Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach treating patients with lupus profundus?
For lupus profundus/lupus panniculitis, I would first confirm the diagnosis with a deep punch biopsy or incisional biopsy. The differential for lupus profundus includes factitial panniculitis, traumatic panniculitis, morphea profundus, and subcutaneous panniculitis-like T-cell lymphoma.Once the diag...
How long can you treat dermatomyositis with IVIG?
Typically, in best-case scenarios, you can treat dermatomyositis with IVIG for 1 year, but some patients require it for 18-24 months, and the minority of patients continue to require it over several years. Some patients may only need it until you achieve improvement, especially in some countries whe...
How would you approach a patient with MPO-positive isolated peripheral nerve vasculitis?
AAV can present with a peripheral neuropathy as a first manifestation. The first question we're often facing is whether a biopsy is necessary. If the neuropathy pattern is one of mononeuritis multiplex and there are no atypical features or other atypical serologic findings, I sometimes forego nerve ...
How will you adjust your approach to steroid taper in patients with PMR also on sarilumab?
I would try to replicate the prednisone taper followed in the SAPHYR study that weaned patients off over 14 weeks, understanding that there may be patients that won’t be able to taper the prednisone so aggressively or may benefit, in the opinion of the treating physician, from longer tapers (e.g., 4...
What is your preferred management for eruptive vellus hair cysts?
I have not found any topical medication that helps to clear these and often end up doing quick electrodessication one by one for these small cysts.
Do you routinely prescribe PPI prophylaxis for myeloma patients who will be on low-dose aspirin and weekly dexamethasone?
Depends on the dose of weekly dexamethasone. If 40 mg weekly, would use PPI. If given along with cyclophosphamide as CyBorD, would use PPI regardless of dose of dex; if symptomatic gastritis on aspirin or dex, will use PPI even with lower doses of dex.
In a young female with severe osteoporosis due to congenital estrogen deficiency, can estrogen be prescribed if genetic testing for congenital disorders reveals a heterozygous Factor V Leiden mutation?
First of all, I don't think testing for inherited thrombophilia is warranted in a patient with no personal or family history of thrombosis. Given the multigenic nature of thrombophilia and our limited ability to test for it, it's difficult if not impossible to determine an individual's risk of throm...
What is the risk of serious bacterial infection in a febrile solid tumor patient who has not yet started cancer-directed therapy and has normal cell counts with no central line?
This depends on the type of the tumor, the location, and the individual circumstances. It may not be wrong in this scenario to draw blood cultures and give a dose of ceftriaxone pending 24-hour results, but this practice may also vary based on these different variables e.g. RMS of paranasal-ear area...
In patients taking biologics who are planning joint replacement and are known MRSA carriers do you perform decolonization prior to surgery?
Is there a role for phlebotomy in secondary polycythemia?
Prefatory to answering the question, I think it's important to specify the full nature of the problem because there is confusion in the hematology literature about the criterion used to define erythrocytosis as well as the phlebotomy target in secondary erythrocytosis. Currently, hematologists use t...