Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
How do you follow up a patient with esophageal adenocarcinoma who is not a surgical candidate after finishing chemoradiation?
I am assuming that this patient has adenocarcinoma and also had definitive dosing radiation (50.4 Gy +) and not neoadjuvant dosing as was used in the CROSS trial (41.4 Gy). If that is the case, you would use the same surveillance as you would after surgery which is H&P every 3-6 mo with labs and sca...
How would you approach an elderly patient with tibial plateau insufficiency fracture and normal DEXA?
Tibial plateau fractures are common among young individuals and often the result of trauma or injury. In the elderly, they can be related to injury but as well as poor bone strength and quality. In the aging population if DXA testing is normal and the fracture is not the result of major injury searc...
How should you work up calvarium or other osseous lesions when found during the initial staging of a patient with a new diagnosis of NSCLC otherwise non-metastatic?
In general, I try to "prove" metastatic disease to ensure appropriate staging. I have had several situations where a skull or other osseous lesion is suspicious on CT and have tried to assess by PET or NM bone scan - ultimately though, have referred for biopsy and have actually diagnosed several int...
How do you manage a diabetic patient with generalized myasthenia gravis post thymectomy previously treated with Imuran?
There is some additional information required to answer this question, specifically: a) did the patient have thymoma on pathological exam? and perhaps the most important b) What was the clinical status of the patient's MG prior to thymectomy (severity, MG ADL/QMG scores)? and c) Was azathioprine the...
Can APLS cause a false positive HIT ELISA?
Yes, that has been reported: Pauzner et al., PMID 19291166.
What is the optimal management of a patient needing surgical clearance for a knee replacement with VWF Ag and factor VIII between 40-50 and no bleeding history?
This is a difficult question. I would make sure that the patients had adequate "stress tests" of their hemostatic system before concluding they have no bleeding history. For example, it is difficult to estimate the bleeding risk if somebody has never had surgery or pregnancy and has been on OCP sinc...
What is your approach to tapering therapy in a patient with recurrent pericarditis now well-controlled on rilonacept?
Good question, since rilonacept was only approved 1.5 years ago, a lot of this is gleaned (i.e. expert opinion) from those that participated in the Rhapsody clinical trial.In terms of actual data, the long-term follow-up from Rhapsody was just presented at AHA.2022. Of those in the extension that de...
Do you prescribe antifibrotics to patients with combined pulmonary fibrosis and emphysema (CPFE)?
The definition of CPFE is not very well standardized. CPFE commonly presents with upper lung-predominant emphysema and basilar/peripheral-predominant fibrosis. Pulmonary fibrosis in CPFE could be due to IPF or other ILDs. I prescribe antifibrotics for patients with CPFE-IPF and CPFE-other ILDs with ...
How would you manage an adult patient status post subtotal resection of spinal osteoblastoma?
US can be helpful if performed serially. If/when there is evidence of growth, discuss ablation options with IR if feasible.