Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
What are some practical tips for eliciting an accurate history of Raynaud's phenomenon in patients being assessed for CTD?
I use this approach. I first ask patients if they feel generally sensitive to the cold. All patients with Raynaud's should respond yes to this, but this is not specific, as there are many cold-sensitive patients who don't have Raynaud's. I will then ask if their fingers turn any colors in response t...
How do you approach a child with recurrent parotitis who has had negative serum testing for Sjogren's and IgG4 related disease?
Minor salivary gland biopsy is pretty random and subjective; finding >50 lymphocytes per set field is not that specific/helpful. I would think a parotid gland biopsy and extensive work-up (TB, HIV, sarcoid, lymphoma, etc.) is in order.
How do you counsel patients with postural orthostatic tachycardia syndrome (POTS) regarding safe and effective exercise regimens?
It depends on where they're starting from. If they're starting from scratch, I give them two recommendations: first is the Children's Hospital of Philadelphia protocol, and if they live in town, I refer them to our PT facility at Vanderbilt (The Dayani Center) to have our PT folks help them get star...
How frequently do you monitor CT scans, PFTs, and TTEs in patients with ILA or mild ILD?
Typically, I want my patients with ILD to be seen in clinic every 3-4 months, but of course, that depends a great deal on individual circumstances (e.g., disease severity, what we're doing for their disease, etc.). My typical approach is to have my patients perform spiro, DLCO, and 6MWT Q 3-4 months...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
How do you approach initial steroid dosing in patients with eosinophilic fasciitis?
I usually start with a high dose at 60 mg daily for a few weeks, then add DMARDs like MTX.
In a patient with sicca symptoms and SS-B antibodies only, can a minor salivary gland lip biopsy with lymphoid aggregates, but also scattered areas of acute neutrophilic inflammation be consistent with Sjogren's Disease?
I agree with @Dr. First Last and cannot speculate on the neutrophils.I'd also like to point out that a French study showed that only 1% of isolated anti-SSB patients had Sjogren's disease, SjD (Jardel et al., PMID 28931060); all others had other autoimmune diseases, neoplasia, infection, and solitar...
Do you find trabecular bone score (TBS) useful in patients with a history of ankylosing spondylitis when screening for vertebral fracture risk?
Yes, the ankylosing spondylitis population is a group that could benefit from the evaluation of TBS. DXA-based spine bone mineral density is artificially elevated in the setting of ankylosing spondylitis (due to osteosclerotic artifact from underlying disease), and therefore, spine bone density is a...
Would you consider using LDRT for joint pain/arthritis caused by aromatase inhibitors as a means to keep patients on therapy?
I would try this. I think there is an inflammatory component to this, and the subjective complaints appear to mimic OA. However, I do think this would be a wonderful group of patients to try this on. They are probably already comfortable with radiation, the achiness/discomfort from ET is real and we...
What is the preferred osteoporosis therapy after completing teriparatide in a young woman planning pregnancy within the next year?
It would be helpful to know the T-scores of the spine and femoral neck. I also like to have the bone remodeling markers. My recommendation would be adequate calcium intake of 1000 mg daily, preferably from diet, and 4000 IUs of vitamin D daily, not only to help preserve bone health, but vitamin D al...