Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to counseling severely frail older adults regarding their planning for invasive life-sustaining therapy?
My approach is pragmatic, evidence-based, and bi-directional. Patients/family make the decision, but I ensure they are fully informed about the pros and cons and provide them time to think through.
Would you initiate anti-arrhythmic drug therapy in patients who are asymptomatic and have normal LV function but with a PVC burden > 20 percent?
I overall agree with Dr. @Dr. First Last's approach. There are important considerations with high-burden PVCs beyond LVEF. The morphology can be helpful with regard is this consistent or atypical appearance of idiopathic PVCs. I will typically do an assessment for underlying structural heart disease...
With the growth of non-alcoholic beverages (e.g., NA beer, liquor, etc), how do you approach a patient's consumption of these products in the setting of alcohol related liver disease?
This is definitely a challenging conundrum to deal with. Historically, even the NA beverages would have 0.5% alcohol, so they weren't truly NA. With time, that has seemingly changed. Regardless, my approach is the same. I strongly advise against the idea that NA beverages are allowed. Mostly because...
Do you prefer using unfractionated heparin or low molecular weight heparin in stable patients presenting with NSTE ACS awaiting primary PCI (assuming normal renal function)?
Unfractionated heparin, with its much shorter T 1/2, is preferred to enoxaparin (T 1/2 12 odd hours), even in the era of transradial procedures (as opposed to transfemoral cases with higher bleed risk).
How do you counsel patients who are interested in using kratom for chronic pain management?
I am not a pain management expert, but would recommend against use for chronic pain management. Risks outweigh in a significant order. It's not FDA-approved for any form of pain treatment. There is no dosage reference to use. The pain control one gets may be too low compared to the addictive risks, ...
How do you counsel patients with blepharospasm regarding driving?
I do not have a specific protocol for driving with blepharospasm, so I would advise assessing each case individually. Occupational therapy can perform standardized driving assessments for safety if there is a concern.
What would be the clinical role of SGLT-2 inhibitors for lupus nephritis given it has an indication for proteinuria related to CKD?
The benefit for SGLT-2 inhibitors at slowing the progression of kidney disease or death from cardiovascular causes had been well established in patients with diabetic nephropathy. Further studies continued to demonstrate benefit in non-diabetic, proteinuric kidney disease (HR, 0.72 (95% CI, 0.64-0.8...
How do you approach titration or transitioning to Cobenfy in patients currently on an antipsychotic?
Antipsychotics with significant anticholinergic activity, such as olanzapine and clozapine, can add to the effects of trospium contained in xanomeline-trospium combination. Product labeling reads "Concomitant use of COBENFY with other antimuscarinic drugs that produce anticholinergic adverse reactio...
Should we be recommending a specific daily protein intake to prevent sarcopenia in geriatric patients, or do you find it more beneficial to focus on encouraging activity within their mobility limitations to preserve muscle mass?
Muscle mass decreases about 3–8% per decade after the age of 30, with this rate of decline increasing after age 60. (Holloszy, PMID 10959208 and Melton et al., PMID 10855597). Hospitalizations also cause acute muscle loss, disproportionately more in older adults."Among medically stable older adults,...
How have the results of the U.S. POINTER study involving multidomain lifestyle interventions to protect cognitive function influenced your practice?
Let me start my response by acknowledging that I was a site PI for this study at Wake Forrest.I think this study was important because it gives us more data that a healthy lifestyle can delay the onset of cognitive changes. As a dementia specialist, it is great to be able to counsel patients who hav...