Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When do you recommend acamprosate vs. naltrexone for medication-assisted therapy in alcohol use disorder?
I would suggest starting naltrexone for about a week and then transitioning to Vivitrol shots. Continue Vivitrol every four weeks as a maintenance treatment regardless of drinking levels. I would also recommend at the start of the treatment, getting some baseline labs to include a CBC, comprehensive...
In what cases do you recommend the use of gabapentin for off-label use in alcohol use disorder?
Often patients with AUD who decline first-line medication treatments, i.e., naltrexone or acamprosate, are more open to gabapentin when advised of its potential benefits for anxiety, mood, and sleep, as these are common issues that drive alcohol cravings and use. Flexible dose titrations starting wi...
How do you approach pharmacologic management of OCD in patients with comorbid bipolar disorder, particularly when considering SSRIs or clomipramine?
This is a great question! Depending on the study you read, anywhere from 10% to 25% of patients with bipolar disorder have comorbid OCD. The challenge, as you might imagine, is that treatment with SRIs in the absence of a mood stabilizer may run the risk of inducing a manic episode. A larger debate...
What is the optimal frequency and duration of post-operative radiological surveillance following resection of a solitary fibrous tumor?
Partly depends on the subset of SFT. The classic variant is low-grade, indolent clinical behavior and can recur late (several years later) requiring (maybe less frequent) but long-term follow-up for 10 years or even beyond. The malignant SFTs have a shorter natural history and typical sarcoma follow...
Is there a role for DOAC use for patients with unprovoked PE, that have had recent sleeve gastrectomy with duodenal bypass?
Alterations in the gastrointestinal (GI) tract following bariatric surgery, as well as altered or reduced oral intake, have the potential to impair the absorption of both DOACs and VKAs in the acute setting. DOACs are absorbed in the upper GI tract, which is altered by the most common bariatric surg...
What is the role of surveillance imaging after first line therapy in patients with aggressive lymphomas?
Most relapses from complete remission in patients with diffuse large B-cell lymphoma are symptomatic. I am aware of no evidence that surveillance leads to the diagnosis of asymptomatic relapses that are more likely to respond to salvage therapy. My own concern about frequent surveillance is the adve...
Would you consider adding niacin to the lipid lowering regimen in statin-intolerant patients who cannot afford PCSK9i or bempedoic acid?
Yes, in a patient who absolutely cannot take a statin or other common alternatives such as ezetimibe, PCSK9 inhibitors, or Bempedoic acid, Niacin for ASCVD risk reduction is still a reasonable choice. While the combination of statin and niacin has been shown to be unhelpful (and possibly of greater ...
How do you identify the subset of heart failure patients who are likely to benefit from cardiac resynchronization therapy in the setting of an RBBB pattern?
There are no good criteria to delineate which patients with RBBB will benefit from traditional CRT. The best contemporary strategy is to consider CRT if a patient has an RBBB > 150 ms, an atypical morphology (suggesting an underlying delay in the LBBB or an IVCD), and Class III-IV HF symptoms. One m...
How would you evaluate a patient with an isolated high RBC count but with a normal hemoglobin and hematocrit?
My first question would be, how long has the elevated red cell count been present? I ask this because, in a study of 10,000 individuals, erythrocytosis was initially found in 88 but after a year only 11 still had this finding (Ruggeri et al., PMID 13679323). If therefore, the observation is recent, ...
Would you extend the duration of anticoagulation in patients with a provoked DVT, but evidence of residual clot at 3 months?
This is a really interesting discussion. I do tend to get Dopplers at the end of the anticoagulation treatment period, but only to assess the new baseline and to help decision-making in the future if they develop new symptoms and have another Doppler. I find this to be very helpful to understand if ...