Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you recommend switching a diabetic CKD patient on oral semaglutide to the subcutaneous form since the benefits in CKD have primarily been reported in studies using subcutaneous GLP-1 receptor agonists?
Personally, I would not do so today. Obviously, the patient was prescribed oral semaglutide (SEMA) as opposed to injected SEMA for some reason. Assuming that the reason persists (e.g., preference for oral, greater availability) and the response with respect to A1c and weight has been reasonable, I w...
Does norethindrone suppress FSH, LH completely?
I don't think progesterone alone would suppress LH and FSH completely so other pituitary hormones should be checked and if low, check MRI of sella. Also check for other exogenous hormone use/OTC supplements.
Do you consider skin involvement associated with tattoos to be a marker of disease activity and an indication to start treatment in a patient with sarcoidosis?
Some patients give a clear history of swelling/pain/itch of tattoos coincident with extra-cutaneous symptoms. Others report no relationship. The variability may be related to the age, number, and size of the tattoos and the pigments they contain. Tattoos that cause symptoms should certainly be treat...
How do you counsel patients on migraine "triggers"?
What often triggers headaches or migraines is not just one factor acting alone, but rather a combination of triggers compounding together. Consequently, it's generally more effective and less demanding to prevent triggers from compounding, rather than avoiding them altogether. However, the first ste...
What is your institution's active surveillance protocol?
The topic of active surveillance continues to evolve in light of the PIVOT trial and rapid adoption of mpMRI for initial staging. The 2014 NCCN guidelines summarize commonly used approaches, does not yet advocate for mpMRI, but declares an urgent need for more research. Meanwhile, the 2014 NICE Guid...
Should we be more concerned about cardiac toxicity following breast radiotherapy?
The way I interpret the data with all caveats that threshold dose and time period for any cardiac morbidity is significantly lower than what was expected. For that reason, all efforts should be made to avoid any direct photon beam wherever possible to go through any portion of heart by using any one...
What is the difference between involved node and involved site irradiation?
In both involved node and involved site (ISRT), prechemotherapy GTV determines the CTV. However, ISRT accommodates cases in which optimal prechemotherapy imaging is not available to the radiation oncologist. In ISRT, clinical judgment in conjunction with the best available imaging is used to contour...
Should I decline to treat a patient with a first site of metastasis who refuses a biopsy?
Ideally, all patients with a first site of metastatic disease should have a biopsy. However, the details are critical. Is the location amenable to a bx? Is the patient's performance status poor? Has it been an extended period of time since treatment for the primary disease? Is it a solitary metastas...
Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?
I think looking at data both show very similar sensitivity and specificity for staging and is matter of expertise and resources available at the institution.
Should early referral to palliative care be standard of care for all patients with metastatic cancer?
There are data to support that early palliative care involvement can improve patient quality of life. One study that specifically comes to mind is a study published by Temel et al in NEJM 2010 (http://www.ncbi.nlm.nih.gov/pubmed/20818875) in the setting of metastatic NSCLC. This study randomized pat...