Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What are best practices for engaging with multidisciplinary colleagues to ensure patients with earlier stage NSCLC are being appropriately considered for novel adjuvant therapies?
Treatment of early stage or locally advanced stage NSCLC truly requires a cohesive multidisciplinary team and consistent messaging. Many, if not all, of these cases should be discussed prospectively at a multidisciplinary tumor board. It is also important to set expectations with patients up front a...
How do you approach the management of immunosuppression in patients with lupus nephritis that go on to dialysis?
It depends entirely on their disease status and profile. It is not unusual for patients to have decreased disease activity when they go on HD. If there is still clinical activity though, I maintain them on immune suppressives and prefer mycophenolate mofetil (a major anti-renal transplant rejection ...
What are your preferred treatment options for patients with cholestatic pruritus who do not respond to light therapy?
Great question as in my experience phototherapy does not have high success rate for this. Agree that rifampicin can help quite a bit! Here is an algorithm you might find useful: Initially treat with a bile acid sequestrant such as cholestyramine (total daily dose of 4 to 16 grams) If this does no...
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...
What is your approach to evaluation of underlying autoimmune disease in patients with bilateral scleromalacia?
Scleromalacia perforans is an uncommon form of scleritis wherein there is scleral melt in an otherwise white/quiet appearing eye. The most common systemic association for scleromalacia perforans is with long standing rheumatoid arthritis. Other etiologies of scleritis should also be considered: syst...
Does testing for elevated serum homocysteine have any relevance in thrombophilia management?
Homocystine levels is part of a DVT workup. Although rare, it is a factor in DVT risk. The gene mutation in MTHFR contributes to the elevation and the mutation frequency is extremely high. However, elevation is almost never seen due to added and natural folate in the diet.
How should one manage a patient with leukocytosis and borderline detectable BCR-ABL without other clinical features of CML such as basophilia or splenomegaly?
Leukocytosis has many causes and I will assume within the context of this question that we can narrow the definition to neutrophilic leukocytosis, and that it has been persistent without evidence of an underlying infection, cancer, inflammatory disorder, significant obesity, exposure to a drug or to...
Is a biopsy of either skin or muscle always indicated in the diagnosis of dermatomyositis?
A biopsy of either skin or muscle is not always necessary and the need for each depends on each patient's presentation. A typical history and physical exam, along with MRI or EMG findings, or more importantly, a positive myositis specific antibody can be adequate to make the diagnosis of dermatomyos...
Have you seen patients who develop neuromuscular disorders following COVID-19 vaccination?
I have personally seen and managed post vaccine Bell's palsy and one patient with Brachial neuritis, both with improvement after few months.Mahajan et al., PMID 33890680
In what circumstances do you pursue labial salivary gland biopsy in an asymptomatic patient with high titer ANA and positive SSA?
I seldom, if ever, suggest a lip biopsy in the work-up of patients with Sjogren's syndrome. It is invasive, and even the histo-pathological interpretation is often open to question. I typically refer patients to an ophthalmologist for a diagnosis of keratoconjunctivitis sicca, if present, and if nec...