SOMETHING NEW

   Medical science is getting better every day. Certain things that we did not even imagine in past have developed  and even today it is very difficult to understand certain developments. But certain things which are easy to understand  and difficult to do are also there. In the treatment of cancer now a days blood cells called Lymphocytes are taken out from a cancer patient and are 'programmed '(??)  and then multiplied and then injected in the patient to take care of cancer. This process is easy to understand . But very difficult to actually know as to what is being done . What does a programming of a cell means ?But it is easy to explain. The new treatments for COPD are also such treatments where it is easy to understand  and easy to explain. That brings me to the story for today. 

  I have seen this patient for 3-4 years and she had episodes of respiratory infection when I saw her for the first time . She is in her early seventies and she never smoked . She had cough  and then I saw her . The chest X-ray was normal  and  treated her with antibiotics and the steroids .She did OK  and I did do breathing test and that came as normal . But she had cough and so she was started on treatment for asthma . She did OK and then she weaned herself of the medicines for asthma . She would get periodic episodes of cough and then she would see me and I would treat her with  steroids and inhalers  and she would linger for few days with persistent cough and then would get better . 

   This continued and then the cough got worse and then in spite of doing steroids and antibiotics and inhalers , she would still have bad coughing spells . I did do further work up and we did CT scan and that was normal. I also did measurement of immunoglobulin - These are proteins - globulins that are important for immunity and they prevent the recurrent infection. She did have low immunoglobulin. So I wanted to  give her replacement for the immune globulin . But her hematologist did not want to do that. In any case she continued to have cough and she was admitted few times for the control of her symptoms. Then  I decided to do the bronchoscopy. When I did the bronchoscopy ,I found out that she had problem with trachea and major bronchial tubes . Normally the trachea has cartilages and that gives trachea the support and it does not collapse. Theses cartilages are semicircular and  also extend to main bronchi . That act like scaffolding . But her trachea would collapse when she would exhale or cough  and that   was causing constant cough. So I told her that we need someone to do a stent  and see if that would work out.. She was seen by interventional lung specialist. But he felt that she would need  surgery and stents may not be enough. So I have to send her to Mayo clinic . 

    So such a stent placement was not there 10 years ago and even when they did do it 5 years ago it was in the infancy and also no  one would have thought of doing surgery on trachea in an adult patient few years ago . I still feel that the cause of this is lack of immune globulin leading to recurrent respiratory infections and damage that was caused by persistent inflammation. I feel that she would need replacement for that in future . Stay tune .

INADEQUECY OF MEDICINE

     I have been in medical practice for many years and have realized that the medicine is never perfect or 100% . We can treat 2 people with same condition and same situation and same diagnosis  and still not get the same results. We have the same machine but the result of the same treatment is not the same. So someone may say that it may be due to the circumstances or that people are not like car or any other machine and so people have different outcome. Some may say that it is due to KARMA, Whatever may the cause, we know that we get different results. But then the question comes as to how we can anticipate as to who is going to have out of ordinary results and then avoid the same treatment and do something different in these exceptional patients. Yes medicine is trying to do that and I often feel that our tests are not adequate. That brings me to the story for today. 

   I saw this patient in office sent to me by radiation doctor. She was 70 years old female who had noticed a lump on mammography and so they had planned lumpectomy and then radiation . The radiation physician had ordered a chest x- ray as she was a smoker  and that showed abnormality. So she had CT scan done and that showed the abnormality and so she was sent to me. The original thought was that the abnormality may be due to scars. I saw the lady and she was current smoker  and I felt that the abnormality could be a lung cancer . So I did the work up and she had Bronchoscopy and PET scan and then a breathing test. I had no 100 % proof that the lung abnormality was cancer but on PET scan it was  showing increased activity and so I wanted to have her do surgery. Certainly she had breast cancer also and that needed to be taken out. So she had the breast cancer surgery and then the lungs . The lymph nodes were negative. (The lymph nodes  drain different areas  and so they can show the spread) So when the PET scan had no uptake in nodes the surgeon still did  the lymph node biopsy before taking out the cancer and that was also negative for the cancer spread. So she had the mass taken out and and that was a cancer and the nodes on further biopsy did not show any spread of cancer. She had some issues after the surgery and that needed to be fixed but overall she did OK . So she had breast cancer and then lung cancer - both notice at the same time  and taken out and no residual cancer as far as WE CAN TELL The pet scan had not shown any spread and the biopsy had not shown any spread. 

     We continued to follow her and she had a follow up PET scan about 8 months after the original scan and that showed that there was activity in the nodes . So now the question was is it cancer and if it is then is is RECURRENCE OF THE LUNG CANCER or BREAST CANCER .The breast cancer is notorious in it's tendency to come back after several months and sometimes years .So she did have additional biopsy and it was not breast cancer but it was recurrence of Lung Cancer.

   So we had done a PET scan , which is suppose to be 85% accurate in picking up cancer  and that was negative . She had the same lymph node biopsy before taking out lung cancer and that also did not show the cancer spread . Then she had additional sampling of the same nodes  at the time of surgery to take out lung cancer and that was also negative . And now in less than a year - just 8 months she has the same nodes showing the spread of cancer. So the tests that we did were not adequate to pick up the cancer !

   Just a note - some labs are doing what is called circulating tumor DNA - a blood test that will pick up certain DNA of the tumor to predict recurrence of a cancer earlier that it is obvious on scans. So this may be a future .But if CTDNA is positive then the question is How do you treat?

ELEPHANT IN THE ROOM

    In medicine sometimes we have extreme positions. The so called pendulum swings to he other direction.I have seen use of certain drugs for a certain condition as routine 'acceptable' treatment  and then suddenly it falls off the favorite train and then no one uses it . Theophylline is one such drug . 20 years ago there were several pharmaceutical companies that were making brand name theophylline  and now there is none. We also use a term  "The elephant in the room". This brings me to the story for today. 

     I saw this 90 years old patient in office and then she was diagnosed to have asthma  and also she was obese and may have had sleep apnea. But she did not want sleep study and so she was on oxygen which is not accepted treatment for sleep apnea now a days. But when the oxygen drops badly during sleep, one can not deny use of oxygen .She was admitted to hosp and she had  multiple problems . She had shortness of the breath and she had swelling in the legs and she has problem with her kidneys.So she was seen by hospital doctor and as expected they had called cardiologist and kidney specialist and pulmonary specialist . So when I saw her she was in hospital for she was in hospital for 3 days . I saw her and she had acceptable oxygen saturation at rest and she has significant edema in legs and her kidneys were not functioning well. She had clear lungs but no one had given her home inhalers which were prescribed for her asthma in past . So i started them. The cardiologist had seen and done echocardiogram  and the heart function was good and he has no other suggestion. The kidney doctor was giving her diuretics and her  her swelling was getting better  and she had some improvement renal function. What struck me in this patient was that her lungs were clear and the oxygen was fine and she still felt short of breath. Certainly it could be due to being 89 years old with low activity  and de conditioning and may be some heart problem and certainly may be even lung issues. But she also had anemia  and they had done the work up and she had problem with production of red cells.( think of red cells as a product of a factory. Let  us take an example of making shirts.So if there are less shirts available in market, then  it could be due to factory not making enough or that they are sold too quickly. - high demand or that there is not enough raw material . The same thing is true about red cells . The raw material - iron B12 or other r=things may not be enough or we have a loss of blood or it could be that the bone marrow the factory is defective.)So she had problem with production of red cells. That is not uncommon in patient with kidney problem. I followed her for few days . What I noticed is that in spite of inhalers and edema getting better and the kidney function improving she was still short of breath.And I also noticed that the anemia was not any better and was somewhat worse . Her hemoglobin -which carries the oxygen in blood was half the normal. So patients with anemia are short of breath as their system has to work harder to provide oxygen as the blood does not carry same amount of oxygen.So I finally called the hospital doctor  and asked her to give BLOOD TRANSFUSION. In past we used to transfuse even with much higher hemoglobin. But then we realize that that was causing problems in future  and so now the pendulum has swung to other extreme and no one thinks of transfusion even though this 90 years old lady was shortness of breath was perfect candidate for giving blood . So this was the big elephant in the room and no one was talking about it or treating it or may be no one could THINK about it .  

GUT FEELING

    I have talked about some of the new things in diagnosis of cancer . I have also done that in my YOU TUBE  video . If you are interested it's under the name JUST A TALK . But sometimes all the tests that one can do may not going to give diagnosis  and sometimes one has to go by old GUT FEELING. So this is one of the stories where I did that . 

   I saw this female patient who had  an auto accident and then she went to ER. They did do some spine X- ray and scans  and that showed a small pulmonary nodule like 10 mm . She was told to see primary care doctor  and she had no insurance and so she decided to wait for 3 - 4 months till she got insurance . She saw PCP and then she was sent to me .She was less than 60 years old  and she had not smoked for 28 years  and had no pulmonary symptoms. The new CT scan had shown that the nodule had increased by few mm . This was in 4-5 months. I did the work up I did the TET scan and also the bronchoscopy  and I also did breathing test. 

   The  Bronchoscopy was negative  and it was not expected to give me the diagnosis but I wanted to make sure that there was no other cause for the nodule. The Breathing test was OK  and the PET  scan showed mild uptake  and radiologist felt that it could be inflammatory . But in addition to that I also did a new blood test called NODIFY . This is a new blood test  and I think it was approved last year . It tests certain proteins in blood and certain other things and that can give a probability of cancer . So One can calculate the probability based on several characteristics of the nodule -like size , location, spiculation, age , sex of the patient and the history of smoking etc. Then  based on the the blood test reports the probability is recalculated  and it may be increased or decreased. Or the test may not change it at all. So this is a new test and it is more than 95 % sensitive. The test was done in this patient. and it was  reported as reduced probability . 

  So we had low uptake on PET SCAN nd reduced probability on this new blood test  and she was not a smoker . So now we had several options. One was to do a needle biopsy which may or may not give diagnosis. The other option was to wait and watch the CT scan in 3 months  and if it grows then do surgery  and lastly do surgery now . I decided to tell patient to do open biopsy or surgery. It was not based on TESTS that we did but it was based on my Gut feeling  and the fact that the nodule has increased and in my mind ANYTHING THAT INCREASES MUST COME OUT.

  She saw a surgeon  and he decided to do needle biopsy and that showed high suspicion for cancer  and so she had surgery and the surgery did confirm Lung Cancer  and she did very well . 

VARIOUS FACES OF COVID

    We have seen COVID infection for more than 1 year and I have seen may share of the disease. I do not have vast experience ,but I have seen different presentation and severity  and it is not actual 'changing ' face but it is just the variation in presentation. All the statistics does down the drain when you see theses kind of variation. So the so called 'risk factors' are valid for majority of patients but one can not hold them as 'Gospel truth'.In 2020 earlier part of the disease I saw a 91 years old African American women who had not left her home  and had significant hear problem ,hypertension and had possible heart failure  and may be pneumonia admitted . She was to be discharge to a extended care facility  and so at the time of discharge we did COVID test and to my surprise and horror it came positive.She did not have fever, she had no oxygen issues  and she did not have much cough or upper respiratory symptoms and she also was never exposed to crowd. So how did she acquire it or why she was asymptomatic  and lastly in spite of all the risk factors,she had no problem with 'recovery'? (she was never sick so not sure there was any need for recovery) That brings to me the patient story for today. 

    I saw this 74 years old male patient several years ago. He came to me for cough. He had seen primary care physician and also then allergist and he has had work up. He had allergies and was treated  and then he came to me as the cough continued . I did the work up and he had pulmonary fibrosis - scars tissues in lungs and so he had cough . I told him that we will do work up to find any etiology for the scar tissues and that was done and we did not fond any. So we decided to do follow up and in case the fibrosis gets worse we will star the treatment . I followed him for more than 2 years and the CT SCAN and the breathing tests were OK and did not show any deterioration. He stopped coming  and then after a gap of many months to a year he came to see me and he had some shortness of breath in addition to cough. The cough was also worse. So I did the same tests and nor=ted that on breathing test he was worse . So we started him on treatment with relatively new drug . He was doing OK but continued to have cough and even though I had told him that the cough will continue and not much could be done for it other than giving cough medicines , he was frustrated . He was teaching i one of the centers and the cough was bothersome . So he had called me many times  and I did add some different cough medicines  and at times tried steroids too. So one day he called me and he was having coughing spells and also had chest pressure . He was a older patient and had lung problem and so when he had chest pressure I told him to go to ER. I was concerned about things like heart or clot in lungs . He went to ER  and had CT scan done and that showed no clot. As routine goes he had COVID test done and that was positive. He had no fever and no upper respiratory symptoms. His oxygen saturation was fine  and he looked OK To my surprise, when I saw him in ER he had mask which was not covering nose  and was in hallway. We admitted him for observation only because he was OLD  and had LUNG DISEASE - the so called risk factors . I discharged him after 2 and half days when he had no new complaints . 

   So here is a older patient with high blood pressure , lung problem-all the risk factors for bad outcome   and was teaching  and had COVID and had no problem due to it. That is why we are not like automobile machine- same model and make but different response.

NATURE OR NURTURED

    This question is often brought up , is it nature or nurtured. When we have a disease that can not be explained we talk about is it related to nature - genes etc or due to environment -nurtured. And it is very difficult  to answer it . In medicine the studies are done in twins to see if the GENES determine the outcome or how they were brought up . This is seen in studies for depression or bipolar or also for even homosexuality. That brings me to today's story. 

    I saw this patient may be 4 years ago and he had shortness of breath. He was admitted to a hospital  and was seen by cardiologist and lung specialist and hospital doctor and was told that heart was OK and he has emphysema. He decided to come to me  and so I did the work up and told him that he seems to have aortic valve problem and I admitted  and then  had aortic valve surgery. He also had HIV  and he had discontinued the medications  and so we had to start the HIV medicines . He did not come to my office much and he was followed by cardiologist. I did not know what was happening as he did  not come and he had major problem as heart. 

    I did see him every time he was in hospital. The cardiologist told me that he was noncompliant with meds . He was admitted and had shortness of breath and every time when I saw him I felt that he had cardiac problem and when we did echocardiograms, his pumping action was down to 20-25%The meds were adjusted and then he was OK for a while and then he would have same problem . The cardiologist felt that he would improve with the newer medicines . In span of 4 months he has been admitted 3 times  and he has not seen me in office for his COPD in last 2 years. So now for last 6-8 months he has not improved  and now for last 3 months they have told him that he will need a defibrillator. Patient has not made up his mind as to have it done or not. 

   So I  saw the problem with aortic valve  and we acted upon it and he had surgery and he did get better . Now he is worsening and the question is -is it related to his noncompliance or is it that in spite of surgery and medications he had bad genes  and he was going to get worse . 

  ISIT NATURE OR NURTURED  

WHY ? WE DON'T KNOW

   In medicine and in general our life we see things that can be explained on the basis of our knowledge or logic or science. I have often said that the GOD has kept us guising. The man thinks that we KNOW and then the God or an incidence tells us that we DON'T KNOW everything. Many years ago my professor of Preventive and Social medicine had a heart attack and I went to see him in hospital. In those days we did not have stents  and all the modern things that we have to treat the heart attack. He made a statement to me . 'I don't smoke , I don't eat meat and I eat lots of fish and I don't drink alcohol, I exercise  and my cholesterol is normal. I do or have high blood pressure or diabetes - I still have heart attack !'Since then we have much more understanding of atherosclerosis and heart attack and the risk factors but the basic statement is still true. We have no clue as to why some get sick and some don't. That brings me to the story for today. 

   I saw this male patient of about 70 years of age . He had been smoker and had COPD. He did not have much shortness of breath and he had routine chest X- ray and that was abnormal. So he came to me and then I did the work up. He had bronchoscopy and PET scan and breathing test and biopsy  and he had lung cancer . Based on the tests that we had done he had cancer that could be resected  and there was no evidence of spread of the cancer to any organs or the lymph nodes . So I sent him to thoracic surgery. and he also thought that he needed surgery So he had surgery and the cancer was out. The margins were clean and no blood vessels were invaded  and no lymph nodes showed any spread of the cancer . He was seen by cancer specialist and was told that he does not need any chemotherapy as there was spread . 

    More than a year went by and he was followed by VA cancer specialist and he was doing ok . He came to me  and he was doing fine . Then last time when he came to me he had laryngitis. He had lost his voice and so I was concerned  and I wanted to do CT scan and he told me that his cancer doctor had done the scan and that was fine and I did see the report and he had nothing on the CT scan to suggest any recurrence. So I sent him to ENT to check on throat- vocal cords . He had paralysis of left vocal cord! So ENT doctor did new CT SCAN - 1 month from the last one and he did it with contrast  and that showed that he had recurrence at the site of resection. Just to explain medical anatomy - the nerve that supplies to left vocal cord comes down and goes in chest and winds around left central part where there are nodes and blood vessels  and then goes back in neck and goes to vocal cord. So when there is cancer in middle of left central part this nerve can get caught and the vocal cord can get paralysed . So he had that and I did do biopsy  and he has recurrence. 

    So all the odds were in favor of so called CURE and then he had CT scan  and that did not show tumor and then in one month new CT scan did show the cancer !So do we really know or we are just medical statisticians ?