Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How long would you anticoagulate for PE developed after air travel in a woman on an estrogen-containing vaginal ring for contraception?
This patient has two transient (“provoking”) factors that may have contributed to her pulmonary embolism (PE): the use of estrogen-containing contraception and, presumably, a recent long-haul air travel. Traditionally, it has been assumed that, after three months of treatment for the initial venous ...
Given the cardioprotective and renoprotective effects of SGLT2 inhibitors, should we consider administering to patients with well controlled type 1 diabetes despite the risk of DKA?
The key word in this question is "consider". GIven the lack of published clinical trials to assess efficacy (CV and CKD hard outcomes) versus safety (DKA) in this population, an answer at this time would be a qualified yes, with the qualifications being a well-motivated patient who adheres to self-g...
How do you interpret a high positive RNP in the setting of a negative ANA and negative sm/RNP?
This is a challenging scenario that we often see in clinical practice with our current multiplex assays. A great reference is the following ACR abstract: Clinical Significance of RNP Antibodies in Diagnosis of Systemic Autoimmune Rheumatic Disease When Detected By Multiplex Immunoassay. As demonstra...
When is a paraneoplastic panel indicated when working up patients with neuromuscular conditions?
How would you interpret a positive dsDNA in a patient with a negative ANA performed via indirect immunofluorescence?
Another important consideration is the methodology by which the anti-dsDNA antibody was assessed. Most commercial labs use EIA, which is sensitive but not as specific as Farr or Crithidia assays. Many positive EIA results are negative when checked by these more specific methodologies.
How do you approach a negative ANA and positive dsDNA in patients with arthralgia, hair loss, or other UCTD features?
This could easily be a person with early (evolving) ANA-negative SLE (depending on the dsDNA titer) or early UCTD. If the dsDNA titer is low my concerns are somewhat diminished. I certainly would not assign a diagnosis of SLE given the information provided, with special reference to the person's anx...
Are there instances when you obtain an abdominal X-ray over an ultrasound or CT scan for kidney stone surveillance in a patient with recurrent calcium based nephrolithiasis?
Currently, no. My goal with renal imaging is to determine the number, size and position of stones. Before the advent of ultrasound and CT scanning, I used KUB with tomograms. Those have been replaced by CT and ultrasound for more accuracy and less radiation. My urologic colleagues may use an abdomin...
What is your preferred protocol for squaric acid (SADBE) treatments for alopecia areata/totalis?
Based on a few series published showing that sensitization is not necessary for contact immunotherapy, I tend to do one of two things: Start patients at squaric acid 0.001% solution every other day at home and increase the concentration by 10 (0.01%, then 0.1%, then 0.5%) monthly if not reacting. ...
What is your preferred prophylactic agent in idiopathic angioedema?
I start them on Zyrtec and titrate up to 4x daily dosing as I would in chronic urticaria.
How do you approach treatment of depression in Graves' Disease?
Though depression is often associated with hypothyroidism, it has also been found to be associated with hyperthyroid states and depression itself can impact thyroid function levels (1, 2). It is important to normalize thyroid function as psychiatric symptoms physiologically stemming from hyperthyro...