Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you routinely hold SGLT2 inhibitors prescribed for CHF or CKD in acutely ill patients upon admission to the hospital?
Thanks for this great question. The use of SGLT2 inhibitors in the hospital has been increasing dramatically, given their great effects on CKD and CHF for both diabetic and non-diabetic patients. There are simple direct contraindications for using SGLT2s, which would include patients with ketosis in...
How can I incorporate neuromuscular ultrasound into my practice with limited prior experience?
I think it's awesome when anybody is willing to implement a new tool into their established clinical workflow. My suggestion, if you are already an EMGer, would be to start small and simple with a focus on upper extremity focal neuropathy and practice, practice, practice.Carpal tunnel syndrome and u...
How do you manage perioperative anticoagulation for a patient with a history of recent, surgically provoked VTE?
In most cases, bridging is rarely indicated because the bleeding risk usually outweighs the risk of VTE recurrence during a short (1–2 day) interruption of anticoagulation. However, after a recent VTE (defined as <3 months), the estimated risk of VTE recurrence is high (>15–20% per year) (still low ...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...
What is your approach to bisphosphonate use in patients with advanced chronic kidney disease and osteoporosis?
I have used serum markers of bone turnover in decision-making for patients with chronic renal disease, both to initiate treatment and to monitor response. This seems to have a basis in the literature (Smout et al., PMID 35703216).This approach has also helped to minimize doses of oral bisphosphonate...
What is your treatment algorithm for management of retroperitoneal fibrosis that does not respond to high-dose glucocorticoids?
There are a number of caveats to this. Is the retroperitoneal fibrosis biopsy-proven and/or IgG4 disease ruled out? If a case is refractory, I first question whether the diagnosis is correct and will often biopsy in this situation with more than an FNA biopsy. The second question is how long have t...
What techniques do you find most helpful to optimize image acquisition for cardiac POCUS in patients with poor acoustic windows?
For the parasternal windows, your enemies are ribs and lungs. Regarding ribs: Whenever an image gets dark, people tend to try and crank up the gain knob to compensate. In many cases, however, it's usually because one of the edges of the probe is abutting a rib. Try and slide the probe a few millimet...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
What is your clinical approach to deprescribing vs continuing low-dose aspirin used for primary prevention in older adults who are already taking this medication?
I generally continue a low-dose aspirin in patients at higher risk (e.g., diabetes, CKD, strong family history) who would be at risk for a significant reduction in quality of life were s/he to have a cardiac/vascular/cerebrovascular event, provided there is no history of significant anemia (transfus...