CONTACTS
SUBJECTS
CBC Lab WBC VA No Results
2003 -
2003 - ..
2004 - Summary/Objective
2005 -
200501 - Follow up ref SDS 69 0000. ref SDS 68 0000.
200502 -
200503 -
200504 -
200505 -
200507 - ..
2006 -
2007 -
2008 - Background
2009 -
200901 - On 131016 1632 submit letter for agenda meeting to review lab results
200902 - scheduled 131017 1000. ref SDS 37 X45G
200904 - ..
200905 - On 140131 0815 ordered another lab - cbc, electrolytes, lipid with NMR
200906 - - from Labcor to get LDL-P. ref SDS 50 X45G
200908 - ..
200909 - On 140201 1159 had full lab with NMR lipid panel drawn at John Muir
200910 - Hospital on Treat, and by Labcorp. ref SDS 51 RP4N
200912 - ..
200913 - On 140203 1147 had partial lab drawn at VA in Martinez. ref SDS 52
200914 - KK9M
200916 - ..
200917 - On 140507 0857 ordered another full lab from Labcorp with NMR lipid
200918 - panel. ref SDS 58 OO5G
200920 - ..
200921 - On 140508 1133 lab blood daw at Labcorp with John Muir Medical Center
200922 - on Treat Blvd in Concord. ref SDS 59 445G
200924 - ..
200925 - On 140514 0950 VA partial lab at Medical Center in San Francisco.
200926 - ref SDS 61 X45G
200928 - ..
200929 - On 140518 0920 letter to VA submits consolidated blood tests from
200930 - Labcorp on 140508 and the VA on 140514, to prepare for the meeting on
200931 - 140519. ref SDS 63 1V6M Advise that VA has not ordered follow up lab
200932 - to check Electrolytes (Chem Profile) requested by Doctor Egan to
200933 - assess previously elevated potassium (K) 5.6, that cause electrical
200934 - problems for the heart. ref SDS 63 DV4M Medication side effects of
200935 - dizziness have subsided. ref SDS 63 DV50 Dry mouth and urination have
200936 - increased. ref SDS 63 DV56 Peripheral neuropathy related to elevated
200937 - bilirubin has recurred. ref SDS 63 DV59
200939 - ..
200940 - On 140518 0920 at 2244 received letter from Doctor Alba notifying not
200941 - to get blood draw at lab prior to meeting with medical team tomorrow
200942 - morning. ref SDS 63 RW7O
200944 - ..
200945 - On 140520 0732 background and planning for getting supplemental labs
200946 - on electrolyte (Chem Profile), and EPC. ref SDS 65 X45G
200948 - ..
200949 - On 140520 0732 at 0743 letter requests VA order electrolyte (Chem
200950 - Profile) lab order today. ref SDS 65 YW4H, and include lab for EPC.
200951 - ref SDS 65 4U46 Doctor Sandhu notified that medical team in San
200952 - Francisco discusses increased urination indicates possible prostate
200953 - issues. ref SDS 65 4U95 During meeting on 140519, decided that mild
200954 - symptoms peripheral neuropathy possibly due to statin treatment does
200955 - not justify ending statin tratement, because treatments have been
200956 - effective managing lipids. ref SDS 65 4U4F
200958 - ..
200959 - On 140520 0732 at 0812 letter from VA advises Doctor Alba will order
200960 - Chem Profile lab when she arrives at the hospital. ref SDS 65 4V5H
200962 - ..
200963 - On 140520 0732 at 1017 VA partial lab at Medical Center in San
200964 - Franciso for electrolyte (Chem) panel that was omitted on lab 140514.
200965 - ref SDS 65 KK9M Glucose, sodium, potassium declined, with potassium
200966 - (K 5.2) still at high end of range for Labcorp and slightly above VA
200967 - range, ref SDS 65 ZG5O; bilirubin declined dramatically. ref SDS 65
200968 - 015M
200970 - ..
200971 - On 140520 0732 at 1028 VA letter Doctor Alba requests clarification of
200972 - scope for EPC lab. ref SDS 65 654J Called to explain scope of EPC
200973 - lab, but encountered poor connection using cell phone. ref SDS 65 U63N
200975 - ..
200976 - On 140520 0732 at 1609 VA letter - Doctor Alba ordered EPC lab, she
200977 - advises EPC lab requires approval by lab staff of doctor's
200978 - justification. ref SDS 65 AF5L
200980 - ..
200981 - On 140520 0732 at 1617 letter to VA submits justification for doctor
200982 - to submit with order for EPC lab that saves lives, time, and money.
200983 - ref SDS 65 JP8O
200985 - ..
200986 - On 140522 1052 letter to Doctor Egan at Martinez submits results of
200987 - labs on Electrolyte Chem Profile showing Potassium, which Doctor Egan
200988 - requested. ref SDS 66 X45G
200990 - ..
200991 - On 140529 0942 letter to Doctor Alba at VA Medical Center in San
200992 - Francisco adise placed order with Release of Information Department to
200993 - submit Progress Notes for meeting on 140519, so no need for Doctor
200994 - Alba so submit. ref SDS 67 X45G Recommend correcting errors in prior
200995 - notes so they are carried forward in Progress Notes for meeting on
200996 - 140519. ref SDS 67 QF6T Recommend Progress Notes cite patient support
200997 - to improve lipid labs past 6 months, ref SDS 67 QF67, referencing the
200998 - lab report on 140514 0950, ref SDS 61 W25L, which also presents
200999 - extended exercise, weight loss, and diet changes. ref SDS 61 I17G
201000 - Asked about progress getting approval for EPC lab. ref SDS 67 QG3U
201001 - Request VA order coronary CT angiography with calcium score to
201002 - evaluate regression of athersclerosis, as a result of good labs from
201003 - medication and extended exercise the past 6 months. ref SDS 67 QG38
201005 - ..
201006 - On 140610 0930 letter asks again about publishing Progress Notes for
201007 - meeting at the VA on 140519. ref SDS 68 X45G Reminds to order EPC and
201008 - coronary CTA tests. ref SDS 68 LJ61 Customer offers to order EPC and
201009 - coronayr CTA tests in order to save time for the VA. ref SDS 68 LJ6L
201010 - Report peripheral neuropathy and urination symptoms have again
201011 - subsided. ref SDS 68 LJ6Y
201013 - ..
201014 - On 140610 0930 at 1115 letter from Doctor Alba advising that Progress
201015 - Notes for meeting on 140519, were completed last week. ref SDS 68 W84I
201017 - ..
201018 - On 140610 0930 at 1114 letter asks Doctor Alba about progress ordering
201019 - EPC lab and coronary CTA with calcium score, ref SDS 68 KH3O, repeating
201020 - request in the letter earlier this morning, ref SDS 68 LJ61, but not
201021 - discussed in Doctor Alba's letter received at 1115. ref SDS 68 W84I
201023 - ..
201024 - On 140612 1048 VA letter notifies refuse order coronary CTA to test
201025 - for level of atherosclerosis because history of CABG surgery on
201026 - 091022, shows coronary artery disease, which VA relies upon to
201027 - speculate plaques remain in arteries, therefore, CT angiography, is
201028 - not going to add any value to your current diagnoses or treatment.
201029 - ref SDS 70 X45G
201031 - ..
201032 - On 140626 1652 letter notify VA commend Doctor Alba correcting errors
201033 - in Progress Notes in prior meeting so they are not replicated in
201034 - Progress Notes for meeting on 140519. ref SDS 0 X45G Commend VA
201035 - timely prescription refill on Ezetibime and Atorvastatin. ref SDS 0
201036 - MY9Y Offer to defer lab on EPC to assess prospects for regression of
201037 - atherosclerosis, since EPC should be favorable based on increased
201038 - exercise that has increased WBC 50%. ref SDS 0 MY45 Review VA refusal
201039 - to order coronary CTA aligns with prior experience at Kaiser ordering
201040 - CT testing to evaluate pulmonary embolism. ref SDS 0 MY51 VA grounds
201041 - for refusing CTA testing that results will not aid care for patients
201042 - with CABG surgery, conflicts with the record showing CTA is commonly
201043 - performed to assess recovery from atherosclerosis who have undergone
201044 - CABG surgery. ref SDS 0 MZ33 Request recommendations for 2nd opinions
201045 - on CTA testing. ref SDS 0 MZ82
201046 -
201047 -
201048 -
201049 -
201050 -
201051 -
201053 - ..
2011 -
2012 -
2013 - Progress
2014 -
201401 - Letter to Doctor Alba at VA saying...
201402 -
201403 - 1. Subject: Second Opinion Coronary CT Angiography
201404 - Date: 2014-06-26 17:38
201412 - ..
201413 - 2. Have not had time to review your Progress Notes in the record.
201414 - Scanning through quickly shows you did a good job fixing past
201415 - mistakes, so the notes now read well. Will submit comments
201416 - next week.
201418 - ..
201419 - 3. I am grateful that your recent prescription for Ezetimibe was
201420 - for more than 1 month, so refills won't be needed so often
201421 - going forward. As well, just today, received in the mail a
201422 - refill on Atorvastatin, which I did not order. Last night I
201423 - was considered ordering a refill, but counted and found about
201424 - 20 10 mg half-pills remain, so deferred the order. Imagine my
201425 - surprise getting an order I only thought about placing.
201427 - ..
201428 - 4. Clearly, all the folks having a good time in the media
201429 - criticizing the VA, have had not time to check the record of
201430 - great care in my case.
201432 - ..
201433 - 5. Please remember to check with the lab on the request to perform
201434 - EPC testing, mentioned in your letter on 140612, as still
201435 - pending approval at the lab (see below). Naturally, we expect
201436 - this to be a good number, because WBC increased 50% in the
201437 - recent Labcorp test on 140508, now at the high end of the
201438 - range. The same exercise hiking 1000 miles the past 3 months
201439 - that yielded this result for WBC, should produce high ECP.
201440 - Only testing will show this.
201441 -
201442 - [On 140703 1938 Doctor Alba reports EPC issue discussed
201443 - among team at VA in detail; determined no justification to
201444 - evaluate EPC toward coronary CTA to assess regression of
201445 - atherosclerosis, ref SDS 71 H167, which VA maintains
201446 - requires treatment, shown in Progress Notes on 140519 0800,
201447 - ref SDS 64 OW76, based solely on history of atherosclerosis
201448 - requiring CABG x4 surgery on 091022, 5 years ago, as
201449 - presented in VA Progress Notes on 140519 0800, ref SDS 64
201450 - OW49, and without knowledge of actual current condition
201451 - resulting from intervening events, e.g., 120% rise from HDL
201452 - 30 to HDL 67, shown in labs on 140514 0950. ref SDS 61 W25L
201454 - ..
201455 - 6. If it is politically easier to defer EPC testing, I concur.
201456 - Results only indicate, along with high HDL, that regression of
201457 - plaques is occurring. [...previously submitted to VA in letter
201458 - on 140515 2043. ref SDS 62 YM61...]. Evaluating regression of
201459 - atherosclerosis requires coronary CT angiography.
201461 - ..
201462 - 7. VA refusal to order a coronary CTA, set out in your letter on
201463 - 140612, ref SDS 69 X45G, is understandable, given limited time
201464 - to study the case. This occurred often at Kaiser, shown by
201465 - case study on 10 or 12 2nd opinions we got for Millie, set out
201466 - in the record on 090213. ref SDS 2 K36J
201467 -
201468 - [...below on 140626 1652 letter asks for recommendations on
201469 - getting 2nd opinion. ref SDS 0 MZ82
201471 - ..
201472 - [On 140703 1938 VA in San Francisco Medical Center
201473 - recommends getting 2nd opinion from Doctor Egan at VA
201474 - Clinia in Martinez, on ordering coronary CTA to evaluate
201475 - regression of atherosclerosis. ref SDS 72 H233
201477 - ..
201478 - 8. Millie had stage 4 cancer for nearly 10 years. Maintaining
201479 - quality of life required timely diagnosis and care for many
201480 - secondary maladies, and 11 recurrences of cancer. Doctor Benz
201481 - at UCSF provided 2 of the 2nd opinions. The first correlates
201482 - well with the instant case.
201484 - ..
201485 - 9. On 040420, Mil began treatment for secondary IBC in clinical
201486 - trial with Bevacizumab. Within 2 months, she suffered various
201487 - side effects, including shortness of breath walking up stairs
201488 - at home, walking from the parking lot to BART, etc. She was a
201489 - well conditioned athlete, who could run for miles, so we
201490 - suspected a new issue. Mil requested a CT test for pulmonary
201491 - embolism based on evident side effects, and public reports that
201492 - Bevacizumab caused PE. The doctor in the limited time for
201493 - studying the record refused to order the work. As here, he
201494 - suggested Millie suffer side effects, noting her cancer marker
201495 - had declined. He was reluctant to investigate anything that
201496 - might disrupt initial favorable response to treatment.
201497 - Instead, he suggested getting 2nd opinions from Stanford and
201498 - UCSF, so we did that.
201500 - ..
201501 - 10. The day we returned from meeting with Doctor Benz at UCSF, we
201502 - got a call late at night saying Millie had to rush over to
201503 - Kaiser for an emergency CT test (see the record on 041104.
201504 - ref SDS 1 RZ4I
201506 - ..
201507 - 11. Turned out Doctor Benz called Kaiser after we left, and
201508 - recommended the CT test. During the meeting the next day, the
201509 - doctor said the CT test showed pulmonary embolism was causing
201510 - causing Millie's symptoms. Treatment with Bevacizumab was
201511 - ended that day, she went on warfarin "for life." They didn't
201512 - have another treatment lined up, so the cancer marker began
201513 - rising, it was mess for months. Somehow, we squeaked by thanks
201514 - to 2nd opinion support.
201516 - ..
201517 - 12. As you can in the case study on 090213, these scenarios
201518 - occurred over and over again, where Mil was saved with 2nd
201519 - opinions. Kaiser always did a good job implementing
201520 - recommendations in those opinions. Millie was grateful that
201521 - Kaiser responded well to support within the doctor/patient
201522 - partnership.
201524 - ..
201525 - 13. In this case, like Kaiser, the VA has done outstanding work,
201526 - including heart (CABG +4) surgery on 091022, and continuing
201527 - through our recent meeting on 140519. At that time, there was
201528 - reason to believe regression has occurred in atherosclerotic
201529 - plaques, sufficient to justify reducing treatment, and
201530 - consequent adverse side effects. You correctly note in a
201531 - letter on 140612...
201533 - ..
201534 - "...we know you have plaques in your arteries." ref SDS 69 X45G
201536 - ..
201537 - 14. You further say in part, as Kaiser said numerous times in the
201538 - prior case...
201540 - ..
201541 - "The CT angiography, is not going to add any value to your
201542 - current diagnoses or treatment." ref SDS 69 W67N
201544 - ..
201545 - 15. This opinion might be aided by further professional support.
201547 - ..
201548 - 16. Coronary CT angiography produces a calcium score. For example,
201549 - research on 131125 found that Tim Russert, a former news
201550 - broadcaster who died of heart attack, ordered on his own a
201551 - coronary CTA and had a score of 250, despite LDL-C < 70. As
201552 - here, his doctor knew he had plaques, but not how much (see
201553 - line NZ0402. ref SDS 44 N73K
201555 - ..
201556 - 17. Is my score 0, 20, 100, 300???
201558 - ..
201559 - 18. There is much reporting in the public media that coronary CTA
201560 - testing is common for patients who have a history of CABG...
201561 -
201562 - 1. PubMed
201564 - ..
201565 - Cardiac CT angiography after coronary bypass surgery:
201566 - prevalence of incidental findings.
201567 -
201568 - http://www.ncbi.nlm.nih.gov/pubmed/17646469
201569 -
201570 - ...and saying in part...
201572 - ..
201573 - Cardiac CT angiography (CTA) is commonly performed after
201574 - coronary artery bypass grafting surgery (CABG)... to
201575 - retrospectively assess the prevalence of unsuspected
201576 - disease identified on cardiac CTA examinations after CABG
201577 - and to determine their potential clinical significance.
201578 - CTA was performed postoperatively in 259 patients (mean,
201579 - 5.2 days), and 40 patients underwent a follow-up CT scan
201580 - (mean, 12.7 months).
201582 - ..
201583 - 2. Journal of American College of Cardiology...
201584 -
201585 - http://imaging.onlinejacc.org/article.aspx?articleID=1879181
201587 - ..
201588 - 3. Computed Tomography Imaging in 2012
201589 -
201590 - http://books.google.ca/books?id=ASu3TUDBNCcC&pg=PA85&lpg=PA85&dq=coronary+CTA+CABG&source=bl&ots=IPn9-8gHpB&sig=iJsUE_5KAdrUjXV2kAY-Z28Rt0M&hl=en&sa=X&ei=c6asU53uBYKryATT_YGwAQ&ved=0CE8Q6AEwCA#v=onepage&q=coronary%20CTA%20CABG&f=false
201591 -
201592 - ...and saying in part...
201594 - ..
201595 - "Coronary CTA is highly accurate for the assessment of
201596 - coronary artery bypass graft (CABG) stenosis, and its use
201597 - for this purpose is endorsed by current Appropriate Use
201598 - Criteria.
201600 - ..
201601 - 4. Journal of Cardiology Cases
201602 - Volume 5, Issue 2, April 2012, Pages e92–e95
201604 - ..
201605 - Regression of coronary plaque after coronary artery bypass graft
201606 -
201607 - http://www.sciencedirect.com/science/article/pii/S1878540912000035
201608 -
201609 - ...and saying in part...
201611 - ..
201612 - Three years after treatment, 64-MDCT showed mild stenosis
201613 - and a regression of plaque in the LMT. The mean density of
201614 - the plaque was 73.1 HU (intermediate plaque) [...before
201615 - CABG and 32.4 after CABG; plaque size reduced from 20.7 to
201616 - 4.26...]
201618 - ..
201619 - 19. My intent is to assess results of interventions following CABG
201620 - +4 on 091022, and for the purpose of adjusting treatment in
201621 - time to be effective, and for moderating side effects.
201623 - ..
201624 - 20. I respect the VA's good faith opinion that this is unnecessary,
201625 - and propose getting 2nd opinion to assist the VA in continuing
201626 - outstanding care in this case.
201627 -
201628 - [On 140703 1938 VA in San Francisco Medical Center
201629 - recommends getting 2nd opinion from Doctor Egan at VA
201630 - Clinia in Martinez, on ordering coronary CTA to evaluate
201631 - regression of atherosclerosis. ref SDS 72 H233
201633 - ..
201634 - 21. Please submit references on doctors the VA feels would be
201635 - helpful on 2nd opinions for coronary CTA.
201636 -
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201650 -
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2017 -