Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What medications would you have a patient avoid with an IgE mediated reaction to cyclobenzaprine?
The mechanism of immediate hypersensitivity to cyclobenzaprine is likely MRGPRX2-mediated rather than IgE-mediated. MRGPRX2 is a G-protein coupled receptor (GPCR) predominantly expressed in human mast cells. Upon activation, MRGPRX2 triggers mast cell degranulation and anaphylactic reactions. MRGPRX...
In what cases do you use baclofen for alcohol use disorder?
As Dr. @Dr. First Last mentioned, it's generally not a first-line choice (at least in the US). It is much more popular in Europe, but efficacy usually comes at notably higher doses. In one case series from 144 patients treated with baclofen in a French clinic, the mean maximum dose was 211 mg daily ...
What is your preferred first line management of alcohol use disorder with concomitant depression?
I continue to recommend FDA approved AUD treatment options regardless of concomitant depression - offering naltrexone as a first line and acamprosate as a first line alternative and disulfiram (for those interested in complete abstinence and have someone who can help assist in accountability for dai...
What is your preferred first line management of alcohol use disorder with concomitant depression?
I continue to recommend FDA approved AUD treatment options regardless of concomitant depression - offering naltrexone as a first line and acamprosate as a first line alternative and disulfiram (for those interested in complete abstinence and have someone who can help assist in accountability for dai...
How do you approach screening for occult cardiac or tracheal involvement in a patient with relapsing polychondritis?
Hello! Dynamic CT and echo, if you have suspicion of vasculitis (physical exam, sx), a CTA can help. Happy to discuss your case.
Is asymptomatic long QT syndrome a contraindication for starting AIT?
No.
What is the rationale/evidence to support doing 4 puffs of albuterol vs. 2 puffs for a reversibility study?
The rationale per ATS in 2005 is that 4 puffs of albuterol is higher on the dose-response curve and thus would potentially avoid getting a suboptimal (< 12%, < 200 mL) response from 2 puffs. Having said that, there was a study of this issue in 240 pediatric patients showing non-inferiority of 2 puff...
Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden > 20 percent?
I overall agree with Dr. @Dr. First Last's approach. There are important considerations with high-burden PVCs beyond LVEF. The morphology can be helpful with regard is this consistent or atypical appearance of idiopathic PVCs. I will typically do an assessment for underlying structural heart disease...
With the growth of non-alcoholic beverages (e.g., NA beer, liquor, etc), how do you approach a patient's consumption of these products in the setting of alcohol related liver disease?
This is definitely a challenging conundrum to deal with. Historically, even the NA beverages would have 0.5% alcohol, so they weren't truly NA. With time, that has seemingly changed. Regardless, my approach is the same. I strongly advise against the idea that NA beverages are allowed. Mostly because...
How do you counsel patients with blepharospasm regarding driving?
I do not have a specific protocol for driving with blepharospasm, so I would advise assessing each case individually. Occupational therapy can perform standardized driving assessments for safety if there is a concern.