Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients referred for abnormal light chain ratio when individual light chains are in normal range?
It appears you are referring to a situation where the uninvolved light chain is quite suppressed and the potentially involved light chain is normal, generating an abnormal ratio. There are other situations such as in CKD where both kappa and lambda light chains will be elevated but the ratio will be...
Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?
There are a few case reports of VTE following COVID-19 vaccinations (approximately 10 based on my PubMed review today). However, VTE has a high incidence of 0.1% in the general population and much higher after age 45 (Mary Cushman, PMID 17433897), so determining a causal relationship between the vac...
Do you screen for HLA-B*5801 prior to starting allopurinol in patients of backgrounds other than Asian or African-American?
The guidelines now recommend checking for the presence of the HLA-B*5801 gene only in Asians and African-Americans. However, in our clinic, we are checking for the presence of this gene on everybody who becomes a candidate to receive allopurinol, partly due to the fact that we are doing a study. Int...
How have you been counseling patients with sickle cell regarding a 3rd COVID vaccine?
People who are elderly or immunosuppressed appear likely to benefit from a 3rd dose of mRNA vaccines. Whether or not this applies to a more general population, including people with sickle cell disease is unknown. Sickle cell disease patients are not immunosuppressed in the typical meaning of this t...
Do you recommend COVID vaccination in patients with antiphospholipid antibody positivity or other prothrombotic states not on anti-coagulation?
There are hypothetical reasons that the COVID-19 vaccine might increase thrombophilia in individuals with APS/APLAs. However, the only controlled study I could find, Absence of hypercoagulability after nCoV-19 vaccination: An observational pilot study by Campello et al., PMID 34246010 did not show a...
In your practice, do you usually check MMA and B12 simultaneously or start with B12 levels and check MMA only if indeterminate?
I usually check the B-12 level first. If it is very low, I treat and look for a response. If normal in the ambiguous zone, I get an MMA.
How do you counsel patients regarding the cardiovascular risk of febuxostat?
We understand that gout is a very inflammatory state and in general that inflammatory states can be a risk factor for cardiovascular disease. Although studies such as this have shown an increased all cause and cardiovascular mortality in febuxostat group compared to allopurinol group, it is importan...
How do you manage severe fibrosis/contracture and breast/axilla pain in a patient with a history of breast radiation who cannot tolerate trental?
I have seen some patients with dramatic responses to pentoxifylline (Trental) and vitamin E, but the regimen needs to be continued for at least one year to prevent relapse (Delanian et al., PMID 12829674). However, this patient cannot tolerate Trental, so that is not feasible. Hyperbaric oxygen has ...
How do you counsel young adults with antibody-negative necrotizing myopathy on prognosis and long-term monitoring/treatment?
The first step is to rule out other conditions that are associated with necrotizing myopathy, that can affect treatment and prognosis, like malignancy, thyroid disease, or genetic muscle diseases. History, physical exam, basic laboratory work-up, family history, age-appropriate malignancy screening,...
What is your standard workup and treatment for an incidentally-noted splanchnic vein thrombosis?
Splanchnic vein thromboses are clots found in the portal, splenic, mesenteric or supra-hepatic veins. These can be very challenging because they are often incidentally found and asymptomatic and for these folks, it is very unclear whether we even need to treat them or do any other evaluation. As wit...