Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
When is the index of suspicion high for paraneoplastic systemic sclerosis in terms of clinical and serological presentation and how will you work it up?
This is a great question. Data on the risk for malignancy in newly diagnosed scleroderma patients has been emerging for the past 10 years or so. To date, it appears that the strongest risk factors may be autoantibody with RNA polymerase 3 antibodies showing consistent increase in risk amongst sclero...
What is your approach to patients who present with unilateral Raynaud's?
Thank you for that excellent question! Typically, Raynaud’s phenomenon impacts multiple digits of both hands (and often feet; sometimes tip of the nose, ears, nipples) and is often symmetric in the case of primary and can be asymmetric in Secondary Raynaud’s (often sparing the thumb). In some cases,...
How do you recommend tapering IVIG in patients whose inflammatory myositis has achieved remission?
This is a very good question without any right or wrong answer. My practice is to start tapering the IVIG 6 months after the patient has achieved clinical remission. I usually start decreasing the dose of the IVIG, but the other option is to extend the interval between the patient's infusions. The e...
How would you counsel a patient with active SLE on treatment, low to moderate level of one of the APLS antibodies, and remote history of provoked blood clot regarding perioperative anticoagulation?
Without knowing more specific details, my approach would be to repeat the full panel of antiphospholipid antibodies, institute treatment with HCQ if not there already, discontinue all estrogen products and counsel the patient against smoking. I would coordinate perioperative anticoagulation with a h...
What would be your next step in workup for a patient with IgG Kappa Monoclonal protein detected on SPEP and free lambda light chains found in the urine, with chronic diarrhea for 3 years and concern for GI amyloidosis?
This is a great question. I think the most important thing when it comes to the consideration of amyloidosis is thinking of it in the first place! For patients with MGUS (or myeloma) but with red flag symptoms of amyloidosis, it is important to work these up. The studies recommended may differ base...
How do you diagnose and manage patients with hypnagogic shooting headache?
Hypnagogic stabbing headache is not an entity. Hypnic headache is and so is stabbing headache. We diagnose both conditions based on the history. Hypnic headache resembles cluster headache, except that the headaches are bilateral. If they last (significantly) longer than 1-2 hours, the proper diagnos...
How do you approach management of a patient with lower extremity ulcers from livedoid vasculopathy with a history Sjogren’s and Factor V Leiden?
Assess for additional procoagulant risk factors (smoking, phospholipid Abs, estrogen, paraprotein), and mitigate.Maximize pain management and wound care.In Sjogren's with vasculopathy, pts have responded to hydroxychloroquine, aspirin, and pentoxifylline. When lesions resolve, have continue hydroxyc...
Would you recommend genetic polymorphic testing before the initiation of antiplatelet medication in patients with ICAD?
This is not a bad idea if a rapid test is available. If the patient has clopidogrel resistance, I would treat it with brilinta.
Is concomitant use of azathioprine and febuxostat safe from a bone marrow toxicity standpoint?
No- Logan et al., PMID 31885095.See evidence. If you must use both for outside reasons- start really low and slow and monitor very very closely!
How do you manage a patient with progressive cerebellar ataxia and positive cardiolipin antibodies?
I would be very cautious attributing ataxia to the presence of ACL (even if they were persistent). While an association between ataxia and apl has been described, the differential is extremely broad and should be carefully worked up in conjunction with a neurology team. Some of the more common cause...