Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Is it safe to use quinacrine in SLE patients with a history of hydroxychloroquine-associated retinopathy?
To my knowledge, quinacrine, an anti-malarial, is not FDA-approved for use in the US. It may be obtained from compounding pharmacies but the FDA makes no assertions regarding either its safety or its efficacy. For lupus, it has been used primarily as adjunctive therapy for cutaneous disease, e.g. ad...
How do you utilize at-home seizure monitoring devices for your patients with epilepsy?
Absolutely! All video recordings are useful; home videos, cellphones, security cameras, etc.Benbadis, PMID 36891282
What is the optimal approach to treat isolated diastolic hypertension?
Isolated diastolic hypertension occurs less commonly in the adult population, where the majority of the outcome trials in hypertension have been conducted. Much of the treatment of hypertension in younger patients is extrapolated from these trials. In my practice, I look more closely for secondary c...
What recommendations do you offer for patients who have a peritoneal dialysis catheter and who wish to swim?
Exercise is an important part of health maintenance for all individuals, including those with ESKD requiring peritoneal dialysis (PD). Swimming is an excellent form of exercise for PD patients because it is not associated with increased intra-abdominal pressure, and is a low-impact aerobic activity ...
How often do you monitor the eosinophil count after initiating anti-IL5 therapy for HAE?
First, I monitor the eosinophil count to determine that the medication has reduced the numbers of eosinophils. Second, I do not have a regular (established) schedule for testing after that. I do usually obtain a CBC and diff at each clinic, namely about every six months. Third, I pay particular atte...
How would you confirm the diagnosis of splenic marginal zone lymphoma without utilizing splenic biopsy or splenectomy?
You can usually make the diagnosis by immunophenotyping of peripheral blood and bone marrow. The typical morphology of circulating cells is "villous cells"; cells with long cytoplasmic projections around the entire perimeter of the cell. The typical phenotype is CD20+ (bright), CD5-, CD10-, CD23- as...
What work up do you recommend in post bariatric surgery patients who are slowly gaining back the weight despite no changes in diet?
Depending on which surgical procedure they had and how long ago they had it, patients may need evaluation by their surgeon. Meanwhile, I approach these patients similarly to patients who have not had surgery. I look for reasons for their weight gain such as change in diet (even if patient denies it ...
What is your threshold to repeat a kidney biopsy in a patient with a history of lupus nephritis who is on maintenance therapy and develops subtle changes in urinary protein excretion or microscopic hematuria?
There have been a number of lupus biopsy and treatment questions here lately. The management of lupus nephritis is VERY difficult with innumerable permutations of past and present, biopsy nuances, symptoms, and treatment histories. The answer to this question depends on more than "subtle changes in...
How would you manage an elderly patient with mild pancytopenia who refuses bone marrow biopsy and whose flow cytometry is suggestive of CMML/MDS?
My management would be tailored depending on the age of the patient, and more importantly, their goals of care. For geriatric patients who are not transplant eligible, the goals of therapy are focused on improving quality of life. Depending on the counts, you may still be able to obtain valuable NGS...
For patients with central hypothyroidism and a clear etiology (such as recent head irradiation), do you recommend brain imaging prior to starting thyroid hormone replacement therapy?
Levothyroxine does not cause tumor growth, and therefore you do not need to image before starting therapy. However, in general, it takes a long time for central hypothyroidism to develop after radiation, therefore in the presence of an early reduction in FT4 you must consider the possibility of the ...