Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage severe fibrosis/contracture and breast/axilla pain in a patient with a history of breast radiation who cannot tolerate trental?
I have seen some patients with dramatic responses to pentoxifylline (Trental) and vitamin E, but the regimen needs to be continued for at least one year to prevent relapse (Delanian et al., PMID 12829674). However, this patient cannot tolerate Trental, so that is not feasible. Hyperbaric oxygen has ...
How do you counsel young adults with antibody-negative necrotizing myopathy on prognosis and long-term monitoring/treatment?
The first step is to rule out other conditions that are associated with necrotizing myopathy, that can affect treatment and prognosis, like malignancy, thyroid disease, or genetic muscle diseases. History, physical exam, basic laboratory work-up, family history, age-appropriate malignancy screening,...
What is your standard workup and treatment for an incidentally-noted splanchnic vein thrombosis?
Splanchnic vein thromboses are clots found in the portal, splenic, mesenteric or supra-hepatic veins. These can be very challenging because they are often incidentally found and asymptomatic and for these folks, it is very unclear whether we even need to treat them or do any other evaluation. As wit...
What is your approach to post-operative prophylactic anticoagulation for patients undergoing minimally invasive surgery for gynecologic malignancies?
Recommendation:This is a great question; one our group has recently been discussing. My current practice is to advise patients with gynecologic malignancies undergoing minimally invasive surgery (MIS) to receive extended prophylaxis (4-week course of apixaban) depending on individual risk factors. A...
Is there any reason to stop mesalamine in a patient with UC undergoing breast/regional nodal radiation?
I have run into this situation a few times and have not stopped mesalamine during breast radiation. Have not noticed any issues.
What treatment modalities do you offer patients who have ataxia?
This is a great question; thank you for posting it. Approaching management for ataxia like many neurodegenerative movement disorders is a two-pronged approach of physical/occupational/speech therapy and oral therapeutics.Physical therapy can improve balance and mobility in hereditary and cerebellar ...
At what intervals do you obtain DEXA scans for patients on antiseizure medications?
In patients with thrombocytosis with negative MPN workup from peripheral blood and bone marrow, is there a role for daily 81mg aspirin or other treatment?
In the absence of an MPN, there is no data to support the use of low-dose ASA. Unless there was extreme thrombosis and acquired von Willebrand syndrome, there would also be little reason to bring the platelet count down as well. In the absence of MPN, thrombocytosis itself is not a risk factor for t...
What guidance do you give to patients and families regarding resuming vaccination after completion of chemotherapy?
In our practice, for vaccine series that have not been started or only a single prior dose has been administered, we recommend a new vaccine series according to the CDC regular or catch up schedule. For vaccine series that have been started with at least 2 prior doses, or completed, we recommend a s...
In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?
Not a lot of controlled trials that address each situation so we rely on expert consensus and judgement, and more importantly, balancing the risk of hemorrhage vs thrombosis. ASH guidelines define chronic persistent risk factors as 1) Active cancer (e.g., ongoing chemotherapy; recurrent or progressi...