Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the optimal management of a patient needing surgical clearance for a knee replacement with VWF Ag and factor VIII between 40-50 and no bleeding history?
This is a difficult question. I would make sure that the patients had adequate "stress tests" of their hemostatic system before concluding they have no bleeding history. For example, it is difficult to estimate the bleeding risk if somebody has never had surgery or pregnancy and has been on OCP sinc...
What is your approach to tapering therapy in a patient with recurrent pericarditis now well-controlled on rilonacept?
Good question, since rilonacept was only approved 1.5 years ago, a lot of this is gleaned (i.e. expert opinion) from those that participated in the Rhapsody clinical trial.In terms of actual data, the long-term follow-up from Rhapsody was just presented at AHA.2022. Of those in the extension that de...
Do you prescribe antifibrotics to patients with combined pulmonary fibrosis and emphysema (CPFE)?
The definition of CPFE is not very well standardized. CPFE commonly presents with upper lung-predominant emphysema and basilar/peripheral-predominant fibrosis. Pulmonary fibrosis in CPFE could be due to IPF or other ILDs. I prescribe antifibrotics for patients with CPFE-IPF and CPFE-other ILDs with ...
How would you manage an adult patient status post subtotal resection of spinal osteoblastoma?
US can be helpful if performed serially. If/when there is evidence of growth, discuss ablation options with IR if feasible.
How do you counsel NSCLC patients receiving SBRT on fatigue?
The first thing is to warn the patient and their family that fatigue is possible, and that it peaks about 2 weeks after treatment ends. I also remind them that SBRT is like surgery in that it causes some damage that requires energy to repair, so some fatigue is to be expected. Finally, I tell them t...
Do you routinely screen for pulmonary artery aneurysm in patients with Behcet's?
I don't routinely screen Behcet syndrome patients for pulmonary artery aneurysms. They are a rare manifestation of Behcet syndrome; however, some clinical features increase the likelihood of pulmonary artery aneurysms. Behcet patients with thrombophlebitis are at increased risk of having pulmonary a...
Does recent COVID-19 infection result in elevated PSA?
A study from Turkey showed that PSA can increase sometimes dramatically in men with BPH (not necessarily with prostate cancer) during active COVID infection, from an average of 1.5 pre-COVID to 4.3 during active infection. (Cinislioglu et al., PMID 34626600). One can imagine a similar phenomenon may...
What is your approach to the management of a patient with PAH who is resistant to contraception and planning a pregnancy?
PAH in pregnancy is associated with high maternal mortality despite the advanced therapies we now have available. Therefore, my first step is counseling the patient so she is aware of all the potential risks associated with a pregnancy. If she is already pregnant, I then discuss the option of termin...
In patients with secondary Sjogren's how do you approach screening for lymphoproliferative malignancy?
1. Firstly, I do not discriminate between "secondary" and "primary" Sjogren's disease. There is currently a "Nomenclature Initiative" by the Sjogren's Foundation, led by Dr. Alan Baer, Director of the Sjögren’s Clinic at Johns Hopkins, and Dr. Manuel Ramos-Casals, a Sjogren's expert in Spain. Thus f...
What is your approach to steroid sparing therapy in patients with suspected CTD-ILD?
It depends on numerous factors: What's the underlying CTD? Has the patient been trialed on immunomodulatory agents before? What's the risk of therapy in this patient? And many others. It's a big topic. To delve into some of the above by bullet point: Most guidance for immune suppression is driven by...