CAN ONE SLEEP ON IT ?

      I have not done much on sleep medicine stories. I do practice sleep medicine - mainly sleep   apnea. Bot some times we get different problems associated with sleep. To sleep on -is used when one wants to postpone making decision. But I m using it differently. We se patients that has certain characteristics of someone who has sleep apneas . Apneas means one stops breathing and Hypopnea means the breath is smaller and is associated with oxygen saturation drop. On an average we have these episodes less than 5 per hour. When they occur more than 30 per hour of sleep it is considered severe . And I have seen as high as 90 per hour. These episodes are counted as -episodes per HOUR OF SLEEP and not hour of recording. This brings me to story for today. 

   I have seen this patient for last few years. He was quite obese and had sleep apneas and that was treated with pressurized mask called CPAP-CONTIUOUS POSITIVE AIRWAY PRESSURE. This keeps airways open and the that prevents the apneas and hypopneas. He was doing good . Then he had some other medical problems - liver related and also has some personal problems that caused stress. He lost weight and was not sleeping well. he attributed that to old machine and  wanted new machine. I needed new sleep study to justify new machine as he had done the sleep study many years ago and he had new health insurance and they would not approve new machine without new sleep study. So we decided to do new sleep study. The sleep study was done  and he did not sleep well and the study came back showing he has NO SLEEP APNEA. He did not believe that and wanted second sleep study . the first was done in sleep lab and he felt that he could not sleep there in unusual surroundings. He felt that if we do the study AT HOME then he will be in his own bed and bedroom and he will sleep better.   The home sleep studies are not as good as one done in sleep lab , but his thinking was correct. People may not fall asleep in lab, as they are in unfamiliar surroundings. So I ordered Home sleep study . That also came back as having no sleep apneas. Now we both are stuck . He does not sleep well - in lab study he slept less than 10 % of the time. He definitely has Insomnia and when one does not sleep well during night , he will have drowsiness and fatigue and lack of energy during day time  and also will feel sleepy - all the signs and symptoms of sleep apneas. He wants me to get new machine and he wants me to increase the pressure settings on his current machine. No one will give him new machine unless he has diagnosis of sleep apneas and I cannot increase pressure when he does not have diagnosis of apneas . It is quite possible that he has NO APNES  and all the problems are related to Insomnia or it is also possible that he did ot sleep well when sleep study was done and so we did not get apneas. But there is not much we can do . I did order new sleep study with sleeping pill . But his insurance company REFUED THAT stating that he had already 2 sleep studies . 

  AND WE CANNOT SLEEP ON IT !!!

THE OLD DICTUM IS NOT ALWAYS CORRECT

     When we were in medical school , we were told that one does not  need of try to explain the symptoms with 2 different diagnosis . When a patient  is having some complaints , we should not have 2 different diagnosis to explain the problem . And that is true in many conditions and also in most patients .But sometimes we have 2 different diagnosis and then it becomes difficult to 'work up ' for 2 different diseases. This brings me to the story for today. 

    I had seen this male patient may be 3-4 years ago . He was admitted with pneumonia - 6 or more months ago and was seen by lung specialist .He was a smoker and had abnormal chest x- ray and then CT scan chest . He was treated with antibiotics and also  had bronchoscopy. He was discharged and was told that looks like he had cancer  and no diagnosis was done . He and his family were not happy and so they came to me. I reviewed the scans and the reports and realized that he had bronchoscopy and the samples - which take 6-7 weeks to finalized - was positive for atypical TB called MAC. I explained him the reports and started him of 3 different antibiotics  that needs to be continued for 18 months. I did tell them that he had abnormal CT scan and that needs to be followed as he could still have cancer. He was a smoker and had COPD. He did not have good lung capacity - reserve to do open lung biopsy.

    We followed him and did new CT scan several times and that continued to show improvement and the nodules that we were concerned had become smaller. We di complete the MAC medicines and then did CT scan and it continued to show improvement. Then last one was a problem . He had no new complaints and he had done sputum for TB - MAC and that was OK and the Ct scan showed that one of the nodules ,which was very small , like 4-5 mm or 1/5th of an inch , had doubled in size- still less than 10 mm or less than half an inch. I was concerned and I had interventional lung specialist do biopsy. This is relatively new procedure - may be 4-5 years old where computer guides to do biopsy in right segment and so the yield is high. This is more effective and when patient is not a good candidate for open lung biopsy due to poor lung capacity , we can get diagnosis. So the biopsy was done and HE HAD CANCER . So he did have MAC and he did respond to treatment - and he DID NOT have cancer 3-4 years ago - but now he has cancer . 

ALL THAT GLITTER IS NOT ----

      In medicine we often come across things that still brings in an element of surprise. We have known the disease but not always expect the diagnosis as it is not the common one and so when we see that then we are surprised . The story that I am going to tell is one such story .

     I saw this patient at the request of primary care physician. It is not very common that a primary care physician calls me 'personify'.  We do get request to a patient ASAP or STAT. But on rare occasions the physician calls and want to talk to me . This time I had a message that he wanted to talk to me ASAP. He had seen a patient who had cough. He was a 66 years old patient, who had not smoked for 30 years. He had cough and so he saw PCP  and was treated with usual medicines - cough syrup, an antibiotic and when that did not work an Inhaler - bronchodilator inhaler. He continued to have cough and and so the PCP did a CT scan of the chest . The CT scan showed a growth in the one of the bronchus and so he was sent to me. I saw the patient and he was little obese male. He had high blood pressure and had no other medical history. He had quit smoking many years ago and he had cough for 6-8 weeks . He had some rattling in the chest and when I asked he did have at one or 2 times blood tinged sputum. The medicines that the PCP had given had not helped much . The CT scan did show a growth in the bronchus and that did noit look like mucous plug The lung segment distant to the growth was collapsed . There was no question that he had a mass in the bronchus and that was blocking the entry of the air going tn the middle part and to some extent lower part of the lung. The mass was irritating the bronchus and to get that out the body was reacting by having bad coughing spells. 

      I explained the patient that I am concerned about cancer and we will do the work up . He was scheduled for the PET scan - which picks up concentration of the glucose and that tells us the chance of malignancy and if the cancer had spread to other organs . We also ordered breathing test - to know if in case we decide to cut part of the lung that has cancer , he has enough breathing capacity to tolerate the surgery. I also decided to do bronchoscopy  and see if we can do the biopsy of the mass. I am not sure why but I also told him that there is a possibility that this Growth could be BENIGN and not a cancer. .I did  the bronchoscopy and I saw a shinning smooth surface mass obstructing middle and lower lobe bronchus. The look was that of a benign growth called CARCINOID. The lung cancer has appearance of chewed meat - very irregular friable and not smooth surface mass . The cancers have more blood supply and so they bleed easily. THIS MASS did not have that appearance. The carcinoid tumors are considered  benign growth that SOMETIMES CAN SPREAD or the other way to say it is that CARCINOID is a malignant tumor that RARELY SPREADS. In any case the treatment is to do surgery. The carcinoid tumors also bleed when biopsied . So the best option is to have surgeon cut the part of the lung that has carcinoid. 

      So all that glitter is not GOLD and not a likely to be cancer but is or may be CARCINOID. 

    

HEALTH CARE COST AND MEDICARE

    Several years ago I saw a study that showed that when people reached Medicare Age , the suddenly health care expenses went up. Is it a surprise ?Do we really need a study to KNOW that and FIND CAUSE for it ? The answer is obvious. When people are getting OLDER there are health issues and that increases the cost . When we have Health Insurance ,then we tend to USE IT. Certain things are recommended after certain age - vaccines - preventive tests like  colonoscopy -mammograms . I know some of them are to be done at an earlier age than 65 years , but still with HIGH DEDUCTIBLE Health insurance , people tend to POSTPONE them. That brings me to my today's patient.

    I saw this 67 years old patient in office. He has been smoker and has continued to smoke . He had NO HEATK insurance till he got Medicare . Once he had that , he had colonoscopy and had some polyps removed . He had routine blood tests done and he had elevated cholesterols - lipid and so he was started on statins - medications  and since he was a smoker he had routine LOW DOSE RADIATION SCREENING CT SCAN OF THE CHEST. Now a days for last few years. Low dose Radiation CT scan of chest is covered by Medicare and other Health insurances in patients who are over 50 years of age and are current smoker or ex smoker for 14 years . One has to take in to account the smoking pack history and also the age that we do screening is also being reduced. The idea was that we DETECT AND TREAT cancer Early, by doing the scan .But the problem is to ACT WHEN WE DO THE TESTS 

  He had Ct scan done in October and that showed a nodule in lung . Then then a PET SCAN was done and that was also abnormal and so he was old to see lung specialist and cancer specialist . He did not do anything and continued to smoke . Noe that he comes to me , I have to repeat the CT scan and also PET SCAN and certainly do additional work up like breathing tests and biopsy and may be even surgery . And if the cancer has grown or has spread then chemotherapy . That all will increase the COST . So to have insurance is good and that certainly increases the USE of tests , but then acting in time will reduce the cost of health care .If he needed statin 5 or more years ago then using them would reduce the cost of cardiac and vascular problems that elevated lipid would cause. So one needs to have health insurance - do proper tests  and ACT ON IT and that will reduce the health care cost on long run. 

WHEN IS ONE SAFE -??NEVER

         When we talk about the cancer and then say that 'one is cured', we have different time durations that we take in to account to make a statement that the cancer is cured . The melanoma for example ,can come back after many years and so is breast cancer. So when we have someone with breast cancer we talk about 'disease free interval'. But sometimes we have problem. Usually the lung cancer does not come back after disease free interval of 3 years ,but I had seen one coming back after 5 years . This is rare. But then there is a increased incidence of SECOND CANCER when one has one cancer ,which complicates out thinking. 

    This brings me to the story for today. I had seen this male patient several years ago. He was a smoker in past and then quit. He has some COPD and also had Sleep Apnea. He had kidney mass  12 years ago and that was detected and then he had kidney taken out and that was cancerous . The oncologist and urologist did follow up and after 5 years he was told he was fine and 'cured . of renal cancer. Then 7 years ago he had a lung mass and so we did the biopsy and he had lung cancer . At that time when we saw the mass in the lungs ,we had thought of that being related to kidney cancer . But then when we took out the mass ,it was NEW LUNG CANCER and not related to his kidney cancer which was -at that time - taken out 3 years ago. The oncologist followed him and then I continued to do the new scans. After 2 years or 3 years of 'cancer free ' time , we did the scan every year. The last scan was clear and there was no cancer or recurrences of the cancer. AND when we did the new CT scan , I had a shock. On physical examination ,he had some prominence of breast bone that he had noticed few days ago and he had a mass behind the breast bone and also other mass in the lungs. So now he has a cancer - most likely and I am not sure if it is NEW or old - recurrence of the old Cancer. The work is is in progress. 

NOTHING NEW HERE-IN CANCER DETECTION

    The Medicare has approved payment for the Yearly screening CT scan of the chest - so called Low dose  Radiation Ct scan - for early detection of lung cancer .This is done in current smokers or Ex smokers for up to 14 years. So now a days we are seeing many patients that have some abnormality that is detected on these scans . The smaller nodules - like few mm 1-5 or even up to 8 mm are difficult to work up. Many people have come out with different tests to find out if the nodule seen is cancerous or not . The PET scan that I have talked about in many blogs , does not do good job if the nodule is less than 8 mm in size  and even at 8 mm it is difficult. The conventional bronchoscopy or needle biopsy are not good enough to get the tissue diagnosis and then we are left with doing a follow up of the CT scan .There were some blood tests that came out ,one called NODIFY and that detected certain protein and then it is used to calculate 'probability' of cancer  and still does not 'give' the tissue diagnosis. It just tells you if the probability is increased or not. So we are left with only option of OPEN BIOPSY. That brings me to the story for today.

   I had seen this male who was 73 years old and has been a smoker in past . He had COPD and that was mild . But due to history of smoking , he had periodical - yearly CT scan chest One done 1 year ago had shown a nodule and that was small - small for doing PET scan or any other biopsy. This was the low dose radiation CT scan . He had new one a year down the road and this time the nodule had grown . It was 11 mm . So now he was sent to me . We did the routine work up. Did a breathing test  and bronchoscopy . I also ordered a PET scan . The regular bronchoscopy was OK and the breathing test showed he had mild COPD he had no shortness of breath and he had stopped smoking 2-3 years ago. The PET scan showed NO UPTAKE. The no or low uptake means that the cells in the nodule do not have higher than normal metabolism. The increased uptake is related to higher than normal metabolic rate in  cancer cells - that is why they GROW rapidly. Sometimes slow growing cancer may have low pick up as they do not have very high metabolic rate.

   So, we have limited options. The growth in one year indicates - something is happening and I am concerned that it is SLOW GROWING CANCER .But I do not have enough proof that it is cancer or is likely to be cancer like positive PET scan. So now only option I have is to have surgeon take it out - which means surgery .In spite of all the new tests that are developed, we still have to do the surgery to be SURE that it is or it is not CANCER. And not all the nodules that grow are cancerous - may be 2-5 % are not.

FIND THE ABNORMAL THING IN THE PICTURE

     When my kids were growing, there used to be a puzzle where the kids have to find out abnormal thing in the picture like a bird with one wing or a flower is missing a petal etc. Sometimes in medicine I feel the same way . Thre are so many things that are wrong that we have to go through them . In medicine we used to have dictum that symptoms are most of the time explained by one diagnosis or condition and one need not try to get to 2 or 3 different conditions that could explain them. That brings me to the story for today. 

   I saw this  years old male for pulmonary problems . He was nonsmoker and had been diagnosed to have asthma . He was admitted to a hospital and had treatment done for the asthma and then discharged. As usual he did not come with any old records .So I looked at the hospital records and realized that he had CT scan done and that had shown a nodule. So I asked him if any additional work up was done like special scan or biopsy etc. . and the answer was no. It looked like he had severe asthma and he needed steroids all the time . He had a nodule and he was wheezing . So I ordered a PET scan and scheduled him for the biopsy /bronchoscopy. The PET scan was done and that showed that the nodule had high pick up of glucose on PET scan and so the nodule was likely to be cancerous or at least needed further work up. 2 days before the bronchoscopy ,I was informed by my office that his insurance denied doing the biopsy and the procedure at the hospital where I had scheduled it . This was the same hospital where he was admitted  and had CT scan done , but they told us that it was emergency. He had missed doing the breathing test and he also did the blood tests for allergies , but he had continued taking steroids and so they would not be accurate. I saw him in office again. We decided to start him on some biological agents for control of asthma and did the forms. At the same time I called a interventional pulmonologist to do the biopsy who was affiliated with the hospital system where the insurance would allow the procedure .You might think that story would end here ,but no. The pulmonologist called me telling me that they made several phone calls and he did not answer even when they left messages .He also had severe back pain and so he was seeing spine surgeon. I again called him and made sure that he comes for the breathing test and also made appointment for him to see this new pulmonologist.

     So like the picture where we had to found odd or abnormal things , we have several things here . He has more than 1 problem - asthma , back pain and pulmonary nodule . He was admitted and and they did find the nodule but no additional test were ordered or done or follow up set - may be he did not want or do it -I don't know . Then the insurance covered the hospital for the admission and work up but would not cover out patient procedure . He did not show up for breathing test .He did blood tests while taking steroids - making the tests invalid. He did not respond to new pulmonologist for the biopsy.

    Hope we can get new medicines for his asthma and he will keep appointment with new pulmonary doctor and also get the biopsy done.

CENTURY OLD PROBLEM

     In changing face of medicine ,we are seeing more and more older patients. It is not uncommon to see 3-5 patients in a day who are more than 80 years old . But sometimes I have seen patients who are more than 90 years old . The problem with some of theses patients is that some are in good physical state but not mentally and some are good mentally and not good physically. So it becomes an issue as to how to treat such older population and many patients and families are not ready for conservative management till end. This brongs me to the story for today. 

      I have seen this patient for many years . He was admitted with some cough and then I was consulted .He was worked up and was dx to have fibrosis - scarring in the lungs .He had rheumatoid arthritis and the conclusion was that the fibrosis was due to rheumatoid arthritis. When I saw him in hospital , we had started getting new drugs for fibrosis but they were approved for fibrosis of 'unknown cause' - the so called 'Idiopathic fibrosis '. So I was not very keen on starting him on new drug at advanced age especially since the drugs have side effects on liver and also DO NOT CURE or REVERSE the process. As time went by we did get the drug approved for any fibrosis and . So, I started him on the medications He had some drop in oxygen when he would walk and so he was also started on oxygen. He was also getting medications for arthritis. He was doing OK . He was very active and had a day care enter and had 65 kids in it and used to go there every day for few hours . He was using oxygen ,but sometimes did OK even without it . He did have a set back when he had bleeding from the stomach ulcer and needed blood transfusion. 

    Years passed by . He was now 99 and then would be 100 years old soon . We do breathing test to see if he was any better or worse . WE HAD DONE IT BUT WE HAD NO NROMAL VALVUES FOR 100 YEARS OLD PATIENT. Then the specialty pharmacy called our office informing us that he had passed away. He was old and so I did not think much. The disease was bad and he was very old and more oxygen dependent now. But then he showed up in office as the medications were stooped by the drug company. We were surprised and we did new forms for him to get the medications. 

    He had been getting worse and was more short of breath and also needed to be on oxygen 24 hours a day. He was 101 years old . I ordered CT scan . Now here is a problem . If the CT scan would have shown 'worsening of the fibrosis ' I could have changed nothing. He was mentally fine and was only physically getting worse .But I did and the CT scan showed that he had 3 MASSES and had swollen Lymph nodes suggesting inoperable lung cancer!

    Now what ?I called him and his wife in office. I was not sure how much work up we can do in this 101 years old patient with need for oxygen all the time. I also knew that unless we have biopsy, we cannot give him treatment like chemotherapy and the chemotherapy would not cure him but cause many side effects, which will make his life worse. So, what can I offer ?I decided to send him to radiation doctor and also to interventional pulmonary specialist and also radiologist. The radiologist could do a needle biopsy - but he was not very keen due to to his advanced age and high risk of collapse of lung due to location of the mass. The same was with the interventional lung specialist. The patient and his wife made it easier for me . They decided NOT TO DO ANYTHING at this time. 

THE CHANCE

    I have seen progress in medicine and many of the diseases which had no specific treatment in past ,now has some and we are making progress. But sometimes when a new drug comes to market , there are people who 'demand' it be used and there are some physicians who use it. I feel that sometimes there is some  overuse. Recently a drug came in market for COPD -chronic obstructive lung disease, which is relatively old drug and approved for asthma and  some other conditions in past for last few years , and now approved for COPD. The drug representatives were in my office the other day and were asking me how come I am not using it yet . My answer was I need to find appropriate patient for the use . But your collogues are using a lot  ,was the comment. My answer was may be they have more appropriate patient . But that brings me to the patient for today.  

  I had seen this male patient - may be  years old 3-4 years ago . He had chronic cough and so we did the work up . It looked like  that he may have some allergies and some mild asthma. I did some investigations and did treat his asthma , which was seen on his breathing test , but he had some reduction in his diffusion capacity. The oxygen and carbon dioxide 'diffuse' across the lungs  or air sacks and when we m= checked that as part of breathing test , we found out that that was reduced . So I did CT scan and he had some  ILD - Interstitial  Lung Disease. - something that can cause fibrosis - scarring in lungs and also can cause cough and shortness of breath. ]This also can be seen with allergies and also can be related to certain medications and then some have no known cause and so we call it Idiopathic . This last one has poor prognosis . 

  I did the work up and he had no known allergies  and no work history and the bronchoscopy did not show any infection. So we talked on the diagnosis and some treatment . The drugs that were approved in may be are costly , do not reverse or cure the disease , but just reduce the rate of decline . In my personal opinion, which I had expressed in an interview when the drug came out in USA is that we do not have clear cut knowledge as which patient will get worse and which will not. So, it is very difficult to decide - o tests that can tell us on the 'chance' of worsening .So I do repeat tests in 4-6 months and anybody who worsens we start the drug . If they are very sick and have need for the oxygen ,then I start then quickly. 

  This patient had family history of such lung problem and so he was to go to John Hopkins for some research. We watched him . He did not get worse , but he was stable for a year or more and then I continued to do follow up. He had also gone to Hopkins and they did some blood tests on genetics work up. He continued ton do follow up and the cough had subsided and then the diffusion got better and after 3 years or more his last CT scan shows minimal scarring - the CT scan is significantly improved. 

   He does not need medications and if I had started him on medications , he would have been counted as 'success story'. The drug company has data that shows that when medications were started 'early ' they did better , but how many of them could have not had progression of the disease even if they were not on drug? This is impossible to be determined as we cannot and will not hold the drug if we have the worsening disease.

   My be in future we will have some tests - markers that will tell us as who is going to get worse and we can start drug quickly, and not overuse it.   

DOUBLING TIME AND VARIATION

    I see many patients who have abnormal CT scan and the scan shows nodule , we do tests to find out as to the cause of the nodules . Just for the sake of knowledge, the solid nodules , and nodules with speculations are more likely to be cancerous than ground glass  nodule which is like haziness. There are many things taken in to account when we think of the nodules and they may be male- female, size of the nodules and characters of the nodule , smoking history, age , upper lobe -lower lobe etc. But with smaller size we tend to do follow up of scans . How often one should do scans is based on possibility of the nodule being cancer and growth pattern and how our science can detect it at it's earliest . The nodules which are very small are impossible to be biopsied. Her we think of doubling time of cancer - how long does it take for the nodule to become double it's size in volume. The fast growing cancer will double in 45 days and slow growing will double in more than 1 year , but many will do size change which can be detected , in 90-120 days . This brings me to the story for the day. 

   I have seen this patient and his wife for last 10 years or so. Bothe of them were smoker and had COPD -emphysema and they were on medications , needed oxygen at times and steroids . Also needed hospitalization. But continued to smoke . He had a ct scan of chest may be 2and half years ago and gthat showed a nodule . The nodule was small and so we talked about the possibility of cancer as he has been smoker and he did not want much testing and ,so, we did do follow up of the scan and he agreed . The new scan was done and that did not show much change . Then we did do another follow up and that showed that the nodule had grown and now it was over an centimeter . So I asked him to do PET scan . He was not very keen on doing PET scan, but finally he did it. The nodule did pick up and so it was now more likely to be cancerous . He was not a good candidate for surgery as he needed oxygen and had poor reserve - based on breathing test to undergo surgery and resection. So I suggested doing radiation after doing a needle biopsy. He refused biopsy and did not want radiation, but wanted to just do follow up .I told him that if the nodule becomes too big - larger than an inch, short course f radiation will not be option and then he will need prolonged course of radiation. He still did not want radiation. So I have done few more scans and then nodule has grown by very small amount may be 2 mm - 25 mm make an inch . Almost 3 years have passed by since we detected the nodule first time. I am sure that he has a cancer , but it is growing at such low rate that he falls out side the 90-120 days rule. 

 So much for the doubling time discussion.