Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For patients undergoing TNT for rectal cancer with planned operative management, what is the optimal sequencing and timing of workup imaging and procedures?
I think the question that is posed does not really make sense as written. One should not be making decisions about management (i.e. TNT) before the staging evaluation is complete. If a patient presents with a newly diagnosed rectal cancer, the first thing to do is to stage to find out whether the pr...
What is your preferred method for diagnosing adenine phosphoribosyltransferase (APRT) deficiency in a patient with recurrent kidney stones and abnormal crystalluria?
Genetic testing using a panel that includes APRT is the most reliable and straightforward thing to do. There is not a laboratory in the United States currently that can measure urinary or blood dihydroxy adenine. You can send a blood spot to the University of California San Diego lab for enzymatic a...
What is your approach to pacemaker lead thromboses in terms of threshold for lead extraction and initiation of systemic anticoagulation?
This is a question that often comes up. In general, most thrombi found on chronic pacing leads incidentally noted on an echo in our experience are not problematic. However, the bigger question is whether the mass noted is indeed a thrombus versus some vegetation related to an infection. In one publi...
Are there any non-beta-lactam antibiotic options for treatment of neurosyphilis in non-pregnant adults?
Doxycycline is a consideration. There are no conclusive data, but a few anecdotal reports are supportive -- the most recent (in a brief PubMed search) cited below. On the other hand, there is at least one case report (also cited) of a patient treated with doxycycline who subsequently re-presented wi...
How do you time PET/CT surveillance and COVID boosters?
I have not changed the timing of PET surveillance imaging around vaccinations but 1) is a frequent question from patients, and 2) I have seen a fair amount of false positive FDG avid axillary adenopathy post-vaccination. Think this tends to be too unpredictable in the duration of these imaging findi...
How reliable is an exercise stress echo in the diagnosis of exercise-induced heart failure with preserved ejection fraction?
This is my understanding of HFpEF. It is a clinical diagnosis of exertional Dyspnea in patients with risk factors such as HTN, atherosclerosis and Hyperlipidemia, increased BMI, and inactivity. A new classification means stage A only risk factors, stage B has some organ dysfunction such as LVH, left...
How long do you anticoagulate for cirrhosis patients who have portal vein thrombosis extending to the mesenteric veins?
I recommend indefinite anticoagulation for most patients with portal vein thrombosis, and at least 3-6 months if there are risk factors for bleeding. Once they complete anticoagulation for the first 6 months, I re-evaluate their risk of recurrent thrombosis vs bleeding, and if there is an underlying...
In which situations do you preferentially use an MCOT in lieu of a standard event monitor?
In most situations where the concern for "actionable" arrhythmias is low (e.g., isolated palpitations, mild lightheadedness, AF burden, PVC burden, known persistent AF for assessment of rate control, etc.), I typically would use an extended 7-14 day Holter mostly for symptom-arrhythmia correlation s...
What therapies do you routinely use to prevent mucus plug formation after endobronchial stent placement?
After airway stent placement, especially silicone stents and/or Y stents, I start my patients on albuterol neb BID; hypertonic saline neb BID, and NAC neb BID. If there are any issues with adherence, I use either albuterol + hypertonic saline or albuterol + NAC depending on patient preference. If th...
What is your approach to bridging anticoagulation in patients with history of recent HIT?
One should not re-expose patients with past HIT to heparins. Even with remote HIT, there is a high rate of serologic recurrence (eg, Warkentin and Anderson, PMID 27114458) and while the rate of overt HIT relapse may be low with proper precautions, I have seen and published a couple of fatal HIT recu...