MISSED STEPS ?

   In medicine we often see that the patients  have come symptoms and then the investigation is done and then we end up with dead end .But then tracing back the work up we realize that we should have taken different course of action / work up. It is often stated that 3rd doctor is smarter than first two as the first 2 physicians have done some work up and have ruled out certain diseases. I also often say that your eyes don't see what your mind does not think.'That brings me to the story of today's patient. 

   I saw this patient in office as the care giver was my patient. She had no relatives and this patient of my was taking care of her in her own home. She was relatively young late sixties and had been smoker and had high blood pressure and dementia. She had some cough and then a chest x- ray was done and that showed some abnormality and so the PCP ordered CT scan chest and when that came back abnormal , snt her to oncologist. This is first missed step. When the diagnosis of cancer is not established what is oncologist going to do? The oncologist does treat cancer with chemotherapy or now a days Immunotherapy. But when we don't know if patient has cancer or what type , the oncologist cannot do anything . The oncologist decided to do PET scan. The PET scan shows uptake of glucose in whole body and organs and when the uptake is higher at a particular area which correspond to the abnormality on CT scan , the suspicion for cancer is increased . Again the diagnosis is not yet established and it is only the possibility of cancer that is increased as infection and inflammation also can show increased uptake of glucose. The PET scan was scheduled but not done and the oncologist sent her to Chest or thoracic surgeon. In my estimate this was second missed step. The CT scan findings were indicative of left lung mass and possible SPREAD TO CENTRAL LYMPH NODES . With is findings the patient will not be  candidate for resecting or cutting out cancer. If the central or hilar nodes are involved by cancer, then cutting out primary cancer does not help to improve prognosis  and patient is 'inoperable'. In addition to that ,she was  a smoker and had COPD the lung disease that is caused by smoking and that reduces lung capacity. We did not know if she had enough RESERVE lung capacity to undergo surgery in which part or whole of left may need to be removed. In between someone sent her to radiologist to do biopsy of the mass in the lung and that did confirm the lung cancer. Again this may have been miss step as we still did not know if the lymph node was showing spread or not , and that is a crucial step Then the care giver asked me to see her . We did schedule PET scan and also did breathing test. She was also sent to a interventional lung specialist for the biopsy of that lymph node which was seem to be involved.

    The PET scan did confirm uptake in lung mass and also in various nodes .So essentially she was not operable / resectable. The breathing test did show significant reduction in lung capacity and so she would not do well with surgery. I explained that to patient and the care giver . Patient had some dementia and so I was not sure how much she understood. I spoke to the care giver, but she was told by oncologist that she needs to be seen by chest surgeon and have surgery. So they had mind set on surgery. 

  

NOTHING IS KOSHER

    In medicine we have often talked on rare bird or certain things that we feel comfortable about certain findings .But the medicine is statistic and as one knows that not 100%. So I say there is nothing is Kosher. I have often stated that with statistic ,one can put one hand in boiling water and other in ice cold water and YO ARE AT COMFORT !! But in medicine we have certain things that are common and when we are proved wrong or we have deviation from 'usual; we don't like  as we did not expect it. That brings me to the story for today.

  I saw the patient about 70 years old male who has been 2 pack a day smoker. He had a CT scan done by PCP and that showed a nodule about 13 mm - just half an inch in size . So he was sent to us . I did start the work up .I explained the patient that, I am concerned about high chance of cancer and needs to answer 3 questions ,i.e. Is it cancer , Has it spread and What can be done as treatment. I ordered a PET scan and breathing test and did bronchoscopy. Some how he did not do pet scan for 6 weeks and rest of the work up was done. He came to see me again . The bronchoscopy did not show much and so when we had done washing and brushing - what I call as pap smear of the deeper parts of the lung came back as normal. But the PET scan was not normal and to my surprise, the nodule which was 13 mm was now 21 -23 mm and had increased uptake, indicating that it was likely to be cancer. But more than that the growth in such a short time indicated rapidly growing or aggressive cancer .I also was not very happy that many of the lymph odes which were not reported as enlarged , were enlarged and had uptake, indicating spread of the cancer. 

  I explained it to him and decided to send for additional biopsies and also have chest surgeon look at him in case the nodes are not positive then he can resect it out. 

NATURE OR NURTURED OR KARMA

    I have been in practice for many years and I have seen patients and their family members. It is is not uncommon to have patients - husband and wife to go to same family physician, but for them to have same system problems like lungs also is not that uncommon. Again we ac see lung related problems in both husband and wife simply due to smoking history or exposure. So I have seen husband and wife with COPD - EMPHYSEMA as both were smokers and I have few pairs of husband and wife who had cancer of the lungs. But I have also seen some families that have diseases that cannot be explained on the basis of smoking or exposure that could have happened being living together. Again genetics could explain, but it is not that common. That brings me to case for the day. 

  I had seen this lady several years ago - may be 25 years ago. She was a smoker and had high blood pressure. She quit smoking and had abnormal chest x- ray. We did the usual work up and she had cancer of the lung and she had decent lung capacity and there was no evidence of spread of the cancer . So she underwent a surgery and she had cure . She did well and came to me for follow up for 2-3 years and then stopped coming . She came back again for some cough. She had not smoked for almost 30 years and she had no new diagnosis other than high blood pressure . Her daughter also used to be my patient . She had 3 daughters and each one of them had major medical problem. One that was my patient had scleroderma  and had some scar tissues - fibrosis of the lungs and had other problems associated with scleroderma . She was on oxygen and she did not want lung transplant and she continued to get worse over period of 5-6 years and then dies . Her other daughter who had seen me for short time had diagnosis of lupus and had developed kidney failure and over period of time she got worse and then needed dialysis and that was continued for several years and then she also died . Her third daughter also had many medical problem and I never saw her as patient as she was not here and when I talked to patient about her , she was in nursing home at very early age due to medical issues . 

   So, here we have a mother who had cancer of the lung and she got cured , had 3 daughters who all had various medical problems and they all dies BEFORE patient and they did not have smoking related diagnosis but had so called Autoimmune disease like scleroderma and lupus etc. What could explain such sad story? How could they had that bad gene that made caused the diseases and made them so sick that they died before their mother? Certainly all were in the same environment and that could not explain. So then what was the cause ? I do not know  But may be KARMA and some kind of give and take that brought them together . 

   By the way may patient had new spot of the lung and she refused the work up as she told me that if she has new cancer she was nnot going to do anything about it. 

THINGS ARE UNUSUAL - BUT MAY BE NOT THAT MUCH

    I have been in medicine for many years and have seen things that are very very common like asthma or COPD , pneumonia and may be even cancer. But sometimes even common diseases can present as very interesting presentation, though anything that is interesting for for health care professionals is bad news for patients . That brings me to today's story.

  I have been seeing this patient for a while , She has been ex smoker -quit many years ago and had some COPD . She has had routine x- ray - CT scan in past and that was ok . But this time she had sputum tinged with blood. So I did new CT scan and the report was very sketchy, There was mention of some abnormality in right bronchus , but no mention of any tumor.  I had planned bronchoscopy any way and  then with the abnormal findings on CT scan, i also ordered PET scan. In PET scan glucose pick up of normal tissues / organ is compared to the abnormal areas seen on CT scan and if the pick up is increased that indicated cancer - infection etc. . The accuracy of picking up cancer is about 80%.The bronchoscopy was done before the PET scan was done and that showed that the main bronchus - was narrowed and that looked like external pressure. There was no mass as such that I could biopsy. I did do some brushings - pap smear from  the bronchus. The PET scan was done and that showed that there was a mass and that was making the right bronchus narrowed and there was greatly increased in that mass suggesting that it was cancer. But the scan also showed that she had increased uptake in thyroid .She had seen thyroid specialist less than one year and had biopsy and that was OK. But the PET scan was abnormal and so I asked interventional radiologist to do biopsy of the thyroid . The lung mass was there too and so I called interventional pulmonary doctor and he did do ultrasound guided biopsy and he called me that preliminary report was that it was thyroid cancer . The thyroid biopsy was done before the lung biopsy and that also showed thyroid cancer. 

  So I called patient and told her that she seems to have thyroid cancer that has spread to lungs . I also called oncologist too and ask him to see her. But the story did not end there . I checked the final report on the lung biopsy and that was not a thyroid cancer but it was usual lung cancer !!So she had 2 different cancers -one thyroid and other lung cancer . Due to location and spread  to the central lymph nodes , that was not resectable or operable and so we will need chemo and may be radiation . I am not sure what would be best for thyroid cancer - ? surgery or some different chemo or both ? I will let oncologist decide on that.

ALL GOOD THINGS MUST COME TO END ??

  We often say that all the good things must come to end. So does it apply in medicine? Many a times we have patients who have bad news or a bad diagnosis and it feels like the things are not going well. But then  things improve . We are happy and so is patient. In some cases the events take turn for better and then the patient is on recovery path and certainly that can and does last for long time. But in some cases this does not happen and usually we KNOW that or have EXPECTED that . This is a story for something like that. 

   I saw this patient few years ago - may be 10 years ago. He was a young male who had smoked and had continued to smoke and had COPD - the chronic lung disease that happens when one is smoker. He had diabetes too. He was not very compliant and had blood sugars which were high and the HB A1 c was also high . Every time he came for the follow up we had a talk as he did not even attempt to reduce smoking  and sugars continued to be elevated . One day we did a CT scan and he had abnormality . WE did the work up and he had MAC- atypical TB -called mycobacterial avium. He was treated by me and we did get infectious disease to se him and he did OK . The Ct scan improved and the sputum recheck shoed that the bacteria had cleared . We did do follow up and he was doing well and had continued to smoke and also had uncontrolled diabetes continued . As a routine we did follow up CT scan chest - it was almost 2 years that he was diagnosed with MAC and wanted to see if we could stop the treatment. The CT scan was abnormal in past and i did not expect it to be normal as he had a cavity and that would have healed with scars and so the abnormality will be still there . This time the scan was abnormal and it felt that he may have some lymph nodes swollen. That could be due to the MAC or could be due to cancer as he had continued to smoke. We did the further work up and did what is called EBUS- ultrasound guided biopsy of the nodes and it showed lung cancer. The COPD was bad and he had oxygen and the type of lung cancer was such that he could not have had surgery even if he had normal lung capacity and with lymph nodes positive he would not have been a surgical candidate. He was sent to medical oncologist and he was started on chemo.  He continued to smoke and he had some issues with chemotherapy. As the immunity is suppressed with chemotherapy, we continued him on MAC medicines , as otherwise the MAC would spread with body's immunity reduced. 

  The time was going on and 2 years went by and I was thinking that he is 'cured ' of cancer in spite of smoking and he was off the chemotherapy . But as I said all good things come to end , new CT scan dne had shown new lesion and older spot was growing and the nodes which were down in size were increasing in size . So he had recurrence!

   I have talked to him and the work is started again to see if he has new cancer or old one back.

DO NOT ASK FOR THE DIRECTION TO PLACE WHERE YOU DON'T GO

     In medicine I have said that do not ask for the direction to a place where you do not want to go. As we are seeing aging population, this has become more and more common . Patient having some blood in stool will need work up . But then if the patient is very old - and very old can be determined by family and physician only - and say has dementia , is it worth finding the cause and doing million dollars work up with INVASIVE procedures which have some risk, when we know that we are not doing the treatment which is ideal like surgery. A good doctor may suggest certain work up and treatment and a good doctor will take in account not only the diagnosis , but also other factors. That brings me to story for today. 

    I saw this 85 years old female . She had pain in abdomen and so she went to walk in clinic and they did Ct scan of the belly - abdomen. (I am not sure  as to what was the thought process -or differential diagnosis that they did CT scan -but now a days that is a knee jerk reaction) .The scan showed no abnormality in abdomen or pelvis , but showed a nodule in the lung . She had a CT scan of chest in past - few years ago and that had shown a nodule  and she had seen a lung specialist 4 years ago. And he had told them to watch it , rather that doing additional biopsy etc . That had happened 7 years ago . So she was 78 years old . Again I was not the physician and not sure what was taken in to account when the decision was made. The size of the nodule was smaller and now after several years when CT scan of belly was done it appeared to show increase in size. So she was sent to me. She had not done CT scan of chest. 

   She was older lady but seems to understand very well and was accompanied by caring family. I looked at reports and also tried to find out any old reports that might help. I tried to check 2-3 hospital and radiology centers to see if there was any scan of the chest in last 3 years and could not find any. She had no pulmonary complaints. If the size seen on scan of the belly was correct the spot or the nodule had grown in last few years . So it was likely to be slow growing cancer or a scar cancer - cancer developing in old scar. Either way we needed work up . I often tell patients that we need to answer 3 questions - 1 Is it cancer 2 Has it spread  and 3 what kind of treatment we need / can do.  The treatment of cancer - if it is - is surgery-radiation-chemo. Here comes the point of making decision as to what kind of work up we should do. If the patient does not want surgery or it is felt that the surgery is too risky then how much should be the work up? Ideally we would do PET scan , Breathing test to assess lung capacity and biopsy. But if patient does not want any  treatment like surgery or chemotherapy, how much invasive work up we should do. If we don't want to go a place why should we ask for the direction to that place ? This lady did not want surgery and chemo and the family agreed . Then do we need to do biopsy ? I suggested doing a PET SCAN which can pick up cancer in may be 80-85% of the cases So I decided to do the PET scan and if that is positive , consider radiation treatment without biosy or just do follow up Ct scan in 3 months and see if it grows . 

    Again I would be curious as to what would AI suggest . 

RIGHT OR WRONG ?

     In life we often say that each one of us has opinion and sometimes we have 2 opinion especially if we are talking about politicians. But even normal people have different opinions and the same hold true in medicine. Most of the time we all have same opinion -may be because we all read the same book or have seen same study. No one will argue about treating high blood pressure or high blood sugars. But then we it comes to certain other conditions in elderly , we have different opinion. No one can state that his way is the only correct way. Take for example HBA1C , the indicator of diabetic control. In younger patients we like it around 6 or may be even less-close to as normal as it could be. But in elderly such a tight control is not good or could be detrimental. In elderly patient who may be living alone or who may be living with spouse who also may be elderly, it is more dangerous to have low blood sugar than high sugar . The low sugar can lead to unconsciousness and brain damage , while high blood sugar -not extremely high sugar is not that bad. This kind of thinking brings me to case for today. 

  I had seen this 80 years old patient in office . He had diagnosis of lung cancer and then we had surgery and he did well and did not need any additional chemotherapy of radiation and did ok .He did have some shortness of breath and I saw him and the work up was ok .He came to me for few months and then stopped . After a gap of 3 years he came to me and had some shortness of breath and we did do new CT scan and that showed density next to  suture line. In past we had seen that density and followed it and it was stable for couple of years. This time it looked like it had increased. So, I saw him . By now he was elderly , fragile and had some dementia. He had reduced activity partly related to shortness of breath and partly related to aging , dementia etc. I did order new PET scan and new breathing test. The wife was a nurse  and she wanted everything done and wanted to see thoracic surgery - the same one who had done surgery 3-4 years ago . I ordered the tests and she saw him. He ordered a biopsy of the mass. I did PET scan and that showed very high uptake in the mass -suggesting that it is cancer . Certainly we did not know the exact diagnosis or what type. The physician who was to do the biopsy is in the same group as the surgeon. I had suggested asking radiation doctor to see him as I did not feel he would do well with surgery cutting out part of the lung and also he would do well with chemo. The wife wanted surgery as 'that is the BEST treatment for the cancer'. But the surgeon agreed with me and told her that doing surgery was too risky. I had suggested not doing any biopsy but just based on PET scan treat with radiation . But the surgeon wanted his group doctor to do lung biopsy. I asked them - if biopsy is positive - would you take chemo the answer was NO. I asked if the biopsy is negative for the cancer would consider radiation treatment based on PET scan? the answer was YES . So my question is why do a test that does not change the course of treatment in this elderly fragile patient.  

    There is no answer and he will have the biopsy and radiation treatment !! RIGHT OR WRONG.

  

GOOD OR BAD ?

      In medicine we make decisions  and then live by it. The decisions are made based on our understandings of the tests  and not all are available for all of us .Could AI make a different outcome - I don't know . I don't think so. So most of the time we are correct and sometimes we are not. So the new tests are developed .That brings me to the story for the today. 

     I saw this lady several years ago. She had mild asthma and she came to me and we did tests and then started her on medicines and she did well. But ew people have this thinking that they can 'cure' the decision and then they will not need medicines . It does not happen in many conditions, but still some think it in that way. So she went to allergist and he did tests and then continued the same meds. But she did not come back to me. She was stable and then after 3-4 years she had shortness of breath and she was admitted and I was called. She had a clot in lungs  and that made her short of breath. The asthma was stable . But when a CT scan was done, she had not only pulmonary embolism, but also ha =d a spot on the lung . This was not seen before  and she was concerned. She has been nonsmoker  and had new clot. So I decided that we will do the out patient work up. But at this time we wanted to have her treatment for the clot. The oncologist was also called and they concentrated on the clot rather that the spot on the lung. She was discharged  and then we did the work up as out patient. 

  She was treated with blood thinner /anticoagulation. She had follow up with her cancer doctor and no new tests were done .She came to me after 4-6 weeks . I ordered a PET SCAN As I have mentioned in my previous blogs the PET scan shows metabolic activity of the cells and is good in 85 % cases for picking up cancer. We decided to do bronchoscopy and we had to hold the blood thinner for 3 days and then the bronchoscopy was OK. We had done breathing test and I had asked her to see a chest surgeon too. The PET scan was showing that the spot on the lung was hot -it had pick up and so I had her see the thoracic surgeon. He saw her and no decision was made. She came to see me and by then it was almost 6-7 weeks from the PET scan. I saw her I was expecting that the surgeon would have done the surgery and then I will see her. SO when I saw her in office and no surgery was planned, I called the surgeon and scheduled her for new CT scan . The surgeon called me and he could not tell me why no surgery was planned , but he agreed that the spot needed to come out. The new Ct scan was done and she had the same spot with may be minimal increase.

    The surgery was done  and - and - there was no CANCER. It was a infarct related to the clot. With the clot part of lung had infarct and bleeding and so that did not get better with time. But it was not cancer. 

   So the decision made based on PET scan was correct , but the Good news was that there was no cancer  and Bad news was that she had surgery- a invasive procedure . 

  We have some new tests - CTDNA - circulating tumor DNA, Nodify etc. . We check the DNA of the cancer cells from simple blood test , we have antibody for cells and protein associated with the cancer etc. But NONE is 100% . Hope we will have it one day. 

DR GOOGLE

    I have done my medical education many years ago and since then the medicine has grown and we have been able to keep with new developments . But now a days we have added the burden of computer educated generation where patients have seen . checked on computer and think they know the answers 

  We still have many patients that trust their doctors , but still we have sometimes problem and we have to explain things . It is difficult to wife off the slate which is not clean to start with and write new things .  Sometimes it is not fault with patients but with people surrounding  That brings me to the story for today.      I saw this 80 plus years old patient in office for shortness of breath . HE was smoker and had diagnosis of laryngeal cancer and that was treated and he was better and was in remission . He had COPD  and he has shortness of breath  and so he came to me . I asked him questions and I found out that he was admitted to hospital  and he had CT scan and that had shown nodule , the so called spot on the lung, He did not have any new Ct scan after the discharge 4 months ago.  So I ordered the new CT scan and that showed that the nodule had grown . That means that it was likely to be cancer . Since he had laryngeal cancer , there was possibility of new lung cancer or metastasis. So I ordered the PET scan . The  PET scan  picks up cancer may be 85% of the time . The PET scan showed activity in the lung nodule and also some activity in food pipe esophagus . We had done breathing test and he had severe compromised lung function. He was older and had bad lungs and enlarging nodule . So I asked interventional lung specialist to see him and do navigational bronchoscopy and biopsy . Ehen the biopsy was done it came back positive for cancer. She called me and the family and she wanted them to see cancer doctor - oncologist  and Gastroenetrologist.  I called the family as I wanted to discuss the further work up and treatment plan . I was told by family that they know it is cancer and what was I going to do . I insisted on bringing them in .

    I had discussion with them  and i was glad that they came . They were confused between oncologist and Gstro. I told them that he did not have great lung capacity and he was not a candidate for lot of invasive tests . But we needed to know if this spot - that had biopsy positive for cancer was ARISING IN LUNG or had started in esophagus and SPREAD TO LUNG . The distinction was very important as if there was no cancer of esophagus , then we could do short treatment of the lung cancer called stereotactic radiation and that will not cause much problem with h9 compromised lungs and has some cure rate . In contrast to that if he has had esophageal cancer, then treatment of the lung nodule will be not useful and then either chemo or localized radiation to esophagus will be needed  and that may cause difficulty in swallowing and need feeding tube - may be. These kind of things was not there when thy had checked on  Google. 

   I cleared him for doing endoscopy and when they left they were happy that they came. .  .

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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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 !!! . 

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.

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 !!!