Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How are you deciding between injectable and oral formulations of buprenorphine, given new studies suggesting injectable performs similarly in regards to safety and efficacy when compared to oral buprenorphine?
The study referenced here was a randomized trial evaluation of the initiation of buprenorphine in an emergency room setting, comparing long-acting injectable formulations with transmucosal formulations. It showed that both formulations are safe and effective even for patients with active/recent fent...
Would you consider sotalol to be a suitable non-selective beta blocker for primary prevention of variceal bleeding in a patient who requires sotalol for treatment of arrhythmia in the setting of Fontan-associated liver disease and clinically significant portal hypertension?
The answer to this question will need to be case-by-case, unfortunately.The short answer:The priority in this patient's case for using sotalol is likely the underlying heart disease and its associated arrhythmia, and this cardiac benefit would not be achieved by carvedilol and other NSBBs. Thus, it ...
Do you obtain liver biopsy to confirm the diagnosis of cirrhosis if cirrhotic liver morphology is noted on imaging?
This question touches upon two interesting trends: 1) There is an increasing trend in Radiology to report "cirrhotic liver morphology" in the "Impressions" section. When you then review the Body of the report, often these cases are noted to only have a heterogeneous appearing liver with surface nodu...
In patients with inflammatory bowel disease with low rectal cancer with planned proctocolectomy, would you consider creation of a pouch?
This is a very difficult case- are you speaking of Ulcerative Colitis or Crohn's disease? If UC - can consider pouch but really depends on the stage of the primary rectal cancer. If neoadjuvant chemoradiation is given, the likelihood of an ileoanal J-pouch functioning appropriately is low. Generally...
How do you screen for colon cancer in patients with Behcet syndrome with colonic involvement?
Behcet syndrome, unlike some other rheumatologic conditions, for the most part, has not been shown to increase risk of malignancies in patients. This may in part be due to the fact that the disease tends to get milder/less severe with time and treatment. As such, colon cancer screening should follow...
What role do you feel there is for antibiotics in the management of severe perianal Crohn's disease?
Without access to biologics you still should have access to a thiopurine. That has some efficacy and was all we had prior to biologics along with chronic antibiotics.
How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?
Patients with Crohn's Disease (or IBD) can develop features of large vessel vasculitis or even other forms of vasculitis. The first consideration in a young patient would be determining the type of vasculitis--whether there is a distribution and clinical picture suggestive of TAK. It is important to...
What diet do you recommend for patients with inflammatory bowel disease?
This is a good question and very commonly comes up. The first step is really understanding what the expectations and goals are. If the goal is to achieve remission in people with inflammation who are symptomatic and want to use diet as monotherapy or in conjunction with meds, I discuss various thera...
How do you approach caring for patients admitted with decompensated CHF, but who also exhibit hypotension and do not have overt signs of hypervolemia on exam?
This is a case where you might be concerned about the patient sliding into cardiogenic shock. Remember that in the context of chronic heart failure, cardiogenic shock tends to present more insidiously because these patients are typically compensated at low or borderline low cardiac output (Abraham e...
How do you adjust medications for patients with eosinophilic esophagitis who responded to budesonide or PPI, and when do you repeat EGD?
Repeat EGD after BID PPI is normal- do you decrease to once-a-day PPI? When to repeat EGD if ever? I try to decrease to once daily in the morning, but if so, I repeat an endoscopy 3 months later to make sure histologic remission is still maintained. After response to Budesonide, continue life-lo...