Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach patients with underlying psychiatric disorders who refuse CML treatment due to not believing their diagnosis?
Importantly, having an underlying psychiatric disorder doesn't unto itself mean that the patient lacks the capacity to make their own medical decisions. Further information is necessary about the patient's understanding, their current status, etc., to make that determination. At many institutions, p...
Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?
Yes. My own practice is to perform testing for antiphospholipid antibodies in all patients with unprovoked VTE and also in patients with arterial thrombosis. Testing should include assays for lupus anticoagulant, anti-cardiolipin antibodies (IgG and IgM), and anti-beta 2 glycoprotein I antibodies (I...
How would you manage VTE in a patient with bleeding disorder such as hemophilia?
Management of VTE in a patient with an inherited bleeding disorder depends on the specific disease, the severity of the bleeding disorder, and the past history of bleeding in that patient. In patients with serious past bleeding and low levels of factor, anticoagulants may be contraindicated and loca...
How do you approach the use of steroids for active muscle disease in patients with scleroderma-myositis overlap syndromes?
For patients with mild myopathy (mild weakness and CPK elevation), I tend to avoid steroids altogether if I can and just treat them with other therapy (like MMF or MTX). For patients with severe myopathy, particularly if they are very weak or have oropharyngeal weakness and at risk for aspiration, I...
At what platelet count would you feel comfortable dosing aspirin 81 mg for coronary artery disease in a patient with ITP?
In a patient with ITP, I would certainly feel comfortable dosing aspirin 81mg daily at a platelet of 50,000 or greater. As you know, the risk of bleeding in a patient with ITP is less than would be expected at a particular platelet count because the circulating platelets in ITP are young and large. ...
What is the role for angiography in the workup of digital ischemia?
Digital ischemia is an especially serious complication in patients with rheumatic disease, particularly scleroderma but can also be a feature of lupus, vasculitis (ANCA associated, PAN), antiphospholipid syndrome, and rheumatoid vasculitis, among others.The presence of digital pain with permanent/pe...
How do you manage HIT in a patient with high bleeding risk?
If bleeding risk associated with the administration of an alternative anticoagulant is unacceptably risky, I usually recommend the administration of IVIG. Theodore E. Warkentin, PMID 31274032
Do you routinely obtain a chest x-ray prior to initiating anti-TNF or other biologic therapy?
I don't routinely order a chest x-ray in patients with negative quantiferon (or other latent TB testing such as the T-spot) before starting biologics. The chest x-ray is much less specific for latent TB, particularly in the United States where TB is not endemic. Patients may have granulomas or other...
Are you comfortable using DOACs in obese patients with VTE?
Although there are no direct randomized trials in this population of patients, emerging data from systematic reviews suggest that DOACs are non-inferior to warfarin in patients >120 kg. (Elshafei et al., PMID 32556939).
What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?
This is a difficult condition to manage and personalized approach/risk stratification is key. There are several potential considerations:Warfarin therapy could be intensified, anti-platelet agents could be considered (although not in combination with LMWH).For patients with an underlying autoimmune ...