Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are there particular concerns related to the use of B-cell depletion therapies such as rituximab for rheumatic disease during the COVID-19 pandemic?
The attendant depletion of CD20+ B cells associated with treatment with rituximab likely results in impaired development of host immunity to previously unrecognized microbial pathogens. This has, therefore, been of concern in the context of the Covid-19 pandemic due to potential greater adverse outc...
How do you approach diagnosing a patient with Iron Refractory Iron Deficiency Anemia (IRIDA)?
Iron-Refractory Iron Deficiency Anemia should be suspected when there is a lack of response to oral iron and only a partial response to intravenous iron. One should make sure there is not a chronic underlying inflammatory process to explain the lack of iron absorption or lack of the expected respons...
Do hemoglobin S levels always correlate with SCD phenotype?
The severity of sickle cell disease (SCD) is usually associated with the level of hemoglobin S (HbS). For example, HbSS and HbSB0 thalassemia, which generally have higher HbS levels, are usually more severe than HbSC and HbSB+ thalassemia. While patients with HbSC and HbSB+ thalassemia typically hav...
Is there a role for anti-neutrophil antibody testing in the workup of neutropenia?
In my view, anti-neutrophil antibodies add little to the work-up of neutropenia. Drs. @Dr. First Last and @Dr. First Last presented an abstract at ASH in 2015 that summarized restyles for 60 pediatric persons with a diagnosis of autoimmune or idiopathic neutropenia. The sensitivity and specificity o...
What are the benefits of sending HLA B27 genotype over HLA B27 antigen when evaluating for spondyloarthritis?
HLA-B27 is strongly associated with ankylosing spondylitis (AS) which is an inflammatory rheumatic disease that affects the spine, the sacroilliac joints, and peripheral joints. It is also associated with other diseases like acute anterior uveitis, inflammatory bowel disease, or psoriasis. HLA-B27 t...
How would you manage a patient with type 1 cryoglobulinemia secondary to MGUS?
Rituxan can be tried if IgM type MGUS. Please find the attached ASH article on How I treat cryoglobulinemia by Muchtar, Magen, and Gertz; PMID 27799164.
Is there a role for measuring hydroxychloroquine blood levels in clinical practice?
This is being actively investigated by a number of groups around the world, with no final consensus, but the groups in France have studied this the longest, and published the most, to date. The major outcome has been that some (quite a few) patients had very low levels, who admitted on careful quest...
How does a history of splenectomy alter how you counsel patients on the infection risk of TNF inhibitors or other biologics?
In general, a history of splenectomy would lead to an increased concern regarding infections with parasitemia and encapsulated organisms (particularly Strep. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitides). However, I would not consider prior splenectomy an absolute contraindi...
How do you approach a patient found to have a coronary lesion suggestive of vasculitis on coronary CT?
I am not sure what findings are considered “suggestive of vasculitis on coronary CT”. Vasculitis in the coronary arteries is quite rare but can be seen in several vasculitides. There is a big difference in seeing angiographic changes atypical for atherosclerosis (which I assume is what is meant by t...
What is considered an adequate treatment period to assess response of AAV induction therapy with rituximab or cyclophosphamide?
This is an issue of considerable interest both clinically and for research studies, and the approach to both settings is currently similar: are there any signs or symptoms of ongoing active disease? The key words being “ongoing” and “active”. The expectation once glucocorticoids are started and then...