Saturday, July 24, 2021

TREAT OR NOT TREAT

   In out life we often have to make decision daily as to do things this way or that way . Take this road or do highway. order this food or that food . Take a phone call from this person or not . But in medicine we make the decision which is some times more complex that ordering topping on pizza. In many cases the flexibility of decision is not there. If I see elevated blood pressure or blood sugar, there is no question about if we should treat it or not .We treat it -period. But in certain other condition, we have to make a decision. This brings me to the story for today. 

   I saw this 91 years old male patient for the cough . He had cough off and on for 3-4 months  and he had no shortness of breath or other complaints . He was not a smoker and though was 91 years old , he was overall OK . He had some memory problems but lived by himself  and had not lost weight or had fever . He did not have history of asthma or gastroesophageal reflux - the 2 most common causes of chronic cough The Chest X- ray was done  and that had nothing impressive but some upper lobe scars. So I did some more testing . I di CT scan of chest and that showed some upper lobe scars  and some other abnormality that could go for Old TB. I was concerned  and so I did not do breathing test  and instead I gave him an inhaler for possible asthma  and I asked him to do sputum for tb bacteria. I had planned for doing the breathing test, but his sputum came showing that it was growing TB bacteria. This was preliminary  and the final report in case of TB can take as much as 6 weeks . Some times we can get report in 3-4 weeks if the TB bacteria is of type that grows fast . I had planned to do breathing test but I cancelled it till I get the culture. 

    I called the patient and the son and told them that the sputum is growing something and to be on safe side keep him indoor. Then they came to see me after 2-3 weeks . By then I had received the identification of the bacteria . It was atypical TB . The Mycobacteria is a family name  and the Mycobacterium Tuberculosis is the one which is contagious and MUST BE treated and isolate in the first few days  and also family close contact will be needed to be checked . But the mycobacteria are not like that. They do need prolong treatment and have similar symptoms ,but they are not contagious.So when they came to see me ,I had to decide on the treatment . I had 2 choces one was to treat this 91 years old patient with 3 MDICINES for 18 months or not to treat but watch it . tHt medines used can have liver problem , eye problem . So I had to talk to them . Her was a 91 years old patient who had sputum growing atypical TB  and had no complaints other than some cough. 

          TO TREAT OR NOT TO TREAT ?WAS MY QUSTION. . 

I decided to watch him with new CT scan and new sputum check and clinically. 

Sunday, July 18, 2021

NEVER SAY NEVER

    We have a saying in medicine . We never say never in medicine. I have written many a times on unexpected and surprises that we see in different patient. But in spite of knowing that we never say never in medicine , things seem to come as surprise  and then we say "there is exception to every rule". That brings me to the story for today . 

  I had known this lady for many years . Her husband was may patient and he had cancer of the lung and when we diagnosed it he had spread of the cancer to liver and he did survive for 4 years or so . She started seeing me after he had died . She had also smoked and she had COPD  and we did the work up. She then developed lung cancer. She was 'lucky' and we had diagnosed the cancer in time - or at least we thought. She did ok but when the surgery was done she had some of the lymph nodes showing spread of cancer. So we did have her see oncologist and had treatment with chemotherapy. She continued to do OK and she had COPD  and she had shortness of breath and needed oxygen .She also had gained weight and she had sleep apnea . I had told her after the diagnosis of the cancer  and the need for the treatment to 'prevent' the recurrence that the recurrence happens most in first year and then less in second  and least in third year after the diagnosis. After 3 rd year the chance of recurrence is not there  and so you are cured if there is no evidence of cancer after 3 years . 

   Five years had gone by after the surgery and she had new scan. She had CT scan and then PET scan. That was abnormal and so she came to me. Five years had gone by since we had diagnosed cancer and she had surgery. So the possibility of old cancer coming again was low or not there . But patients who have one cancer have high chance of having second cancer is high and then depending upon the type of cancer the treatment may be different. The abnormality was in such a location that simple way to do the biopsy was not possible . I spoke to interventional radiologist and he did not feel he could get it and suggested that biopsy with ultrasound guidance through a bronchoscope was better choice . But the interventional pulmonologist did not feel EBUS or navigational bronchoscopy could get the diagnosis. I did ot want open biopsy as this was not a curative surgery and she was oxygen dependent COPD . So the risk was higher . But I had no choice  and so she did see the surgeon and had a biopsy  and it was NOT A NEW CANCER but it was the SAME CANCER that was taken out 5 years ago. 

                   THAT IS WHY IN MEDICINE WE NEVER SAY NEVER!

Sunday, June 27, 2021

SOMETHING NEW

   Medical science is getting better every day. Certain things that we did not even imagine in past have developed  and even today it is very difficult to understand certain developments. But certain things which are easy to understand  and difficult to do are also there. In the treatment of cancer now a days blood cells called Lymphocytes are taken out from a cancer patient and are 'programmed '(??)  and then multiplied and then injected in the patient to take care of cancer. This process is easy to understand . But very difficult to actually know as to what is being done . What does a programming of a cell means ?But it is easy to explain. The new treatments for COPD are also such treatments where it is easy to understand  and easy to explain. That brings me to the story for today. 

  I have seen this patient for 3-4 years and she had episodes of respiratory infection when I saw her for the first time . She is in her early seventies and she never smoked . She had cough  and then I saw her . The chest X-ray was normal  and  treated her with antibiotics and the steroids .She did OK  and I did do breathing test and that came as normal . But she had cough and so she was started on treatment for asthma . She did OK and then she weaned herself of the medicines for asthma . She would get periodic episodes of cough and then she would see me and I would treat her with  steroids and inhalers  and she would linger for few days with persistent cough and then would get better . 

   This continued and then the cough got worse and then in spite of doing steroids and antibiotics and inhalers , she would still have bad coughing spells . I did do further work up and we did CT scan and that was normal. I also did measurement of immunoglobulin - These are proteins - globulins that are important for immunity and they prevent the recurrent infection. She did have low immunoglobulin. So I wanted to  give her replacement for the immune globulin . But her hematologist did not want to do that. In any case she continued to have cough and she was admitted few times for the control of her symptoms. Then  I decided to do the bronchoscopy. When I did the bronchoscopy ,I found out that she had problem with trachea and major bronchial tubes . Normally the trachea has cartilages and that gives trachea the support and it does not collapse. Theses cartilages are semicircular and  also extend to main bronchi . That act like scaffolding . But her trachea would collapse when she would exhale or cough  and that   was causing constant cough. So I told her that we need someone to do a stent  and see if that would work out.. She was seen by interventional lung specialist. But he felt that she would need  surgery and stents may not be enough. So I have to send her to Mayo clinic . 

    So such a stent placement was not there 10 years ago and even when they did do it 5 years ago it was in the infancy and also no  one would have thought of doing surgery on trachea in an adult patient few years ago . I still feel that the cause of this is lack of immune globulin leading to recurrent respiratory infections and damage that was caused by persistent inflammation. I feel that she would need replacement for that in future . Stay tune .

Sunday, June 13, 2021

INADEQUECY OF MEDICINE

     I have been in medical practice for many years and have realized that the medicine is never perfect or 100% . We can treat 2 people with same condition and same situation and same diagnosis  and still not get the same results. We have the same machine but the result of the same treatment is not the same. So someone may say that it may be due to the circumstances or that people are not like car or any other machine and so people have different outcome. Some may say that it is due to KARMA, Whatever may the cause, we know that we get different results. But then the question comes as to how we can anticipate as to who is going to have out of ordinary results and then avoid the same treatment and do something different in these exceptional patients. Yes medicine is trying to do that and I often feel that our tests are not adequate. That brings me to the story for today. 

   I saw this patient in office sent to me by radiation doctor. She was 70 years old female who had noticed a lump on mammography and so they had planned lumpectomy and then radiation . The radiation physician had ordered a chest x- ray as she was a smoker  and that showed abnormality. So she had CT scan done and that showed the abnormality and so she was sent to me. The original thought was that the abnormality may be due to scars. I saw the lady and she was current smoker  and I felt that the abnormality could be a lung cancer . So I did the work up and she had Bronchoscopy and PET scan and then a breathing test. I had no 100 % proof that the lung abnormality was cancer but on PET scan it was  showing increased activity and so I wanted to have her do surgery. Certainly she had breast cancer also and that needed to be taken out. So she had the breast cancer surgery and then the lungs . The lymph nodes were negative. (The lymph nodes  drain different areas  and so they can show the spread) So when the PET scan had no uptake in nodes the surgeon still did  the lymph node biopsy before taking out the cancer and that was also negative for the cancer spread. So she had the mass taken out and and that was a cancer and the nodes on further biopsy did not show any spread of cancer. She had some issues after the surgery and that needed to be fixed but overall she did OK . So she had breast cancer and then lung cancer - both notice at the same time  and taken out and no residual cancer as far as WE CAN TELL The pet scan had not shown any spread and the biopsy had not shown any spread. 

     We continued to follow her and she had a follow up PET scan about 8 months after the original scan and that showed that there was activity in the nodes . So now the question was is it cancer and if it is then is is RECURRENCE OF THE LUNG CANCER or BREAST CANCER .The breast cancer is notorious in it's tendency to come back after several months and sometimes years .So she did have additional biopsy and it was not breast cancer but it was recurrence of Lung Cancer.

   So we had done a PET scan , which is suppose to be 85% accurate in picking up cancer  and that was negative . She had the same lymph node biopsy before taking out lung cancer and that also did not show the cancer spread . Then she had additional sampling of the same nodes  at the time of surgery to take out lung cancer and that was also negative . And now in less than a year - just 8 months she has the same nodes showing the spread of cancer. So the tests that we did were not adequate to pick up the cancer !

   Just a note - some labs are doing what is called circulating tumor DNA - a blood test that will pick up certain DNA of the tumor to predict recurrence of a cancer earlier that it is obvious on scans. So this may be a future .But if CTDNA is positive then the question is How do you treat?

Sunday, May 30, 2021

ELEPHANT IN THE ROOM

    In medicine sometimes we have extreme positions. The so called pendulum swings to he other direction.I have seen use of certain drugs for a certain condition as routine 'acceptable' treatment  and then suddenly it falls off the favorite train and then no one uses it . Theophylline is one such drug . 20 years ago there were several pharmaceutical companies that were making brand name theophylline  and now there is none. We also use a term  "The elephant in the room". This brings me to the story for today. 

     I saw this 90 years old patient in office and then she was diagnosed to have asthma  and also she was obese and may have had sleep apnea. But she did not want sleep study and so she was on oxygen which is not accepted treatment for sleep apnea now a days. But when the oxygen drops badly during sleep, one can not deny use of oxygen .She was admitted to hosp and she had  multiple problems . She had shortness of the breath and she had swelling in the legs and she has problem with her kidneys.So she was seen by hospital doctor and as expected they had called cardiologist and kidney specialist and pulmonary specialist . So when I saw her she was in hospital for she was in hospital for 3 days . I saw her and she had acceptable oxygen saturation at rest and she has significant edema in legs and her kidneys were not functioning well. She had clear lungs but no one had given her home inhalers which were prescribed for her asthma in past . So i started them. The cardiologist had seen and done echocardiogram  and the heart function was good and he has no other suggestion. The kidney doctor was giving her diuretics and her  her swelling was getting better  and she had some improvement renal function. What struck me in this patient was that her lungs were clear and the oxygen was fine and she still felt short of breath. Certainly it could be due to being 89 years old with low activity  and de conditioning and may be some heart problem and certainly may be even lung issues. But she also had anemia  and they had done the work up and she had problem with production of red cells.( think of red cells as a product of a factory. Let  us take an example of making shirts.So if there are less shirts available in market, then  it could be due to factory not making enough or that they are sold too quickly. - high demand or that there is not enough raw material . The same thing is true about red cells . The raw material - iron B12 or other r=things may not be enough or we have a loss of blood or it could be that the bone marrow the factory is defective.)So she had problem with production of red cells. That is not uncommon in patient with kidney problem. I followed her for few days . What I noticed is that in spite of inhalers and edema getting better and the kidney function improving she was still short of breath.And I also noticed that the anemia was not any better and was somewhat worse . Her hemoglobin -which carries the oxygen in blood was half the normal. So patients with anemia are short of breath as their system has to work harder to provide oxygen as the blood does not carry same amount of oxygen.So I finally called the hospital doctor  and asked her to give BLOOD TRANSFUSION. In past we used to transfuse even with much higher hemoglobin. But then we realize that that was causing problems in future  and so now the pendulum has swung to other extreme and no one thinks of transfusion even though this 90 years old lady was shortness of breath was perfect candidate for giving blood . So this was the big elephant in the room and no one was talking about it or treating it or may be no one could THINK about it .  

Saturday, May 22, 2021

GUT FEELING

    I have talked about some of the new things in diagnosis of cancer . I have also done that in my YOU TUBE  video . If you are interested it's under the name JUST A TALK . But sometimes all the tests that one can do may not going to give diagnosis  and sometimes one has to go by old GUT FEELING. So this is one of the stories where I did that . 

   I saw this female patient who had  an auto accident and then she went to ER. They did do some spine X- ray and scans  and that showed a small pulmonary nodule like 10 mm . She was told to see primary care doctor  and she had no insurance and so she decided to wait for 3 - 4 months till she got insurance . She saw PCP and then she was sent to me .She was less than 60 years old  and she had not smoked for 28 years  and had no pulmonary symptoms. The new CT scan had shown that the nodule had increased by few mm . This was in 4-5 months. I did the work up I did the TET scan and also the bronchoscopy  and I also did breathing test. 

   The  Bronchoscopy was negative  and it was not expected to give me the diagnosis but I wanted to make sure that there was no other cause for the nodule. The Breathing test was OK  and the PET  scan showed mild uptake  and radiologist felt that it could be inflammatory . But in addition to that I also did a new blood test called NODIFY . This is a new blood test  and I think it was approved last year . It tests certain proteins in blood and certain other things and that can give a probability of cancer . So One can calculate the probability based on several characteristics of the nodule -like size , location, spiculation, age , sex of the patient and the history of smoking etc. Then  based on the the blood test reports the probability is recalculated  and it may be increased or decreased. Or the test may not change it at all. So this is a new test and it is more than 95 % sensitive. The test was done in this patient. and it was  reported as reduced probability . 

  So we had low uptake on PET SCAN nd reduced probability on this new blood test  and she was not a smoker . So now we had several options. One was to do a needle biopsy which may or may not give diagnosis. The other option was to wait and watch the CT scan in 3 months  and if it grows then do surgery  and lastly do surgery now . I decided to tell patient to do open biopsy or surgery. It was not based on TESTS that we did but it was based on my Gut feeling  and the fact that the nodule has increased and in my mind ANYTHING THAT INCREASES MUST COME OUT.

  She saw a surgeon  and he decided to do needle biopsy and that showed high suspicion for cancer  and so she had surgery and the surgery did confirm Lung Cancer  and she did very well . 

Sunday, May 16, 2021

VARIOUS FACES OF COVID

    We have seen COVID infection for more than 1 year and I have seen may share of the disease. I do not have vast experience ,but I have seen different presentation and severity  and it is not actual 'changing ' face but it is just the variation in presentation. All the statistics does down the drain when you see theses kind of variation. So the so called 'risk factors' are valid for majority of patients but one can not hold them as 'Gospel truth'.In 2020 earlier part of the disease I saw a 91 years old African American women who had not left her home  and had significant hear problem ,hypertension and had possible heart failure  and may be pneumonia admitted . She was to be discharge to a extended care facility  and so at the time of discharge we did COVID test and to my surprise and horror it came positive.She did not have fever, she had no oxygen issues  and she did not have much cough or upper respiratory symptoms and she also was never exposed to crowd. So how did she acquire it or why she was asymptomatic  and lastly in spite of all the risk factors,she had no problem with 'recovery'? (she was never sick so not sure there was any need for recovery) That brings to me the patient story for today. 

    I saw this 74 years old male patient several years ago. He came to me for cough. He had seen primary care physician and also then allergist and he has had work up. He had allergies and was treated  and then he came to me as the cough continued . I did the work up and he had pulmonary fibrosis - scars tissues in lungs and so he had cough . I told him that we will do work up to find any etiology for the scar tissues and that was done and we did not fond any. So we decided to do follow up and in case the fibrosis gets worse we will star the treatment . I followed him for more than 2 years and the CT SCAN and the breathing tests were OK and did not show any deterioration. He stopped coming  and then after a gap of many months to a year he came to see me and he had some shortness of breath in addition to cough. The cough was also worse. So I did the same tests and nor=ted that on breathing test he was worse . So we started him on treatment with relatively new drug . He was doing OK but continued to have cough and even though I had told him that the cough will continue and not much could be done for it other than giving cough medicines , he was frustrated . He was teaching i one of the centers and the cough was bothersome . So he had called me many times  and I did add some different cough medicines  and at times tried steroids too. So one day he called me and he was having coughing spells and also had chest pressure . He was a older patient and had lung problem and so when he had chest pressure I told him to go to ER. I was concerned about things like heart or clot in lungs . He went to ER  and had CT scan done and that showed no clot. As routine goes he had COVID test done and that was positive. He had no fever and no upper respiratory symptoms. His oxygen saturation was fine  and he looked OK To my surprise, when I saw him in ER he had mask which was not covering nose  and was in hallway. We admitted him for observation only because he was OLD  and had LUNG DISEASE - the so called risk factors . I discharged him after 2 and half days when he had no new complaints . 

   So here is a older patient with high blood pressure , lung problem-all the risk factors for bad outcome   and was teaching  and had COVID and had no problem due to it. That is why we are not like automobile machine- same model and make but different response.