Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is the preferred imaging modality to evaluate subaortic membranes in patients with aortic valve disease?
Transesophageal echocardiography is the preferred modality for evaluating subaortic membranes, especially if transthoracic echo is equivocal.
How would you interpret a positive single specific markers like SSA or SSB in setting of working up an connective tissue disease, especially when ANA is negative?
Ha! Good question. And this is an issue I literally just talked about with our residents during an autoimmune labs lecture that I give. If you have a negative ANA by IFA (immunofluorescence assay), the sensitivity of such a test is extremely high (99%) as hundreds of antinuclear antibodies are scree...
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...
How often would you repeat testing in a patient suspected of Cyclic Cushing's?
24-hour urine-free cortisol and MN saliva cortisol are preferred tests over ON dex suppression. The exact frequency depends on the severity of the symptoms, generally about every 3 months.
In patients with secondary osteoporosis due to primary hyperparathyroidism, should parathyroidectomy be recommended in the setting of recent prior bisphosphonate use?
I would recommend parathyroid surgery in a person with confirmed primary hyperparathyroidism and osteoporosis as the bone density will increase in most patients after surgery. Many of the patients with osteoporosis may have received bisphosphonates. In rare situations, a patient may have received a ...
How would you evaluate and treat a disabling tongue tremor?
This is a very interesting presentation. First, establishing phenomenology is needed. Is this a tremor or does it appear tremulous? Tremor is oscillatory and rhythmic. If these movements do not fit this pattern, consideration of neuromuscular disorders, like myorhythmia, or other movement disorders ...
What treatment options do you recommend in a patient with idiopathic granulomatous mastitis that has not improved on steroids and methotrexate?
I have multiple cases of IGM that I have treated successfully and have gone into remission or at least not needing any prednisone with azathioprine monotherapy and combo methotrexate and adalimumab.
Do you recommend monitoring IgG level in patients with AAV receiving rituximab?
Yes! At the OSU Vasculitis clinic, we check IgG before every rituximab infusion. At a minimum, it must be done yearly to ensure no impending CVID or to change rituximab.
How do you manage immunosuppressive medications in patients who develop a pneumonia?
For most bacterial pneumonia in transplant patients, I prefer to avoid changing immunosuppressives and simply administer appropriate antibiotic therapy. This approach is effective and minimizes the risk of triggering acute rejection. For viral etiologies, I will often reduce or hold cell cycle inhi...
How would you approach peri-operative immunosuppressive management of a patient with Behcet's, currently controlled on azathioprine, who needs genital surgery?
It might be helpful to know what kind of genital surgery is planned and why. Here are a few general thoughts: There are little data to guide a unified approach outside of BD patients who need vascular surgery. Standard rules of thumb are to 1) reduce surgeries to a necessary minimum and 2) regard mo...