Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
If prompted as an outpatient, how do you counsel patients on the rare cardiac complications of vaccinations including myocarditis?
Not a common event so the incidence is low and depends on patient exposure as to why getting vaccinated in the first place and always a good idea to discuss the risks and benefits of vaccination.
When is the best time to consider left atrial appendage closure for secondary stroke prevention in patients with atrial fibrillation?
There is equipoise about the timing of left atrial appendage closure following ischemic stroke. Due to the need to temporarily treat a patient with either dual antiplatelet or anticoagulation therapy, it is reasonable to wait until after the acute stroke period has passed to allow for healing of inf...
Should GLP-1 agonists be weaned in patients who have achieved goal weight loss and glycemic control?
This is a good question that comes up often. The short answer is no -- GLP-1 receptor agonists should not be weaned after achieving goals. There are several trials where GLP-1RA has been discontinued after 6 or more months of therapy and weight regain is substantial on average and the loss of glycem...
Do you utilize serial MRI imaging in patients with axial spondyloarthritis to ensure good disease control or do you rely on symptoms and physical exam to assess treatment response?
The ACR 2019 guidelines recommend that MRI could provide useful information in cases where the level of disease activity was unclear and where this information would influence treatment decisions. For patients with nr-axSpA, the imaging should focus on the sacroiliac joints. In interpreting MRI resu...
How does omalizumab play a role in the armamentarium of atopic dermatitis?
There are various reports (>30 citations) in the literature documenting Xolair efficacy in atopic dermatitis. The study designs include randomized placebo-controlled trials, retrospective case series, and case studies.A review of the literature published in 2019 by Holm & Thomsen, PMID 30717578 prov...
Are there patients with gout in whom you would choose febuxostat first line over allopurinol for urate lowering therapy?
While both allopurinol and febuxostat have shown efficacy in reducing uric acid levels, in most cases allopurinol remains the first-line choice with and is considered safe. The main exception is for patients of Asian descent (especially Chinese, Korean or Thai) or who are Black, as they have a much ...
What is your approach to patients with severe sicca symptoms and history of B Cell lymphoma?
For your patient with SjD, B-cell lymphoma, and severe sicca; in addition to treating them with HCQ, I would also: Be diligent with treating the sicca sxs proactively to prevent dental loss and vision problems using the previous guidelines (Zero et al., PMID 26762707 and Foulks et al., PMID 25881996...
What steps do you recommend to ensure continued viral suppression and prevent drug resistance in an HIV patient on injectable cabotegravir and rilpivirine who misses their scheduled injection appointment by two weeks?
When the patient returns to clinic, I would check an HIV VL and CD4 count and simply restart the same ART (cabaneuva). If the VL comes back high then resistance testing should be performed and the ART can be adjusted.
What additional studies would you obtain for a patient with end stage kidney disease on hemodialysis who has persistent hypercalcemia and low PTH?
No studies or measures until I got the patient off Vit D, sensipar, and possibly Ca-based binders, and watched for a couple of months to see if PTH came up and hypercalcemia resolved. This is typical adynamic bone disease until proven otherwise.
What is your approach to management of radiation-induced bullous pemphigoid?
Bullous Pemphigoid (BP) is a pruritic autoimmune blistering disease characterized by tense bullae that is rarely caused by radiotherapy. There have been >30 reports in the literature related to RT with most being localized to the radiated location, with rare reports of BP at non-irradiated sites or ...