Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach and manage anorexia and appetite loss in people with advanced cancer?
Anorexia/cachexia is often distressing to patients and families and it is this distress that is the target of many of the interventions for this syndrome as there are, in general, no effective therapies. Patients and families are routinely battling over the lack of eating as this causes further disc...
When should vaccines be given if not received prior to the start of high dose radiation (40-50 Gy) to the spleen?
Mortality due to infections is increased in asplenic individuals as well as those receiving radiation therapy to the spleen. The risk is low but measurable. For example, in a large Childhood Cancer Survivor Study, the cumulative incidence (35 years) after splenectomy of late infection-related mortal...
Which IV medications do you offer for outpatient headache infusions?
Eptinezumab (Vyepti) in a dose of 100 or 300 mg. It is a CGRP antibody marketed for the preventive treatment of episodic or chronic migraine. However, in a randomized, double-blinded, placebo-controlled trial treating patients with 100 mg IV for moderate or severe migraine headache, it met the FDA-d...
What treatments and resources have you found helpful for ichthyosis vulgaris patients?
I also make sure to get my patients enrolled in Beiersdorf's free Aquaphor/Eucerin program. They help patients with ichthyosis by providing free products to them. Here's how to do it: Beiersdorf/Eucerin – Aquaphor has a program for families that use large amounts of Aquaphor. The company will send ...
Do you consider anti-viral prophylaxis in patients taking JAK inhibitors who have recurrent uncomplicated Zoster infection, but would prefer not changing therapy?
This is a really good question without a clear answer. Patients on JAK inhibitors are not only at increased risk for VZV but also for recurrence. Data from Kevin Winthrop and colleagues examining the tofacitinib database revealed that patients with RA and PSA are at 10 to 20 times increased risk for...
Which patients with intermediate and high risk prostate cancer should not receive androgen deprivation therapy?
Based on randomized trials that didn't exclude patients with cardiac risk factors, an overall survival benefit has been observed for intermediate and high risk localized prostate cancer. Review of RTOG studies has not detected an increase in cardiovascular events. That said, appropriate management o...
What is the likelihood of a successful pregnancy following pelvic irradiation?
This is a very important question. The risks on future fertiltiy from radiation therapy to the abdomen/pelvis are twofold.1) Dose to the ovaries. The LD-50 to the ovaries may be as low as 2 Gy, thus the risk of ovarian dysfunction and premature menopause, is high. 2) Dose to the uterus leading to po...
After pelvic irradiation, how often do you recommend that female patients use a vaginal dilator and for how long?
The need for a vaginal dilator is dependent on the degree of stenosis, and related to the total dose, dose per fraction for HDR brachy patients, and patients underlying tendency to form scar tissue. In general we suggest evaluation by the physician every 3 months. If it appears that scar tissue con...
Can you observe low grade follicular lymphoma if the involved node(s) have been surgically removed?
There are certainly circumstances where observation for limited stage, low grade follicular lymphoma is warranted. I would not rely on surgical resection alone for cure however. Occasionally surgery can be curative in Stage I extranodal MALT lymphoma.
How often do you order follow up mammograms after breast radiotherapy?
We do it once a year, as doing them more frequently than that has not been shown to improve outcomes and this is endorsed by national societies. There is a recent paper which showed higher yields with 6 month mammograms but this has not shown to improve outcomes and our approach at present is a year...