Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to the management of pressure ulcers in bedbound older adults who are community-dwelling?
Management of pressure ulcers in bedbound community-dwelling older adults centers on three pillars: Pressure off-loading, nutritional optimization, and stage-appropriate wound care, supported by an interdisciplinary approach that includes caregiver education. Pressure Off-Loading This is the single ...
Do you feel high dose Symbicort or Dulera is appropriate to use for SMART despite these doses not being studied in clinical trials?
One of the primary purposes of SMART therapy is to provide extra doses of ICS to patients inadequately controlled enough to use rescue inhalers. The other major purpose is to do this with a single inhaler instead of 2 or 3. So if the patient's baseline asthma is severe enough to require high-dose Sy...
Do you routinely recommend transition to dual PO antibiotic coverage for strep species and MRSA, for patients with purulent cellulitis and in the absence of culture data?
I use mostly Linezolid because: It’s now much cheaper. Even if on serotonin drugs, I can half the serotonin dose while they are on it. Covers pretty much all Strep and Staph, including MRSA. Protein synthesis inhibition may reduce toxins (like clinda in Strep fasciitis). There is no renal dose adju...
How do you counsel patients on the risks and benefits of chemotherapy or radiation offered with palliative intent?
Before I start counseling a patient on these decisions, I want to know a few things first. I would want to know from the oncologists what they think the benefits are (i.e., how much more time might they get? Symptom control?) and what the risks are. The chances that the patient will see a benefit. ...
What is your approach to antibiotic selection for bacterial species that demonstrate susceptibility to penicillins or cephalosporins on testing, but are known to harbor inducible AmpC resistance?
I will assess how long I am treating the person/infection, and go from there in terms of how likely I am to induce the AmpC based on the duration of treatment. For example, if it's a 7-day course for UTI or GN bacteremia, I may risk the penicillin/cephalosporin (based on susceptibilities, of course)...
Do you recommend IV sodium bicarbonate for patients with rhabdomyolysis and AKI without metabolic alkalosis or hypocalcemia?
The primary goal of IV fluids and urine alkalinization in patients with rhabdomyolysis is to prevent AKI, not to treat established AKI. The most important factor in preventing AKI is early and vigorous fluid administration (aiming to achieve a brisk diuresis of 200-400 ml/hr), while the choice of IV...
What is your approach to the management of asymptomatic bacteriuria in an elderly patient without clear urinary symptoms but with cognitive changes and falls?
Asymptomatic bacteruria does not cause altered mental status. Data suggests that when we attribute acute changes to it, we will be wrong about 85% of the time, thereby missing the true etiology. It is a difficult thing to educate staff of senior living facilities and families who have been told it w...
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
What is your approach to managing sclerosing mesenteritis (mesenteric panniculitis)?
I have seen and followed dozens of patients with this diagnosis. As noted above, it is important foremost to be sure of the diagnosis. Mesenteric panniculitis can be part of the IgG4 associated spectrum and so a biopsy is useful if it can be done safely. The other disease in the differential is carc...
What baseline work-up or "staging" do you do in patients with a new diagnosis of Sjogren's (i.e., PFT, cryoglobulins, complement, RF, UA)?
The baseline workup I like to do in patients newly diagnosed with Sjogren's are the following lab tests with rationale: ANA (almost all patients have a high titer ANA that is positive - typically it is a speckled pattern Extractable nuclear antigen (ENA) testing looking for SSA (anti-Ro antibody) +/...