CONTACTS
SUBJECTS
VA Prescribe Atorvastin 10 MG Trial 4 Weeks Evaluate Side Effects In
4903 -
4903 - ..
4904 - Summary/Objective
4905 -
490501 - Follow up ref SDS 40 0000. ref SDS 39 0000.
490502 -
490503 - Meeting to review clinical trials for lowering cholesterol.
490504 -
490505 - [On 131125 0005 research found dizziness less common side
490506 - effect taking ezetimibe (zetia). ref SDS 45 JO6K
490507 -
490508 - [On 140430 0900 letter to VA notifies some minor dizziness
490509 - has begun while taking Atorvastatin 10mg with Ezetimibe
490510 - 10mg. ref SDS 52 PU43
490512 - ..
490513 - [On 160715 1630 Doctor Yoo Progress Notes in Neurology
490514 - sets goal for LDL < 100, appears conflicting with VA
490515 - goals for LCL < 70. ref SDS 59 O45I
490517 - ..
490518 - [On 170314 0817 Doctor Shunk proposed inquiry for including
490519 - the patient in coronary MRI study undersay at VMCSF; Karen
490520 - will follow up. ref SDS 60 A24I
490521 -
490522 -
490523 -
490524 -
490526 - ..
4906 -
4907 -
4908 - Background
4909 -
4910 -
491001 - Lab on 131015, showing cholesterol remained high, 131015 0724,
491002 - ref SDS 37 BE6O, conflict with increased exercise and weight loss,
491003 - discussed in the letter to the medical team yesterday on 131016 1632.
491004 - ref SDS 38 IW57
491006 - ..
491007 - On 131017 1000 VA medical chart Progress Notes assessment report
491008 - patient status CAD stable, asymptomatic. hyperlipidemia not
491009 - controlled. ref SDS 39 T24N
491011 - ..
491012 - On 131017 1000 Doctor Egan proposed referring patient for clinical
491013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 39 179N
491015 - ..
491016 - On 131017 1000 VA medical chart Progress Notes assessment report
491017 - patient status hyperlipidemia not controlled, ref SDS 39 PSXT; Doctor
491018 - Egan makes referral to SF VA Medical Center for consult on
491019 - participation clinical trials, ref SDS 39 EU9F, with experimental
491020 - agents such as AMG 145 and REGN 727 to resolve multiple statin
491021 - intolerances. ref SDS 39 CN4H
491023 - ..
491024 - On 131103 received letter from VA SF Medical Center scheduling meeting
491025 - on 131121 1000, to consider clinical trial for lowering cholesteral.
491026 - ref SDS 40 YT4N
491027 -
491028 - Thursday November 21, 2013 1000 METAB-FELLOW-THRUSDAY Clinic
491030 - ..
491031 - On 131112 New York Times published several articles reporting that the
491032 - day before on 131113, American Heart Association published new
491033 - guidelines for treating CAD patients that expand use of statin
491034 - medication regardless of cholesterol levels, ref SDS 41 0001, and
491035 - further raise the LDL 70 to LDL 190, as a target for cardiovascular
491036 - risk. ref SDS 41 CW6H
491038 - ..
491039 - On 131114 New York Times published several articles reporting that the
491040 - day before on 131113, American Heart Association published new
491041 - guidelines for treating CAD patients. ref SDS 42 SH6G
491042 -
491043 -
491045 - ..
4911 -
4912 -
4913 - Progress
4914 -
491401 - Hyperlipidemia Not Controlled Cholesterol Elevated Despite Exercise
491402 - Cholesterol Elevated Despite Exercise Discuss Clinical Trial
491403 - Clinical Trial Considered Lower Cholesterol Without Statin Drugs
491404 -
491405 - Follow up ref SDS 40 VY6H, ref SDS 39 VY6H.
491406 -
491407 - Meeting with Doctor Diana Alba, with UCSF Dep of Medicine, Division of
491408 - Endoncrinology and Metabolism,
491410 - ..
491411 - We rviewed patient history showing...
491412 -
491413 - 1. Doctor Egan reported in Progress Notes patient hiked 1200 miles
491414 - for 5 months, shown on 131017 1000, ref SDS 39 UU7J, from lab
491415 - on 130529, ref SDS 33 BE6O, to lab on 131015. ref SDS 37 BE6O
491417 - ..
491418 - Hyperlipademia evident in lab on 131015 0724, ref SDS 37 BE6O,
491419 - appears conflicting with level of exercise.
491421 - ..
491422 - Doctor Alba advised during the meeting today her understanding that
491423 - exercise does not stimulate production of LDL cholesterol.
491424 -
491425 - [On 131125 0005 research found patient with high LDL 249
491426 - was "healthy" with low risk for arterialsclorosis CVD
491427 - because HDL > 50 and triglycerides < 100 so TG/HDL ratio
491428 - below 2, indicating LDL particle size is "protective"
491429 - because it is "large and fluffy" that cannot penetrate
491430 - endothelial lining of artery walls. ref SDS 45 6P4N
491432 - ..
491433 - [On 131125 0005 research indicates high LDL lipid test
491434 - results, like LDL 249 in lab on 131015 0724, ref SDS 37
491435 - BE6O, are well tolerated and even healthy, if discordant,
491436 - ref SDS 45 OB7L, with LDL-P < 1000, ref SDS 45 K68N, if LDL
491437 - particle size is large, and this occurs when triglycerides
491438 - < 100 and HDL > 50, ref SDS 45 338N; exercise increases
491439 - HDL, ref SDS 45 W76M, and lowers triglycerides. ref SDS 45
491440 - QP9F
491442 - ..
491443 - Meeting agenda continues...
491444 -
491445 - 2. Patient diet consistes of macoroni cheese broccolli onion
491446 - mushrooms avocado onion tomato asparagus tuna salmon, shown in
491447 - case study on 120101 0900. ref SDS 13 7G6K This diet nominally
491448 - aids cholesterol control, shown by nutrition chart, in the
491449 - record on 070307 1322, ref SDS 1 KM7K
491451 - ..
491452 - 3. On 130603 0930 Medical Chart Progress Notes show Lipitor also called
491453 - ATORVASTATIN is listed in prescribed medications and status is "hold."
491454 - ref SDS 35 YH7I This reflects patient history suffering severe side
491455 - effects with statin medications, reported during the meeting 5 months
491456 - ago on 121206 0900. ref SDS 25 I05F
491458 - ..
491459 - 4. Research on 131112 found New York Times report AHA published
491460 - new guidelines that increase LDL 190 goals from LDL 70.
491461 - ref SDS 41 P16M Increased statin market based on unspecified
491462 - studies indicating this saves lives, regardless of lowering
491463 - cholesterol. ref SDS 41 HK9O
491465 - ..
491466 - Doctor Alba advised that the VA and UCSF are still reviewing the new
491467 - AHA guidelines. At this time the revised goal of LDL 190 has not
491468 - been accepted for VA cardiology practice.
491470 - ..
491471 - Meeting agenda continues...
491472 -
491473 - 5. Research on 131112 found that cholesterol has very high
491474 - nutritional value, ref SDS 41 CG6I, and lists 6 health
491475 - benefits. ref SDS 41 HC5L
491477 - ..
491478 - Can cholesterol be lowered without adversely affecting...
491479 -
491480 - 1. Hormones........................ ref SDS 41 HC5L
491481 - 2. Digestion....................... ref SDS 41 ME3G
491482 - 3. Cell membranes.................. ref SDS 41 WF4O
491483 - 4. Immune system................... ref SDS 41 9K6K
491484 - 5. Vitamin D - cancer.............. ref SDS 41 6L9H
491486 - ..
491487 - See also Wikipedia presents helpful background on the science of
491488 - cholesterol, including discussion of LDL and HDL issues...
491489 -
491490 - https://en.wikipedia.org/wiki/Cholesterol#Physiology
491492 - ..
491493 - Doctor Alba commented that cholesterol has many health benefits.
491494 - cardiology practice balances benefits with avoiding death from
491495 - arterialsclorosis caused by high LDL cholestorol that settles in
491496 - blood vessels and becomes plaque that clogs blood flow.
491498 - ..
491499 - She gave an example of elevated HDL cholesterol helps resolve
491500 - atherosclerosis. However, doctors have medications to prescribe for
491501 - lowering LDL, but there is no medication that raises HDL to prevent
491502 - atherosclerosis. Therefore cardiology practice prescribes drugs to
491503 - lower LDL levels.
491504 -
491506 - ..
491507 - Meeting agenda continues...
491508 -
491509 - 6. Research on 131114 found New York Times criticized AHA
491510 - guidelines for expanding use of statins, as not based on
491511 - science nor study evidence. 131114 0819, ref SDS 42 UJ5I
491513 - ..
491514 - One of 2 authors who wrote this NYT Op Ed is Doctor Rita F
491515 - Redberg, a cardiologist at the University of California, San
491516 - Francisco Medical Center and the editor of JAMA Internal
491517 - Medicine. ref SDS 42 7J31
491519 - ..
491520 - Doctor Alba could not find contact information for Doctor Redberg in
491521 - Cardiology at UCSF. She will make further inquiies after the meeting
491522 - about engaging Doctor Redberg to support the Welch case,
491524 - ..
491525 - Meeting agenda continues...
491526 -
491527 - 7. Patient history taking statins caused severe side effects of
491528 - myopathy, dizziness, parathesia, and dehydration from increased
491529 - urination, reported in Doctor Egan's Progress notes for meeting
491530 - on 131017 1000, ref SDS 39 PR5G and ref SDS 39 TX50
491531 -
491532 - [On 140213 0830 patient initially suffered minimal side
491533 - effects taking minimal dose Atorvastatin 10 mg and
491534 - Ezetimibe 10 mg for only 2 months. ref SDS 51 JT3M
491536 - ..
491537 - 8. Objectives
491538 -
491539 - 1. Might a study be fashioned to evaluate maintaining good health
491540 - through diet and exercise compared with using statins?
491541 -
491542 - The goal to lower cholesterol is to maintain cardiovascular
491543 - health, including regression of atherosclerosis. Patient
491544 - was hiking 3 - 11 miles per day, 4 - 6 days a week for 10
491545 - years to help wife maintain blood counts needed for getting
491546 - chemotherapy. Millie died on 100729 0510. ref SDS 7 EK4I
491547 - She wanted a promise exercise would continue after she
491548 - died. Regimen did continue, and gradually increased around
491549 - April this year, to hiking 11 miles per day, 7 days a week.
491551 - ..
491552 - [On 131125 0005 research finds physical exercise
491553 - increases both HDL and EPCs, which rapidly regresses
491554 - plaque in blood vessels. ref SDS 45 186Y
491556 - ..
491557 - [On 131216 0028 letter to Doctor Alba and medical team
491558 - submits pending issues to discuss during meeting on
491559 - 131219. ref SDS 48 8N50
491561 - ..
491562 - Diana said this high level of physical activity should be
491563 - continued.
491564 -
491565 - [...below on 131121 0930 Progress Notes say to continue
491566 - physical activity. ref SDS 0 864I
491567 -
491569 - ..
491570 - 2. Targeted drug treatment to lower cholesterol without side
491571 - effects.
491573 - ..
491574 - PCSK9 drugs being developed and tested in clinical trials
491575 - by Amgen and Regeneron, reported last year on 120325 1312,
491576 - ref SDS 16 QG8R, was discussed with Doctor Egan during the
491577 - meeting at the VA on 131017. ref SDS 39 PS4M At that time,
491578 - Doctor Egan reported in Progress Notes of patient medical
491579 - chart that assessment of patient status indicates
491580 - hyperlipidemia not controlled, ref SDS 39 PSXT; Doctor Egan
491581 - made referral to SF VA Medical Center for consult on
491582 - participation clinical trials, ref SDS 39 EU9F, with
491583 - experimental agents such as AMG 145 and REGN 727 to resolve
491584 - multiple statin intolerances. ref SDS 39 CN4H
491585 -
491586 - [...below on 131121 0930 at 1125 suggestion to ask
491587 - Doctor Kane at UCSF about clinical trials for non-statin
491588 - drugs. ref SDS 0 MZ4K
491590 - ..
491591 - [...below on 131121 0930 VA Progress Notes in medical
491592 - chart report consideration for patient to participate in
491593 - clinical trial testing PCSK9 drugs to manage cholesterol
491594 - for lowering CVD risk through regression of
491595 - atherosclerosis. ref SDS 0 Q17I
491596 -
491598 - ..
491599 - Atorvastatin 4-week Trial Predicate Clinical Trial Add Zetia 10 MG
491600 -
491601 - Doctor Alba prescribed trying Atorvastatin (Lipitor) 10 mg everyother
491602 - day for 4 weeks to assess lowering cholesterol LDL 249. Will then
491603 - evaluate adding a 2nd drug, Zetia 10 mg, which together are intended
491604 - to lower cholesterol and to reduce side effects from taking statin
491605 - drugs alone.
491607 - ..
491608 - [...below on 131121 0930, VA Progress Notes reflect
491609 - understadings to take Atorvastatin 10 mg low dose for a
491610 - period of 4 weeks to test tolerance, then assess adding
491611 - Ezetimibe 10 mg. ref SDS 0 S26O
491613 - ..
491614 - [On 131121 1604 in another record later today, VA
491615 - prescription RX # 5674471 for Atorvastatin 20 mg has been
491616 - ordered. ref SDS 44 GH5M
491618 - ..
491619 - [On 131125 0005 letter from Karen reports VA work plan to
491620 - take statin drug low dose Atvorstatin 10 mg for 4 weeks,
491621 - then add Zetia 10 mg in clinical trial for lowering
491622 - cholesterol. ref SDS 45 V154
491624 - ..
491625 - [On 131125 0005 research seems to indicate this clincial
491626 - trial of low dose Atorvasatatin 10 mg with Zeitia 10 mg has
491627 - lowered cholesterol to LDL < 70. ref SDS 45 WL7I
491629 - ..
491630 - [On 131125 0005 research found ezetimibe (Zetia) mg added
491631 - to Atorvastatin 20 mg yielded significantly greater changes
491632 - to HDL and Triglycerides (TG), than taking Atorvastatin in
491633 - higher doses, e.g., 20 or 40 mg. ref SDS 45 CO56
491635 - ..
491636 - [On 131125 0005 research finds ezetimibe (Zetia) for
491637 - secondary drug recommended by "expert" to treat high risk
491638 - CVD patient, ref SDS 45 XG4N, where LDL-P is high and
491639 - discordant with low LDL-C, approximated by TG/HDL-C ratio <
491640 - 2, ref SDS 45 QS9F, which is shown by evidence in this case
491641 - from lab on 131015 0724. ref SDS 37 BE6O
491643 - ..
491644 - [On 131125 0005 research study finds Atorvastatin 10 mg
491645 - combined with ezetimibe 10 mg yielded 0.4% regression
491646 - atherosclerosis plaques over 1 year. ref SDS 45 Z56P
491648 - ..
491649 - [On 131205 1448 received new prescription for Atvorstatin
491650 - 20 mg, ordered by Doctor Alba today for 4-week trial to
491651 - assess side effects for adding 2nd drug, Zetia 10 mg to
491652 - lower LDL 249. ref SDS 46 GH5M
491654 - ..
491655 - [On 131216 0028 letter to Doctor Alba and medical team
491656 - submits pending issues to discuss during meeting on 131219.
491657 - ref SDS 48 8N50
491659 - ..
491660 - [On 131230 1450 received prescription for Ezetimibe,
491661 - ref SDS 50 5N3O, so begin trial Atorvastatin 10 mg and
491662 - Ezetimite 10 mg to manage cholesterol, shown in case study
491663 - on 120101 0900. ref SDS 14 6A6H
491665 - -
491666 - Side effects of Atorvastatin (Lipitor) were reviewed with Doctor Egan
491667 - during meeting at VA on 130603 0930. ref SDS 34 PC6O
491669 - ..
491670 - Will meet again in 4 weeks to review results of Doctor Alba's research
491671 - for a clinical trial that does not involve statin drugs; and decide on
491672 - best course of care.
491674 - ..
491675 - This evening started taking Atorvastatin 40 mg, reported in case study
491676 - on 120101 0900, ref SDS 13 RN3F, and on hand from prior prescription
491677 - ordered by Doctor Egan, shown in Progress Notes for meeting on 130603
491678 - 0930. ref SDS 34 1X3L
491680 - ..
491681 - [On 131125 0005 research found ezetimibe (zetia) mg added
491682 - to Atorvastatin 20 mg yielded significantly greater changes
491683 - to HDL and Triglycerides (TG), than taking Atorvastatin in
491684 - higher doses, e.g., 20 or 40 mg. ref SDS 45 CO56
491686 - ..
491687 - [On 131125 0005 research found dizziness less common side
491688 - effect taking ezetimibe (zetia). ref SDS 45 JO6K
491690 - ..
491691 - [On 131205 1448 received new prescription for Atvorstatin
491692 - 20 mg, ordered by Doctor Alba today for 4-week trial to
491693 - assess side effects for adding 2nd drug, Zetia 10 mg to
491694 - lower LDL 249. ref SDS 46 GH5M
491696 - ..
491697 - [On 131216 0028 letter to Doctor Alba and medical team
491698 - submits pending issues to discuss during meeting on 131219.
491699 - ref SDS 48 8N50
491701 - ..
491702 - [On 140430 0900 letter to VA notifies some minor dizziness
491703 - has begun while taking Atorvastatin 10mg with Ezetimibe
491704 - 10mg. ref SDS 52 PU43
491705 -
491706 -
491707 -
491708 -
491709 -
491711 - ..
4918 -
4919 -
4920 - 1125
4921 -
492101 - Met with Karen and Doctor Shunk in Cardiology located in Building 203
492102 - across the street from the clinics.
492104 - ..
492105 - Karen was pleased to hear former cabg x4 patient in 2009, climbed
492106 - Half Dome in Yosemite this past September 18, 2013.
492107 -
492108 - [On 131125 0005 letter to Karen confirms understandings
492109 - from meeting at VA SF Medical Center today, ref SDS 45
492110 - HY6O, and commend VA for excellent care. ref SDS 45 UK3R
492112 - ..
492113 - We discussed testing for regression of atherosclerosis based on
492114 - increased endurance exercise this year to prepare for Half Dome, and
492115 - continuing into Ocotober, November, listed in case study on 120101,
492116 - showing...
492117 -
492118 - 2013 Miles Source
492119 - April................ 140........ ref SDS 13 Q48M
492120 - May.................. 302........ ref SDS 13 QG3F
492121 - June ................ 89........ ref SDS 13 765L
492122 - July................. 172........ ref SDS 13 T78G
492123 - August............... 297........ ref SDS 13 554N
492124 - September............ 225........ ref SDS 13 419J
492125 - October.............. 373........ ref SDS 13 6F9N
492127 - ..
492128 - Doctor Shunk cautioned against doing an invasive surgical procedure
492129 - solely to assess regression of atherosclerotic plaques, like the IVUS
492130 - angiogram study he did on 091021, ref SDS 3 7L43, which led to CABG
492131 - +4 heart surgery the next day, brilliantly performed by Doctor Tseng,
492132 - and her team on 091022. ref SDS 4 PQWU
492133 -
492134 - [On 170314 0817 Doctor Shunk proposed inquiry for including
492135 - the patient in coronary MRI study undersay at VMCSF; Karen
492136 - will follow up. ref SDS 60 A24I
492138 - ..
492139 - We considered non-invasive methods, for example after Doctor Shunk did
492140 - invasive angiography in the early morning of 091021 0716, Irene later
492141 - performed ultrasound procedure that tested blood flow to the brain on
492142 - 091021 0716 at 1207. ref SDS 3 04CH This non-invasive test verfied
492143 - patient was a viable candidate for CABG performed the next day on
492144 - 091022.
492146 - ..
492147 - Today, there was not enough time for further discussion. Doctor
492148 - Shunk and Karen urged further research for effective non-invasive
492149 - modalities to test for response to treatment that regresses
492150 - atherosclerosis.
492152 - ..
492153 - [On 131125 0005 research found regression of
492154 - atherosclerosis occurs rapidly with endurance exercise that
492155 - increases endothelial progenitor cells (EPC) produced by
492156 - bone marrow, similar to WBC, ref SDS 45 1855, and increases
492157 - production of HDL cholesterol mainly in the liver and
492158 - intestine, ref SDS 45 RA7K; non-invasive coronary CTA with
492159 - calcium score can test for response to treatment with high
492160 - levels of endurance exercise for regression of
492161 - atherosclerosis. ref SDS 45 278M
492163 - ..
492164 - [On 140515 letter to medical team reports visiting
492165 - San Francisco Medical Center Radiology Department on
492166 - doing coronary CTA assess regression of
492167 - atherosclerotic plaques resulting from
492168 - interventions, including CABG +4 on 091022, with
492169 - subsequent high levels of hyperlipedimeia (LDL 249),
492170 - followed by dramatic decline in LDL-P and rise of
492171 - HDL. ref SDS 53 YM41
492173 - ..
492174 - [On 140805 1030 meeting Karen in Cardiology Administration
492175 - discussed testing with coronary CTA and calcium score
492176 - standard of care to evaluate response to treatment for
492177 - regression of atherosclerosis based on hiking 300 miles per
492178 - month that lowered LDL-P 851, HDL 67 TG 58. ref SDS 54 IW6M
492180 - ..
492181 - [On 150526 1148 Karen recommended consulting Doctor Simpson
492182 - on ordering CCTA for testing response to treatment for
492183 - regressing atherosclerosis, toward lowering line of care in
492184 - order reduce debilitating side effects. ref SDS 55 3G4O
492186 - ..
492187 - [On 150925 0336 Karen in Cardiology asked schedule Clerk,
492188 - Joe, to schedule meeting with Doctor Simpson for
492189 - consultation on ordering CCTA. ref SDS 56 GK9I
492191 - ..
492192 - [On 151014 0900 meeting with Doctor Simpson scheduled CCTA
492193 - with calcium score on 151019 0930. ref SDS 57 OG3N
492195 - ..
492196 - [On 151019 0930 CCTA with calcium score performed; meeting
492197 - with doctor in Radiology Department reviewed requirements
492198 - for calcium score to evaluate response to treatment
492199 - recovering from atherosclorosis. ref SDS 58 GR4K At the
492200 - end of the meeting, the doctor agreed to perform calcium
492201 - score for comprehensive CCTA test. ref SDS 58 LQ5F
492203 - ..
492204 - [On 170314 0817 Doctor Shunk proposed inquiry for including
492205 - the patient in coronary MRI study underway at VMCSF; Karen
492206 - will follow up. ref SDS 60 A24I
492207 -
492209 - ..
492210 - Karen advised that Doctor Tseng has been promoted to Chief of Surgery,
492211 - taking over for retiring Doctor Ratcliffe. Elaine was attending for
492212 - CABG x4 surgery on 091022 0700. ref SDS 4 PQWU Doctor Ratcliffe
492213 - supervised recovery after Doctor Tseng was on vacation for a week,
492214 - e.g., reviewing feeding tube issue on 091030 0810. ref SDS 5 03GF
492215 -
492216 -
492218 - ..
492219 - Chia Seeds Lower Cholesterol Control Weight Increase Energy
492220 -
492221 - Karen suggested trying Chia seeds to lower cholesterol without
492222 - medications. She indicated Chia seeds boost energy as well.
492223 -
492224 - [On 120101 0900 case study reports on 131125, began adding
492225 - Chia seeds to daily diet. ref SDS 14 746M
492227 - ..
492228 - [On 131125 0005 letter notifies Karen implemented
492229 - suggestion adding Chia seeds to daily diet. ref SDS 45 YU66
492230 -
492232 - ..
492233 - Later, research on the Internet found...
492234 -
492235 - CHIPRX.COM
492236 -
492237 - Fitness
492238 -
492239 - How Chia Seeds Can Benefit Your Health
492240 - 6 Great Reasons to Start Eating Chia Seed
492241 -
492242 - http://www.chiprx.com/chia-seeds-benefit-health-6-great-reasons-start-eating-chia-seed/
492244 - ..
492245 - Chia seeds are becoming a popular nutritional item thanks
492246 - to all the attention it has been getting on TV shows like
492247 - Dr OZ. However, they have been around for years as people
492248 - from various cultures from as far back as the BC era have
492249 - used it to help treat medical problems like joint pain. A
492250 - member of the mint family, Chia is mainly produced in
492251 - Mexico and provides a bunch of health benefits that people
492252 - are beginning to use as an important part of a healthy
492253 - diet.
492255 - ..
492256 - Health Benefits of Chia Seeds
492257 -
492258 - 1. Omega 3 Fatty Acids
492259 -
492260 - Omega 3 fatty acids have some of best anti-inflammatory
492261 - properties available in nature. Chia seeds have the
492262 - most omega 3 fatty acids than any other plant out
492263 - there. These essential fats can help decrease
492264 - inflammation and pain your body may be experiencing.
492265 - Along with reducing inflammation the omega 3 fatty
492266 - acids naturally found in chia seeds can improve your
492267 - cognitive function, decrease high cholesterol, and keep
492268 - your joints lubricated.
492270 - ..
492271 - 2. Protein
492272 -
492273 - Everybody needs protein, as it is an essential part of
492274 - every cell inside our body. Everything from our hair
492275 - to nails is made up of protein. Protein helps to build
492276 - your bones, muscles, skin, and helps repair damaged
492277 - tissues. Chia seeds are packed with this
492278 - macronutrient. In fact, just 1 ounce of chia seeds has
492279 - 4.4 grams of protein. If you are a vegan then chia
492280 - seeds should be included in your daily diet to make
492281 - sure your body gets all the complete protein it needs.
492283 - ..
492284 - 3. Fiber
492285 -
492286 - Chia seeds is a rich source of fiber which can help
492287 - decrease inflammation, keep your bowel functioning
492288 - properly, increase weight loss, and decrease your
492289 - cholesterol. Just two tablespoons of chia contains at
492290 - least 10 grams of fiber, which will give you most of
492291 - your daily recommended fiber intake.
492293 - ..
492294 - 4. Antioxidants
492295 -
492296 - Antioxidants are the compounds your body needs to
492297 - fight off certain diseases, infections, and cancers.
492298 - Chia is a great source of various antioxidants like
492299 - quercetin, myricetin, and cholorgenic acid. These
492300 - antioxidants that chia packs can benefit you in more
492301 - ways than one when it comes to your health. For
492302 - example, chlorogenic acid has great anti-cancer
492303 - properties that can kill free radicals that cause
492304 - certain cancers.
492306 - ..
492307 - This antioxidant can also help you slow down the
492308 - release of glucose in your bloodstream after you eat,
492309 - and help you decrease your chances of experiencing Type
492310 - 2 Diabetes. These antioxidants naturally found in chia
492311 - seeds can also help improve your heart health and
492312 - improve the health of your liver and gallbladder.
492314 - ..
492315 - 5. Minerals
492316 -
492317 - Chia is a fantastic source of minerals like potassium,
492318 - magnesium, calcium, and manganese that can help you
492319 - lower your high blood pressure.
492321 - ..
492322 - 6. Using Chia Seeds For Health Problems
492324 - ..
492325 - With all these different essential nutrients that chia
492326 - seeds contain you can see why it is important to start
492327 - eating them. Check out some of the health problems you
492328 - can use chia seeds to remedy.
492330 - ..
492331 - 7. Weight Loss
492332 -
492333 - Eating chia seeds can help you reduce your appetite
492334 - because of the rich amount of fiber it contains. Chia
492335 - will help block the absorption of calories, which will
492336 - help your diet be successful.
492338 - ..
492339 - 8. Arthritis
492340 -
492341 - Arthritis can cause a lot of pain in your joints. The
492342 - more chia seeds you eat the more lubricated your joints
492343 - will be, which will reduce the pain associated with
492344 - this condition. The omega 3 fatty acids in chia will
492345 - give you the anti-inflammatory properties you need to
492346 - decrease the swelling.
492348 - ..
492349 - 9. Diabetes
492350 -
492351 - Since chia seeds are effective at regulating carbs and
492352 - the sugars they are converted into. Chia will create a
492353 - barrier inside your stomach to assist with slowing down
492354 - the digestion of sugar in your blood, which will help
492355 - keep a diabetics glucose level down.
492357 - ..
492358 - 10. Skin, Hair, & Nail Health
492359 -
492360 - Thanks to the essential fatty acids found in chia this
492361 - food item can keep your nails, hair, and skin looking
492362 - youthful. These seeds will keep your body hydrated and
492363 - moisturized to fight of dry and irritated skin.
492365 - ..
492366 - 11. Heart Health
492367 -
492368 - If you want to avoid heart problems like cardiovascular
492369 - disease it is a good idea to add chia to your diet. It
492370 - is the essential fatty acids in chia that can add more
492371 - good cholesterol to your system and reduce the amount
492372 - of bad cholesterol. Bad cholesterol, also known as
492373 - LDL, is a huge cause of heart disease so anything you
492374 - can do to reduce this cholesterol will improve your
492375 - heart health.
492377 - ..
492378 - 12. Increase Your Energy Level
492379 -
492380 - The hydrophilic properties in chia seeds can assist you
492381 - with regulating your electrolytes which will have a
492382 - positive effect on your energy levels. Chia contains
492383 - complex carbs that will gradually break down over time
492384 - in your system so your energy levels stay up for
492385 - enhanced stamina. The essential fatty acids in chia
492386 - like omega 3 will improve your mood and mental energy.
492388 - ..
492389 - 13. How to Add Chia To Your Diet
492390 -
492391 - You can add chia seeds to just about anything you eat.
492392 - Add it to your cereal, salads, or add them to your
492393 - favorite baked item before you put it in the oven to
492394 - bake. You can also eat the seeds just as they are or
492395 - use them to make a smoothie. Finally, you can try
492396 - making a chia paste by soaking the seeds for around
492397 - thirty minutes until a clear paste forms.
492399 - ..
492400 - 14. John is a health enthusiast that writes on various
492401 - health topics. He is currently doing some online
492402 - research at Wart Removal Experts on natural ways to
492403 - remove warts.
492404 -
492405 -
492406 -
492408 - ..
492409 - Karen indicated Doctor John Kane at UCSF is a good contact for
492410 - participating in a clinical trial of new targeted and non-static drugs
492411 - - PCSK9, discussed with Doctor Alba earlier this morning, per above.
492412 - ref SDS 0 545O
492414 - ..
492415 - Doctor Shunk provided helpful guidance to focus on lowering LDL
492416 - cholesterol along with lifestyle of healthy diet and exercise.
492418 - ..
492419 - Karen indicated that Doctor Kane is a good contact for lipid trials.
492420 -
492421 - [On 131125 0005 letter from Karen reports VA work plan to
492422 - take statin drug low dose Atvorstatin 10 mg for 4 weeks,
492423 - then add Zetia 10 mg in clinical trial for lowering
492424 - cholesterol. ref SDS 45 V154
492426 - ..
492427 - [On 131125 0005 research finds ezetimibe (zetia) for
492428 - secondary drug recommended by "expert" to treat high risk
492429 - CVD patient, ref SDS 45 XG4N, where LDL-P is high and
492430 - discordant with low LDL-C, approximated by TG/HDL-C ratio <
492431 - 2, ref SDS 45 QS9F, which is shown by evidence in this case
492432 - from lab on 131015 0724. ref SDS 37 BE6O
492434 - ..
492435 - [On 131216 0028 letter to Doctor Alba and medical team
492436 - submits pending issues to discuss during meeting on 131219.
492437 - ref SDS 48 8N50
492438 -
492439 -
492440 -
492441 -
492442 -
4925 -
SUBJECTS
Examination Progress Notes Endocrinology Medical Chart Meeting 13112
5903 -
590401 - ..
590402 - Medical Chart Progress Notes Meeting 131121 VA SF Medical Center
590403 -
590404 - Follow up ref SDS 39 TF5O. ref SDS 35 TF5O.
590405 -
590406 - 1. LOCAL TITLE: ENDOCRINE-METABOLISM CLINIC (MED)
590407 - STANDARD TITLE: ENDOCRINOLOGY OUTPATITNE NOTE
590408 - DATE OF NOTE: NOV 21, 2013 @ 0956
590409 - ENTRY DATE: NOV 21, 2013 @095641
590419 - ..
590420 - CC: high cholesterol
590422 - ..
590423 - 2. HPI:
590424 -
590425 - 1. 68 year old male with history of CAD, s/p CABG in 2009,
590426 - Hyperlipidemia, achalasia, s/p lap heller myotomy and
590427 - fundoplication in 2009, who was referred by his Cardiologist,
590428 - Doctor Egan for management of hyperlipidemia.
590430 - ..
590431 - 2. Patient was started on Simvastatin approximately 2-3 years
590432 - ago, LDL at that time was around 180's - reports this his
590433 - LDL dropped to 96 while on simvastatin, however he reports
590434 - he develop "left shoulder myopathy"- he described pain on
590435 - his left shoulder and inability to raise it above 90
590436 - degrees- No CPK on records.
590438 - ..
590439 - 3. He was then started on Rosuvastatin 10 mg po daily and
590440 - report that his LDL improved. Rosuvastatin was then
590441 - increased to 20 mg and he developed sexual dysfunction,
590442 - dizziness, dry mouth and right foot numbness. As per
590443 - cardiology notes in September 2012- rosuvastatin was
590444 - decreased to 10 mg po daily and dizziness improved, but he
590445 - continued to complain of right foot numbness. He now has
590446 - he has been off the rosuvastatin since 12/2012, and he
590447 - continues to complain of right foot nmbness, but he reports
590448 - less episodes of right sole numbness with decreased
590449 - intensity.
590451 - ..
590452 - Comment...
590454 - ..
590455 - Over the past year there have been 7 episodes while hiking of
590456 - peripheral neuropathy (parethesia, numbness, tingling) documented in
590457 - the record after ending Rosuvastatin on 121206. These events subsided
590458 - within .5 to 1 mile, as follows...
590459 -
590460 - 1. Left foot after 1.5 miles.......... 121212, ref SDS 13 VH5O
590462 - ..
590463 - 2. Right foot after 1 mile............ 130107, ref SDS 13 8H5F
590464 - Left foot after 1.5 miles.......... 130107, ref SDS 13 8H5F
590466 - ..
590467 - 3. Right foot after .25 miles......... 130210, ref SDS 13 PV8I
590468 - Left foot after 2 miles............ 130210, ref SDS 13 PV8I
590470 - ..
590471 - 4. Right foot after .5 miles.......... 130604, ref SDS 13 X14N
590473 - ..
590474 - 5. Right foot after .5 miles.......... 130609, ref SDS 13 8G5L
590476 - ..
590477 - 6. Right foot after .5 miles.......... 130610, ref SDS 13 TH3K
590479 - ..
590480 - 7. Right foot after .5 miles.......... 130614, ref SDS 13 TSUY
590482 - ..
590483 - VA Progress Notes HPI continues...
590484 -
590485 - Of note, he was seen by neurology February 2013 for the
590486 - foot numbness, Vit B12 level was within normal range,
590487 - fasting glucose level ranges from 108 to 115 mg/dl, Hgalc
590488 - 5.5 October 2013, as per neurology notes no evidence of
590489 - radiculopathy or neuropathy.
590491 - ..
590492 - Patient history shows meeting with Doctor Abrams on 130227 0930.
590493 - ref SDS 29 PPWW At that time, the doctor indicated no evidence for
590494 - spinal stenosis causing peripheral neuropathy. ref SDS 29 UT6T The
590495 - doctor ordered HGA1c lab. 130227 0930, ref SDS 29 P44K However, it is
590496 - not reported for the lab performed the next day on 130228 1140,
590497 - ref SDS 30 RP4N, nor in the follow up lab 3 months later on 130529
590498 - 0818. ref SDS 33 RP4N HGA1c 5.5 range 4.1 - 6, was reported for lab
590499 - on 131015 0724. ref SDS 37 9F4O
590501 - ..
590502 - VA Progress Notes HPI continues...
590503 -
590504 - 8. Mr Welch would like to be part of a clinical trial for a
590505 - new lipid lowering medication; in particular he is asking
590506 - about AMG 145- PCSK9 inhibitors. Regarding other lipid
590507 - lowering agents, he has never Zetia, has been offered
590508 - colestipol as per records, but concerned for midly elevated
590509 - total bilirubin [1.7].
590511 - ..
590512 - This aligns with discussion on participating clinical trial, per
590513 - above, ref SDS 0 545O, based on Doctor Egan's Progress Notes with
590514 - assessment that patient hyperlipidemia not controlled, ref SDS 39
590515 - PSXT; Doctor Egan made referral to SF VA Medical Center for consult on
590516 - participation clinical trials, ref SDS 39 EU9F, with experimental
590517 - agents such as AMG 145 and REGN 727 to resolve multiple statin
590518 - intolerances. ref SDS 39 CN4H
590520 - ..
590521 - PCSK9 drugs being developed independently by Amgen and Regeneron
590522 - presents an alternative to statin drugs for treating atherosclerosis
590523 - was reported in an article reviewed on 120325 1312. ref SDS 16 QG8R
590524 -
590525 - [...below on 131121 0930 VA Progress Notes in medical
590526 - chart report plan to investigate clincial trials to
590527 - treat atherosclerosis with PCSK9 drugs, rather than
590528 - statins. ref SDS 0 X53M
590530 - ..
590531 - VA Progress Notes Meeting 131121 continue...
590532 -
590533 - 9. He denies CP, SOB, Denies abdominal pain, muscle pain.
590534 - Reports occassional right foot numbness.
590536 - ..
590537 - 10. He is very active- hikes 2-4 times per week- about 14
590538 - miles. Reports low fat/low cholesterol diet, avoid
590539 - processed and fried foot
590541 - ..
590542 - Patient history hiking was discussed during the meeting, per above.
590543 - ref SDS 0 4B6M Past 2 years patient hiked 11 miles per day 4 - 5
590544 - times per week, shown in case study on 120101 0900. ref SDS 13 QJ5I
590545 - Past 6 months patient hikes 5 - 7 times per week, 11 miles per day.
590546 - ref SDS 13 YI5I
590548 - ..
590549 - VA Progress Notes Meeting 131121 continue...
590550 -
590551 - 3. PMH:
590552 -
590553 - 1. Esophageal Achalasia
590554 - 2. CAD s/p CABG x4 in 2009
590555 - 3. GERD
590556 - 4. Hyperlipidemia
590558 - ..
590559 - 4. PSH:
590560 -
590561 - 1. CABG (10/22/2009)
590562 - 2. Left knee repair
590563 - 3. Lap heller myotomy, fundoplication December 2009
590564 - 4. EGD dilations
590566 - ..
590567 - 5. MEDICATIONS
590568 -
590569 - 1. Omeprazole 20 mg BID
590571 - ..
590572 - 6. Social History:
590573 -
590574 - 1. Tobacco: Denies smoking
590575 - 2. Alcohol: social
590576 - 3. Ilicit drugs: denies
590578 - ..
590579 - 7. Family History:
590580 -
590581 - 1. Father: stroke age 65
590582 - 2. Mother: deceased " old age"
590583 - 3. 7 brothers/sisters: healthy-
590584 - 4. Denies family hx of high cholesterol, heart disease
590586 - ..
590587 - Comment...
590589 - ..
590590 - Older sister, died from lung cancer at age 58.
590592 - ..
590593 - Younger sister died at about age 55 from unknow causes, was way
590594 - overweight, drank and smoked.
590596 - ..
590597 - There is no record of high cholesterol nor heart disease, so patient
590598 - can neither deny nor affirm family history on these issues. Seems
590599 - likely father suffered high cholesterol, and seems likely younger
590600 - sister did as well.
590601 -
590602 - [On 131216 0028 corrections to family history were
590603 - submitted to the VA. ref SDS 48 8N61
590605 - ..
590606 - VA Progress Notes HPI continues...
590607 -
590608 - 8. PHYSICAL EXAM
590609 -
590610 - 1. Vital Signs:
590611 -
590612 - 1. HT: 66 in [167.6 cm] (12/16/2009 1800)
590613 - 2. WT: 178.8 lb [81.3 kg] (11/21/2013 0947)
590614 - 3. HR: 60 (11/21/2013 0947)
590615 - 4. BP: 129/75 (11/21/2013 0947)
590616 - 5. Temp: 97.1 F [36.2 C] (12/20/2009 0846)
590617 - 6. O2 Sat: 11/21/13 094703 091
590618 - 7. BMI: 28.9 (Overweight)
590620 - ..
590621 - 2. Gen : NAD, AAO x3
590623 - ..
590624 - 3. HEENT : NC/AT, MMM, PERRL.
590626 - ..
590627 - 4. Neck : supple, no thyromegaly
590629 - ..
590630 - 5. CARDIO : BRR
590632 - ..
590633 - 6. LUNGS : CTA Bl, no wheeze
590635 - ..
590636 - 7. ABD : soft, NT/ND.
590638 - ..
590639 - 8. EXT : no edema, no cyanosis, no xanthemas, no achiles
590640 - tendon thickening
590642 - ..
590643 - 9. LABS:
590644 -
590645 - 1. October 2013
590646 -
590647 - TC............. 321
590648 - LDL............ 249
590649 - HLD............ 50
590650 - TG............. 85
590651 - TBil........... 1.7
590653 - ..
590654 - HLD 50 should be HDL 50 - minor correction.
590656 - ..
590657 - Triglycerides (TG) reported 109 not 85, for lab on 131015 0724.
590658 - ref SDS 37 BE6O
590659 -
590660 - [On 131219 0930 Progress Notes for next meeting repeats
590661 - error reporting TG 85, should be 109. ref SDS 49 FJ6G
590663 - ..
590664 - VA Progress Notes LABS continues...
590665 -
590666 - 2. May 2013
590667 -
590668 - TC............. 307
590669 - LDL............ 240
590670 - HLD............ 54
590671 - TG............. 85
590672 - TBil........... 1.3
590674 - ..
590675 - 3. November 2012
590676 -
590677 - TC............. 173
590678 - LDL............ 105
590679 - HLD............ 57
590680 - TG............. 53
590681 - TBil........... 1.6
590682 -
590683 - 4. 14 December 2009
590684 -
590685 - TC............. 241 H 100 - 240 PLASMA
590686 - LDL (Calcultd). 170 H - 131 PLASMA
590687 - HLD............ 44 35 - PLASMA
590688 - TG............. 136 10 - 190 PLASMA
590690 - ..
590691 - 10. Assessment and Plan:
590692 -
590693 - 1. 68 year old male with history of CAD, s/p CABG in 2009,
590694 - Hyperlipidemia, referred by cardiology for management of
590695 - hyperlipidemia. Most recent LDL 249 in a patient with known
590696 - CAD- unclear history of myopathy secondary to simvastatin,
590697 - and neuropathy and sexual dysfunction secondary to
590698 - Rosuvastatin. Regarding history to right foot numbness, he
590699 - continues to have symptoms despite been off Rosuvastatin for
590700 - 10 months now, so unclear casual effect.
590702 - ..
590703 - Comment...
590705 - ..
590706 - Patient history shows peripheral neuropathy (parathesia - numbness,
590707 - tingling) first reported on 120422 - see case study on 120101 0900.
590708 - ref SDS 13 RQQT Rosuvastatin 10 mg started on 110823, see case study
590709 - on 101010 0744. ref SDS 8 KF8O Rosuvastatin 20 mg began daily use on
590710 - 120208. ref SDS 13 RR4F Severely debilitating peripheral neuropathy
590711 - occurred on 120513, see case study on 120101. ref SDS 13 F97O Similar
590712 - episode on 120625. ref SDS 13 7G5M Patient history continues showing
590713 - daily episodes until Rosuvastatin ended on 121206, ref SDS 13 GC6N,
590714 - e.g., standing in waiting room at VA to get lab, right foot went numb
590715 - - had to walk through halls to relieve condition. ref SDS 13 X75H
590716 - Over the past year, peripheral neuropathy right foot has gradually
590717 - subsided in frequency and intensity. No reports of episodes for past
590718 - 2 months; however, very occasionally, while standing in line, e.g.,
590719 - Costco, may feel slight thickness in right foot - could be
590720 - imagination.
590722 - ..
590723 - VA Progress Notes Assessment and Plan continue...
590724 -
590725 - 2. Prolonged discussion of best approach to treat hyperlipdemia,
590726 - patient understands that LDL goal < 70. He also understands
590727 - that despite appropriate diet and exercise, his LDL is still
590728 - not at goal, and20ncreasing exercise activity is of little
590729 - benefit at this point, since elevated cholesterol in his case
590730 - has a genetic component, that needs to be treated with
590731 - medication.
590733 - ..
590734 - [On 160715 1630 Doctor Yoo Progress Notes in Neurology
590735 - sets goal for LDL < 100, appears conflicting with VA
590736 - goals for LCL < 70. ref SDS 59 O45I
590738 - ..
590739 - 3. He agrees to try Atorvastatin low dose, it seems it was
590740 - prescribed in the past, but patient reports not taking it.
590742 - ..
590743 - 4. We need to do combination therapy, so we can add Zetia 10 mg
590744 - daily. Patient is hesitant to start both medications at the
590745 - same time for fear of possible side effects, so agrees to try
590746 - Atorvastatin for 4 weeks, and monitor any side effects, then we
590747 - can add Zetia and recheck lipids.
590749 - ..
590750 - 5. Plan:
590751 -
590752 - 1. Trial of Atorvastatin 10 mg po daily, if tolerated we
590753 - can increase to maximum dose to reach LDL goal
590754 -
590755 - 2. Start Zetia 10 mg po daily in 4 weeks.
590757 - ..
590758 - This plan aligns with understandings from meeting today, as shown in
590759 - the record above. ref SDS 0 6H6K
590761 - ..
590762 - [On 131125 0005 research finds ezetimibe (zetia) for
590763 - secondary drug recommended by "expert" to treat high
590764 - risk CAD patient, ref SDS 45 XG4N, where LDL-P is
590765 - high and discordant with low LDL-C, approximated by
590766 - TG/HDL-C ratio < 2, ref SDS 45 QS9F, which is shown
590767 - by evidence in this case from lab on 131015 0724.
590768 - ref SDS 37 BE6O
590770 - ..
590771 - [On 131125 0005 research found ezetimibe (zetia) mg
590772 - added to Atorvastatin 20 mg yielded significantly
590773 - greater changes to HDL and Triglycerides (TG), than
590774 - taking Atorvastatin in higher doses, e.g., 20 or 40
590775 - mg. ref SDS 45 CO56
590777 - ..
590778 - VA Progress Notes Plan continues...
590779 -
590780 - 3. Regarding medical trial- PCSK9 is not available at this
590781 - time, but I will contact UCSF to determine if there are
590782 - any ongoing trials for lipid lowering medications and
590783 - see if Mr Welch could participate in any of them.
590785 - ..
590786 - This implements discussion during the meeting today, on finding
590787 - clinical trial for PCSK9 to recover from atherosclerosis, without
590788 - using statins, shown above. ref SDS 0 1P5M, and as further cited in
590789 - the Progress Notes. ref SDS 0 Q17I
590791 - ..
590792 - VA Progress Notes Plan continues...
590793 -
590794 - 4. Continue physical activity and low fat/low
590795 - cholesterol diet.
590797 - ..
590798 - Physical activity hiking 11 miles per day 6 - 7 times per week, per
590799 - above. ref SDS 0 Q184
590801 - ..
590802 - VA Progress Notes Plan continues...
590803 -
590804 - 5. RTC in 4 weeks
590805 -
590806 - [On 131210 received letter from Doctor Alba asking about
590807 - progress taking Atorvastatin 40 mg, and requesting
590808 - submission of pending issues for next meeting. ref SDS 47
590809 - HY6O
590811 - ..
590812 - [On 131216 0028 letter to Doctor Alba and medical
590813 - team submits pending issues to discuss during
590814 - meeting on 131219, ref SDS 48 8N50, and lists
590815 - TG/HDL-C ratio and LDL-P issues. ref SDS 48 6T49
590817 - ..
590818 - 6. Patient was discussed with Doctor Bikle
590820 - ..
590821 - 11. Clinical Reminder Activity
590822 -
590823 - MED REC NON PRIMARY CARE:
590825 - ..
590826 - Medication Reconciliation completed, including non-VA
590827 - medications and descrepancies, if identified, were addressed.
590828 - Medication, medication changes and importance of medication
590829 - management were reviewed with the patient/caregiver. An
590830 - updated list of reconciled medications have been provided to
590831 - the patient/caregiver.
590843 -
590844 -
590845 -
590846 -
590847 -
590848 -
590849 -
590850 -
590851 -
590852 -
590853 -
590854 -
5909 -