Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For how long would you treat a patient with dematiaceous fungi growing on a native heart valve discovered at the time of valve replacement?
The first step is to determine whether the positive culture may be a contaminant, as it very well could be. Every valve sent for culture should have also been sent for histopathological examination. In a patient with fungal endocarditis, one should expect to find evidence of acute inflammation and t...
How do you approach conversations regarding discontinuation of transfusions in patients with advanced hematologic malignancies who are otherwise appropriate for hospice?
While not an expert in leukemia care or MDS, the answer is nuanced (both in the care of patients and to hospice agencies). Some hospice programs will make exceptions to blood transfusions depending on how frequent - so it is always good to ask. From a clinical perspective, important to consider whet...
What is your surveillance approach for outpatient monitoring of ICI myocarditis?
Screening and surveillance strategies for outpatient monitoring of ICI myocarditis are not well-defined. The best surveillance approach would be based on clinical risk assessment, followed by biomarker and imaging data. The risk factors for ICI myocarditis remain to be clarified, but the most valida...
How would you plan a post-op, distal rectal adenocarcinoma s/p neo-adjuvant chemotherapy and APR with minimal treatment response?
The PROSPECT trial evaluated the omission of radiotherapy from preoperative management for cases that presented with a disease that could be resected with a sphincter-sparing TME. In addition, if the disease responded poorly to preoperative FOLFOX, then patients on that arm were required to receive ...
What is your strategy for managing immunosuppression in patients with a kidney transplant who develop metastatic cancer?
This is a difficult situation. I presume this question refers to cancers for which there is no option of cure. We always discuss the goals of care and review with the patient and their treating oncologist what the prognosis might be. If chemotherapy or check-point inhibitor treatment is planned we ...
Do you routinely recommend a sleep study in patients with clinical history of REM-sleep behavior disorder?
I do routinely recommend and perform in lab sleep testing for patients with suspected REM behavior disorder (RBD). The finding of REM sleep without atonia (RSWA) is supportive of a diagnosis of RBD, as atonia is normally presented in individuals (without RBD) during REM sleep. RBD can be a tricky di...
Do you advise your patients with cystinuria to perform home urine pH testing?
Definitely! Keeping urine pH above 7.0 is one of the most effective ways of preventing cystine crystallization. pH testing strips can be purchased cheaply on the Internet or in “big box” stores. (Pharmacies are much more expensive). I suggest testing four times daily and adjusting the urinary alkali...
What are some potential etiologies to consider for isolated, mildly elevated BNP levels with normal TTE findings in an asymptomatic, elderly patient?
BNP and pro-BNP both increase with age, especially in women, and must therefore be interpreted in that context. Pro-BNP less than 300 pg/mL indicates low likelihood for acute heart failure at all ages (though there are exceptions). The recommended age-based thresholds for diagnosing heart failure/vo...
Do you monitor CBCs to assess for drug toxicity in patients on nintedanib?
Not typically. I've never been advised to check these, but it's worth re-examining whether it's worthwhile. Looking at the side effect profile in INBUILD and INPULSIS doesn't reveal any major cytopenias. It doesn't appear to be on the FDA prescription information, either. I think this question arise...
For a patient with idiopathic hypercalciuria and a history of calcium kidney stones who has not normalized 24-hr urine calcium level on thiazide diuretic, is there evidence for targeting a certain urine calcium level for decreased future risk of nephrolithiasis and osteoporosis?
A good question, and the answer depends on your definition of a "normal" urine calcium level. If you use the standard definition of abnormal, the upper 5 percentile, depending on your laboratory, you will get values for upper normal calciuria in the 250-300 mg per day. However, approximately 10% of ...