Saturday, February 3, 2024

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.

Saturday, January 6, 2024

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 !!! 

Sunday, December 31, 2023

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.

Sunday, December 17, 2023

HOW DO YOU DECIDE?

   We have all known the difficulties in diagnosing some diseases or even simple disease which may not show typical signs or symptoms of the disease. But when one knows the diagnosis and still have problem in making decision. This is due to circumstances that are there. I am talking about that kind of situation today. 

   I had known and seen this patient for  many years. She was elderly and had mild asthma and had h/o breast caner. She was doing fine . She was quite stable till she had COVID , She was admitted to hospital  and had pneumonia and had need for oxygen . With usual treatment for COVID she did well and was discharged . But then was readmitted for irregular heart beats. She was seen by cardiologist. And medications were adjusted . She did OK but continued to have problem with heart rate .She had this problem in past and had been on blood thinner but then had gastrointestinal bleeding and  so she was taken off the blood thinner. She was discharged and readmitted  and the story repeats . The next admission to hospital she had developed fluid around her both lungs and needed oxygen supplementation. I saw her  and then decided to take the fluid out with catheter to get her better quickly as she was on diuretics - water pill . She did better , but had another echocardiogram - ultrasound of the heart and that showed that one of her heart valves was not working well and had elevated pressure in lungs called pulmonary hypertension. So the cardiologist decided -this time to talk to her about surgical repair. Certainly now a days there are less invasive surgeries to repair such valves , but it is still surgery and she would need additional invasive work up . She would need TEE Ultra Sound of heart looking by putting a probe in esophagus  and then checking the coronary arteries by doing cardiac catheterization. Though not much invasive these procedures do carry a risk. And if  heart catheterization shows' blockage then she will need intervention like stent  and she will need to be on blood thinner . If the blockage is significant that it cannot be fixed with stent ,then will need bypass surgery. So the question that I have is SHOLD WE DO THE WORK UP OR NOT ? And if needs arise for major surgery , should we do it ? Not an easy decision.   

Saturday, November 25, 2023

PATCH WORK

    In our general life we are always to to make decisions as to do a 'temporary patch work or do permeant fix'. So the AC is broke and the tech tells you  we can get it working with some  minor or less expensive parts or we can change major things and that will be warrantied . With cheaper work there is no guaranty that things will last but it is less expensive.  The came thing may be for roof repair or car problems. I fell that in medicine  is the same. We see patients in office or in hospitals, that are admitted for some diagnosis and then we fix it but that does not change the underlying problems or treat it . Example will be someone admitted for pneumonia with underlying COPD in smoker . So, we treat pneumonia but the patient continues to smoke  and gets CIOPD worse. We did not address that. This is very clear cut. But I am going to tell you  the story of a patient where this extend to more that such obvious thing. 

  I have know this patient for many years. She had some COPD  and she also had some cardiac issues . She was quite obese and it was to a point that she could not get of her bed  on her own. She was admitted with swelling in her feet and she was short of breath and so she was admitted and we treated her . She had some fluid around her lungs . She was treated and then sent home . She was readmitted and has same thin  and we tried to treat her . In her 5th or 6th hospitalization, she had increased fluid around her lungs , mainly left lung. She was very heavy women. Normally I drain the fluid by inserting a needle. But I was not sure that if my needle was long enough to 'reach' the fluid . So I asked the radiologist to insert a catheter. He agreed , but when he tried to do it he could not get needle long enough and so he was not successful. I had to call chest surgeon. He did put in a catheter under anesthesia. Over period of days one day she got agitated and pulled out catheter. She was treated and discharged . She was back again with shortness of breath and she had low hemoglobin and then she was again sent home and she was  back in hospital and this time her salt in blood was low . 

   During every one of these hospitalization, the problems were same - shortness of breath, swelling of the feet ,fluid around her lungs and low hemoglobin etc. She never was able to get out of her bed , let alone getting to walk Her weight was same and she has nothing else changed . We did 'fix' the problems that we saw , but did we really FIX anything or was that the PATCH WORK - A TEMPERARY BANDAGE ?

Sunday, November 5, 2023

WHAT WOULD AI DO ?

  Now a days we have news about AI - Artificial Intelligence. AI passed the Medical board- AI passed Bar examination and many other areas where AI is doing different things that we thought ONLY HUMANS can do. Sometimes we come across cases where on surface it may look same but one has to apply different approach to the differential diagnosis  and work up. That brings me to the patients for today. 

   I had seen these new patients . One was a young man who had been diagnosed with HIV and has been on medicines for last 4-5 years and had done well. But then he had some brain infection-meningitis - infection  of covering of the brain to be exact and was treated and did well. He had then pain in the belly and so went to ER and had CT scan of the belly done  and that was normal. But in the CT scan of the belly , there was some abnormality noted in lungs . 

    He was discharged and saw PCP and he noticed the abnormality in lungs and he had not seen lung specialist and so he was sent to me. When he had meningitis , he was on respirator and he had tracheostomy and also feeding tube  and he had not had CT scan of chest .So, it was difficult to know if the abnormality seen on CT scan of belly was new or old. I saw him and ordered CT scan of the chest , which was never done . That showed the same thing that was seen on CT scan of the abdomen .- he had a cavity - are of the lung where there is  lucency or air in the center of he congestion.

    I saw this second patient at the same time . Hw was 78 years old and has had minor stroke  and had some cough  and had no fever . He had cough and he had seen Primary physician and had chest X- rat done . He was treated with antibiotics and then he had no change in his cough and so had CT scan and that showed again a cavity. I saw him  and he had good oxygen and also had some cough. 

    So we have 2 different patients with same Ct scan findings , the age is different and the past medical history is also different. The etiologies of the problem could be very different in these 2 patient . In the first patient who has compromised immunity, due to HIV he could have Tuberculosis or Fungal infection etc. The older gentleman could have aspirated - food or liquid going down wrong way in the lungs instead of esophagus, leading to pneumonia and lung abscess.

   The same CT scan findings - some difference , one has the abnormality in upper part of the lung , other has it in lower part of the lung - the cause could be different and work up could be different too. Would AI pick it up ?  I did the work up and result in my future blog.

 

Saturday, October 14, 2023

NO RIGHT WAY

    In medicine there are more than one way to do things  and the AI will not be able to give one final way. In Mathematics, 2 plus 2 make 4  and that can not be changed and it is true under all conditions. In medicine sometimes we do things differently in different patient and there is no right or wrong way. I  saw 2 different patients  and they had very similar problems. And I will tell you one at time. 

The patient that I saw was that of my other patient, who had COPD and he had smoked for many years and he had quit ,but it had taken toll and he had COPD and he had shortness of breath and he  needed oxygen. I saw him and he had large mass and we did biopsy and he had cancer and he was not a candidate for surgery based on many factors like being on oxygen with advanced COPD and also the mass was invading the center of the lung . So we did radiation therapy and he did OK . Then his wife came to me. She was about 80 years old and had smoked many years ago. She saw her PCP  and had some cough and some shortness of breath and when she saw PCP her oxygen was low and she was started on oxygen and she had CT scan of the chest done and that was abnormal and so she was sent to me .

  She was elderly women and she has been on 3 L oxygen and she had some shortness of breath and she had not had any chest x- ray in recent past till she had the CT scan . The CT scan showed Aright upper lobe mass and that had invaded the hilum the center of the lung . She also had significant fluid around her lung  and she was short of breath. She had irregular heart beats and had not seen cardiologist but was on blood thinner. So I had high suspicion for cancer which had spread to lymph nodes  and also the fluid that was seen , was most likely due to cancer. She was on oxygen and had COPD  and she  did not want any chemotherapy same as her husband. So I had a choice . I could do bronchoscopy and biopsy and see if I can get the diagnosis of cancer  and then drain the fluid and see if there are cancer cells in it. If my bronchoscopy and biopsy does not give diagnosis then i will have to ask radiologist to do needle biopsy of the mass and if the fluid  reaccumulates then we have to have a catheter put in for periodic drainage. Since she was on blood thinner, we will have to hold it for 5 days every time we did any invasive procedure. So if I did all these procedures we will be stopping and starting blood thinner many times . So I decided to do thing that I thought was RIGHT for THIS PATIENT. 

  I called radiologist and asked him to do needle biopsy of the lung mass and at the same time put in catheter , under the presumption that the fluid was due to cancer and will come back if just drained and then will need drainage again or the catheter for periodic drainage. 

  THIS WAS THE RIGHT WAY FOR HER IN MY UNDERSTANDING . 

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