CONTACTS
SUBJECTS
VA Prescribe Atorvastin 10 MG Trial 4 Weeks Evaluate Side Effects In
6003 -
6003 - ..
6004 - Summary/Objective
6005 -
600501 - Follow up ref SDS 55 0000. ref SDS 54 0000.
600502 -
600503 - Letter from VA today, notifies that Progress Notes for meeting on
600504 - 131219, have been posted and are available for customer to receive
600505 - from ROI department. ref SDS 0 HY6O Cause for 6-weeks delay issuing
600506 - Progress Notes not clear in the record. ref SDS 0 V44F VA Progress
600507 - Notes for meeting on 131219, are comprehensive and helpful.
600508 - ref SDS 0 MR3G Progress Notes have many minor grammatical errors
600509 - likely due to limited time, ref SDS 0 MZ5H, VA does not support NMR
600510 - lipid tests to determine LDL-P and discordance with LDL-C; patient can
600511 - obtain test from another lab. ref SDS 0 CE80 VA letter today
600512 - maintains discordance with low LDL-P and high LDL-C is "unhealthy" -
600513 - submits no evidence from medical literature supporting this
600514 - proposition, nor to address literature submitted to the VA stating
600515 - discordance is the healthiest condition for CVD patients. ref SDS 0
600516 - 6U4L VA concurs that lowering weight toward BMI standards aids
600517 - resolving hyperlipidemia. ref SDS 0 8N9H VA maintains lifestyle
600518 - through exercise and diet to control weight and hyperlipidemia require
600519 - support taking statin medications, e.g., Atorvastatin and Ezetimibe.
600520 - ref SDS 0 GT5F VA letter today says patient mis-reads literature on
600521 - discordance between LDL-P and LDL-C, and proposes discussions to
600522 - clarify this matter during meeting scheduled on 140213. ref SDS 0 HU5M
600523 - VA prefers patient get labs drawn at San Francisco VA Medical Center.
600524 - ref SDS 0 PT3M
600525 -
600526 -
600527 -
600528 -
600529 -
600530 -
600532 - ..
6006 -
6007 -
6008 - Background
6009 -
6010 -
601001 - Lab on 131015, showing cholesterol remained high, 131015 0724,
601002 - ref SDS 37 BE6O, conflict with increased exercise and weight loss,
601003 - discussed in the letter to the medical team yesterday on 131016 1632.
601004 - ref SDS 38 IW57
601006 - ..
601007 - On 131017 1000 VA medical chart Progress Notes assessment report
601008 - patient status CAD stable, asymptomatic. hyperlipidemia not
601009 - controlled. ref SDS 39 T24N
601011 - ..
601012 - On 131017 1000 Doctor Egan proposed referring patient for clinical
601013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 39 179N
601015 - ..
601016 - On 131017 1000 VA medical chart Progress Notes assessment report
601017 - patient status hyperlipidemia not controlled, ref SDS 39 PSXT; Doctor
601018 - Egan makes referral to SF VA Medical Center for consult on
601019 - participation clinical trials, ref SDS 39 EU9F, with experimental
601020 - agents such as AMG 145 and REGN 727 to resolve multiple statin
601021 - intolerances. ref SDS 39 CN4H
601023 - ..
601024 - On 131103 received letter from VA SF Medical Center scheduling meeting
601025 - on 131121 1000, to consider clinical trial for lowering cholesteral.
601026 - ref SDS 40 YT4N
601028 - ..
601029 - On 131112 New York Times published several articles reporting that the
601030 - day before on 131113, American Heart Association published new
601031 - guidelines for treating CAD patients that expand use of statin
601032 - medication regardless of cholesterol levels, ref SDS 41 0001, and
601033 - further raise the LDL 70 to LDL 190, as a target for cardiovascular
601034 - risk. ref SDS 41 CW6H
601036 - ..
601037 - On 131114 New York Times published several articles reporting that the
601038 - day before on 131113, American Heart Association published new
601039 - guidelines for treating CAD patients. ref SDS 42 SH6G
601041 - ..
601042 - On 131121 1604 meeting with Doctor Alba at San Francisco Medical
601043 - Center - prescribed Atorvastatin 20 mg 4-week trial and evaluate
601044 - adding Zetia 10 mg, schedule follow up on 131219 0930. ref SDS 43 6H6K
601046 - ..
601047 - On 131121 1604 in another record later today, VA prescription RX #
601048 - 5674471 for Atorvastatin 20 mg has been ordered. ref SDS 44 GH5M
601050 - ..
601051 - On 131125 0005 letter from Karen reports VA work plan to take statin
601052 - drug low dose Atvorstatin 10 mg for 4 weeks, then add Zetia 10 mg in
601053 - clinical trial for lowering cholesterol. ref SDS 46 V154
601055 - ..
601056 - On 131125 0005 research seems to indicate this clincial trial of low
601057 - dose Atorvasatatin 10 mg with Zeitia 10 mg has lowered cholesterol LDL
601058 - 70.
601060 - ..
601061 - On 131205 1448 received new prescription for Atvorstatin 20 mg,
601062 - ordered by Doctor Alba today for 4-week trial to assess side effects
601063 - for adding 2nd drug, Zetia 10 mg to lower LDL 249. ref SDS 47 GH5M
601065 - ..
601066 - On 131216 0028 letter to Doctor Alba submit agenda for meeting at VA
601067 - SFMC on 131219. ref SDS 48 HY6O
601069 - ..
601070 - On 131219 0930 meeting Doctor Alba at San Francisco VA Medical Center
601071 - ordered Ezedimibe 10 mg prescription for adding to Atorvastatin, and
601072 - ordered blood test to evaluate changes in lipid profile. 131219 0930,
601073 - ref SDS 49 NJ6G
601075 - ..
601076 - On 131230 1450, received Ezetimibe in US mail, ref SDS 50 5N3O,
601077 - ordered by Doctor Alba on 131219, 131219 0930, ref SDS 49 6H6K; begin
601078 - trial to manage cholesterol with Atorvastatin 10 mg and Ezetimibe 10
601079 - mg, planned during meeting at VA on 131121 0930. ref SDS 43 6H6K
601081 - ..
601082 - On 140114 0845 letter to Diana request Progress Notes meeting 131219,
601083 - ref SDS 51 HY6O, and ask about expanding scope pending lab to include
601084 - LDL-P. ref SDS 51 2140
601086 - ..
601087 - On 140115 1842 letter Diana will look for Progress Notes meeting
601088 - 131219, ref SDS 53 HY6O; investigating prospects for ordering lab test
601089 - LDL-P, ref SDS 53 CE80; VA claims patient cholesterol and LDL are above
601090 - target. ref SDS 53 CE91 VA further claims testing LDL-P not effective
601091 - in this case because LDL-C is not optimal. ref SDS 53 FF4H
601093 - ..
601094 - On 140116 0814 letter thanks Doctor Alba for investigting to find
601095 - Progress Notes for meeting at VA on 131219. ref SDS 54 HY6O Cite
601096 - research indicating patient with discordant LDL-C high and LDL-P low,
601097 - shown in patient lab on 131015, constitutes least risk for
601098 - arterialsclorosis disorder, CVD, mycardial infarction. ref SDS 54 735Y
601100 - ..
601101 - On 140128 1327 letter asks again about Progress Notes meeting 131219,
601102 - ref SDS 55 HY6O; report hiking 11 miles per day continued, weight hit
601103 - 165, ref SDS 55 TZ8U; ask where to get lab at VA Martinez, in San
601104 - Francisco, or at UCSF. ref SDS 55 TZ96 No side effects from
601105 - Atorvastatin and Ezetimibe. ref SDS 55 TZ99
601107 - ..
601108 - On 140131 0815 have not received instructions from VA on getting lab
601109 - to test LDL-P, so ordered test. ref SDS 56 OO5G lab blood draw at
601110 - Labcorp in Walnut Creek on Ygnacio Valley Road. ref SDS 56 NT6T
601112 - ..
601113 - On 140201 1159 obtained blood draw for Lipid NMR test at Labcor on
601114 - Health Testing Centers order # 27716, ref SDS 57 KQ4L, showing
601115 - "concordance" LDL-P 861, LDL-C 81, HDL 61, TG 68, LDL (pattern A) size
601116 - = large bouyant protective. ref SDS 57 IM9N
601118 - ..
601119 - On 140203 1147 since have not received instructions from VA, obtained
601120 - blood draw at VA in Martinez to cross check Labcorp blood test. 140203
601121 - 1147, ref SDS 58 KK9M
601123 - ..
601124 - On 140204 1236 letter from VA today, notifies that Progress Notes for
601125 - meeting on 131219, have been posted and are available for customer to
601126 - receive from ROI department. ref SDS 0 HY6O Cause for 6-weeks delay
601127 - issuing Progress Notes not clear in the record. ref SDS 0 V44F VA
601128 - Progress Notes for meeting on 131219, are comprehensive and helpful.
601129 - ref SDS 0 MR3G Progress Notes have many minor grammatical errors
601130 - likely due to limited time, ref SDS 0 MZ5H, VA does not support NMR
601131 - lipid tests to determine LDL-P and discordance with LDL-C; patient can
601132 - obtain test from another lab. ref SDS 0 CE80 VA letter today
601133 - maintains discordance with low LDL-P and high LDL-C is "unhealthy" -
601134 - submits no evidence from medical literature supporting this
601135 - proposition, nor to address literature submitted to the VA stating
601136 - discordance is the healthiest condition for CVD patients. ref SDS 0
601137 - 6U4L VA concurs that lowering weight toward BMI standards aids
601138 - resolving hyperlipidemia. ref SDS 0 8N9H VA maintains lifestyle
601139 - through exercise and diet to control weight and hyperlipidemia require
601140 - support taking statin medications, e.g., Atorvastatin and Ezetimibe.
601141 - ref SDS 0 GT5F VA letter today says patient mis-reads literature on
601142 - discordance between LDL-P and LDL-C, and proposes discussions to
601143 - clarify this matter during meeting scheduled on 140213. ref SDS 0 HU5M
601144 - VA prefers patient get labs drawn at San Francisco VA Medical Center.
601145 - ref SDS 0 PT3M
601146 -
601147 -
601148 -
601149 -
601151 - ..
6012 -
6013 -
6014 - Progress
6015 -
601501 - Progress Notes Submit for Meeting at VA SFMC 131219
601502 - Medical Mistakes Hectic Schedule Too Many People Having Too Many Problems
601503 -
601504 - Follow up ref SDS 55 HY6O, ref SDS 54 HY6O.
601505 -
601506 - Letter from Diana Alba, MD says...
601507 -
601508 - 1. Subject: RE: Pending Lab Include LDL-P Evaluate Discordance
601509 - Date: 2014-02-04 11:45
601515 -
601516 - Hope you are doing well. The note from December 19th is on
601517 - CPRS, so you can request a copy like you have done before.
601519 - ..
601520 - VA responds to the request for Progress Notes for the meeting on
601521 - 131219, which request was submitted to the VA in a letter on 140114
601522 - 0845, ref SDS 51 HY6O, VA letter the next day advised that Progress
601523 - Notes would be issued for meeting on 131219, reported in the record on
601524 - 140115 1842. ref SDS 52 HY6O Progress Notes for meeting with VA on
601525 - 131219, were requested again in a recent letter 8 days ago, on 140128
601526 - 1327, ref SDS 55 HY6O
601528 - ..
601529 - VA Progress Notes for meeting at VA in San Francisco on 131219, were
601530 - received a few days after getting the VA letter today, and show
601531 - Progress Notes were "entered" on 140115, reported in the record on
601532 - 131219 0930, ref SDS 49 476K, and signed for release a week later on
601533 - 140121. ref SDS 49 YZ6G
601535 - ..
601536 - There is nothing in the record indicating why Progress Notes for
601537 - meeting on 131219 0930. ref SDS 49 476K were not available to the
601538 - customer until 6-weeks later, a few days after getting the VA's letter
601539 - today.
601541 - ..
601542 - Overall Progress Notes for meeting on 131219, are comprehensive and
601543 - helpful. ref SDS 49 476K
601545 - ..
601546 - Complexities managing cholesterol levels for cardiovascular health are
601547 - reviewed in the Progress Notes to align with published literature,
601548 - shown on 131219 0930. ref SDS 49 OT9N
601550 - ..
601551 - Apart from expected differences on managing LDL cholesterol, which is
601552 - evolving and controversial in the literature, the Progress Notes have
601553 - many errors of grammar and construction, including omission of
601554 - citations, which makes review difficult for accuracy, meaning and
601555 - intent, e.g....
601556 -
601557 - continue SB continues........................... ref SDS 49 6K9K
601558 - the point SB this point......................... ref SDS 49 WF5J
601559 - website SB websites............................. ref SDS 49 WF5J
601560 - trail SB trial.................................. ref SDS 49 WF5J
601561 - this his SB that his............................ ref SDS 49 ON3G
601562 - he now has he has SB he now has................. ref SDS 49 CO4G
601563 - LDL-P vs LDL-P SB LDL-P vs LDL-C................ ref SDS 49 NT5J
601564 - measured of LDL-C SB measurement of LDL-P....... ref SDS 49 NT5J
601565 - parentheses ( ] are mixed....................... ref SDS 49 NT6J
601566 - that The Friedewald SB that the Friedewald...... ref SDS 49 NT6J
601567 - know you is SB know he is....................... ref SDS 49 NT6J
601569 - ..
601570 - This record shows challenges for doctors working long hours with many
601571 - patients and minimal support. There should be a system of
601572 - proof-reading by another doctor or admin to maintain communication
601573 - standards for accuracy and clarity. Probably a budget problem likely
601574 - to get worse in the years ahead.
601576 - ..
601577 - Since communication is a predicate to action (see POIMS, ref OF 4
601578 - IE6L, mounting errors in communication pressage medical mistakes that
601579 - accelerate health care costs, cited previously in national reporting
601580 - on 990912. ref SDS 1 0960
601581 -
601582 -
601583 -
601585 - ..
601586 - LDL-P Add to Pending Lab Evaluate Discordant
601587 - Hyperlipidemia Patient Discordant Test Pending Lab LDL-P
601588 -
601589 - Follow up ref SDS 55 CE80, ref SDS 54 CE80.
601590 -
601591 - Letter from Diana Alba, MD says continues...
601593 - ..
601594 - 3. Regarding the LDL-p and LDL-C. The VA does not do LDL-P
601595 - measurements- I discussed it with the lab medicine service, and
601596 - the lab here does not run and the external lab that we use for
601597 - other tests, does not run it either. So, the VA won't cover
601598 - it. If you are still interested in doing it, we can find a lab
601599 - that is running the test at this time, and we can refer you to
601600 - them, but you will have to cover the cost.
601602 - ..
601603 - This responds to the question on including NMR test to evaulate LDL-P,
601604 - presented in the letter to the VA on 140116 0814. ref SDS 54 H253
601606 - ..
601607 - On 140201 1159 obtained blood draw for Lipid NMR test at Labcor on
601608 - Health Testing Centers order # 27716, ref SDS 57 KQ4L, showing
601609 - "concordance" LDL-P 861, LDL-C 81, HDL 61, TG 68, LDL (pattern A) size
601610 - = large bouyant protective. ref SDS 57 IM9N
601612 - ..
601613 - On 140203 1147 obtained blood draw at VA in Martinez, ref SDS 58 X45G,
601614 - showing LDL-C 93, HDL 58, TG 47, ref SDS 58 IM9N indicating
601615 - "concordance" LDL-P 626, LDL (pattern A) size = large bouyant
601616 - protective. ref SDS 58 QV5G
601618 - ..
601619 - Letter from Diana Alba, MD says continues...
601620 -
601621 - 4. I discussed this subject again with one of our lipid Experts -
601622 - Dr Feingold, and as I explain to you before, we know you have
601623 - elevated LDL-C, with high total cholesterol and a high non-HDL.
601624 - They are all marker for risk for cardiovascular disease- you
601625 - had asked before, if this was unhealthy, and YES it is
601626 - definitely unhealthy.
601628 - ..
601629 - The doctor references lab 3 months ago on 131015 0724, ref SDS 37
601630 - BE6O, showing LDL 249, and cholesterol 321, and HDL 50, which makes
601631 - non-HDL-C 271 (321 - 50). Labcorp test report on 140201, shows the
601632 - range for non-HDL-C = 0 - 129. 140201 1159, ref SDS 57 5C7M This
601633 - makes non-HDL-C 271 "high" for the test on 131015, as noted by the VA
601634 - letter today.
601636 - ..
601637 - VA letter characterizes this condition as "unhealthy," responding to
601638 - question in the letter to the VA on 131125 0005. ref SDS 45 UK91
601640 - ..
601641 - Research characterizes this condition as "healthy"... in that, patient
601642 - with similar lipid profile: LDL-C 246, cholesterol 326 and HDL 65,
601643 - which makes non-HDL 261, which is "high" compared to Labcorp range 0 -
601644 - 129; yet, this patient claims to be "healthy" because LDL-P is low,
601645 - and LDL size is large, reported on 131125 0005, ref SDS 45 6P4N
601647 - ..
601648 - This patient (as presented in the research) maintains that HDL above
601649 - 50 and triglycerides below 100 indicates LDL particle size will be the
601650 - large, fluffy "protective" kind. 131125 0005, ref SDS 45 5P5N Since
601651 - the lipid history on 140203, indicates triglycerides have been
601652 - consistently < 100, and HDL >= 50 following CABG +4 surgery on 091022,
601653 - ref SDS 58 W25L, it may as well represent discordance with low LDL-P
601654 - and high LDL-C, i.e., "healthy."
601656 - ..
601657 - Accordingly, more research is needed to assess and support
601658 - determinations of "healthy" and "unhealthy" lipid profile in the
601659 - instant case with respect to discordance, as set out in the letter to
601660 - the VA on 131216 0028. ref SDS 48 6T60
601662 - ..
601663 - Pending further review, since Laborp NMR test on 140201, found
601664 - non-HDL-C 95, ref SDS 57 5C7M, this 67% reduction from non-HDL-C 271,
601665 - falls well within guidance of "healthy" condition, as well.
601667 - ..
601668 - Letter from Diana Alba, MD says continues...
601669 -
601670 - 5. However, measuring LDL-particles, when we already know that
601671 - your LDL-C and non-HDL is very high, will not add or change
601672 - your current regimen. Despite diet and exercise, like
601673 - mentioned before, your condition-elevated LDL- has genetic
601674 - bases- is not just lifestyle.
601676 - ..
601677 - VA letter seems to repeat same point in prior letter on 140115 1842,
601678 - ref SDS 52 FF4H, which point was questioned in a letter to the VA the
601679 - next day on 140116 0814. ref SDS 54 H29T
601681 - ..
601682 - VA Progress Notes for meeting on 131219, state in part that LDL-P has
601683 - a stronger association than LDL-C for cardiovascular health.
601684 - ref SDS 49 GO35
601686 - ..
601687 - VA letter today, does not refute, nor offer opposing evidence on
601688 - discordance issue, presented in the letter on 140116 0814, ref SDS 54
601689 - H29T, and citing research on 131125, indicating the primary driver of
601690 - CVD is elevated LDL-P, rather than LDL-C. ref SDS 45 FI3G
601692 - ..
601693 - Considerable analysis is presented in articles reported on 131125,
601694 - including following....
601695 -
601696 - When people argue with me about why it's unnecessary to
601697 - check LDL-P or apoB because it's much easier and cheaper to
601698 - check LDL-C, I like to remind them of what Clint Eastwood
601699 - would probably say in such a situation: "You've got to ask
601700 - yourself one question: Do I feel lucky? Well, do ya,
601701 - punk?" ref SDS 45 RM6K
601703 - ..
601704 - LDL-P (or apoB) is the best predictor of adverse cardiac
601705 - events, which has been documented repeatedly in every major
601706 - cardiovascular risk study. ref SDS 45 4R3O
601708 - ..
601709 - There is no way of determining which individual patient may
601710 - have discordant LDL-C and LDL-P without measuring both
601711 - markers. ref SDS 45 4R49
601713 - ..
601714 - Letter from Diana Alba, MD says continues...
601715 -
601716 - 6. We had also discussed that hitting your target BMI/weight will
601717 - obviously help for overall health, however at this point it is
601718 - clear that there is genetic component and we need to treat
601719 - this.
601721 - ..
601722 - Lowering weight to 165, was discussed during the meeting at the VA on
601723 - 131219 0930, ref SDS 49 A56N, and further aligns with in Progress
601724 - Notes. ref SDS 49 F56N
601726 - ..
601727 - Letter from Diana Alba, MD says continues...
601728 -
601729 - 7. If you are referring to discordant LDL- based on you
601730 - exercise/diet and LDL levels, yes they are discordant- but
601731 - again your cholesterol is not going to improve with lifestyle
601732 - modifications, because there is genetic component and you need
601733 - treatment- statin/Zetia.
601735 - ..
601736 - 8. However, if you are referring to discordant LDL-C and
601737 - LDL-particles, then you misunderstood the literature- and we
601738 - can talk about this on your next appointment.
601740 - ..
601741 - Discordance between LDL-C and LDL-P was presented with citations to
601742 - the VA in the letter on 140116 0814. ref SDS 54 H29T
601743 -
601744 - "The highest risk and lowest risk groups are those with
601745 - discordant LDL-C and LDL-P. The high risk group has high
601746 - LDL-P and low LDL-C, while the lowest risk group has high
601747 - LDL-C with low LDL-P. Only a minority of physicians would
601748 - know that there is a segment of the population with elevated
601749 - LDL-C who are at low risk! The same conclusion will be
601750 - drawn from the next study." (...shown in research on 131125
601751 - - see line GM0688 para 9. ref SDS 46 FI3G
601753 - ..
601754 - VA's assertion in the letter today, that this literature was
601755 - "misunderstood" is not supported with opposing evidence. At this
601756 - time, the only evidence indicates the VA's representation is
601757 - conflicting.
601759 - ..
601760 - Letter from Diana Alba, MD says continues...
601761 -
601762 - 9. I ordered a lipid panel with a direct measure of LDL-C, so I
601763 - will prefer If you do your labs here, since I'm not sure if
601764 - they can do direct LDL measurement at Martinez. See you soon
601766 - ..
601767 - Lab at VA in Martinez was performed on 140203 1147, ref SDS 58 X45G,
601768 - because VA did not respond to letter asking where to have blood drawn,
601769 - presented in the letter to the VA on 140128 1327. ref SDS 55 TZ96
601770 -
601771 - [On 140514 0950 blood draw for lab to support meeting with
601772 - Doctor Alba on 140519, was performed at VA Medical Center
601773 - in San Francisco in order to include LDL Direct.
601774 - ref SDS 59 X45G
601776 - ..
601777 - Letter from Diana Alba, MD says concludes...
601778 -
601783 -
601784 -
601785 -
601786 -
601787 -
601788 -
601789 -
601790 -
601791 -
6018 -