Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...
How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long-term CVD risk?
This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...
How will your approach to screening and diagnosis of early dementia change given newly available therapies for early Alzheimer's disease?
As it stands, it is not recommended to screen asymptomatic patients for the proteins seen in Alzheimer’s disease outside of clinical trials (i.e., AHEAD 3-45). However, with the emergence of new treatment options in the clinic, I foresee an influx of patients with cognitive symptoms who need a preci...
How do you manage persistent rectal bleeding in the setting of rectal adenocarcinoma in a treatment-naive patient?
For a locally advanced rectal adenocarcinoma in the era of TNT, treatment of the tumor with either chemoradiation or chemotherapy upfront is reasonable, and both choices are known to palliate colorectal cancers effectively. With more severe bleeding, we often consider starting with chemoradiation th...
In an older adults with dementia-related behavioral symptoms refractory to nonpharmacological management in whom you are starting SSRI, do you ever consider a short course of antipsychotic medication to overlap with the initiation of SSRI while waiting for therapeutic effect?
The American Geriatric Society recommends that antipsychotics may be considered when behaviors do not respond to non-pharmacological management and the patient is at risk of harming themselves or others. Thereby, it may be reasonable to overlap short-term antipsychotic with SSRI initiation in older ...
How do you decide when and how often to reach out to patients with serious mental illness who are disengaging from care due to psychosocial stressors?
Outreach is always determined on a case-by-case basis, so it's difficult to give a definitive answer on this. Important factors to consider are the person's functional status, potential risk for harm without care, their decision-making ability, and the intensity of stressors. Obviously, those who ar...
With data suggesting that menopause contributes to major cardiovascular, bone, and cognitive outcomes, what changes should internal medicine clinicians make in risk assessment, HRT counseling, and long‑term monitoring for midlife women?
This is an interesting question because there are no new data about menopause as a risk factor for CV, bone, or brain health. These BMJ guidelines are very helpful and reflect a new approach to the treatment of menopausal symptoms, which is hormone therapy first. My patients usually want to try alte...
With OpenBiome no longer in operation, what is your current approach for obtaining FMT for inpatients with acute severe/fulminant C. difficile infection unresponsive to antibiotics?
Consider Rebyota by enema or flex sig, similar to what you had done with standard FMT.
Do you consider use of oral antibiotics for complicated polymicrobial intra-abdominal infections?
Depends on how you're defining "complicated" IAI. Source control is key (I like this review: Source Control and Antibiotics in Intra-Abdominal Infections), especially if there's a fistula or anastomotic leak; but once an abscess is <5cm, if I have oral options that the patient can tolerate/dosed app...
Do you routinely recommend transition to dual PO antibiotic coverage for strep species and MRSA, for patients with purulent cellulitis and in the absence of culture data?
I use mostly Linezolid because: It’s now much cheaper. Even if on serotonin drugs, I can half the serotonin dose while they are on it. Covers pretty much all Strep and Staph, including MRSA. Protein synthesis inhibition may reduce toxins (like clinda in Strep fasciitis). There is no renal dose adju...