Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Based on results from the VOYAGER PAD trial, when would you consider the primary use of rivaroxaban with aspirin +/- clopidogrel as opposed to conventional aspirin +/- clopidogrel in patients undergoing lower extremity revascularization?
Based on the results of the VOYAGER PAD trial, I would consider using rivaroxaban with ASA before undergoing revascularization.
What workup do you initiate for thoracic outlet syndrome?
This is a long and complicated topic and I would propose to read the Consensus reporting standards for thoracic outlet syndrome published in 2016 by the Society for Vascular Surgery (see below). I will summarize a few key points from the article: Diagnosis of neurogenic TOS is basically CLINICAL, an...
What management do you recommend in patients with backpack palsy?
Backpack palsy is a well-known brachial plexus injury, often affecting the upper/middle trunks, resulting from carrying heavy loads on the shoulders and upper back. I used to believe that it is typically a stretch injury causing transient neurapraxia (demyelination) with minimal axonal loss and an o...
What is the preferred imaging modality to evaluate subaortic membranes in patients with aortic valve disease?
Transesophageal echocardiography is the preferred modality for evaluating subaortic membranes, especially if transthoracic echo is equivocal.
How would you interpret a positive single specific markers like SSA or SSB in setting of working up an connective tissue disease, especially when ANA is negative?
Ha! Good question. And this is an issue I literally just talked about with our residents during an autoimmune labs lecture that I give. If you have a negative ANA by IFA (immunofluorescence assay), the sensitivity of such a test is extremely high (99%) as hundreds of antinuclear antibodies are scree...
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...
How often would you repeat testing in a patient suspected of Cyclic Cushing's?
24-hour urine-free cortisol and MN saliva cortisol are preferred tests over ON dex suppression. The exact frequency depends on the severity of the symptoms, generally about every 3 months.
In patients with secondary osteoporosis due to primary hyperparathyroidism, should parathyroidectomy be recommended in the setting of recent prior bisphosphonate use?
I would recommend parathyroid surgery in a person with confirmed primary hyperparathyroidism and osteoporosis as the bone density will increase in most patients after surgery. Many of the patients with osteoporosis may have received bisphosphonates. In rare situations, a patient may have received a ...
How would you evaluate and treat a disabling tongue tremor?
This is a very interesting presentation. First, establishing phenomenology is needed. Is this a tremor or does it appear tremulous? Tremor is oscillatory and rhythmic. If these movements do not fit this pattern, consideration of neuromuscular disorders, like myorhythmia, or other movement disorders ...
What treatment options do you recommend in a patient with idiopathic granulomatous mastitis that has not improved on steroids and methotrexate?
I have multiple cases of IGM that I have treated successfully and have gone into remission or at least not needing any prednisone with azathioprine monotherapy and combo methotrexate and adalimumab.