THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: June 26, 2014 04:52 PM Thursday; Rod Welch

VA letter order coronary CTA to assess atherosclerosis.

1...Summary/Objective


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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 e92e95                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
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 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201642 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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201648 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201649 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201650 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201651 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201652 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
201653 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2017 -