Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What factors would influence your decision to use or avoid heparin bridging in patients with mechanical heart valves resuming anticoagulation after intracerebral hemorrhage?
The main conclusion from the publication by Sakusic et al., PMID 39102615 was that withholding anticoagulation for the first seven days after ICH is safe in patients with mechanical heart valves and bridging with intravenous heparin to coumadin upon resumption of anticoagulation should be avoided. T...
When would you consider aspirin for long term management of unprovoked VTE after initial therapeutic anticoagulation?
The WARFASA trial randomly assigned patients with first unprovoked VTE who had completed 6-18 months of anticoagulation to 2 additional years of aspirin versus placebo. While the study demonstrated a 40% reduction in recurrent thrombotic events, the rates of VTE in those receiving aspirin were still...
How do you counsel patients with bipolar disorder who want to breastfeed?
This is a great question! Many women desire to breastfeed their babies, and providers often encourage the initiation of breastfeeding in the immediate postpartum period. For women with underlying bipolar disorder, this decision can be more nuanced. Nursing a young infant requires multiple feedings ...
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...
When would you consider a kidney biopsy in a patient with longstanding diabetes and hypertension (baseline creatinine 4-5, 4+ proteinuria) who was recently found to have dsDNA positivity?
Only if something changed clinically, urine protein abrupt increase, hematuria microscopic, increase in trajectory of creatinine, or symptoms suggestive of SLE. I feel bad when I biopsy a diabetic only to find diabetic nephropathy, but if you never find diabetic nephropathy, you aren't doing enough...
Should intervention be considered for an intermediate flow-limiting coronary lesion that does not correlate with perfusion defects on stress testing in a patient with atypical anginal symptoms?
This is a kind of question that gets into the realm of the "art of medicine". There are multiple questions within this single question. I will try to answer each of them. What is an angina and what is atypical angina: I have come across a wide variety of angina syndromes throughout my clinical expe...
How do you counsel patients with alopecia on the timing of response and what sort of outcomes they should expect with JAK inhibitors?
The timing of responses to treatment with JAK inhibitors in alopecia areata can be quite variable, although they typically take at least a few months at the minimum. Some patients can notice a substantial response by 3 months of treatment, but that's more the exception than the rule. When I counsel ...
Should metformin be used in women with PCOS for weight loss?
I would not use metformin with the goal of weight loss in PCOS. Its effects on weight loss are modest (probably a few kg at most) and inconsistent. I agree with the Endocrine Society 2013 guidelines and that recommend metformin should not be used for the treatment of PCOS unless there is coexisting ...
How do you decide whether average-risk patients should undergo annual or biennial breast cancer screening?
It's gotten really tricky in the last few years! The ACS and ACR (of course) recommend annual screening, and the USPSTF, as well as other societies, recommend biennial screening. ACS guidelines recommend annual screening from age 45-54, since it seems to make a difference in premenopausal women (bot...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...