ALL THAT GLITTERS IS NOT GOLD

     We have a saying 'All that glitters is not gold .' This is so true in medicine and also in amny other aspects of life . Many a times we come across people that we think are OK or honest or good and then our experience tells us otherwise . But in medicine we depend upon many tests  and then newer tests ae suppose to be 'better' than our own judgements or intuition. So we make decision based on theses tests  and most of the times they are accurate and sometimes not so . In medicine we talk about sensitivity and specificity of a test . These words mean what is the chance of Picking up disease when positive and missing when negative  and also How specific they are when they are positive. So a test could be positive highly sensitive , but may not be specific . As the time goes on and we have more and more experience and data , we know the values and make out decisions based on that . That brings me to the story for today. 

    I had seen this patient many years ago and then she had allergies and asthma and she was treated and did good . She saw allergist and then was started on allergy shots and so she stopped coming to me . She then was admitted to hospital with shortness of breath and she had CT scan done and a clot in her lungs was diagnosed . She had a history of a clot in lungs in past and so now she has be on blood thinner - anticoagulation for life long . But when we had done CT scan ,she also had a nodule. A nodule is density less than 2.5 cm , We call density a mass , when it is larger than 2.5 cm or an inch. I did the work up .As she had recent clot, we did not do any biopsy.  I did do breathing test to assess her lung capacity and then also did PET SCAN . As I have mentioned in my  previous blogs , the PET SCAN picks up glucose activity - metabolism in cells and so when higher concentration of glucose is picked up the likelihood of cancer is higher .So we did PET scan and she had high pick up in the nodule. So, I sent her to a chest surgeon. He saw her and was not too sure or I am not sure , but did not do surgery. She came back to me and was quite concerned as to the possibility of cancer was raised and she had family history of lung cancer and she was worried that if we leave the cancer for longer time , then it may spread and then surgery will be mute . I saw her again and was not sure . So I called the surgeon. He wanted to do new scans  and then decide .I told him the concern of the patient and also my concern as the PET scan was positive and suggestive of cancer. 

    He saw her in office and then she had surgery done. The lymph nodes were negative of cancer and the Majority of the nodule was scar and inflammation. There was a 1 mm portion that was abnormal called CARCINOID. The carcinoid is considered as either a benign tumor which very rarely can spread or malignant tumor which very rarely spread . Si I don't think she had cancer but the PET scan was positive !! and we based our decision on the test !!

PRACTICLE PROBLEMS IN MEDICINE

     I have known practical problem in every field and then sometimes there are solutions and sometimes there  are none. I remember of a joke where the Government officer is asking for the proof of being alive ,before approving the passion, when the person is standing in front of him, And the height of stupidity in following the rules is that he makes a statement that ;you have the certificate fir this year ,but where is the one for last year?'  In medicine that problem is similar, That brings me to the story for today. 

   I had known this lady for long time .She was more than 90 year sold now and she had history of breast cancer. She also had sleep apnea and she was on PAP positive -airway -pressure mask for that. She also had asthma .She had some problem and so had chest X-ray and that showed a density . So we did CT scan and she had a nodule . A nodule is something which is density less than 2.5 cm. The cancer specialist were called in and I was also called in The cancer specialist wanted to do needle biopsy to get the diagnosis -as to if it was cancer and if it was , what kind so they could treat her. I had known her and so I talked to her and asked her if she ever would consider surgery or chemotherapy? She said no. The small nodules when PET scan is positive , we consider surgery , as that is the best treatment for cancer. In her case we did PET SCAN and that did show uptake in the nodule and so it was most likely to be cancer. So then I suggested short course of radiation -pin point radiation- called stereotactic radiation . This is done in 5 days  and the cure rate is good .She agreed .

    I thought we are done .She did OK for few months  and then she had cough and shortness of breath and the X- ray showed fluid around her lungs . So she had that taken out and that showed cells of lung cancer. So she had lung cancer that had spread to pleura - covering of the lungs. Now the question was what should we do about the fluid . In patients with cancer the fluid tends to come back . So I suggested putting in a catheter that can stay for up to a year and we can drain fluid periodically, at home with a vacuum  bottle and she does not need to have procedure done over and over again. She agreed and we did the catheter. We arranged for a nurse to help her and she was sent home. 

   The problem started after the discharge . She lived alone and was 93 years old. The Medicare denied to pat for the nurse to come to her place and drain the fluid . Normally we have family members who can do this job ,But here she had no one at home  and the friends that she had were also older. I had sever calls from her and her  relatives who were out of state. I called social service and case managers at the hospital and could not get any way to approve the nurse going there. Finally someone suggested getting Hospice to help . Certainly she would qualify - she had lung cancer and the fluid was related to that and she was 93 years old and no chemo was planned and her life expectancy was limited . So she was perfect candidate for the Hospice service .She did not want to be with Hospice , but we had no choice . 

   This is practicle problem in Medicine.

YOUTUBE VIDEOS

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The next one will be on Personality change after heart transplant.

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TAKING STEPS FOR REDUCING CARDIOVASCULER DISEASE

    I am always interested in staying healthy , may it be exercise or diet or dietary supplements and I have done many videos on these topics. I came across an article on walking. We all know that walking or doing exercise nis good , but we do not have understandings to how much is needed to be beneficial. I have asked my elderly patients as to how much they walk. And I get an answer I work in yard or I don't just sit ,but do house work  etc. .But as far as calorie consumption is concerned that kind of exercise is minimal ,e.g. 16 French fries is equal to 31 minutes of cycling or 90 mins of house work is same as far as calories are concerned to 52 peanuts. So today I am going to write on how many steps are good .

    They did analysis of almost 77000 people . They were divide in low sedentary life and high sedentary life based on history , Less than 10.5 hr. and more than 10.5 hrs. The steps were recorded by patients and then the patients were followed for 6-7 years . The 2200 steps were at 5th percentile. So when they compared the overall mortality and cardiovascular disease. risk in various people they found out that more risk was directly proportional to number of steps. The 2200 steps were considered as base line . The benefit was gradually increasing .So those who took more steps had more benefit. The maximum benefit was derived in reducing overall mortality was somewhere between 9000 to 10500 steps. So doing more than 10500 steps did not reduce mortality or  incidence of cardiovascular disease The walking minimal 4000 to 5000 steps are required for the benefit. 

   In conclusion, we need to walk or 'take steps to reduce mortality and cardiovascular incidence. Minimal required is 4000 to 5000 steps a day and maximum beyond which the benefit does not increase is 10500 steps. 

  SO START TODAY - START WALKING !!! . 

SOCIAL OR MEDICAL

    In the one of the books written by DR Atchut Gavande titled MORTAL, he writes about his grand father who died after age 100 .He was active for long time but when he had problem the 'family' took care of him . This may be due to the fact that there were many members in the family who lived together and they did not have nuclear family  with husband - wife and kids. But now a days we are depending upon society - government or insurance etc. rather that family friends etc. This brings me to story for today . 

   I had known this patient for many years . He had lung disease -COPD , that happens when one is smoker . He had shortness of breath and then we tried various medications and inhalers and he was OK ,but still had shortness of breath. He lived by himself and had not been married. He needed oxygen as his oxygen levels were low . As the disease progressed , he started having retention of carbon dioxide. In COPD - lung disease with smoking -mild disease does not need oxygen . As the disease gets worse, then one needs oxygen and then when the disease progresses lungs cannot wash out CO2 and so then they need more treatment. Now a days we can start them on respirator or ventilator. The machine helps the patient's breath and also 'generates' breath if there is no spontaneous breath by the patient. In past we needed a tube to be inserted in trachea to use ventilator . But now a days we use pressurizes mask system, similar to one that we use with sleep apnea. This is called NIV -Noninvasive Ventilator. So, we started him on that .And he did well . He was stable and awake and could do certain things - physical activity better.

   One day he had a fall and broke his left arm and came to ER , they send him to orthopedic doctor to be seen as out patient after having a soft cast. He was home for 7 days and could not use the mask and NIV and came to ER.I saw him and he was stable . We did do some changes in his medicines , but the problem was that with  broken arm- and he is left handed , he cannot put the mask on own  and so he was not using it when he was at home  and so he got worse. All that he needs is to use NIV for 12-16 hrs  and he will be fine . But who can put the mask on him and take it off when he has broken arm? He has a friend but she has hip problem and surgery and cannot help him. He has a sibling but they cannot help. So we have to send him to some place . If he has cast the fracture will take long time to heal - may be 2 months and even after that he may not have adequate use of arm. So then he has to be in rehab center and insurance may not pay for that. This is more of a social problem than a medical. But if social problem is not taken care then the medical problem will get worse. 

    This is the modern day life and it's problems.

DOUBLING TIME OF TUMOR

  In medicine we observe and then do investigation and then come to conclusion on certain FACTS. We recently started doin Low Dose Radiation CT scan of chest to diagnose lung cancer in early stage. The test was approved for patients who have been smoker or ex smoker for 14 years and over certain age and certain pack year history. This has created sometimes more problem than answer. We have seen tiny nodules - mm in size that we do know what to do. Then we came with some suggestion to do follow up on theses nodules. At mm size we cannot get the tissue with needle biopsy and with PET SCAN and we cannot operate on everyone. So we have developed some criteria  as to how often to do follow up on these nodules with CT scan. If the nodule is 8 mm -1/3 rd of inch then we need to do follow up in 3 months , if it is 5-8 mm then do CT scan in 4 months and if less than 5 mm then do CT scan in 66 months. This is based on what is called Doubling Time.-How much time a cancer will take to double in VOLUME. Again not all cancers double in same time  and there are outliers. So some will be very slow growing and some will be fast growing . That brings me to my patient for today. 

  This patient was followed by me for some years . He had been smoker in past and had  COPD . He had CT scan and had 4 mm nodule. We had done some follow up CT scan and the nodule had not changed for more than 1 year. The average doubling time of lung cancer is 90 to 10 days  and so we usually do CT scan follow up in 3-4 months. Again not all will follow this growth pattern and sometimes same cancer may have different growth rate at different time  and in different organs when it metastasizes. But it is good way to do the follow up . So he was stable . Roughly about 9 months after his last CT scan chest ,he saw cardiologist . He decided to do CT scan to check on his aorta.. That showed  stable 4 mm nodule but showed NEW MASS of 2.5 cm or one inch. I saw him and did the work up . He had PET SCAN and that showed increased uptake. There is some size difference between the PET scan and CT scan . But the point that I am trying to make is how did this inch size tumor happened when there was none 8 months ago. What is the growth pattern and why on PET scan it is not same rate increasing but some decrease in size. But in general the doubling time is good way to do follow up . But not all CANCERS HAVE HEARD ON THIS OR DON'T WANT TO FOLLOW TH RULES !!! 

CAD IN ASIAN INDIANS

    This is the last one of the blog entry for 2023. I had gone on a vacation with group of people and one of the friends who was with us, had a phone call and he lost his young cousin to CAD. This struck me and thought that I will do one blog on CAD - coronary Artery Disease in  Indians. 

   The incidence of CAD id 2.5 % in US while prevalence of CAD for Indians in India is 11% if they do not have Diabetes and is 21.4% if they have diabetes. Usually the prevalence reduces from the country of origin but stays higher than Americans when one emigrates ,but with Indians that has not been the story. In UK it is 2-3 times that of national average. In Singapore the heart attack rate is 3 times higher than Chinese and in California hospitalization is 4 times that of white Americans. In rural India the prevalence is 6% in ages 34 to 64 years and in urban it is double that. This is same as Indians in US. 

   We all know the risk factors -obesity, smoking, hypertension, diabetes and lipids -metabolic syndrome. But they don't show as to why the CAD is that malignant in Indians . More than 50 % of the deaths due to CAD occur in patients less than 50 years of age and 25% of the heart attack patients are less than 40 years old  When one looks at BMI - Body Mass Index the BMI  is slightly higher than 25 -the upper cutoff of overweight in Urban areas while in rural area the BMI is 20., But the abdominal obesity -love handles is much higher in urban area Indians The waist to hip ratio is one way to know this abdominal obesity. It is 0.99 in urban area and in rural area it is 0.95. This causes type 2 diabetes and lipid problems and insulin resistance. The Visceral fat -the fat around organs in belly - can be assessed by doing MRI . But the waist to hip ratio can predict it quite well. Doing high intensity exercise prevents the CAD and most Indians do not do it.

   Type 2 diabetes in US prevalence is 5.3% while that in Indians in US it is 18 %.Indians in India it is 12 - 14% So somehow type 2 diabetes  is much higher in Asian Indians in US.50 % of Indians are vegetarian but we tend to consume more fats -butter -ghee - cheese and paneer. We eat less fruits and vegetables  and tend to REUSE OIL. Kerala has highest incidence of CAD attributed to excessive use of coconut oil. 

   Smoking is less prevalent in Indians in US  and also hypertension is also less prevalent in Indians in US But type 2 diabetes- insulin resistance is higher  and also lipid abnormality is more problem. Indians have less of 'good cholesterol' called HDL and increased of 'bad cholesterol ' called LDL we have increased triglyceride. and Lipoprotein a.

   Inflammatory markers like CRP is higher in Indians Homocysteine is also elevated  and certainly there are genetic factors .

  So, Indians are mildly overweight with more abdominal fat, have low HDL and high LDL and triglyceride and lipoprotein a  and do less exercise . We have more working hours  and more stress  and have more inflammatory markers. We also have type 2 diabetes  and also use too much fats , less fruits and vegetables and less exercise. Some of us have bad genes. 

   We can change some factors and some we cannot. I do not need to tell you what you can change.

AS WE START 2024 HOPE WE CAN CHANGE THIS.