are you comfortable utilizing Stelara (ustekinumab) as biologic treatment of psoriasis for patients with a history of severe latex allergy?
I don't have a lot of data to go on. On the one hand, I would be comfortable, as I doubt there would be any problem as long as the patient didn't touch the latex in the needle cover. But since we have many products without latex, perhaps it would be prudent to use those first. If other options were ...
How do you approach Pityriasis rubra pilaris that is retinoid resistant?
I find most PRPs to respond, at best, incompletely to retinoids - they are not my first line. Any TNF-alpha or IL-12/23 inhibitor is reasonable to try, and there are no head-to-head trials to my knowledge to endorse one other. Mtx may need to be added. IL-17s likely work too for some patients. Depen...
How do you approach PJP prophylaxis in patients with rheumatic disease on corticosteroids?
Here is a graphic I made covering PJP Prophylaxis with Dr. @Dr. First Last if anyone is interested! As noted, one can check absolute lymphocyte count (ALC) or CD4 count as factors to further risk stratify as well.
How do you approach the management of poorly controlled migraines during pregnancy?
This is an excellent question and area of frequent discussion. You can start with Lidocaine nerve blocks: occipital, supra-orbital, and temporal. Sometimes, just IV fluids will help for acute migraines. Other options include Reglan, caffeine, and APAP. If in the second trimester, I will do steroid t...