Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the use and interpretation of the FDA-approved plasma pTau181 blood test for Alzheimer's disease in a community-dwelling older adult with subjective cognitive complaints and a normal cognitive screen?
I follow current guidelines, which recommend against testing in those without objective cognitive impairment, given the high rate of false positives. Unless the pre-test probability is high, I would not test. That having been said, future developments (such as subQ modes of anti-amyloid Rx, greater ...
How do you approach the use and interpretation of the FDA-approved plasma pTau181 blood test for Alzheimer's disease in a community-dwelling older adult with subjective cognitive complaints and a normal cognitive screen?
I follow current guidelines, which recommend against testing in those without objective cognitive impairment, given the high rate of false positives. Unless the pre-test probability is high, I would not test. That having been said, future developments (such as subQ modes of anti-amyloid Rx, greater ...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
In your clinical practice, do you find that patients with moderate dementia due to Alzheimer's see much benefit from increasing donepezil dosing from 10 mg/day to a higher dose such as 23 mg/day?
Personally, I do not see much benefit in increasing to 23 mg. To be fair, I do not do this very often, as our cognitive neurologists that I trained with during fellowship rarely did this, given their experience that 23 mg did not offer noticeably more benefit and often many more side effects. I have...
How long do you treat retroperitoneal fibrosis with immunosuppression?
I normally treat for 9 months to a year depending on response. I have found PET CT useful in determining if there is active ongoing inflammation.
What are best practices for taking care of lung cancer patients during the COVID-19 pandemic?
This is a great question, and as always there is no one size fits all. For patients on active treatment for lung cancer such as chemoimmunotherapy, I continue to stress the importance of hand washing, social distancing, and to work on reducing wait times in the waiting room to limit exposure, etc. I...
What is your view on the potential role of immune-targeted therapies in Parkinson’s disease?
In my opinion, the role of immune-targeted therapies in Parkinson’s disease remains uncertain at this time. While both activated microglial cells and various cytokines associated with immune activation have been detected in Parkinson’s patients, it remains unclear whether these are pathologically si...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
Consideration of risk factors is important. Routinely, someone without these risk factors, and if getting a short burst of steroids, the GI prophylaxis is not given. PPIs carry certain risks, including increased risk of C. Diff infection or even pneumonia. So, they should be avoided if not indicated...
How do you decide when to use acid-suppressive medications for GI prophylaxis when patients are on prolonged corticosteroid therapy?
Consideration of risk factors is important. Routinely, someone without these risk factors, and if getting a short burst of steroids, the GI prophylaxis is not given. PPIs carry certain risks, including increased risk of C. Diff infection or even pneumonia. So, they should be avoided if not indicated...
What is your approach to using pegloticase in patients with congestive heart failure?
Clinical trial data show developing CHF exacerbation in 2% of patients while on Pegloticase treatment, while real-world data show higher numbers (6.4%), so careful patient selection and stabilization of CHF are necessary before starting treatment, and need close monitoring while receiving treatment....