Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you manage GI side effects related to CFTR modulator therapy?
We have found that for most patients liver enzymes abnormalities are small and transient; however, for about 1% of patients there are severe elevations and these patients are much more difficult to manage, even after withdrawal, and tough to re-challenge; it is also not patients with severe liver di...
In a patient with history of scleroderma renal crisis resulting in ESRD, would you recommend using steroids for when needed?
The frequency and timing of recurrent Scleroderma Renal Crisis are largely unknown. Majority of the reports available are from patients with ESRD that underwent renal transplant with recurrence in allograft - overall this is rare, with most occurring between 3 months to 2 years post-transplant, but ...
Do you recommend a kidney biopsy in a patient with myelodysplastic syndrome diagnosed two years prior who develops new onset proteinuria?
The decision to perform a kidney biopsy on any patient should hinge around whether the diagnosis can be made non-invasively (very rare), whether the biopsy should not impose an undue risk to the patient, and if a change in treatment may result from the biopsy diagnosis.In MDS, a variety of lesions m...
For patients with microscopic hematuria, do you prefer a lab submitted urinalysis sample undergoes automated urine analysis or microscopic analysis by laboratory staff for quantification of red blood cells?
If quantification is really the question here, and not RBC casts or acanthocytes, I don't know if it really matters, I use both the dipstick blood and the microscopic data for that. A bigger problem is discordance, dipstick blood and minimal cells, which on an exam is pigmenturia but in real life is...
Can you use apixaban or rivaroxaban in case of dabigatran failure?
It depends on the indication of anticoagulation, co-morbidities, etc. In the absence of any direct data, in general, failure in the setting of venous thrombosis or atrial fibrillation it would seem reasonable to consider transition to an agent with a different mechanism of action.
Do you personally review all imaging you order or rely judiciously on radiologist interpretation?
In my practice, I do like to review the images and the reports for all the studies I order. While I trust my radiology colleagues, I find reviewing the images myself helps both my patients and my own understanding of the disease process. For operative patients, I like to look when the study is initi...
In what situations/patient population would you consider placing an implantable cardiac monitor in favor of external monitors for long-term dynamic monitoring of atrial fibrillation?
This is an excellent question and I think we need the remainder of the publication to make our best estimates (specifically Table 1 and the n for results, including % ablated - couldn't find online or any pictures of slide data on Twitter). The online MONITOR-AF late-breaking trial abstract is avail...
What is your approach to the management of patients with isolated cervical adenopathy related to sarcoidosis?
Establishing a diagnosis of sarcoidosis solely on the basis of isolated cervical adenopathy can present a challenge. Although thoracic adenopathy—alone or in combination with other extra-nodal clinical features—is part of the classic illness script for sarcoidosis, peripheral adenopathy as the exclu...
What is your approach to continuing or altering therapy when inheriting a patient with combined biologic immunosuppression that is in excess of guidelines?
This is by far the hardest task assigned for a practicing rheumatologist. Inheriting a patient on a regimen you did not develop and are uncomfortable continuing poses a daunting challenge: you are challenging the patient’s relationship with the previous rheumatologist, the control of the patient’s d...
How do you approach a persistently elevated mean platelet volume and immature platelet fraction in an otherwise healthy patient with a normal platelet count?
I am trying to understand the circumstances where this question might arise. Nowadays, when patients can readily see CBC results before their clinicians, they might notice the H or L designations and ask. In general, I would not think twice about "slightly out of range" CBC parameters in a single me...