Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
If a patient who has tolerated allopurinol for a prolonged period of time is subsequently found to be positive for the HLA-B*58:01 gene, how would you manage urate-lowering therapy thereafter?
There is a strong association between the presence of the HLA-B*58:01 allele and allopurinol-related severe cutaneous adverse reactions (SCAR* - Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis or Severe Hypersensitivity Syndrome). This association was demonstrated in a Taiwanese study by Hung e...
Have you used lithium for agitation in dementia?
Non-pharmacologic approaches are first indicated. If they fail, then a psychotropic treatment algorithm is indicated, which generally starts with a serotonin reuptake inhibitor. Lithium would not be considered standard or first-line treatment for agitation in Alzheimer's disease, and in most other m...
Do you routinely check digoxin levels, and if so, when would you consider using Digibind in chronic digoxin use patients?
The subanalysis of the DIG trial gave some insight into the value of keeping digoxin levels below 1.0. If HF patients, I tend to look at the levels for that reason. I rarely use digoxin for AF as there is little evidence of benefit with some evidence of harm. Re: use of digibind, I limit this if t...
How do you decide between atorvastatin versus rosuvastatin and their high-intensity doses for statin-naive patients following a STEMI and PCI?
20 mg of Crestor is highly effective and tolerable.
How do you decide between atorvastatin versus rosuvastatin and their high-intensity doses for statin-naive patients following a STEMI and PCI?
20 mg of Crestor is highly effective and tolerable.
How do you approach the treatment of patients with Ehlers-Danlos hypermobile type with chronic muscle spasms with minimal exertion?
You accept that EDS is a genetic connective tissue disorder and not a rheumatological issue. You check hormones and vitamins to ensure they are in range: especially Mg with the cramps. Some EDS patients find working with an EDS physical therapist is beneficial: the goal being to learn how to exercis...
How would you approach a patient with a recent MI s/p DES who is being considered for neoadjuvant chemotherapy for TNBC?
This is mostly opinion as there is not data specific to this situation. First, I would coordinate closely with the cardiologist, preferably someone with knowledge of cardio-oncology. Presumably the patient is already on cardioprotective medications, such as beta blocker and ACE inhibitor, but if not...
In light of recent measles outbreaks in the US, would you recommend an MMR booster for immunocompetent patients born before 1957?
I would not recommend a measles vaccine for a person born before 1957. This year has been chosen because people before born before 1957 have a very very high likelihood of having had measles because virtually all children got this highly contagious disease. On the other hand, there is no harm to get...
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...