Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach immunosuppressive therapy in lupus-associated pulmonary arterial hypertension?
I agree with Dr. @Dr. First Last that pulmonary arterial hypertension in SLE is infrequent. In the October issue of arthritis and rheumatology, the prevalence was 2.54% in a cohort of Chinese patients. Management requires distinguishing amongst the 5 WHO groups of PAH, which in lupus includes the fo...
Why are autoantibodies not often detected on monoclonal gammopathy assays (SPEP/IFE, quantitiative immunoglobulins)?
Autoantibodies do not cause a false positive M protein. Even though autoantibodies may target a specific antigen, they are polyclonal. Rarely, a very high rheumatoid factor titer can produce a broad-based (polyclonal) peak in the electrophoretic pattern. UpToDate
Is there an equivalent test for serum viscosity in sickle cell disease?
I would not typically order serum viscosity outside of the setting of paraproteinemia. In that setting, I still think serum viscosity is useful, especially as opposed to plasma viscosity, which might be elevated in a sickle cell patient due to the acute phase reactant fibrinogen. It is true also th...
Do you recommend anticoagulation for a splenic infarct in patients with myelofibrosis and splenomegaly?
I generally do not recommend anticoagulation for a splenic infarct in patients with MF and splenomegaly. The situations where I would anticoagulate: ff they have a splanchic vein thrombosis, or clear evidence of embolic disease (i.e., other areas affected in addition to the spleen). However, general...
Is it okay to use medications associated with drug-induced lupus in patients with SLE?
In the current era, I find it useful to divide drug-induced lupus into two classes. First, the traditional medications such as procainamide and hydralazine that are associated with ANA by IFA, anti-histone antibodies, and a type of drug induced lupus not characterized by certain clinical features su...
How would you manage an active rheumatoid arthritis patient on suppressive antibiotic therapy for ocular HSV who has abnormal liver function tests?
As an ophthalmologist, I will answer this selectively. The choice of immunomodulation for RA in the setting of liver dysfunction, I would defer to rheumatology (I do know that there are plenty of appropriate options that minimize risk to the liver). As far as the ocular HSV, I have many patients wit...
How would you time COVID-19 vaccination with someone on R-CHOP chemotherapy?
It is really hard to time COVID vaccine while on chemo. Although ideal time would be as far away from chemo as possible (3-6 months) or 6 weeks before chemo starts, that is not practical in someone getting q 3 week R-CHOP. I would recommend giving it when available and if possible, time it on a diff...
How do you clinically distinguish between cutaneous lupus with photosensitivity and polymorphic light eruption-like reactions?
Polymorphous light eruption (PMLE) typically occurs at the onset of Spring or Summer when patients have been exposed to light for the first time that season. Because patients' faces are usually not covered up, even in the winter (in non-COVID times), they usually continue to get sun on their faces. ...
What are the current official guidelines regarding COVID-19 vaccination for patients with cancer or for hematologic conditions?
There are a number of resources available to guide clinicians on these decisions. I recommend the COVID-19 Resources webpage curated by the American Society of Hematology (COI, I'm the editor of that website). https://www.hematology.org/covid-19 This website includes guidance on immunizations in the...
What are your thoughts on use of 14-3-3 serum levels in rheumatoid arthritis in conjunction with RF and ACPA?
Until we have a perfect test, it's always worth considering new tests for rheumatoid arthritis (RA). And there are hints that this test may be useful.14-3-3eta is a member of a family of chaperone proteins found in the serum of some patients with RA and other rheumatic diseases.Studies suggest this ...