Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
What factors should be considered when deciding whether to omit radiation in pediatric/AYA patients receiving N+AVD, particularly regarding long-term outcomes and second malignancy risks?
Based on the early data from S1826, it appears that radiation can be omitted if end-of-therapy scans (after 6 cycles of therapy) show metabolic remission of disease. The ability to limit RT to 1% of patients is encouraging for potential reduction in late effects such as cardiovascular disease and SM...
In patients with confirmed hypercortisolism with a high/normal unsuppressed ACTH who have both a pituitary adenoma and adrenal adenoma identified on imaging, can you reliably use DHEA-S to determine the source of cortisol production?
There is a difference between high-normal and unsuppressed ACTH. If ACTH is high-normal, this is ACTH-dependent Cushing. However, you can have mild adrenal Cushing without fully suppressed ACTH (e.g., ACTH in the 10-20 pg/ml range and sometimes even above 20). I don't think you can rely on DHEAS in ...
How do you approach managing intolerable vivid dreams as a side effect of SSRIs?
There are several distinct options I go over with patients who have this side effect. It often self-resolves, but can take a few (up to 6) months to resolve, and there is no guarantee. If the patient is willing to tough it out, I often have them do nothing. But, we are talking about it being an int...
How do people approach non-HIV patients with hepatitis B, a negative Hepatitis B E antigen, normal LFTs and relatively low HBV DNA between 2000-20000?
Treatment of chronic Hep B is recommended to prevent maternal-fetal transmission, reactivation during chemotherapy, recurrence after liver transplantation, and in patients with decompensated cirrhosis. Treatment has been shown to reverse fibrosis and cirrhosis. Specifically referring to the above sc...
How would you approach a patient with a recent MI s/p DES who is being considered for neoadjuvant chemotherapy for TNBC?
This is mostly opinion as there is not data specific to this situation. First, I would coordinate closely with the cardiologist, preferably someone with knowledge of cardio-oncology. Presumably the patient is already on cardioprotective medications, such as beta blocker and ACE inhibitor, but if not...
When starting stress dose steroids for patient with primary adrenal insufficiency, how do you decide whether to start hydrocortisone 100 mg every 8 hours versus 50 mg every 6 hours?
Stress doses of steroids in patients with primary adrenal insufficiency depend on the anticipated stress. The dose of steroids can be doubled or tripled depending on the stress. For example, in cases of maximal stress such as major surgery, the dose can be similar to the dose used for an adrenal cri...
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
With the rise in home monitoring devices, how should we approach asymptomatic NSVT detected in healthy individuals with no prior cardiac history and with low risk cardiac profile?
With home monitoring devices, we are finding a lot of arrhythmias that would have previously remained unidentified. If episodes of NSVT are being found on home monitoring devices, the patient should receive a formal monitor to confirm NSVT. The formal monitor should be a Holter monitor that is able ...