Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach patients with a history of lymphoma in remission who are in need of immunosuppressive (e.g. TNF blockers, 6MP) or other therapies (e.g. JAK inhibitors) for autoimmune disease that have been linked with the development of lymphoma?
Dierickx et al., PMID 26384356. Yes, you can resume immunosuppression (IS) safely. If rituximab can be used for auto immune disease treatment that would be perfect.The prior treatment for lymphoma if it included rituximab would have taken care of the b cell reservoir.If high risk for recurrence of l...
How do you manage acute tenesmus related to SpaceOAR?
Fortunately, this does not happen very often. First, make sure there is no mucosal injury by inquiring about significant hematochezia. If there is, then delay sim, consult colorectal surgeon or GI just to be safe, but usually, this will resolve with conservative management. If there is no hematoche...
How would you approach refractory gangrenous Raynaud's secondary to type one cryoglobulins?
Type I cryoglobulins are monoclonal immunoglobulins, and typically occur in the context of a hematologic disorder such as MGUS, multiple myeloma, Waldenstrom macroglobulinemia, or lymphoma. Vascular occlusions due to the cryoglobulins may occur and lead to digital ischemia.The patient should be eval...
When is it necessary to monitor the QTc interval in patients on hydroxychloroquine?
The answer to this question is not straightforward mainly because there are limited data in this area. Hydroxychloroquine and Chloroquine directly affect cardiac repolarization and are associated with QT prolongation. Given this, there is an argument for getting a baseline ECG for patients initiatin...
Are there any concerns about using nintedanib in a patient with progressive fibrosing ILD on background mycophenolate?
The SENSCIS trial randomized patients with SSc associated ILD to Nintedanib or placebo. I think about half of these patients were still taking MMF. There was no negative signal in the group on MMF and Nintedanib, they fared at least as well as those who got Nintedanib alone and both did better than ...
How would you manage an incidental catheter-related thrombosis in a functioning dialysis catheter?
If the patient is asymptomatic and the catheter is functioning well, I recommend starting anticoagulation.If the patient develops symptoms, he or she should still be anticoagulated but the catheter removed. Anticoagulation options in ESRD patients include Coumadin, Eliquis (my preference is a dose o...
What is the importance of finding a positive titer for FGFR3 and what treatment would be advised for these patients?
The significance of positive FGFR3 antibodies in patients with neuropathy, and the optimal treatment regimen for those patients remain to be determined. Based on the largest case series of FGFR3-IgG + patients to date, the antibodies seem to be associated predominantly, if not exclusively, with non-...
Are there scenarios where you send additional antibodies beyond anti-centromere, Scl-70, and RNA polymerase III in suspected scleroderma patients?
While these are the most common ANA subtypes in scleroderma, there are several other antibodies that are important. High titer ANA's with a speckled pattern may be U1 RNP and may be associated with overlap disease (MCTD). ANA's with a nucleolar pattern can be U3 RNP (fibrillarin), Th/To, or PM -Scl,...
For low rectal adenocarcinoma that extends to the anus through the internal sphincter muscle, would you recommend neoadjuvant therapy in a patient who will undergo APR?
Yes, since the margin is positive and local recurrence rates are high for low rectal cancer patients such as this, they should be treated with neoadjuvant chemoradiation including the inguinals with IMRT.
Would you start tocilizumab in a patient with temporal arteritis and cirrhosis?
This is a challenging question as data regarding this question is lacking and the decision should be individualized to the specific presentation and through shared decision making. In general, I would consider using TCZ in such clinical situations. While TCZ can cause hepatotoxicity, it's not typic...