Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage a DOAC if interested in testing for lupus anticoagulant?
Testing for anti-phospholipid antibodies encompasses two broad categories of testing. One is an ELISA based (aka solid phase) set of tests that include anti-cardiolipin and anti-beta 2 glycoprotein I antibodies. ELISA assay are not affected by DOACs. For the second lupus anticoagulant (aka fluid pha...
What are the indications for anticoagulation in splenic infarctions?
A great reminder that splenic infarct relates to ARTERIAL thromboembolism and not to VENOUS VTE. Too often, I see massive, blind thrombophilia work-up for (incidentally) detected splenic infarcts.
How do you approach evaluation for underlying rheumatologic disease in patients with chronic asymptomatic thrombocytopenia?
APL testing as well as evaluation for SLE and Sjogrens with complement, urine, antibody testing, not just an ANA.
How do steroids and/or DMARDs affect biopsy results if a renal biopsy for suspected lupus nephritis is delayed?
In contrast to GCA/TA, where the Mayo clinic has published data that steroid treatment for as much as circa 2-4 weeks is unlikely to result in a false-negative biopsy, as long as accounts for the skip phenomenon and carefully examines multiple sections of the biopsy, I am unaware of similar informat...
Is there a BMI cutoff for which you no longer recommend kidney transplantation in a patient with end stage kidney disease and obesity?
BMI cutoff for transplantation varies widely across institutions so it is important to know your local transplant center guidelines. In general, a BMI > 40 kg/m2 is considered to be a contraindication with many centers. Some centers will recommend bariatric surgery (often not a bypass or duodenal sw...
What can prostate patients do for sexual function while on ADT?
While libido drops for most men on ADT, sexual function is still an important component for many, and educating on what to expect will help prevent disappointment or confusion. First, some men can get an erection with testosterone suppressed, but it is less common and not as firm an erection as wha...
How do you taper phenobarbital in a patient with epilepsy?
Since the risk of withdrawal seizures is high, it's best to administer clobazam. The dose depends on the dose of phenobarbital. After a week, clobazam can be discontinued gradually, tapering off without the risk of withdrawal.
How often should you screen for lymphoma in patients with primary Sjogren's syndrome?
Depends on index of suspicion, I don't have a set schedule. In addition to assessing the initial "phenotype" and disease activity of SjD, I want to know baseline status of quantitative Ig's and if a monoclonal is present. I reassess based on clinical scenario over time. Some colleagues will recommen...
For patients who have previously undergone MAZE ligation presenting with paroxysmal atrial fibrillation, how would you counsel them on the risk of stroke long-term when deciding whether or not to start or continue anticoagulation?
The decision to start or continue anticoagulation in patients with atrial fibrillation can be challenging, even after LAA closure. Specifically related to surgical closure of the LAA (excluding percutaneous LAAO, such as Watchman or Amulet), anticoagulation is still recommended indefinitely if suppo...
How do you determine which patients you prescribe 5-fluorouracil vs 5-fluorouracil with calcipotriene for actinic field disease?
We tend to prescribe almost exclusively 5FU + calcipotriene as a compounded agent, the cost is reasonable usually around $50 for 30gms. Standard treatment is BID x 4 days, but many times use up to 7 days, and the response increases through 14 days with what patients experience. Patient adherence is...