Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Would you give antithrombin concentrate for surgical VTE prophylaxis in case of congenital AT deficiency?
There is no role for routine antithrombin (AT) infusions. In selected situations, during high risk e.g. periods surgery or labor and delivery, etc when anticoagulants are interrupted, AT replenishment is reasonable.
How would you manage someone with antithrombin deficiency who has recurrent VTE on a DOAC?
I would consider Coumadin or an alternative NOAC. Repeat eval to make sure there is not a second gene defect. Also consider antithrombin III prophylaxis.
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
I would refer to the following article that provides the most up-to-date definitions (including the definitions for low-level antibodies) and risk stratification tools including APL-S and GAPSS that are developed for people with autoimmune conditions. The article also discusses the levels of evidenc...
When would you consider a workup for C. diff in a patient with diarrhea under-going concurrent chemoradiotherapy for rectal cancer?
Good question – and hard to pinpoint a strict answer. I think any time the diarrhea is out of proportion to expectation (i.e., very early in RT course), clinically significant (dehydration, etc), and not controlled or responding to anti-diarrheal medications, especially in the setting of C. diff ris...
What is your approach to workup for an underlying disorder in a patient with bilateral hip avascular necrosis?
The approach to assessing hip osteonecrosis is to address the potential causes: Is there a history of antecedent trauma? Is there a family history of osteonecrosis? Is there a history of significant alcohol use? Is there a history of recent corticosteroid use? Is there a history of pancreatitis? Is ...
Would you consider the use of dual antifibrotic therapy (nintedanib and pirfenidone together) for progressive fibrosing ILD?
Pirfenidone and Nintedanib have different antifibrotic mechanisms of action, and emerging data suggests that these complex molecules may possess previously unknown pleiotropic properties. It is unclear whether a synergistic effect might be realized from combination therapy with these agents, and ind...
Do you recommend genetic testing after a patient on clopidogrel has a stroke based on the results of the CHANCE-2 trial?
No, the data from CHANCE-2 (Wang et al., PMID 34708996) was based on a strictly Asian population and results need to be validated elsewhere for it to change practice.
What is the negative predictive value of a negative extended myositis panel in dermatomyositis patients?
The short answer is "not great, but it depends" since the more nuanced answer is contingent on: the constellation of myositis-specific antibodies (MSA) included on the panel, the nitty-gritty of how the commercial lab is checking the MSA included (this detail can change between vendors, or even ...
How do you manage psoriatic arthritis in patients who are planning to start treatment with checkpoint inhibitors for underlying malignancy?
This is a very important question, and I think rheumatologists will encounter cases like this more frequently as immune checkpoint inhibitors (ICIs) are being increasingly used. Roughly, 50% of patients with co-existing autoimmune disorders and malignancies have flare-ups of their autoimmune disorde...
How do you manage recurrent inflammatory pleural effusions in lupus pleuritis?
I'll stick to the immunomodulatory treatments and not discuss thoracentesis and pleurodesis for large and recurrent effusions. (These are rarely needed anyway, and I'd get the help of a pulmonologist). There really are no large study, or evidence-based proven therapies for pleural effusions and pleu...