Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you check vitamin B6 routinely in the work up of anemia?
I only consider it when I see ringed sideroblasts in the marrow. It is on the differential of things that lead to ringed sideroblasts. "Pyridoxine responsive anemia", which can be inherited or acquired. However, in my experience, it is very rare. Even the couple of people I have had with mildly decr...
What is your recommended management algorithm for bleeding associated with an acquired factor VIII inhibitor?
Fragner et al., Cureus 2022.
In what conditions can you see roving eye movements?
Roving eye movements are seen in comatose patients with intact oculomotor/ brainstem function. These movements can be conjugate or dysconjugate with no pathological significance between the two. Movements are usually horizontal, but vertical eye movements can also occur. Their presence rules out psy...
Are there best practices or data regarding the use of open notes among oncology patients?
The 21st Century Cures Act regulation (effective April 2021) required that clinical notes such as consult and office notes be shared with patients, e.g. “open notes.” In general, surveys of patients with cancer and their clinicians suggest that open notes are viewed favorably (Salmi et al., PMID 330...
Do you offer adjuvant therapy for rectal intramucosal carcinoma within a large rectal adenoma?
Not if the margins are negative and it’s not into the muscularis.
How do you approach treating cutaneous PAN?
I've had personal experience with treating at least a dozen patients with cutaneous polyarteritis nodosa. The diagnosis was made by the clinical appearance of the lesions usually erythematous nodules that spontaneously may disappear leaving behind a livedo pattern. A biopsy of the lesion verified th...
Do you recommend patients wait to have a total hip sx after salvage radiation for RP?
No, I would not require a waiting period because of the total hip replacement. I standardly use IMRT and we typically avoid incoming beams through artificial joints anyways because of the attenuation. Thus, more likely to use a static multi-beam plan than VMAT if the patient has an artificial hip. U...
Do you routinely monitor the QTc when adding voclosporin to hydroxychloroquine in a patient with lupus nephritis?
I approach this situation similar to any drug that can potentially prolong QTc intervals when used with hydroxychloroquine (HCQ). [see final comment at the bottom]Quick answer: No, I do not monitor ECGs (QTc) in patients taking voclosporin (VOC) plus HCQ unless they are at high risk for QTc prolonga...
Why do we not typically see features of rhabdomyolysis or acute kidney injury with idiopathic inflammatory myopathies?
Because rhabdomyolysis leading to AKI means acute massive necrosis of a large number of muscle fibers with resulting release of myoglobin In blood and precipitation of myoglobin in renal tubules, leading to tubular necrosis. This acute extensive myonecrosis typically does not occur with IIMs, with t...
Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?
In this scenario, our patient with lupus is young and does not have features of APS. Nevertheless, any patient with Libman Sacks endocarditis carries a heightened risk for embolization. Regarding anticoagulation, the literature on this subject is anecdotal and conflicting with some authors recommend...