WEIGHT LOSS AND TRANSPLANT

    I  wrote in my past blog about how the lung transplant is not like fixing hernia or taking a mole out. It is not a 'cure' by any stretch of imagination when we talk about Lung transplant.But there is more to lung transplant than just getting a match. The kidney or renal transplant is done much more commonly as the kidneys can be obtained even from cadaver or LIVE Donner. But for Lung transplant we need a match only from someone who is dying- but not dead. So who will get it is pure luck. In past we used to do both lungs  and for last more than 10 years or so we are doing single lung transplant . This helps in number of ways. Instead of one patient getting transplant, we have 2 patients getting it . In case of rejection, patient still has one of his own lung.But there are many problems  and issues.Weight or ideal weight is important . One can not be too heavy or too skinny .

    That brings me to the story of my patient for today. I have known this patient for more than 5 years . He was 60 years old male who was heavy and had shortness of breath. He was a smoker and had quit. But the smoking had done it's damage  and he had COPD - emphysema . He had shortness or breath and lots of cough and sputum . He was seen by me  and he was started on medications  and he did better. He continued to work . I had told him that part of the problem is his obesity. The shortness of breath can happen due to obesity and also deconditioning which happens due to lack of exercise. The part of the reduction of pulmonary reserve could be due to big belly and obesity. So weight loss was essential. But he did not loose much . Over period of time he got worse  and then he needed to be on oxygen . He continued to work as he had desk job and he could do it. I did new breathing and he was worse and so I did ask to to consider lung transplant evaluation. He agreed  and he did go and was evaluated by the Transplant physician. They told him that he was a good candidate , but it may take another 6 months or so for him to be perfect candidate or to be on active list . But that can happen only if he would loose 20- 25 lbs of weight, That amount of weight loss would not bring his weight to ideal body weight but that was essential per the transplant MD. The time passed  and he continued to get worse  and the shortness of breath was worse  and his need for oxygen went up . Instead of 2 L he needed 5 L oxygen . He did go back to the transplant group of physicians He had not lost a single LB but instead had gained . So then he did not go to them for 6 months. They told him that he has to loose some weight and they will see him again. I was doing follow up and he was admitted couple of times . Then I did routine yearly chest x- ray and that showed a spot on the lung . The suspicion for cancer was high and so I did PET SCAN  and that was positive  and so he most likely had cancer of the lung , He was not a candidate for any surgical intervention. I did needle biopsy and so I send him for radiation  and then oncologist . 

     The transplant was out of question and he has not lost any weight  and has continued to gain some with not much physical activity. 

   The question that bothers me is that if he has a lung transplant what would have happened. If he had transplanted the lung that developed the cancer , he would not have cancer now  and if it was the other lung -- then the transplant would have been wasted ???

TO EARLY TOO LATE

    We often have situations when we are told that one is too early or too late. Many a time when the diagnosis of cancer is done , we sometimes have to say it is too late. But sometimes I h seen patients, I have to say either too early or too late. I have recently 3-4 patients that this has happened  and the problem is that it is not anybody's fault. If there is some it is bad luck . 

      I had seen this patient for last few years . When I saw him for the first he was smoker and he had quit.. He had exertional shortness of breath and he came to me  and he had COPD. the lung disease that is caused by smoking . By then he had quit smoking for few years  and so i did the work up. He had the  medications started  and I did do a CT SCAN  and he had a bleb or bullous. The damage to lung tissue can cause  a blister or like a grape area which has not much going to that area  and that causes problem. If it is larger then it can press on normal lung tissue  and that can lead to more shortness of breath. So the CT scan did confirm a larger bleb and I thought that if we can get it cut , it would help the remaining lung to expand  and that may help the breathing problem. Certainly there  was a risk in surgery  and it may not help also. But if that bleb would rupture, it would cause collapse of the lung and more issues which would have to be dealt as emergency.He wanted to get a second opinion and so he went to Mayo clinic  and they did agree that that needed to be taken care  and they also found out some opening in the septum of the heart's upper chamber  and they felt that that needed to be  closed  and so they did that and then he had the bullectomy. He did very well and the shortness of the breath was better. He continued to work and saw me periodically.

        About 3 years ago, he started having problem and then we did additional work up . He  had new tests  and his breathing test was getting worse  and that decline was noted  and so I did adjust the medications  and he had also gained some weight and so i also did the sleep study and also asked him to see cardiologist. He had sleep apnea  and he was started on CPAP  and he did better . He also joined gym and some diet and did better. The cardiology work up was OK  and he lost some weight and was doing better. He was also sent to Lung Transplant evaluation and they felt he was bad but not bad enough to have lung transplant and so they decided to watch him . For last 6 months or more he had done follow up with me  and also heart doctor and also lung transplant . He continued to get worse  and then my work up showed some infections  and so we did treat him . I had done few CT scans  and did also bronchoscopies . The some of the unusual infections were treated by Infection specialist  and that was going on for 6-8 months  and he continued to be followed by all of us. He was felt to be a candidate for transplant , but may be little too early  and so he was just followed up. 

    He continued to have good  and bad days  and i saw him few times  and then I received a note from transplant doctor . The note stated that he had cardiac problem and taking it to account his age  and cardiac problem and other issues he will not be a good candidate for transplant and they were closing the file . I had not seen him recently and so I  called him  and came to know that he was in the hospital where I do  not go. So I pulled up his hospital records. He had more shortness of breath  and he saw cardiologist and they admitted him for high heart rate . They did the work up and his heart had worsened  and he had weak heart muscles  and they did start him on medications. He decided to see Mayo clinic  and they sent me a letter that he had too many problems including getting old  and he will not be good candidate for transplant . 

   So 3-4 years ago he was a good candidate but it was little too early , now he is not a good candidate as it is too late. I have seen this happen too many times I will write about other patients next time. 

TOXINS AND CANCER

    I often see patients with abnormal CT scan or chest x- ray. I had written an article  titled Darwin,Mouse and Me . The article was related to the Theory of evolution proposed and accepted by scientific community  and how it is supported by genetics that we know today and was not known or thought about when Darwin proposed it . But I had some objections about as to WHY did evolution happened . So I stated certain genes  and mutation that happens in them which explained some of the diseases. But this mutation does not support the theory of Survival of Fittest  and Procreation as the causes given by Darwin . The mutation that causes the host to die soon like breast cancer gene BRCA1 and BRCA2 .So why would this mutation occur? I had suggested Law Of Karma as the possible explanation. The editor of the magazine that did published it had a question as to could be due to certain toxins that we get exposed to it. So the toxins do play the role in development of cancer  and now a days we are inundated with commercial by many layers on Talc exposure , Round up exposure , Zantac  and many other things that may have contributed to development of cancer. But why only some get it and not all develop cancer ?But that is not the point of the discussion. But this brings me to today's story.
    I saw this 72 years old male patient who had smoked 2 PPD for many years.He had some cough and some shortness of breath. He had chest X- ray done by PCP  and it was abnormal  and so he had CT scan and that showed a mass. So he was sent to me.He has been smoking  and also drinking 5-6 drinks a day He had clear lungs  and I told him the possibility of the cancer and the work up. We talked about the PET SCAN  and the biopsy and that included either bronchoscopy or needle biopsy or even open biopsy.He was not very agreeable. He was not very happy  and did not want too many tests.His concern was radiation exposure that according to him can cause cancer. I told him that radiation for chest x- ray is very low  and even CT scan has more radiation exposure but it is much less than the dose used to treat cancer. After discussion he agreed for PET SCAN  and that was positive and that did suggest high possibility of cancer. He was smoker and had a PET positive mass and so the chance of cancer was high. He did not want any more tests  and so after the discussion we decided to do new scan in 3-4 months He did not want it that soon  and so we agreed to do it in 5 months . He had new CT scan in 5 months  and to my surprised the mass had not grown but was slightly smaller.So he did not want to do anything . I told him that he still has possibility of cancer and biopsy was indicated to confirm or rule it out .He did not want it. He was more concerned about the radiation and that causing the cancer. He had not cut down on smoking or drinking alcohol. He was firm about not doing more CT scan. So we decided to do follow up in office in 6 months.
     He came back and he was feeling fine . I asked him on smoking and he had not reduced from 2 PPD  and no change in alcohol intake . He told me that he has smoked for more than 50 years  and it was very difficult . I asked him that is 50 years of smoking was not enough? After the talk he agreed to do the CT scan  and the CT scan was done  and to my surprise the CT scan showed significant reduction in the mass. He was happy . He did not come for follow up  and then after a year he came for the follow up .He was still smoking and drinking and had not worsened  and did not want CT scan  and still worried abut the radiation causing cancer and not worried about smoking causing cancer or drinking alcohol and it's side effects on body .
   He did not have cancer - at least as off today .

BOON OR CURSE

   IN medicine ,we often get new tests  and many a times they are useful and sometimes create problems I had talked about a test in past called liquid biopsy. It was testing tumor DNA. This test is being used successfully in diagnosing recurrence and also the follow up of treatment . In the beginning this was started as early diagnosis of lung  and breast cancer with nodule. The problem that happens is what do you do when nodules are small or not there  and one finds tumor DNA , then what do you do ?The same that has happened to me in one of the patients that I see.
    There is a new test that was approved recently . It is for the diagnosis of lung cancer , But it is not for the diagnosis but to get a probability of cancer when someone has lung nodule.Now a days we have been doing more CT scans of the chest as there was screening Low dose radiation CT scan approved be medicare  and other insurances  and so we can do a CT scan in patients who are smokers or ex smokers for 14 years  and so on, . So there are calculators developed based on the size , location, smoking history  and age  and sex and type of nodule. Theses do not give any diagnosis of cancer ,but give the probability of cancer . They are used in making a decision  on further course of action. So a new test was added . So one calculates the probability based on the above mentioned criteria  and then blood test is added as additional factor in calculating the probability of the same
So I saw this patient who had quit smoking 30 years ago and had CT scan of chest She is 70 years old  and had not much pulmonary symptoms  and had some cough  and so during work up CT scan was done . She had some nodules  and one was 10 mm. This is minimal size for doing PET SCAN . So I did PET SCAN  and that was OK which means the nodule did not pick up glucose , which means it was not hyper metabolic. So I decided to watch it with CT scans . over period of time we did do new CT scans  and they were stable but the radiologist reported the size to be 8 or 9 mm instead of 10 mm . The last CT scan it was reported as increased by 1 mm. Just to clarify , 25 mm make  and inch . So this was very small  and I did not know what to say . So I did new PET scan and that did not show any glucose uptake.That was good but radiologist reported that slow growing cancer may not pick up on PET scan. But then I did the new blood test, The probability calculated based on all the factors before the blood test was done, For those who may be interested there is Mayo clinic calculator which you can google.After the blood test the PROBABILITY OF NODULE BEING CANCER INCREASED ALMOST DOUBLE. So now the problem
    She has not smoked for 30 years . The nodule is barely if at all increased by 1 mm in 10 months  and she has no symptoms . So what should be done . The bronchoscopy would not give diagnosis - which I have done . The needle biopsy may be attempted but with given size may not give the diagnosis. So should I do open biopsy ?
    So in this case it has created more questions than answers!

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STITCH IN TIME ----

  There is a saying that stitch in time saves none. If one does things in time then one does not have to worry about getting things worse. The saying is is related to clothes  but it also applies to our every action and every decision that we make or action that we do . It may be diabetes  and eating sugars or blood pressure  and salt intake. . If we do not do action in time  and the diabetes or blood pressure gets worse  and has complications , then acting in right way will not help us as much as if we would have taken precautions early. I have seen this in many patients and that brings me to today.s patient.
    I saw this patient who was 78 years old  and had some dementia . He came with family  and i could not figure out why he came to me . He had some abnormality , He was in hospital and he had pain the belly. He had CT scan of the belly done  and that showed some abnormality in lung and so had CT scan of the chest done  and that showed a very tiny nodule. He had seen primary care doctor  and he sent him to me . He had also seen Gastroenterology  and he was planning to do endoscopies . I had no reports  and I got them  and I was surprised He had very tiny nodule in lung  but had a mass in pancreas  and also in liver . The patient of the family did not know about it  and they were surprised . I explained it to them that he seems to have cancer that seems to have spread to liver and may be lung . The endoscopies will not help but he needs diagnosis of cancer by biopsy  and then we can decide as to the treatment . The Lung nodule was too small  and there was no way anybody could do biopsy of the nodule. So I decided to do the PET scan to know the extent of the cancer and scheduled him to have biopsy of the Liver
  He had the biopsy and that did confirm the diagnosis of cancer He had pancreatic cancer  and the biopsy did show that liver spread was confirmed . I saw them in office  and told them the diagnosis  and the treatment options of chemo . I also told them on chemotherapy and the side effects  and the 'prognosis' . I told them that the pancreatic cancer with spread to liver is not good news They decided to go ahead with chemo. I had told them to consider future choices  and also the poor prognosis  and DNR or Do Not Resuscitate status . Thew were not sure.
    He was admitted  in hospital  and he had received chemo and the blood counts were low . He had some pain and that was due to enlarging Liver metastasis.He was given pain medications  and that caused more confusion and I again talked to the familyb. I told them that in spite of treatment he was not doing well and the cancer had increased and they need to see the oncologist  and see they could consider radiation which has less side effects  and may be do no treatment ts .We also talked about the DNR .
    He was discharge  and then was readmitted  and it happened . I had expected it. He had cardiac arrest and they did CPR  and he had to be put on respirator  and also had rib fractures  and collapse of lung and had to have tube put in chest to re expand the lung. We had the discussion and they agrees after 3 days to make him partial DNR . Now the decision had to made to withdraw the machine - respirator . That was much more traumatic to his wife  and sons . But once someone is on respirator , we can not withdraw without doing the forms for withdrawal of LIFE SUPPORTS .
THIS IS I CALL STITCH IN TIME . If they had made the decision in advanced for DNR, we would ot have gone through he suffering for patient - the tubes , rib fractures, chest tube  and also the family to make the withdrawal decision . . 

COVID AND BRAHMAM

    When we look at the God or the so called Brahmam id described as all pervading, limitless omnipresent etc In the religious words, it has no limit from what is called DESH,-KAL,-VYAKTI -means space ,time and identification.As one can imagine everything anything that we know has space limitation , time limitation and specific identification limitation.But the God or Brahmam has none of these limitation.What is chair is not a pot is the last limitation.. In these days we feel the same about covid  and that brings me to the story of patient for today.
    I was called to see this 67 years old male for shortness of breath and a clot in lungs. He was a male patient who had no history of smoking or drinking alcohol and had history of well controlled high blood pressure. He had some calf pain few days ago and then on the day of admission. He used to walk 3 miles  and he started having shortness of the breath and so he decided to come to hospital. He also had right sided chest pain and he had then CT chest  and that showed large clot in the right lung and some on left side as well. He had history that his daughter had coagulation factor problem and she has significant clots  and was in ICU few years ago. So the siblings  and parents were tested  and he had same problem but he was not treated for the problem as he did not have any problem .So from the history of his own illness and the history of the coagulation problem  and also the ct chest it was clear that he had pulmonary embolism  and he had it most likely due to certain coagulation factor problem. He had no fever and no cough and no exposure to anybody with covid  and he had no symptoms of upper respiratory infection. So he really did not have anything to suggest COVID infection. But one of the things that we know is that in patients with covid , they do get blood clots . So automatically test for covid was ordered . This meant that he will be transferred to the floor where the hospital kept all covid and suspected covid patients . The test takes sometimes 2 days to get results . HE REFUSED. He did not want to be on covid ward while waiting for the results .
    So now the question came up as to what to do .We have been so much afraid of covid - rightly so in many instances that we are going overboard  and have lost all the common sense. I saw a cardiologist washing potato chips bag and a salad dressing single serving bag. So the covid is like God pervading all our actions  and seems to present every where !