Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you counsel patients on the risks versus benefits of JAK inhibitors for the treatment of alopecia?
Because alopecia areata is a chronic condition that often occurs in healthy patients, risks of immunosuppressant medications need to be considered. Safety comparisons must be individualized based on the limited data available. Medications such as JAK inhibitors, which can yield immediate results, ma...
For patients with nephrolithiasis and hypercalciuria attributed to a parathyroid adenoma, how long after a partial parathyroidectomy do you assess for improvement in 24-hour urine calcium levels?
An interesting question! The physiology of parathyroid hormone is to reabsorb urinary calcium; that is why most patients with primary hyperparathyroidism are hypercalcemic! The better question is why are they hypercalciuric? I think the best answer has to do with the filtered load of calcium exceedi...
Is monitoring for fetal heart block recommended in pregnant patients with only slightly elevated SSA?
At this time, we don't have a consensus on the titer that causes heart block and how that changes across different labs. Dr. Buyon's group did present this at ACR. So I would recommend HCQ and monitoring for this patient.
Would you treat a hemochromatosis carrier with IV iron if they have iron deficiency anemia in conjunction with elevated ferritin?
This scenario, with numbers like these, suggests another underlying issue. A carrier of hemochromatosis cannot typically have a ferritin level of >900 due to hemochromatosis. The TSAT of <10% corroborates this statement. If this patient is real, they likely have an underlying inflammatory disorder ...
What is your approach to monitoring patients with cardiac sarcoid while tapering immunosuppression?
Monitoring of patients with cardiac sarcoidosis (CS) is critical to optimizing therapy and improving outcomes. Once a decision has been made to institute immunosuppressive therapy, it is important that the efficacy of therapy is demonstrated and that the duration of therapy is guided by the response...
Is there a role for systemic therapy for a patient with scleroderma sine sclerosis, with esophageal strictures and Raynaud’s syndrome, but no pulmonary involvement?
We don't have any evidence that immunosuppression (assuming that is what you are referring to) would play a role in the treatment of the esophageal disease or the Raynaud phenomenon. Also, we don't have any data to suggest that this would have any overall long-term "disease-modifying" effects. So in...
Do you start aspirin for patients with incidentally found intracranial vertebral stenosis?
I'm not aware of any clinical trial evidence, but in this scenario, I would probably start with baby aspirin.
What considerations do you take when evaluating a patient for kidney transplantation who has a history of kidney disease and an abdominal aortic aneurysm treated with past stenting?
If the external iliac vessels are spared then the patient does not have an absolute contraindication to transplantation. The risk factors associated with the AAA will need careful review, e.g., smoking, cholesterol, hypertension, CAD, and other vascular diseases, and mitigated if possible. Anecdotal...
For a pedunculated rectal polyp found to be adenocarcinoma after endoscopic removal, with PNI as the only adverse feature, would you recommend additional treatment such as surgery or chemoradiation?
Yes