Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to post-operative prophylactic anticoagulation for patients undergoing minimally invasive surgery for gynecologic malignancies?
Recommendation:This is a great question; one our group has recently been discussing. My current practice is to advise patients with gynecologic malignancies undergoing minimally invasive surgery (MIS) to receive extended prophylaxis (4-week course of apixaban) depending on individual risk factors. A...
Is there any reason to stop mesalamine in a patient with UC undergoing breast/regional nodal radiation?
I have run into this situation a few times and have not stopped mesalamine during breast radiation. Have not noticed any issues.
What treatment modalities do you offer patients who have ataxia?
This is a great question; thank you for posting it. Approaching management for ataxia like many neurodegenerative movement disorders is a two-pronged approach of physical/occupational/speech therapy and oral therapeutics.Physical therapy can improve balance and mobility in hereditary and cerebellar ...
At what intervals do you obtain DEXA scans for patients on antiseizure medications?
In patients with thrombocytosis with negative MPN workup from peripheral blood and bone marrow, is there a role for daily 81mg aspirin or other treatment?
In the absence of an MPN, there is no data to support the use of low-dose ASA. Unless there was extreme thrombosis and acquired von Willebrand syndrome, there would also be little reason to bring the platelet count down as well. In the absence of MPN, thrombocytosis itself is not a risk factor for t...
What guidance do you give to patients and families regarding resuming vaccination after completion of chemotherapy?
In our practice, for vaccine series that have not been started or only a single prior dose has been administered, we recommend a new vaccine series according to the CDC regular or catch up schedule. For vaccine series that have been started with at least 2 prior doses, or completed, we recommend a s...
In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?
Not a lot of controlled trials that address each situation so we rely on expert consensus and judgement, and more importantly, balancing the risk of hemorrhage vs thrombosis. ASH guidelines define chronic persistent risk factors as 1) Active cancer (e.g., ongoing chemotherapy; recurrent or progressi...
How would you approach osteoporosis management in a patient who fractures while on denosumab therapy?
This is a scenario that we run into at times and is very difficult with data suggesting a decline in BMD after discontinuation of denosumab as well as data from DATA-Switch trial from 2015 revealed that switching from denosumab to teriparatide resulted in progressive or transient bone loss. I would ...
How do you manage a patient with superficial venous thrombosis with close proximity (<3 cm) to deep veins and an inherited thrombophilia ?
I would treat the patient for 3 months with a DOAC and then repeat the scan. If the clot is resolved, I would order a d-dimer and Factor VIII level on anticoagulation. If the tests are negative, I would stop the DOAC and retest at 30, 90, and 180 days. If tests remain negative then stay off anticoag...
Given the "LDL Paradox", in which RA patients with the highest levels of inflammation can have ultra-low levels of LDL (<70), how do you approach initiation of statin therapy in these patients?
Evaluate lipids at the time of remission/low disease activity and if elevated and the patient is a good candidate for statin therapy, initiate a statin using criteria for the general population.