Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach treating idiopathic aortitis?
Before classifying a patient as ‘idiopathic’ or ‘clinically isolated aortitis’ (CIA), one must carefully consider that the aortitis may be a manifestation of a systemic condition, particularly giant cell arteritis or Takayasu arteritis. Other systemic diseases associated with aortitis include IgG4-...
What duration of dual antiplatelet therapy do you use for secondary prevention of ischemic stroke due to intracranial atherosclerotic disease?
It is a fair question that we don't have a solid evidence-based answer for. I agree that the SAMMPRIS trial was driven by events within the first 30 days, although this was primarily driven by procedure-related events in the stented group. We do know that intracranial athero (ICAS) risk of stroke re...
What is the right approach in terms of GDMT and device consideration for patients with intermittent LBBB (QRS duration exceeding 150ms) and HFrEF?
I would not consider an intermittent left bundle as criteria for BiV pacing. I would actually not consider it in my assessment of heart failure gdmt or device therapy in isolation, whatsoever.
How do you manage patients with chronic migraine as well as medication overuse headaches?
I agree with Dr. @Dr. First Last about the treatment for chronic migraine and MOH for patients on opiates and/or barbiturates. If they are taking frequent opiates, I prefer to have a pain management doctor detoxify them. In the past, I slowly decreased their medication while giving them long-acting ...
How would you manage gout with hyperuricemia >10 mg/dl despite the maximum dose of allopurinol plus probenecid and a prior allergic reaction to pegloticase?
I am not sure what dose of allopurinol the patient is taking, how long he was on pegloticase, and if he had MTX or MMF with it. I can usually reduce the uric acid level with allopurinol and febuxostat. The key question here is whether the patient is taking the drug daily or not.
How do you time Evenity after completion of Forteo?
If a physician is considering transitioning an osteoporotic patient from a PTH treatment to romosozumab, there is no reason to delay. It should be fine to start romosozumab immediately upon discontinuing PTH if it is clinically indicated. However, it is important to remember that romosozumab has a b...
When can abdominal surgery be safely performed for presumptive ovarian cancer in a patient with recent pulmonary emboli?
In general, the standard approach is to try to wait as long as possible after the thrombotic event, at the very least three months. This may not be possible, we then reduce that time interval to one month. Given the urgent nature of the surgical intervention, one approach is to wait one month and co...
Do you diagnose obstruction by the criteria of FEV1/FVC < 70% or < LLN?
Using lower limit of normal for FEV1/FVC ratio may reduce misclassification of airway obstruction but despite years of discussion and arguments it remains unclear whether it is a better approach. The simplicity of the fixed ratio approach to me remains a very important consideration and it is the ap...
What is the indication for phlebotomy in compound heterozygous hemochromatosis?
The indication for phlebotomy is proven or strongly suspected iron overload. The likelihood of expression in these individuals is low. An elevated ferritin is often due to reasons other than iron overload such as fatty liver or alcohol intake. I usually do a liver ultrasound in this circumstance. If...
Would you recommend AV fistula placement in a CKD Stage 5 patient who is over the age of 80?
An elderly patient who is functionally independent (i.e., not frail) without comorbidity (suggesting good survival) & good vein mapping may proceed with AVF creation if he/ she decides they want dialysis. This has to be done at least 9 months prior to HD. Predicting when HD will be needed is itself ...