Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
At what stage of the neuropathy workup do you screen for B6 toxicity?
In my experience, vitamin B6 deficiency due to poor oral intake is very uncommon. However, toxicity may occur with supplementation typically more than 2 gm/day, although chronic use of 50 mg/d may also be a cause. Vitamin B6 is present in many supplements and toxicity may cause direct damage to the ...
How would you treat a patient with rectal cancer with a solitary lung metastasis, who now has no evidence of disease after total neoadjuvant therapy followed by rectal surgery and resection of the solitary metastasis?
Surveillance! Assuming this patient received “complete” total neoadjuvant therapy with at least 3-4 months of systemic therapy, preoperative radiotherapy to the pelvis and curative intent operations to the pelvis and lung with no evidence of residual disease on post-op imaging- this is the early out...
Do you warn patients about suicidal ideation when starting anti-seizure medications?
Yes. I always discuss with every patient the FDA's warning on increased risk for suicidal ideation and behavior when I start an antiseizure medication (ASM). Here are the reasons: Nowadays, patients go to the internet and review the adverse events of prescribed medications. In the case of ASMs, the...
Should there be a role for sacubitril-valsartan in the management of patients with heart failure with preserved ejection fraction?
When it comes to HFpEF, we don't have a lot of effective therapies in our armamentarium. SGLT2 inhibitors have known cardiovascular benefits and were shown primarily to reduce hospitalization in EMPEROR-Preserved and DELIVER. Arguably, spironolactone can be included here despite a trial (TOPCAT) tha...
Is there a specific INR cut-off value that would prompt you to consider administering vitamin K for patients with mechanical valves requiring urgent non-cardiac surgery and if so, what would be your starting dose?
For urgent surgery that could result in significant bleeding, I would give vitamin K if the INR was 1.6 or higher. I would avoid high doses of vitamin K so as to allow more rapid anticoagulation post-op. Usually one dose of 5mg is enough. I would start low molecular weight heparin post op until INR ...
Should we routinely include geriatric functional assessments to determine candidacy for TAVR?
Studies have shown that 40-50% of older patients with severe AS and high (≥8%) or prohibitive (≥15%) risk for perioperative mortality with surgical aortic valve replacement (based on the STS score) fail to survive with improved quality of life 1 year after undergoing TAVR. This suggests that TAVR ma...
What exfoliative regimen do you recommend for patients with recurrent plantar keratoderma?
Keratolytics are my go-to for keratodermas, particularly urea 40% or ammonium lactate. You can also have salicyclic acid compounded with propylene glycol, although I have rarely had to do this. For certain patients, it is helpful to soak the feet for 10-15 minutes, file down areas with a pumice ston...
Is there a role for the use of biologics as steroid sparing agents in treating patients with ABPA who are intolerant to prednisone?
Treatment for ABPA is generally guided by IgE levels and corticosteroids remain the main drug therapy regardless of classification in both people with cystic fibrosis (CF) and without. Limited treatment with antifungal therapy (itraconazole or voriconazole) is considered usually first in individuals...
Do you recommend patients consume dairy products over taking calcium carbonate with meals if they have recurrent calcium based nephrolithiasis and persistent hyperoxaluria?
I generally consider the decision between dairy and calcium tablets in the context of other medical conditions. For instance, if the patient has surgical or medical short gut syndrome as a cause of hyperoxaluria, I favor using calcium tablets to help compensate for the enteric loss of bicarbonate in...
What is your treatment approach for pregnant patients with IgA nephropathy who have worsening proteinuria during the first trimester?
Difficult question to answer without more details, but I would consider the following factors: One is whether it appears that the IgA is active. When was the last biopsy, and how much hematuria is present? Two would be if this is 'worsening proteinuria' is really just the first time proteinuria has ...