Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the utility of MRI for identifying disease activity in myositis patients when physical exam and labs are inconclusive?
Agree with @Dr. First Last, however, I want to caution about sensitivity and specificity of muscle MRI for a particular situation you are suggesting i.e., to evaluate if patient has active or inactive disease, has not been studied or proven. The muscle MRI, in general, has good sensitivity and speci...
What treatment options would you recommend for a patient with severe generalized pustular psoriasis who has a history of colon cancer (s/p chemotherapy) and well-controlled HIV?
I'd feel comfortable doing an IL17 or IL23. Bimekizumab would be my first choice with it's higher efficacy with almost all types of psoriasis. There's also a small dataset showing it worked quite well for GPP in a subset of japanese patients. IL36 is my favorite drug for GPP but I'm not aware of an...
What infections should we rule out in patients who develop diarrhea on immunotherapy?
Immunotherapy is known to be associated with immune-mediated diarrhea and colitis (IMDC). However, it remains unclear whether cancer patients undergoing immunotherapy are at a heightened risk for Clostridioides difficile colitis infection (CDI). A retrospective study focusing on patients treated wit...
When do you consider stenting in patients with recurrent stroke with ICAD?
If the original and recurrent stroke are both in the territory of the stenotic artery and if the patient has failed a trial of dual antiplatelet therapy and statin, then I would strongly consider stenting.
What are your recommendations for the long-term management of patients who have experienced Takotsubo cardiomyopathy, particularly regarding ongoing medication management and follow-up imaging?
The management of Takotsubo cardiomyopathy (TTC) focuses on both the acute phase and long-term care. While specific guidelines for TTC are still evolving, a tailored approach based on individual patient profiles and clinical circumstances is recommended. In regards to the long-term medication strate...
How do you counsel patients who wish to travel to high altitudes with myasthenia gravis?
It can be a challenge as high altitude can unleash fatigue, shortness of breath, increased weakness, etc. In a myasthenic patient, it is important to recognize this as some of the symptoms may resemble myasthenic exacerbation acutely. Counseling patients on optimal control of generalized myasthenia ...
How would you manage active psoriasis and psoriatic arthritis in patient on Rituximab and prednisone for MPO positive vasculitis?
The answer is it depends on several factors, the most important being how severe the psoriasis is and if the patient has axial involvement. Since the patient has failed or not responded to methotrexate or apremilast, adding these would not be an option here.While we do not have much data on combinat...
Should methotrexate be categorically avoided in RA patients with COPD or RA-ILD?
Thanks for raising a very important question. It is something that every practicing Rheumatologist comes across several times during their career.The traditional teaching has always been to avoid using Methotrexate in patients with underlying pulmonary conditions due to the associated risk of Hypers...
Should MTX be avoided in RA patients with asymptomatic lung nodules?
It is well established that in some RA patients, methotrexate does cause accelerated nodulosis predominantly in the hands which improves after stopping the medication. That does not mean having pulmonary nodules is a contraindication to use methotrexate. I recommend doing frequent chest x-rays for m...
Do you recommend antibiotic prophylaxis for an ESKD patient with a tunneled dialysis catheter who is planned for a dental procedure?
I do not. Which procedures require antibiotic prophylaxis has always been a very confusing issue for me. It also seems to change often. However, with dental procedures, the main organism responsible for bacteremia is streptococcus of viridans group which is an unlikely cause of line infection. I thi...