Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For patients admitted while taking chronic outpatient opioids, how do you decide whether to resume their baseline opioid regimen at discharge versus tapering or modifying therapy during hospitalization?
I'm not sure there's a single right answer here. My only recommendation is for patients who are on chronic outpatient opiates: please talk to their ambulatory clinician before making any significant changes. Their ambulatory doctor knows them over time and can give you advice regarding what's happen...
How do you manage incidentally found venous sinus thrombosis?
I would make sure first that it is not simply a congenitally small sinus. If there is truly a CVST, I would probably treat with a DOAC for 3 months and reassess with CTV.
When do you recommend patients get vaccinations with respect to their RT course?
I agree with @Dr. First Last's reply, and find that some patients are under the impression they are immunocompromised during radiation therapy and thus should avoid vaccines, when in fact the opposite is true. The skepticism behind the science of vaccination also can lead to avoidance, and so I try ...
How do you wean off of primidone in patients with essential tremors?
If a patient has been on primidone for less than one month, it can be simply discontinued in most cases. Slower withdrawal may be necessary in patients with seizures, patients on multiple other medications, or with other abnormal metabolism. For patients needing a slower taper, generally lowering th...
How do you counsel patients on the risks and benefits of chemotherapy or radiation offered with palliative intent?
Before I start counseling a patient on these decisions, I want to know a few things first. I would want to know from the oncologists what they think the benefits are (i.e., how much more time might they get? Symptom control?) and what the risks are. The chances that the patient will see a benefit. ...
What is your treatment paradigm for rectal cancer in the setting of COVID-19?
We haven't changed our standard recommendation: short course radiation -> 3-4 months of FOLFOX. In a very timely manner, the RAPIDO ASCO abstract was released here in May. It showed that the patients who received short course radiation -> FOLFOX had improved pCR, less disease related treatment failu...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...
What measures should we take regarding routine follow-up visits for well patients in surveillance during the coronavirus pandemic?
3-6 months.
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...