Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For low rectal adenocarcinoma that extends to the anus through the internal sphincter muscle, would you recommend neoadjuvant therapy in a patient who will undergo APR?
Yes, since the margin is positive and local recurrence rates are high for low rectal cancer patients such as this, they should be treated with neoadjuvant chemoradiation including the inguinals with IMRT.
Would you start tocilizumab in a patient with temporal arteritis and cirrhosis?
This is a challenging question as data regarding this question is lacking and the decision should be individualized to the specific presentation and through shared decision making. In general, I would consider using TCZ in such clinical situations. While TCZ can cause hepatotoxicity, it's not typic...
What is your approach following R1 resection in a patient who has received total neoadjuvant therapy for rectal cancer?
This is a challenging scenario and there is not a one-size fits all solution. My decision making would involve thorough assessment of the patient's performance status, co-morbidities, pre-treatment extent of disease, tolerance of therapy, and review of what TNT regimen was employed: number of chemo ...
When do you trial pyridostigmine in a patient with suspected myasthenia gravis?
I usually try it very early on if I have a reasonable suspicion. Compared to the tensilon test and even the neostigmine test, a diagnostic trial of pyridostigmine is safer and more resource-efficient. Diagnostic trials of pyridostigmine are not particularly evidence-based, nor is treatment, but this...
Would you use inhaled steroids with or without oral steroids for the treatment of radiation pneumonitis?
I have not tried inhaled steroids instead of oral steroids for symptomatic radiation pneumonitis much in my practice. Many patients are already on inhaled steroids at baseline, and many who develop pneumonitis have severe symptoms. That being said, avoiding oral steroids could be particularly import...
How do you approach treatment for arthritis associated with multicentric reticulohistiocytosis?
There are no systematic treatment studies of multicentric reticulohistiocytosis due to its rarity. There are, however, numerous case reports of TNF inhibitors used with success, frequently requiring higher doses than used for rheumatoid arthritis. As this condition is based on proliferation of osteo...
How would you approach chronic isolated severe non-cyclic neutropenia with negative bone marrow and rheumatologic work-up?
My preference would be to use G-CSF at the lowest effective dose, i.e., the dose that maintains the ANC >1000. The risk of inducing leukemia is low in individuals with idiopathic, chronic neutropenia, but it is positively correlated with the G-CSF dose. There are also other side effects like bone pa...
What immunosuppressive agents aside from steroids would you use to treat bronchiolitis obliterans in a patient with long-standing seropositive RA?
There is little doubt that bronchiolitis obliterans can be a devastating lung disease. Corticosteroids remain the primary anchor therapy, however, virtually all patients will require an additional agent. Rituximab has become the primary choice and there is evidence, though mostly anecdotal, that it ...
How do you approach screening for inflammatory bowel disease prior to starting IL-17 inhibitors?
IL-17i are now widely used to treat skin psoriasis (PsO), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA). Genetic and epidemiologic studies suggest the coincidence of these diseases and Crohn’s diseases (CD) as they may present concomitantly in the same patient or affect a family membe...
Is there a role for antibody testing to confirm vaccine response for patients on rituximab after COVID-19 vaccination?
It's a great question, but I do not feel that routinely performing COVID antibody testing would help in the management of these patients: We don't know how well most commercial antibody testing correlates with neutralizing antibody/immune-status (esp. if qualitative testing is performed), and I have...