Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach a patient with new temporal headache, temporal artery tenderness and TA biopsy with mild thickening, but normal inflammatory markers?
Some more information is needed. Is this bilateral or unilateral and if the latter is there a potential other cause? Was this patient started on prednisone for presumed GCA prior to obtaining the temporal artery biopsy and if so how long before? When were the “inflammatory markers” measured relative...
In which patients with suspected IgA nephropathy and microalbuminuria would you recommend a kidney biopsy?
There are no guidelines to answer this question. This is my approach. In proteinuric patients, with intact kidney function, threshold proteinuria (UPCR) of 0.5 g/g, or UACR <300 mg/g would be an indication to biopsy. In diseases such as IgA Nephropathy, treatment is driven by the degree of proteinur...
What are the important aspects that you mention when consenting patients for hemodialysis?
I will answer this question a little differently than I think was the intent of the person asking the question. I find that many patients are resistant to starting dialysis at first. In my first conversation with them, I will make it clear to them that the problem is the kidney failure and not the d...
Is a bone marrow necessary in patient with splenomegaly and polycythemia vera?
Yes. Bone marrow is necessary in a patient with polycythemia vera and splenomegaly. There is a possibility of missing ET or associated primary or secondary myelofibrosis. The only way to distinguish between the three bcr-abl negative MPN namely MF, ET, and PV is by performing a bone marrow biopsy an...
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...