Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage the developmental and behavioral regression seen in Down Syndrome Disintegrative Disorder (DSDD)?
Thank you for this important question. One of the keys is to ensure that the change and regression being seen is DSDD or something else. Sometimes, this is confused with Alzheimer's seen in older individuals with Down syndrome. DSDD is seen in much younger people, late teens, and 20's as a more rapi...
How do you decide between using immediate-release versus long-acting lithium?
In general, long-acting (i.e., controlled release) lithium is thought to cause less nausea and other common side effects (like tremors) than IR formulations but has also been associated with higher rates of diarrhea due to differences in absorption. Another consideration may be the dose you are try...
Should systemic anticoagulation be considered for patients with a less than 1% atrial fibrillation burden on outpatient monitoring with an elevated CHADSVASc score and acceptable bleeding risk?
This is a recurrent question. My policy is to anticoagulate such patients. The cutoff for anticoagulation is still controversial though. I believe that any episodes lasting longer than 5 min deserve anticoagulation. Not so sure what to do with shorter episodes but my philosophy is that prevention of...
How have you incorporated new psoriasis therapies such as deucravacitinib and bimekizumab into your hierarchy of psoriasis treatments?
I have had good success with both deucravacitinib and bimekizumab and these agents are two welcome additions to our psoriasis treatment arsenal. For deucravacitinib, ever since I included it in my list of options in treating psoriasis - as an aside, I used to skip over orals due to lack of efficacy ...
How do you counsel patients on the risks and benefits of an IL-23 agent versus an IL-17A or IL-17A/F agent?
Both IL-17 and IL-23 agents have demonstrated excellent efficacy for psoriasis. Choosing between them often comes down to access and insurance coverage.With that being said, considerations include: Side effect profile: The side effect profile for both IL-23 and IL-17 agents is similar, with the exc...
How soon after excising a keloid do you inject kenalog?
When I possible, I prefer to shave and leave no suture behind. I inject with TAC at the time of the surgery. I wait a few weeks and then start topical imiquimod qohs x 6 weeks and have patients follow up then.
What is your approach to management of tremors in a kidney transplant recipient who is taking a CNI for immunosuppression?
This can be a really vesing problem for patients. My approach is somewhat dependent upon the severity of the tremors. I will sometimes try some low dose propranolol, 10 mg po BID-TID, or more often I will try converting from a the shorting acting forms of tacrolimus (Q12 hour formulations) to the lo...
What is your approach to evaluation and management of GERD in a patient with IPF?
When evaluating GERD in a patient with idiopathic pulmonary fibrosis (IPF), I prioritize obtaining a detailed history of GERD symptoms, as this aids in guiding both diagnostic and management decisions. Many IPF patients may not exhibit classic GERD symptoms like heartburn or regurgitation. Instead, ...
Do you wait on initiating biologic therapy for guttate psoriasis?
First, and foremost, it is important to identify the trigger for guttate psoriasis, which is often caused by step (which requires antibiotics). For most patients, a guttate flare will resolve on its own. When using biologics, we can help clear guttate psoriasis (note, this is largely based on anecd...
Do you check for EGFR and other mutations in patients with squamous cell lung cancer, including in adjuvant setting before considering immunotherapy?
Yes, I do. Our Cancer Institute performs NGS reflex testing for all patients with newly-diagnosed lung cancer, regardless of stage or histology. Although EGFR or other mutations are less common in squamous cell lung cancer, they do exist, and this also allows for testing for other mutations (MET exo...