Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Can liquid biopsy be substituted for tissue biopsy in a lung mass that is radiologically suspicious for primary lung cancer when CT-guided biopsy cannot be done?
Generally, the utility of liquid biopsy remains in the ability to provide genomic information from cfDNA. A liquid biopsy will not provide a definitive tissue diagnosis and does not provide information about histology. When a histologic diagnosis is made with biopsy or FNA but the sample is insuffic...
Do you stop treatment for a prostate cancer patient diagnosed with acute radiation proctitis with significant pain?
I would first check the treatment fields and treatment setup to ensure that there isn't excessive dose going to the anorectum. As with all toxicities in radiation oncology, one must exclude other possible reasons for the anorectal pain such as hemorrhoids, infection, or inflammatory bowel disease. I...
How do you counsel patients who are candidates for a clinical trial regarding their options?
I typically discuss the option with patients as early as possible in their diagnosis, and explain that at some point during their treatment they may become a candidate for a clinical trial. I discuss resources to look into clinical trials and what they mean for patients. We discuss patient website r...
Is there a role for G-CSF treatment for SLE patients with persistent neutropenia?
There may be a role for G-CSF for treatment of SLE-related neutropenia, though would recommend using with caution only for severe neutropenia (ANC less than 500) and at lowest dose. The use of G-CSF has been looked at in small case series over the years for both SLE patients with neutropenia and Fel...
Do you image the spine in addition to the sacroiliac joints when you suspect axial spondyloarthritis?
This is a great question and a single correct answer does not exist. Axial SpA affecting the spine without SI joint involvement does occur but is seen in a minority of the patients. The exact prevalence is hard to determine due to lack of longitudinal data as well as significant variability in prese...
How do you approach immunosuppressive therapy in lupus-associated pulmonary arterial hypertension?
I agree with Dr. @Dr. First Last that pulmonary arterial hypertension in SLE is infrequent. In the October issue of arthritis and rheumatology, the prevalence was 2.54% in a cohort of Chinese patients. Management requires distinguishing amongst the 5 WHO groups of PAH, which in lupus includes the fo...
Why are autoantibodies not often detected on monoclonal gammopathy assays (SPEP/IFE, quantitiative immunoglobulins)?
Autoantibodies do not cause a false positive M protein. Even though autoantibodies may target a specific antigen, they are polyclonal. Rarely, a very high rheumatoid factor titer can produce a broad-based (polyclonal) peak in the electrophoretic pattern. UpToDate
Is there an equivalent test for serum viscosity in sickle cell disease?
I would not typically order serum viscosity outside of the setting of paraproteinemia. In that setting, I still think serum viscosity is useful, especially as opposed to plasma viscosity, which might be elevated in a sickle cell patient due to the acute phase reactant fibrinogen. It is true also th...
Do you recommend anticoagulation for a splenic infarct in patients with myelofibrosis and splenomegaly?
I generally do not recommend anticoagulation for a splenic infarct in patients with MF and splenomegaly. The situations where I would anticoagulate: ff they have a splanchic vein thrombosis, or clear evidence of embolic disease (i.e., other areas affected in addition to the spleen). However, general...
Is it okay to use medications associated with drug-induced lupus in patients with SLE?
In the current era, I find it useful to divide drug-induced lupus into two classes. First, the traditional medications such as procainamide and hydralazine that are associated with ANA by IFA, anti-histone antibodies, and a type of drug induced lupus not characterized by certain clinical features su...