Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to managing pyoderma gangrenosum recalcitrant to oral steroids?
Pyoderma gangrenosum is notoriously difficult to treat. The first thing I'd recommend in a case refractory to steroids is to reconsider the diagnosis. Notably, a high percentage of PG is misdiagnosed, so lack of response may indicate that you are dealing with a mimicker (e.g., infection, neoplasm, v...
When would you consider a diagnosis of peritonitis in a patient with SLE?
As noted in the question, clinically significant peritonitis is unusual/rare in lupus patients. In 25 years, I have seen two patients I was convinced had lupus peritonitis. The common thread was that both of them had had at least one abdominal surgery for an acute abdomen. The patients were known to...
Would you prescribe vaginal estrogen cream for vaginal dryness to a patient in her 40s with a history of stage IA granulosa cell tumor?
Systemic serum absorption after use of low-dose vaginal estradiol inserts (such as 10 mcg estradiol tablet or 7.5 mcg/day estradiol ring) is very low. One study (Notelovitz et al., PMID 12039110) showed that baseline serum estradiol levels were 7-8 pg/ml in postmenopausal women. With the use of a 10...
Should in-office oscillometry for lung function measurements be utilized in pediatric patients who are unable to reliably perform spirometry?
We don't use oscillometry right now in our office, but the current issue of Annals has several outstanding editorials and reviews looking at oscillometry and how to implement it in your practice. I highly recommend looking at these papers:Link to whole issueEditorials: Oscillometry-determined small ...
How do you counsel patients and caregivers on dietary interventions for autism?
Whole foods diet, e.g., Whole30.com. All the information on that website is free. I will remove common food allergens. Remove all synthetic food dyes. 100% organic to protect the microbiome. Consider a spore-based probiotic for a few months.
What are outpatient strategies to mitigate taxane-induced peripheral neuropathy?
At the present time, there are no established means for preventing taxane-induced neuropathy other than limiting the dose that is given. In patients who are receiving taxane therapy and have developed significant neuropathy, ASCO guidelines suggest that discussion should be had with patients with re...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
How do you advise families about the risks and benefits of long-term SSRI use for children who being treated at a very early age (e.g., early elementary school)?
Sorry, but I usually reframe this question when I get it. There is no good data as there is no way to study patients long-term. So to get an idea of what would be required, it would be to randomize a clinical population (anxiety, depression, OCD) to drug and placebo for an extended period to be abl...
How have you incorporated LED light therapies in your practice?
High quality evidence is nearly nonexistent, thus I have not incorporated this into my practice.
What is your approach to treating patients with chronically brittle nails?
Brittle nails is a relatively common condition, but pathophysiology of this nail condition is poorly understood. Thus, there is limited clinical trial data of treatments. Inflammatory, infectious, and systemic and traumatic conditions should be ruled in/out before starting treatment. For all patient...