Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
In a patient who fractures after several years of denosumab therapy, would you wait 6 months after the last denosumab injection to start an anabolic agent or could start an anabolic agent sooner?
In a patient on any antiresorptive drug who fractures, we should consider an anabolic drug. A fracture does not always mean the drug has failed but we should consider changing to an anabolic since we have good evidence that anabolics have superior fracture risk reduction. Denosumab is of course mor...
What is your approach to screening for complete heart block in an asymptomatic pregnant patient with negative SSA and positive SSB antibodies?
There are case reports of congenital heart block (CHB) due to anti-RNP antibody in anti-SSA/SSB-negative pregnant women (Izmirly et al., PMID 28709760). However, it is so rare that too many fetal heart monitoring tests would need to be done to identify these rare events. The amount of time and money...
Do you use anticoagulation in cancer patients who develop an unprovoked superficial vein thrombosis?
It depends on the extent of the thrombus and clinical circumstances. Superficial vein thrombosis is triggered by the presence of malignancy. For distal minimal symptomatic thrombosis, I would consider time limited anticoagulation. For more proximal and symptomatic thrombosis, I would consider more e...
Do you change your monitoring strategy for a high risk prostate cancer after XRT if the initial PSAs have never been very high?
In general, a patient whose volume of cancer is out of proportion to their PSA makes me nervous. So, I'm much more worried about the patient with a PSA of 5 and multiple cores positive for high volumes of Grade Group 4-5 cancer than I am about the patient with a PSA of 5 and a single positive core s...
Do you recommend surveillance for secondary malignancies of the rectum and bladder after prostate XRT?
I think it's important to be sure that patients are up to date with screening for colorectal cancer before beginning a course of prostate XRT. I have had an occasional patient who was found to have a colorectal cancer on colonoscopy performed pre-treatment because they were out of compliance with sc...
How do you counsel patients on preventing nail damage with constant pedicures/manicures and nail polish?
I recommend that patients avoid cuticle or pushing, which makes then prone to both acute and chronic paronychias. The acetone removal process for gel manicures thins the nail plate - this has been shown in scanning electron microscopy studies. There is mounting evidence that UV dryers used to cure...
What treatments have you found helpful in treating recurrent aphthous ulcers?
Recurrent aphthous ulcers can be tricky to manage and recalcitrant to multiple therapies. I usually start with colchicine and topical corticosteroids. If that fails I move on to thalidomide. I have found that therapies in-between are unsuccessful.
Would you continue warfarin anticoagulation in patients with unprovoked DVT if switching to low-dose DOAC is cost-prohibitive?
Would continue warfarin if this is cost-effective and doing well.
Does aerobic exercise lead to any change in ability to perform ADLs in patients with Parkinson's disease?
In this article, improvement in overall fitness was seen in patients in the aerobic exercise group. I could not find a scale that specifically looked at ADLs in this study.In a meta-analysis and systematic analysis published in NPJ Parkinson's Disease, authors found aerobic exercise had beneficial e...
What level of exercise do you recommend in patients with Parkinson's disease?
I recommend aerobic exercise for at least 30 minutes/day, 5 days a week. These recommendations are of course based on patient's physical ability. I usually advise using a stationary bicycle and if that is not possible, a recumbent bicycle for aerobic exercise. This way if there is bad weather or una...