Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage a patient with diffuse Systemic Sclerosis who develops severe rapidly progressive calcinosis?
Unfortunately, calcinosis cutis is a very challenging and frustrating manifestation of Systemic sclerosis to tackle. When extensive, response to trial of interventions is further unlikely or poor. The primary goal of treatment is to minimize symptoms and alleviate functional limitations rather than ...
How would you approach a stage II colon cancer with negative ctDNA but markedly elevated CEA level post-colectomy?
Thanks for the question. Highly complicated case. Few things matter here. First, what platform is used for ctDNA testing (whether tumor informed or not), and second whether this is T4 or T3 disease. It would be unusual to have high CEA but negative ctDNA in a true minimal residual disease (MRD). For...
Is there any role for iron chelation in a patient with iatrogenic transfusion-induced iron overload such as in patients with end-stage kidney or liver disease?
There is a point with transfusion that iron overload starts to cause significant organ damage. With the advent of deferasirox (Jadenu), oral iron chelation can maintain equilibrium with ongoing transfusion. I would not start till ferritin is 1500 or higher to avoid risk of chelation of other heavy m...
Do you consider Anti-carbamylated protein antibodies (anti-CarP) as having any significance in evaluation of patients if RF and ACPA negative and clinically no active synovitis yet widespread arthralgias and generalized osteoarthritis?
Anti-CarP has been touted as another biomarker for early RA with rates of positivity in ACPA and/or RF-negative patients ranging from 4.5 % in a recent study by Ricchiuti et al., PMID 35885566 to 23.6% in the French ESPOIR cohort. Ricchiuti described anti-CarP tracked the most closely with 14-3-3 et...
How will you approach tapering sarilumab in patients with PMR in remission?
Unfortunately, there is no data at the moment to inform decisions about the optimal duration of sarilumab treatment for PMR patients and how to discontinue this medication. The clinical trial that demonstrated efficacy was limited to 12 months and the drug was stopped altogether after that period. N...
Do you continue belimumab throughout pregnancy?
@Dr. First Last: @Dr. First Last is absolutely correct regarding the limitations of our studies regarding using belimumab in pregnancy.However, how much more evidence do we need?No one is going to perform a prospective randomized controlled trial. I and some others I know are feeling more comfortabl...
When do you use clinical decision tools, like HERDOO2 or DASH, to determine duration of anticoagulation in venous thromboembolism?
I do not use the clinical decision tools as I find that they do not properly account for all variables that impact anticoagulation decision-making in a patient-by-patient case.
Do you routinely use hypertonic saline for pulmonary toileting in patients with non-CF bronchiectasis?
We routinely use hypertonic saline (3% or 7%) inhaled twice daily with oscillatory PEP therapy in non-CF bronchiectasis. The Aerobika device is helpful as the saline can be directly administered through the device with an Aeroeclipse nebulizer, which many patients find more beneficial. I have found ...
How do you manage a patient with no history of miscarriage but who is unable to conceive, who has a positive lupus anticoagulant without diagnosis of antiphospholipid syndrome?
I would be very leery of linking infertility to a positive lupus anticoagulant result. Whether or not the patient has antiphospholipid syndrome the evidence linking antiphospholipid antibodies to infertility (as opposed to loss of an established pregnancy) is somewhere between weak and nonexistent. ...
How do you plan to use canakinumab for the treatment of gout?
I recently had this approved for a gentleman with severe tophaceous gout who does not want to be on allopurinol due to mobilization flares and had anaphylaxis to pegloticase. He has CKD and multiple cardiac comorbidities which limit colchicine as prophylactic agent and difficulty with controlling bl...