Saturday, October 21, 2017


      I am always amazed with the new inventions and new techniques in medicine. But some of them are so good and may be an advantage for the patient and for the physicians. But sometimes it adds to the problems . So few years ago I was talking to some one  who happened to little older . She had tried to get pregnant and was not successful . She had test tube baby - fertilization done out side the body , then selected embryos implanted in the uterus. Due to the advanced age of the mother, they were doing blood tests from the mother starting at age 10 weeks . The blood tests were done again done at periodic time . The mother's blood is tested for fetal DNA. This can help detect the Down's  syndrome and some other fetal abnormality . The amount of the DNA is increased as the pregnancy advances. So the mother's blood gets fetal DNA even though the two bloods don't mix. While I was thinking about this , i looked in to it and realize that similar thing could be done for cancer or tumors. So I looked in to it and was surprised that there were some scratchy studies done in the past .

     And then I came across the study where blood tests are being done for very small nodules in the lungs and some as small as 3 mm and some much larger as much as 30 mm . This is called 'liquid biopsy" The studies are being done for breast cancer and the lung cancer and urine for bladder cancer. So I now know local physician involved in this study. I am not sure what would come out , but I was excited to know that some one was doing the study .

     But then I came across a study which was published recently and the lung cancer . They did the blood test in patients who were treated for the lung cancer and had NO EVIDENCE of the cancer. Those who had the positive blood test for ??tumor marker- had higher incidence of the recurrence of the cancer.But here is my problem . So if the blood test is positive and one has no evidence of the cancer , should we treat it with more chemotherapy or just watch it . The problem is that even though the blood test may suggest that some cancer cells are still in the body , not everyone comes with the recurrence , may be the body's immunity takes care of small tumor load. So treating everyone , we may be over treating , and that adds to the cost and the side effects .This problem was much worst when in past some did similar blood tests in high risk patient , who had no evidence of the cancer anywhere in the body, and the tests came back as positive . So now what do you do . Without the actual tumor , one can nor select appropriate chemotherapy and what kind of follow up can we done to see if patient is Responding or not. So when these tests are done we need something more or better to help patients and doctors to make these decisions. Otherwise we have tests and the reports , and no answers or treatment plan . And on top of that it adds to the anxiety on part of the patients and the family . It also may create problems with getting Health insurance and Life insurance .

       I know this blog is not a patient story , but I think it tells the real dilemma that will be added to medical decisions , when medicine is Art and Science combined in my opinion.  

Sunday, October 15, 2017


                 I have been in medical practice for many years . More I see , more I realize that NOTHING is perfect. I guise that patients when they come to doctors do not read books and so the presentation of these patients is not always like it is  written in books. . So sometimes it is not perfect  or 2 plus 2 does not make 4. And sometimes you come across these patients in clusters. So this brings me to today's story.

                    I saw this 67 years old male patient for abnormal CT scan of the chest . He was a smoker and he had quit few years ago .He had some cough and he had some clear sputum . He had no fever and had not noticed any blood in sputum . He had though lost 15 lbs of weight in last 3 months and upon questioning , he told me that the food did not taste the same , and so he was eating less and so he lost weight . He did not have any excessive sweating at night . He had chest x- ray and then when it was noted to be abnormal , he had CT scan of the chest . The CT scan of the chest showed a cavitary area in the upper lobe . I told him and his wife that this could be cancer or infection . Or it could be TB . Sometimes we have a tumor blocking the secretions and then that can lead to pneumonia and then the middle part of the pneumonia can liquefy and that can look like this . But sometimes infection without tumor can also have similar appearance . Sometimes TB can look like this  and the RB is more common in upper part of the lung .
           So we did PET scan and bronchoscopy . The PET SCAN showed that the area in the upper lobe was quite hot and there were some lymph nodes that were hit too . These nodes were not seen enlarged on CT scan . I did the bronchoscopy and it did not show any blocking tumor or for that matter any abnormality . The abnormal area was quite large and was almost 10-12 cm and was occupying the entire upper lobe. So I did not do any biopsy . The breathing test did show some reduction in the reserve , but it was adequate for the surgery , in case we decided to take out the upper lobe. There were no cancer cells in the cytology of the samples that I collected .So I spoke to a surgeon and he saw the patient . He decided to do the bx of the lymph nodes first and then if negative , consider taking out the lobe .
        I was OK with it till I got a call from Lab on the samples that I had sent was growing TB like bacteria . So now I am now faced with the decision . This is a ex smoker and the positive PET scan could be due cancer or TB or infection . The lymph nodes could also be due to cancer or infection . Sometimes cancer and infection or atypical TB could be in same patient at the same time . So what should be the next step . Should we do the biopsy and the surgery to take out part of the lung > or should we treat the atypical TB and then do the follow up CT scan . The problem with this approach is the CT scan may not improve in 2 or 3 months. So no change in the CT scan does not mean that atypical infection is not the cause and it does not rule out or rule in cancer . Doing surgery in this patient and then if the surgery shows only Atypical TB , then we have done major surgery for medically y treatable infection , which can be cured by medicines in most cases and surgery in not needed. But it is  cancer and infection together, then the waiting is is not good option , but open biopsy is the only thing that can give us 100 % answer.

      This is what I call medical practice and the Watson -computer can not solve and it becomes art and the science together . 

Sunday, October 8, 2017


      Being in medical practice for so many years , I come across the patients that I can not fully understand the diagnosis. So sometimes I send them to Mayo Clinic or Shands Hospital at UF. I am in a way happy when they come back with no additional diagnosis or different treatment. But then I also feel bad that we can not CHANGE the disease. But sometimes I know the problem and I refer patients to other consultants and the patient comes back with some additional tests and no answers. I can understand the frustrations that patients go through. But I can not not tell my frustrations to patients or the family . I have also a problem when I explain the problems ans still the questions are the same. This brings me to the the patient of today.

      I saw this lady , 72 years old for chronic cough . It started many months ago and then the PCP gave her some antibiotics and then the cough medicines and the inhalers that are uses for asthma .It was OK and she still did have the cough and so she came to see me . She looked comfortable and did not have big or severe bouts of the cough when she was in my office . She had good oxygen saturation at rest. She had couple of family members with her. Her lungs had crackles on examination and that suggested to me that she had some fibrosis -scar tissue in the lungs . Whenever there is injury to lungs -from infection or chemicals or some unknown causes -there is chance of the healing leaving patients with scar tissues . The first symptom of the scar tissue  in the lungs is cough . The fibrosis can get worse quickly --6 months -was at one time called vanishing lung syndrome -or it can last many years and does not shorten the life . So it is unpredictable.
    So I explained them my initial impression . We did the CT scan and the breathing test and the oxygen check on walking . The scared  lung does not allow the oxygen transfer quickly when the demand go up and the circulation is rapid . So her CT scan was consistent with fibrosis and the breathing test did show that the diffusion capacity - the process of oxygen transfer was low at 32 % out of 100%. The walking also dropped the oxygen . So now I had to decide if there is any cause for the scars . The fibrosis for which there is NO CAUSE is called idiopathic or IPF , There are 2 new drugs that were approved only in 2015 and the cost is ONLY $50000 per year. They are not approved for the scar tissues that have a cause .So I did the work up . One of the causes of the fibrosis is conditions like scleroderma or rheumatoid arthritis or lupus. Some times in older patients there may be a problem with swallowing and the food or the liquid can go in to lungs and not in food pipe or esophagues . This can lead to chemical injury on repeated basis and that can lead to fibrosis .
       So I did the blood tests for the autoimmune diseases and did the swallow study. The autoimmune blood tests were strongly positive and the swallow study was abnormal , but not that bad . I did the tests that measures the contractions of the food pipe , as that is abnormal in some autoimmune diseases and so that leads to aspiration . This was severely impaired and the report stated 'consistent with connective tissue disorder '-one of the auto immune diseases . So in my mind the circle was complete . She had some auto immune process which impaired the contractions of the food pipe and that lead to aspiration - food and the liquids going in the lungs and causing the injury which healed with scar tissues and that caused the cough. Some of these auto immune diseases also can cause the scaring in the lungs without the aspiration .
    So I explained the situation to the patient and the family . I told them to see the Gasroenterologist and the Rheumatologist . I sent all the reports to both . The patient came back stating to me that Gastroenterologist did the endoscopy and it was normal . The rheumatologist did some tests and told her she was OK . The endoscopy can not diagnose the aspiration and the scars tissues and the strongly positive blood tests and the esophageal motility problem -all were pointing to the auto immune process. I did show them the reports and the explained them the whole things . And I still had the question -so why I am coughing ?

    I can not give an expensive medicine that has not been approved and proved to help scar tissues in this condition . So I my only way was to call them or send them my notes and my conclusions.