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: April 12, 2017 10:00 AM Wednesday;
Rod Welch
VA Cardiology meeting with Doctor Simpson on HDL, atherosclerosis.
1...Summary/Objective
2...Hiking Controls HDL Weight Blood Pressure Spreadsheet Study
3...Blood Pressure Correlates Elevated PPI Drugs Needed for Acalasia
4...Frequent Urination High Blood Pressure Caused High PPI Statin Dose
5...Frequent Urination Taking Statins Does Not Align With Study during 2011
6...Many Patients Report Frequent Urination Correlates With Statin Medications
7...Welch Case With Anecdotal Evidence Frequent Urination Taking Statins
8...High Blood Pressure Treat Lower PPI Repair Feet Knees for Hiking
9...Hiking Work Plan Supartz Repair Knees MRI Feet Verify Diagnosis
10...Feet MRI Verify Plantar Plate Tear Treat Plantarflexion Taping
11...Plantarflexion Taping Physical Therapy Develop Scheme Protect Plantar Plate Tear
12...Future Maintain Elevated HDL When Age Degrades Body Cannot Hike
13...Hiking Switched from Running When Age Degraded Body 30 Years Ago
14...Time Ran Out Running Switched to Hiking Has Time Run Out Again
15...HDL Increased Hike 11-15 Miles Per Day 300 Miles Per Month 2500 Annually
16...Hike 11-15 Miles Per Day 300 Miles Per Month 2500 Annually Increased HDL
17...Hiking Paved Streets Avoid Concrete Sidewalks Maintain Speed Avoid Injuries
18...Alternate Aerobic Exercise No Evidence Elevates HDL
19...Biking Swimming Body Supported by Medium No Evidence Increase HDL
20...Elliptical Trainer Might Emulate Hiking Raise HDL Reduce Injuries
21...Plantar Plate Tear May React Adverseley Elliptical Trainer
22...Elliptical Trainer Stationery Exercise Boring
23...Boredeom Disincentive Stationery Exercise Elliptical Trainer
24...Hiking Resolved Age Related Injuries Hips Back Shoulders
25...Weight Loss and Gain Tracks Hiking
26...Hiking Fun Emotional Rewards Drive Raising HDL > 60
27...Injuries Diminish Hiking Incentives Investigate Alternatives
28...Doctor Simpson Posed Trial Elliptical Trainer Evaluate Raise HDL
29...HDL Evaluate Elliptical Trainer with No Cost Trial at Gym
30...CCTA 151019 Found No Significant Plaque 6 Years After CABG x4
31...Atherosclerosis HDL Regress Not Settled Medical Science in Cardiology
32...HDL Regress Atherosclerosis Not Settled Medical Science in Cardiology
33...Cardiology Skeptical Atherosclerosis Regress Elevated HDL
34...LDL 50 Cardiology Prescribes Statins Manage Risks Atherosclerosis
35...Atherosclerosis LDL 50 Slow Advance Cardiology Prescribes Statins
36...Cardiology Statins Lower LDL 50 Manage Risks Atherosclerosis
37...HDL > 60 Regress Atherosclerosis Reverse Cholesterol Transport RCT
38...Atherosclerosis HDL > 60 Regress Plaque Reverse Cholesterol Transport RCT
39...RCT Not Established Cardiology Science HDL > 60 Regress Plaque
40...Centenarians Commonly Have Elevated HDL Avoid Atherosclerosis Despite Age
41...HDL Elevated People Living to 100 Avoid Age Accumulated Atherosclerosis
42...HDL Debate Discovery Assessment Exciting Time Cardiology
43...Cardiology Debate HDL Exciting Period Experiment Discovery Assessment
........European Society of Cardiology (ESC) Congress 2013
44...Walking Meetings Cognition Benefit Increased Blood Flow
45...Cognition Stimulated by Hiking Elevate HDL Increase Blood Flow
46...Hiking Elevate HDL Stimulates Cognition by Increasing Blood Flow
47...HDL Advocates Cardiology Friendly Forces
........Relation of Increased Prebeta-1 High-Density Lipoprotein
........Levels to Risk of Coronary Heart Disease
48...CCTA Cardiology Voices Object Presidents Checking Coronary Risk
49...President Obama HDL 61 Exercise Walking CCTA Minimal Atherosclerosis Risk
........Why I am Wary of Many Cardiac Screening Tests
50...CCTA October 2017 Follow Up Favorable CCTA October 19 2015
51...Radiation Risks CCTA Minimal Compared Benefits Test Response to Treatment
52...HDL Metric of Success Regressing Atherosclerosis Surival 5, 10, 20 Years
53...Medical Chart Progress Notes for Cardiology Meeting 151014
54...Progress Notes Cardiology Meeting 151014 Doctor Simpson
55...Doctor Simpson Progress Notes Cardiology Meeting 151014
ACTION ITEMS..................
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1...I will look into a more HDL-positive cardiologist to see
CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 25 0000, ref SDS 23 0000.
040502 -
040503 - Meeting with Doctor Simpson review negative cardiology metrics from
040504 - not hiking compared with favorable metrics for HDL, weight, blood
040505 - pressure from hiking 11 - 15 miles per day 6 - 7 days per week for
040506 - past 5 years. ref SDS 0 I35I Blood pressure elevated taking high dose
040507 - PPI, ref SDS 0 GG80, required to treat failed Dor fundoplication
040508 - beginning OA 140509, 5 years after surgery on 091216, which
040509 - subsequently causes increased reflux causing increased ulceration
040510 - LESV. ref SDS 0 5H4K Will defer adding new pills to lower blood
040511 - pressure until after experimenting to lower blood pressure by lowering
040512 - PPI, pending meeting with GI Department on 170419. ref SDS 0 NU3J
040513 - Research study in 2011, recently submitted by Doctor Simpson, found
040514 - statin treatment did not cause frequent urination under controls of
040515 - clinical study. Search on Internet found continuing anecdotal reports
040516 - that people taking statins suffered frequent urination. This aligns
040517 - with patient experience. ref SDS 0 EE7H Equally work in Orthopedics
040518 - will try to enable hiking that will lower blood pressure, reduce
040519 - weight, and raise HDL. ref SDS 0 GG74 Physical Therapy will apply
040520 - Rocktape wrapping to protect Plantar Plate Tear in bottom right
040521 - forefoot to enable healing while hiking. ref SDS 0 QP6M Doctor
040522 - Simpson noted age (injuries) may prevent hiking in this case, as
040523 - occurred decades earlier with running. What alternative exercise can
040524 - replace hiking that has proven effective for controlling HDL, weight
040525 - and blood pressure? ref SDS 0 QV8I The doctor cited favorable metrics
040526 - hiking 11 - 15 miles per day 5 - 7 days per week - 70% on asphalt
040527 - streets, 30% on concrete sidewalks. Uniform surface enables speed
040528 - that increases health metrics, and enables focused thinking
040529 - (meditating) to solve complex problems. Half Dome is only off-road
040530 - hiking to annually test medical condition. ref SDS 0 2X4K Swimming
040531 - and cycling do not seem viable alternatives to raise HDL 140%, as
040532 - occurred in this case. ref SDS 0 2X5L Doctor Simpson uses an
040533 - elliptical trainer for an hour, ref SDS 0 5G6M, and reports this is
040534 - boring, ref SDS 0 VV5I; contrasted with hiking through suburbs and
040535 - countryside for 3 - 4 hours is fun. ref SDS 0 S169 Hiking resolved
040536 - age-related pain in hips, back, shoulders, neck. ref SDS 0 OX4J CCTA
040537 - on 151019, found no significant atherosclerosis plaque in this case,
040538 - after patient held HDL > 60 for 18 months. ref SDS 0 VQ4N Doctor
040539 - Simpson reviewed Cardiology practice lowering cholesterol LDL < 50 so
040540 - patients can slow advance of atherosclerosis. ref SDS 0 OP5M Elevated
040541 - HDL > 60 common trait centenarians. ref SDS 0 XG9G Health care
040542 - professionals' support for HDL collapsed when drug company clinical
040543 - trials yielded adverse results raising HDL with drugs. ref SDS 0 Y47H
040544 - Have not seen studies of hiking that raises HDL and EPC blood elements
040545 - with consequent favorable CCTA tests. ref SDS 0 LO4F Doctor Simpson
040546 - will inquire in the Cardiology Department for interest evaluating
040547 - patients who elevate HDL with hiking to navigate advancing age with
040548 - stronger mental and physical faculties. Doctor Redberg at UCSF has
040549 - written on benefits of HDL. ref SDS 0 E95N She has been critical of
040550 - CCTA testing for response to treatment. ref SDS 0 YR4F These cross
040551 - views make research difficult on raising HDL with exercise.
040552 - ref SDS 0 OR5I Work plan - do another CCTA in October to test for
040553 - response to treatment; may wait another year. ref SDS 0 AQ9J Burning
040554 - question: what is metric of benefits elevating HDL > 60 short of
040555 - death?
040557 - ..
040558 - [On 170506 0850 did workout at Orangetheory Fitness gym
040559 - with intent to try elliptical trainer; however the workout
040560 - that day did not include this equipment. ref SDS 40 HF8K
040561 -
040562 -
040563 -
040564 -
040565 -
040566 -
040567 -
040569 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Hiking Controls HDL Weight Blood Pressure Spreadsheet Study
040902 - Blood Pressure Correlates Elevated PPI Drugs Needed for Acalasia
040903 - Frequent Urination High Blood Pressure Caused High PPI Statin Dose
040904 -
040905 - Follow up ref SDS 25 I35I.
040906 -
040907 - Doctor Simpson initially noted increased weight and blood pressure,
040908 - and drop in HDL (from 72 on 170216 to 54) reported today, ref SDS 35
040909 - 5C7M, for this review cycle. He cited the clinical study showing
040910 - hiking controls all three health metrics, which was submitted to the
040911 - doctor by copy of letter on 170410 1623. ref SDS 33 YK8G
040913 - ..
040914 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
040916 - ..
040917 - Doctor Simpson commented favorably on raising a severely negative
040918 - health risk - HDL 30, at time of heart surgery on 091022 - to a
040919 - significantly favorable profile - HDL 73 reported this past February -
040920 - by hiking 11 - 15 miles per day. He seemed to indicate this is the
040921 - only instance where HDL has increased by orders of magnitude from
040922 - exercise. There are no clinical trials of anyone else hiking these
040923 - levels for 5 years with HDL rising significantly in tandem with
040924 - significantly increased mileage. Previously, the doctor commented
040925 - this is the best patient record he has ever had, reported on 161012
040926 - 1000. ref SDS 25 K589
040928 - ..
040929 - [On 170522 0003 letter to Karen and medical team on VA
040930 - advancing walking for improving health, based on pamphlet
040931 - on 101 reasons for walking. ref SDS 41 D048
040933 - ..
040934 - Concern today is significantly elevated blood pressure: 142/108 and
040935 - on 2nd test - 144/80, caused by adverse effects of injuries that have
040936 - prevented hiking the past 4 months.
040938 - ..
040939 - Another factor increasing blood pressure is Proton Pump Inhibitor
040940 - (PPI) medication, begun in 2010.
040942 - -
040943 - On 101218 1642 research found PPI (Omeprazole) causes high blood
040944 - pressure. ref SDS 4 1J5G
040946 - ..
040947 - On 111201 0928 sudden increase blood pressure may be caused by 2 years
040948 - taking Omeprazole; and high dose for prior 12 months. ref SDS 5 ZM5H
040950 - ..
040951 - On 120322 1030 notified Doctor Lee during meeting at VA changed dose
040952 - for Omeprazole from 80 to 20 mg, and this reduced blood pressure back
040953 - to normal range. ref SDS 7 UH5F
040955 - ..
040956 - On 160816 0800 Doctor Lee switched from low dose Omeprazole 20mg every
040957 - other day, to high dose Pantoprazole 80 mg everyday. ref SDS 24 Q05K
040958 - This was needed to resolve ulceration of lower esophageal sphincter
040959 - valve (LESV). Fundoplication performed with Heller Myotomy surgery
040960 - prevented acid reflux from the stomach into the esophagus, beginning
040961 - on 091216 0600. ref SDS 2 KE9U Fundoplication began loosening,
040962 - reported in Progress Notes with EGD procedure on 140509 0900.
040963 - ref SDS 12 I93F which then allowed increased acid reflux from stomach
040964 - into esophagus, reported on 161115 0800. ref SDS 26 K44N
040966 - ..
040967 - At that time on 160816, research found Pantoprazole (PPI) also causes
040968 - high blood pressure in some cases. ref SDS 24 Q05K
040970 - ..
040971 - Today, Doctor Simpson indicated he could prescribe pills that lower
040972 - blood pressure being raised by PPI pills, and at a period when hiking
040973 - has been significantly curtailed due to injuries, reported to Doctor
040974 - Tang in Podiatry on 170314 0930. ref SDS 29 PV6G
040975 -
040976 - [On 170523 0850 much lower blood pressure reported after
040977 - hiking 6 days enabled by improved knee and feet care.
040978 - ref SDS 42 1I6M
040980 - ..
040981 - Related Doctor Stewart proposing yesterday, to get more pills from
040982 - Urology for lowering frequent urination also caused by taking PPI and
040983 - statin pills. Currently taking low dose Atorvastatin 10 and Ezetamibe
040984 - 10 every other day, which has yielded moderately favorable cholesterol
040985 - profile, shown in labs today, reported on 170412 0700. ref SDS 35 U45J
040987 - ..
040988 - Therefore, to reduce blood pressure and frequent urination will first
040989 - reduce current high dose PPI, planned for review on 170419, with
040990 - Doctor Lee in GI Clinic at VAMC Sacremento; and, will further maintain
040991 - current low dose statin treatment. This effort is supported by the
040992 - record reducing both PPI and statins correlated with lower blood
040993 - pressure and eliminated frequent urination, reported on 111201 (see
040994 - case study on 101010 0744. ref SDS 3 734L
040996 - ..
040997 - Equally, experience found reducing statins resolved peripheral
040998 - neuropathy and dehydration from frequent urination, reported on 120906
040999 - (see case study on 120101 0900. ref SDS 6 SQ6H).
041001 - ..
041002 - On 121206 paused statin to recover dehydration from frequent urination
041003 - and peripheral neuropathy. ref SDS 6 GC6N
041005 - ..
041006 - On 150809 pause statins recover severe dehydration from frequent
041007 - urination (see case study on 140101 0600. ref SDS 11 GH3G
041009 - ..
041010 - On 150819 also paused/reduced PPI recover frequent urination, prepare
041011 - for Half Dome. ref SDS 11 4Q5F
041013 - ..
041014 - On 160911 paused both statins and PPI prepare for Half Dome.
041015 - ref SDS 20 E29K
041017 - ..
041018 - See as well medication spreadsheet...
041019 -
041020 - F:\05\00003\SM\CC\CHMG\FNGC\CJGK\achalasia_meds_lesv.xlsx
041021 -
041023 - ..
041024 - Frequent Urination Taking Statins Does Not Align With Study during 2011
041025 - Many Patients Report Frequent Urination Correlates With Statin Medications
041026 - Welch Case With Anecdotal Evidence Frequent Urination Taking Statins
041027 -
041028 - Doctor Simpson cited study he submitted in a letter, which found
041029 - statins do not cause frequent urination, reported recently on 170410
041030 - 1352. ref SDS 32 X45G
041032 - ..
041033 - We reviewed results of Internet search associating statins with
041034 - frequent urination. There are hundreds of hits reporting frequent
041035 - urination occurs from taking statin medications.
041037 - ..
041038 - Doctor Simpson commented these are anecdotal reports.
041040 - ..
041041 - Evidence indicates this case is another "anecdote."
041042 -
041044 - ..
041045 - High Blood Pressure Treat Lower PPI Repair Feet Knees for Hiking
041046 -
041047 - This record supports deferring pills to lower blood pressure until
041048 - after efforts in Orthopedics to restore normal hiking, which has been
041049 - effective maintaining healthy numbers, as noted by the doctor today,
041050 - per above. ref SDS 0 I35I Only in the past year, when a raft of
041051 - injuries curtailed hiking, has blood pressure noticably increased. On
041052 - 160816, increasing to high dose Pantoprazole 80 mg compounded elevated
041053 - blood pressure.
041055 - ..
041056 - [On 170523 0850 much lower blood pressure reported after
041057 - hiking 6 days enabled by improved knee and feet care.
041058 - ref SDS 42 1I6M
041060 - ..
041061 - Meeting Doctor Lee in GI Clinic at VAMC Sacramento scheduled next week
041062 - on 170419 0900. Will review reducing PPI toward lowering blood
041063 - pressure, and frequent urination in that severe ulceration that
041064 - required high dose PPI is now resolved, as planned in the meeting with
041065 - Doctor Lee on 170404 0800. ref SDS 31 XP5K
041066 -
041067 -
041069 - ..
041070 - Hiking Work Plan Supartz Repair Knees MRI Feet Verify Diagnosis
041071 - Feet MRI Verify Plantar Plate Tear Treat Plantarflexion Taping
041072 - Plantarflexion Taping Physical Therapy Develop Scheme Protect Plantar Plate Tear
041073 -
041074 - Doctor Simpson again noted hiking is critical in this case to lowering
041075 - weight and blood pressure, and raising HDL for healthy CVD profile.
041077 - ..
041078 - Doctor Simpson asked about plans to resume hiking?
041080 - ..
041081 - Current work plan following MRI on feet this morning, reported in
041082 - another record on 170412 0800. ref SDS 36 SG4K, is meeting with Doctor
041083 - Thuillier in Orthopedics on Monday, 170417. Develop line of care to
041084 - recover from plantar plate tear, and to maintain knee integrity
041085 - possibly with 2 more injections Supartz making a total of 5 in right
041086 - knee, and start with 3 injections in left knee.
041088 - ..
041089 - Will request Doctor Thuillier make referral to Outpatient Physical
041090 - Therapy for applying Rocktape, or equal, in different schemes to
041091 - identify the best solution in this case for plantar plate tear to heal
041092 - while hiking, planned in the meeting with Sharlene in Outpatient
041093 - Physical Therapy yesterday on 170411 1528. ref SDS 34 5M79
041094 -
041095 -
041097 - ..
041098 - Future Maintain Elevated HDL When Age Degrades Body Cannot Hike
041099 - Hiking Switched from Running When Age Degraded Body 30 Years Ago
041100 - Time Ran Out Running Switched to Hiking Has Time Run Out Again
041101 -
041102 - Doctor Simpson asked about the future? How will patient maintain
041103 - level of exercise to maintain benefits of endurance exercise that
041104 - maintain healthy HDL, weight, and blood pressure in the face of rising
041105 - repetitive stress injuiries? He mentioned several times that 15 mile
041106 - (4-hour) hikes present elevated risks of injury.
041108 - ..
041109 - This is a critical question - hopefully not for another 5 years or so;
041110 - but, time may run out sooner. For example, beginning in 1983, Millie
041111 - and I used to run on the Embarcadero up to Fisherman's Warf and return
041112 - at the Wheel, sometimes continue out to the fishing pier, and
041113 - sometimes over the hill at Fort Mason to Marina Green, do a lap and
041114 - return. Sometimes we ran out to Fort Point, beneath the Golden Gate
041115 - Bridge. There were other routes through the City on California, Bush,
041116 - Market, and of course we ran South on Embarcadero out beyond where
041117 - Giants Stadium is now located, but at that time there was a huge blue
041118 - building that was one of our markers.
041120 - ..
041121 - Eventually, time ran out on running with injuries piling up.
041122 - Hamstring pulls, MCL, ankles. Millie got plantar fasciitis. So we
041123 - had to stop running. Years later in 2002, Millie got cancer and took
041124 - up hiking to maintain WBC (actually AnC, but WBC is major component)
041125 - in order to get treatments. So, I went with her, starting a modest
041126 - regimen - 3 to 6 miles per day 4 - 5 times a week. Hiking at this
041127 - level caused only hamstring pulls and blisters, which are fairly easy
041128 - to treat.
041130 - ..
041131 - Today, Doctor Simpson poses the question: has the clock ticked again
041132 - with time running out on hiking?
041133 -
041134 -
041136 - ..
041137 - HDL Increased Hike 11-15 Miles Per Day 300 Miles Per Month 2500 Annually
041138 - Hike 11-15 Miles Per Day 300 Miles Per Month 2500 Annually Increased HDL
041139 - Hiking Paved Streets Avoid Concrete Sidewalks Maintain Speed Avoid Injuries
041140 -
041141 - Doctor Simpson was kind expressly noting health benefits of extended
041142 - endurance exercise since 2010, now hiking 11 - 15 miles per day, 300
041143 - miles per month, 2,500 miles per year. He asked if this mileage is on
041144 - streets?
041146 - ..
041147 - Explained goal to avoid concrete; however, the route has about 3 miles
041148 - of concrete sidewalk, where the roadway shoulder is too narrow for
041149 - walking on pavement. The majority of mileage is on asphalt pavement,
041150 - because it is softer and so more forgiving to prevent orthopedic
041151 - injuries to hips, knees and feet.
041153 - ..
041154 - Except for Half Dome, which is an annual metric of overall health and
041155 - functionality, all hiking is on commercial streets. This provides a
041156 - uniform surface that does not require concentration, nor moderating
041157 - speed to safely traverse complex, difficult terraine, i.e., avoid
041158 - twisted ankles, knees, hips, falls, as occurs in off-road hiking -
041159 - Half Dome is an extreme example. The uniform surface frees the mind
041160 - to think, meditate, solve problems. It further enables hiking and
041161 - running at speed, which yields higher benefits, including elevated
041162 - HDL.
041163 -
041164 -
041166 - ..
041167 - Alternate Aerobic Exercise No Evidence Elevates HDL
041168 - Biking Swimming Body Supported by Medium No Evidence Increase HDL
041169 -
041170 - Doctor Simpson suggested transitioning to alternative aerobic
041171 - exercise.
041173 - ..
041174 - The doctor was not enthusiastic about switching to swimming nor to
041175 - biking for maintaining elevated HDL. Seems likely both yield good
041176 - numbers for weight and blood pressure.
041178 - ..
041179 - Parenthetically, the body may react by increasing HDL from hiking and
041180 - running, because human genetics evolved to support bipedal mobility
041181 - essential for life. People have always swam, but 99.9% of the time
041182 - has been on land. Body effects of biking are new in relation to human
041183 - evolution going back to earlier forms. Hiking and running are
041184 - innately human survival activities.
041186 - ..
041187 - For example, on 130828, Slate article "Disheartening Medicine"
041188 - reported former President George W Bush biking for health maintenance
041189 - and recreation, saying he "...cycles dozens of miles at a time."
041190 -
041191 - http://www.slate.com/articles/health_and_science/medical_examiner/2013/08/heart_procedures_in_presidents_problems_with_george_w_bush_barack_obama.html
041193 - ..
041194 - The article does not report HDL, but disclosed the former president
041195 - underwent routine medical checkup, including a treadmill test that
041196 - showed a problem. He then had a chest CT scan that confirmed a
041197 - coronary blockage. The next day, doctors implanted a stent to open
041198 - the narrowed artery. As in the Welch case on 091022, whatever the
041199 - former president was doing, it was not enough to prevent a coronary
041200 - problem.
041202 - ..
041203 - "Dozens of miles at a time," sounds like a lot, but the important
041204 - factor is time. Depending on terrane, 36 miles (3 dozen) can be
041205 - covered in 2 hours by fit cyclists. Many cycling enthusiasts bike 100
041206 - even 300 miles and more on weekends, so Mr Bush likely did this as
041207 - well. How often is this done? Busy people, like presidents, and
041208 - former presidents have difficulty carving out 2 hours a day, much less
041209 - 3 - 4 hours, for exercise, 5 - 7 times a week, as in the Welch case.
041210 - Assuming, the former president made a strong commitment, it may
041211 - indicate biking is not effective raising HDL > 60 to a protective
041212 - level.
041214 - ..
041215 - Today, explained continual adverse results biking all around San
041216 - Francisco. A favorite route was across the Golden Gate Bridge,
041217 - through Sausalito, out to Corta Madera and back to Golden Gateway
041218 - across from the Ferry Building, about 60 miles, but only once or twice
041219 - a week a few times a month at most. Suffered continual flat tires,
041220 - and was hit by cars several times. There is a lot of coasting with
041221 - biking, rather than steady expenditure of energy that occurs with
041222 - hiking. As well, the bike supports body weight, rather than the legs.
041224 - ..
041225 - Doctor Simpson noted that water supports body weight when swimming, so
041226 - there is less expenditure of energy. Both biking and swimming may
041227 - increase HDL, if done with sufficient time and effort. There are no
041228 - studies showing this occurs, as there is with hiking. Swimming and
041229 - biking present logistic and cost constraints. Walking out the door
041230 - and around the block is mind numbingly fast, easy, beneficial.
041231 -
041232 -
041234 - ..
041235 - Elliptical Trainer Might Emulate Hiking Raise HDL Reduce Injuries
041236 - Plantar Plate Tear May React Adverseley Elliptical Trainer
041237 -
041238 - The doctor cited favorable personal experience using elliptical
041239 - trainer. He suggested doing this in a gym, rather than buying the
041240 - equipment. Use one with arms and legs.
041241 -
041242 - [On 170503 1350 schedule workout on elliptical trainer at
041243 - Orangetheory Fitness gym, planned on 170506. ref SDS 39
041244 - WF7N
041246 - ..
041247 - [On 170506 0850 did workout at Orangetheory Fitness gym
041248 - with intent to try elliptical trainer; however the workout
041249 - that day did not include this equipment. ref SDS 40 HF8K
041251 - ..
041252 - A challenge using elliptical trainer is the current orthopedic deficit
041253 - of plantar plate tear, diagnosed by Doctor Thuillier on 170327 1430.
041254 - ref SDS 30 I54I The MRI performed this morning will assess the
041255 - severity of injury, reported in another record on 170412 0800.
041256 - ref SDS 36 HQ5O Actually, the pain has subsided just today, and so
041257 - recovery may ensue. Meeting on Monday, 170417, will develop line of
041258 - care with support in Outpatient Physical Therapy experimenting to
041259 - apply effective plantarflexion taping scheme that protects Plantar
041260 - Plate against further injury while hiking. Alternatively, may have to
041261 - wait another month or so for further healing to occur.
041262 -
041263 - [On 170721 0848 research found plantar plate tears occur
041264 - with runners cross training on elliptical trainers.
041265 - ref SDS 43 HH5K
041267 - ..
041268 - For example, several weeks ago, drove home from Medford, after
041269 - visiting mother at Providence Medical Center. Some 2 hours into the
041270 - drive, somewhere past Corning, the right foot pressing on the gas
041271 - pedal began experiencing rising pain from the plantar plate tear.
041272 - After a few more miles about 0100a, had to pull off to the side of
041273 - Highway 5, and let Kathy complete the drive home. This level of pain
041274 - might occur from consistend pressure using the elliptical trainer
041275 - device. We can experiment to find out.
041276 -
041278 - ..
041279 - Elliptical Trainer Stationery Exercise Boring
041280 - Boredeom Disincentive Stationery Exercise Elliptical Trainer
041281 -
041282 - Another problem is bordom. There is a big difference traversing a
041283 - route through varying topography with cars and trucks wizzing by at
041284 - 60+ mph along part of the way, cows grazing, deer running here and
041285 - there, birds going every which way. Having done this hike a thousand+
041286 - times, the mind innately divides the route into sections based on
041287 - markers: street light, change in width and slope of shoulder, street
041288 - corner, a tree, hill, creek, etc. On passing one marker focus turns
041289 - to the next. Proceeding through 11 or even 15 miles, there is no
041290 - thought of how much time this takes, but only of the next marker. The
041291 - mind anticipates how much time, setting, risks, level of effort to
041292 - reach the next marker. None of this occurs using a stationary
041293 - excercise device, and so boredom is a negative incentive to avoid
041294 - prolonged use required for exercise to consistently raise and maintain
041295 - elevated HDL, plus other benefits of aerobic exercise.
041297 - ..
041298 - Doctor Simpson laughed, and said: "I know. I use the darn thing for
041299 - an hour, and it seems like forever."
041301 - ..
041302 - There is a question about how often an hour a day workout on an
041303 - elliptical trainer is needed to get comparable results to hiking 3 - 4
041304 - hours (11 - 15 miles) per day 7 days a week, needed to elevate HDL?
041305 - Can experiment with 1 hour 5 days a week, 2 hours 7 days a week, etc.,
041306 - and check response to treatment. Sounds very boring.
041308 - ..
041309 - Agreed to investigate using elliptical trainer.
041310 -
041311 - [On 170503 1350 schedule workout on elliptical trainer at
041312 - Orangetheory Fitness gym, planned on 170506. ref SDS 39
041313 - WF7N
041314 -
041315 - [On 170506 0850 did workout at Orangetheory Fitness gym
041316 - with intent to try elliptical trainer; however the workout
041317 - that day did not include this equipment. ref SDS 40 HF8K
041319 - ..
041320 - [On 170721 0848 research found plantar plate tears occur
041321 - with runners cross training on elliptical trainers.
041322 - ref SDS 43 HH5K
041323 -
041324 -
041326 - ..
041327 - Hiking Resolved Age Related Injuries Hips Back Shoulders
041328 -
041329 - Another incentive for hiking is collateral health benefits, besides
041330 - elevating HDL. At about age 50, long after running had stopped, and
041331 - before starting to hike, began experiencing hip, back and shoulder
041332 - pain, which gradually increased in frequency and severity. Near age
041333 - 58, began hiking at low levels with Millie. Over the next few years
041334 - hiking gradually increased, and beginning in 2011, hiking increased by
041335 - orders of magnitude. All these age-related pains resolved, possibly
041336 - with increased blood flow from regression of atherosclerosis. Maybe
041337 - this occurs with swimming and biking, even elliptical training. There
041338 - is no record of this benefit with these other modalities.
041339 -
041341 - ..
041342 - Weight Loss and Gain Tracks Hiking
041343 -
041344 - Hiking has a compound effect on weight gain and loss. Eating before
041345 - hikes causes nausea, thus reduced eating. Hiking per se burns glucose
041346 - and triglycerides that otherwise cause weight gain. When hiking,
041347 - "grazing" does not occur, and post-hike fatigue reduces incentive to
041348 - eat. Whereas, not hiking has the reverse effect. Working in the
041349 - office at home, the mind eventually ponders benefits of eating
041350 - something that tastes good. This doesn't happen when hiking. Thus,
041351 - as seen in the study, weight clearly moves in tandem with hiking...
041353 - ..
041354 - F:\05\00003\SM\CC\CHMG\FNGC\CJGK\achalasia_meds_lesv.xlsx
041355 -
041357 - ..
041358 - Hiking Fun Emotional Rewards Drive Raising HDL > 60
041359 -
041360 - Another incentive for hiking is how much fun it is. Endorphins kick
041361 - in, and there is real joy experiencing power, speed and endurance of
041362 - the body cruising through the countryside. At Lafayette Reservoir
041363 - people are doing 1 or 2 3-mile laps. On the weekend it is packed and
041364 - so fun seeing so many people enjoying public facilities. Sometimes
041365 - you see somone you know coming the other way, and so reverse direction
041366 - to visit and catch up together. Nobody else hikes the primary 11 mile
041367 - route in Concord, especially along Ygnacio Valley Road. There are
041368 - occasional bikers. No other hikers nor bikers take Crystal Ranch
041369 - Road, so it is lonely. But there is appreciation and thankfulness
041370 - that the body can handle this effort, knowing it drives a critical
041371 - health marker. There is also appreciation when people drive by
041372 - honking and waving encouragement. Sometimes people stop where safe
041373 - and roll a window down to say they are encouraged to hike themselves
041374 - seeing someone out everyday. One day a woman driver stopped traffic
041375 - at a busy intersection during the evening commute. She was making a
041376 - right hand turn, so I sprinted across to avoid holding her up. But,
041377 - she honked and motioned me over. Rolling down her window, she related
041378 - seeing me all the time along the 4 mile stretch of Ygnacio Valley
041379 - Road. She further said she is a cardiologist, and tells her patients
041380 - about this hiker. That was all she had time to say, because people
041381 - were backed up behind honking for her to turn right. Needless to say:
041382 - favorable public comments are encouraging.
041383 -
041384 -
041386 - ..
041387 - Injuries Diminish Hiking Incentives Investigate Alternatives
041388 - Doctor Simpson Posed Trial Elliptical Trainer Evaluate Raise HDL
041389 - HDL Evaluate Elliptical Trainer with No Cost Trial at Gym
041390 -
041391 - Of course injuries diminish incentives, and so balance must be struck
041392 - between benefits of exercise, and maintaining the ability to exercise
041393 - at all. Hopefully, we are not there yet.
041395 - ..
041396 - Doctor Simpson suggested getting a no-cost trial membership to test
041397 - the elliptical trainer. He noted there about 20 gyms in the Concord
041398 - area, and the trial may find elliptical exercise causes less pressure
041399 - on the plantar plate than both hiking and even driving.
041401 - ..
041402 - Having evidently elevated baseline HDL from 30 to 60, it might be
041403 - possible to reduce mileage and thereby reduce exposure to injury, yet
041404 - still maintain elevated HDL, and even increase it in order to maintain
041405 - regression of atherosclerosis through reverse cholesterol transport
041406 - (RCT).
041407 -
041409 - ..
041410 - CCTA 151019 Found No Significant Plaque 6 Years After CABG x4
041411 - Atherosclerosis HDL Regress Not Settled Medical Science in Cardiology
041412 - HDL Regress Atherosclerosis Not Settled Medical Science in Cardiology
041413 - Cardiology Skeptical Atherosclerosis Regress Elevated HDL
041414 -
041415 - The doctor seemed to say HDL does not regress atherosclerosis,
041416 - indicating reverse cholesterol transport (RCT) does not occur with
041417 - elevated HDL. This appears conflicting with research on 131125 0005.
041418 - ref SDS 10 HG7N
041420 - ..
041421 - We reviewed CCTA on 151019 0930, ref SDS 17 8Q6I, which he ordered on
041422 - 151014 0900. ref SDS 16 OG3N
041424 - ..
041425 - The doctor said the CCTA did not find there was no atherosclerosis.
041427 - ..
041428 - We read again addendum findings. ref SDS 17 SU62 He pointed out that
041429 - Doctor Jha wrote...
041430 -
041431 - No significant calcified plaque is seen in the bypass grafts.
041432 - All the bypass grafts are opacified with contrast without
041433 - evidence for filling defect or wall calcifications. ref SDS 17
041434 - SU62
041436 - ..
041437 - No calcification is seen in the aortic wall in the visualized
041438 - portions of the thoracic aorta. No ostial calcifications at
041439 - the origins of great vessels from the aortic arch. ref SDS 17
041440 - SU67
041442 - ..
041443 - Doctor Simpson indicated finding "no significant" plaque, does not
041444 - mean there is no plaque, since plaque can occur below a level that can
041445 - be identified by CT technology.
041447 - ..
041448 - There was discussion about significance of "non-significant" plaque
041449 - that might exist in the walls of blood vessels, which cannot be
041450 - identified with CCTA technology.
041452 - ..
041453 - The doctor seemed to further note that non-significant plaque in
041454 - arteries below the level that can be identified with CT technology is
041455 - not significant to patient health. This follows from Cardiology
041456 - practice relying on "patent" - considered normal - blood flow defined
041457 - to occur with up to 70% blockage, reported in the record following
041458 - CABG x4 on 091022 0700. ref SDS 1 RY6H The original CCTA report
041459 - simply stated all the bypass grafts are patent, shown on 151019 0930.
041460 - ref SDS 17 JW8O There were then 2 meetings and a great deal of
041461 - analysis leading up to the addendum, in which 2 radiologists
041462 - maintainted there was no blockage of any kind visible in the CT scan
041463 - on 151019. That would seem to indicate the blood vessels are as open
041464 - as is humanly possible to determine with current technology. So, yes
041465 - there is residual plaque, but not significant to health.
041466 -
041468 - ..
041469 - LDL < 50 Cardiology Prescribes Statins Manage Risks Atherosclerosis
041470 - Atherosclerosis LDL < 50 Slow Advance Cardiology Prescribes Statins
041471 - Cardiology Statins Lower LDL < 50 Manage Risks Atherosclerosis
041472 -
041473 - Doctor Simpson indicated Cardiology practice overwhelmingly strives to
041474 - lower LDL. He advised that standard of care prescribes statins for
041475 - lowering lab markers to LDL < 50, in order to avoid risk of
041476 - non-significant plaque increasing to significant health risks of
041477 - atherosclerosis.
041479 - ..
041480 - Previously, the doctor discussed adding aspirin and raising statins
041481 - from 10 mg every other day to 80 mg every day. At that time LDL went
041482 - up to 170, reported on 161012 1000. ref SDS 25 K568
041483 -
041484 - [On 170726 1600 Doctor Tucker drew blood for PRP injection
041485 - therapy to recover from plantar plate tear, metatarsalgia,
041486 - and left knee osteoarthritis; she found thicker than
041487 - expected blood, and so recommended patient take Baby
041488 - Aspirin to thin the blood that helps prevent coronary
041489 - events. ref SDS 44 TZ99
041491 - ..
041492 - LDL presents a floating target in cardiology. VA labs list healthy
041493 - LDL < 131, and patient had LDL 117, reported on 170412 0700.
041494 - ref SDS 35 657M Labcorp says LDL < 160 is healthy. American Heart
041495 - Association (AHA) says LDL < 190 healthy, reported on 131112 1422.
041496 - ref SDS 8 HT87
041498 - ..
041499 - Doctor Simpson will look for literature explaining rationale for
041500 - lowering LDL < 50.
041502 - ..
041503 - We considered Cardiology practice may have settled on lowering LDL,
041504 - because there is no record of patients regressing athersclerosis to
041505 - non-significant levels by raising HDL > 60. The record showing a
041506 - patient has done this might therefore interest doctors seeking a
041507 - positive complement to reverse, rather than merely slow advance of
041508 - life ending atherosclerosis. Regressing atherosclerosis might benefit
041509 - cognition, digestion, immunity and healing from increased blood flow.
041510 -
041511 -
041513 - ..
041514 - HDL > 60 Regress Atherosclerosis Reverse Cholesterol Transport RCT
041515 - Atherosclerosis HDL > 60 Regress Plaque Reverse Cholesterol Transport RCT
041516 - RCT Not Established Cardiology Science HDL > 60 Regress Plaque
041517 -
041518 - Doctor Simpson seemed aware of patient goals to avoid significant
041519 - atherosclerosis health risks by maintaining HDL at levels which
041520 - regress plaque through reverse cholesterol transport (RTC) - generally
041521 - near and above HDL 60 - by hiking 11 - 15 miles over 3 - 4 hours per
041522 - day and 5 - 7 days a week, as shown in case study submitted with the
041523 - copy of the letter he received on 170410 1623. ref SDS 33 YK8G
041525 - ..
041526 - The doctor seemed to say this patient goal has been accomplished
041527 - raising HDL 30 at the time of CABG in 2009, to HDL 73. He seemed
041528 - however to question that having elevated HDL, the patient benefits
041529 - from consequent RCT, and so LDL must be lowered to 50 by increasing
041530 - statin medications.
041531 -
041533 - ..
041534 - Centenarians Commonly Have Elevated HDL Avoid Atherosclerosis Despite Age
041535 - HDL Elevated People Living to 100 Avoid Age Accumulated Atherosclerosis
041536 -
041537 - We reviewed research on vascular cell senesence indicating about the
041538 - only thing common to centenarians (people living near and above 100)
041539 - is elevated HDL, reported on 150406 0740. ref SDS 14 4J97 An
041540 - attractive explanation is that HDL regresses and protects against the
041541 - ravages of atherosclerosis from plaque that clogs blood vessels.
041542 - Unless removed by HDL and repaired with EPCs, plaque accumulates with
041543 - age, thereby choking distribution of oxygen and nutrients from cells
041544 - and so ending life. LDL is not reported for centenarians, indicating
041545 - researchers have not found corollary patterns for centenarians. This
041546 - does not mean LDL is not important for people who have innately low
041547 - HDL and cannot elevate HDL to a healthy level with hiking.
041549 - ..
041550 - [On 170423 1427 Amy commented on signficance of
041551 - centenarians having common trait of elevated HDL.
041552 - ref SDS 37 UY47
041553 -
041555 - ..
041556 - HDL Debate Discovery Assessment Exciting Time Cardiology
041557 - Cardiology Debate HDL Exciting Period Experiment Discovery Assessment
041558 -
041559 - Doctor Simpson noted today, that 20 years ago everyone in Cardiology
041560 - believed HDL was the most important marker for coronary health.
041561 - However, all the drug studies by major pharmaceuticals found in the
041562 - past few years, that patients died with coronary events despite
041563 - elevating HDL with drugs. Universal support collapsed. People just
041564 - gave up.
041566 - ..
041567 - For example see report on 160405 1305, Evacetrapib raised HDL 130%
041568 - failed clinical trial Eli Lilly cholesterol drug CEPT inhibitor did
041569 - not reduce CV events; raised blood pressure (hypertension),
041570 - ref SDS 22 AF51 Doctors discouraged Merck anacetrapib and Amgen
041571 - TA-8995 which raise HDL similarly, expect fail to improve clinical
041572 - outcomes. ref SDS 22 OH42
041574 - ..
041575 - There seems wide agreement that HDL has favorable effect on
041576 - atherosclerosis plaque. Experts debate why drug induced HDL failed,
041577 - see the record on...
041579 - ..
041580 - European Society of Cardiology (ESC) Congress 2013
041581 -
041582 - Robert Harrington, MD: Hi. I'm Bob Harrington from Stanford
041583 - University. I'm here at the European Society of Cardiology
041584 - (ESC) meetings in Amsterdam and have had an opportunity to talk
041585 - with a few colleagues about some of the hot, breaking science
041586 - at these meetings. Joining me today is Renu Virmani,
041587 - pathologist from Washington, DC. Welcome, Renu. ref SDS 10 8H3M
041589 - ..
041590 - Conference attendees pondered evident dilemma from the record shwoing
041591 - people with low HDL < 35 present high risk for adverse coronary
041592 - events; yet, drug trials that raised HDL did not yield favorable
041593 - results. ref SDS 10 Q338
041595 - ..
041596 - Cursory research on these trials seems to indicate study-patients were
041597 - already at advanced stages of atherosclerosis, and then expected
041598 - elevating HDL with drugs would prevent death.
041600 - ..
041601 - Today, we reviewed the role of raising EPCs along with HDL for reverse
041602 - cholosterol transport (RCT) to be effective. Merely raising HDL is
041603 - not enough, reported in research on 131125 0005. ref SDS 10 6O9M Like
041604 - Millie, who Doctor Johnson prescribed hiking to raise ANC for making
041605 - chemotherapy effective, these study patients equally needed to raise
041606 - ECPs to make HDL effective. Mil was able and willing to do that.
041607 - Possibly people weakened with athersoclerosis could not, or didn't
041608 - even try, because there was no support in the study.
041610 - ..
041611 - Moreover, the quality of HDL increased with drugs, may be less than
041612 - HDL increased with innate exercise, i.e., increasing HDL with hiking
041613 - may have structure and capability that drugs have not yet emulated.
041615 - ..
041616 - Doctor Harrington, and collagues at the European Conference in 2013,
041617 - describe success infusing patients with HDL, ref SDS 10 A55M, but
041618 - nobody discussed results of patients innately increasing HDL through
041619 - extended endurance exercise, in this case hiking, as shown in the
041620 - study...
041621 -
041622 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
041623 -
041625 - ..
041626 - Walking Meetings Cognition Benefit Increased Blood Flow
041627 - Cognition Stimulated by Hiking Elevate HDL Increase Blood Flow
041628 - Hiking Elevate HDL Stimulates Cognition by Increasing Blood Flow
041629 -
041630 - Today, Doctor Simpson seemed to concur that naturally produced HDL may
041631 - work better than drug induced HDL, i.e., there may be a qualitative
041632 - difference. He seemed to say that HDL has other benefits besides
041633 - regressing atherosclerosis.
041635 - ..
041636 - After the meeting, research found...
041637 -
041638 - The Globe and Mail
041639 -
041640 - Walk the talk: Why you have to try this new (and healthy)
041641 - business meeting style
041643 - ..
041644 - Published: 2014 05 08
041645 -
041646 - http://www.theglobeandmail.com/life/health-and-fitness/health/why-your-brain-will-thank-you-if-you-take-it-for-a-walk/article18543218/
041648 - ..
041649 - The article says in part...
041650 -
041651 - US President Barack Obama has made a habit of promenading
041652 - around the White House grounds with his chief of staff.
041653 - Facebook CEO Mark Zuckerberg and Hikmet Ersek, CEO of Western
041654 - Union Co., have abandoned the boardroom in favour of group
041655 - outings on foot.
041657 - ..
041658 - A study from Stanford University released in April found that
041659 - walking boosted creative output by an average of 60 per cent.
041661 - ..
041662 - The researchers found... walking outside produced "the most
041663 - novel and highest quality analogies,"... The effect was so
041664 - powerful that researchers detected a residual creative boost in
041665 - seated participants who had taken an earlier walk.
041667 - ..
041668 - There is an awareness during hiking that the mind can think through
041669 - complex scenarios to anticipate failure that would otherwise not be
041670 - recognized until after spending time and money discovers disjunction;
041671 - whereas, continuing walking enables traveling altnerate scenarios that
041672 - give greater promise of success on implementation. Increased blood
041673 - flow to the brain may be a factor from elevating HDL. Another is
041674 - reduced input, enabling focus, see NWO...
041675 -
041676 - http://www.welchco.com/03/00050/01/09/03/02/03/0309.HTM#OR6J
041677 -
041678 -
041680 - ..
041681 - HDL Advocates Cardiology Friendly Forces
041682 -
041683 - Doctor Simpson will make inquiries for anyone in Cardiology who might
041684 - collaborate on evaluating effects of raising HDL to regress
041685 - atherosclerosis as shown in the case study correlating hiking and HDL
041686 - levels...
041688 - ..
041689 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
041691 - ..
041692 - [...below on 170412 1000 Progress Notes report the doctor
041693 - will look for an HDL-positive cardiologist. ref SDS 0 EO5O
041695 - ..
041696 - Possibly Doctor Harrington at Stanford, and others attending the
041697 - European Cardiology Conference in 2013, referenced above, might
041698 - collaborate with us. ref SDS 0 D85K Doubtless more recent
041699 - professional events have influenced others to consider HDL benefits
041700 - combined with EPCs elevated through hiking.
041702 - ..
041703 - After the meeting research found Doctor Rita F Redberg on staff at
041704 - UCSF may have an interest in HDL. Her work was cited in the meeting
041705 - with Doctor Alba (Doctor Feingold, attending) on 131121 0930.
041706 - ref SDS 9 9H5L
041708 - ..
041709 - Doctor Redberg contributed to an article...
041710 -
041711 - The American Journal of Cardiology
041712 -
041713 - August 1, 2011 Vol 108, Issue 3, Pages 360-366
041714 -
041715 - Relation of Increased Prebeta-1 High-Density Lipoprotein
041716 - Levels to Risk of Coronary Heart Disease
041717 -
041718 - http://www.ajconline.org/article/S0002-9149(11)01349-X/abstract
041720 - ..
041721 - Only the abstract for the article is available at this location. The
041722 - first sentence says...
041723 -
041724 - Pre?-1 high-density lipoprotein (HDL) plays a key role in
041725 - reverse cholesterol transport by promoting cholesterol efflux.
041727 - ..
041728 - This para further says...
041729 -
041730 - Pre?-1 HDL was significantly and positively associated with
041731 - CHD and MI even after adjustment for established risk factors
041733 - ..
041734 - RCT is a major objective for raising HDL. Therefore, if that occurs,
041735 - as in this case, there could be a corollary interest in testing for
041736 - response to treatment with CCTA, i.e., was cholesterol reverse
041737 - transported?
041738 -
041739 -
041741 - ..
041742 - CCTA Cardiology Voices Object Presidents Checking Coronary Risk
041743 - President Obama HDL 61 Exercise Walking CCTA Minimal Atherosclerosis Risk
041744 -
041745 - Her recent article in WSJ on 160701, requires subscription, however,
041746 - the headline reads...
041747 -
041748 - Why I am Wary of Many Cardiac Screening Tests
041749 -
041750 - https://blogs.wsj.com/experts/2016/07/01/why-im-wary-of-many-cardiac-screening-tests/
041752 - ..
041753 - Without awareness of content, this headline aligns with earlier
041754 - articles where Doctor Redberg criticizes CCTA testing for response to
041755 - treatment as unnecessary and risks exposure to radiation. Doctor
041756 - Redberg noted in a Powerpoint presentation, sometime around 2010 and
041757 - now on the Internet, citing then President Obama allowing his annual
041758 - health checkup at age 48 to be published.
041760 - ..
041761 - Notably the President's checkup reported HDL 61 and CCTA showed
041762 - minimal atherosclerosis plaque. His family, and the nation are
041763 - relieved.
041765 - ..
041766 - The former president reports his preferred exercise is walking.
041768 - ..
041769 - Last year in June 2016, the President and his family visited Yosemite
041770 - to promote National Parks. Among many activities, the President, wife
041771 - and daughters drove to Galcier Point, and then hiked back to the
041772 - Valley Floor....
041773 -
041774 - http://www.sacbee.com/news/local/environment/article84694532.html
041776 - ..
041777 - The President's reliance on hiking was again reported climbing the
041778 - grueling Kono Head Crater Stairs on Christmas vacation 2015, in
041779 - Hawaii. This 1048 wooden stair trail rises on a steep incline some
041780 - 1208 feet, reported in dailymail.com...
041781 -
041782 - http://www.dailymail.co.uk/news/article-3371684/Obamas-hit-hiking-trail-day-four-Family-s-luxurious-two-week-Hawaiian-vacation.html
041784 - ..
041785 - However, voices from powerful Cardiology circles of influence strongly
041786 - object to both President Bush and President Obama getting CCTA tests
041787 - to discover their condition in time to take effective action against
041788 - significant athersocerlotic risks. Reliance on symptoms and labs
041789 - alone are secondary. Primary testing requires CCTA showing the
041790 - condition of blood vessels, as best can be determined, giving people a
041791 - choice about their future within the framework of doctor and patient
041792 - partnership.
041794 - ..
041795 - Routine testing response to treatment guides modifying treatement to
041796 - regress vascular sclerosis in order to strengthen mental and physical
041797 - faculties, similar to CT testing for cancer patients that routinely
041798 - guide changes to treatment.
041799 -
041800 -
041802 - ..
041803 - CCTA October 2017 Follow Up Favorable CCTA October 19 2015
041804 - Radiation Risks CCTA Minimal Compared Benefits Test Response to Treatment
041805 -
041806 - Therefore planned today, doing another CCTA in October after Half
041807 - Dome, in order to evaluate whether any non-significant plaque found in
041808 - the prior test on 151019, has become signficant, despite elevating HDL
041809 - 73, and in light of reduced hiking due to injury.
041811 - ..
041812 - Doctor Simpson asked about risks of radiation exposure doing CT tests
041813 - on 2 year intervals?
041815 - ..
041816 - Considered risks of advancing atherosclerosis that compound
041817 - infirmities of age outweigh theoretical risks of CCTA testing response
041818 - to treatment, similar to oncology practice. For nearly 10 years there
041819 - were numerous periods when Kaiser and UCSFMC gave Millie monthly, and
041820 - sometimes weekly CT tests for response to treatment that guided care.
041821 - She survived stage IV cancer in continual treatment with a life worth
041822 - living - working on the job, traveling to Europe, playing ball with
041823 - grandkids, hiking at Lafayette Reservoir.
041825 - ..
041826 - Doctor Simpson suggested waiting another year to do CCTA testing
041827 - response to treatment in this case, and thereon extend evaluation of
041828 - elevated HDL regressing atherosclerosis.
041830 - ..
041831 - We discussed advantages of timely testing for response to treatment so
041832 - that line of care can be adjusted in time to be effective. We are now
041833 - 2 years out from prior CCTA finding no plaque in blood vessels covered
041834 - by the CT scan (see addendum) on 151019 0930. ref SDS 17 SU62 In the
041835 - meeting to review these prior findings on 151028, Doctor Simpson
041836 - advised that atherosclerotic plaque advances within 2 years after
041837 - CABG. ref SDS 18 5L98 Accordingly, 2 years seems a good benchmark to
041838 - track progression of CVD.
041840 - ..
041841 - [...below on 170412 1000 Doctor Simpson reports in Progress
041842 - Notes planning to ask Radiology when another CCTA will be
041843 - helpful. ref SDS 0 1M50
041845 - ..
041846 - [...below on 170412 1000 Progress Notes Doctor Simpson
041847 - filed addendum on 170414, relating understandings from
041848 - discussion with radiologists that CCTA 2 years ago on
041849 - 151019, found patient did not have "significant stenoses of
041850 - = or > 50% vessel diameter," which seems to imply patient
041851 - may have had stenoses of 30%, 40%, 49% - 2 years ago in
041852 - October 2015, and therefore in light of patients low statin
041853 - dose CCTA can show progression of plaque > 50% vessel
041854 - diameter which requires higher dose statin medication.
041855 - ref SDS 0 8H5G
041857 - ..
041858 - Additionally, in the meeting with Doctor Simpson on 151014, there was
041859 - discussion that CCTA can assess damage to endothelial lining of blood
041860 - vessels caused by PPI that is in turn causing significantly high blood
041861 - pressure. ref SDS 16 T26N Beginning on 160816, PPI was elevated from
041862 - 20 to 80. Blood pressure is now in the range of 150 85, far above the
041863 - range of 120 65, when PPI dose is at 20.
041864 -
041865 -
041867 - ..
041868 - HDL Metric of Success Regressing Atherosclerosis Surival 5, 10, 20 Years
041869 -
041870 - Question persists: what is the metric? How long must the patient
041871 - survive to satisfy goals of drug company HDML trials?
041873 - ..
041874 - If the patient succumbs to CVD in 3, 5, 10 years will align with HDL
041875 - drug studies that failed, per above. ref SDS 0 Y47H If not, survival
041876 - with elevated HDL may offer another line of care echoing a prominent
041877 - Cardiologist at Stanford quoted as saying in effect: "The best
041878 - medicine for atheroclerosis is sweat."
041879 -
041902 -
041903 -
041904 -
0420 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Medical Chart Progress Notes for Cardiology Meeting 151014
050403 - Progress Notes Cardiology Meeting 151014 Doctor Simpson
050404 - Doctor Simpson Progress Notes Cardiology Meeting 151014
050405 -
050406 - Follow up
050407 -
050424 -
050425 -
050426 - 1. Date/Time: 12 Apr 2017 @ 1540
050427 - Note Title: CARDIOLOGY CLINIC ATTENDING NOTE (MED)
050428 - Location: San Francisco CA VAMC
050429 - Signed By: SIMPSON,PAUL C
050430 - Co-signed By: SIMPSON,PAUL C
050431 - Date/Time Signed: 12 Apr 2017 @ 1601
050433 - ..
050434 - 2. LOCAL TITLE: CARDIOLOGY CLINIC ATTENDING NOTE (MED)
050435 - STANDARD TITLE: CARDIOLOGY ATTENDING NOTE
050436 - DATE OF NOTE: APR 12, 2017@15:40 ENTRY DATE: APR 12, 2017@15:40:29
050437 - AUTHOR: SIMPSON,PAUL C EXP COSIGNER:
050438 - URGENCY: STATUS: COMPLETED
050439 -
050440 - *** CARDIOLOGY CLINIC ATTENDING NOTE (MED) Has ADDENDA *** (see below. ref SDS 0 8H5G)
050441 -
050444 - 3. 72 y.o. MALE who is a patient of RETTBERG,LAUREN.
050446 - ..
050447 - 4. Most Recent VITAL SIGNS:
050448 - Height: 64.5 in [163.8 cm] (06/03/2016 10:59)
050449 - Weight: 189.6 lb [86.2 kg] (04/12/2017 09:50)
050450 - BMI: 32.1 (Obesity Level I)
050451 - Temp: 98.2 F [36.8 C] (07/20/2016 05:14)
050452 - Pulse: 91 (04/12/2017 09:50)
050453 - Comments:
050455 - ..
050456 - Resp: 19 (07/20/2016 05:14)
050457 - BP: 144/80 (04/12/2017 09:50)
050459 - ..
050460 - O2 Sat: 4/12/17 09:50:31 O297
050462 - ..
050463 - ID/CC:
050465 - ..
050466 - 5. 72 swm from concord returns to routine f/u CAD sp CABG and to
050467 - monitor CRFs; last 10-12-16.
050469 - ..
050470 - 6. ASSESS:
050471 -
050472 - -he continues to do well clinically, w/o chest pain, dyspnea,
050473 - or syncope
050475 - ..
050476 - -however he has been unable to do his usual long hikes due to
050477 - foot problems, and his wt is up (plus 11 lbs) and BP is
050478 - trending more to HTN. -lipids are similar to last fall (HDL
050479 - ~60, LDL ~120) -today's foot MRI not reported yet
050480 -
050482 - ..
050483 - 7. PLAN:
050484 -
050485 - 1. we as usual went over my suggestion of high intensity
050486 - statin to reduce LDL, and asa, he wishes to cont as is, no
050487 - asa d/t achalasia problems, will use low- dose statin plus
050488 - ezet on a qod schedule, and exercise to raise HDL and
050489 - regress atherosclerosis.
050491 - ..
050492 - 2. he is having attention to his feet (a taping procedure)
050493 - and will hopefully get back to exercise
050495 - ..
050496 - 3. he will look into a gym where he could do an elliptical
050497 - machine w/o foot trauma
050499 - ..
050500 - This aligns with understandings during the meeting this morning, per
050501 - above. ref SDS 0 TS6G
050503 - ..
050504 - Progress Notes continue...
050505 -
050506 - 4. I will review his cor CTA, and ask Radiol when a repeat
050507 - seems useful; he is very intent to know if progression; if
050508 - yes, would increase statin.
050510 - ..
050511 - During the meeting this morning, there was consideration to order
050512 - follow up CCTA testing for response to treatment OA October 2017,
050513 - since cardiovascular plaque typically progresses within 2 years after
050514 - CABG, per above. ref SDS 0 AQ9J
050515 -
050516 - [...below on 170412 1000 Progress Notes Doctor Simpson
050517 - filed addendum on 170414, relating understandings from
050518 - discussion with radiologists that CCTA 2 years ago on
050519 - 151019, found patient did not have "significant stenoses of
050520 - = or > 50% vessel diameter," which seems to imply patient
050521 - may have had stenoses of 30%, 40%, 49% - 2 years ago in
050522 - October 2015, and therefore in light of patients low statin
050523 - dose CCTA can show progression of plaque > 50% vessel
050524 - diameter which requires higher dose statin medication.
050525 - ref SDS 0 8H5G
050527 - ..
050528 - Progress Notes continue...
050529 -
050530 - 5. I will see again in Sept after he climbs half-Dome. Lipids
050531 - ordered for sept 1
050533 - ..
050534 - Ordering lipid panel on Sep 1, should be find for getting labs the
050535 - day after Half Dome on 170914.
050537 - ..
050538 - Progress Notes continue...
050539 -
050540 - 6. I will look into a more HDL-positive cardiologist to see
050541 - him
050543 - ..
050544 - This aligns with discussion during the meeting today, per above.
050545 - ref SDS 0 E95N
050547 - ..
050548 - Doctor Simpson's Progress Notes continue...
050549 -
050550 - 8. CARD PROBLEMS:
050551 -
050552 - 1. CAD sp CABG here 10-22-09 (LIMA, SVG diag, ramus, PDA)
050553 -
050554 - 1. for angina and severe 3VD
050555 -
050556 - 2. last seen CT Surg 11-19-09
050557 -
050558 - 3. last TTE here 7-15-16 wnl
050559 -
050560 - 4. carotid US 9-20-16 sml plaque R bulb, no stenoses
050562 - ..
050563 - 5. cor CTA 10-19-15 all grafts open; reading "Coronary
050564 - calcium score is calculated to be 1360.
050566 - ..
050567 - No significant calcified plaque is seen in the bypass
050568 - grafts. All the bypass grafts are opacified with
050569 - contrast without evidence for filling defect or wall
050570 - calcifications.
050572 - ..
050573 - No calcification is seen in the aortic wall in the
050574 - visualized portions of the thoracic aorta. No ostial
050575 - calcifications at the origins of great vessels from the
050576 - aortic arch."
050578 - ..
050579 - Notation in Progress Notes today, related to addendum filed for CCTA
050580 - on 151019, and reportd of calculated calcium score 1360, should
050581 - explain this pertains only to bypassed arteries, which have no effect
050582 - on patient health, as reported by Doctor Elicker during meeting on
050583 - 151203 1014. ref SDS 19 4S6M
050584 -
050585 - [...below in this record on 170412 1000 below
050587 - ..
050588 - Doctor Simpson's Progress Notes continue...
050589 -
050590 - 2. hyperlipidemia; LDL varies greatly w extent of statin rx
050591 -
050592 - 3. overwt/obesity (BMI ~30). but very fit.
050593 -
050594 - 4. statin SEs: freq urination, dry feet, pain left arm
050596 - ..
050597 - 5. HTN, intermittent
050598 -
050600 - ..
050601 - 9. OTHER:
050602 -
050603 - 1. achalasia sp ops, frequent egd/dilation
050604 - 2. LLE hematoma w cellulitis sp fall (adm here 9-23 to 9-25-15)
050605 - 3. fx R radius (same fall)
050606 - 4. may16 balance issues possiblky ear, resolved
050607 - 5. stroke-like event at EGD jun16; no recur, brain MRIs wnl,
050608 - possibly periop med-related
050610 - ..
050611 - 10. SH [...Social History...]
050612 -
050613 - 1. lives concord
050614 - single has gf
050615 -
050616 - 2. wife of many years died of breast ca a few yrs ago
050618 - ..
050619 - 3. Gets up 3-6 am often to walk, on asphalt, bed early am, so not
050620 - much sleep. one
050622 - ..
050623 - 4. meal a day in evening, but healthy (fish, avocados, vegs). no
050624 - walking lately d/t feet.
050625 -
050627 - ..
050628 - 11. HPI [...History Present Illness...]
050629 -
050630 - 1. doing excellent
050631 - 2. no cv sxs.
050632 - 3. plantar problem esp right foot so can't hike as usual
050633 -
050635 - ..
050636 - 12. Active Medications:
050637 -
050638 - 1. ASPIRIN 81MG CHEW TAB CHEW ONE TABLET ORALLY EVERY not taking
050639 - DAY TO THIN BLOOD
050640 - 2. ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET taking qod
050641 - ORALLY AT BEDTIME FOR CHOLESTEROL
050642 - 3. DICLOFENAC NA 1% TOP GEL APPLY 2 GRAM STRIP TOPICALLY
050643 - EVERY 6 HOURS AS NEEDED TO AFFECTED AREAS FOR PAIN
050644 - 4. OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE ORALLY EVERYOTHER DAY taking pantop
050645 -
050646 - 5. pls ezetimide 10 qod
050647 -
050648 -
050650 - ..
050651 - 13. Computerized Problem List is the source for the following:
050652 -
050653 - 1. Metatarsalgia 05/25/2016
050654 - 2. Fall on same level, Onset 00/00/2015 05/25/2016
050655 - 3. History of coronary artery bypass grafting, 10/14/2015
050656 - Onset 10/00/2009
050657 - SFVA LIMA, SVGs diag, ramus, PDA
050659 - ..
050660 - 4. Hyperlipidemia 10/14/2015
050661 - 5. Body mass index 30+ - obesity 10/14/2015
050662 - 6. Chronic ischemic heart disease 10/14/2015
050663 - 7. Esophageal stricture (SNOMED CT 63305008) 05/04/2016
050664 -
050666 - ..
050667 - 14. LABS
050669 - ..
050670 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050671 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050673 - ..
050674 - Report Released Date/Time: Apr 12, 2017@10:19
050675 - Provider: SIMPSON,PAUL C
050676 - Specimen: SERUM. CH 0412 81
050677 - Specimen Collection Date: Apr 12, 2017@07:02
050678 - Test name Result units Ref. range Site Code
050679 - HEMOGLOBIN A1C 5.9 % 4.0 - 6.0 [662]
050680 - ===============================================================================
050681 -
050682 -
050684 - ..
050685 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050686 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050688 - ..
050689 - Report Released Date/Time: Apr 12, 2017@08:03
050690 - Provider: SIMPSON,PAUL C
050691 - Specimen: PLASMA. CH 0412 80
050692 - Specimen Collection Date: Apr 12, 2017@07:02
050693 - Test name Result units Ref. range Site Code
050694 - EGFR 73 mL/min Ref: >=60 [662]
050695 - SODIUM 142 mmol/L 135 - 145 [662]
050696 - POTASSIUM 4.4 mmol/L 3.3 - 4.8 [662]
050697 - CHLORIDE 104 mmol/L 101 - 112 [662]
050698 - CARBON DIOXIDE 31 mmol/L 24 - 32 [662]
050699 - ANION GAP 7 mmol/L 5 - 20 [662]
050700 - UREA NITROGEN 20 mg/dL 10 - 24 [662]
050701 - CREATININE 1.00 mg/dL 0.6 - 1.3 [662]
050702 - GLUCOSE 110 mg/dl 65 - 115 [662]
050703 - CALCIUM 9.3 mg/dL 8.5 - 10.5 [662]
050704 - CHOLESTEROL 184 mg/dl 100 - 240 [662]
050705 - TRIGLYCERIDE 67 mg/dl 10 - 190 [662]
050706 - HIGH DENSITY LIPOPROT (HDL) 54 mg/dl Ref: >=35 [662]
050707 - Eval: HDL <35 is associated with increased risk of CAD.
050708 - LDL CHOL(Calculated) 117 mg/dl Ref: <=131 [662]
050709 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050710 - ===============================================================================
050711 -
050712 -
050714 - ..
050715 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050716 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050718 - ..
050719 - Report Released Date/Time: Apr 12, 2017@07:34
050720 - Provider: SIMPSON,PAUL C
050721 - Specimen: BLOOD. HE 0412 70
050722 - Specimen Collection Date: Apr 12, 2017@07:02
050723 - Test name Result units Ref. range Site Code
050724 - WBC 9.51 K/cmm 4.8 - 10.8 [662]
050725 - RBC 5.28 M/cmm 4.7 - 6.1 [662]
050726 - HEMOGLOBIN 15.4 g/dl 14 - 18 [662]
050727 - HEMATOCRIT 46.1 % 42 - 52 [662]
050728 - MCV 87.3 fL 80 - 100 [662]
050729 - MCH 29.2 pg 27 - 32 [662]
050730 - MCHC 33.4 gm/dL 32 - 36 [662]
050731 - PLATELET COUNT 323 K/cmm 140 - 450 [662]
050732 - ===============================================================================
050733 -
050734 -
050736 - ..
050737 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050738 -
050739 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050741 - ..
050742 - Report Released Date/Time: Feb 06, 2017@11:43
050743 - Provider: SIMPSON,PAUL C
050744 - Specimen: PLASMA. CH 0206 491
050745 - Specimen Collection Date: Feb 06, 2017@10:49
050746 - Test name Result units Ref. range Site Code
050747 - CHOLESTEROL 196 mg/dl 100 - 240 [662]
050748 - TRIGLYCERIDE 72 mg/dl 10 - 190 [662]
050749 - HIGH DENSITY LIPOPROT (HDL) 61 mg/dl Ref: >=35 [662]
050750 - Eval: HDL <35 is associated with increased risk of CAD.
050751 - LDL CHOL(Calculated) 121 mg/dl Ref: <=131 [662]
050752 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050753 - ===============================================================================
050754 -
050755 -
050757 - ..
050758 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050759 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050761 - ..
050762 - Report Released Date/Time: Oct 12, 2016@12:11
050763 - Provider: SIMPSON,PAUL C
050764 - Specimen: PLASMA. CH 1012 608
050765 - Specimen Collection Date: Oct 12, 2016@11:16
050766 - Test name Result units Ref. range Site Code
050767 - EGFR 87 mL/min Ref: >=60 [662]
050768 - SODIUM 142 mmol/L 135 - 145 [662]
050769 - POTASSIUM 4.6 mmol/L 3.3 - 4.8 [662]
050770 - CHLORIDE 110 mmol/L 101 - 112 [662]
050771 - CARBON DIOXIDE 26 mmol/L 24 - 32 [662]
050772 - ANION GAP 6 mmol/L 5 - 20 [662]
050773 - UREA NITROGEN 29 H mg/dL 10 - 24 [662]
050774 - CREATININE 0.87 mg/dL 0.6 - 1.3 [662]
050775 - GLUCOSE 109 mg/dl 65 - 115 [662]
050776 - CALCIUM 8.4 L mg/dL 8.5 - 10.5 [662]
050777 - ===============================================================================
050778 -
050779 -
050781 - ..
050782 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050783 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050785 - ..
050786 - Report Released Date/Time: Oct 11, 2016@12:17
050787 - Provider: SIMPSON,PAUL C
050788 - Specimen: PLASMA. CH 1011 628
050789 - Specimen Collection Date: Oct 11, 2016@11:14
050790 - Test name Result units Ref. range Site Code
050791 - CRP-HS 3.9 mg/L 0.2 - 7.5 [662]
050792 - Eval: Inflammation reference range: 0.2 - 7.5 mg/L
050793 - Eval: For assessment of risk for cardiovascular disease in adults,
050794 - Eval: the CDC and AHA recommend the following guidelines based on two
050795 - Eval: test results, two weeks apart in metabolically stable patients:
050796 - Eval:
050797 - Eval: Cardiovascular Disease Risk CRP-HS mg/L
050798 - Eval: Low......................<1.0
050799 - Eval: Average......................1.0-3.0
050800 - Eval: High.......................>3.0 - 10.0
050801 - Eval: Indeterminate...................>10
050802 - Eval:
050803 - Eval: If CRP-HS level is >10 mg/L, the patient should be evaluated
050804 - Eval: for possible sources of infection or inflammation. Repeat CRP-HS
050805 - Eval: may also be appropriate.
050806 - CHOLESTEROL 237 mg/dl 100 - 240 [662]
050807 - TRIGLYCERIDE 65 mg/dl 10 - 190 [662]
050808 - HIGH DENSITY LIPOPROT (HDL) 62 mg/dl Ref: >=35 [662]
050809 - Eval: HDL <35 is associated with increased risk of CAD.
050810 - LDL CHOL(Calculated) 162 H mg/dl Ref: <=131 [662]
050811 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050812 - ===============================================================================
050813 -
050814 -
050816 - ..
050817 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050818 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050820 - ..
050821 - Report Released Date/Time: Oct 11, 2016@12:43
050822 - Provider: SIMPSON,PAUL C
050823 - Specimen: SERUM. CH 1011 627
050824 - Specimen Collection Date: Oct 11, 2016@11:14
050825 - Test name Result units Ref. range Site Code
050826 - HEMOGLOBIN A1C 5.7 % 4.0 - 6.0 [662]
050827 - ===============================================================================
050828 -
050829 -
050831 - ..
050832 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050833 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050835 - ..
050836 - Report Released Date/Time: Oct 11, 2016@12:01
050837 - Provider: SIMPSON,PAUL C
050838 - Specimen: BLOOD. HE 1011 199
050839 - Specimen Collection Date: Oct 11, 2016@11:14
050840 - Test name Result units Ref. range Site Code
050841 - WBC 13.89 H K/cmm 4.8 - 10.8 [662]
050842 - RBC 5.32 M/cmm 4.7 - 6.1 [662]
050843 - HEMOGLOBIN 15.2 g/dl 14 - 18 [662]
050844 - HEMATOCRIT 47.5 % 42 - 52 [662]
050845 - MCV 89.3 fL 80 - 100 [662]
050846 - MCH 28.6 pg 27 - 32 [662]
050847 - MCHC 32.0 gm/dL 32 - 36 [662]
050848 - PLATELET COUNT 385 K/cmm 140 - 450 [662]
050849 - ===============================================================================
050850 -
050851 -
050853 - ..
050854 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050855 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050857 - ..
050858 - Report Released Date/Time: Oct 11, 2016@12:14
050859 - Provider: SIMPSON,PAUL C
050860 - Specimen: PLASMA. CH 1011 626
050861 - Specimen Collection Date: Oct 11, 2016@11:14
050862 - Test name Result units Ref. range Site Code
050863 - EGFR 65 mL/min Ref: >=60 [662]
050864 - SODIUM 144 mmol/L 135 - 145 [662]
050865 - POTASSIUM 6.0 H mmol/L 3.3 - 4.8 [662]
050866 - CHLORIDE 107 mmol/L 101 - 112 [662]
050867 - CARBON DIOXIDE 28 mmol/L 24 - 32 [662]
050868 - ANION GAP 9 mmol/L 5 - 20 [662]
050869 - UREA NITROGEN 37 H mg/dL 10 - 24 [662]
050870 - CREATININE 1.11 mg/dL 0.6 - 1.3 [662]
050871 - GLUCOSE 109 mg/dl 65 - 115 [662]
050872 - CALCIUM 9.6 mg/dL 8.5 - 10.5 [662]
050873 - ALBUMIN 4.3 gm/dL 3.3 - 5.2 [662]
050874 - PROTEIN, TOTAL 7.0 g/dL 6.0 - 8.5 [662]
050875 - ALKALINE PHOSPHATASE 90 U/L 40 - 125 [662]
050876 - SGOT 27 U/L 5 - 35 [662]
050877 - SGPT 25 U/L 7 - 56 [662]
050878 - BILIRUBIN, TOTAL 1.7 H mg/dL 0.1 - 1.2 [662]
050879 - BILIRUBIN, DIRECT 0.1 mg/dL 0.1 - 0.5 [662]
050880 - CHOLESTEROL 231 mg/dl 100 - 240 [662]
050881 - TRIGLYCERIDE 66 mg/dl 10 - 190 [662]
050882 - HIGH DENSITY LIPOPROT (HDL) 62 mg/dl Ref: >=35 [662]
050883 - Eval: HDL <35 is associated with increased risk of CAD.
050884 - LDL CHOL(Calculated) 156 H mg/dl Ref: <=131 [662]
050885 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050886 - ===============================================================================
050887 -
050888 -
050889 -
050891 - ..
050892 - 15. Clinical Reminder Activity
050893 - MED REC NON PRIMARY CARE:
050894 - Current medications reviewed with patient/caregiver and reconciliation
050895 - of medications related to today's visit completed, including non-VA
050896 - medications and discrepancies, if identified, were addressed.
050897 - Medication changes and the importance of medication management were
050898 - reviewed with the patient/caregiver today based on individual needs.
050900 - ..
050901 - Patient/caregiver acknowledged understanding of instructions as
050902 - stated.
050904 - ..
050905 - An updated list of reconciled medications has been provided to the
050906 - patient/caregiver.
050907 -
050908 - /es/ Paul C. Simpson MD
050909 - Attending MD Cardiology, NPI 1548374093
050910 - Signed: 04/12/2017 16:01
050912 - ..
050913 - 16. 04/14/2017 ADDENDUM STATUS: COMPLETED
050914 -
050915 - I re-reviewed his coronary CTA w Radiology.
050917 - ..
050918 - They confirmed that his bypass grafts are open, w/o significant
050919 - stenoses. They confirmed that the technique cannot rule out
050920 - atherosclerosis, but can detect significant stenoses of = or >
050921 - 50% vessel diameter.
050922 -
050923 - /es/ Paul C. Simpson MD
050924 - Attending MD Cardiology, NPI 1548374093
050925 - Signed: 04/14/2017 16:17
050926 -
050928 - ..
050929 - Search on VA Internet system shows no record of radiology report on
050930 - discussion with Doctor Simpson from 170412 - 170414.
050932 - ..
050933 - Progress Notes say that Radiology will be consulted on "...when a
050934 - repeat [...CCTA...] seems useful; he is very intent to know if
050935 - progression; if yes, would increase statin." ref SDS 0 1M50
050937 - ..
050938 - This addendum comment can suggest that since patient did not have
050939 - "significant stenoses of = or > 50% vessel diameter," patient may have
050940 - had stenoses of 30%, 40%, 49% - 2 years ago in October 2015, and
050941 - therefore in light of patients low statin dose CCTA can show
050942 - progression of plaque > 50% vessel diameter which requires higher dose
050943 - statin medication.
050945 - ..
050946 - What does review with "Radiology" mean in relation to addendum filed
050947 - by Doctor Priyanka Jha for CCTA on 151019 0930. ref SDS 17 SU62 Who
050948 - is "They." What do their Progress Notes say about interaction with
050949 - Doctor Simpson in this case?
050950 -
050951 - [On 170428 1205 notified Doctors Jha and Elicker that on
050952 - 170414, Doctor Simpson discussed CCTA performed on 151019,
050953 - with "Radiology" and wrote addendum to Progress Notes
050954 - saying "they" said something, indicating continuing
050955 - Cardiology controversy centered on taking high dose
050956 - statins. ref SDS 38 SQ5F
050958 - ..
050959 - Does "technique" in this comment refer to CT software automatically
050960 - calculating atherosclerotic plaque? In this case, Radiologists did
050961 - not rely solely on CCTA calculating plaque. They personally examined
050962 - the scans and found no evidence of plaque anywhere in the scans.
050964 - ..
050965 - Limitations of 50% or any other measure of accuracy for CCTA
050966 - "technique" measuring calcified plaque referenced in Doctor Simpson's
050967 - addendum today, per above, ref SDS 0 8H5G, were not the basis for
050968 - Doctor Jah's addendum to CCTA on 151019, 151019 0930, ref SDS 17 SU62,
050969 - in that both Doctor Elicker and Doctor Jha relied on direct
050970 - examination of CT scans to determine there was no evidence of
050971 - atherosclerosis plaque or blockages of any kind in any amount anywhere
050972 - in the blood vessels scanned at that time on 151019, reported by
050973 - Doctor Elicker on 151203 1014. ref SDS 19 SZ5F Doctor Jha said the
050974 - same thing on 160104 0855. ref SDS 21 SU3M
050976 - ..
050977 - What then is significance of saying in the addendum on 170414:
050978 - "...detect significant stenoses of = or > 50% vessel diameter" per
050979 - above, ref SDS 0 8H5G, in relation to Cardiology/Radiology standards
050980 - for classifying plaque type I <= 25%, type II 26% - 50%, type III 51%
050981 - - 75% and type IV > 75% of vessel circumference, reviewed in the
050982 - record on 131125 0005. ref SDS 10 958K
050983 -
050984 - 
050986 - ..
050987 - Research in the record on 131125 lists article dated last year on
050988 - 160505 saying in part...
050989 -
050990 - CCTA has highest accuracy in diagnosing the coronary artery
050991 - stenosis of type I-II calcified plaques, but has a
050992 - significant decrease in specificity, PPV and accuracy in
050993 - type III-IV calcified plaque. ref SDS 10 XF6G
050995 - ..
050996 - Since Doctor Simpson's "re-review" of CCTA on 151019, does not change
050997 - findings, the effort to ask other doctors, i.e., "they," for yet
050998 - another opinion seems curious.
050999 -
051000 -
051001 -
051002 -
051003 -
051004 -
051005 -
051006 -
051007 -
051008 -
051009 -
051010 -
051011 -
0511 -