Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Do you have any suggestions about how to improve rheumatology training in internal medicine residency programs?
As an academic rheumatologist and also an internal medicine program director, I have a strong vested interest in promoting rheumatology. Our clinics are set up so residents have the opportunity to work with varied preceptors to encounter a wide array of pathology as well as practice styles. We have ...
What is your work up and management for patients who develop neuropathy on a TNF inhibitor?
The first issue to address is whether the neuropathy is truly related to the TNF blocker. This can be challenging as many of our patients who were prescribed these drugs may have an underlying neuropathy related to their disease. For example, we know that patients with RA are susceptible to developi...
What would be the recommended management for patients with rectal adenocarcinoma with rectovaginal fistula at presentation?
Diverting colostomy, preop RT chemo, and surgery.
What do you use to treat a GCA patient refractory to methotrexate who responded but had adverse effects with both tocilizumab and sarilumab?
This is a challenging group and we don't have a clear answer. Aside from stretching their steroid taper, which is always an option, alternative off label therapies could be considered. From conventional DMARDs, you could try leflunomide. The IL12/23 inhibitor ustekinumab has been studied and has had...
Is there any role for direct oral anticoagulants in the treatment of antiphospholipid syndrome?
Triple-negative APS is a confusing category as includes seronegative APS, APS with non-conforming aPL such as anti-phosphatidylserine-prothrombin amongst others, and the universe of patients with thrombotic events unrelated to antibody-mediated hypercoagulable state (eg Protein S, C or anti-thrombin...
How would you manage gastrointestinal bleeding after radiation therapy for pancreas cancer?
In our ablative RT experience (100Gy BED, Reyngold, JAMAOncology, in press), we have had a 2.6% rate of bleeding possibly related to RT in patients not on anticoagulation and 15% in patients are on anticoagulation. Using the point dose constraints (60Gy in 25# and 45Gy in 15#), we have typically see...
In what situations do you check for HIV status in your workup for inflammatory arthritis?
This brings up a great point - HIV screening is recommended for all patients at least once, and more frequently if the patient has risk factors for HIV. Seeing a patient in the clinic is a great opportunity to ensure they have been screened appropriately for HIV. In rheumatic disease situations, HIV...
How do you evaluate an isolated prolonged aPTT in patients?
This is a common problem. First, if possible, find out if there has been a normal PTT in the past which usually eliminates inherited deficiencies. Second, take a bleeding and clotting history including family history, presence of known liver disease, and any medications. Sometimes it is not recogniz...
What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?
I would put CPPD arthritis high on the differential, as the wrist is a common site for CPPD arthropathy in the elderly. In the right context, septic arthritis is a possibility, particularly if the patient is immunosuppressed. Indolent infections such as fungal or mycobacterial are possibilities. Les...
Is it safe to treat checkpoint inhibitor-induced arthritis with methotrexate or biologics?
How the safety of methotrexate or biologics compares to long term steroid use to treated checkpoint-inhibitor inflammatory arthritis has not been determined. With that said, steroids can have deleterious effects on the tumor response in addition to all the other known side effects. Therefore, for pa...