Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
What is the optimal work-up for patient with repeatedly negative biopsies of a mid-rectal lesion with signs of malignant etiology?
It is not that rare to get negative biopsies initially in rectal cancer, as superficial tissue only is biopsied. I generally recommend that at repeat biopsies, attempts are made to biopsy deeply to get diagnostic tissue. One approach is to have the surgeons biopsy with a rigid endoscope- they can us...
How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?
Difficult question. First, I would make sure that the ulcers you are trying to treat are really ischemic in etiology. These would typically be ulcers that are on the fingertips in association with significant Raynaud's. Other etiology for ulcers would be trauma/skin fragility (over PIP joints most c...
How do you interpret granulomatous features on a muscle biopsy?
The differential for granulomatous myopathies is quite wide and depends on the clinical scenario. The most common diagnosis would still be sarcoidosis, but can also be seen with Crohn's disease, myopathy associated with anti-mitochondrial antibodies, rheumatoid arthritis, GPA/EGPA, rheumatoid arthri...
Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?
Clinical trials of TNF inhibitors have identified a small but increased risk of malignancy with the use of TNF inhibitors, and most, but not all, of the follow-up studies done with real-world registries have confirmed this. These registries are of course sometimes affected by the behavior of physici...
Do you have any suggestions about how to improve rheumatology training in internal medicine residency programs?
As an academic rheumatologist and also an internal medicine program director, I have a strong vested interest in promoting rheumatology. Our clinics are set up so residents have the opportunity to work with varied preceptors to encounter a wide array of pathology as well as practice styles. We have ...
What is your work up and management for patients who develop neuropathy on a TNF inhibitor?
The first issue to address is whether the neuropathy is truly related to the TNF blocker. This can be challenging as many of our patients who were prescribed these drugs may have an underlying neuropathy related to their disease. For example, we know that patients with RA are susceptible to developi...
What would be the recommended management for patients with rectal adenocarcinoma with rectovaginal fistula at presentation?
Diverting colostomy, preop RT chemo, and surgery.
What do you use to treat a GCA patient refractory to methotrexate who responded but had adverse effects with both tocilizumab and sarilumab?
This is a challenging group and we don't have a clear answer. Aside from stretching their steroid taper, which is always an option, alternative off label therapies could be considered. From conventional DMARDs, you could try leflunomide. The IL12/23 inhibitor ustekinumab has been studied and has had...
Is there any role for direct oral anticoagulants in the treatment of antiphospholipid syndrome?
Triple-negative APS is a confusing category as includes seronegative APS, APS with non-conforming aPL such as anti-phosphatidylserine-prothrombin amongst others, and the universe of patients with thrombotic events unrelated to antibody-mediated hypercoagulable state (eg Protein S, C or anti-thrombin...