Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you start and manage therapeutic SC heparin for acute thrombosis in pregnancy as the patient approaches delivery?
This is an excellent question and my approach to such a patient has changed over time. In my experience, therapeutic subcutaneous UFH is incredibly unpredictable--women may come in in labor on therapeutic UFH thinking that they will be able to get an epidural, but despite waiting hours and hours, th...
Do you recommend Hyaluronic Acid Therapy for vaginal dryness in female patients post pelvic RT?
I do not. Not saying you shouldn’t though. I recommend coconut oil which can be used with a vaginal dilator, for intercourse or purely for hydration. If ineffective, I will refer back to gynecology. There may be a role for topical estrogen depending on the cancer histology.
Are there situations when you a 1K dialysis bath as a long-term outpatient prescription for patients with ESKD?
I cannot think of a situation where this would be needed, and based on available data I recommend against it.In the hospital setting, there is some data that doing dialysis with a 1K bath is beneficial and can reduce mortality, see Singh et al., PMID 34476092.The same cannot be said for long-term di...
In patients with suspected RCVS, is there a role for preventative CCB if headache has resolved/now asymptomatic?
In short, the use of CCBs in RCVS is only for the prevention of thunderclap headache (TCH) recurrence. Since their purpose is to prevent TCH recurrence, they are often used when the patient is asymptomatic as well (i.e., even after the index TCH has resolved). They do have no impact on eventual clin...
When do you recommend starting a continuous opioid infusion for symptom control at the end of life?
If the RN who is at the bedside and administering intermittent opiate doses is reporting hourly administration/dosing needs, then an infusion may be warranted to optimize pain, comfort, and/or control of symptoms.
What strategies have you found to be most helpful in improving patient compliance with vaginal dilator use after pelvic radiotherapy?
We attempted a randomized feasability trial to a study dilator use and test a theoretically driven enhanced educational program (EEP) to increase adherence, We did not find increased adherence to the EEP program. At present, other than good physician and nursing counselling, I am unaware of signific...
For a patient with vaginal adhesions/stenosis, do you recommend any other therapy besides a dilator?
Yes! In patients who have received radiation and have stenosis I frequently given topical estrogen cream with their dilators to help prevent or treat vaginal stenosis. My patents report that it helps with the pain associated with vaginal atrophy when they try to use their dilator. I treat a lot of c...
Is obesity a risk factor for recurrence after definitive treatment for endometrial cancer?
The most common cause of death in early stage endometrial cancer is not cancer but cardiovascular. Anything to reduce cardiovascular risk would help reduce mortality
How do you manage a screening pap smear result of HSIL and HPV16+ in a first trimester pregnancy?
Colposcopy to rule out invasion; if invasion is suspected, then biopsy. Otherwise, wait until delivery and re-evaluate. It is unlikely that invasive disease will develop in the short time of gestation. I believe these are the ASCCP guidelines.
Do you recommend the HPV vaccination for your young patients with HPV-associated cancers or pre-cancers who have not yet been vaccinated?
Yes, worth getting vaccinated to reduce risk for recurrent dysplasia. Lichter et al., PMID 32282601. Di Donato et al., PMID 33919003. Jentschke et al., PMID 32762871.