CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 16 0000. ref SDS 14 0000.
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 151019, VA Radiology performed CCTA. ref SDS 6 NV5I The report
040902 - interpreting the test merely states all bypass grafts are patent.
040903 - ref SDS 6 JW8O The VA also reported a finding that calcium score was
040904 - not calculated. ref SDS 6 8Q6I
040906 - ..
040907 - On 151203, met with Bret Elicker in the Radiology Department of the VA
040908 - Medical Center in San Francisco. Doctor Elicker advised that he read
040909 - the CCTA scan file created on 151019, and found no evidence of any
040910 - lesions or blockages in the active circulatory system. ref SDS 8 SZ5F
040911 - The doctor also reported that a calcium score was generated and the
040912 - result was about 1200, ref SDS 8 4S6M, and that all of this calcium
040913 - was found in the bypassed blood vessels, and so none is present in the
040914 - active circulatory system. As a result, calcium found in the bypassed
040915 - blood vessels presents no risk to patient health, longevity, nor to
040916 - quality of life. ref SDS 8 QW4K
040918 - ..
040919 - On 151204, ordered 2nd opinion from SLDC to obtain written
040920 - confirmation of findings from CCTA, ref SDS 9 644K, performed at the
040921 - VA Medical Center in San Francisco on 151019.
040923 - ..
040924 - On 151215 1642 received 2nd opinion from SLDC. ref SDS 11 RV5F For
040925 - some reason, the letter does not present detailed findings to clarify
040926 - the VA's original report that "All bypass grafts are patent."
040927 - ref SDS 11 A88O
040929 - ..
040930 - On 151215 1642 at 2156 sent letter to Doctor Vernacchia at SLDC
040931 - requesting clarification of 2nd opinion letter. ref SDS 11 MZ5L
040933 - ..
040934 - On 151216 0915 received letter from Doctor Vernacchia saying SLDC does
040935 - not have "equipment" to render a medical opinion of amount of
040936 - stenosis,lesions and blockages in active circulatory system.
040937 - ref SDS 12 5O4H
040939 - ..
040940 - On 151217 submitted letter to Doctor Elicker requesting amendment to
040941 - clarify findings for CCTA, 151217 2052, ref SDS 13 Y630, performed on
040942 - 151019 that says simply all bypass grafts are patent. ref SDS 6 8Q6I
040944 - ..
040945 - On 151223 0921 called Doctor Elicker, and he recommending meeting with
040946 - the attending physician, Doctor Priyanka Jha, to file an addendum that
040947 - clafifies the radiology report for CCTA on 151019. ref SDS 14 A46I
040949 - ..
040950 - On 150104 0855 meeting Doctor Jha in Radiology at VA Medical Center in
040951 - San Francisco, the doctor confirmed that CCTA on 151019 found
040952 - radiology policy and practice no plaque build up of any kind (other
040953 - than bypassed blood vessels) establishes none were evident from the
040954 - CCTA test on 151019. You also advised that plaque in bypassed blood
040955 - vessels presents no risk to patient health. ref SDS 16 054G
040956 -
040957 -
040958 -
040960 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Sent letter to Doctor Jha saying...
041302 -
041303 - 1. Subject: Addendum Clarify Findings CCTA Oct 19 2015
041304 - Date: 2016-01-07 14:56
041313 - ..
041314 - 2. Thanks for visiting this past Monday, on 160104 in the VA
041315 - Radiology Department, ref SDS 16 Y55N, to consider filing an
041316 - addendum to the report on the CCTA performed on 151019. It was
041317 - a pleasure meeting you, and especially helpful seeing you
041318 - demonstrate on the computer how to interpret the CCTA study.
041319 - ref SDS 16 6G3F Our discussion on Monday, aligns with
041320 - understandings meeting with Doctor Elicker, as shown in the
041321 - letter to him on 151217, below. ref SDS 13 EX4G
041323 - ..
041324 - 3. To summarize, you advised that radiology policy and practice
041325 - reporting no findings of plaque build up of any kind (other
041326 - than bypassed blood vessels) establishes none were evident from
041327 - the CCTA test on 151019. You also advised that plaque in
041328 - bypassed blood vessels presents no risk to patient health.
041329 - ...[referencing meeting with Doctor Jah on 160104 0855,
041330 - ref SDS 16 X64K...].
041332 - ..
041333 - 4. Based on your explanation, no addendum is needed. I now feel
041334 - comfortable experimenting to reduce statin and hiking
041335 - treatments in order to reduce debilitating side effects.
041336 - Hopefully, less hiking can still maintain HDL say above 50, and
041337 - allow LDL to float in the range of 200 with reduced statin
041338 - medication. We can do another CCTA test next next year or in
041339 - 18 months and adjust line of care to maintain favorable
041340 - conditions reported in your study on 151019, as clarified by
041341 - you and Doctor Elicker. [...summarized above, ref SDS 0 8P52,
041342 - and referencing the record on 160104 0855. ref SDS 16 X64K...].
041344 - ..
041345 - 5. None-the-less I would like to explore with you language that
041346 - might be helpful working with the cardiology team in my case,
041347 - and further applying CCTA in the broader population, as
041348 - integral to treating atherosclerosis for patients who regress
041349 - plaques by raising HDL through exercise. There is a lot on the
041350 - Internet reporting CCTA imaging studies for CABG patients [...
041351 - listed in the record meeting with Doctor Alba on 140519 0800,
041352 - ref SDS 3 OF7N...], yet there is great resistance in some
041353 - circles for this application. [...see also on 140519,
041354 - ref SDS 3 J83H, and recent meeting this year with Doctor
041355 - Wisneski on 151005 1102. ref SDS 4 VZ4L...].
041357 - ..
041358 - 6. What then can be said to clarify results for CCTA on 151019,
041359 - that will be professional and constructive to move the ball
041360 - forward? Your stellar background in medical research offers a
041361 - promising path.
041363 - ..
041364 - 7. As we discussed, we are not solely concerned with the bypass
041365 - grafts per se, but rather the active circulatory system. Some
041366 - in Cardiology have commented that merely because bypass grafts
041367 - show no evidence of plaque, there could be plaque in other
041368 - blood vessels that risks adverse events. [...referencing
041369 - meeting with Doctor Wisneski on 151005 1102. ref SDS 4
041370 - RF7L...].
041372 - ..
041373 - 8. It might turn out that most (90%, 80%??) adverse events occur
041374 - from plaques in the coronary area, and so doing a broader CT
041375 - study is not cost effective. But in considering efficacy of
041376 - reliance on CCTA to guide treatment for atherosclerosis, should
041377 - CT study be expanded to the abdomen, where you are an expert,
041378 - the pelvis, etc? I am not requesting expanded testing in this
041379 - case, but just asking about the general case.
041381 - ..
041382 - 9. Here is language to consider for an addendum...
041383 -
041384 - *********************
041385 - "The 4 native blood vessels bypassed in CABG surgery on October
041386 - 22, 2009, show increased interim plaque buildup with calcium
041387 - score of 1200(??), and present no risk to patient health.
041389 - ..
041390 - The active circulatory system visible in the CT scan, and
041391 - including the 4 bypass grafts, shows no evidence of
041392 - calcification nor plaque build up of any kind or amount,
041393 - indicating substantial recovery from patient atherosclerosis
041394 - profile that required CABG surgery 6 years ago."
041395 - *********************
041397 - ..
041398 - 10. I realize the addendum ultimately filed, if any, will be
041399 - different. This approach addresses the reason CCTA testing was
041400 - requested to provide evidence for reducing treatment that
041401 - causes debilitating side effects, similar to CT testing in
041402 - oncology.
041404 - ..
041405 - 11. For example, I had forgotten we did a CT test on 091102, even
041406 - though it is reported in the record for the purpose of
041407 - evaluating sudden elevated WBC that delayed discharge following
041408 - CABG - see discussion with Paula on 091102 line 045324.
041409 - ref SDS 2 RD8G
041411 - ..
041412 - 12. The report on that test makes no findings on atherosclerosis
041413 - plaques, calcium , etc. ref SDS 2 FR6G
041415 - ..
041416 - 13. However, you and Colin evidently looked at that earlier scan
041417 - file to compare with your recent study on 151019. As you know,
041418 - the CT 6 years ago on 091102, covered the chest, abdomen and
041419 - pelvis, and so might provide a foundation to comprehensively
041420 - assess regression of plaques in relation to current and future
041421 - studies.
041423 - ..
041424 - 14. Again, it was a pleasure meeting you. Doctor Simpson who
041425 - ordered the CCTA recognized it is an experiment to explore new
041426 - territory treating atherosclerosis, reported in a meeting on
041427 - 151014 (see line 041766. ref SDS 5 OG3N
041429 - ..
041430 - 15. Thanks very much for considering this initiative. I am very
041431 - grateful for continued outstanding care by everyone at the VA
041432 - Medical Center in San Francisco.
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