Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For patients over 90 years old, is there any foreseeable benefit to undergoing left atrial appendage occlusion over permanent cessation of anticoagulation, particularly for those at high risk for major bleeding?
I would have no qualms about referring a 90+ year-old patient with a-fib and high bleeding risk for an LAA occlusion device. However, this requires a shared decision-making process whereby the risks and benefits of the various treatment options are discussed with the patient and, when appropriate, t...
What is your approach to monitoring of inflammatory markers during treatment of native vertebral osteomyelitis?
As long as the patient is clinically stable and CRP is coming down, there is generally no need for follow up imaging. Key reference: Kowalski et al., PMID 16779743.Also, good to remember that ESR is a very expensive test which basically measures fibrinogen (may cost $500 or more since it has to be r...
When would you consider initiating patients with CAD and aortic stenosis on PCSK9 inhibitors (as an adjunct to statin therapy), given favorable findings in the FOURIER trial?
There are limited data to support PCSK9 inhibitors in the treatment of aortic stenosis, and in fact, most is theoretical. Elevation of lipoprotein (a) levels independently increases the risk of in early-onset CAD and calcific aortic stenosis. Lp(a) levels are lowered by PCSK9 inhibitors by ~20-30%, ...
What is your approach to differentiating tender spots (as in fibromyalgia) and enthesitis (as in axSpA)?
The tender points in fibromyalgia are not limited to tendon insertion sites but are much more generalized, such as in the middle of the muscles of the neck, shoulders and back. Often tender points in fibromyalgia are found at the costochondral junction and at the lateral epicondyle or other tendons ...
How would you treat intermittent hematuria post prostate radiation?
The citation below, good article, and excerpt below, a summary that may answer your question. Our urology colleagues would appreciate it if we initiated a workup like this, but I would always ask the patient to see a urologist as well. HBOT should be considered. “For grade 1 and grade 2 types, sympt...
Do you start immunosuppression for enlarging pulmonary nodules without symptoms, impaired pulmonary function, or extra-pulmonary disease in a patient with sarcoidosis?
First consider whether further diagnostic workup is necessary, to increase your confidence that enlarging nodules, changing pulmonary function, or extrapulmonary disease is due to sarcoidosis. Sarcoidosis patients have an increased risk of cancer in the early peri-diagnostic period, likely due to th...
What is the role of anticoagulation in patients with septic thrombophlebitis?
The role of heparin anticoagulation in septic thrombophlebitis is controversial. There are limited to no randomized trials to document outcomes. A systematic review (Falagas et al., PMID 17222406) supported this practice, and the Infectious Disease Society also supports this practice. The role of or...
Is there a role for biologic therapies in asthma-COPD overlap syndrome with evidence of type 2 inflammation?
While there are ongoing studies regarding the potential role of biologics in COPD care, to date, the data remains unclear. The whole issue of COPD/ asthma overlap syndrome remains controversial and I know of no clear data defining a role of biologics. However, I would suggest that the stronger the a...
How do you interpret elevations in ESR and CRP in the setting of increased BMI?
Increases in BMI (overweight and obesity range) have been shown to be associated with elevated CRP and ESR, with stronger associations shown with CRP specifically. Interestingly, the association between elevated CRP and obesity seems to be stronger in female populations than in male patients.In the ...
How do you approach deprescribing psychiatric medications in elderly patients with polypharmacy concerns?
Briefly, I take 6 steps in my mind to tackle this carefully. Is prescribing really necessary? Can they try non-pharmacological management first? Carefully review the medical, surgical, and social history to avoid possible complications. Thorough medication reconciliation (including OTCs, herbals, ...