Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the normal range of spinal tap opening pressure?
Normal range is variable based upon supine versus sitting up, diurnal variations, etc., but the most important thing is what is considered "Low" and "High". For any patient, despite of age and BMI, supine opening pressure above 250 mm of water is considered high, and <6 mm of water is considered low...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
What antithrombotic regimen do you recommend prior to and in anticipation of CEA for patients with symptomatic carotid stenosis?
Dual antiplatelet therapy with aspirin and clopidogrel
Do you counsel patients against driving who presents with transient global amnesia?
No. A single episode of TGA is usually isolated and I would never consider driving precautions. No data suggests that an episode of TGA suggests an increased risk of LOC or seizures in the future. Additionally, I am not aware that TGA itself poses a driving risk.
When would you add acyclovir for treatment of Bell's Palsy in addition to steroids and symptomatic care?
At onset along with steroids and PT for neurostim and other modalities.
Would you recommend short-term dual antiplatelet therapy for a patient who received tPA, and is otherwise eligible for dual antiplatelet therapy per POINT or SAMMPRIS trial?
I would recommend dual antiplatelet therapy for 21 days for eligible patients. The risk of recurrence is highest in the first few days and patients will likely still benefit. I would just ensure the patient has no hemorrhage in their 24-hour scan and they would otherwise meet the criteria for the CH...
What is your practice for the timing of resumption of oral anticoagulation after ICH?
These are great questions and no good answers (therefore the question). In the near future, well-designed prospective studies and clinical trials will settle the uncertainties.Timing of resumption of anticoagulation has been addressed in modeling studies of risks of recurrent bleeding and thromboemb...
How do you approach the treatment of SREAT (steroid-responsive encephalopathy with autoimmune thyroiditis) after initial pulse dose steroids?
The diagnosis of this disease entity is hugely debated. I myself do not think that the diagnosis exists. A large segment of the normal population has antibodies and the goal of Rx in supposed cases is unclear/poorly defined.
Would you favor restarting anticoagulation or pursuing left atrial appendage closure in a patient with hemorrhagic stroke on anticoagulation for non-valvular atrial fibrillation?
That is a great question, thank you for bringing it up. The answer really depends on the likely etiology of the intracerebral hemorrhage. For example, if the hemorrhage is subcortical and the etiology is thought to be likely related to hypertension, it is reasonable to resume anticoagulation when sa...
How do you approach the workup of a patient with incidentally found pachymeningitis?
In general, when we think about the meninges, we consider the leptomeninges and the pachymeninges separately, though many of the disorders of one can also cause disease in the other. We also consider whether the pachymeningitis is focal and nodular or diffuse. Common causes of pachymeningitis are in...