Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In patients with suspected RCVS, is there a role for preventative CCB if headache has resolved/now asymptomatic?
In short, the use of CCBs in RCVS is only for the prevention of thunderclap headache (TCH) recurrence. Since their purpose is to prevent TCH recurrence, they are often used when the patient is asymptomatic as well (i.e., even after the index TCH has resolved). They do have no impact on eventual clin...
When do you recommend starting a continuous opioid infusion for symptom control at the end of life?
If the RN who is at the bedside and administering intermittent opiate doses is reporting hourly administration/dosing needs, then an infusion may be warranted to optimize pain, comfort, and/or control of symptoms.
What strategies have you found to be most helpful in improving patient compliance with vaginal dilator use after pelvic radiotherapy?
We attempted a randomized feasability trial to a study dilator use and test a theoretically driven enhanced educational program (EEP) to increase adherence, We did not find increased adherence to the EEP program. At present, other than good physician and nursing counselling, I am unaware of signific...
For a patient with vaginal adhesions/stenosis, do you recommend any other therapy besides a dilator?
Yes! In patients who have received radiation and have stenosis I frequently given topical estrogen cream with their dilators to help prevent or treat vaginal stenosis. My patents report that it helps with the pain associated with vaginal atrophy when they try to use their dilator. I treat a lot of c...
Is obesity a risk factor for recurrence after definitive treatment for endometrial cancer?
The most common cause of death in early stage endometrial cancer is not cancer but cardiovascular. Anything to reduce cardiovascular risk would help reduce mortality
How do you manage a screening pap smear result of HSIL and HPV16+ in a first trimester pregnancy?
Colposcopy to rule out invasion; if invasion is suspected, then biopsy. Otherwise, wait until delivery and re-evaluate. It is unlikely that invasive disease will develop in the short time of gestation. I believe these are the ASCCP guidelines.
Do you recommend the HPV vaccination for your young patients with HPV-associated cancers or pre-cancers who have not yet been vaccinated?
Yes, worth getting vaccinated to reduce risk for recurrent dysplasia. Lichter et al., PMID 32282601. Di Donato et al., PMID 33919003. Jentschke et al., PMID 32762871.
How would your follow-up change for a patient, non-surgical candidate, with endometrial cancer treated with definitive radiation?
I assume that the question refers to how follow-up would differ between a patient treated adjuvantly, i.e., following surgery, versus treated definitively, i.e., not a surgical candidate. I think there are quite a few variables here. Probably the most important consideration is the extent to which t...
Do you take patients off anticoagulation for tandem and ovoid or tandem and ring procedures?
We don't take them off anti coagulant for intracaviatry alone unless using a hybrid applicator
Do you routinely discuss HRT with patients that have undergone surgical menopause due to treatment of cervical cancer?
Yes, I routinely discuss it with premenopausal patients and it is an important part of their care. If they will be having chemoradiation for a locally advanced cancer, I will discuss pros/cons of ovarian transposition. With adenocarcinomas, some patients do opt for oophorectomy if a radical hysterec...