Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Due to the thrombotic nature of COVID-19, should we be discontinuing tamoxifen temporarily in patients with an active infection?
It is not clear (at least to me) what the thrombogenic potential of COVID-19 is, or in what settings it manifests (i.e., hospitalized patient with an increasing O2 required or intubated, in which there are some preliminary reports, versus the asymptomatic or minimally symptomatic patients). It seems...
Should patients about to start radiation be required to have COVID-19 testing, if resources are available?
We are also pre-testing all procedural cases using PCR, but are doing symptom/question screening for all outpatients, not allowing visitors outside of special situations, and maintaining social distancing in the hospital (decreasing areas for patients to sit) so they are forced to remain apart. The ...
Are patients with bleeding disorders receiving plasma-derived products at increased risk of acquiring COVID-19?
No. The current process of manipulation of plasma derived products eliminates SARS-Cov-2. SARS-CoV-2 is a large virus (120 nm diameter) with a lipid envelope. Therefore, it is highly susceptible to processing steps used in processing such as solvent-detergent, low pH incubation, caprylate-pasteuriza...
Do you routinely prescribe anticoagulation for patients on active chemotherapy?
This is dependent on the risk factors of the patient for the development of VTE. Recently published ASCO guidelines (JCO 2019) incorporated the additional recommendation of VTE prophylaxis for high risk outpatients receiving chemotherapy with either eliquis, xarelto, or LMWH. The Khorana scoring sys...
Should new patients requiring chemotherapy be tested for COVID-19 prior to starting treatment?
At Vanderbilt, we are testing asymptomatic patients for COVID if they are getting a 'high-risk' regimen, which we have empirically defined as: CAR-T cells, BMT, combined chemo/XRT, regimens normally requiring growth factor support etc. There are not great data to advise on specific risks for specifi...
When do you stop immunosuppressants in patients with GPA?
It depends on the severity of the initial presenting symptoms and which organs were involved. However, generally, I don't stop all treatments and maintain the patient on at least MTX or azathioprine, potentially for life, even if these were not part of the initial remission-inducing regimen, such as...
Would you anticoagulate a patient with an isolated arterial thrombosis in the setting of an inherited thrombophilia?
The situations in which anticoagulation is clearly required in cases of arterial thrombosis are: stroke or systemic embolism in association with atrial fibrillation or mechanical heart valves or presence of a mural thrombus (where anticoagulation with an appropriate agent should be administered prop...
When sending patients for follow up chest CT's after SBRT or chemoRT, how do you determine whether to send for scans with or without IV contrast?
My rule for lung SBRT has been to minimize the use of contrast given the patient population we are treating (elderly, frail, and a desire to minimize kidney stressors), and the fact that we are following lung parenchymal lesions which are generally well visualized without contrast. I also have never...
How do you approach the decision of whether and when to initiate therapy in patients who remain COVID-19 positive >2 weeks after infection but are asymptomatic from the virus?
If the patient is asymptomatic or minimally symptomatic, we have elected to initiate therapy for the patient. We have treated the patient in full PPE at the end of the day with no other patients in the clinic. Efforts should be made to minimize patient contact throughout the clinic. We have the pat...
What is your next step in patients with polymyositis without interstitial lung disease who are refractory to methotrexate?
In general, first-line treatment for myositis patients includes methotrexate, azathioprine or CellCept. The exact choice of agent depends on concomitant manifestations of the disease, like lung disease or arthritis, and can move on to the next one if they fail one of them. At the same time though, w...