Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you qualify and treat a patient with neutropenia, anemia, and abnormal NK cell population with normal trilineage marrow maturation?
I would run a molecular test to confirm that the clonality does not show a CD8-positive clone, as that is more common in LGL. The findings of a clonal NK population by flow cytometry would be enough, in the setting of neutropenia and anemia, to consider a diagnosis of NK cell LGL.
How do you handle the situation where a curative-intent patient unexpectedly passes away while under treatment?
As many of the patients we treat are older and have numerous co-morbidities, this is not that rare an occurrence. Of course, we would presume to avoid treating patients with curative intent if it is readily apparent that their life span will be short due to other non-malignant illness. That said, I ...
What is your approach to a low grade appendiceal mucinous neoplasm found incidentally at appendectomy?
If there is no high-grade component (adenocarcinoma), appendectomy is sufficient. There is no role for adjuvant therapy and no need for surveillance imaging in this setting. Low-grade appendiceal mucinous neoplasms with disseminated peritoneal adenomucinosis (pseudomyxoma peritonei) constitute an en...
How do you approach rising gastrin and chromogranin levels without radiographic evidence of disease in patients with gastrinoma that has been fully resected?
We see this scenario with some frequency - rising hormone or peptide levels in functional NETs without radiographic evidence of disease. My next step would be to get the new Ga68 DOTA TATE PET/CT - essentially a new generation octreoscan with high sensitivity and specificity. These scans often pick ...
For patients with a history of seizures secondary to brain metastases, what are your criteria for discontinuing antiepileptic medications if the seizures have been controlled since SRS or surgery?
Brain metastases patients are discussed at our multidisciplinary brain metastases tumor board whether they have received SRS, surgery or WBRT. In general, I like to keep antiepileptics for up to three months in patients who have seizures that are controlled. Factors that I consider for discontinuing...
What is the appropriate follow up after chemoradiotherapy for patients with anal SCC?
A few points of note. First, the evaluation of the primary site is usually better done by a physical exam than by any imaging study. Therefore, a careful rectal/anal exam is essential at each follow-up. I will usually observe residual abnormalities in the canal as long as it is regressing and there ...
In what situations do you obtain both a pelvic MRI and EUS for rectal cancer staging and treatment planning?
I'm not sure that T2N1 is boderline - preop CRT is still a standard of care for node positive disease. Generally, thin slice (3mm or less) MRI with external (if available) or internal coil is the preferred staging modality for patients with newly diagnosed rectal cancer. Utilize the T2 images and c...
Among the many assays/tests available for "liquid biopsies" in metastatic NSCLC, are there any situations where you would want to use one specific assay over the others?
There are many commercial and academic assays under development. None are approved at the moment and none have been shown to be superior. Use of a well reported commercial assay with whom your institution has experience is reasonable
When would you recommend hyperbaric oxygen treatments for skin ulceration/non-healing wounds in a radiated field?
I agree with @Dr. First Last' answer. Careful planning and attempts to avoid non-healing wounds is important, but this can happen. Conservative management should be used before hyperbaric O2 except for severe toxicities such as radiation optic neuropathy where all reasonable measures should be consi...
How do you talk to patients about clinical trials?
I try to incorporate the clinical trial idea into the standard of care recommendation/discussion at the time of initial treatment decision making. After making a standard of care rx recommendation, I tell patients that my recommendation is based upon this treatment being the winner of a prior trial ...