Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you consider giving ESA for anemia secondary to chronic kidney disease in a patient with follicular lymphoma in remission and on rituximab maintenance?
Yes. The risk of ESA has been re-evaluated and is not considered a risk of NHL. Even with the prior retrospective data, follicular lymphoma is not a curable disease and therefore ESA would not have been contraindicated.
For rectal adenocarcinoma initially staged as T2N0 and treated with upfront surgical resection, but pathologically upstaged to pT3N0 without high risk features, how do you approach adjuvant therapy?
It is not uncommon for a rectal cancer which was initially felt to be T1-2 and node negative to be revealed to be more advanced stage after surgery. To know what to do in these settings, we have to go “old school” and revisit trials reported in the 1990s, combined with lessons learned in the 2000s.S...
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...