Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What indicators do you use to identify patients with CTD-ILD who do not have potential to improve from continued immunosuppressive therapy?
This is an interesting question. We need to clarify what this phrase means "who do not have potential to improve". It may be easier to identify patients who may benefit from therapy.ILD physicians work under the motto, 'stability is success'. Thus, improvement may mean 'did not deteriorate'. Minimal...
How do you approach treatment of vasculitis in a sickle cell disease patient?
Will highly depend on the vasculitis type and the acuity of the situation. For ANCA vasculitis, approaches based on rituximab and low glucocorticoid doses might be attractive (granted not severe disease, e.g. RPGN, DAH which should require pulse glucocorticoids). For large vessel vasculitis, a si...
How would you approach a patient with refractory polymyositis (elevated CK, weakness) despite MMF, IVIG, and moderate dose prednisone?
This is a tricky question as true "polymyositis" is exceedingly rare. In most cases, inflammatory myositis without a rash can be further categorized as an immune-mediated necrotizing myopathy, antisynthetase/overlap myositis, or IBM. So when faced with a refractory polymyositis, the first thing I wo...
Are there circumstances when you may consider imaging enthesitis in patients with psoriatic arthritis?
If you already know that there is "enthesitis", then there may not be a reason for imaging. However, there are a few circumstances to consider imaging entheses in a patient with psoriatic arthritis:1) When there is concomitant widespread pain syndrome and the enthesis is tender but not swollen on ph...
What is your approach to differentiating SLE flare in pregnancy vs pre-eclampsia?
Differentiating SLE flare in pregnancy from pre-eclampsia is challenging. This is particularly so because SLE patients have a higher risk of developing pre-eclampsia during pregnancy. There are no hard and fast rules, and often time as a provider, you are never 100% certain if a patient is having a ...
In which patients with oncologic or hematologic disorders are you recommending a 3rd dose of mRNA COVID vaccine?
In the ideal world, we would tailor the need for booster shots based on whether or not a patient achieves an appropriate immunologic response and maintains that response for long periods of time. This would include both seroconversion and T-cell-mediated immunity. However, we have neither routine no...
Do you recommend that patients undergoing radiation treatment get a COVID vaccine booster?
Yes, we are recommending the third dose booster for our patients who are moderately or severely immunosuppressed. In addition to anyone getting chemoradiation, I would consider anyone treated with large field radiation to begin that category. As for timing, would start before treatment ideally. As f...
How will you use REGEN-COV (casirivimab/imdevimab-monoclonal antibody treatment recently approved under EUA as post-exposure prophylaxis for Covid) in rheumatic patients on immunosuppressive therapy?
Like most other treatments, I've tried to triage use of REGEN-COV post-exposure prophylaxis (PEP) based on the other risk factors that a patient has:The NEJM study published by O'Brien et al. PMID 34347950 did show marked benefit in REGEN-COV post-exposure prophylaxis vs. placebo in the (a) decreasi...
Would you pursue temporal artery biopsy in patients with PMR who develop cranial GCA symptoms and have been on PMR dose steroids for one year?
This is a challenging question. While the literature would suggest that the rate of positive biopsies after 14 days of prednisone have similar positivity to those done before 14 days (Achkar et al., PMID 8185147, retrospective study with potential for bias), there is no data to my knowledge regardin...
How would you manage early-stage low rectal cancer in a patient unable or unwilling to undergo surgery?
This patient may have multiple non-TME alternative options. Trans-anal excision with or without post-op CRT based upon pathological risk factors would be one option. Alternatively, CRT as part of a non-operative management/watch and wait strategy is also associated with favorable outcomes. Here are ...