Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to distinguishing a Jarisch-Herxheimer reaction from a delayed anaphylactoid reaction?
As with most things in medicine, this is context-dependent. The Jarisch-Herxheimer reaction is a systemic inflammatory response to the death of bacteria (most commonly associated with spirochetes and in particular, syphilis), typically in the hours following antibiotic administration. This response ...
What medications would you have a patient avoid with an IgE mediated reaction to cyclobenzaprine?
The mechanism of immediate hypersensitivity to cyclobenzaprine is likely MRGPRX2-mediated rather than IgE-mediated. MRGPRX2 is a G-protein coupled receptor (GPCR) predominantly expressed in human mast cells. Upon activation, MRGPRX2 triggers mast cell degranulation and anaphylactic reactions. MRGPRX...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
What is your preferred first line management of alcohol use disorder with concomitant depression?
The presence of comorbid depression doesn't significantly change the way I think about pharmacotherapy for AUD. I would still consider disulfiram, naltrexone (PO and IM), and acamprosate as equivalent first-line agents. It's worth noting that distinguishing between major depressive disorder and subs...
What is your preferred first line management of alcohol use disorder with concomitant depression?
The presence of comorbid depression doesn't significantly change the way I think about pharmacotherapy for AUD. I would still consider disulfiram, naltrexone (PO and IM), and acamprosate as equivalent first-line agents. It's worth noting that distinguishing between major depressive disorder and subs...
How do you approach screening for occult cardiac or tracheal involvement in a patient with relapsing polychondritis?
Hello! Dynamic CT and echo, if you have suspicion of vasculitis (physical exam, sx), a CTA can help. Happy to discuss your case.
Is asymptomatic long QT syndrome a contraindication for starting AIT?
No.
How do you counsel patients with blepharospasm regarding driving?
I do not have a specific protocol for driving with blepharospasm, so I would advise assessing each case individually. Occupational therapy can perform standardized driving assessments for safety if there is a concern.
Should we be recommending a specific daily protein intake to prevent sarcopenia in geriatric patients, or do you find it more beneficial to focus on encouraging activity within their mobility limitations to preserve muscle mass?
Muscle mass decreases about 3–8% per decade after the age of 30, with this rate of decline increasing after age 60. (Holloszy, PMID 10959208 and Melton et al., PMID 10855597). Hospitalizations also cause acute muscle loss, disproportionately more in older adults."Among medically stable older adults,...
How have the results of the U.S. POINTER study involving multidomain lifestyle interventions to protect cognitive function influenced your practice?
Let me start my response by acknowledging that I was a site PI for this study at Wake Forrest.I think this study was important because it gives us more data that a healthy lifestyle can delay the onset of cognitive changes. As a dementia specialist, it is great to be able to counsel patients who hav...