Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you recommend carotid ultrasound screening at some point post definitive H&N XRT?
Yes. I start 4 years out from treatment. You don’t have to wait for a trial to prove it is effective and cost effective. You don’t want to wait until you’ve seen your first cured patient die or be seriously incapacitated by a CVA. If there are no other risk factors and/or no significant stenosis I ...
Is there a minimum work-up necessary in patients with an ANA greater than 1:160 and no clinical symptoms suggestive of lupus (i.e., specific antibodies, UA)?
My personal practice has been to get the "ANA subtypes" and a UA for prot/Cr ratio, but I do this with the idea of needing to have a complete picture. Clinical symptoms are still king.
How would you approach a patient with end stage kidney disease on peritoneal dialysis who has an adequate Kt/V but persistent azotemia?
This question could serve as the springboard for a very lengthy discussion/ debate regarding PD "adequacy"- a term that ought to be outlawed! That said, I will try to be brief. First off, it must be recognized that Kt/V (by default meaning that for urea) is a very poor measure of the quality of dial...
What is your approach to evaluation in patients who present with erythromelalgia?
Erythromelalgia is a tough condition to treat. I usually break it down into diagnostic workup and treatment as follows: Diagnostic workup: I usually just get a CBC yearly to look for myeloproliferative disorders. Treatment: I have not had a lot of luck with topicals being too effective, so I usuall...
Would you consider switching choice of P2Y12 inhibitor for patients with ISR (non-ACS presentation), with acceptable bleeding risk?
There is no need to change P2Y12 inhibitor in case of ISR without ACS. There are no studies that suggest such approach is indicated or can be helpful. Also, patients are taking their current P2Y12 inhibitor for a while and they are used to the medications. Changing the medication can raise cost with...
How do you apply the CDC PrEP guidelines for cisgender women, particularly when faced with underreported risk behaviors or uncertain partner HIV status?
This can be quite difficult, especially in places like where I live in Texas, where PrEP literacy is low. There is still a lot of education that needs to take place in the community about how HIV is still a threat that you can do something about, particularly for women. On a global basis, getting th...
Do you recommend avoiding ESAs in pregnant patients with anemia of chronic kidney disease who also have preeclampsia?
Yes
What are your strategies for safely prescribing peritoneal dialysis for patients who have pets at home?
Pets are an important part of many people's lives, giving comfort, joy, relaxation, companionship, and even providing opportunities for exercise - therefore we should not exclude patients from home dialysis simply due to the presence of pets in the home. Some key strategies to help reduce PD complic...
When do you begin antifibrotic therapy for a patient with newly diagnosed ILD that is not IPF?
The evidence behind starting anti-fibrotic therapy for non-IPF ILD is largely based on the results of the INBUILD trial where patients who have non-IPF ILD who demonstrate progression (based on at least a 10% decline in FVC or a 5% decline in FVC with worsening symptoms or radiologic progression) ha...
What pentoxifylline and vitamin E dose do you typically use for both the prevention and treatment of radiation-associated fibrosis after breast RT?
Pentoxifylline 400 mg three times daily and Vit E 400 iU once daily.In a small retrospective review, tolerance to Pentoxifylline was improved with the use of concurrent antiemetic therapy. Of those on antiemetic therapy, 89% completed pentoxifylline as prescribed versus 48% of those without antiemet...