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.

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.   

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 ?

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.

 

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 . 

 . 

MINE FIELDS IN MEDICINE

      I have heard this statement that when  Taliban terrorist left certain areas they left the place with mines  and they were unpredictable and can explode anyplace that we did not expect. I have felt the same thing in medicine. This is so true in case of cancer . I don't like when a patient diagnosed with cancer and have gotten treatment with chemotherapy, come for the follow up in my office and tell me that the oncologist told them that the cancer is gone. I know better that making such a statement and so does the oncologist. But patients like that and then when the cancer comes back, then we have hard time explaining the recurrence. And I call this as the mine field where we have no way of knowing all the mines -the metastasis -which are there, but not obvious. That brings me to story for today. 

 I had seen this young woman who had been diagnosed with breast cancer and she has had surgery and then radiation and then chemo. She had some abnormality in lungs and that also was breast cancer. She also had some bone spread. She was short of breath and so she had chest x- ray and she had fluid built up around her lungs and so she came to me. We did drain more than a litter and it showed cancer cells and so we did follow up chest x- ray in 3-4 weeks and the fluid had come back. So we did a catheter to drain fluid periodically at home. She did well and she had some chemotherapy changed and she was ok . The fluid drainage continued to be less and less. 

     More than  months passed by and i get a call from ER . She was in ER for shortness of breath. I spoke to the ER physician and told him to do the CT scan as she had 'white out' on right side - suggesting either the fluid or collapse of the lung. Sometimes the catheter may get clogged or may not be in 'right ' place. The CT scan showed that her right lung had collapsed . I  did bronchoscopy to see if her  right lung bronchus was blocked from 'inside' or it was due to pressure from 'outside' . If she had blockage from inside then I could put in radiation catheter and that would treat / burn the tumor and then that will help 'open' the obstruction. She did not have any tumor inside the bronchus, so she had pressure from outside . So we called radiation oncologist and she was started on radiation. 

    So she had breast cancer - that had spread to lungs - then had pleural fluid  and now mass that was pressing on the bronchus - just like new mines were discovered every so often. Then I had a call from Mayo clinic where she had gone for second opinion. The oncologist called me and told me that she had done MRI of the liver and SHE HAD MULTIPLE METASTASIS TO LIVER. Just like another mine exploding in her face .

CATCH BEFORE ---

    I n case of many medical conditions, if we catch in time , we have higher success. This is true even with infection . heart disease diabetes etc. . If we treat diabetes or high blood pressure early then we can prevent the complications that are associated with it. This is also true with cancer . In medicine we have tried to  diagnose earliest stage and then hope that we can achieve cure. We have stared  doing tests like DNA pieces of tumor in blood, this is called CTDNA . -Circulating Tumor DNA .But it is not a test that many labs do and even many physicians are not aware of it. It also raises some questions as to what to do if the test is positive. 3-4 years ago Medicare approved CT scan of chest as screening for early diagnosis of lung cancer in patients who recurrent smoker or ex- smoker for 14 years. This has certainly helped , but also has raised some anxiety when the CT scan shows some nonspecific abnormality  and needs follow up. But sometimes I feel that it's not always possible to 'CATCH' cancer early. The story that I am going to tell is one of that kind. 

   I saw this patient who was in mid or late eighties. He had quit smoking many years ago. He had quit smoking many years ago . he had some cough and usual treatment with cough medicines and antibiotics did not help. So, he had chest X- ray and then had more antibiotics . He then had CT scan and that was abnormal and so he came to me. He had some cough and no fever . He had no shortness of breath. There was nothing special in special examination. The CT scan showed  abnormality and had a cavitary area in lung . That could be an infection or cancer. So we decided to do further work up . We did PET scan. The PET scan shows where the glucose is concentrated and that depends upon metabolic activity of the cells. So it picks up in 8- plus % of the cancer. The PET scan showed increased activity in the cavitary area and also some lymph nodes. There was no evidence of any activity in any other areas , We did the EBUS - ultrasound guided biopsy through bronchoscope and that showed lung cancer -highly likely. I had discussion with patient and family and decide to send him for radiation treatment to the lession in lung. . Surgery was not an option and I had called and asked a surgeon to some additional biopsy and he had refused. He and his family did not want any surgery or chemotherapy so, radiation was the only option. I called radiation doctor and he gave him appointment 

  3 weeks had passed and he was admitted with weakness and hospital doctor had admitted. .When I was called in ,he was seen by cancer specialist and infectious disease doctor and also cardiologist. Tests were planned. He had chest pain and that happened to be due to spread of cancer. The cancer doctor had planned ordered bone biopsy . I talked to  patient and family they did not want any biopsy and so I called radiation doctor to consider radiation to bones where cancer  had spread . He agreed . 

   The PET scan done few days - weeks ago had not shown any spread outside the chest and now he had bone spread in many bones. I am sure cancer had spread tat time but out tests are unable to detect as the amount of cells must be bellow needed to be picked up. But with just given few weeks / days it showed on bone scan and CT scan. 

LIVING WILL AND DNR

    I have seen many patients that have living wills. Now a days if someone goes to hospital , they are asked if they have a Living Will. There is some misunderstanding about the Living Will. Some people  do not understand the difference between the Living Will and the WILL. If someone has gone to an attorney for estate planning they would have done the WILL which is their wish as to how the estate should be divided after their death. The Living Will has nothing to do with estate, but has to do with how one should  act in case they have sickness- how aggressive one should be have  terminal sickness. The living will does not mean DNR  which stands for Do Not Resuscitate. I had seen a letter to Editor in a medical magazine where she was complaining about the care that her mother got when she had stroke . That showed that she the Harvard professor did not understand the difference between DNR and having a living will.

  The Living Will records one's desire to use machines or artificial means of keeping one alive in case of need  and if one DOES NOT want them if the condition is determined to be TERMINAL. In contrast to that the DNR means one does not want to be put on any machines or Resuscitated. In case of Living will the physicians and the relatives have to decide if the condition is terminal - as the language states " in case of my condition is determined to be terminal --". This may take time to decide . Not every cancer  diagnosis is TERMINAL and not in case of heart attack or stroke ,patient dies or is terminal. If one does not want to be put on any life sustaining machines or means or resuscitated ,then they should sign DNR . There is DNR form that is VALID anywhere. The hospital DNR are valid for that hospital stay and that hospital only . But the COMMUNITY DNR is valid anywhere.

   One more form that everyone should have is medical surrogate - someone who is assigned by patient to make Health Care Decisions in case patient cannot make own decision. This person could be spouse , siblings  or children or even unrelated person .

  So in modern days one must have 2 forms Living Will and assigned  Medical Surrogate..

HOUSE AND OUR BODY

    In recent past we are seeing longevity increasing. I am seeing older patients in my practice. It is not unusual for me to see many patients over 80 years of age  and also I see patients older than 90 years of age every week. Some are weak and have some memory problem and some have many medical issues. Some are fully oriented and almost independent and some cannot do much on their own. Some of the families accept the aging process and have limited expectation, but then there are others who have unrealistic expectations. That brings me to the story for today

    I have seen  2 older women at one time Bothe were over 90 years of age . One has been seen by me for many years and she had some cardiac issues and she had some fluid around the lungs  and she also had sleep apnea and so i had done follow up. She started having some problem at night , she had some shortness of breath and she called me and then came to me. She was concerned that the her PAP -the pressurized device that is used for sleep apnea was not working well. I saw her and after examining her that the problem was not with PAP but was due to her heart valve having problem ,She had murmur and also was short of breath and was waking up due to water accumulating in her lungs . The chest x- ray that I did confirmed my suspicion . She was followed by a cardiologist and he had told her that she was fine . I echocardiogram and then had her see the cardiologist . She was diagnosed with severe narrowing of the aortic valve  and he suggested doing a surgery - relatively new type of valve repair called TARV . She did not want it and so we adjusted some medicines and she did ok. She did OK and then had a fall and has some bleeding in brain but did OK But she was getting weak  and so she had to start living with her daughtercard month passed by and she had pain the belly and she came to ER , She had Gall Bladder attack. She now was quite weak and was in no position to undergo gall bladder surgery. So we did a drain and she responded to antibiotics Her numbers - blood tests and oxygen and fever etch was better. But she was weak and tired and could not eat. She could not do any walking and needed help even getting out of bed . She and the family had made decision that she did not want any aggressive treatment. So we decided to try to discharge her home with meds .While I was talking to her and her family , I told them that the house that we have owned looks good and have no obvious  problems ,but the it is old  and slowly somethings go wrong . the paint is pealing and the roof may start leaking or the plumbing may be also an issue. The aging body is like old house  and even though one 'looks' good all the organs are old and they start giving out under stress. One has to understand that .Unfortunately not all patients and families either understand the limitations or accept it. 

SURPRISE

    In medicine I don't like surprises. The surprise is not good for patient  and not for the physician. But we do have them  and since we are not 'all knowing ' the surprises do occur. The story that I am going to tell you, is one of such patients. 

   I saw this patient for abnormal CT scan .The lady was a smoker and had quit 2 years ago and had some persistent cough and so had chest X- ray done and then CT scan. The CT scan did show a mass in the central part of left lung . I saw her and I knew that in all probability it was cancer and the bad part was that due to the location of the mass - dead center of the lung where main bronchus enters the lung - it was not operable. I did the Pet scan and the miss did pick up glucose and was hot and then I did bronchoscopy. It showed that there was a mass in the bronchial tube and that was partially blocking the tube. In such cases the surgery is not possible as there may not be enough bronchial tube to resect / cut. If the cancer is also in central lymph nodes then also surgery will  not be successful. The biopsy came back as SMALL CELL CANCER. The small cell cancer is treated with chemotherapy and sometimes radiation .She was seen by both the physicians - radiation and also oncologist and received treatment.

   She was seen by me few times and she needed oxygen and had done overall OK Then one day she was short of breath and so came to ER and the x- ray showed complete whiteness of the left part of the chest . In X- ray there are only 2 colors - air is black and everything else - fluid - tumor - collapse of lung - all look white . The CT scan was done and the left lungs was collapsed and there was fluid around it . The natural conclusion was that the fluid was due to cancer and that had caused the collapse of the lung. The treatment would be to drain the fluid and then the lung expands. 

   The catheter to drain the fluid - which was though to be very large - was inserted. But then only small amount of fluid came out. The X- ray barely changed - the lung continued to be collapsed . I was nnot happy and that was not expected . But what had happed was that the lung had collapsed DUE TO EXTRISIC PRESSURE from the tumor on the covering of the lung and so the fluid was secondary  to that and the lung was unable to expand . So the catheter did not help much. So, now only option was to do new chemo and may be radiation and see if the lung would expand . The chance of lung opening is not very good . 

   When we see chest x- ray with fluid and collapsed lung in 90% of the time when we drain the fluid the lung expands , but the surprise that the lung could not expand was not a good news for the patient. 

ONE AFTER OTHER

    In medicine we have some of theses saying that is true in majority of cases , but there are exception. The patients have not heard them and so sometimes we have problem . What may be true in many patients or cases , may not apply for one  of the patients. We in medicine go by probability  and that is statistics The 2 words that we talk are 'probable' and 'possible'. Anything and everything is possible , but not everything is probable. The probable is what can happen in majority of cases - say more that 50%. But possible means it can happen but not more than 50 % . So if it can happen 1 in a million it is still called possible though not probable. That brings me to the story for today. 

  I saw this patient in my office . She had a lung nodule and that was less than an inch in size. We did the work up and she had bronchoscopy and PET scan and also breathing tests. She was a smoker and has some shortness of breath, The CT scan had shown the nodule and it also had shown another nodule of 6 mm in size. 25 mm make an inch . The PET scan showed that the larger nodule was positive and the smaller one was not picking up any activity. Certainly that could be a scar or cancer , but with not enough number of cells it was negative on the PET scan. The lungs functions were showing some compromise  and she still had enough reserve to have part of the lung taken out . 

  She did have lung surgery and the nodule was cancerous and all the other things - like lymph nodes, margins and covering of the lung etc. were ok and so she had a high chance of having 'cure. 'She was sent to an oncologist and he told her no need for any additional treatment and she had her family were happy. She was happy . He did new CT scan in 3 months  and that was OK but the smaller nodule had grown by 2-3 mm , So the oncologist wanted to do PET SCAN in 3 months . She saw me and I saw the CT scan and the growth though only by 2 mm was bothersome . So I called the surgeon and pushed for having new PET SCAN done sooner . The PET scan was done  and she had pick up in the nodule though faint. I talked to the surgeon. Interestingly enough her lung function had not gone down much in spite of having a part of the lung removed . So the surgeon did do second surgery and took out the nodule that had grown  and IT WAS CANCER . The good part -if there is anything good about having cancer - was that it was a different  type of cancer . If it was of same type then that means she had a spread of a cancer in first place and that would not have been a good news . So she seems to have had 2 separate independent lung cancer starting at the same time - something that we don't see commonly . Or to state it differently, it is possible but not probable to have 2 lung cancers in the same lung at the same time . But she did !!

INSANITY

   Someone had said that the definition of Insanity is to doing the same thing over and again and expect different results. Certainly I am not talking about  learning or trying to be successful. There one can improve and achieve the goal . There was a Royal Air Force pilot and he had successful mission bombing Germany. But then in one of the missions his plane was shot and he lost his leg. He was POW and Germans made a prosthesis for the leg . They never expected but he got the leg and he escaped . He was back on missions to bomb the Enemy . He was again caught and lost second leg  and he had new prosthesis and he escaped again .In spite of losing both legs, one day he was trying to ride a horse and he fell off 30 or so times before he could ride. This type of repeated efforts is worth appreciating. But I was talking about some other reputations, where doing same thing over and again is not going to change outcome. 

   I have known this patient for many years . Had some low oxygen and then had pneumonia. He also had chronic pain pain and was on pain medicines - narcotics and so her carbon dioxide was high and so oxygen was low . I did work up and found out that he was having aspiration and that means water or food was going wrong way in the lungs causing injury and inflammation and pneumonia. He had further work up and he had very poor function of the food pipe. The contraction of the muscles of the esophagus are not there. She was sent to a surgeon and she had a surgery and that did not work. Unfortunately I have seen this too often . In this condition food stays in  food pipe and it comes up and then trickles down the lungs. Unfortunately patient has difficulty of swallowing . He went from one GI specialist to other . Every one did the same thing - endoscopy . Every time different medications were tried - not much different from one other and she gets pneumonia and then gets admitted . HE has no change in medicines or symptoms , and he has changed GI specialist 10 times locally and out of the our place .He gets endoscopies every time he has seen ne doctor. I have told him that only 100 % almost -100% will be to not eat through mouth but have a feeding tube put in for nutritional support. He does not want it and we are doing same thing over and over again ,expecting different results. 

( This is esophageal motility disorder called Achalasia )

MEDIACAL PROBABILITY

   In past I have stated that in medicine we treat patients many a times based on probability. But at the same time the probability is based on science  and so we know based on education and studies and experience that certain diseases are likely to be present and certain are not likely. But that is never 100%. So, in medicine we talked of 2 words one is Probability and other is Possibility. To understand this I will say that everything is possible but not probable. The word probability means that that the chance is more than 50 %. So it is possible that I will be President of US but it is not probable that I will be President. That brings me to a story for today. 

   I saw this patient who happen to be spouse of my other patient. She was 70 years old and has never smoked , but was exposed to second hand smoke from her husband. Sh started with cough and the PCP gave her some antibiotics and some cough syrup and then the cough continued and so he did chest x- ray and that showed some abnormality and so more antibiotics were given . She had o fever and she has no chest pain and she has stable weight . She had no shortness of breath, She saw me and we did the work up ..I though she may have mild asthma and so did some work up like Pulmonary Functions studies and also allergy blood tests called IGE and RAST. I also gave her some inhalers and steroids - prednisone . She felt better but still had cough . The steroids did help the cough  and when they were stopped she had cough . So I decided to do CT scan and I was surprised. She had a mass like density in upper part of the lung. So we decided to do Bronchoscopy . That was done and no obstructing cancer was seen and the biopsy showed inflammation and there was no bacteria or TB or mold. I decided to allow the body ti=o heal and so did follow up CT  scan in 6 weeks or 8 weeks . The CT scan did not change much . Now I was stuck. She had what looks like pneumonia but that was not getting better and so I did PET scan . The PET scan tends to pick up metabolic activity of the cells  and when there is cancer or infection, there will be cells which are more metabolically active than normal cells, and so they show more glucose uptake.The test is 80 % accurate . In case of my patient it did not show much pick up. I was stuck . I had suggested her to se thoracic surgery to do OPEN BIOPSY. .She came to my office for the follow up. I though that based on the low pick up we could wait and do new Ct scan .The size of the 'mass like density ' was also smaller. So I decided that we will do new CT scann in future  amy be 2-3 months . She had seen the surgeon same day that I saw her  and he felt the same thing, that based on PET SCAN findings , we should wait  and not do surgery now. OUR DECISION IS BASED ON PROBAILITY of cancer being low with low pick up on PET scan. The possibility of cancer is still there but it is less probable based on low pick up on PET  SCAN  and also on smaller size of the mass. 

   Let us see what happens . By the way her cough is gone with inhalers alone.

ACCIDENTAL DICOVERY

     In medicine we do tests  and sometimes we do tests that we expect to be negative. It is like calling someone expecting him to be not home and then leaving message , and taking credit that we did call. When someone has clot in lungs, we try to find out why . So we do the work up. The clot in lungs come from some other source - usually from leg veins  and then a small portion of the clot gets detached and then goes to lungs where it blocks the circulation and that causes the shortness of breath and other symptoms. There are reasons why a clot may form in leg veins - so called DEEP VEIN THROMBOSIS. Usually it happens due to inactivity - long distance travelblog injury  or surgery and also other causes. Immobility leads to stagnation of the circulation and that leads to clot and so this is called PROVOKED.  Then there are clots which form when we cannot see the cause. This is called UNPROVOKED clot. That brings me to the today's patient. 

    I was called to see this patient . He was 70 years old and had some cough and no shortness of breath, He had 3-4 episodes of so called Pneumonia in last few months. He had some chest pain and so he went to walk in clinic and had CT scan done and that showed a clot in the lungs  and so he was admitted. But it also showed a density in the lungs and so there was a concern as what that was. I saw him and he was also seen by hematologist. They had ordered some blood tests - this is to know if there is 'tendency to form clot' so called Hypercoagulation status . For some reason related to abnormality in blood itself which makes forming clot easier. But they also ordered CT scan of abdomen and pelvis . Now I have seen this being done many times as OCULT CANCER can present as Unprovoked Clot. I have not seen any new discovery in past many years when CT scan is done . But in this case it showed  a mass in stomach, Normally the stomach is a hollow cavity or a bag and mass in it is nit obvious on CT scan. But this time it did  and so we have him do a biopsy and that showed a type of a tumor not very common called GIST -gastro-intestinal stromal tumor. 

   So, we have a patient who had pneumonia  and CT scan showed a clot  and also a clot in leg - which is common scenario, but now we also have other abnormality in lung which could be a tumor or pneumonia or clot related  infarcted lung . But he also has a tumor in stomach. 

   We will do  follow up CT scan of lung and also PET scan and then he will need surgery to remove the stomach mass . If the lung abnormality does not clear , he will need biopsy of that too. But for now with clot and need for blood thinner we have not done any surgery or additional biopsies. 

ONE TWO AND THREE ?

   In medicine we have saying that usually we do not have 2 diagnosis . This  does not mean that a patient has only one diagnosis . It means that when a patient presents with a symptom or complaints , we may start with differential diagnosis - what different diseases could explain the problem ,but at the end of work up we have one Final Diagnosis. But sometimes we have exception to the rule. That brings me to patient for the today. 

    I was asked to see this patient who was doing fine . He had seen his  PCP and has had done follow up regularly as I  understand. But had cough and shortness of breath and so he came to ER and then had work up. He was found to have quite extensive pneumonia. He had pneumonia on both sides. The right was much more affected than left side. He had not been smoker and had no previous history of lung problems. He was admitted and the hospital physician started him on antibiotics. He was found to be anemic and  so the work up was done and he had iron deficiency . So he was given iron. 

    I saw him and was some what surprised that he had extensive pneumonia on both sides as he was not a smoker and his only other medical problem was chronic back problem and he ha shad some kind of surgery for that .I asked him questions as to what had happened . He had history of narrowing of the esophagus and he has had dilatation done in past -last one was 7-8 months ago . He had vomited and then started having problem and he had called PCP and then was told to come to ER The vomiting episode was only once and so neither the ER physician or the Hospital physician who admitted had asked or mentioned in their notes .So we did the work up. I did swallow study and X- ray of the esophagus  and sure enough he had severe narrowing of the lower part of the esophagus  and he also had severe reflux . So now we have 2 different problems or may be 3 . He had pneumonia which was caused by aspiration when he vomited  and he also had vomiting due to narrowed esophagus. The anemia may be due to severe reflux with oozing of blood from there . But it also could be due to problem with absorption of iron. Iron deficiency is uncommon in men unless they have loss of blood from peptic ulcer or colon polyps or cancer . 

    But the problem list did not end . We did CT scan of the abdomen and that showed a renal mass - mass in the kidney which was potentially cancerous . So we had initial diagnosis of pneumonia  and then the narrowing of the esophagus  and anemia and renal tumor..   

CHANGING FACE OF MEDICINE

     I have written in past about medicine has changed in last 10 years or so what we never thought was possible has been done routinely. But I also remember when Obamacare came in there was a talk od so called Death squad '. How do you handle he aging population . Do we older members of our society same as younger members or treat them same? I have always maintain that every case should be treated based on INDIVIDUAL and as a GROUP . and I feel the same. But problem is becoming more frequent. That brings me to the talk for today. 

  I have seen at least 3-4 patients who were older than 89 years of age . The  good part was hat though they were old they all were in fairly good health  and had some issues but not depilating. But they were old. The second part was that 2 of 3 were also menially clear and one had fair amount of memory loss. The common factor was that all 3 had a pulmonary nodule that was PET positive . So I saw 2 of them who had a nodule  and that had grown in time . I had seen them and decided to do follow up CT scan and the nodule grew and so we did do PET scan and then showed that the nodule had uptake suggesting that it was cancerous . The growth and the positive PET SCAN was almost 100% suggesting that it was cancer. Now a days we have techniques like Navigational bronchoscopy ,which gives us diagnostic yield much higher than what we could have gotten in past with simple bronchoscopy. We also have better technique of needle biopsy. But we decided not do it as they were not interested in getting chemotherapy. So there was no need for tissue type - what kind of cancer it is as chemotherapy is based on type of cancer. We did radiation therapy - a short one 5 sessions in all 3  and that is suppose to give cure in many - may be 80% in these small cancers . 

    Then I saw this 4th patient, who has weak heart and had fluid around the lung and then when I treated it with diuretics the fluid is gone but now he has a nodule which is growing. So he is 95 years old who has heart problem and has increasing nodule - how do you handle it -stay tuned .

DISTRACTION

     Sometimes we have situation where we see things that are more prominent and miss what may be subtle but more important. I f you have gone for murder mystry dinner show , you might have realized this. The obvious suspect is not the correct answer. I remember when we used to have a radiologist who used to teach us how to read chest x- ray. He would show a x-ray  and ask one of us to read it. We would read the most prominent findings  and then miss the subtle but important findings. He wpild put up x- ray that looks normal as far as lungs and heart are concerned but had fracture of upper arm bone which would be missed by Intern. I have seen this in my life again ' A subtle fracture of shoulder was missed even by radiologist when there were other findings in lungs like fluid .But the story that I am going to tell is similar but little different.

     I was asked to see this patient in hospital.. She had presented to hospital ER with back pain . She was a88 years old lady who had back pain for 3 months . Her PCP had  done x- ray of the lower back and had treated with some muscle relaxant and pain meds . She continued to suffer and so came to ER , She used to stay in Florida for 4-5 months  and then go back to upstate for 6 months or so. She had a physician up state whom she trusted most  and she would have been considered snow bird. She had not smoked for 50 years  and had been followed by number of physicians at both places .The x- ray of the spine was done and she had some arthritis . The Chest x- ray was done and that showed a mass lke density in upper lobe  and so I was asked to see her. I saw her and had discussion with her  and her daughter in law . I told them that she may hve a cancer of the Lung and we could do biopsy to confirm or rule it out . She was not very keen on doing any procedure and since she was nonsmoker , I decided to do PET scan as out patient . For now she was being treated for possible pneumonia by hospital doctor and I continued that . Certainly CT scan was ordered by me  and then I saw her next day. The Ct scan confirmed the abnormality that was seen on plain x- ray. I talked to her son this time and he had all old reports in a file - not a common things to see. He showed me a report where there was some infiltrates in same area where this time a mass was seen . That report was almost 9 months old. So she had something but no CT scan or any other  additional tests. So, I told them that it is possible that she may have a slow growing tumor may be be like carcinoid which can grow over period of many months or even years . She had back pain. and that was not worked up. I ordered CT scan of the spine  and that showed abnormality in lumber 3 vertebra. Oncologist was seeing her and had ordered a bone scan. I asked radiologist  to the biopsy of the spine . She was agreeable as I had told them that she could have cancer that has spread to bone. The biopsy did confirm cancer. 

    So, she had most likely lung cancer that spread to spine and that was causing pain for last 3 months. She came with back pain and that was not worked up by hospital physician and they were distracted  by lung abnormality  and then when we started doing work up for the back pain , the diagnosis of cancer spreading to spine was established . I had called radiation doctor for radiation even before we had the diagnosis of cancer established. 

MEDICINE AND ME

    I have been in medicine for many years and sometimes things become routine. We sometimes feel that not much new is going to be seen especially if one is doing subspecialty and not general medicine. But then you see a case and that tells me that no 2 things are same. I see pulmonary patients and so my practice has may be 10 common diseases that I see. One of them is COPD , the disease that is caused by smoking .I see all sort of stages from mild to severe and some end stage. Due to common factor of smoking I also see patients who have COPD , develop cancer of the lung. But we also have surprises at times.

    I have been seeing this patient for many years . He has been smoker and has not quit smoking even though the disease is severe. He also had diabetes and he had developed abnormal chest x- ray many years ago . We did work up and he had a cavity and it was related to atypical TB called MAC . The treatment of this MAC is prolonged and takes 18 months . So he was started on 3 medicines and then when he continued to have positive sputum for MAC bacteria ,I added 4th drug and that was given for a year . He responded to that and the sputum was negative now - showing no evidence of MAC. I told him that we can stop MAC medicines when he comes for the follow up .

      I also did CT scan to follow the disease and few months ago he had some lymph node enlargement. That could be due to MAC and so I did new CT scan and the nodes were bigger . The MAC was doing better but the nodes were slightly larger. So we deiced to have him see another physician to do biopsy of the nodes . He waited for few days  and then missed follow up and . So I called his wife and him and got the procedure scheduled . The biopsy was done  and now he has lung cancer . The diagnosis was small cell cancer.. The small cell cancer is not surgical condition- it cannot be resected ,but can be treated with chemotherapy . With his COPD  and nodes involved  and tissue diagnosis of small cell cancer he is not a surgical candidate. But my problem is that I was going to stop the medicines for MAC .But now chemotherapy to be started , it will suppress immunity  and that can flare up the MAC . So I am forced to continue the medicines untill such a time when  and if he will be off chemo. 

DON'T ASK DIRECTION TO PLACE THAT YOU DON'T WANT TO GO !

   I have always said in medicine, that do not ask the for thr direction to the place that you do not want to go. In medicine many a times we tend to do 'routine' tests and then when the reports come back have difficulty in explaining the report . When I was doing internship , I had done a test on a patient and that came back abnormal. When asked  the cardiologist on the case  as to why the test was abnormal. His answer was ' I would not have done the test and then I don't have to explain the results.". I have tried to follow yhat principle in my medical life. 

    I saw this new patient. He was 55 years old  and he has some eye problems and so he went to see doctor. He had cataract surgery and he was told that he may have a disease called sarcoidosis. He was sent to me I saw him and he had no lung or breathing complaints and he was nonsmoker .His examination was unremarkable. He had done a blood test which is specific for sarcoidosis .It is called ACE  level - Angiotensin Converting Enzyme level. The only condition in which this is elevated is sarcoid. The Fan=mily Physician had done that  and it was elevated . He had CT scan of the chest done and that showed some abnormality in lungs  and as I expected it also showed that he had some lymph nodes enlarged . This was consistent with diagnosis of sarcoid. So  based on eye examination and elevated ACE level and now the CT scan findings -- all pointed to sarcoidosis .But we needed the biopsy . The findings on CT scan had minimal abnormality in lungs  and the nodes were enlarged . So I decided to have the nodes biopsied . So I sent him to another physician who did a procedure calle EBUS . In this procedure  the biopsies or aspiration of lymph nodes is done with a needle 

   The procedure was done and samples were sent . The biopsy did come back showing sarcoid as the diagnosis. But the sample was also sent for what is called flow cytometry. In this test cells are analyzed  and that showed some abnormality . I am not sure if we had explanation for this . I am not sure if the cells seen were due to sarcoid  and inflammation or was there different cause . So I had to send him for additional tests and send him to cancer specialist  to rule out lymph node cancer . Again that adds to the tests  and in all probability he has sarcoid  and not a cancer . But since we did the test  and that showed some abnormality, we have to do additional tests. 

DIFFERENT STROKES FOR DIFFERENT FOLKS

    We have saying that there are different strokes for different folks What I may like or enjoy others may not like or enjoy. But in medicine the computer generated treatment will not be different for 2 patients but will be different based on patient's and their family's choice. I have realized this long time ago and so the medicine is as much a Science as it is Art .That brings me to the story for today. 

  I had seen 2 different patients in my office . One was a 93 years old female who had abnormal CT scan of the chest . She had a nodule . The spot on the lung is called nodule when the size is less that 2 or 2.5 cm - roughly less than an inch. It was may be half an inch in size . She was otherwise doing OK and we decided to do minimal work up. With that size it was difficult to do biopsy if not impossible and  she has no symptoms from it . I did do the PET scan. It showed that there was some activity but not very high . So we decided to do follow up CT scan . She continued to have no complaints . We did do the new ct scan and then another one . At the end of 8 months or so the nodule had grown by may be 3-5 mm  and so after discussion I did new PET SCAN .The PET SCAN this time showed more activity that before . So I had discussion. It most likely was slow growing cancer . The size increase though minor and the increase in PET scan uptake was suggesting that it was slow growing and so we had discussion. I suggested BOT TO DO BIOPSY or surgery ,but do radiation treatment . For a small nodule we can do what is called stereotactic radiation ,which is 5 sessions of radiation and the success rate is vert high for such a cancer . We will not know what type of a cancer it is and so no chemotherapy or immunotherapy will be offered. She did not want chemo or surgery and so the decision was easy. She did very well. 

   I also saw another patient. He was 90 years old and had some dementia . He had some cough and he had CT scan done by his PCP  and that was abnormal and so he came to me .I looked at him and then found out that he had prostate cancer in past and he had several CT scans in past We could find out 2 old Ct scan  and the nodule had grown over period of one year. By chance the new Ct scan report had not bothered to check old scans and so I had to pull them out . I spoke to patient and family. I suggested doing a PET scan and then consider work up if it had increased uptake. They were reluctant for any work up. I was not sure why did they come to me if they did not want any work up. After I had more explanation the daughter agreed for PET scan ,but she was still not sure if they would go ahead with radiation -short course like I did in other patient . So the similar age patents , similar growth in nodule ,but thought process was different . 

UNENDING LEARNING

      I often say that in life ,one should never stop learning. Certainly learning new skill will help prevent dementia  and may be even improve in some patients. Learning new language or musical instrument or even brushing teeth or shaving or combing with different hand ,will help to develop some new connections and that may help . But sometimes doctors and same hold about other fields, people stop learning and then with  doing same thing over and again , they get burnt out or bored. So one has to do same things most of the time ,but always think out side the box, when things don't add up . 

    That brings me to story for today. I saw this female patient fo abnormal chest x- ray / CT scan chest  and shortness of breath. She was a young  lady who had shortness of breath going on for few months and she saw  PCP .He ordered CT scan of the chest and that showed some abnormality. So she was sent to me . The CT scan showed some density in the middle part of chest , called mediastinum  and the radiologist thought that to be related to  THYMUS. The Thymus is a gland which we have till infancy and then it disappears But sometimes we continue to see the remnant of that and sometimes it can grow  and then some patients may have Myasthenia Gravis  and sometimes it becomes cancerous called thymoma. So she was seen by neurologist and he did all sort of different tests  and they came back as OK and she did not have Myasthenia Gravis . I saw her and  and did breathing test and did new CT scan of chest, There was no difference in the soft tissue that was seen on first CT scan done 3 months ago. The breathing test done showed mild Asthma  and I started her on inhaler for that .She had shortness of breath and so we did walk test and her oxygen saturation dropped and I could not explain that . 

   The neurologist had seen her and done more blood tests and did  not find anything wrong and she continued to have shortness of breath. She was sent to a chest surgeon though the thymic tissue had not changed on another scan. She continued to have shortness of breath. The chest surgeon sent her to ne lung specialist in his own group  and he did same tests that I had done . But she saw a different , new neurologist who also specialized in genetic disorders. He felt she had no major neurological problems ,but did do genetic tastings . I spoke to him and he did not feel she has had any problems. But then I got a call from her new primary care physician .He informed me that she had a disease base on genetic testing - called POMPE'S DISEASE 

   I has heard about it but had b=never seen a patient with that diagnosis nor did PCP or the neurologist who diagnosed it . But at least we know the diagnosis.

ONE OR TWO OR THREE?

    In Medicine we had a rule. When we see patient, and there are number of symptoms, try to explain all the findings with one diagnosis, rather than explaining different findings with different diagnosis. That does not mean 2 different diseases cannot be there in the same patient. But that is not common. We have seen atypical TB and cancer in the same patient . But that is not a common occurrence. But then in medicine one can never say never. That brings me to the story for today.

   I saw this patient . He was 66 years old patient and had a ulcer or a wound on his legs . He was working and has been doing a full time job and also has been followed by a physician as out patient. He had seen surgeon in past for the wound and was treated. He started having pain  in the leg and he called PCP but could not get appointment for a month or 6 weeks. ,So he decided to come. I was called in as he had abnormal chest x- ray and then the CT SCAN of the chest. I saw the patient . He as obese  and had lot of edema in legs and had a big ulcer that looked infected . But he also had abnormal CT scan of chest and the radiologist had not compared that with old one . He had severe pneumonia few years ago and was on ventilator  and he had that in right lungs as he could tell me . The scan from almost 2 years ago showed same findings of scar tissue in the same area . He also had some lymph nodes enlarged and they also looked to be about the same. But what also caught my eyes was that he had some changes in liver  and that suggested early cirrhosis. I had asked the radiologist to check old CT scan and all that he did was mention the scars in lungs and did not bothered to  tell about the lymph nodes  and also nothing about the liver. He had new CT scan of abdomen and that showed that he had a stone in ureter and that was blocking the kidney and so we called urologist . He was also anemic and so the work up was done . This is a patient who came for the ulcer and a nonhealing wound on leg  and we found out abnormal chest CT  and anemia and some liver abnormality and also renal stone . 

    The work up was done  and he has anemia due to bone marrow not working properly . The bone marrow makes the white cells and red cells and platelets ,so when it is not making these cells then the blood counts drop. He seems to have the problem . He may have contribution from the liver not being normal  and also the infection - the wound. I don't think that the lymph nodes enlargement is due to that but it also may be due to that. So we have a patient who comes for wound which was there for few months  and now had anemia due to bone marrow not working  and kidney stone  and also some nodes enlarged and liver issues . None of these were know to him or were diagnosed even though he has been followed by a physician regularly !!