Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What dose and duration of steroid therapy do you use in steroid responsive ILD?
This is an extremely challenging question to answer as "steroid-responsive lung disease" encompasses a variety of formal and informal diagnoses as well as a variety of different clinical scenarios. Additionally, the dose and duration of corticosteroids would depend on patient factors and comorbid co...
Do you find MRI helpful to differentiate early erosive OA from psoriatic arthritis when early X-ray changes in both conditions may be hard to distinguish?
This is a great question to discuss. I do not in general let imaging dictate my decision about a diagnosis but factor it into the entire evaluation. I find the examination in conjunction with radiographs of the hands AND the feet help me sort out many of these issues. Symmetry, distribution, and par...
How do you counsel patients on preventing and treating "maskne"?
Prevention: Cleanse and moisturize the face daily using products that are appropriate for your skin type. If using a cloth mask, make sure it is washed regularly. Take off the mask when safe and appropriate. Skip makeup when wearing a mask. If makeup cannot be avoided, make sure it is labeled "non...
Can bleeding risk when switching from VKA treatment to a NOAC in frail, elderly patients be accurately compared if individual times in therapeutic range while on VKA treatment are not captured?
It has been postulated that, among patients who do not have an INR within therapeutic range, about half have subtherapeutic values and half have supratherapeutic values. Therefore, the latter are at higher risk of bleeding complications. Time in therapeutic range (TTR) ranges around 60-70% in random...
Do you use apremilast in combination with biologic DMARDs for psoriatic arthritis and/or psoriasis?
I have used apremilast in combination with a biologic in my practice. Monotherapy with biologics is not always effective in relevant treatment domains in patients with psoriasis and psoriatic arthritis. Then the choices are to switch to a different biologic agent, add a traditional DMARD or consider...
How would you approach management of incidentally identified unilateral retinal vasculitis with subsequent labs revealing +P-ANCA?
This anecdote raises at least 3 fascinating questions. First, how do you approach asymptomatic retinal vasculitis? Often a retinal vasculitis is defined by the dye, fluorescein, leaking from a retinal vessel on a study called a fluorescein angiogram. By this definition, pedal edema would be a pedal ...
In people who have had a single detected episode of atrial fibrillation, but none documented subsequently, is there any consideration for increased thrombolembolic risk just from altered atrial architecture, impaired contractility?
Clarification, impaired left atrial contractility
Do you always aspirate effusions in patients with knee osteoarthritis prior to injecting hyaluronic acid?
There is strong biologic plausibility that one should always aspirate an effusion before injecting hyaluronic acid. Even a mildly inflammatory effusion will have an excess of white cells. White cells produce hyaluronidase. Hyaluronidase catalyzes the degradation of hyaluronic acid and renders it ina...
Is there risk for local recurrence if thymoma received CT guided biopsy transgressing the capsule prior to surgery?
I polled two board-certified thoracic surgeons in our institution and here is the compilation of their responses: "The data associating tumor spread with biopsy are, in general, anecdotal and outdated. Pleural spread is a common route of metastasis but there are no clear data to link it to biopsy. W...
Do you avoid ESAs in patients with end stage kidney disease who also have heart failure due to increased risk of stroke?
If the question is whether I avoid ESAs in patients with ESKD who also have heart failure, the answer is no for several reasons. The warning in the ESA package insert regarding using ESAs with caution in patients with heart failure (HF) comes from the CHOIR study (Singh, et al., PMID 17108343) of no...