Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Should all patients diagnosed with B12 deficiency get a baseline EGD?
It is important to determine the cause of B12 deficiency. The majority of cases are due to pernicious anemia (atrophic gastritis and lack of intrinsic factor), I presume this question relates to that group. If there is another cause such as intestinal malabsorption or bacterial overgrowth, this does...
In patients with inflammatory bowel disease with low rectal cancer with planned proctocolectomy, would you consider creation of a pouch?
This is a very difficult case- are you speaking of Ulcerative Colitis or Crohn's disease? If UC - can consider pouch but really depends on the stage of the primary rectal cancer. If neoadjuvant chemoradiation is given, the likelihood of an ileoanal J-pouch functioning appropriately is low. Generally...
How do you screen for colon cancer in patients with Behcet syndrome with colonic involvement?
Behcet syndrome, unlike some other rheumatologic conditions, for the most part, has not been shown to increase risk of malignancies in patients. This may in part be due to the fact that the disease tends to get milder/less severe with time and treatment. As such, colon cancer screening should follow...
How would you approach new-onset large vessel vasculitis in a young patient with Crohn's disease?
Patients with Crohn's Disease (or IBD) can develop features of large vessel vasculitis or even other forms of vasculitis. The first consideration in a young patient would be determining the type of vasculitis--whether there is a distribution and clinical picture suggestive of TAK. It is important to...
What diet do you recommend for patients with inflammatory bowel disease?
This is a good question and very commonly comes up. The first step is really understanding what the expectations and goals are. If the goal is to achieve remission in people with inflammation who are symptomatic and want to use diet as monotherapy or in conjunction with meds, I discuss various thera...
How do you adjust medications for patients with eosinophilic esophagitis who responded to budesonide or PPI, and when do you repeat EGD?
Repeat EGD after BID PPI is normal- do you decrease to once-a-day PPI? When to repeat EGD if ever? I try to decrease to once daily in the morning, but if so, I repeat an endoscopy 3 months later to make sure histologic remission is still maintained. After response to Budesonide, continue life-lo...
What are your preferred treatment options for patients with chronic non-healing leg ulcers?
In addition to all the typical things (decreasing edema with meds, compression, etc + treating superinfection, critical colonization, or debriding eschars), there is some evidence for pentoxifylline 400 mg TID or 800 BID in ulcerations of any etiology. There is also newer evidence for using topical ...
What are your preferred treatment options for patients with chronic non-healing leg ulcers?
In addition to all the typical things (decreasing edema with meds, compression, etc + treating superinfection, critical colonization, or debriding eschars), there is some evidence for pentoxifylline 400 mg TID or 800 BID in ulcerations of any etiology. There is also newer evidence for using topical ...
How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?
This is definitely a concern, and tools/calculators can only take us so far. I have come across scenarios where, the e.g., pulmonary respiratory failure calculator provided a low score, and based on the history, I thought the patient was at high risk. A few weeks later, before the surgery, the patie...
How do you approach balancing the risks and benefits of elective surgery with patients who have multiple co-morbidities (e.g., frailty, chronic kidney disease, and COPD), when standard risk calculators do not capture the full complexity of their condition?
This is definitely a concern, and tools/calculators can only take us so far. I have come across scenarios where, the e.g., pulmonary respiratory failure calculator provided a low score, and based on the history, I thought the patient was at high risk. A few weeks later, before the surgery, the patie...