Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
What is your treatment algorithm for RS3PE?
RS3PE is an interesting condition. In my experience, it typically presents older individuals aged 70 and beyond. Men are more commonly affected. The upper extremities are generally involved unilaterally or bilaterally. In cases of unilateral involvement, one should consider other diagnoses as well, ...
When suspecting a diagnosis of complex regional pain syndrome (or reflex sympathetic dystrophy), what workup should be done to confirm or exclude it?
Every evaluation begins with a thorough history and physical, particularly to look for other explanations of pain to this region. In my opinion, unilateral symptoms are much easier to assess than bilateral symptoms. Bilateral CRPS is reported but it is quite unusual. I am more likely to support a di...
How do you differentiate between axial psoriatic arthritis and axial spondylitis with psoriasis, and is it important to distinguish between these two conditions from a prognostic and treatment perspective?
This is an ongoing controversy in the field(s), with some studies suggesting that clinical differences allow differentiation of axial involvement in psoriatic arthritis from classical ankylosing spondylitis. The concept was recently the topic of a study by Feld and colleagues published in Rheumatolo...
How do you treat small fiber neuropathy associated with rheumatic conditions like Sjogren’s syndrome?
Have primarily followed the recommendations of Julius Birnbaum's group from Hopkins Sjogren's Center and use neuroleptics, primarily gabapentin. The main issue for Sjogren's patients with significant sicca symptoms is that many of the options we have for neuropathic pain increase dryness symptoms, s...
How would you approach post op management of a patient s/p BSO for cystic pelvic mass with fallopian STIC lesion on final pathology?
STIC lesions are considered precursors to ovarian cancer. The role of surveillance and chemotherapy is unclear. In a comprehensive review of 78 women with isolated STIC lesions, Patrono et al found 3 patients with subsequent primary peritoneal cancer among the BRCA patients with a STIC lesion; this ...
Are there any clinical situations in which checking for anti-chromatin antibodies is helpful?
Chromatin is the native complex of histones and DNA found in the cell nucleus of eukaryotes. The prevalence of anti-chromatin (nucleosome) antibodies in systemic lupus erythematosus (SLE) varies from 50% to 90%, being similar to that of the historic LE cell.The question is whether this provides addi...
What is the optimal work-up for patient with repeatedly negative biopsies of a mid-rectal lesion with signs of malignant etiology?
It is not that rare to get negative biopsies initially in rectal cancer, as superficial tissue only is biopsied. I generally recommend that at repeat biopsies, attempts are made to biopsy deeply to get diagnostic tissue. One approach is to have the surgeons biopsy with a rigid endoscope- they can us...
How do you manage severe Raynaud's phenomenon with ulceration in scleroderma patients that is refractory to oral agents (CCBs, PDEis, ARBs, and ERAs)?
Difficult question. First, I would make sure that the ulcers you are trying to treat are really ischemic in etiology. These would typically be ulcers that are on the fingertips in association with significant Raynaud's. Other etiology for ulcers would be trauma/skin fragility (over PIP joints most c...
How do you interpret granulomatous features on a muscle biopsy?
The differential for granulomatous myopathies is quite wide and depends on the clinical scenario. The most common diagnosis would still be sarcoidosis, but can also be seen with Crohn's disease, myopathy associated with anti-mitochondrial antibodies, rheumatoid arthritis, GPA/EGPA, rheumatoid arthri...
Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?
Clinical trials of TNF inhibitors have identified a small but increased risk of malignancy with the use of TNF inhibitors, and most, but not all, of the follow-up studies done with real-world registries have confirmed this. These registries are of course sometimes affected by the behavior of physici...