Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach post-operative VTE prophylaxis for renal transplant in patients with a prior history of provoked VTE?
I am not aware of published systematic reviews, risk models, or evidence-based guidelines for post-operative prophylaxis in renal transplant patients. Given both increased risk for VTE and bleeding, it is not surprising that there is a large variation in practice (for relatively recent survey on t...
What EKG findings are most concerning when screening asymptomatic athletes in the outpatient setting?
The first answer is quite simple: anything that fulfills the International/Seattle Wash U/Stanford criteria for further evaluation of young athletes was first proposed in 2011 by Uberoi et al., PMID 21824936, and subsequently modified Drezner et al., PMID 28258178.From my personal experience, I "lig...
When would you consider offering PVC ablation for otherwise healthy patients with preserved LV systolic function?
I would generally not offer an ablation for PVC burden alone but may consider further workup/counseling or even ablation if other factors are present. I would obtain a more detailed history to determine if the patient has symptoms/limitations that they did not initially express, which would lead me ...
Is there a role for nocturnal supplemental oxygen as opposed to no therapy in patients with OSA who are unable to tolerate PAP therapy?
I do not use supplemental oxygen as a sole therapy for sleep-disordered breathing (SDB). Treatment with Positive Airway Pressure (PAP) is the initial treatment of choice for SDB. There is no indication to use supplemental oxygen for patients who do not accept or tolerate PAP therapy. Instead, oxygen...
Have the results of the ancillary study of the VITAL trial, demonstrating that Vitamin D3 supplementation did not reduce the incident rate of fractures in generally healthy midlife and older adults, changed how you prescribe Vitamin D?
It should be appreciated that the function of vitamin D is to maintain a serum calcium concentration in a normal range to maintain neuromuscular function and most metabolic functions. It can accomplish this by increasing intestinal calcium absorption. When there is inadequate calcium in the diet, th...
Would you consider teriparatide use in a patient with prior radiation therapy, given that the black box warning regarding osteosarcoma risk has been removed by the FDA?
The rat studies were unequivocal that both teriparatide and abaloparatide increased the risk of osteosarcoma in rats given high doses for essentially their entire lifespan. Upon approval of teriparatide, Lilly agreed to a post-marketing pharmacovigilance study that started out as a case-finding stud...
Is there a role for SGLT-2 inhibitors in the treatment of chronic hypomagnesemia?
A meta-analysis of 18 randomized controlled trials showed that the use of SGLT2 inhibitors can result in a significant increase in the serum magnesium level. These trials, however, were not specifically designed to assess the effect of SGLT2 inhibitors on the serum magnesium level. Studies have show...
Do you have a preferred oral magnesium formulation for patients with hypomagnesemia secondary to Gitleman syndrome and who also have chronic diarrhea?
Compared to other magnesium supplements, magnesium glycinate tends to cause less diarrhea and is better tolerated by my patients with Gitelman syndrome.
How do you manage a DOAC if interested in testing for lupus anticoagulant?
Testing for anti-phospholipid antibodies encompasses two broad categories of testing. One is an ELISA based (aka solid phase) set of tests that include anti-cardiolipin and anti-beta 2 glycoprotein I antibodies. ELISA assay are not affected by DOACs. For the second lupus anticoagulant (aka fluid pha...
What are the indications for anticoagulation in splenic infarctions?
A great reminder that splenic infarct relates to ARTERIAL thromboembolism and not to VENOUS VTE. Too often, I see massive, blind thrombophilia work-up for (incidentally) detected splenic infarcts.