Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
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...
How would you manage gastrointestinal bleeding after radiation therapy for pancreas cancer?
In our ablative RT experience (100Gy BED, Reyngold, JAMAOncology, in press), we have had a 2.6% rate of bleeding possibly related to RT in patients not on anticoagulation and 15% in patients are on anticoagulation. Using the point dose constraints (60Gy in 25# and 45Gy in 15#), we have typically see...
In what situations do you check for HIV status in your workup for inflammatory arthritis?
This brings up a great point - HIV screening is recommended for all patients at least once, and more frequently if the patient has risk factors for HIV. Seeing a patient in the clinic is a great opportunity to ensure they have been screened appropriately for HIV. In rheumatic disease situations, HIV...
How do you evaluate an isolated prolonged aPTT in patients?
This is a common problem. First, if possible, find out if there has been a normal PTT in the past which usually eliminates inherited deficiencies. Second, take a bleeding and clotting history including family history, presence of known liver disease, and any medications. Sometimes it is not recogniz...
What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?
I would put CPPD arthritis high on the differential, as the wrist is a common site for CPPD arthropathy in the elderly. In the right context, septic arthritis is a possibility, particularly if the patient is immunosuppressed. Indolent infections such as fungal or mycobacterial are possibilities. Les...
Is it safe to treat checkpoint inhibitor-induced arthritis with methotrexate or biologics?
How the safety of methotrexate or biologics compares to long term steroid use to treated checkpoint-inhibitor inflammatory arthritis has not been determined. With that said, steroids can have deleterious effects on the tumor response in addition to all the other known side effects. Therefore, for pa...
What is your approach to bladder cancer surveillance in patients who have received cyclophosphamide?
Risk of bladder cancer following cyclophosphamide treatment can be associated with oral therapy and likely also related to cumulative dose (1). Risk of bladder cancer with intermittent IV cyclophosphamide has been reported in some observational studies, but has not been consistently reproduced (2). ...
How do you manage VTE in the setting of persistent severe thrombocytopenia?
The thrombosis versus bleeding risk ratio should be weighed. The risk of VTE recurrence or propagation is highest in the first 30 days and we know that thrombocytopenia does not attenuate this risk. Providers should favor anticoagulation. In the case of cancer-associated thrombosis and chemotherapy-...