IS IT JUST LUCK?

      In medicine we act based on what we think or know as facts. But many a times the facts are based on statistics. When we treat someone with  bronchitis- cough with yellow sputum, fever and wheezes= we treat with certain antibiotics and expect it will help and cure the respiratory infection. I believe that treating with antibiotics to cure him his based on FACTS .But in reality it is based on statistics and experience that antibiotics work in certain infection. But it may or may  not. But I often used to say that if one puts one hand in boiling water and other in ice cold water , 'statistically ' he is at comfort. That brings me to the story for today. 

    I saw this 70 years old male who was a smoker for cough and congestion. He had been smoker for 50 plus years and had no desire to quit. He had cough and wheezes and we did work up. he had breathing test and chest x- ray and was started on some bronchodilator. He continued to see me for 2 years and was doing OK .He had COPD and that was mild and he was active and cough improved . Then when I did new chest x- ray , he had abnormality . When I called him and wanted to do CT scan, he wanted to hold off and wanted antibiotics. So I did that and the repeat chest X- ray continued to show the abnormality . We did work up and he had cancer diagnosed . He underwent surgery and cancer was taken out. But he had some lymph nodes positive for cancer spread and so i sent him to oncologist and radiation doctor. He was told that the chance of recurrence in increased when the nodes show spread and he should have chemotherapy and or radiation . He did not want any further treatment. 

     I continued to do follow up and in next year or two, he had ne scan showing new mass . Again we did the work up and he had new cancer. I sent him to thoracic surgery and he did not feel surgery was an option as he had cancer spread to lymph nodes and so we decided to do radiation and suggested chemo and he was not sure . I continued to do follow up and he was doing OK . He had continued to smoke and the breathing test did not show much worsening. He did get radiation and no chemo.

   I continued to do the follow up and did periodic CT scan . 2 years or so after the second cancer. He was doing great and he had continued to smoke and was having no new complaints. He had new CT scan and he had some chest wall pain. The CT scan showed that he had new tumors and the ribs on rt side were also involved  and showed cancer. I sent him to radiation oncologist and medical oncologist . He was started on radiation and immunotherapy. He had some additional medications for pain . Almost 2 years have passed and he has continued to smoke  and has had new scans and breathing test . The breathing test does not show any significant worsening from previous one . He does not need oxygen .He has not been on any cancer medications for more than a year .AND HE IS AGAIN CANCER FREE . 

NOT SURE WHAT SHOULD HAVE HAPPENED TO HIM STATISTICALLY !!

MEDICAL DILEMMA

       In medical practice, we see different types of patients . Some that want medicines and others who are reluctant to take medicine. Some want every test in the world and others don't want any tests - including ones that could help diagnose and treat the element. One of the problem that I face is that if the medicines are not taken at right time then the disease could progress. But we do  not have clear cut understanding as who will will get worse and who will be OK. Certainly high blood pressure , diabetes and cancer are exception and I am sure there are many others conditions including  infection. But one infection is such that we have some variation. That brings me to story for today. 

    The MAC or Atypical Mycobacterial Infection ,also called Mycobacterial Avium is one such. I have seen many patients and some are old and some are young. This is  a chronic infection and may present as cough , abnormal CT scan of chest or may have additional complaints .Recently came across few patients , that taught me that we have a CLINICAL CHOICE . 

    I have seen 2 patients both over 80 years of age now who had MAC. One had it more than 5-7 years ago and we treated it . The treatment is for 18 months with 3 drugs and many do  not like it. This lady continued to have problem and we treated her. Then a new medicine came in and we added that and she was cured. She had no new pulmonary complaints and she seems to be doing OK But after a gap of no treatment for more than a year she had some more cough and so I did do CT scan and then sputum check and she had recurrence of the MAC. I talked to her and started her on medicines. But within a month or two , she called me and told me that she has decided to stop it and just want to see what happens . We have talked to her on dangers of not taking medicines , and then continued to do follow up. In next 18 months , she had no problem and continues to have no worsening of CT scan and no positive sputum cultures. The same thing has happened to one of my other patient . She had MAC and abnormal CT scan and we did try treatment and she could not take medicines as she felt miserable .So after 8 months of treatment she stopped it. We have followed her for 2 plus years  and initially the Ct scan was worse , but in spite of no treatment, the CT scan was stable or may be little better. She has stable weight and we have not done any treatment. 

  The contrast to that we have a young lady who had abnormal CT scan and then diagnosed as MAC and treated her. After 3-4 months she had  positive sputum and so we added 4th drug and she did well and we could stop medicines after 18-20 months of treatment and she did good for 1 year . She had low weight and new scan showed worsening  and so we wanted  to start medicines and she did not want. So after 6 months of observation , we did testing and she agreed to start medicines.

   So in the older patients no medicines has worked so far , but in some other younger patients it has not .