Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How often do you find a food allergy on a skin test in an EoE patient that when avoided will result in significant resolution of EoE?
I do not skin test for food allergies when seeing a pediatric patient with EoE unless they have symptoms consistent with IgE mediated food allergy. My approach is to discuss different treatment options including dupilumab, swallowed steroids, and diet therapy (assuming the patient has already been t...
What are the most effective treatments for flat warts on the face?
Facial flat warts are notoriously difficult to treat. I’ve had success using Tretinoin 0.025-0.05% cr HS MWF HS and iniquimod 5% cr sparingly on the lesions only HS T and Th. It is often slow but steady progress without scarring as long as the patient does not have significant actinic damage.
Would you recommend switching to DAPT for patients on anticoagulation who develop symptoms of a TIA secondary to ICAD?
It is important to remember that there is more to stroke secondary prevention than antithrombotics. Our use of DAPT in ICAD comes from the SAMMPRIS trial, in which patients in the control group did better than expected compared to historical controls with ICAD in the WASID trial. Recall however, tha...
How has the use of CGMs informed or improved your management of patients with pre diabetes or diabetes not on insulin?
Yes. It has led to behavior modification with diet and movement choices.
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
What is your approach for gout flare prophylaxis in patients with diabetes and advanced CKD?
Flare prophylaxis is an essential component of gout management when initiating treatment with uric acid lowering drugs (ULD). It is proven that with initiation of uric acid lowering therapy will induce gout flares, much to the chagrin of patients and doctors alike. Further that flare prophylaxis wit...
What is your approach to urate lowering therapy in patient with gout who is on azathioprine (for example, for transplant), where allopurinol and febuxostat are both contraindicated?
This is unfortunately not an uncommon scenario. As mentioned in the question, xanthine oxidase inhibitors such as allopurinol and febuxostat are contraindicated in patients on azathioprine or 6-MP and using them almost always leads to cytopenias due to azathioprine/6-MP toxicity (even in low doses)....
How do you approach the management of patients with suspected membranous lupus nephritis who are found to have positive PLA2R antibodies?
In a patient with known SLE with proteinuria > 500 mg/g and (+) PLA2R antibodies in the serum, a kidney biopsy would be warranted. PLA2R staining should be performed on the kidney biopsy. PLA2R staining must co-localize on the subepithelial aspect in a granular fashion similar to IgG in PLA2R posit...
How would you approach the treatment for patients with renal-limited ANCA vasculitis who have persistent proteinuria, hematuria, and ANCA titers and have completed a steroid taper and received three doses of rituximab?
Renal limited ANCA is usually MPO associated. Isolated PR-3 involvement of the kidneys are rare. Further information is needed in making a decision for this case. We need to know when the patient was diagnosed with ANCA vasculitis. What was the Serum creatinine at presentation? When was the kidney b...
Do you recommend initiating immunosuppression and plasmapheresis in patients with dialysis dependent AKI in the setting of anti-GBM disease who do not have pulmonary involvement?
Anti-GBM disease is a rare disorder (incidence perhaps 1:1,000,000 adults/year) that is characterized as a small vessel vasculitis mediated by anti-GBM antibodies directed against the alpha-3-chain of collagen IV in basement membranes. Perhaps half of patients have disease that involves both the kid...