CONTACTS
SUBJECTS
Fundoplication Dor Failed Redo Complicated High Risk Correct Ulcerat
3803 -
3803 - ..
3804 - Summary/Objective
3805 -
380501 - Follow up ref SDS D5 0000. ref SDS D3 0000.
380502 -
380503 - Excellent meeting with Doctor Stewart in General Surgery VA MC San
380504 - Francisco to review options for laparosonic Dor fundoplication and
380505 - correct hiatal hernia toward resolution of ulceration to LESV.
380506 - ref SDS 0 NN6J The doctor clarified that redo of Nissen
380507 - fundoplication with full wrap has high success rate, but redo of Dor
380508 - fundoplication with only partial wrap required for Heller Myotomy
380509 - surgery, involved in this case, is more complicated and risky.
380510 - ref SDS 0 L44F There is 50% chance laparosonic procedure would damage
380511 - tissue, requiring immediate switch to conventional invasive surgery
380512 - placing the operation and the patient at higher risk of complications.
380513 - ref SDS 0 GT5G Patient explained today that Doctor Lee did not make a
380514 - referral for redo of fundoplication. EGD Progress Notes report
380515 - loosening of fundoplication and hiatal hernia with ulceration of LESV,
380516 - beginning on 140509. The patient requested referral to investigate
380517 - remedies. ref SDS 0 IX9J Doctor Stewart asked if swallowing problems
380518 - were resolved after Heller Myotomy surgery on 091216? Reviewed
380519 - recurrent swallowing problems past 6 years with improvements from EGD
380520 - dilations performed by Doctor Lee. Duration of improved swallowing
380521 - increased from 4 to 6 months on adding triamcinolone steroid
380522 - injections to LESV. ref SDS 0 M28L Significant burping (reflux)
380523 - remains a persistent symptom of gastroesophageal issues which may have
380524 - contributed to loosening Dor fundoplication. ref SDS 0 F65K Pictures
380525 - from EGD dilation procedures the past 6 years show progression of Dor
380526 - fundoplication loosening beginning on 140509. ref SDS 0 RV3G The VA
380527 - computer system today was unable to access recent pictures of the
380528 - procedure last month on 150421, that show changes to fundoplication.
380529 - ref SDS 0 F65O Doctor Stewart developed work plan for staff support
380530 - to retrieve photographic evidence on VA computer system. She ordered
380531 - CT barium swallow and gastric emptying tests over the next several
380532 - days. Results will aid assessing severity of ulceration, hiatal
380533 - hernia and failure of fundoplication, and weighing prospects for
380534 - remedies, including redo Dor fundoplication, in relation to risks of
380535 - any such procedure. ref SDS 0 KQ5M Doctor Stewart scheduled follow up
380536 - meeting on 150602 to review this additional evidence and prescibe best
380537 - course of care. ref SDS 0 GG4G After meeting with Doctor Stewart went
380538 - to Radiology and scheduled CT Barium Swallow study for 150527 0930.
380539 - ref SDS 0 WY3O Then went to Nuclear Medicine and scheduled Gastric
380540 - Emptying test for 150603 0800. ref SDS 0 A74F Since this test on
380541 - 150603, will be after 150602, returned to Module #2 and re-scheduled
380542 - meeting with Doctor Stewart on 150623. ref SDS 0 SO3F Scheduling
380543 - mix-ups were resolved to align Doctor Stewart's comprehensive work
380544 - plan with relevant VA elements. ref SDS 0 QS3X
380545 -
380546 - [On 150527 0930 VA Medical Center in San Francisco
380547 - performed another CT Barium Swallow test - preliminary
380548 - results are favorable indicating patient has not suffered
380549 - recurrent achalasia symtom of distorted esophagus, commonly
380550 - called "bird beak," rather esophagus looks normal.
380551 - ref SDS D9 V56N
380553 - ..
380554 - [On 150529 1202 letter to Isagani submits the record
380555 - meeting with Doctor Stewart the day before on 150526, and
380556 - transmits photographs she requested, as planned meeting
380557 - with Isagani the next day on 150527. ref SDS E1 SQ50
380559 - ..
380560 - [On 150603 0800 visit VA Medical Center in San Francisco
380561 - and met Charissa for Gastric Emptying test. ref SDS E4
380562 - K37G
380563 -
380564 -
380565 -
380566 -
380567 -
380568 -
380570 - ..
3806 -
3807 -
3808 - Background
3809 -
380901 - On 050629 meeting Primary Care swallowing and vomiting problems
380902 - reported. ref SDS 1 K78K
380904 - ..
380905 - On 050714 barium swallow test, ref SDS 2 2I4S, showed esophagus
380906 - distorted by swallowing problems. ref SDS 2 WE4H
380908 - ..
380909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.
380910 - ref SDS 3 DG8G Ultrasound test ordered to verify initial diagnosis of
380911 - swallowing and vomiting problems. ref SDS 3 6E7H Primary Care made
380912 - referral to GI clinic for care to resolve swallowing problems.
380913 - ref SDS 3 0G7M
380915 - ..
380916 - On 050830 ultrasound test evaluate swallowing problems possible
380917 - diagnosis achalasia. ref SDS 4 DG8G
380919 - ..
380920 - On 050830 results received barium swallow test performed on 050714,
380921 - findings in the lower esophagus and gastroesophageal junction are
380922 - consistent with achalasia - recommend endoscopic examination.
380923 - ref SDS 4 6H9S
380925 - ..
380926 - On 050906 report ultrasound test on 050830, finds no cause for
380927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R
380929 - ..
380930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.
380931 - ref SDS 6 HP9H Orders endoscopy (EGD) test to verify diagnosis of
380932 - achalasia and assess for cancer. ref SDS 6 NZ5H
380934 - ..
380935 - On 051209 GI Clinic endoscopy examination preliminary findings no
380936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted
380937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,
380938 - then a procedure can be schedule for next month to dilate the
380939 - esophageal sphincter valve. ref SDS 7 NZ5H
380941 - ..
380942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M
380944 - ..
380945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)
380946 - Clinic reporting that the biopsy was negative for cancer and
380947 - infection; next step is manometry test to verify achalasia, then
380948 - treatment for achalasia. ref SDS 9 4Q3R
380950 - ..
380951 - On 060125 manometry test scheduled for 060209 0800. ref SDS 10 GG9I
380953 - ..
380954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed
380955 - until 060223, due to equipment failure. ref SDS 11 OW6M
380957 - ..
380958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center
380959 - reports manometry equipment still broken; has been sent out for
380960 - repairs and there is no date at this time on when the equipment will
380961 - be available for use at the VA. ref SDS 12 ND7M
380963 - ..
380964 - On 060330 endoscopy follow up examination at GI Department Sacramento
380965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA
380966 - Sacramento condition precedent treatment recover from achalasia.
380967 - ref SDS 13 VX4G
380969 - ..
380970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,
380971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomiting problems
380972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for
380973 - treatment with pneumatic dilation. ref SDS 13 MD5G
380975 - ..
380976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and
380977 - pneumatic balloon materials on hand to perform dilation for treating
380978 - achalasia; treatment delayed until diagnostic data is received from
380979 - Sacramento VA Medical Center from manometry test performed on 060330;
380980 - doctor following up to obtain data; will submit test data to patient
380981 - during the week of 060508, along with a schedule to treat achalasia.
380982 - ref SDS 14 FT6M
380984 - ..
380985 - On 060614 Martinez VA GI clinic reports increased work load treating
380986 - soldiers returning from war in Iraq requires prioritizing; patient
380987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the
380988 - customer of the schedule based on current priorities. ref SDS 15 J86N
380990 - ..
380991 - On 070220 letter to VA asks about progress getting test results from
380992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16
380993 - 5R5R
380995 - ..
380996 - On 090812 1030 continued vomiting achalasia causes weight loss 30
380997 - pounds in a few months, Primary Care physician notified GI clinic to
380998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O
381000 - ..
381001 - On 090908 meeting GI Clinic in Martinez reports treatment for
381002 - achalasia still waiting to receive results for manometry test on
381003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46 Prepared new
381004 - work plan to treat achalasia without manometry test results, because
381005 - the doctor performed the test 3 years ago, and is so knows results
381006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;
381007 - schedules treatment for achalasia after treadmill stress test,
381008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette
381009 - Reservoir which have not occurred doing extended exercise hiking 3 -
381010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N
381012 - ..
381013 - On 091021 report history achalasia issue during meeting with
381014 - cardiothoracic surgery team to prepare for heart bypass surgery the
381015 - next day. ref SDS 20 NX6M Surgery team will coordinate with
381016 - anesthesia team to provide swallowing relief during heart surgery to
381017 - prevent choking. ref SDS 20 R78O
381019 - ..
381020 - On 091022 0700 meeting anesthesia team - Doctor Brzezinski not familiar
381021 - with achalasia - asked if achalasia has been reported to the VA?
381022 - ref SDS 21 JF9K While being prepared with IVs for surgery, patient
381023 - assists anesthesia find VA records on achalasia, ref SDS 21 2W4K;
381024 - Doctor Brzezinski makes plans for patient care and safety so that
381025 - achalasia does not risk death during heart surgery. ref SDS 21 GX4J
381027 - ..
381028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.
381029 - ref SDS 21 PQWU
381031 - ..
381032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco
381033 - Medical Center during recovery from heart surgery, proposes Heller
381034 - Myotomy surgery rather than pneumatic (balloon) dilation as more
381035 - effective and longer lasting solution to recover from swallowing and
381036 - vomiting problems caused by achalasia. ref SDS 24 KE3B
381038 - ..
381039 - On 091030 0800 at 1430 received documentation from GI Department at
381040 - San Francisco Medical Center - review shows 3 different treatments for
381041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.
381042 - ref SDS 24 495I
381044 - ..
381045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor
381046 - Ratcliff concerned about how to maintain nutrition for the patient to
381047 - recover from heart surgery while digestion remains problematic due to
381048 - achalasia; proposes feeding tube for several months until Heller
381049 - Myotomy surgery. ref SDS 24 03GF
381051 - ..
381052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to
381053 - recover from achalasia. 091216 0600, ref SDS 36 KE9U
381055 - ..
381056 - On 100202 meeting with Doctor Lee - report swallowing and vomiting
381057 - problems 3 months after Heller Myotomy surgery. Doctor explains
381058 - achalasia disease breaks nerve connections from the brain that
381059 - contract the esophagus to force food and liquid from the mouth through
381060 - the esophagus; as well broken nerve connections prevent the lower
381061 - esophageal sphincter valve (LESV) to relax so that content can pass
381062 - into the stomach. Without esophageal contractions, food and liquid
381063 - can only reach the stomach with gravity, but since the LESV won't
381064 - relax the patient continues to have swallowing and vomiting problems,
381065 - despite Heller Myotomy surgery on 091216, intended to maintain
381066 - adequate opening into the stomach. ref SDS 47 485W
381068 - ..
381069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
381070 - from 11 to 15 mm. ref SDS 48 WR6L
381072 - ..
381073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV
381074 - from 11 to 15 mm. ref SDS 55 JE6X
381076 - ..
381077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)
381078 - without sedation, ref SDS 68 BE7K - dilated LESV again from 11 to 14
381079 - mm. ref SDS 68 BF6L
381081 - ..
381082 - On 101216 1021 letter commends medical team for excellent work, and
381083 - confirms schedule next EGD on 110218 0730. ref SDS 70 K35G
381085 - ..
381086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using
381087 - anesthesia with Fentanyl. ref SDS 72 PQWY LESV dilated 11 - 14 mm,
381088 - and added triamcinolone steroid injections to resist contraction of
381089 - LESV so that swallowing is maintained over the next 3 month cycle.
381090 - ref SDS 72 SR4G
381092 - ..
381093 - On 110429 0830 5th EGD dilation at VA in Martinez - triamcinolone
381094 - steroid injections worked well to resist contraction of LESV so that
381095 - swallowing was maintained over the prior 3 month cycle, ref SDS 76
381096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 76 U23I, and
381097 - triamcinolone injections were continued. ref SDS 76 SS5N
381099 - ..
381100 - On 110607 1414 visited GI Department, ref SDS 78 HC5H, and Charlene
381101 - reported a computer mistakes requires scheduling next EGD dilation on
381102 - 110819 0830. ref SDS 78 N642 Requested meeting with Doctor Lee to
381103 - review pending action items. ref SDS 78 4P6J,
381105 - ..
381106 - On 110819 0830 EGD and Dilation of stricture at lower esophageal sphincter
381107 - valve. Triamcinolone steroid injections worked well to resist
381108 - contraction of LESV so that swallowing is maintained over the prior 3
381109 - month cycle, so LESV dilated from 15 - 16.5 mm, ref SDS 81 J978, and
381110 - triamcinolone injections were continued. ref SDS 81 J985
381112 - ..
381113 - On 111115 1300 EGD dilation procedure - triamcinolone steroid injections
381114 - worked well over the prior 3 month cycle, so LESV dilated from 16.5 -
381115 - 18 mm, ref SDS 82 IR57; for some reason triamcinolone injections to
381116 - resist contraction of LESV was not performed. ref SDS 82 IS6L
381118 - ..
381119 - On 120322 1030 EGD dilation procedure - swallowing and vomiting problems
381120 - increased without triamcinolone steroid injections on prior 3 month
381121 - cycle. ref SDS 84 UI9H LESV dilated from 16.5 - 18 mm. ref SDS 84
381122 - 516N Triamcinolone injections to resist contraction of LESV was not
381123 - performed. ref SDS 84 5179
381125 - ..
381126 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA
381127 - business unit; reported patient history. ref SDS 87 RG9K Scheduled
381128 - EGD and dilation procedure for 1300; returned and performed procedure,
381129 - ref SDS 87 TB4J; dilated from 15 mm to 18 mm. ref SDS 87 XB51
381130 - Swallowing and vomiting problems increased after omitting
381131 - triamcinolone steroid injections to resist contraction of LESV after
381132 - dilation, ref SDS 87 TZ4M; therefore, injections were resumed to
381133 - complement dilation to enable and maintain effective swallowing.
381134 - ref SDS 87 R87N
381136 - ..
381137 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found
381138 - improvement recovering from achalasia, LESV contracted only slightly
381139 - from 18 mm down to 15 mm. ref SDS 95 Q333
381141 - ..
381142 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV
381143 - remained at 18 MM, ref SDS A0 CO5N, same as dilated 4 months earlier
381144 - on 130110 0900. ref SDS 95 Q333 Report CT test on 130117, shows
381145 - esophagus fully recovered from severe distortions caused by achalasia
381146 - 8 years earlier. ref SDS A0 MT6F Doctor Lee injected steroid again to
381147 - maintain swallowing. ref SDS A0 F38G Prescribed reducing Omeprazole
381148 - to 1 pill per day. ref SDS A0 R74M Scheduled next EGD dilation in 6
381149 - months, instead of 3. ref SDS A0 6P6G
381151 - ..
381152 - On 131115 0700 meeting Doctor Lee EGD procedure dilation LESV from 16.5
381153 - to 18 mm. ref SDS A6 CO5N Triamcinolone steroid injected again to
381154 - maintain improved swallowing. ref SDS A6 I167 Omeprazole medication
381155 - maintained 20 mg taken morning and evening for 1 month, then reduce to
381156 - 20 mg once per day. ref SDS A6 R74M Biopsies taken. ref SDS A6 3N8L
381158 - ..
381159 - On 131121 1604 ordered refill of Omeprazole to aid digestion. There
381160 - is 1 refill remaining. ref SDS A7 YS4O
381162 - ..
381163 - On 131205 1443 received order for Omeprazole prescription placed on
381164 - 131121. ref SDS A9 5N3O
381166 - ..
381167 - On 140318 1043 received letter cancelling meeting scheduled for
381168 - EGD/Dilation procedure on 140425 1000, ref SDS B1 935L; a second
381169 - letter scheduled procedure on 140509 0900. ref SDS B1 5D7H
381171 - ..
381172 - On 140401 1659 ordered refill Omeprazole; none are remaining; need
381173 - Doctor Lee to order new prescription to increase refills. ref SDS B2
381174 - 4P5M
381176 - ..
381177 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical
381178 - center in Sacramento, Mather. ref SDS B4 K37G Pre-op preparation went
381179 - well - IV setup on first stick. ref SDS B4 EP75 Doctor ordered
381180 - refills for Omeprazole. ref SDS B4 AW5O Doctor patient partnership
381181 - continues to progress with doctor reading patient history to be
381182 - prepared for effective meeting. ref SDS B4 ZZ6J Doctor Lee recalled
381183 - today having made timely referral for heart surgery, enabling patient
381184 - to recover and hike Half Dome 4 years later. ref SDS B4 0N6I Reported
381185 - swallowing and vomiting problems reduced past 6 months with
381186 - triamcinolone steroid injections to resist contraction of LESV.
381187 - ref SDS B4 VV6N Doctor Lee dilated LESV contracted to only 16.5 MM
381188 - over past 6 months with triamcinolone steroid injections to resist
381189 - contraction; he dilated LESV back to 18 MMy, ref SDS B4 5H5J,
381190 - scheduled next EGD dilation in 6 months since this worked well the
381191 - past 6 months with triamcinolone steroid injections. ref SDS B4 549I
381192 - The doctor explained that since there was no tearing of LESV during
381193 - procedure today, triamcinolone steroid was not injected into LESV to
381194 - resist contraction. ref SDS B4 I167 Progress notes report small
381195 - tearing of LESV during dilation procedure. ref SDS B4 P680
381197 - ..
381198 - On 140718 1017 planning for notifying VA to update current fill date
381199 - for Omeprazole. ref SDS B8 U88L Kathy visited VA in Sacramento, and
381200 - requested changing refill date for Omeprazole to 140718. ref SDS B8
381201 - OL5K VA representative called customer, and said Doctor Lee would
381202 - call back later that day to consider action on updating scheduled
381203 - refill date of Omeprazole to 140718. ref SDS B8 U76M
381205 - ..
381206 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with
381207 - triamcinolone injection soonest, if cancellation occurs; but, not an
381208 - emergency, ref SDS C0 W83K, based on history rising vomiting
381209 - swallowing problems, shown in patient history case study on 120101,
381210 - beginning 140712. ref SDS 83 4E4M
381212 - ..
381213 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,
381214 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento
381215 - will be notified about rising achalasia symptoms for consideration to
381216 - advance EGD dilation procedure. ref SDS C1 EX78
381218 - ..
381219 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met
381220 - with Lapria again, who advised that the VA responded in a letter on
381221 - 141001, to the letter on 140810, and further scheduled a meeting with
381222 - Doctor Lee on 141121 1530. ref SDS C2 QJ5N
381224 - ..
381225 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA
381226 - Sacramento Medical Center on 141107 0800, for next EGD dilation.
381227 - ref SDS C3 K37G Submit record showing normal swallowing occurs longer
381228 - with triamcinolone steroid injection to resist contraction of LESV.
381229 - ref SDS C3 3U97 Request schedule next EGD dilation in 4 months, and
381230 - if LESV does not contract, then schedule following EGD dilation in 6
381231 - months. ref SDS C3 3U66 Notified results of Half Dome hike.
381232 - ref SDS C3 3U6Y
381234 - ..
381235 - On 141107 0800 EGD dilation procedure - setting IV for conscious
381236 - sedation required 3 sticks. ref SDS C4 5W5I Meeting Doctor Lee guided
381237 - by agenda facilitated collaboration through doctor patient
381238 - partnership. ref SDS C4 VV6N Doctor explained increased difficulty
381239 - swallowing due to experiment omitting triamcinolone steroid injection
381240 - on prior procedure, ref SDS C4 4U8I, shown by LESV contracting back to
381241 - from 15 mm. ref SDS C4 T55I Progress Notes report finding ulceration
381242 - and hiatal hernia. ref SDS C4 MG6N Photographs seem to show
381243 - significantly different condition of fundoplication from a year
381244 - earlier. ref SDS C4 I74I
381246 - ..
381247 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center
381248 - Sacramento report swallowing improved with triamcinolone steroid
381249 - injections on 141107 EGD dilation procedure. ref SDS D0 0M6I Doctor
381250 - Lee advised that increased orange juice consumption aids digestion,
381251 - and presents no health risks. ref SDS D0 YF5M Scheduled next EGD
381252 - dilation procedure on 150421 1300. ref SDS D0 PS4O Fundoplication
381253 - failure increases acid burn that caused ulceration with hiatal hernia
381254 - with increased recurrence achalasia. ref SDS D0 O56O Doctor Lee will
381255 - make referral to Doctor Stewart at General Surgery VA Medical Center
381256 - in San Francisco for consideration of "redo" fundoplication.
381257 - ref SDS D0 JQ5J Doctor Lee completed Progress Notes for EGD dilation
381258 - on 141107. ref SDS D0 PS53 Doctor Lee will recommend Doctor Stewart
381259 - order CT test to evaluate recurrence achalasia due to failure
381260 - fundoplication. ref SDS D0 TH5M This test can include coronary CTA to
381261 - evaluate regression atherosclerosis. ref SDS D0 GB56
381263 - ..
381264 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting
381265 - the next day on 150421 1300 for EGD dilation. ref SDS D2 0M6I
381267 - ..
381268 - On 150421 0800 Met with Doctor Lee for EGD Dilation procedure
381269 - ref SDS D3 GD4H Reported pain level 2 right knee MCL. ref SDS D3 LO9K
381270 - Doctor Lee advised referral to San Francisco will be filed after EGD
381271 - dilation procedure to evaluate loosening fundoplication. ref SDS D3
381272 - DZ4I Patient reported difficulty swallowing this cycle did not occur
381273 - until 4 weeks or so, because triamcinolone steroid injected during
381274 - prior procedure on 141107, ref SDS D3 P55L, and shown by EGD dilation
381275 - LESV from 16.5 mm back to 18 mm. ref SDS D3 HU42 Progress Notes
381276 - report findings of hiatal hernia. ref SDS D3 QD6O Impression
381277 - ulceration subsided to mere erosions. ref SDS D3 PXXY
381279 - ..
381280 - On 150521 0800 met with Doctor Lee at VA MC in Sacramento (Mather) to
381281 - review EGD Dilation procedure last month on 140421. The doctor
381282 - accessed on VA computer system photographs from procedure on 140521,
381283 - which showed bubbles. ref SDS D6 0M6I Doctor Lee explained recent
381284 - vomiting may be due to relaxation of practice eating procedures.
381285 - ref SDS D6 WT9L Reviewed photographs showing current loosened
381286 - condition of fundoplication markedly different from condition a year
381287 - ago. ref SDS D6 FV5O Fundoplication occurs below LESV, causing hiatal
381288 - hernia to push stomach into esophagus. ref SDS D6 IA5O Plan to
381289 - request CT barium swallow test to evaluate recurrence distortion
381290 - esophagus above LESV. ref SDS D6 OG6L
381292 - ..
381293 - On 150526 1300 excellent meeting Doctor Stewart General Surgery VA MC
381294 - San Francisco options laparosonic Dor fundoplication and correct hiatal
381295 - hernia toward resolution of ulceration to LESV. ref SDS 0 NN6J Doctor
381296 - clarified redo Nissen fundoplication with full wrap high success rate,
381297 - but redo Dor fundoplication with partial wrap for Heller Myotomy
381298 - surgery is more complicated. ref SDS 0 L44F 50% chance laparosonic
381299 - would damage tissue so immediate switch to invasive surgery causing
381300 - higher risk of complications. ref SDS 0 GT5G Doctor Stewart asked if
381301 - swallowing problems were resolved after Heller Myotomy surgery on
381302 - 091219? Recurrent swallowing problems past 6 years improved EGD
381303 - dilations every 4 months by Doctor Lee, improvement increased to 6
381304 - months on adding triamcinolone steroid injections to LESV. ref SDS 0
381305 - M28L Significant burping (reflux) persistent symptom gastroesophageal
381306 - issues. ref SDS 0 F65K Pictures from EGD dilations show progression
381307 - of Dor fundoplication loosening beginning on 140509. ref SDS 0 RV3G
381308 - VA computer system unable to access pictures showing changes to
381309 - fundoplication. ref SDS 0 F65O Doctor Stewart work plan staff support
381310 - to retrieve photographic evidence on VA computer system. Ordered CT
381311 - barium swallow and gastric emptying tests to further assess severity
381312 - of ulceration, hiatal hernia and failure of fundoplication, and
381313 - further analyse remedies, including redo Dor fundoplication.
381314 - ref SDS 0 KQ5M Doctor Stewart scheduled follow up meeting on 150602
381315 - to review this additional evidence and consider best course of care.
381316 - ref SDS 0 GG4G Went to Radiology and scheduled CT Barium Swallow
381317 - study for 150527 0930. ref SDS 0 WY3O Then went to Nuclear Medicine
381318 - and scheduled Gastric Emptying test for 150603 0800. ref SDS 0 A74F
381319 - Since this test on 150603, will be after 150602, returned to Module #2
381320 - and re-scheduled meeting with Doctor Stewart on 150623. ref SDS 0 SO3F
381321 - Scheduling mix-ups were resolved, ensuring Doctor Stewart's
381322 - comprehensive work plan is aligned with all relevant VA elements.
381323 - ref SDS 0 QS3X
381324 -
381325 -
381326 -
381327 -
381328 -
381330 - ..
3814 -
3815 -
3816 - Progress
381701 - ..
381702 - Evaluate Redo Fundoplication and Correct Hiatal Hernia
381703 - Fundoplication Evaluate Redo Resolve Hiatal Hernia Ulceration
381704 -
381705 - Follow up ref SDS D5 NU8L, ref SDS D3 NU8L.
381706 -
381707 - Agenda...
381708 -
381709 - 1. Fundoplication repair hiatal hernia if needed performed by
381710 - Doctor Stewart during Heller Myotomy surgery on 091216, 091216
381711 - 0600, ref SDS 36 KE9U, as explained in Progress Notes for
381712 - patient consent, shown in the record on 100928 0706.
381713 - ref SDS 57 B04R Description of surgery is further reported.
381714 - ref SDS 57 VK8F
381716 - ..
381717 - On 150319, Doctor Lee showed fundoplication has unraveled,
381718 - ref SDS D0 KN6F - photograph #4 from EGD dilation on 141107,
381719 - listed in Progress Notes. ref SDS C4 H19J Findings of
381720 - "ulceration" and "Hiatal hernia" in Progress Notes on 140509,
381721 - ref SDS B4 P396, correlates with loosening of fundoplication,
381722 - set out in Impressions from Progress Notes on 140509 0900.
381723 - ref SDS B4 I93F
381725 - ..
381726 - Today, discussed requirements to redo fundoplication and correct
381727 - hiatal hernia.
381729 - ..
381730 - Research indicates laparosonic redo fundoplication has 93% success
381731 - rate, reported on 150319 0800. ref SDS D0 2D95
381732 -
381733 -
381735 - ..
381736 - Dor Fundoplication Redo Complicated Risks Patient Injury
381737 - Nissen Dor Fundoplications Much Different Like Apples Oranges
381738 - Apples Oranges Nissen Much Different from Dor Fundoplications
381739 -
381740 - Doctor Stewart clarified that "Nissen fundoplication" has a high
381741 - success rate. This aligns with research on 150319, that identifies
381742 - Nissen fundoplication has 93% success rate with laparosonic procedures.
381743 - ref SDS D0 2D46
381745 - ..
381746 - Doctor Stewart advised that "Dor fundoplication" was performed in this
381747 - case to compliment Heller Myotomy surgery on 091216. This is aligns
381748 - with Progress Notes, set out in the record on 100928. ref SDS 57 VK8F
381750 - ..
381751 - The doctor further explained that Dor fundoplication only partially
381752 - wraps to protect LESV from reflux, which is standard of care for
381753 - Heller Myotomy surgery that modifies LESV to facilitate swallowing.
381754 - The doctor emphasized today that Dor fundoplication is much different
381755 - from Nissen fundoplication that constructs a "full" wrap.
381757 - ..
381758 - After the meeting research found several articles reporting studies
381759 - found Dor fundoplication more effective than Nissen fundoplication for
381760 - improving dysphagia (swallowing) and GERD (reflux, burping)....
381761 -
381762 - Annals of Surgery Volume 257, Number 5, May 2013
381763 -
381764 - Laparoscopic Anterior 180-Degree Versus Nissen Fundoplication
381765 - for Gastroesophageal Reflux Disease
381766 - Systematic Review and Meta-Analysis of Randomized Clinical Trials
381767 -
381768 - http://surgery.med.ubc.ca/files/2013/06/Tjc13junKG.pdf
381770 - ..
381771 - Conclusions: At 1 and 5 years, dysphagia and gas-related
381772 - symptoms are lower after 180-degree LAF than after LNF, and
381773 - esophageal acid exposure and esophagitis are similar, with no
381774 - differences in heartburn scores, patient satisfaction,
381775 - dilatations, and reoperation rate. These results lend level 1a
381776 - support for the use of 180-degree LAF for the surgical
381777 - treatment of gastroesophageal reflux disease.
381779 - ..
381780 - Another study makes similar conclusions...
381782 - ..
381783 - The Eurasian Journal of Medicine
381785 - ..
381786 - Fundoplication After Heller Myotomy: A Retrospective
381787 - Comparison Between Nissen and Dor
381789 - ..
381790 - Eurasian J Med 2011; 43: 133-140
381791 - DOI: 10.5152/eajm.2011.31
381792 -
381793 - http://www.eajm.org/text.php3?id=405
381795 - ..
381796 - Another study found similar results for dysphagia. Nissen-Rossetti
381797 - fundoplication seems superior to Dor fundoplication preventing
381798 - oesophageal acid exposure, even if clinical and statistical relevance
381799 - of this finding was not clearly evident at the mid-term follow-up.
381800 - (see bottom of Discussion, beginning "In conclusion..."
381801 -
381802 - Baishedeng Publishing Group
381803 - World Journal of Gastroenterology
381805 - ..
381806 - Laparoscopic calibrated total vs partial fundoplication
381807 - following Heller myotomy for oesophageal achalasia
381809 - ..
381810 - World J Gastroenterol 2011 August 7; 17(29): 3431-3440
381811 -
381812 - http://www.wjgnet.com/1007-9327/full/v17/i29/3431.htm
381814 - ..
381815 - During the meeting today, Doctor Stewart commented that GI doctors are
381816 - often not aware of distinctions between Nissen and Dor fundoplications
381817 - with respect to success rates for redo surgery.
381819 - ..
381820 - There was discussion that Doctor Lee has not recommended nor commented
381821 - on redo fundoplication. Referral to General Surgery was requested by
381822 - the patient, set out in Progress Notes for EGD dilation on 150421
381823 - 1210. ref SDS D3 KT6F Patient requested referral to investigate
381824 - evident change in fundoplication, findings of ulceration on LESV, and
381825 - hiatal hernia, which had not previously existed, reported on 141107,
381826 - ref SDS C4 QD6O, and as further shown in the record meeting with
381827 - Doctor Lee at VA MC Sacramento (Mather) on 150319 0800. ref SDS D0
381828 - JQ5J
381830 - ..
381831 - Doctor Stewart explained "redo" Nissen fundoplication is generally
381832 - successful using laparosonic surgery; however, redo Dor fundoplication
381833 - is more complicated and has greater risks. She seemed to say scarring
381834 - (adhesions) from the original surgery could impede laparosonic surgery
381835 - to redo Dor fundoplication, possibly damaging native tissue. In that
381836 - case, she would have to immediately switch to conventional surgery
381837 - using an incision into the stomach to access fundoplication site near
381838 - LESV, repair tissue damaged by laparoscopic efforts, and then attempt
381839 - to complete redo Dor fundoplication.
381841 - ..
381842 - It was unclear today why scarring per se would not equally impede
381843 - Nissen fundoplication. Perhaps because a full wrap can be stitched
381844 - together to form a more durable connection, than merely stitching the
381845 - half wrap to native tissue. Research found references to "anchoring"
381846 - Dor fundoplication that is not required for Nissen methods. In any
381847 - case the doctor seemed wary to prescribe redo Dor fundoplication. She
381848 - described the decision to redo Dor fundoplication is like "apples and
381849 - oranges" compared to redo fully wrapped Nissen fundoplication.
381851 - ..
381852 - After the meeting could not find research on redo Dor fundoplication,
381853 - including success rates, which was reported for Nissen fundoplication
381854 - surgery.
381855 -
381856 -
381858 - ..
381859 - Redo Dor Fundoplication High Risk Laparoscopic Switch Invasive Incision Surgery
381860 - 50% Laparoscopic Redo Dor Fundoplication Switch Invasive Incision Surgery
381861 -
381862 - Doctor Stewart seemed further to indicate she has not done many "redo"
381863 - Dor fundoplications. Moreover, about 50% required switching during
381864 - laparosonic surgery to conventional incision surgery. This is
381865 - inherently more invasive and so more risky, with much longer recovery.
381866 - As a result, redo Dor fundoplication should only be attempted where
381867 - symptoms from failed fundoplication are greater than risks of
381868 - attempting laparoscopic redo, including ultimately invasive
381869 - conventional surgery. This cautious forecast conflicts with high
381870 - confidence presenting Heller Myotomy surgery with fundoplication on
381871 - 091030 0810. ref SDS 24 OY64
381873 - ..
381874 - If redo Dor fundoplication is performed in this case, need review of
381875 - eating practices or other means to reduce risk of "repaired Dor
381876 - fundoplication" loosening again.
381878 - ..
381879 - Doctor Stewart asked about symptoms?
381881 - ..
381882 - She asked if swallowing improved after Heller Myotomy surgery on
381883 - 091216?
381885 - ..
381886 - Severe swallowing problems required EGD dilations beginning on 100305,
381887 - 3 months after Heller Myotomy surgery and continuing initially with 4
381888 - and now 6 month intervals to the most recent procedure last month...
381889 -
381890 - LESV Dilated
381891 - Date from - to
381892 - 150421 16.5 18.....triamcinolone.... ref SDS D3 I167
381893 - 141107 15 18.....triamcinolone.... ref SDS C4 I167
381894 - 140509 16.5 18...................... ref SDS B4 P680
381895 - 131115 16.5 18.....triamcinolone.... ref SDS A6 RZ45
381896 - 130416 18 18.....triamcinolone.... ref SDS A0 Y850
381897 - 130110 15 18.....triamcinolone.... ref SDS 95 Q333
381898 - 120925 15 18.....triamcinolone.... ref SDS 87 XB51
381899 - 120322 16.5 18...................... ref SDS 84 516N
381900 - 111115 16.5 18...................... ref SDS 82 IR57
381901 - 110819 15 16.5...triamcinolone.... ref SDS 81 J978
381902 - 110429 13 16.5...triamcinolone.... ref SDS 76 U23I
381903 - 110218 11 14.....triamcinolone.... ref SDS 72 AA5O
381904 - 101210 11 14...................... ref SDS 68 H347
381905 - 100827 11 15...................... ref SDS 55 JE6X
381906 - 100305 11 15...................... ref SDS 48 WR6L
381908 - ..
381909 - As shown, LESV tightened back to 11 mm on the first 4 dilations in
381910 - 2010; but, on 110218, the doctor tried injection with triamcinolone
381911 - steroid into LESV. Subsequent dilations achieved noticeably less
381912 - contraction, with improved swallowing. The doctor twice tried
381913 - omitting triamcinolone injections, and caused increased contraction
381914 - of LESV that swallowing more difficult.
381916 - ..
381917 - Doctor Stewart was pleased that adding triamcinolone injections has
381918 - aided swallowing by extending the time between dilations from 4
381919 - months to 6 months the past 2 years.
381921 - ..
381922 - Acid reflux is another symptom that occurs involuntarily, causing
381923 - significant burping throughout the day. Could this strong burping
381924 - have caused Dor fundoplication to loosen?
381925 -
381926 -
381927 -
381928 -
3820 -
SUBJECTS
Dor Fundoplication Redo Assess Need Based on Best Evidence Severity
4903 -
490401 - ..
490402 - Dor Fundoplication Assess Need Based on Photographs EGD Dilations
490403 - Photographic Evidence Dor Fundoplication Loosened Progress Notes Nov 7, 2014
490404 -
490405 - Doctor Stewart asked to see pictures showing severity of Dor
490406 - fundoplication unravelling in order to assess risks of attempting
490407 - laparoscopic surgery to redo it, now 6 years after original work on
490408 - 091216.
490410 - ..
490411 - Pictures Doctor Lee showed during the recent meeting last week at VA
490412 - MC in Sacramento on 150521, ref SDS D6 FV5O, from EGD dilation
490413 - procedure on 150421, present clear and vivid evidence of change in Dor
490414 - fundoplication comparing photographs during prior EGD dilation
490415 - procedure on 131115, with finding at that time 18 months ago...
490416 -
490417 - Fundoplication remains intact.......... ref SDS A6 JW4I
490418 -
490419 - ...as shown in the photograph...
490420 -
490421 - F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13-photograph.docx
490423 - ..
490424 - The EGD dilation procedure a year later on 141107, shows markedly
490425 - different condition...
490426 -
490427 - F:\05\00003\SM\CC\AGMJ\20141107-080000\EGD-11_07_2014-10_19-04-photograph.pdf
490429 - ..
490430 - Doctor Stewart tried to access photographs on the VA computer system
490431 - server in Sacramento (Mather), which Doctor Lee presented last week at
490432 - VA MC in Sacramento (Mather) on 150521 0800, ref SDS D6 FV5O, showing
490433 - current status of fundoplication is markedly different from the
490434 - original work on 091216. However, computer difficulties today
490435 - prevented access in San Francisco to medical records on the VA server
490436 - in Sacramento. Difficulties, delays accessing records across the VA
490437 - computer system has been a continuing challenge, reported by Doctor
490438 - Ratcliff, former Chief of Surgery, on 091029 0700. ref SDS 23 CR7M
490439 - Problems occurred earlier on the day of surgery for CABG +4, reported
490440 - by Doctor Brzezinski, Chief of Anesthesia, on 091022 0700. ref SDS 21
490441 - 2W4K
490443 - ..
490444 - [...below on 150526 1300 at 1504 Charissa had problems due
490445 - to slow response using VA computer system to schedule
490446 - Gastric Empty test in Nuclear Medicine. ref SDS 0 EY5F
490448 - ..
490449 - On 100911 0800 VA credited for improving speed of access to computer
490450 - records; discussed "Knowledge Management loop" that redundancy and
490451 - ignoring the record collapses productivity and vitiates care because
490452 - health care professionals do not have command and control of the
490453 - record on patient history, ref SDS 56 OL50, citing case study of work
490454 - at VA on 091021. ref SDS 20 FB5N
490456 - ..
490457 - There wasn't enough time during the meeting today, for the doctor to
490458 - see these photographs on the patient's computer (c16), sitting on the
490459 - desk next to the VA computer.
490460 -
490461 - [On 150527 0930 meeting with support staff - they could not
490462 - access VA computer system server at Sacramento server;
490463 - Isagani suggested the patient submit relevant photographs
490464 - with email to assist Doctor Stewart in evaluating patient
490465 - history toward deciding remedies for failed Dor
490466 - fundoplication. ref SDS E0 2X5F
490468 - ..
490469 - [On 150529 1202 letter to Isagani submits the record
490470 - meeting with Doctor Stewart the day before on 150526, and
490471 - transmits photographs she requested, as planned meeting
490472 - with Isagani the next day on 150527. ref SDS E1 SQ50
490474 - ..
490475 - [On 150529 1327 letter to Doctor Lee notifying that on
490476 - 150526, Doctor Stewart was unable to access photographs for
490477 - EGD dilations stored on VA computer server in Sacramento
490478 - performed by Doctor Lee at VA Martinez and past few years
490479 - at VA MC Sacramento, and so requested that the doctor
490480 - coordinate with admin staff (Jessica) to submit these
490481 - photographs on a CD so the patient can support the medical
490482 - team. ref SDS E2 L342
490484 - ..
490485 - [On 150602 1035 called Jessica at VA MC Sacramento for
490486 - pictures from all EGD dilations. ref SDS E3 KQ5M
490488 - ..
490489 - [On 150604 1621 called Jessica at VA MC Sacramento for
490490 - pictures from all EGD dilations. ref SDS E5 KQ5M
490491 -
490492 -
490493 -
490494 -
490495 -
490496 -
490497 -
490498 -
4905 -
SUBJECTS
Dor Fundoplication Redo Work Plan Access VA Computer System Photogra
6603 -
660401 - ..
660402 - Work Plan Review Photographic Evidence Barium and Gastric Emptying Test
660403 -
660404 -
660405 - 2. Doctor Stewart proposed work plan to assess remedies for
660406 - loosening of Dor fundoplication, hiatal hernia and ulceration
660407 - of LESV...
660408 -
660409 - 1. Staff will continue efforts after the meeting to access
660410 - from VA computer in Sacramento photographs that show Dor
660411 - fundoplication intact on 131115 and beginning to unravel on
660412 - 141107, per above. ref SDS 0 RV3G
660414 - ..
660415 - 2. CT barium swallow test scheduled tomorrow evaluate
660416 - esophagus for achalasia distortion.
660418 - ..
660419 - Previously, on 130122 Doctor Stewart was pleased CT test on
660420 - 130117, showed esophagus had fully recovered from past
660421 - distortion caused by achalasia, ref SDS 97 VL7N, following
660422 - Heller Myotomy surgery and repeated dilations showing LESV
660423 - contractions reduced with injections of triamcinolone
660424 - steroids, per above. ref SDS 0 8J43
660426 - ..
660427 - Today, during the meeting the doctor used the VA computer
660428 - in the examination room to order this test for tomorrow on
660429 - 150527.
660430 -
660431 - [...below on 150526 1300 at 1440 went to Radiology
660432 - Department and scheduled CT barium swallow test for
660433 - tomorrow 150527 0930. ref SDS 0 MQ5M
660435 - ..
660436 - [On 150527 0930 VA Medical Center in San Francisco
660437 - performed another CT Barium Swallow test - preliminary
660438 - results are favorable indicating patient has not
660439 - suffered recurrent achalasia symtom of distorted
660440 - esophagus, commonly called "bird beak," rather esophagus
660441 - looks normal. ref SDS D9 V56N
660443 - ..
660444 - 3. Gastric emptying test scheduled tomorrow in Nuclear
660445 - Medicine to assess severity of acid reflux that Dor
660446 - fundoplication was constructed to prevent scarring the
660447 - LESV.
660449 - ..
660450 - Today, during the meeting the doctor used the VA computer
660451 - in the examination room to order this test on 150528, the
660452 - day after the CT Barium Swallow study.
660453 -
660454 - [...below on 150526 1300 at 1417 Mike in Radiology
660455 - coordinated with Nuclear Medicine and advised Gastric
660456 - Emptying test cannot be less than 3 days following CT
660457 - barium swallow test; therefore, meeting with Doctor
660458 - Stewart must be changed. ref SDS 0 S59G
660460 - ..
660461 - [...below on 150526 1300 at 1504 Chrissa in Nuclear
660462 - Medicine scheduled Gastric Emptying test on 150603 0800.
660463 - ref SDS 0 FY4M
660465 - ..
660466 - [On 150603 0800 visit VA Medical Center in San Francisco
660467 - and met Charissa for Gastric Emptying test. ref SDS E4
660468 - K37G
660470 - ..
660471 - 4. Return to clinic on 150602 for review of findings from
660472 - prescribed studies.
660474 - ..
660475 - [...below on 150526 1300 at 1532 May in Clinic Module #2
660476 - changed the meeting with Doctor Stewart from 150602 to
660477 - 150623 1300. ref SDS 0 SO3F
660479 - ..
660480 - Thanked Doctor Stewart for thorough and timely consideration of new
660481 - issues managing chronic achalasia.
660482 -
660483 -
660484 -
6605 -
SUBJECTS
Coronary CT Angiography CCTA May Find Regression Atherosclorosis Pla
7803 -
780401 - ..
780402 - CCTA Findings Reduce Statin Drug Side Effects
780403 - Fat Chance Book Manage Metabolic Syndrome Overweight Obesity
780404 - Metabolic Syndrome Manage Overweight Obesity Book Fat Chance
780405 -
780406 -
780407 - 3. Coronary CTA test can further test response to treatment for
780408 - recovery from CVD, based on 5 years hiking 11 miles per day
780409 - that raised HDL 30 to HDL 70, shown in patient history...
780410 -
780411 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
780413 - ..
780414 - Background showing coronary CTA standard of care evaluate post
780415 - CABG, shown in Progress Notes on 140519 0800. ref SDS B5 OF7N
780417 - ..
780418 - Doctor Stewart seemed to say coronary CTA is sometimes requested to
780419 - assess patient readiness and ability to withstand surgery, if the
780420 - patient shows significant CAD symptoms, for example hypertension,
780421 - obesity, also "metabolic syndrome." She feels in this case, favorable
780422 - labs (e.g., HDL 70 on 150209, ref SDS C9 U45J), show patient history
780423 - taking statin drugs, and endurance exercise obviates this requirement.
780425 - ..
780426 - Discussed prospects to reduce side effects of statin drugs and
780427 - endurance exercise. CCTA tests might show atherosclerotic plaques
780428 - have rapidly regressed through endurance exercise hiking 11 miles per
780429 - day / 300 miles per month for the past few years, along with elevated
780430 - EPCs and HDL. This could enable a lower statin drug profile along
780431 - with reduced regimen of exercise to reduce side effects.
780433 - ..
780434 - Doctor Stewart recommended the book "Fat Chance" authored by Robert H
780435 - Lustig, to address metabolic syndrome, a related matter to lipid labs.
780437 - ..
780438 - Obesity described as "metabolic syndrome" in medical literature is a
780439 - high risk factor for CVD/CAD, often presents with elevated
780440 - triglycerides, reviewed in the record on 131125 0005. ref SDS A8 C347
780441 - Lipid history in this case shows triglycerides over past 10 years have
780442 - been below 140, and in recent years below 100, reported in study on
780443 - 150512 1330. ref SDS D4 W25L
780445 - ..
780446 - After the meeting, review found...
780447 -
780448 - SCIENTIFIC REVIEW OF ROBERT LUSTIG'S FAT CHANCE
780449 -
780450 - MARK KERN, PHD, RD, CSSD,
780451 - PROFESSOR OF EXERCISE AND NUTRITIONAL
780452 - SCIENCES AT SAN DIEGO STATE UNIVERSITY
780453 -
780454 - http://sweetenerstudies.com/sites/default/files/resources/files/Scientific-Review-of-Lustigs-Fat-Chance.pdf
780456 - ..
780457 - Doctor Kern reviews "Fat Chance" unfavorably citing scientific
780458 - inaccuracies and lack of support in medical literature and clinical
780459 - studies, writing about being overweight (metabolic syndrome and
780460 - obesity), saying in conclusion...
780461 -
780462 - Fat Chance: Beating the Odds Against Sugar, Processed
780463 - Food, Obesity and Disease is the product of one
780464 - individual's point of view - a perspective that is not
780465 - supported by the vast majority of scientific research on
780466 - nutrition and metabolism. This review highlights the
780467 - critical need for the increased communication of weight
780468 - management strategies that are science-based and realistic.
780469 - As we've witnessed in the past several decades, blaming one
780470 - particular food or ingredient for the obesity and chronic
780471 - disease rates in America is unsubstantiated; restriction
780472 - and avoidance of particular foods (especially those that
780473 - are most enjoyed by many consumers) is not a sustainable
780474 - healthy eating strategy. Numerous scientific authorities,
780475 - including the Academy for Nutrition and Dietetics, have
780476 - acknowledged that the most effective way to achieve and
780477 - sustain a healthy weight is to exercise regularly and eat a
780478 - balanced, nutrient-dense diet that allows for the enjoyment
780479 - of all foods within individual calorie limits. Books like
780480 - Fat Chance are regressive and only serve to increase
780481 - consumer confusion about nutrition, rather than help create
780482 - smarter consumers who are able to make informed decisions
780483 - about their health.
780485 - ..
780486 - The reviewer's sentiments reflect personal experience managing
780487 - quantity of eating in relation to daily expenditure through endurance
780488 - exercise drives weight control and healthy labs, shown in the study...
780489 -
780490 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
780491 -
780492 -
780493 -
780494 -
780495 -
7805 -
SUBJECTS
Statins Side Effects Recover Recommend CoQ10 Natural Substance Human
8803 -
880401 - ..
880402 - Co-Q-10 Drugs to Recover Low Energy Side Effects Statin Drugs
880403 -
880404 - Doctor Stewart recommended research on CoQ10 for possible application
880405 - in this case to recover from statin drug side effects.
880406 -
880407 - The general impression that CoQ10 boosts energy may indicate there is
880408 - no role in this case shown by case study on diet and exercise
880409 - reporting over the past 3 years hiking 11 miles per day, 300 miles
880410 - per month, i.e., low energy is not an issue.
880412 - ..
880413 - After the meeting review found...
880414 -
880415 - Webmd
880417 - ..
880418 - Coenzyme Q10 - Topic Overview
880419 - What is coenzyme Q10?
880420 -
880421 - http://www.webmd.com/heart-disease/heart-failure/tc/coenzyme-q10-topic-overview
880423 - ..
880424 - Last Updated: June 11, 2013
880426 - ..
880427 - Coenzyme Q10 (CoQ10) is a substance similar to a vitamin.
880428 - It is found in every cell of the body. Your body makes
880429 - CoQ10, and your cells use it to produce energy your body
880430 - needs for cell growth and maintenance. It also functions
880431 - as an antioxidant, which protects the body from damage
880432 - caused by harmful molecules. CoQ10 is naturally present in
880433 - small amounts in a wide variety of foods, but levels are
880434 - particularly high in organ meats such as heart, liver, and
880435 - kidney, as well as beef, soy oil, sardines, mackerel, and
880436 - peanuts.
880438 - ..
880439 - Coenzymes help enzymes work to digest food and perform
880440 - other body processes, and they help protect the heart and
880441 - skeletal muscles.
880443 - ..
880444 - CoQ10 is available in the United States as a dietary
880445 - supplement. It is also known as Q10, vitamin Q10,
880446 - ubiquinone, or ubidecarenone.
880448 - ..
880449 - What is CoQ10 used for?
880451 - ..
880452 - Many claims are made about CoQ10. It is said to help heart
880453 - failure, as well as cancer, muscular dystrophy, and
880454 - periodontal disease. It is also said to boost energy and
880455 - speed recovery from exercise. Some people take it to help
880456 - reduce the effects certain medicines can have on the heart,
880457 - muscles, and other organs.
880459 - ..
880460 - Research does not support a helpful effect of CoQ10 in
880461 - periodontal (gum) disease, muscular dystrophy, or exercise
880462 - recovery.
880464 - ..
880465 - This does not sound promising.
880467 - ..
880468 - Article continues...
880469 -
880470 - Medicines for high cholesterol (statins) and medicines
880471 - that lower blood sugar cause a decrease of CoQ10 levels
880472 - and reduce the effects of CoQ10 supplements. CoQ10 can
880473 - reduce the body's response to the blood thinner
880474 - (anticoagulant) medicine warfarin (Coumadin) and can
880475 - decrease insulin requirements in people with diabetes.
880477 - ..
880478 - This does not sound promising either.
880479 -
880480 -
880481 -
880482 -
880483 -
8805 -
SUBJECTS
CT Barium Swallow Test Radiology Schedule 150527 0930 Evaluate Achal
A803 -
A804 - 1417
A80501 - ..
A80502 - CT Barium Swallow Test Scheduled 150527 0930
A80503 - Meeting Radiology Department on 2nd Floor Building 200.
A80504 -
A80505 - After meeting with Doctor Stewart in General Surgery Clinic, went to
A80506 - the Radiology Department on the 2nd floor of Building 200.
A80508 - ..
A80509 - Mike found in the VA computer system Doctor Stewart's order for GI
A80510 - examination using CT for barium swallow test, entered 30 minutes
A80511 - earlier per above. ref SDS 0 MF8H
A80513 - ..
A80514 - Mike scheduled the CT study for tomorrow 150527 0930. Requires
A80515 - fasting after midnight.
A80517 - ..
A80518 - Mike asked about prior similar studies?
A80520 - ..
A80521 - On 050714 CT barium swallow test ordered by Doctor Sandhu in Primary
A80522 - Care Clinic VA Martinez CA, to evaluate cause of chronic swallowing
A80523 - problems. ref SDS 2 B94J
A80525 - ..
A80526 - On 091218 CT barium swallow test ordered by Doctor Stewart at VAMCSF
A80527 - to evaluate results of Heller Myotomy surgery to resolve achalasia
A80528 - (swallowing problems), reported in the record on 100928 0706.
A80529 - ref SDS 57 1357
A80531 - ..
A80532 - On 130117 CT barium swallow test ordered by Doctor Lee and performed
A80533 - at VA GI Clinic at Martinez CA, to test resolution of achalasia 3
A80534 - years after Heller Myotomy surgery, and following repeated EGD
A80535 - dilation procedures 4 times per year. ref SDS 96 OH6G
A80536 -
A80537 - [On 150527 0930 VA Medical Center in San Francisco
A80538 - performed another CT Barium Swallow test - preliminary
A80539 - results are favorable indicating patient has not
A80540 - suffered recurrent achalasia symtom of distorted
A80541 - esophagus, commonly called "bird beak," rather esophagus
A80542 - looks normal. ref SDS D9 V56N
A80544 - ..
A80545 - Mike noticed Doctor Stewart ordered the Gastric Empty study for
A80546 - 150528, the day after the CT Barium Swallow test, per above.
A80547 - ref SDS 0 WT6N He called and talked to the Nuclear Medicine
A80548 - Department, and advised they said the Gastric Empty Study cannot be
A80549 - done until 3 days after the CT Barium Swallow test. Since this will
A80550 - be after 150602, Doctor Stewart should be notified the follow up
A80551 - meeting with her must be rescheduled.
A80552 -
A80553 - [...below on 150526 1300 at 1532 May in Clinic Module #2
A80554 - changed the meeting with Doctor Stewart from 150602 to
A80555 - 150623 1300. ref SDS 0 SO3F
A80557 - ..
A80558 - Thanked Mike for the heads up on coordinating Doctor Stewart's
A80559 - schedule.
A80561 - ..
A80562 - After scheduling the CT barium swallow test for tomorrow, per above,
A80563 - ref SDS 0 ZR6H, asked Mike if there is an "Irene" still working in the
A80564 - Sonogram section of Radiology. Mike said yes, and led the way down
A80565 - the hall and around the corner, reported in another record today on
A80566 - 150526 1432. ref SDS D7 NJ5K Thanked Mike for excellent patient
A80567 - support.
A80569 - ..
A80570 - [On 150526 1432 meeting in Sonogram Unit with Irene.
A80571 - ref SDS D8 NJ5K
A80572 -
A80573 -
A80574 -
A80575 -
A80576 -
A80577 -
A80578 -
A806 -
SUBJECTS
Gastric Emptying Study Radiology Test Nuclear Medicine Scheduled 150
AS03 -
AS04 - 1504
AS0501 - ..
AS0502 - Gastric Emptying Study Scheduled 150603 0800
AS0503 - Meeting Nuclear Medicine Ground Floor Building 202
AS0504 -
AS0505 - After meeting with Mike and touching base with Irene in Radiology, per
AS0506 - above, ref SDS 0 WY3O, went to Nuclear Medicine to schedule Gastric
AS0507 - Emptying test ordered by Doctor Stewart, earlier today, per above.
AS0508 - ref SDS 0 MF92
AS0509 -
AS0511 - ..
AS0512 - This is where the feeding tube was installed after CABG +4 surgery,
AS0513 - reported on 091030 0810. ref SDS 24 LI6C Actually, there is a slight
AS0514 - conflict in the record indicating the feeding tube was installed by
AS0515 - "Internal Radiology." ref SDS 24 1P34 These could be the same unit
AS0516 - simply described differently.
AS0518 - ..
AS0519 - Met Charissa. She is the Technician who will perform the test
AS0520 - tomorrow.
AS0522 - ..
AS0523 - Charissa scheduled the Gastric Emptying test on 150603 0800.
AS0524 -
AS0525 - [On 150603 0800 visit VA Medical Center in San Francisco
AS0526 - and met Charissa for Gastric Emptying test. ref SDS E4 K37G
AS0528 - ..
AS0529 - This took quite some time to schedule the test on 150603, due to more
AS0530 - computer problems, as Doctor Stewart experienced earlier per above.
AS0531 - ref SDS 0 F65O Slow computer response, caused Charissa to collaborate
AS0532 - with a colleague in the adjacent work station, so the order for the
AS0533 - test was partially in 2 different systems.
AS0535 - ..
AS0536 - Scheduling Gastric Emptying test on 150603, changes Doctor Stewart's
AS0537 - preliminary work plan for this test to be done on 150528, per above.
AS0538 - ref SDS 0 MF92; requires re-scheduling meeting with Doctor Stewart
AS0539 - after that date. This will have to be changed by May in Clinic Module
AS0540 - #2
AS0541 -
AS0542 - [...below on 150526 1300 at 1532 May in Clinic Module #2
AS0543 - changed the meeting with Doctor Stewart from 150602 to
AS0544 - 150623 1300. ref SDS 0 SO3F
AS0546 - ..
AS0547 - Numerous documents were received with explanations on logistics and
AS0548 - what to expect for the test.
AS0550 - ..
AS0551 - The test takes about 5 hours, although after the 1st hour the customer
AS0552 - can walk around, then return for additional radiology imaging.
AS0553 -
AS0555 - ..
AS06 -
AS07 -
AS08 - 1532
AS09 -
AS0901 - Clinic #2 General Surgery Meeting May Reschedule Doctor Stewart Meeting
AS0902 -
AS0903 - After meeting with Charissa in Nuclear Medicine, walked back to
AS0904 - Building 200, and visited May at Clinic #2 for General Surgery.
AS0906 - ..
AS0907 - Explained meeting with Doctor Stewart earlier today. She scheduled
AS0908 - follow up meeting on 150602, expecting to review findings and plan
AS0909 - next steps based on results of CT Barium Swallow test in Radiology
AS0910 - tomorrow on 150527, and results of Gastric Emptying study the next day
AS0911 - on 150508, per above. ref SDS 0 GG4G
AS0913 - ..
AS0914 - However, Charissa in Nuclear Medicine just advised that Gastric
AS0915 - Emptying test will be performed on 150603. ref SDS 0 K55L Therefore,
AS0916 - need to change meeting Doctor Stewart scheduled for 150604, or later.
AS0918 - ..
AS0919 - May checked the computer and said the Gastric Emptying test in Nuclear
AS0920 - medicine is actually scheduled for 150608, not 150603, so she cannot
AS0921 - schedule meeting Doctor Stewart on 150604.
AS0923 - ..
AS0924 - This representation conflicted with recollections meeting with
AS0925 - Charissa in Nuclear Medicine, saying the meeting is on 150603 0800.
AS0926 - Handed a document to May showing the schedule for Gastric Emptying
AS0927 - test, just received from Charissa a few minutes ago, per above.
AS0928 - ref SDS 0 K55L
AS0930 - ..
AS0931 - May looked at the document and advised it clearly shows the meeting in
AS0932 - Nuclear Medicine is on 150608, not 150603. She therefore scheduled
AS0933 - the follow up meeting with Doctor Stewart on 150623 1300, to review
AS0934 - both the CT Barium Swallow test, and the Gastric Emptying study.
AS0936 - ..
AS0937 - May returned the document. Sure enough it shows 5 lines saying...
AS0938 -
AS0939 - Monday June 8, 2015 0800 Nuclear Medicine CT Clinic
AS0940 - Monday June 8, 2015 0900 Nuclear Medicine CT Clinic
AS0941 - Monday June 8, 2015 1000 Nuclear Medicine CT Clinic
AS0942 - Monday June 8, 2015 1100 Nuclear Medicine CT Clinic
AS0943 - Monday June 8, 2015 1200 Nuclear Medicine CT Clinic
AS0945 - ..
AS0946 - This shows the distribution of repetitive CT imaging required for the
AS0947 - Gastric Emptying study.
AS0949 - ..
AS0950 - May printed a document confirming the follow up meeting with Doctor
AS0951 - Stewart is now scheduled...
AS0952 -
AS0953 - Tuesday June 23, 2015 1300 Surg-general Fol-up Stewart Clinic
AS0955 - ..
AS0956 - This resolves issue raised by Mike in Radiology, per above,
AS0957 - ref SDS 0 S59G, and aligns with Charissa setting the Gastric Emptying
AS0958 - test on 150603, per above. ref SDS 0 K55L
AS0960 - ..
AS0961 - Thanked May for terrific help sorting this schedule matter.
AS0962 -
AS0963 -
AS0964 -
AS0966 - ..
AS10 -
AS11 -
AS12 - 1544
AS13 -
AS1301 - Gastric Emptying Study Scheduled 150603 0800
AS1302 - Meeting Nuclear Medicine Ground Floor Building 202
AS1303 -
AS1304 - Walked back to Nuclear Medicine. Charissa was still at the front
AS1305 - desk, so this was lucky.
AS1307 - ..
AS1308 - Asked Charissa to clarify the date time for the Gastric Emptying test,
AS1309 - which was discussed earlier as scheduled on 150603, but the
AS1310 - documentation and the VA computer now show it is actually scheduled on
AS1311 - 150608?
AS1313 - ..
AS1314 - Charissa checked her VA computer. She confirmed the test is on 150603
AS1315 - 0800.
AS1317 - ..
AS1318 - This aligns with May rescheduling meeting with Doctor Stewart to
AS1319 - 150623 1300, per above. ref SDS 0 SO3F
AS1321 - ..
AS1322 - Her colleague sitting next to her explained she somehow entered some
AS1323 - of the order for the test incorrectly in another part the VA computer
AS1324 - system (Vista was mentioned). She updated the computer. Charissa
AS1325 - then printed and submitted another document verifying the test is
AS1326 - correctly entered in the VA computer system for 150603 0800.
AS1327 -
AS1328 - Monday June 3, 2015 0800 Nuclear Medicine CT Clinic
AS1329 - Monday June 3, 2015 0900 Nuclear Medicine CT Clinic
AS1330 - Monday June 3, 2015 1000 Nuclear Medicine CT Clinic
AS1331 - Monday June 3, 2015 1100 Nuclear Medicine CT Clinic
AS1332 - Monday June 3, 2015 1200 Nuclear Medicine CT Clinic
AS1334 - ..
AS1335 - Thanked the team for expedient work coordinating this matter.
AS1337 - ..
AS1338 - Look forward to seeing Charissa next week on Wednesday morning.
AS1339 -
AS1340 -
AS1341 -
AS1342 -
AS1343 -
AS1344 -
AS1345 -
AS1346 -
AS1347 -
AS1348 -
AS1349 -
AS1350 -
AS14 -