Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach the use of commercial testing such as AVISE CTD in clinical practice?
Short story to start off with: A little over 20 years ago, I was a young rheumatologist sitting in a meeting room full of more experienced rheumatologists from the Washington DC area. Some of them were very well known in the field. The person in charge asked, "anti-CCP antibodies are now available t...
How do you approach tapering immunosuppression in a patient with a history of Susac Syndrome who has stabilized on MMF and IVIG?
Susac's is a rare disease characterized by an occlusive retinal vasculopathy, eighth nerve disease including hearing loss and balance issues, and CNS disease with a predilection for involvement of the corpus callosum. I am not aware of any randomized controlled data to guide treatment for Susac's, b...
How frequently do you recommend skin cancer screens in your patients with kidney transplants who are on immunosuppression?
We follow the SUNTRAC guidelines. For first screening, very high risk (prior history of NMSC)- 6 months post tx. High risk (older, fair-skinned) - 12 months. Medium risk (younger, fair-skinned) - 24 months. Low risk (dark skinned) - 10 years. Retransplants I usually recommend 6-12 months post-transp...
In male patients in their 60s who had a single episode of PAF (24 hours, terminated spontaneously or with beta-blockers) without recurrence on 30-day monitoring, and without reversible triggers (such as OSA), should lifelong anticoagulation be started when they turn 65, thereby, increasing the CHA2DS2 VASc score to 1?
NO-score of 1 based on age alone coupled with a very low burden of AF=risks of anticoagulation likely greater than no anticoagulation. A reasonable option is PRN anticoagulation for an episode lasting longer than 6 hours-12 hours-certainly 24 hours-keeps options are open for doing cardioversion IF t...
How would you manage recurrent migratory lower extremity thrombophlebitis that occurs despite being on therapeutic apixaban?
The differential diagnosis of Trousseau syndrome (migratory superficial thrombophlebitis) is relatively broad and includes both inflammatory states and undetected proximal DVTs. So I think the short answer about venogram is "maybe," based on how clear is the view by ultrasound. This isn't a typical ...
What is your preferred first-line agent to treat anxiety in patients with Parkinson's disease?
Any standard SSRI/SNRI can be tried. I like to try the SNRIs duloxetine or venlafaxine. If comorbid insomnia is a problem, mirtazapine may be a good choice. Think about talk therapy too. It is important to make sure episodic anxiety is not a non-motor symptom fluctuation related to levodopa or oth...
What is your approach to monitoring patients referred for high titer +RF and +CCP but without active symptoms of inflammatory arthritis?
It has been well described that patients with a +RF and + CCP autoantibody may develop clinically active RA up to two decades or more (potentially lifelong) after the detection of these autoantibodies in a patient. It is now thought that there is a preclinical phase of autoimmune diseases including ...
Do you modify dosing or use of bupropion to mitigate seizure risk in patients without eating disorder who are restricting calories to lose weight?
No. The risk of seizures with bupropion is 0.1% with daily doses below 300 mg and 0.4% with doses up to 450 mg daily. The increased risk of seizures in eating disorders is due to higher risk of severe electrolyte disturbances that result from disordered eating, induced vomiting, and laxative abuse. ...
Is there evidence to suggest there is a withdrawal syndrome from muscle relaxants such as tizanidine?
The answer is yes, there is evidence in published literature supporting withdrawal manifestations from sudden discontinuation of alpha-2 agonists including tizanidine (references below), primarily due to catecholamine surge causing a sympathetic overdrive, affecting the patient's physiological state...
What is your approach to helping parents manage sleep disturbances in patients with autism spectrum disorder?
At our center, we start with sleep hygiene education, using tools such as the Autism Speaks sleep toolkit which has a printable PDF that is free for parental and clinical use. We also try to do therapy on sleep hygiene and our therapists will often try to find out what factors may exist in the home ...