Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your approach to initiating and titrating midodrine for both inpatient and ambulatory settings?
It depends on the indication: Orthostatic Hypotension: 2.5 mg TID CC Inpatient - Check orthostatics SEATED 5', then Standing 1' 3' 5' about one hour after dosing. Increase by 2.5 mg every other dose until patient clinically not orthostatic or 10mg TID CC is achieved or seated hypertension or other s...
Should vasodilatory therapies be considered first-line in the management of hypertension in patients with severe aortic regurgitation?
Yes, ACEi or ARB or dihydropyridine Calcium channel blockers would be the preferred anti-hypertension medication classes in patients with HTN and significant aortic regurgitation. There is no role, however, for using these agents in patients with severe AR without HTN.
Should we have a lower threshold to consider revascularization of coronary lesions in athletes, compared to non-athletes?
Broad question, that may be best asked slightly differently; does CABG or PCI reduce cardiac events in asymptomatic athletes? My approach would be to treadmill stress (preferably MPI) and assess the arrhythmic, ischemic, symptomatic, and hemodynamic burden of disease with exercise stress. And, decid...
When would you consider implantable loop recorders for athletes with nonspecific complaints of palpitations/dizziness, without known history of arrhythmias?
I first do a maximum ECG stress test to see if any arrhythmias could be induced with max exercise. One might also consider a 30-day MCOT monitoring session. The ECG exercise test would also give us some information about the BP response during and after exercise. And, of course, I would start with m...
When is an appropriate time to consider genetic testing for cardiomyopathies for athletes as part of risk stratification for sudden cardiac death, in light of heightened prevalence of cardiac remodeling confounded by exercise and athletic conditioning?
I'm assuming this question is referring to proactive genetic screening rather than evaluation of a patient with clinical signs of heart disease. Clinical screening with EKG, echo and history including family history is a much more effective method of risk stratification. UK Biobank exome sequencing...
When do you consider intrathecal baclofen pump in patients with acquired spasticity?
I am a neurologist in Minneapolis and have directed a spasticity clinic for over 20 years. We typically have at least 100 intrathecal baclofen patients. It is an excellent therapy for selected patients but requires dose adjustments and refills of the Medtronic synchromed pumps. Problems may occur wi...
Do you hold IV iron in the setting of active infection?
While there is no evidence of harm, there is enough conjecture about the danger to make it prudent to wait until infection is controlled. So yes, I do. Further because of the iron restricted erythropoiesis during infection, the efficacy is likely to be blunted.
How do you manage and/or prevent ruxolitinib withdrawal syndrome?
Generally, tapering over a week or two is the best way to prevent it. If immediate discontinuation is needed, can consider using steroids.
What are the perceived implications of broader genomic sequencing as it pertains to interpreting variants of unknown significance and germline predisposition mutations?
Variants of unknown significance (VUS) are constantly being revised when it comes to identifying “potentially pathogenic mutations.” We work with a molecular pathologist as well as the pathologists at Exact Sciences to understand in real time where VUSs fall in regards to their pathogenicity and act...
How do you manage refractory hyponatremia in patients on active therapy in small cell lung cancer?
The classic teaching is that if this is a paraneoplastic SIADH then treat the underlying cancer. If hyponatremia is worsening despite treatment, it might herald progression. I have used tolvaptan in the past as bridge but without effective treatment, this is likely not going to be very effective. Of...