Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you approach microcytosis without anemia with high TSAT and ferritin?
This is likely thalassemia trait with iron overload. I would look at the smear to confirm, consider hemoglobin electrophoresis. Sometimes HFE mutations are cofactors that can add to the iron overload so I look for those. If the ferritin is >300, I consider careful phlebotomy to assess mobilized iron...
What factors should prompt a kidney biopsy to evaluate for monoclonal gammopathy of renal significance in a patient with MGUS and suspected chronic diabetic nephropathy?
A renal bx may be reasonable if there is an unexpected or unexplained increase in the Cr and proteinuria. The presence of Fanconi's syndrome may also be a signal of light chain tubular injury.
How would you manage warfarin in a patient with APLS and alcoholic cirrhosis?
This is an interesting and challenging question that would require a case-by-case review by a team of rheumatologists, hematologists, and hepatologists, as well as an in-depth discussion of the potential risks and benefits with the patient. This reference, O'Leary et al., PMID 30986390, provides a g...
How do you manage GI side effects related to CFTR modulator therapy?
We have found that for most patients liver enzymes abnormalities are small and transient; however, for about 1% of patients there are severe elevations and these patients are much more difficult to manage, even after withdrawal, and tough to re-challenge; it is also not patients with severe liver di...
In a patient with history of scleroderma renal crisis resulting in ESRD, would you recommend using steroids for when needed?
The frequency and timing of recurrent Scleroderma Renal Crisis are largely unknown. Majority of the reports available are from patients with ESRD that underwent renal transplant with recurrence in allograft - overall this is rare, with most occurring between 3 months to 2 years post-transplant, but ...
Do you recommend a kidney biopsy in a patient with myelodysplastic syndrome diagnosed two years prior who develops new onset proteinuria?
The decision to perform a kidney biopsy on any patient should hinge around whether the diagnosis can be made non-invasively (very rare), whether the biopsy should not impose an undue risk to the patient, and if a change in treatment may result from the biopsy diagnosis.In MDS, a variety of lesions m...
For patients with microscopic hematuria, do you prefer a lab submitted urinalysis sample undergoes automated urine analysis or microscopic analysis by laboratory staff for quantification of red blood cells?
If quantification is really the question here, and not RBC casts or acanthocytes, I don't know if it really matters, I use both the dipstick blood and the microscopic data for that. A bigger problem is discordance, dipstick blood and minimal cells, which on an exam is pigmenturia but in real life is...
Can you use apixaban or rivaroxaban in case of dabigatran failure?
It depends on the indication of anticoagulation, co-morbidities, etc. In the absence of any direct data, in general, failure in the setting of venous thrombosis or atrial fibrillation it would seem reasonable to consider transition to an agent with a different mechanism of action.
Do you personally review all imaging you order or rely judiciously on radiologist interpretation?
In my practice, I do like to review the images and the reports for all the studies I order. While I trust my radiology colleagues, I find reviewing the images myself helps both my patients and my own understanding of the disease process. For operative patients, I like to look when the study is initi...
In what situations/patient population would you consider placing an implantable cardiac monitor in favor of external monitors for long-term dynamic monitoring of atrial fibrillation?
This is an excellent question and I think we need the remainder of the publication to make our best estimates (specifically Table 1 and the n for results, including % ablated - couldn't find online or any pictures of slide data on Twitter). The online MONITOR-AF late-breaking trial abstract is avail...