Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When performing salivary gland ultrasound for Sjogren's, what else do you include in the differential diagnosis?
Sarcoid Amyloid
What is the role of kyphoplasty or vertebroplasty in patients with osteoporotic spinal fractures?
Vertebroplasty and kyphoplasty can be grouped together as vertebral augmentation. They have a single indication: To reduce pain arising from a documented vertebral fracture. Kyphoplasty has an inflatable balloon and in theory, can improve vertebral height prior to introduction of the cement. I am no...
What steroid regimen do you employ in the treatment of patients with post COVID-19 pulmonary fibrosis?
I don't use steroids for post-COVID fibrosis. Not only have I not seen steroid-responsiveness in this setting from an anecdotal standpoint, but previous data on steroids in non-COVID pulmonary fibrosis seems clear about the potential harms (e.g., PANTHER trial). If there is a large proportion of gro...
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
This is a good question, especially noting the high rate of recurrent thrombotic events in non-treated patients with antiphospholipid syndrome (up to 29% if untreated, but still significant among treated patients, especially after an arterial event). Edit: to jump to the punchline, I favor adding AS...
What is the recommended management approach in regard to diagnostic evaluation and treatment for patients with homocystinuria and cerebral thrombosis?
I think it’s reasonable to start anticoagulants for 3 to 6 months after getting complete blood test panels for hypercoagulation states. Be careful while interpreting abnormal hypercoagulation test results since many times you may see abnormalities. I would also repeat them within 3 months when the p...
When should we consider screening patients with systemic sarcoidosis for cardiac involvement using cardiac MRI or PET given their high risk for sudden cardiac death and discrepancies between reported cardiac symptoms (2-5%) and evidence of cardiac inflammation on advanced imaging and autopsy findings (>25% of cases)?
The current guideline recommendations are only to pursue advanced imaging in patients who have symptoms, EKG abnormalities or abnormal echocardiogram. In our experience, we have been able to capture patients with strict assessment of these criteria. However, it certainly can be challenging in patien...
Is there a validated risk prediction model you favor to risk stratify patients for cardiotoxicity prior to initiation of chemotherapy?
I would recommend the HFA-ICOS risk calculator as recommended by the 2022 ESC/ICOS Cardio-Oncology guidelines. There is a great discussion here:Strategies for risk stratification and cardiovascular toxicity prevention in patients with cancerAnd there is an easy-to-use version online and on the ESC P...
Among asymptomatic patients with structurally normal TTE undergoing treatment with anthracyclines or alkylating agents that develop mildly elevated BNP and/or troponin levels, would you consider referring them for cardiac MRI to evaluate for subclinical cardiotoxicity?
If TTE images are adequate and the echo is entirely normal, but BNP and/or troponin levels are mildly elevated after anthracyclines or alkylating agents, differential diagnosis includes HFPEF, ischemia, or subclinical cardiotoxicity. If Echo shows unexplained significant LVH, CMR is reasonable to ru...
Would you empirically elective to anticoagulate patients with a remote (i.e. >10 year) history of paroxysmal atrial fibrillation presenting with newly diagnosed CVA, presumed cardioembolic in etiology, without any documented recurrence of AF?
Yes, I would, especially if the etiology is suspicious for being cardio-embolic. As per the ACC/AHA/HRS 2019 Updated Guidelines for AF management, patients with non-sex-related CHA2DS2-VASc score of >/=1 should be offered oral anticoagulation. For this particular patient, that score would be 2.
When is an appropriate time to consider endomyocardial biopsy for non-ischemic cardiomyopathy?
Endomyocardial biopsy is mostly indicated when there is a suspicion for acute myocarditis specially if related with arrhythmias at presentation to r/o giant cell myocarditis, chemotherapy agents related cardiomyopathy specially a tracy clones and immune checkpoint inhibitors, restrictive disease of ...