Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?
Data about the effect of immunosuppression on the efficacy of immune checkpoint inhibitors suggests that there is a negative of effect of being on immunosuppression at the time of ICI initiation on tumor response. So if the patient really has been clinically stable for a long time there are a few op...
Is there a kidney length for which you would no longer recommend attempting a kidney biopsy due to safety concerns and lack of diagnostic yield?
Yes. I definitely do not biopsy very small kidneys. Where you draw the line is the question. I think it is not only the size of the kidney but also the height of the patient. It may be OK to biopsy a patient with a 7.5 cm kidney who is 4 feet 8 but not OK to biopsy an 8 cm kidney in a patient who is...
Do progesterone only oral contraceptive pills affect cortisol binding globulin?
I do not recall any recent publications, but I am sure old studies have examined this question. Based on my clinical experience, there is no significant effect on total cortisol levels.
What is your treatment algorithm for managing porokeratosis?
Porokeratoses do not necessarily require treatment unless desired by the patient for symptomatic or cosmetic reasons. At minimum, I counsel on the increased risk of squamous cell carcinoma within the lesion and recommend sun protection. If treatment is desired, cryotherapy, topical retinoids, imiqui...
What 60 minute cortisol threshold value do you use for diagnosis of adrenal insufficiency after ACTH stimulation?
It depends on the assay. Different assays measure different things. Mass spectrometry is the most accurate available assay at present, and it measures ONLY cortisol. Immunoassays also detect other related compounds, and vary from assay to assay as to which ones. Discussed in PMID 25877990.
How would you approach post-operative VTE prophylaxis for renal transplant in patients with a prior history of provoked VTE?
I am not aware of published systematic reviews, risk models, or evidence-based guidelines for post-operative prophylaxis in renal transplant patients. Given both increased risk for VTE and bleeding, it is not surprising that there is a large variation in practice (for relatively recent survey on t...
What EKG findings are most concerning when screening asymptomatic athletes in the outpatient setting?
The first answer is quite simple: anything that fulfills the International/Seattle Wash U/Stanford criteria for further evaluation of young athletes was first proposed in 2011 by Uberoi et al., PMID 21824936, and subsequently modified Drezner et al., PMID 28258178.From my personal experience, I "lig...
When would you consider offering PVC ablation for otherwise healthy patients with preserved LV systolic function?
I would generally not offer an ablation for PVC burden alone but may consider further workup/counseling or even ablation if other factors are present. I would obtain a more detailed history to determine if the patient has symptoms/limitations that they did not initially express, which would lead me ...
Is there a role for nocturnal supplemental oxygen as opposed to no therapy in patients with OSA who are unable to tolerate PAP therapy?
I do not use supplemental oxygen as a sole therapy for sleep-disordered breathing (SDB). Treatment with Positive Airway Pressure (PAP) is the initial treatment of choice for SDB. There is no indication to use supplemental oxygen for patients who do not accept or tolerate PAP therapy. Instead, oxygen...
Have the results of the ancillary study of the VITAL trial, demonstrating that Vitamin D3 supplementation did not reduce the incident rate of fractures in generally healthy midlife and older adults, changed how you prescribe Vitamin D?
It should be appreciated that the function of vitamin D is to maintain a serum calcium concentration in a normal range to maintain neuromuscular function and most metabolic functions. It can accomplish this by increasing intestinal calcium absorption. When there is inadequate calcium in the diet, th...