Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should a toe-brachial index be obtained in lieu of resting ABI as an initial screen for PAD in high-risk patients such as those with longstanding diabetes or advanced age with stiffened vessels?
Yes, a TBI should be used instead of an ABI in patients with diabetes and chronic kidney disease as the ABI is likely to be inaccurate due to non-compressible vessels. An arterial duplex and TBI should be the test of choice in this patient population.
Would you consider coronary artery calcium scoring or coronary CTA for asymptomatic elite competitive sports athletes undergoing routine screening visits, without a family history significant for coronary artery disease?
I think that would be a "bridge too far" given no family history of premature CAD if we are speaking about a young athlete. If we are speaking about an obese 65-year-old who recently retired and has decided to train for a marathon which has been his/her goal for many years, then yes, coronary calciu...
For young adults (20-39 years of age) with moderate hypercholesterolemia, should we aim to reduce LDL-C levels by > or equal to 50% and maintain them on long-term statin therapy?
Cumulative lifetime exposure to elevated LDL levels is associated with cardiovascular events. That is, even modest elevations of LDL, if present for a long time, can contribute just as much if not more to risk than late-life, elevated LDL. In observational studies, the cumulative lifetime exposure t...
Can DOACs be a reasonable alternative (instead of VKA) for management of LV thrombus post-MI and what is a reasonable follow-up time for surveillance outpatient imaging and subsequent duration of therapy outpatient?
DOAC use is reasonable and would reecho at 6 months. Further therapy is dependent on echo results.
Should statin initiation be considered in young adult patients with autoimmune disease or chronic inflammatory conditions without an elevated ASCVD risk score given risk of underestimation of underlying CVD?
I would if the cholesterol/LDL is elevated or if there is a family history of premature CAD. Otherwise, additional risk stratification with a CT coronary calcium score would be appropriate.
What is your approach to a young adult patient with significant nail psoriasis and not much cutaneous disease?
This is a great question and honestly it depends on how aggressive the patient wants to be. An algorithm could look like this but ultimately you’d discuss it with the patient and see where they stand: Tazarotene +/- Calcipotriene during the week and clobetasol on weekends vs. taclonex or wynzora ev...
How do you manage anti-seizure medications at follow-up in patients who had acute symptomatic seizures due to PRES?
Repeat MRI in 6 months to see if there is a resolution of PRES changes. If resolved and no clinical history concerning for sz then repeat EEG. If EEG and MRI are negative, with no clinical symptoms then slowly taper of AED. Also educate the patient while tapering of meds there is risk of sz, (thi...
When should you discontinue narrow band UVB when a patient is in clinical remission from patch stage mycosis fungoides?
It depends on the patient, and whether they have a history of flaring after stopping phototherapy. In that setting, maintenance phototherapy (once weekly or sometimes every other week) may be helpful.
What recommendations do you have for a transgender female patient with history of prothrombin gene mutation who is interested in starting gender affirming hormone therapy?
A review of the literature suggests that the risk of VTE associated with hormone therapy in this setting is quite low, even in the presence of other risk factors for clotting (see, for example, Mullins et al., PMID 33753543). Furthermore, the presence of an asymptomatic prothrombotic genotype is rar...
Do you continue to routinely screen for renal involvement in a patient with established Sjogren's syndrome who otherwise has only sicca symptoms?
In an article published in Rheumatology and Therapy in December 2021 titled Renal Disease in Primary Sjogren's syndrome. The authors encouraged yearly screening for renal disease as it can occur at any time during the disease course.