DECEPTION

      In medicine we have a trust in certain things . I f often say ,'if this is normal then that is not likely or not possible. And then we come across a case or 2 ,that proves us wrong. If  fasting sugar is 100 mg or less then you don't have diabetes , or if one is not a smoker ,then chance of having lung cancer is very low . The statements are true from statistical stand point.  This brings me to the story for today. 

  I had seen this patient many years ago . She was 70 years old female , who had been smoker and had smoking related lung disease -COPD. She also had a smaa nodule and that was stable for 2 years . So she was lost for follow up. I think she thought that she had stable nodules for 2 years and so it was less likely tat that was cancer and she had continued to smoke . She saw me again after a gap of 5 years. She had been  to hospital for various things including shortness of breath. She had continued to smoke . She had some cough and also no fever, weight loss  and no new CT scan of chest . She had couple of chest x- rays done and they had shown no nodule on right side but had shown some congestion and small fluid on left side in the lower part. 

    I ordered breathing test and a CT scan chest . She was again admitted and I was not consulted or informed and she had suspected stroke and that was cleared . she was discharged and then again readmitted with some cough and some shortness of breath. This time I was called in . She had a CT scan of the chest to rule out clot in the lungs  and the CT scan did not show any clot ,but showed a MASS in the left upper part of the lung which was compressing the bronchus and blood vessle going to left upper lobe of the lung . She also had mass lower down and also on right side next to the center of the lung and also there was another nodule or mass in right lower lobe. This was increased from the CT scan that was done 5 years ago. So here is a lady that had 2-3 chest x- rays of the chest which did not show any mass , but some congestion and some fluid on left LOWER part, now has masses in left upper lobe , left center , rt center and right lower lobe . NONE OF THIS WAS SEEN ON PLAIN CHEST X- RAY . 

     In all probability this is cancer But how much we rely on plain x- ray and now the CT scan showed so many things that were NOT EVEN SUSPECTED by looking at the chest x- ray. This is what I called deception. 

    

TRUTH AND NOTHING BUT THE TRUTH

    In medicine there is nothing which is permanent. When aspirin was discovered for fever , the 'warning' was that patients with heart problem should not use it. I have seen the changes in the thought process of many diseases. The asthma was defined as 'completely reversible airway obstruction.' And then we realized that there is more than just bronchoconstriction. We realized that there was component of inflammation and so then we started treating that .Now we are talking about casket of chain reaction in allergic asthma and how to block that . So ,I thought I will talk about the treatment that we were doing for asthma in past and ow we do not do it. Not that it's discontinued but, but we can not imagine that these treatments were done . 

   So let ma start by telling you that in early 1900, the asthma was treated with radiation therapy.. There are articles published in medical journals as to how to do it. There were 2 different techniques , one was to radiate nasopharynx and other was lungs and abdomen . I am not sure why radiate abdomen. But it was there and the success was good - 90 % doing good in first year and 40 % had longer lasting benefit !!The other was to take out blood from a vein and irradiate it and out in the body . This was also done with idea of 'killing ' antibody ??But that was also done to treat resistant asthma. 

    In India , there was a treatment that was there and is carried out even today . On a full moon day in a year - one particular full moon day only , south of city of Hyderabad, this treatment is carried out . The family that does this, has a special recipe and a 2 inch fish -MURREL  fish is swallowed coated with some spices on MRIGASIRA DAY.. The place is so busy that the government runs special bus service on that day  and thousands of patients are treated . 

   There is also treatment with auto blood . The blood is taken out and then 1/2 ml is injected in but area - intra muscular  shot . The idea is that it produces antibodies and that helps to cure the asthma 

  One other concept that is prevalent and studies have proved it to be wrong , is that if one gets a Chihuahua, the dog gets the asthma and the person is cured . Again there is asthma in the dogs but they do not 'get' it from human beings and certainly the human beings are not 'cured ' of asthma. 

PERSISTENCE PAYS

    In Medicine and in any other field persistence. If one wants to do a surgery -more one does he gets better . The same hold true for shooting baskets . But sometimes one has to dig deep to get to the bottom of the problem. In medicine that should be the rule. That brings me to the story for today.

  I saw this young lady for consultation. She was in her twenties. She had not been smoker and has been physically active , going to gym and not having any problems with breathing. But her boyfriend had noticed some wheezing when she was sleeping .So he told her to see me .She was young lady and had not been smoker and had no other health issues . She had good oxygen saturation and had clear lungs and no wheezing. She had no shortness of breath even when she was running on tread mill. So I was not sure as to what and how to treat . Here is a patient who has clear lungs and has no shortness of breath and only time there is abnormality is noticed is when she is sleeping and that too by her boyfriend . We did a chest x- ray and did breathing test. She had normal chest x- ray and the breathing test showed that she had asthma - obstructive pattern on spirometry. This happens when bronchial tubes collapse with exhalation. So I gave her an inhalers . She come back for the follow up. I asked her if she finds any difference. She told me she tried the inhaler for short time but she has no cough ,no shortness of breath and no wheezing and so how can she see the difference - difference in what ?I told her to use the rescue inhaler as needed in case she is short of breath or has bronchospasm. But I decided to do new breathing test in 3-4 months . She did the  test and the report was same . She had same obstruction . In the first test I had noticed abnormality in one part of the test called flow volume loop . That was seen in the second test too. I was concerned but I had not noticed any strider on trachea and so I was not sure what to make out of it. But this time she wanted me to clear her for surgery for breast augmentation. And I needed more test to make sure that she did not have problem with trachea -the main wind pipe. She was not very happy as I would not clear her unless she had done further testing . I did CT scan . And there it was .She had abnormal aorta  and and abnormal blood vessel crossing the trachea making it narrowed . That would explain the abnormality seen on flow volume loop and perhaps other part of the tests .Her trachea would collapse when she forcefully exhaled or when she was supine .My feeling is that the trachea may not be fully developed or may be not have enough cartilages and support and may be fibrous and so she had no problem when she exercised as that part could stretch  and no air flow obstruction could occur, but the test did show abnormality. 

  I have sent to a tracheal - chest surgeon  and he wants to do additional tests. The jury is out as she has not done the tests yet.She is thinking about it.  

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 !!! .