Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How would you manage an active rheumatoid arthritis patient on suppressive antibiotic therapy for ocular HSV who has abnormal liver function tests?
As an ophthalmologist, I will answer this selectively. The choice of immunomodulation for RA in the setting of liver dysfunction, I would defer to rheumatology (I do know that there are plenty of appropriate options that minimize risk to the liver). As far as the ocular HSV, I have many patients wit...
How would you time COVID-19 vaccination with someone on R-CHOP chemotherapy?
It is really hard to time COVID vaccine while on chemo. Although ideal time would be as far away from chemo as possible (3-6 months) or 6 weeks before chemo starts, that is not practical in someone getting q 3 week R-CHOP. I would recommend giving it when available and if possible, time it on a diff...
How do you clinically distinguish between cutaneous lupus with photosensitivity and polymorphic light eruption-like reactions?
Polymorphous light eruption (PMLE) typically occurs at the onset of Spring or Summer when patients have been exposed to light for the first time that season. Because patients' faces are usually not covered up, even in the winter (in non-COVID times), they usually continue to get sun on their faces. ...
What are the current official guidelines regarding COVID-19 vaccination for patients with cancer or for hematologic conditions?
There are a number of resources available to guide clinicians on these decisions. I recommend the COVID-19 Resources webpage curated by the American Society of Hematology (COI, I'm the editor of that website). https://www.hematology.org/covid-19 This website includes guidance on immunizations in the...
What are your thoughts on use of 14-3-3 serum levels in rheumatoid arthritis in conjunction with RF and ACPA?
Until we have a perfect test, it's always worth considering new tests for rheumatoid arthritis (RA). And there are hints that this test may be useful.14-3-3eta is a member of a family of chaperone proteins found in the serum of some patients with RA and other rheumatic diseases.Studies suggest this ...
How do you approach patients with a history of lymphoma in remission who are in need of immunosuppressive (e.g. TNF blockers, 6MP) or other therapies (e.g. JAK inhibitors) for autoimmune disease that have been linked with the development of lymphoma?
Dierickx et al., PMID 26384356. Yes, you can resume immunosuppression (IS) safely. If rituximab can be used for auto immune disease treatment that would be perfect.The prior treatment for lymphoma if it included rituximab would have taken care of the b cell reservoir.If high risk for recurrence of l...
How do you manage acute tenesmus related to SpaceOAR?
Fortunately, this does not happen very often. First, make sure there is no mucosal injury by inquiring about significant hematochezia. If there is, then delay sim, consult colorectal surgeon or GI just to be safe, but usually, this will resolve with conservative management. If there is no hematoche...
How would you approach refractory gangrenous Raynaud's secondary to type one cryoglobulins?
Type I cryoglobulins are monoclonal immunoglobulins, and typically occur in the context of a hematologic disorder such as MGUS, multiple myeloma, Waldenstrom macroglobulinemia, or lymphoma. Vascular occlusions due to the cryoglobulins may occur and lead to digital ischemia.The patient should be eval...
When is it necessary to monitor the QTc interval in patients on hydroxychloroquine?
The answer to this question is not straightforward mainly because there are limited data in this area. Hydroxychloroquine and Chloroquine directly affect cardiac repolarization and are associated with QT prolongation. Given this, there is an argument for getting a baseline ECG for patients initiatin...
Are there any concerns about using nintedanib in a patient with progressive fibrosing ILD on background mycophenolate?
The SENSCIS trial randomized patients with SSc associated ILD to Nintedanib or placebo. I think about half of these patients were still taking MMF. There was no negative signal in the group on MMF and Nintedanib, they fared at least as well as those who got Nintedanib alone and both did better than ...