Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to using pegloticase in patients with congestive heart failure?
Clinical trial data show developing CHF exacerbation in 2% of patients while on Pegloticase treatment, while real-world data show higher numbers (6.4%), so careful patient selection and stabilization of CHF are necessary before starting treatment, and need close monitoring while receiving treatment....
How do you manage incidentally found venous sinus thrombosis?
I would make sure first that it is not simply a congenitally small sinus. If there is truly a CVST, I would probably treat with a DOAC for 3 months and reassess with CTV.
How do you wean off of primidone in patients with essential tremors?
If a patient has been on primidone for less than one month, it can be simply discontinued in most cases. Slower withdrawal may be necessary in patients with seizures, patients on multiple other medications, or with other abnormal metabolism. For patients needing a slower taper, generally lowering th...
For transgender women patients wanting to address their voice tone, do you first refer to ENT (i.e., for consideration of tracheal shave) or to speech language pathology (i.e., for behavioral speech therapy)?
Our center for transgender medicine and surgery, one of the biggest in the country, recommends speech pathology with a person trained in feminizing voice.
For transgender women patients wanting to address their voice tone, do you first refer to ENT (i.e., for consideration of tracheal shave) or to speech language pathology (i.e., for behavioral speech therapy)?
Our center for transgender medicine and surgery, one of the biggest in the country, recommends speech pathology with a person trained in feminizing voice.
Can cardioversion be safely performed for recurrent atrial fibrillation in patients who have undergone left atrial appendage clipping during CABG, if they are not on chronic anticoagulation anymore?
Based upon the LAAOS III trial, we know that patients with left atrial appendage ligation at the time of cardiac surgery have a lower risk of stroke compared to those who did not when anticoagulation is continued in both groups. The data is much less clear for complete cessation of anticoagulation a...
Is active cocaine or methamphetamine use a contraindication to implanting defibrillators?
As a general principle, I do not think that a potentially life-saving intervention should be withheld in patients with substance use disorders (including tobacco, alcohol, cocaine, methamphetamine, or even IV drugs) unless the risk of the intervention outweighs the anticipated benefit. Further, I be...
Would you consider opting for beta blocker withdrawal to improve exercise capacity in patients with heart failure with preserved ejection fraction and chronotropic incompetence?
The short version of my answer is Yes, however, I will provide more insight into this: When considering beta-blocker withdrawal to improve exercise capacity in patients with HFpEF and chronotropic incompetence, the evidence and guidelines are nuanced. A prospective, randomized, controlled trial "Pre...
Do you frequently recommend the HPV vaccination series to patients above 26 years old?
The FDA approved the use of the 9-valent HPV vaccine in adults aged 27-45 in October 2018. In June 2019, the ACIP recommended that men and women aged 27-45 discuss vaccination with their doctor in a shared decision-making model. Extending mass vaccination for all adults aged 27-45 would cost approxi...
Do you frequently recommend the HPV vaccination series to patients above 26 years old?
The FDA approved the use of the 9-valent HPV vaccine in adults aged 27-45 in October 2018. In June 2019, the ACIP recommended that men and women aged 27-45 discuss vaccination with their doctor in a shared decision-making model. Extending mass vaccination for all adults aged 27-45 would cost approxi...