Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you use clinical decision tools, like HERDOO2 or DASH, to determine duration of anticoagulation in venous thromboembolism?
I do not use the clinical decision tools as I find that they do not properly account for all variables that impact anticoagulation decision-making in a patient-by-patient case.
Do you routinely use hypertonic saline for pulmonary toileting in patients with non-CF bronchiectasis?
We routinely use hypertonic saline (3% or 7%) inhaled twice daily with oscillatory PEP therapy in non-CF bronchiectasis. The Aerobika device is helpful as the saline can be directly administered through the device with an Aeroeclipse nebulizer, which many patients find more beneficial. I have found ...
How do you manage a patient with no history of miscarriage but who is unable to conceive, who has a positive lupus anticoagulant without diagnosis of antiphospholipid syndrome?
I would be very leery of linking infertility to a positive lupus anticoagulant result. Whether or not the patient has antiphospholipid syndrome the evidence linking antiphospholipid antibodies to infertility (as opposed to loss of an established pregnancy) is somewhere between weak and nonexistent. ...
How do you plan to use canakinumab for the treatment of gout?
I recently had this approved for a gentleman with severe tophaceous gout who does not want to be on allopurinol due to mobilization flares and had anaphylaxis to pegloticase. He has CKD and multiple cardiac comorbidities which limit colchicine as prophylactic agent and difficulty with controlling bl...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
How do you instruct patients taking sucralfate?
I have been prescribing carafate for many years now and to this day I don't know if it helps patients or if compliance is possible. I would be curious to know what the experts think.
Which patient population would benefit most from cellulose and citric acid (Plenity) therapy for weight loss?
Theoretically, this could be a treatment option for patients who do not have insurance coverage for/cannot afford GLP-1RA, and who are not candidates for alternative therapy with phentermine, qsymia, or contrave (perhaps due to high blood pressure). However, the weight loss benefit of treatment with...
Would you consider dual antiplatelet therapy for stroke prevention for ICAD in patients with a history of SAH?
It depends on the strength of the indication for DAPT and the cause of SAH. It is important to keep things in perspective: the absolute risk reduction from DAPT for secondary stroke prevention in the POINT, CHANCE, and THALES trials was small (on the order of 1-3% absolute risk reduction) for minor ...
In patients with embolic stroke and a PFO, how often do you go beyond venous Doppler of the lower extremities to screen for DVT (e.g. MRV or CTV abdomen and pelvis)?
No other testing; treat with anticoagulants long term or until PFO fixed & no venous clots.
How do you manage patients with post spinal tap headaches?
There are two tracks of treatment to consider in these patients. The conservative path would be laying supine as much as possible or bed rest, aggressive hydration including intravenously, and caffeine consumption. This should be the first step and tried for 24 to 48 hours before considering procedu...