Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How often do you see bony erosions in patients with Lyme arthritis?
There are three ways that Lyme disease can result in joint involvement. The most common is diffuse arthralgias (not a true arthritis) associated with the acute infection. This is self-limited and does not harm the joint. The second is an inflammatory arthritis that is similar to other infected joint...
Given that high coronary calcium scores portend significantly increased cardiac mortality rates over 5-6 years, is there any data to support performing coronary angiography when the score is very high, e.g. over 1000, even in asymptomatic patients with no objective evidence of ischemia?
The question is; is coronary angiography necessary in asymptomatic folks with extensive CAD on EBCT? Will it tell us more than what we already know; that the patient has extensive CAD? Will it make an asymptomatic patient feel better? Will the information obtained from coronary angiography allow for...
How do you manage introduction of other seeds when the patient has never been exposed and has a sesame allergy?
Since there is considerable cross-reactivity between other seeds, but also with nuts and other foods, one needs to do allergy testing in a sesame seed allergic patient before introducing other seeds. That can be either with prick skin testing or in-vitro testing. However, if one is negative with one...
What is your approach to counseling patients regarding re-initiation of anti-TNF therapy after completion of treatment for non-disseminated pulmonary histoplasmosis?
We published a retrospective study on this topic in 2015 (Vergidis et al., PMID 25870331). We concluded that resumption of TNF-alpha antagonist therapy may be considered in individuals treated for histoplasmosis who have no evidence of residual disease and undetectable Histoplasma antigen levels. We...
At what age do you stop LDCT chest for lung cancer screening?
One of Medicine's three priority-ordered duties is to postpone death. This also pertains to persons who have reached age 81. Lung cancer can occur longer than 15 years after cessation of smoking. Even if surgery can't be done, primary radiation of Stage 1 squamous cell lung carcinoma can result in p...
Do you have a preferred IV iron formulation for pregnant women?
I prefer INFeD, Feraheme, Monoferric, and FCM is okay. INFeD, Feraheme, and Monoferric are also preferred in non-pregnant patients. FCM in non-pregnant patients has a risk of hypophosphatemia, but for some reason, FCM (InjectaFer) does not cause hypophosphatemia in pregnancy, likely due to renal ada...
How do you approach treating and monitoring sarcoidosis manifested by maxillary bone/teeth loss without other symptoms?
I'm very curious how this was determined to be sarcoidosis. Has a PET been done to determine whether this is the only site? Other entities evaluated for like CRMO? Obviously, neoplasm and infection are also important to rule out before immunosuppressive treatment. Conversely, with our limited "tool ...
Which patients, if any, treated according to PROSPECT for an early stage rectal cancer, would you offer surveillance if they achieved cCR after neoadjuvant chemotherapy?
Thanks for the important question. This is a nice but also challenging situation given, at this time, we do not have evidence for organ preservation with chemotherapy alone. Nonetheless, the PROSPECT trial did show approximately 20% of patients indeed achieved pathological compete response (was quit...
Is intermittent fasting effective for weight loss?
Intermittent fasting is a weight loss strategy that cycles between periods of unrestricted eating and brief periods of fasting, with either no food or significant calorie reduction. A wide range of intermittent fasting strategies (e.g. alternate-day fasting and time-restricted daily eating), have be...
Is there a kidney stone size for which you refer your patients with recurrent nephrolithiasis to urology?
Predicting ureteral stone behavior is fraught with error. In general, stones less than or equal to 3 mm in maximum diameter will pass spontaneously if the patient can tolerate the pain. In fact, routine annual follow-up imaging occasionally shows the absence of small stones, but the patient has no m...