Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage patients with end stage kidney disease and recurrent ascites who do not have any evidence of cardiac or liver disease?
This is not a common scenario but we definitely see it. More aggressive dialysis is likely the best treatment if possible not only as far as fluid removal but also as far as clearance. Recommend 4 days per week dialysis. If fluid removal is not adequate then would do large volume peritoneal taps eve...
When do you recommend electrical stimulation (Cefaly device) in patients with chronic migraine, if at all?
The Cefaly device provides transcutaneous electrical nerve stimulation to the supraorbital nerves and has regulatory approval both as an acute and preventive treatment. This device and other neuromodulatory therapies are useful in several settings for the treatment of chronic migraine: Some people ...
How do you approach patients that develop atopic dermatitis while on biologics for psoriasis?
We have a few patients on dual-biologic therapy who have features of both psoriasis and atopic dermatitis, where each is severe enough to merit systemic therapy on their own. Probably a little less now with more JAK inhibitors available, but we still have some patients maintaining on these regimens....
Is there utility to ordering biochemical screening labs for global developmental delay?
When suspected, it might be warranted to do an initial screening for metabolic disorders. Genetic testing is also a good idea, starting with a microsomal microarray and fragile X testing. Whole exome sequencing might follow and is becoming more affordable and covered by insurance.
How do you treat patients with stroke thought to be secondary to Lambl excrescence?
Pathophysiologically, these occur through sheer stress to the valvular endocardium causing small areas to be denuded followed by fibrin deposition and microthrombi formation on the endocardial injury, which can embolize. Histopathologically, they have similarities to fibroelastomas (which are larger...
What is your approach to initial assessment of disease extent in patients with Behcet's disease?
As Behcet's syndrome is a clinical diagnosis, the symptoms that a patient presents with dictates the initial assessment, for the most part. A lot of work up is needed to rule out other conditions that may mimic Behcet's syndrome, however, assuming that has been done, evaluation for eye involvement b...
How important do you feel HLAB51 testing is in diagnosing Behcet's disease?
The diagnosis of Behcet syndrome is based on clinical signs and symptoms. Laboratory testing and imaging studies are usually used to rule out conditions that may mimic Behcet rather than confirm the diagnosis. There is a strong genetic association between HLA-B51 and Behcet. About 50–80% of Behcet p...
What is your first treatment of choice in patients with dermatomyositis sine myositis?
Great question! For better or worse, there isn't a great one-size-fits-all answer since choosing the "best" agent means assessing the severity of the disease, assessing if there are extracutaneous manifestations that also need to be addressed (e.g., interstitial lung disease? inflammatory arthritis?...
How do you transition to an anabolic agent in a patient who develops an atypical fracture while on denosumab?
It is not usual to suffer an atypical fracture of the femur from denosumab, however, they do occur. It is useful to start an anabolic agent, either abaloparatide or teriparatide for both augment fracture healing and to treat the osteoporosis. Both abaloparatide and teriparatide stimulate bone format...
How do you manage osteopenia, osteoporosis and calcium / Vit D supplementation in a patient with calcinosis?
Calcinosis is mineralization of the blood vessels. Currently, there is no evidence to support any association with circulating calcium levels and calcinosis. Therefore, calcium and vitamin D supplementation at recommended levels for age will not increase calcinosis. Also, remember that ASCVD, renal ...