Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For older adults undergoing intermediate-risk non-cardiac surgery, do you routinely check pre-operative pro-BNP levels for risk stratification based on emerging data and updated Canadian guidelines?
Pre-operative NT-proBNP and BNP levels have been featured, not just in the cited Canadian guidelines but also in the 2024 update of the AHA/ACC preoperative evaluation guidelines. (Thompson et al., PMID 39316661). Those guidelines recommend evaluating a pre-op NT-proBNP level if the results will cha...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
How do you consider sending fungal studies in a patient with pneumonia?
This is a very good question. One that I’ve meant to look up for a while, so thank you for prompting me to do so. I agree with Dr. @Dr. First Last's answer (he is also my division chief!), but wanted to expand further. The articles I found most helpful are cited below.When to suspect a fungal pneumo...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
How do you evaluate for an ascending UTI in a patient with a urostomy?
Evaluating for ascending UTI in a patient with a urostomy UA Generally low value; chronic pyuria/mucus makes results unreliable. Urine culture Essential; must be collected from a clean stoma catheterization or a fresh pouch, and not from the urostomy bag. Imaging (CT abdomen and pelvis wit...
How do you evaluate for an ascending UTI in a patient with a urostomy?
Evaluating for ascending UTI in a patient with a urostomy UA Generally low value; chronic pyuria/mucus makes results unreliable. Urine culture Essential; must be collected from a clean stoma catheterization or a fresh pouch, and not from the urostomy bag. Imaging (CT abdomen and pelvis wit...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
Are there scenarios that new visits/consults with patients can be done virtually amidst the COVID-19 outbreak?
Starting 3/16, we began offering lower-complexity / lower-risk patients the option of having a Tele-medicine consult vs re-scheduling to a later date. This offer has been extended broadly to all new consults at our facility when the provider indicates that s/he can extend comparable service virtuall...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...
Do you require an ECG to assess the QTc interval before administering ondansetron to a hospitalized patient without a known cardiac history or QT-prolonging medications?
There is a nice "Things We Do For No Reason" article in Journal of Hospital Medicine on this: "Hospitalists need not order an initial and subsequent ECGs when administering standard doses of intravenous ondansetron for patients without significant risk factors for QTc prolongation. To assess risk fa...