Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Following completion of antiplatelet monotherapy (i.e., Plavix) plus oral anticoagulation in patients with AFib post-PCI, would you favor continuing antiplatelet therapy + OAC, switching from Plavix to aspirin and continuing OAC, or stopping antiplatelet therapy and continuing OAC?
My practice has always been to continue ASA in addition to anticoagulation but I'm starting to change this practice and remove antiplatelet therapy and continue OAC alone, especially in higher bleeding risk patients. There have been a couple of studies (AFIRE and OAC-ALONE) that would seem to suppor...
How do you manage alopecia areata in children with >50% of hair loss that is unresponsive to intralesional or topical steroids?
Treatment typically varies depending on the age of the child and the impact on the child's quality of life. Some options include adding topical minoxidil or compounded topical JAK inhibitors such as topical tofacitinib. In more severe cases, I offer oral minoxidil, monthly pulse prednisone, systemic...
How soon after starting treatment would you repeat imaging in patients with Takayasu to monitor response and ensure you have the correct diagnosis?
The optimal imaging frequency and imaging modality with which to monitor disease activity in TAK are not well defined. I would highlight some general concepts that I find helpful in determining the best monitoring strategy for a given patient. 1. Imaging interval should generally be shorter in patie...
Have you used Karius to aid in the diagnosis of a non-resolving pneumonia, with negative bronchoscopy, biopsy, and other infectious work up in an immunocompetent patient?
Culture-negative hospital-acquired pneumonia is approximately 50%. Positive cultures are complicated by having to correlate results clinically as organisms may contaminate specimens (even if from a protected brush) and include an organism that doesn't even cause pneumonia, such as Enterococcus spp. ...
How do you counsel your breast-cancer survivors about weight-loss/dietary modifications?
Normal body mass index (BMI) and maintenance of weight is associated with a more favorable outcome (in many series both cancer-related and non-related) compared to higher BMI. Similarly higher level of exercise and metabolic equivalent (MET) is also associated with better outcome in many observation...
What would be your index of suspicion for AL amyloidosis with cardiac involvement in a patient with MGUS to prompt further imaging (and which modality would be preferred)?
In short, we will usually be concerned for potential underlying AL cardiomyopathy (AL-CM) in a patient with MGUS if they have symptoms/signs of heart failure. NT Pro BNP is very sensitive for detecting cardiac involvement of amyloid (Zhang et al., PMID 33283202) and troponin can also help. While the...
Would testing for ATTR cardiac amyloidosis be considered in an older patient with bilateral carpal tunnel surgeries and multiple spinal stenosis surgeries, but no obvious cardiac symptoms?
I would not look for ATTR-CM in the absence of cardiac findings such as abnormal echo (increased LV thickness) or conduction abnormalities that are suggestive. Only 10% of patients with bilateral CTS have ATTR-CM. I would do an echo if not done and review ECG. As much as we are concerned about under...
What is the role for iothalamate clearance testing for glomerular filtration estimation in patients with chronic kidney disease?
No role in my opinion. There is a false security for wanting and knowing an "exact" GFR. The eGFR reporting mandate is more a public health issue than useful for individual decision-making. AND iothalamate clearance as a measure of GFR has its own flaw (we did plenty of them in our prior studies wit...
How do you counsel patients regarding risks of cannabis use?
I am in agreement with Dr. @Dr. First Last. Both alcohol and cannabis are legal in most states now, and use is not uncommon in patients of all ages. My stance: Rare/occasional use... probably not going to cause much problem (physical or mental) unless you are addiction prone, or if there is any fami...
How frequently do you monitor for hypocalcemia in patients on romosozumab?
I do not know the clinical safety data well. In my own practice, I never saw anybody get hypocalcemia. I assume the potential cause of hypocalcemia is the anti-resorptive effect of the drug. Before any osteoporosis drug. I get a good chemistry panel, PTH level, vitamin D level, and when appropriate ...