Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach conversations regarding discontinuation of transfusions in patients with advanced hematologic malignancies who are otherwise appropriate for hospice?
While not an expert in leukemia care or MDS, the answer is nuanced (both in the care of patients and to hospice agencies). Some hospice programs will make exceptions to blood transfusions depending on how frequent - so it is always good to ask. From a clinical perspective, important to consider whet...
How would you plan a post-op, distal rectal adenocarcinoma s/p neo-adjuvant chemotherapy and APR with minimal treatment response?
The PROSPECT trial evaluated the omission of radiotherapy from preoperative management for cases that presented with a disease that could be resected with a sphincter-sparing TME. In addition, if the disease responded poorly to preoperative FOLFOX, then patients on that arm were required to receive ...
What is your strategy for managing immunosuppression in patients with a kidney transplant who develop metastatic cancer?
This is a difficult situation. I presume this question refers to cancers for which there is no option of cure. We always discuss the goals of care and review with the patient and their treating oncologist what the prognosis might be. If chemotherapy or check-point inhibitor treatment is planned we ...
Do you routinely recommend a sleep study in patients with clinical history of REM-sleep behavior disorder?
I do routinely recommend and perform in lab sleep testing for patients with suspected REM behavior disorder (RBD). The finding of REM sleep without atonia (RSWA) is supportive of a diagnosis of RBD, as atonia is normally presented in individuals (without RBD) during REM sleep. RBD can be a tricky di...
Do you advise your patients with cystinuria to perform home urine pH testing?
Definitely! Keeping urine pH above 7.0 is one of the most effective ways of preventing cystine crystallization. pH testing strips can be purchased cheaply on the Internet or in “big box” stores. (Pharmacies are much more expensive). I suggest testing four times daily and adjusting the urinary alkali...
What are some potential etiologies to consider for isolated, mildly elevated BNP levels with normal TTE findings in an asymptomatic, elderly patient?
BNP and pro-BNP both increase with age, especially in women, and must therefore be interpreted in that context. Pro-BNP less than 300 pg/mL indicates low likelihood for acute heart failure at all ages (though there are exceptions). The recommended age-based thresholds for diagnosing heart failure/vo...
For a patient with idiopathic hypercalciuria and a history of calcium kidney stones who has not normalized 24-hr urine calcium level on thiazide diuretic, is there evidence for targeting a certain urine calcium level for decreased future risk of nephrolithiasis and osteoporosis?
A good question, and the answer depends on your definition of a "normal" urine calcium level. If you use the standard definition of abnormal, the upper 5 percentile, depending on your laboratory, you will get values for upper normal calciuria in the 250-300 mg per day. However, approximately 10% of ...
What nutritional supplements do you recommend for patients with ALS?
I do not recommend specific supplements. If the question relates to the PEG formula, we use basic formulas and higher caloric versions if needed.
Do you recommend continuous glucose monitoring for patients with Type 2 diabetes who are not on insulin?
When CGM technology was first commercialized, the sensors were bulky, uncomfortable, not very accurate, expensive, and required calibration with a blood glucose meter. Now they are quite small, comfortable, much more accurate, much cheaper, and no longer require calibration. It is a matter of time b...
Would you start once-weekly tirzepatide over once daily basal insulin in a patient with Type 2 diabetes with inadequate control on oral antihyperglycemia drugs?
The issue examined in the paper cited of whether insulin or GLP-1RA is a better strategy in the setting of inadequate control of T2D was a hot question in the first part of this century but has been examined repeatedly and is now codified in global guidelines -- GLP-1RA should be used before insulin...