Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to patients with chronic kidney disease who are found to have pelviectasis without hydronephrosis on renal ultrasound imaging?
Good question. I would involve urology early on. I would get more history as to other signs/symptoms of urinary obstruction (nocturia, BPH symptoms, history of retroperitoneal fibrosis). Then, consider a Lasix urogram.
How would you treat a patient with rectal cancer with a solitary lung metastasis, who now has no evidence of disease after total neoadjuvant therapy followed by rectal surgery and resection of the solitary metastasis?
Surveillance! Assuming this patient received “complete” total neoadjuvant therapy with at least 3-4 months of systemic therapy, preoperative radiotherapy to the pelvis and curative intent operations to the pelvis and lung with no evidence of residual disease on post-op imaging- this is the early out...
Do you warn patients about suicidal ideation when starting anti-seizure medications?
Yes. I always discuss with every patient the FDA's warning on increased risk for suicidal ideation and behavior when I start an antiseizure medication (ASM). Here are the reasons: Nowadays, patients go to the internet and review the adverse events of prescribed medications. In the case of ASMs, the...
Is there a specific INR cut-off value that would prompt you to consider administering vitamin K for patients with mechanical valves requiring urgent non-cardiac surgery and if so, what would be your starting dose?
For urgent surgery that could result in significant bleeding, I would give vitamin K if the INR was 1.6 or higher. I would avoid high doses of vitamin K so as to allow more rapid anticoagulation post-op. Usually one dose of 5mg is enough. I would start low molecular weight heparin post op until INR ...
What exfoliative regimen do you recommend for patients with recurrent plantar keratoderma?
Keratolytics are my go-to for keratodermas, particularly urea 40% or ammonium lactate. You can also have salicyclic acid compounded with propylene glycol, although I have rarely had to do this. For certain patients, it is helpful to soak the feet for 10-15 minutes, file down areas with a pumice ston...
Is there a role for the use of biologics as steroid sparing agents in treating patients with ABPA who are intolerant to prednisone?
Treatment for ABPA is generally guided by IgE levels and corticosteroids remain the main drug therapy regardless of classification in both people with cystic fibrosis (CF) and without. Limited treatment with antifungal therapy (itraconazole or voriconazole) is considered usually first in individuals...
Do you recommend patients consume dairy products over taking calcium carbonate with meals if they have recurrent calcium based nephrolithiasis and persistent hyperoxaluria?
I generally consider the decision between dairy and calcium tablets in the context of other medical conditions. For instance, if the patient has surgical or medical short gut syndrome as a cause of hyperoxaluria, I favor using calcium tablets to help compensate for the enteric loss of bicarbonate in...
Do you try to treat the acidosis resulting from acetazolamide in patients with IIH?
In general, I do not treat the acidosis of acetazolamide use as it occurs in everyone taking the drug. I only treat it if the symptoms of the acidosis interfere with the patient's activities of daily living.
Do you recommend checking 1,25-hydroxy vitamin D levels in patients with recurrent nephrolithiasis who have hypercalciuria of unknown etiology?
No, unless they are hypercalcemic or I suspect renal sarcoidosis. Stephen B Erickson, MD
How do you counsel patients on vaping cessation as compared to smoking cessation?
Presently, evidence-based approaches to vaping cessation are not well-developed. Thus, one should approach nicotine vaping cessation in a similar way to tobacco smoking cessation using a stepped care approach. Motivation to quit (versus reduce) use should be assessed and motivational counselling tec...