Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Other than oxybutynin or mirabegron, what pharmacological and non-pharmacological treatments would you consider for increased urinary frequency (not caused by infection, medications, or resulting in incontinence)?
There are a lot of other treatment modalities, all with benefits and potential side effects to weigh. The place to start, of course, is with behavioral modifications like afternoon/evening fluid management, caffeine reduction, timed voiding, urgency suppression techniques ("biofeedback"), and pelvic...
What is your preferred treatment for arthralgias from AIs?
I usually reassure patients that this is common, and can improve on its own. Because everyone is different i give them options. Duloxetine has the advantage of improving arthralgias, hot flashes and mood. However, a lot of patients are opposed to taking more medication. Acupuncture is effective, and...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
Is there a maximum duration for raloxifene use?
There is relatively scant data on long-term raloxifene use in patients with osteoporosis, but generally, there are no recommendations for a drug holiday. The primary endpoint in the pivotal registration trial, MORE, was incidence of vertebral fracture, and the difference between the raloxifene and p...
Would you use a parathyroid hormone analog for treatment of osteoporosis in a patient with mildly elevated AlkPhos of unclear etiology?
I would be hesitant to administer an anabolic in this setting without first delineating the reason for an elevated AlkPase. I would suggest starting with sorting out the source of the AlkPase (i.e., bone, liver, or gut with measuring bone-specific AlkPase, G-GGT levels, and possibly a liver ultrasou...
How do you approach the significance of +RNP III antibody in a patient with positive ANA but no other signs or symptoms of systemic sclerosis?
RNA polymerase III is a specific autoantibody for a subset of systemic sclerosis associated with severe diffuse cutaneous scleroderma, renal crisis, GAVE, and a strong association with malignancy. If this antibody is identified in the absence of Raynaud's or other symptoms of scleroderma, its signif...
How do you approach the treatment of Crohn's colitis in the setting of immunosuppression for liver transplant?
Good question, as additional immune suppression can increase the risk of infection. The anti-rejection drug mycophenolate can cause diarrhea, which could mimic a Crohn’s flare. I individualize Crohn’s therapy in a liver transplant patient. What type of Crohn’s do they have? What meds were they on pr...
How would you manage and determine the duration of antibiotics for a patient with suspected chronic postoperative spinal implant infection, status post lumbar fusion, now presenting with loosened hardware on imaging, normal inflammatory markers, and no systemic infection symptoms?
Loosening can be identified as lucency around pedicle screws on standard radiography, commonly at the upper or lower ends of the surgical construct. It was graded on a scale of 0-3. High-grade loosening (grade 2 or 3) is associated with increased odds of requiring revision surgery. It can be mechani...
Do you recommend avoiding radial artery access for cardiac catheterization to preserve potential future dialysis access sites in patients with advanced CKD?
With Radial arterial catheterization ( RA-CA), structural damage to the artery manifests as intimal tears and medial dissection along the length of the vessel. Further, even though 2-30% of the arteries will thrombose, about 50% of these will recanalize at 1 month. In spite of this, endothelial func...