Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you determine if a patient is safe to drive after having a PCA infarct?
In many patients with PCA infarction, the answer is clear, that they cannot safely drive. In my state, the law requires 140 degrees of lateral vision for driving privileges, not met by patients with homonymous hemianopsias. These patients need to be told that they cannot legally drive, and this need...
Is there a role for immunosuppression in patients with triple positive antiphospholipid antibodies who do not meet the clinical criteria for APS?
Currently, there are no “clinical” nor “diagnostic” criteria for antiphospholipid syndrome (APS). I suspect your question refers to patients not meeting the Sapporo APS “classification criteria.”There are two primary ways that patients with triple-positive antiphospholipid antibodies (aPLs: anticard...
What hematologic conditions are contraindications for a COVID vaccine?
The short answer is that a history of severe allergic reaction is really the only contraindication to COVID-19 vaccination. Perhaps, patients with systemic mastocytosis might be at increased risk of allergic reaction but I'm not aware of data to support that.The longer answer is a question of timing...
How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?
Ocular inflammation, usually anterior uveitis, can occur as a consequence of bisphosphonate therapy. Virtually always, the bisphosphonate is one that is given intravenously and the ocular inflammation begins a day or two after the treatment. Furthermore, the inflammation is generally self-limited; i...
What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?
If at all possible, I continue to use tocilizumab as a glucocorticoid sparing agent for patients with giant cell arteritis. Given the results of the GIACTA trial, the Villiger trial, and lots of observational data, it is clear that tocilizumab provides efficacy in terms of reducing risk of relapse a...
What are your recommendations regarding methotrexate usage in patients with persistent chest CT changes post COVID pneumonia?
With the raging pandemic and the steady stream of post-COVID inflammatory/fibrotic patients, we are bound to encounter patients with such abnormalities who are on potentially pneumotoxic drugs (or need initiation).With minimal concrete data, any recommendation is purely based on experience.Methotrex...
How would you manage a patient with acquired von Willebrand disease who requires DAPT for arterial disease?
Acquired vWF has many causes: lymphoproliferative disorders; MPN; autoimmune disorders; high flow disorders (Heyde syndrome) and drugs. Treating the underlying disorders would be the safest strategy because DAPT is going to cause bleeding per se in some patients and removing a second cause for bleed...
What particular pre-operative considerations should we consider for SLE patients undergoing elective surgery?
Our guidance in the perioperative management of systemic lupus erythematosus (SLE) patients is essential. A 2016 study showed they are at a much higher risk for falls, thrombosis, acute kidney injury, and infections compared to patients with osteoarthritis (Roberts). This increased risk is even pres...
How do you approach patients with underlying psychiatric disorders who refuse CML treatment due to not believing their diagnosis?
Importantly, having an underlying psychiatric disorder doesn't unto itself mean that the patient lacks the capacity to make their own medical decisions. Further information is necessary about the patient's understanding, their current status, etc., to make that determination. At many institutions, p...
Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?
Yes. My own practice is to perform testing for antiphospholipid antibodies in all patients with unprovoked VTE and also in patients with arterial thrombosis. Testing should include assays for lupus anticoagulant, anti-cardiolipin antibodies (IgG and IgM), and anti-beta 2 glycoprotein I antibodies (I...