Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What are the potential causes for significant discrepancies between predicted A1c by Dexcom CGM and standard serum A1c by lab draw?
When interpreting A1C and CGM results, it is important to remember that neither measure is perfect. As in all clinical conditions, it is important to evaluate A1C and CGM results in the context of the clinical situation. If there is a disparity between the two measures, one should review the limitat...
How do you approach discussing the pill burden of voclosporin with patients who already have to take a regimen such as MMF+HCQ+ACEi and possibly more?
Medication adherence and a chronic disease such as lupus is an issue regardless of the number of medications. For example, hydroxychloroquine is very effective, but studies often show poor adherence as measured blood levels may be undetectable or below the intended therapeutic target.For patients wi...
When do you consider extending the dosing interval for patients on biologics with CRSwNP?
In patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) who are on biologics, I would wait four (4) symptom-free months before considering extending the dose interval. I can only cite personal experience and not evidence in the medical literature.
How do you decide between ordering coronary calcium scoring versus coronary CTA in asymptomatic patients with low to moderate risk for CAD?
Arteries try to “heal” atherosclerotic plaques by calcifying them. Consequently, the presence of coronary artery calcium (CAC) indicates that there is at least some coronary atherosclerotic plaque. The amount of coronary calcium is quantified using the “Agatston” CAC score. The higher the score, the...
What is your outpatient approach to patients with new-onset paroxysmal atrial fibrillation in the setting of acute illness but who are otherwise asymptomatic with normal sinus rhythm post-hospital discharge?
I tend to individualize my approach. In general, I consider any significant episode of atrial fibrillation with a chadsvasc 2 score =/>2 to warrant long-term anticoagulation provided no bleeding contraindications. An acute illness involving infection, trauma or surgery would not likely steer me awa...
What is the duration of steroids that you prescribe for organizing pneumonia?
The recommended duration of corticosteroid therapy for organizing pneumonia is typically 6-12 months, as supported by clinical studies and expert guidelines: Reference 1: American Journal of Respiratory and Critical Care Medicine suggests prolonged steroid therapy, often lasting 6-12 months, to redu...
What prompts you to procure EEG and/or imaging in patients presenting with multiple simple febrile seizures?
History always plays a key role. Is the child developing normally, and how old is the child? Also, were all of the seizures truly simple, or were there other features that make me suspicious that this is actually a "lower seizure threshold" in a patient with underlying epilepsy? Fortunately, a sleep...
In what cases, if any, do you find the use of naltrexone to augment lifestyle interventions (i.e., cognitive behavioral therapy, graded exercise therapy) for chronic fatigue to be helpful?
Absolutely no.
What is the recommended approach to treating severe constipation in patients on GLP1 R agonist therapy?
About half of the people taking these drugs will experience some of these GI side effects (diarrhea or constipation), at least transiently. When I prescribe these meds, I also “prescribe” daily fiber and adequate fluid intake. They should have smaller, frequent meals rather than large meals in one s...
How do you manage stroke-related abulia?
There is surprisingly little recent evidence-based guidance on this front. Most therapeutic options focus on agonism or potentiation of dopamine in the frontal-subcortical circuits. Depending on the center and provider, options include psychostimulants. Any type might do but I prefer methylphenidate...