Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What immunosuppressant will you choose in a patient with necrotizing myopathy partially responding to IV steroids and IVIG with a history of non Hodgkins lymphoma?
The decision should be taken in collaboration with the patient’s oncologist; however, Rituximab would be a reasonable choice to add given that IMNM generally responds well to it (particularly anti-SRP) and that it has a favorable safety profile concerning malignancy.
Which patients with rectal cancer who have not received neoadjuvant treatment do you offer adjuvant radiation to?
In order to answer this question, we may need to step back and first review the indications for radiation treatment in the neoadjuvant setting.Neoadjuvant concurrent chemoradiation or short course radiation treatment is considered to be part of the standard treatment (recommended by guidelines) for ...
In hospitalized patients with significant lower extremity edema, how can you integrate bedside POCUS findings with clinical assessment to guide the decision to start empiric anticoagulation for suspected DVT before formal imaging?
Great question! Especially if the significant lower extremity edema is asymmetric, it sounds like your clinical suspicion would be quite high. When you order a "duplex" study, the sonographer is using 2D ultrasound (aka B mode... white dots on black screen) + Doppler ultrasound (color and spectral)....
What is the clinical significance of a low titer RNP, negative Sm, but Sm/RNP that is very high titer?
Important question as I've seen clinicians incorrectly interpret anti-Sm-RNP as anti-Smith antibody.The different autoantibodies (RNP, Smith, Sm/RNP) react to different antigens as follows: Anti-RNP can react to multiple components (antigens) of the U1 small nuclear RNP particle (snRNP), Anti-Smith ...
What medications have you found helpful in the treatment of stimulant use disorder?
I don't have a slam-dunk 'go-to' medication for stimulant use disorder. I try to employ community reinforcement and contingency management strategies and treat any comorbidity with medication targeted to the symptoms of that comorbid condition. While there is some data supporting stimulants for stim...
How do you approach stimulant-related insomnia for pediatric patients who are otherwise good responses to low-dose stimulant treatment for ADHD?
Clonidine 0.1 mg qhs is my first choice if I have to use something. However, first consider decreasing the stimulant dose or changing to a shorter-acting stimulant. Or go with Strattera so you can use a lower dose of stimulant. Or go with guanfacine so you can also use a lower dose of stimulant. Sti...
Is there a role for routine LP in HIV patients with disseminated histoplasmosis even in the absence of CNS signs/symptoms?
I would not recommend routine LP in the absence of CNS symptoms as it is unlikely to change the management of the infection in someone who has disseminated disease. Prolonged therapy will still be used and as opposed to Cryptococcal meningitis where intracranial pressure management is critical, ther...
Is Metformin contraindicated in patients using long term oxygen therapy at home?
If a patient is stable at home without hypoxia on oxygen and eGFR is over 30 cc/min, I would be comfortable with prescribing metformin at a dose appropriate to the eGFR. Metformin should be stopped for any pulmonary decompensation or hospital admission.
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...