Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend placement of a backup AV fistula in an advanced CKD patient who is planning to do peritoneal dialysis?
This is a controversial point for which I don't believe there to be great data. An old study in the British literature- I can't get my hands on it right now- purportedly demonstrated that only 7% of such fistulae were ever used/ useable. With improved fistula technique and survival this number is un...
What is your institution's active surveillance protocol?
The topic of active surveillance continues to evolve in light of the PIVOT trial and rapid adoption of mpMRI for initial staging. The 2014 NCCN guidelines summarize commonly used approaches, does not yet advocate for mpMRI, but declares an urgent need for more research. Meanwhile, the 2014 NICE Guid...
Should we be more concerned about cardiac toxicity following breast radiotherapy?
The way I interpret the data with all caveats that threshold dose and time period for any cardiac morbidity is significantly lower than what was expected. For that reason, all efforts should be made to avoid any direct photon beam wherever possible to go through any portion of heart by using any one...
What is the difference between involved node and involved site irradiation?
In both involved node and involved site (ISRT), prechemotherapy GTV determines the CTV. However, ISRT accommodates cases in which optimal prechemotherapy imaging is not available to the radiation oncologist. In ISRT, clinical judgment in conjunction with the best available imaging is used to contour...
Should I decline to treat a patient with a first site of metastasis who refuses a biopsy?
Ideally, all patients with a first site of metastatic disease should have a biopsy. However, the details are critical. Is the location amenable to a bx? Is the patient's performance status poor? Has it been an extended period of time since treatment for the primary disease? Is it a solitary metastas...
Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?
I think looking at data both show very similar sensitivity and specificity for staging and is matter of expertise and resources available at the institution.
Should early referral to palliative care be standard of care for all patients with metastatic cancer?
There are data to support that early palliative care involvement can improve patient quality of life. One study that specifically comes to mind is a study published by Temel et al in NEJM 2010 (http://www.ncbi.nlm.nih.gov/pubmed/20818875) in the setting of metastatic NSCLC. This study randomized pat...
How do you take tumor seeding into account when staging NSCLC?
This is a rare situation but based on the current AJCC staging, if this is in same lobe then would stage as T3 disease. If discovered after treatment of the primary disease, we would still treat this like a localized process, as is not hematogenous spread and not like metastatic disease. Seeding of ...
How are patients on anticoagulation managed in the context of intracranial SRS?
At our institution, we do not withhold heparin or warfarin prior to treatment. This risk of intracranial bleed is not felt to be increased as a consequence of treatment. We do use a traditional headframe (using pins to hold to the skull). While there may be an increased risk of bleeding at the pin s...
For elderly patients with locally advanced rectal cancer who are not candidates for surgery or chemotherapy, what would be an appropriate palliative regimen?
There is an old paper from Princess Margaret Hospital ~1980, called "Is the Miles operation really necessary for the treatment of rectal cancer?". (Editor note: 1993 Update). These are patients who were medically inoperable or refused surgery. I believe doses were about 40 Gy. Remember that this was...