Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What treatment / management strategies do you find helpful for cannabis use disorder?
I don’t think I really see that problem in primary care. There are plenty of patients now, it seems the elderly more than young patients, using daily cannabis, and some are even on medical cannabis. I prefer the medical cannabis as the dispensing organizations are highly regulated, which is not true...
In patients with moderate calcific mitral stenosis, possible HFpEF and dyspnea on exertion, how would you differentiate the etiology of the symptoms?
I would consider a dobutamine stress echocardiogram to evaluate the flow across the valve as well as diastolic parameters. If this does not answer the question, an exercise right heart catheterization could be helpful and could also look into concomitant pulmonary hypertension as a cause of dyspnea....
How soon after an elective, uncomplicated coronary intervention would you feel comfortable having a patient travel by air?
Usually, 3-5 days after uncomplicated PCI. But in the era of transradial and 5-fr sheaths, and in the absence of Sx, with preserved LV EF, this may be truncated to 48 hours.
At what age are you comfortable to start prescribing spironolactone for acne in adolescent females?
When I first reported the utility of spironolactone in women, I was concerned about possible development issues,in young women particularly muscle development which is influenced by androgens. After consulting with pediatric endocrinologist colleagues at Children's Hospital Philadelphia who saw no c...
What outpatient therapies do you recommend for continuous or severe pain from migraine that is refractory to acute therapies?
I assume that what we are dealing with here is what we call a migraine status or status migrainosus. This refers to a migraine headache that has continued well beyond its usual duration, for which we often use the arbitrary three-day mark. We base this mark on the erroneous assumption that migraine ...
Would you offer TPO-RAs to a steroid-refractory chronic ITP patient with history of stroke?
Yes, if needed, though with a bit of trepidation, and it probably wouldn't be my first choice. Second-line chronic ITP treatment can include TPO-RA, rituximab, or splenectomy, and no one treatment is clearly better than the others (Neunert et al., PMID 31794604). Both splenectomy and TPO-RAs have in...
What duration of antibiotics do you use in patients with Actinomyces osteomyelitis, i.e., do you stop after 6 weeks or do you give a longer oral antibiotic course?
With actinomycosis at any site, I would treat for a longer duration than other causes of osteomyelitis. Bioavailable oral agent for 4-6 months after a couple of weeks of intravenous antimicrobials has been my practice.
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
I am a radiation oncologist and palliative care physician.I teach: "the hand that writes the opioids, writes the laxatives - or else it does the disimpaction". Opioid induced constipation is very common, can cause physical and psychological discomfort, and have a major impact on quality of life. It ...
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
I am a radiation oncologist and palliative care physician.I teach: "the hand that writes the opioids, writes the laxatives - or else it does the disimpaction". Opioid induced constipation is very common, can cause physical and psychological discomfort, and have a major impact on quality of life. It ...
Are there scenarios in which you would advise using benzodiazepines for the treatment of hyperactive delirium?
The only situation that comes to mind is in patients who have active alcohol or benzodiazepine withdrawal as the etiology of their delirium. Outside of that, I do not use benzodiazepine therapy for delirium due to the risk of adverse effects (including prolonging the delirium) and lack of any data I...