Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What agent and for how long would you treat a patient with asymptomatic azole-resistant C auris candiduria who is planning to undergo a urological procedure?
I would be cautious here. If there are reasonable MICs to fluconazole (SDD but achievable), this would be preferred. Intravesical amphotericin is a good option. But, if this were impossible to achieve, I would be reluctant to use IV amphotericin in any formulation, since there's a risk of harm, and ...
Which imaging modalities and schedule do you use to follow stage I-II follicular lymphoma that was treated with radiotherapy alone?
PET has been demonstrated to be more sensitive and specific in staging for FL as well as a strong independent predictor of outcome after treatment. Patients also have ~50% risk of developing recurrence outside the RT volume - and PET allows for whole-body imaging. PET is therefore the imaging modali...
How long would you continue chronic transfusion therapy for adult sickle cell patients who have had a stroke?
Management of stroke in adults is not informed by the data that is available for children. Assuming that this was not a hemorrhagic stroke and that there was no moya-moya, I would continue transfusions indefinitely. To slow iron accumulation, I would use an exchange transfusion aiming for an HbS lev...
Do you repeat antiphospholipid antibody testing in a patient that previously met criteria for APLS?
I would repeat APL Ab testing if I am trying to risk stratify a patient in preparation for pregnancy or surgery, for example. In some cases (see a recently posted question about stopping anticoagulation in people with prior APLS history), I would also consider rechecking if I am thinking about disco...
Which non-pharmacologic treatments for neuropathic pain have you found most effective?
There is data supporting a positive role for lifestyle changes, primarily physical exercise, suggesting that consistent engagement can reduce neuropathic pain. They included aerobic, resistance, and balance programs for anti-sedentary behavior.
What factors do you consider prior to offering a trial of ICS/LABA therapy versus a methacholine challenge test in patients with suspected asthma but normal pulmonary function testing?
If there is a high suspicion of asthma, have the patient obtain a portable electronic spirometer. If peak flows/FeV1 drops >15% correlate with symptoms, start Rx and follow spiro results. If low suspicion for asthma or very mild symptoms, do methacholine.
What criteria do you use to determine when to start a steroid-sparing agent for hypersensitivity pneumonitis?
This is a very challenging question, acknowledging the difficulty in confidently establishing the diagnosis of HP, limited evidence in general to guide the treatment of HP, and recent small observational studies that conflict prior small observational studies. To attempt to answer, breaking down int...
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
It depends on what is meant by resistant infections; if this means multi-drug resistant bacteria that remain present after treatment ends and when symptoms have returned to baseline, there are many things to consider. First, has the person had many exacerbations before? Or do they have minimal sympt...
When is air travel safe for patients with recent diagnosis of ischemic stroke?
Air travel on a modern commercial jet includes full pressurization and oxygenation, such that I see minimal or no risk to air travel. Flying on a small, private plane would have higher risk, so I would wait longer for that, perhaps even a month. During helicopter flights for acute stroke patients, o...
Which fracture sites outside of the classical spine and hip are considered to be osteoporotic fractures even in the absence of a bone density diagnosis?
Any bone that sustains a fragility fracture can result from osteoporosis. The definition for fragility fracture is a broken bone that occurs after a low-energy trauma, such as a fall from standing height or less, or lifting something light. They are a type of pathologic fracture, which means they ha...