Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you continue hydroxychloroquine in lupus patients who develop cardiomyopathy?
The short answer is yes, in that most lupus patients with cardiomyopathy do not have hydroxychloroquine drug induced cardiac injury. That is to say most of these patients either have ischemic cardiomyopathy or non-drug NICM. With that said, antimalarials can produce adverse effects both on the cardi...
How do you manage oxaliplatin-induced acute peripheral nerve hyperexcitability?
This can be very frustrating for both the patient and the treating physician, as there is little that we can do to prevent this from happening. I have found that assurance is the most important thing that we can do for patients. For example, some patients can develop pharyngolaryngeal dysesthesias (...
Would you re-challenge patients who have had a TNF-associated paradoxical adverse event (such as inflammatory bowel disease) with a different TNF inhibitor?
I honestly have not heard of IBD as a paradoxical event with TNF inhibitors (unless possibly in a patient with underlying IBD that was not being treated adequately with etanercept rather than a monoclonal anti-TNF antibody). On the other hand, I have seen paradoxical psoriasis with TNF inhibitor use...
How do you manage patients who are Hepatitis B core antibody positive/surface antigen negative and starting a biologic DMARD (other than rituximab)?
According to the 2015 American College of Rheumatology Guidelines, a patient with natural immunity to Hepatitis B (Core & Surface Antibody-positive; Antigen-negative, normal liver function tests) can be treated as any other patient. However, monitoring of viral load is recommended "regularly" at 6-1...
What is your treatment algorithm for RS3PE?
RS3PE is an interesting condition. In my experience, it typically presents older individuals aged 70 and beyond. Men are more commonly affected. The upper extremities are generally involved unilaterally or bilaterally. In cases of unilateral involvement, one should consider other diagnoses as well, ...
When suspecting a diagnosis of complex regional pain syndrome (or reflex sympathetic dystrophy), what workup should be done to confirm or exclude it?
Every evaluation begins with a thorough history and physical, particularly to look for other explanations of pain to this region. In my opinion, unilateral symptoms are much easier to assess than bilateral symptoms. Bilateral CRPS is reported but it is quite unusual. I am more likely to support a di...
How do you differentiate between axial psoriatic arthritis and axial spondylitis with psoriasis, and is it important to distinguish between these two conditions from a prognostic and treatment perspective?
This is an ongoing controversy in the field(s), with some studies suggesting that clinical differences allow differentiation of axial involvement in psoriatic arthritis from classical ankylosing spondylitis. The concept was recently the topic of a study by Feld and colleagues published in Rheumatolo...
How do you treat small fiber neuropathy associated with rheumatic conditions like Sjogren’s syndrome?
Have primarily followed the recommendations of Julius Birnbaum's group from Hopkins Sjogren's Center and use neuroleptics, primarily gabapentin. The main issue for Sjogren's patients with significant sicca symptoms is that many of the options we have for neuropathic pain increase dryness symptoms, s...
How would you approach post op management of a patient s/p BSO for cystic pelvic mass with fallopian STIC lesion on final pathology?
STIC lesions are considered precursors to ovarian cancer. The role of surveillance and chemotherapy is unclear. In a comprehensive review of 78 women with isolated STIC lesions, Patrono et al found 3 patients with subsequent primary peritoneal cancer among the BRCA patients with a STIC lesion; this ...
Are there any clinical situations in which checking for anti-chromatin antibodies is helpful?
Chromatin is the native complex of histones and DNA found in the cell nucleus of eukaryotes. The prevalence of anti-chromatin (nucleosome) antibodies in systemic lupus erythematosus (SLE) varies from 50% to 90%, being similar to that of the historic LE cell.The question is whether this provides addi...