Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In patients with post-MI LV thrombus which resolves after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
I think the key word here is akinesis (or dyskinesis); effectively, an immobile segment of myocardium gravitationally farthest south of the ‘northward’ flow of blood across the aortic valve. This effectively allows for stasis in an injured and immobile region... two of the three components of Vircho...
What factors influence your choice between low-dose DOAC therapy and dual antiplatelet therapy for the first 3 months after percutaneous left atrial appendage occlusion?
Using the ADALA study and previous observational studies, the use of apixaban 2.5 mg BID appears to be at least as safe if not safer than the use of DAPT. As a result, in patients who are unable to tolerate full-dose anticoagulation, low-dose DOAC is my first line. However, if patients have cerebra...
For how long do you treat an early spinal hardware infection secondary to MSSA after operative washout and retention of hardware?
This infection is a key research interest of mine and one I'm deeply passionate about. I typically treat with a 12-week induction regimen, preferably using antibiofilm-active agents—an approach adapted from the DATIPO trial for prosthetic joint infections (PJI). I generally do not recommend routine ...
Do you use the homeostatic model assessment (HOMA) to assess for insulin resistance and change your clinical management of patients?
No. As insulin assays are not standardized nationally, glucose measurements are surprisingly variable across methods and institutions, single measurements of fasting glucose and insulin are somewhat quixotic, and as there is a loose relationship of HOMA measures in individuals and gold-standard meas...
What alternative medications other than dapsone would you consider for dermatitis herpetiformis in a sulfa-allergic patient?
Dapsone is a sulfone and in my experience, does not usually cross-react with sulfonamide-allergic patients (e.g., bactrim allergies).
Does 4G/5G polymorphism in the plasminogen activator inhibitor (PAI-1) gene increase the risk of thrombosis?
Venous thromboembolism (VTE) is a classical example of a multifactorial disorder where genetic and environmental factors interact to result in VTE. Of the genetic disorders, in isolation, many are weak risk factors but when combined with other genetic or one or more environmental risk factors increa...
Is there any benefit of using aspirin to mitigate VTE risk in testosterone-induced polycythemia?
Erythrocytosis is a common adverse effect of testosterone therapy, and results from several studies suggest an association between elevated hematocrit (Hct) and risk of VTE (Braekkan et al., PMID 19833630; Ory et al., PMID 35050717). There is currently no data to support the routine use of aspirin o...
For how long would you hold anticoagulation before percutaneous left atrial appendage closure with Watchman or Amulet devices?
Elective left atrial appendage occlusion with both Watchman and Amulet systems most often utilizes continuous uninterrupted oral anticoagulant administration (including the day of procedure) along with intra-procedural heparin to ACT 250-400 during implant. Procedural heparin is reversed immediately...
Do you ever consider close clinical monitoring over antifibrotic therapy in patients ascribed an MDD diagnosis of IPF who have normal lung function and are asymptomatic?
Idiopathic pulmonary fibrosis is by definition a progressive disease with high mortality, thus, clinical practice guidelines would recommend treatment at diagnosis. Based on US and UK epidemiologic studies, IPF has an average life expectancy of 3-4 years without antifibrotic treatment. Furthermore, ...
What patient characteristics prompt you to prescribe vericiguat for patients with heart failure with reduced ejection fraction who are already on standard therapy?
When considering the addition of vericiguat for patients with HFrEF who are already on standard therapy, several patient characteristics guide my decision-making process: Recent Decompensation: I particularly consider vericiguat for patients who have experienced a recent episode of heart failure de...