Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you treat fibromyalgia in your practice or do you refer back to PCP after ruling out autoimmune inflammatory pathology?
The problem of managing fibromyalgia has been the topic of numerous Rheumatology National meetings and more after-hours clinic gatherings. The reality centers around your desire to take care of people; clearly, this is a group of patients who need someone to provide care. Rheumatologists are exceedi...
Is there evidence that oral contraceptive pills are less effective in pre-menopausal women on tamoxifen chemoprevention?
While I am not aware of such study, going back to the history of how the tamoxifen, compound ICI 46,474 was developed as an oral contraceptive, as well as numerous evidence of estrogen-mimicking properties we observed in the laboratory, one can safely assume that tamoxifen will certainly interfere w...
How do you manage muscle pain and irritation due to radiation?
I manage the pain control with steroids.
How do you advise a patient with VTE on indefinite anticoagulants regarding the Ad26.COV2.S Johnson & Johnson/Janssen COVID vaccine?
The thrombotic events seen with the Ad26.COV2.S vaccine do not appear to be associated with a prior history of clotting events. It seems to be a different entity, similar to heparin induced thrombocytopenia, with clinical presentation of thrombosis and thrombocytopenia. Muir et al., PMID 33852795The...
What is your methotrexate initiation strategy in DMARD-naive RA patients?
Best final dose is 20 to 25 mg per week, not 15 mg per week. D Furst
What recommendations are you giving when patients ask about the best 'cancer diet' to be on?
I counsel patients that there is no definitive data on "cancer fighting foods." What we do know is that nutrition is important for patients undergoing active cancer treatment and involving nutrition can be helpful - and is in fact, a component of many geriatric assessment intervention trials. Resear...
What strategies have you found to be most effective in engaging PCPs in a primary-care or shared-care model of survivorship for pediatric and AYA patients who will receive ongoing care in their communities away from their primary oncology treatment site?
This is a challenge for our center, and many other centers as well. The ideal approach would be to have adult primary care physicians associated with our center who have dedicated clinic time to care for cancer survivors, direct access to our expertise and medical records. While we haven't been succ...
How do you manage random-OFF periods in patients with Parkinson's disease who are otherwise having good control of their motor symptoms?
That's a great question. This clinical scenario is perfect for the use of Parkinson's "rescue therapies." Rescue therapies are those that have a quick-onset of action to provide quick relief, without a significant duration of effect and limited side effects. There are two relatively new drugs on th...
How do you approach monitoring of patients found to have a positive anti-dsDNA antibody without other clinical evidence of SLE?
Autoantibodies are typically present for several years before the diagnosis of SLE. The study by Arbuckle et. al of the U.S. Department of Defense Serum Repository showed that ANA was present 3.4 years, and anti-DsDNA antibodies were present 2.2 years before the diagnosis of SLE. These results indic...
How often do you follow ferritin and organ iron-deposition in a patient who has known hereditary hemochromatosis, but no current evidence of iron overload?
Once diagnosis is made, I stress blood donation or less optimally, therapeutic phlebotomy. If donation every 56 days until ferritin <100 and TSAT <30. This assumes asymptomatic without LFT abnormality. Thereafter the intervals can be adjusted to keep parameters in the desired range. I never follow o...