Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
How would you attempt to determine the etiology of intracranial hemorrhage in a patient with newly diagnosed lupus and an active viral infection?
My typical evaluation of a case like this is as follows: 1. Evaluate their lupus disease activity: CBC, CMP, ESR, CRP, C3, C4, dsDNA, urinalysis, urine protein/creatinine ratio (latter two are more for eval of renal disease) 2. Evaluate the cause of ICH: a. MR to further evaluate for other non-ICH r...
How do you counsel Takayasu patients on their prognosis?
Unfortunately, patients with Takayasu arteritis have a higher mortality rate compared to the general population. Most studies suggest a 3-fold higher standardized mortality rate in patients with TAK compared to age-matched healthy controls. Survival rates following TAK diagnosis vary notably between...
Are stress-dose steroids indicated in patients with adrenal insufficiency receiving radiation therapy?
I am not aware of any direct analysis or study that has addressed this question specifically for patients undergoing radiation treatment, but I can comment on the present indications for perioperative stress-dose glucocorticoids in adrenally insufficient patients, from which certain inferences to Ra...
In gout, do MSU crystals form only in tissue, or are there circulating microcrystals of MSU within blood vessels?
The solubility of MSU is dependent upon solute, temperature, and pH. Even with a rapid rise in total body uric acid as seen with tumor lysis syndrome, where uric acid levels can exceed 15 mg/dL, I have never heard of an MSU crystal identified in a serum sample. As I explain to students and patients,...
Is it ever appropriate to use hydroxychloroquine temporarily in higher doses (more than 5mg/kg) to control lupus activity such as skin manifestations?
The risk of retinal toxicity with long-term use of doses higher than 5mg/kg was shown by Melles and Marmor; PMID 25275721. There are reports of developing retinal toxicity even with short-term use of HCQ mostly coming from oncology literature (e.g. Navajas et al., PMID 26651304).There is some publis...
Is there an increased risk of COVID-19 in patients on immunosuppressants?
This is an important question to which there is no clear answer. Intuitively, it would be expected that patients who are immunosuppressed would be at greater risk of Covid infection. However, observational studies suggest that this may not be the case. Haberman et. al., have reported the results of ...
Would you hold all immunosuppressive medications for the first month of LTBI treatment, or just biologics?
This video might answer your question: QD Clinic - Lessons from the clinic - Dx and Treating LTBI with a TNFI inhibitor features Dr. Jack Cush
How do you manage hand-foot syndrome associated with capecitabine (and other conventional chemotherapy agents)?
In the breast cancer world, I see hand-foot syndrome most commonly with capecitabine. I have used topical 10% urea cream with a reasonable amount of success. I have noticed that using it prophylactically seems to help with the prevention of hand-foot syndrome to quite an extent. A couple of randomiz...
How do you manage early rectal symptoms such as tenesmus in a patient undergoing pelvic radiation for prostate cancer?
If patients are having symptoms out of proportion to what you would expect, I consider other potential causes, especially if the usual management approaches aren't working. I've had a few patients over the years with undiagnosed Celiac disease, who got severe early diarrhea during a course of extern...