Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to managing patients with labile blood pressures secondary to baroreflex failure?
Managing BP in the setting of baroreflex failure or dysautonomia is challenging. It is sometimes helpful to educate patients on realistic expectations. Medications will not be able to replace the baroreflex function. Conservative measures like compression socks during the day, bathroom modifications...
What would be your next step in management of a dermatomyositis patient on hydroxychloroquine and methotrexate whose skin is still active?
There are many different options for this kind of scenario. Depending on the physician's preference, patient's lifestyle, and insurance coverage, one could switch to mycophenolate, which seems to be more effective for skin manifestations, or azathioprine. If the patient did have a partial response t...
What immunosuppressive agents would be available to patients with a history of melanoma?
Generally, we try to use conventional synthetic DMARDs when possible. However, studies in RA have not shown an increase in de novo melanoma or recurrence of cancers more generally with TNF-inhibitors. So this is an option for patients with RA and melanoma history who are not responding to csDMARDs. ...
Do you generally prefer to continue hydroxychloroquine in lupus patients who develop ESRD despite the low likelihood of clinically active disease in this patient population?
Yes, I do. In my experience, nephrologists tend to forget or neglect the use of HCQ. HCQ can prevent lupus flare-ups and progression of disease not to mention CV benefits as well as being helpful in addressing APS if present.
How do you choose between antithyroid drugs, RAI, and surgery for hyperthyroidism patients with existing cardiovascular disease, given their varying effects on cardiovascular outcomes?
This recent JAMA study (Chiung-Hui Peng et al., PMID 38436957), and others like it (e.g., Okosieme et al., PMID 30827829) show higher mortality rates and CV disease in patients receiving ATDs vs RAI, or better outcomes with surgery vs both RAI and ATDs (Liu et al., PMID 35822337). The main reason ap...
What is your recommended dosing regimen for propranolol in treating an infantile hemangioma after the proliferative phase?
Generally, in most infants/toddlers that have infantile hemangiomas that are already in the involution phase, I do not start propranolol, but rather wait until the end of the involution phase and then consider PDL or surgery if needed, based on the location/size/appearance of the residual lesion. Pr...
Do you recommend a patient with recurrent nephrolithiasis who is performing a 24 hour urine collection add a urine preservative or keep the specimen refrigerated?
We always add a preservative that will not interfere with any of the analytes to be measured. Additionally, we recommend refrigeration of the specimen. Stephen B Erickson, MD
How do you approach management for CCUS with severe cytopenias?
This is a very timely question since CCUS is now much better defined. CCUS (Clonal cytopenia of undetermined significance) is not a new syndrome, it is a subset of myelodysplasia (MDS), both of which as late as 1983, were actually known as: "Preleukemia". CCUS is an uncommon form of MDS, which has v...
In asymptomatic patients with unfavorable intermediate risk prostate cancer and a PSA <10, how helpful/reliable and clinically useful is bone imaging?
Bone scans amazingly are still something we discuss, and I imagine when we look back in 5 years at this question (at least I hope), people would think it is unthinkable to order a bone scan for intermediate risk with PSA <10 (let alone in localized PCa) instead of MRI and/or PSMA PET/CT.10 years ago...
How do you counsel a woman with a BRCA1 VUS with a high-risk personal history of breast cancer?
There is real harm to patients by ‘acting’ on the presence of VUS in BRCA1; the majority are reclassified as benign. For those who have access to genetics resources, it is very helpful to discuss these results with certified genetics counselors, and formal post-test counseling for patients is recomm...