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From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: ACT UP - 10Q NOT, 4Q maybe
Date: 17 Apr 1997
Newsgroups: misc.health.aids
In <1997Apr16.075938@mcrcr6> holzmr01@mcrcr6.med.nyu.edu (ROBERT S.
HOLZMAN) writes:
>Yes. A cold is an infection of the nose (runny stuffy, complicated by ear
>and sinus infections). Bronchitis is an infection of the bronchial tree
>(cough, wheezing, phlegm), Pneumonia is an infection of the lung air
>spaces (cough, phlegm, sometimes pleurisy). The syndromes may overlap.
>Influenza is a respiratory infection that characteristically causes an
>infectin that progressively descends the respiratory tract from nose to
>bronchial tree and may cause overlapping symptoms.
>
>>Or does it take a doctor to tell the difference?
>
>not usually, only attention to detail. an Xray may also be needed.
I will add for the benefit of laymen that consolidation of the air
spaces (pneumonia), particularly in one spot, may produce big changes
in the how the lungs sound at that spot. You need some experience to
recognize that. Also, this disease is more likely to produce hypoxia,
which these days is easily measured with the aid of device which clips
to a finger or earlobe, and looks at the color of the blood. And, as
Dr. Holzman notes, pneumonia (in the later stages) often produces
characteristic white patches on chest X-ray. Pneumocystis carinii
pneumonia, though, is famous for producing a lot of hypoxia without a
lot of infiltrate, in the early phases.
Steve Harris, M.D.
From: David Rind <rind@enterprise.bidmc.harvard.edu>
Newsgroups: sci.med
Subject: Re: An atypical pneumonia
Date: Thu, 12 Mar 1998 10:18:49 -0500
Terry Gritton wrote:
> An atypical Pneumonia 3/11/98
> How often does one see lower respiratory tract infections that are
> undianosed ( no findings) after 19 days in the hospital?
This is not that unusual a situation at all. Often, diagnoses
of atypical pneumonias are only made weeks later by serologic
studies, assuming someone cares to prove what caused the pneumonia
after the patient has recovered.
Atypical pneumonias can be severe, and can lead to respiratory
failure. Erythromycin in high doses is generally an appropriate
therapy because it covers most of the likely organisms, including
legionella. I believe it is adequate for c. psittaci as well,
though I do not know whether there is evidence that in overwhelming
pneumonia there are better results with tetracyclines like
minocycline. It is one of the realities of these situations that
finding the exact perfect drug is not usually the difference between
someone getting better or dying. The person's own health, the
supportive care provided in the ICU, and luck are probably more
important 19 days into a pneumonia. It is unlikely that there are
still living pathogens in the lungs after a prolonged course of
IV erythromycin -- the problem is usually the damage that has already
been done to the lungs by the pathogens, by the immune system, and
by the high pressures and concentrations of oxygen given to
keep the person alive.
This year we have also seen a lot of severe pneumonias from
influenza, which does not have any well-proven drug therapy.
--
David Rind
rind@enterprise.bidmc.harvard.edu
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.diseases.als,sci.med.nutrition,sci.med
Subject: Re: dying from pneumonia
Date: 2 Nov 1998 05:31:08 GMT
In <363cc22b.10564356@news1.ibm.net> jihardy@ibm.net (Jim Hardy)
writes:
>On 1 Nov 1998 05:10:15 GMT, sbharris@ix.netcom.com(Steven B. Harris)
>wrote:
>
>> ALS is a fatal disease. You may wish to consider that starvation
>>and hypoxia from pneumonia are not bad ways to die (especially with
>>some morphine), but that slowly choking while being more and more
>>paralyzed and in pain, can be torture.
>
>I had a friend in Mexico who died of AIDS from pneumonia (presumably
>PCP) and just started breathing weaker and weaker and for the last few
>hours before his death he couldn't talk, so we got out a chalk board
>for him to write on. He didn't seem to be in any real distress,
>however, i.e. he didn't seem to be gasping for breath or anything, his
>breathing just got weaker and weaker. He died in his home and wasn't
>taking any pain killing drugs. Is this pretty much normal in dying of
>pneumonia?
Yep. Having just your alveoli fill up with fluid often does not
much activate the stretch receptors which give you the feeling of
"drowning." So you drown without any of that. And humans suffer
hypoxia without many symptoms (unlike burrowing creatures like, say,
rabbits, which go nuts in low oxygen environments). Not for nothing is
pnemonia known as the old person's friend.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: pneumonia
Date: 16 Nov 1998 06:59:51 GMT
In <364FA32C.62EE2432@servtech.com> Ed Mathes <emathes@servtech.com>
writes:
>Melvin Billik wrote:
>
>> You asked how did I get the pneumonia???
>> Damned if I know.
>
>I caught pneumonia last year.
>
>I know exactly how I caught it.
>
>I find it interesting that patinet's most always ask "How did I get
>pneumonia?"....closely followed by "Am I contageous?".
>
>In any event. I work in an urgent care center on weekends. Saw a fairly
>sick young man....5 yars old. I was sort of restraining him while the
>nurse was drawing blood. My face was literally inches from his. He
>coughed as I inhaled. 3 days later....fever, chilld, body aches, cough
>and a RML pneumonia on x-ray.
Yep. A really big inoculum can do wondrous things. Still and all,
pneumonia is not a very contageous condition. Not enough that one
ordinarily needs to worry about it.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Explain x-ray findings
Date: 13 Dec 1998 22:41:26 GMT
In <750loq$tc0$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>> For sure. Followup X-rays for pneumonia usually cause more
>> problems than they solve, since they trail clinical cure by so many
>> weeks (even months). And radiologists trying to cover their fannies in
>> case of the rare lawsuit for the rare tumor don't help (gosh, anybody
>> with pneumonia COULD have a TUMOR, right? SURE. Right. So? And the
>> chance of curing somebody with pneumonia because you found that tumor 2
>> months early is...?).
>
>Well, we don't know, do we? All we know is that a major reason for
>pneumonias being slow to resolve is tumor in the passage to the infected
>lung.
Incorrect. That is an incredibly rare reason for slow resolution of
pneumonia on a chest X-ray (if by slow we mean 3 weeks).
> Naturally, no controlled studies have been done - since it would be
>regarded by the great majority as unethical to do so (sort of like the
>Tuskegee syphilis study) - to determine whether waiting 2 months to take
>out a lung tumor is harmful.
Studies to look for lung cancer by screening X-rays in smokers
have been done. They do find tumors a little earlier, on average,
since they find them before they are symptomatic. But guess what?.
Results do not tranlate to increased cure rate, which for lung cancer
is only 5% anyway. This is why screening X-rays for smokers are not
recommended, and not done routinely in any country I know of.
> Most physicians assume that the earlier one removes
>a tumor, the better the chance of catching it before it metastasizes.
I don't know what most physicians assume. The truth, however, is
that it depends on the tumor you're looking for.
>cavalier about tumors is not in vogue at the moment, Steve, even for your
>geriatric cases usually. Have you seen a study or something that
>demonstrates that tumor-ectomy has no effect on geriatric QALY?
Nope. But it's rather unreasonable to assume that if it doesn't
help younger people it doesn't help older ones. Index of suspicion is
raised more by younger people who fail to clear pneumonias rapidly, of
course. Everything heals more slowly in the elderly.
>> A slow recovery from pneumonia (a few weeks) is
>> not a good reason for re-X-raying people, especially elderly people.
>
>This fellow not only had a slow recovery from pneumonia, but STILL has an
>infiltrate.
Most people still have an infiltrate 3 weeks after pneumonia. Even
when they feel great. The X-ray at that point tells you exactly
nothing. Understand? Unless, of course, the person is clearly going
downhill clinically. Which was not the case here.
>A re-X-ray at 6 weeks will not be harmful, and is, in fact, suggested by
>the radiologist. Radiologists have generally studied the data on harmful
>effects of X-rays and would not recommend a harmful follow-up for which
>he could also be sued.
Bullshit. Once again we see your total ignorance of medicine as it
is actually practiced in the real world.
>> Only if somebody has not recovered after several MONTHS (not weeks), or
>> shows signs of going back downhill, are you really forced to start
>> looking again.
>
>And your data, please?
As soon as you provide me with yours suggesting routine serial X-ray
followup of pneumonia until you see a clear lung, as seems to be
suggested by Mr. Idiot Radiologist in this case (granted, that we do
not have ALL of the facts, and who knows what else went into these
decisions).
In any case, I'm not going to start in the habit of providing
citations for everything I say to you, Mr. Anonymous, since you don't
do the same. And you ain't worth the effort, quite frankly. If you
knew what you were doing, you'd look it up on medline yourself, or know
it already from experience. Be my guest. As for experience, we know
already know you think you can feel ovaries in any woman who has them,
which means you either have no experience, or are a wonderful
self-deluder. So that argument's pretty much out for you.
>In general, I would agree that useless tests may do more harm than good,
>but I follow that rule or not depending on the stakes. For a broken
>ankle, sure, I wouldn't mind waiting a little extra time - I'm not
>worried about the signs indicating a tumor.
The signs do not indicate a tumor in this case. This case is a
perfectly common and routine course of pneumonia in an elderly person.
When you hear hoofbeats, think horses, not zebras. And for all you
folks on misc.health.alternative: don't think unicorns, either.
And just to make it clear in case you do not understand: the
radiologist here has absolutely NO business suggesting a repeat X-ray
in this case, simply because the infiltrate has not cleared on a
pneumonia followup in this length of time. None.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Explain x-ray findings
Date: 15 Dec 1998 03:47:45 GMT
In <753ef4$59j$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
>> >Well, we don't know, do we? All we know is that a major reason for
>> >pneumonias being slow to resolve is tumor in the passage to the
>> infected lung.
>>
>> Incorrect. That is an incredibly rare reason for slow resolution of
>> pneumonia on a chest X-ray (if by slow we mean 3 weeks).
>>
>
>Guess again, Steve. 30-50% of early diagnoses of lung cancer have
>recurrent pneumonia or bronchitis. 15% of those with idiopathic
>pneumonia develop lung cancer; these were smokers. In non-smokers, the
>rate is around 2%.
Amazing that you think that anything you said relates to anything I
said. 30-50% of diagnoses of lung cancer have recurrent pneumonias.
This says exactly nothing about what fraction or recurrent pneumonias
are actually lung cancer. Moreover, this is not a recurrent pneumonia,
rather it is a slowly resolving pneumonia (common in people over middle
age) with an X-ray picture which is typical of pneumonia in such
people. Why you wish to go looking for a tumor in a rather typical
pnemonia in a person of this age is the question before us. Is there
any evidence whatsoever that such a practice does anything more than
expose people to radiation and waste their money? I think not. But
you and the radiologist are the ones recommending the medical test.
It's up to the person recommending the test to provide the evidence.
>matter what the numbers, any physician would be remiss to overlook
>that as a possible cause of slow resolution. Perhaps you'd like to
>list the other causes you know of if any besides wrong medication and
>older age.
Pointless. I can use textbooks and medline as zebra generators
whenever I like. That's not the challenge of medicine.
>>
>> Studies to look for long cancer by screening X-rays in smokers
>> have been done. They do find tumors a little earlier, on average,
>> since they find them before they are symptomatic.
>
>What do you mean by a little earlier? A week? Two weeks?
Impossible to say, since no study I know of has looked to see how
long it takes tumors found on incidental or screening X-ray to become
symptomatic. But whatever the time is, it seems rather unlikely to be
one or two weeks. The doubling time for lung tumors is typically
months.
>> But guess what?.
>> Results do not tranlate to increased cure rate, which for lung cancer
>> is only 5% anyway.
>
>What about increased QALY, Steve? What procedures were done in the
>studies you have read? How soon were they done after diagnosis? Where I
>trained, slow resolution was followed up with bronchoscopy. This was
>slower than 3 weeks, granted (more like 4-6, and the guy was a smoker),
>and it was done at a military hospital where profit from unnecessary
>procedures is not a motivating factor. And sure enough, there was the
>tumor sitting at a branch point.
What, in the one case you saw? Amazing.
>> > Most physicians assume that the earlier one removes
>> >a tumor, the better the chance of catching it before it metastasizes.
>>
>> I don't know what most physicians assume. The truth, however, is
>> that it depends on the tumor you're looking for.
>>
>
>True enough. But before it is diagnosed, one has no idea what kind of tumor
>it is, does one? And we don't know yet, do we?
We know it would be a lung tumor. And not a hamartoma, but a
malignant tumor, or otherwise you wouldn't be so hot to re-X-ray it.
So you think repeated lung X-rays for older men people who don't
completely get over pneumonia is a good way to save people from lung
cancer? And your evidence is? As I say, he would recommends the
intervention is under the obligation to provide the evidence.
>The real question is whether YOU can understand that a slowly
>resolving pneumonia is ONE indicator of bronchial tumor.
"Indicator" is the wrong word. A slowly resolving pneumonia is no
more an "indicator" of a tumor than a smoking history is. Most people
who have a lung tumor have a smoking history. That does not mean that
most people with a smoking history has a lung tumor. Or that having a
smoking history merits a chest X-ray. Same problem. The probability
that person A also has B says exactly nothing about the probability
that the person who has B will have A. Medicine is about the
differences between sensitivity, specificity, and positive predictive
value.
>Sure, it is more likely than not that the slow resolution of his
>pneumonia is not due to tumor. Patients generally feel a bit queasy about
>doctors playing dice with their lives, though. In general, they like
>doctors to KNOW what is going on. A follow-up as recommended by the
>radiologist on the case is not in most physician circles a wild idea. It
>is simply good medicine.
No, it isn't, if by that you mean a third X-ray. Sorry.
>> As soon as you provide me with yours suggesting routine serial X-ray
>> followup of pneumonia until you see a clear lung,
>
>Hey, that was not a clear lung. Look at the data, for once, will you, before
>you go shooting off your mouth about something?
Excuse me, but you are arguing for a followup X-ray. If you're not
going to stop when you see a clear lung, when are you going to stop?
>I do when you ask for them. That's because I have them.
Let's see them.
>It's not me you must convince, hic. You have developed a well-deserved
>reputation for sloppy medicine, and if you want to change that, you need
>to demonstrate some scholarship - not just your foul mouth and
>incontinent anger at folks who do not pray to the Nobel-prize wanna-be,
>Mr. Harris.
Ahem. Well, Mr. Anomymous, I can prove I'm an M.D. My reputation
seems to bad only among MD wannabes. If the shoe fits, wear it.
>> If you
>> knew what you were doing, you'd look it up on medline yourself,
>
>I have. And guess what? You are wrong! (Hard pill to swallow, I know,
>but there it is. Take it like a good boy.)
Prove it.
> I know how to feel ovaries in any woman I've examined, and I
>have examined several.
ROFL! "Several"?
> It is not my specialty, and neither is it yours -
>thank goodness.
Pelvic exams are part of geriatrics.
> The problem is not so much in lack of experience on my part,
>but a lack of brains and knowledge of anatomy on your part.
No, it's a lack of experience on your part. Sorry.
>You review the anatomy and rub a few brain cells together if you have any
>left, and you will be able to do the same - that is, if anyone would let
>you near them for that sort of exam.
I do dozens a year. However, if you will only listen to a
gynecologist, I suggest you go talk to one. Please provide what he or
she says, and his or her office phone. This should be very
entertaining.
>> The signs do not indicate a tumor in this case. This case is a
>> perfectly common and routine course of pneumonia in an elderly person.
>
>Give us a break, Steve. This is a slowly resolving pneumonia.
Which is indeed routine in the elderly. If by "slowly" you mean
still feeling unwell 3 weeks later.
> Your calling
>the radiologist an idiot doesn't change the facts. Read the
>literature and get back to us with some scholarship. YOUR OPINION
>means nothing.
More than yours, Ms. Anonymous. In fact, yours is coming to mean
less than nothing. You're rapidly becoming a negative weather vane.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Explain x-ray findings
Date: 15 Dec 1998 04:32:06 GMT
Ammoncircuits (aka, M. Anonymous) quoth:
> Sure, it is more likely than not that the slow resolution of his
>pneumonia is not due to tumor. Patients generally feel a bit queasy
>about doctors playing dice with their lives, though. In general, they
>like doctors to KNOW what is going on. A follow-up as recommended by
>the radiologist on the case is not in most physician circles a wild
>idea. It is simply good medicine.
Comment:
Okay, I looked briefly at the literature on medline. You'll be glad
to know that I found a couple of doctors who would agree with you, if
the followup period was 4-5 weeks (not 3). Alas, the data they present
from the view of working up the pneumonia patient does not back up
their final recommendations. Of 1011 patients hospitalized for
pneumonia (a particularly sick group) they found 13 who had lung cancer
diagnosed that way. But only 4 of these were found on follow-up X-ray
(rather than the initial one), and none of these benefited from the
diagnosis. That's 0 lives saved for 1011 follow up X-rays done, and
this causes the authors to note that X-ray was of no value in their
series for following up pneumonia, if the aim is detecting lung cancer.
Zero helped out of 1011. A bigger series, maybe? The actual number
must be considerably smaller, if it exists. What did you say the
figure was? Oh, that's right, you didn't. We can guess from this
study that you're expecting to X-ray AT LEAST a thousand people without
expecting to help even one. Worse still, even though not one of 1011
people pneumonia patients benefitted from finding a tumor on a followup
X-ray here, you want to X-ray the person asking for advice yet a THIRD
time, looking for a tumor. I would estimate your chances of finding a
study showing the utility of THAT to be REALLY low. But, hey, prove me
wrong.
So how many are you expecting to X-ray to save one, and how many
times each? 10,000? A million? Do you have a limit? It's also a
question for the doctors performing the study below, of course. It's
hard (nay, impossible) to prove a negative. But it's up to you to
prove a positive.
It seems the docs who did this study couldn't help themselves, so
they looked at it from the viewpoint of patients who did have lung
cancer diagnosed. In their series of 232, 12.5% of lung cancers are
found in patients with chronic respiratory infections who don't get
better. But how long was it that they didn't get better? They don't
say in the abstract, and I suspect it would be interesting to look (I
will). But more importantly (indeed, crucially), did the diagnosis for
this 12% do any of THEM any good, either? If lung cancer is 95% fatal,
how many of the 12% found by X-ray due to persistant infection of the
lung were (or would be expected to be) saved by X-raying them at 1
month vs (say) 2 or 3? Questions nobody seems to want to ask. But if
you recommend a test, you'd better have a good reason for it. I can
find none in this instance. If you're going to argue that X-rays
looking for cancer a month after pneumonia save lives, let's see your
evidence. There certainly isn't any below, so you'll have to find
something else. I've done my part.
Steve Harris, M.D.
N Z Med J 1998 Aug 28;111(1072):315-7
Scand J Infect Dis 1993;25(1):93-100
Association of pneumonia and lung cancer: the value of convalescent
chest radiography and follow-up.
Holmberg H, Kragsbjerg P
Department of Infectious Diseases, Orebro Medical Center Hospital,
Sweden.
A retrospective study of 1011 hospitalized patients with pneumonia was
undertaken to assess the value of routine convalescent chest
radiography for detection of underlying lung cancer. To investigate the
mode of clinical onset of pulmonary carcinoma, 232 inpatients with this
diagnosis were also studied. The findings may be summarized as follows:
1) 13/1011 pneumonia patients were found to have previously undiagnosed
pulmonary carcinoma; 2) many of these carcinomas (8/13) were disclosed
by an acute chest X-ray; 3) pulmonary carcinoma was found by
convalescent chest X-ray in 2/88 patients not feeling well and in 2/524
patients feeling well at follow-up, and none of these 4 patients
benefitted from the carcinoma diagnosis; 4) ESR was of no value in
detecting underlying pulmonary carcinoma at follow-up in patients with
pneumonia; 5) of the 232 patients with pulmonary carcinoma, 29 (12.5%)
presented with an acute respiratory tract infection; 6) most of these
latter patients did not recover as expected and their correct diagnosis
was made based on a chest X-ray performed because of persistent
symptoms. We suggest that patients with radiologically verified
pneumonia undergo clinical examination or are interviewed 4-5 weeks
after the onset. If signs or symptoms of respiratory disease persist,
chest X-ray should be performed. We consider, however, that routine
convalescent chest radiography with the aim of detecting any underlying
pulmonary tumour could be omitted if the patient has completely
recovered 1 month after the acute onset of illness.
PMID: 8460356, UI: 93212288
----------
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Explain x-ray findings
Date: 17 Dec 1998 09:15:34 GMT
In <7594fs$aa7s$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
<MBILLIK@prodigy.net> writes:
>Well, here's the latest, as of today (12/16/98).
>U of M Hospital called.
>The 3rd x-ray was completely normal.
>So, it looks like at least on film the pneumonia is resolved.
Comment:
I'm terribly surprised. It could have been a TUMOR, you know. You
really had time to have a fourth X-ray if you hadn't sat on your butt.
Or that spiral CT. Maybe a bronchoscopy while you had the chance.
But you blew it.
Sorry if it looks like I'm having fun at your expense, but I did
want to use this case illustratively, for education. Pity that the
lesson is likely to be lost on those who most need it. I'm sure you've
learned something, anyway.
>I have to repeat one blood test.
>My WBC came back at 3.6 (low end of normal is 4.0).
Ah ha! I knew with enough tests, we'd find something else. Quick,
a bone marrow biopsy. It could be *leukemia.*
>The doc said they did a differential or ratio (I can't remember the exact
>term) and that was normal and there were no immature white cells. But,
>she would like to repeat the test.
Yep-- see. With luck the repeat won't find the same problem, but
it will find something further. God willing.
>My symptom remain: cough. She gave me Zirtek in case it is due to back
>nasal drip. It might be helping somewhat. But it sure makes me even more
>tired, more fatigued, and more sluggish. I am supposed to stick with that
>for a week and see if the cough improves.
Or until you get some worse complication from the Zyrtec. This
case makes me happier and happier. Are you thinking of driving
anywhere?
>General malaise -- I keep getting sweats/chills, nite sweats (no longer
>as severe as they were) and the general feeling of coming down with
>something.
>
>Now, I have heard that even after pneumonia you might feel like crap for
>up to 3 months, but I was told this would be a tired, exhausted feeling.
>I have that, too, but the sweating and `coming down with something
>feeling' is what concerns me.
>
>OK, it has been great having medical folks comment here on the bb. Any
>comments on what is going on now??
No, you need more lab tests. Many, many more lab tests. Yessssss.
More Lab TESTSSSS.
>ALSO, IS THIS STILL SLOWLY RESOLVING PNEUMONIA???
>I mean, the x-rays are clear so maybe it is resolved and this is something
>else???
Chronic anxiety, perhaps. But that's a diagnosis of exclusion.
First, more LAB TEEEEESSSSTSSSS.....
BWAHAHAHAHAH.
Dr. Evil
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Explain x-ray findings
Date: 17 Dec 1998 09:56:20 GMT
In <3676FDEF.38@lucent.com> Martin Braff <braff@lucent.com> writes:
>Steven B. Harris wrote:
>
>>
>> For sure. Followup X-rays for pneumonia usually cause more
>> problems than they solve, since they trail clinical cure by so many
>> weeks (even months).
>
>Are you concerned about the harm caused by the radiation, or some
>other problem? What is the risk associated with chest x-ray?
>I've always thought that the risk is extremely small like one in
>a million will cause cancer. I've also seen people in the
>hospital with pneumonia get follow-up chest x-ray every day for a
>month.
Really sick people in the ICU on ventilators, perhaps. But this is
an outpatient, slowly getting better, who just doesn't feel well as
fast as he wants to. Well, patience is a virtue.
Yes, I'm concerned about radiation, but that's the least of it
(that risk is very small). There's cost, and there's inappropriate use
of resources (radiologists are paid almost as much as surgeons, for
reasons which this case illustrates very well). And there's the very
real danger that further workup will uncover some benign anomally which
will snowball into some more invasive workup, a wrong or irrelevent
diagnosis, and the prescription of multiple drugs, one of which is
bound to have some side effect which will start it all rolling again.
And all because the patient and his doctors just had to DO something.
Well, when you're getting clinically better (even if too slowly for
your liking) you don't necessarily have to DO something. Tincture of
time is the best of the homeopathic remedies. It's available at any
drugstore, USP approved, and you don't need a prescription (alas). I
wish more doctors wrote them, though.
>> And radiologists trying to cover their fannies in
>> case of the rare lawsuit for the rare tumor don't help (gosh, anybody
>> with pneumonia COULD have a TUMOR, right?
>
>Why bring up tumors? Wouldn't the concern be whether the antibotics
>given were effective, or do other antibotics need to be tried.
I didn't originally bring up tumor. But X-rays help tell only tell
you when antibiotics are manifestly failing, and then usually in cases
where you very well knew that anyway, from the vital signs, the
oxymetry, and what the patient looks like today vs. yesterday. FURTHER
X-rays don't help you with antibiotics when your outpatient has
recovered partially from acute pneumonia clinically, and almost
certainly not when you even have evidence of improvement on X-ray.
Indeed, if misused, X-rays may tempt you into prescribing some other
antibiotic that doesn't help (since there's no bacteria in the lung
left to kill), but is expensive, causes population microbial resistance
(gut flora), and has all kinds of chances for side effects of its own.
Come on. Cases like this are why Naturopaths exist. And thrive.
They feed on the produce of radiologists and bad internists. If
anxious patients didn't get orthodox physicians to overtest and
overtreat them every day, we'd hardly have as much hue and cry for
alternative medicine, on the basis of the iatrogenic harm that orthodox
medicine sometimes does, and the absolutely humongous expense that it
generates. Most alternatives are NOT out there making a living by
treating and curing dying people who conventional medicine has given up
on. Not by a long shot. They're out there treating anxiety, and
treating orthodox medicine's mistakes by simply pulling the plug on the
merrygoround for certain people who are stuck on it. Wouldn't it be
nice if we orthodox doctors left them with less to play with?
>> chance of curing somebody with pneumonia because you found that
>>tumor 2 months early is...?). A slow recovery from pneumonia (a
>>few weeks) is not a good reason for re-X-raying people, especially
>>elderly people.
>
>This guy is only 52. Do you consider consider that elderly?
Comment:
Well, I'll have to look at said 52 year old to tell you <1/2 g>.
That's only a half grin because there's a half-truth there.
I can say, sight unseen, that most people, at 52, have figured out
from their medical responses that they're no longer young, and their
recovery from disease is VERY different now.
>> Only if somebody has not recovered after several MONTHS (not weeks), or
>> shows signs of going back downhill, are you really forced to start
>> looking again.
>
>If you just wait months, how would you know for all that time whether
>you are treating with the correct antibotic? If you wait for them to
>go back "downhill" could it be to late at that point?
>
>Marty Braff
No. First of all, you wouldn't treat them with an antibiotic for
months (usually). Long before, you'd stop and see how they did off
medication. And again, you don't use serial chest X-rays to tell that
your patients are recovering from their outpatient pneumonias. If you
do, you're asking for trouble. And getting (at minimum) expense and
hassle.
Of course, you don't have to believe me. Apparently Ammoncircuits
gets very different results in his/her busy internal medicine practice.
;-! So who knows?
Therapeutic Nihilist
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med,alt.support.anxiety-panic
Subject: Re: Explain x-ray findings
Date: 18 Dec 1998 07:08:18 GMT
In <36791C54.F3891A65@thegrid.net> Gordon Held <gheld@thegrid.net>
writes:
>"Steven B. Harris" wrote:
>
>> Most alternatives are NOT out there making a living by treating and
>> curing dying people who conventional medicine has given up on. Not by
>> a long shot. They're out there treating anxiety, and treating orthodox
>> medicine's mistakes by simply pulling the plug on the merrygoround for
>> certain people who are stuck on it. Wouldn't it be nice if we orthodox
>> doctors left them with less to play with?
>
>Steve. In a previous post on a different subject you have said that all
>your patients except the anxious ones have your 24 hour beeper number if
>they need emergency prescription refills, etc.
>
>I wondered then and even more so now how you handle the needs of your
>patients suffering from anxiety. It seems to me that they, of all your
>patients, might need help at any time.
I hope I really didn't write that ALL my patients get my 24 hour
beeper number, without inserting some sort of qualification. Needless
to say, they all don't. The ones I decide after a while have good
judgement, do. People whose primary problem is anxiety certainly
don't. I'm just one person, and I need to sleep. That's what we have
rotating call schedules for, don't you know. And answering services.
You know what killed the housecall in American medicine? The
hospital ER helped, but the real killer was the telephone. It used to
be that if your patient wanted you badly enough for a housecall, then
HE had to make a housecall to let you know it. The situation now is
assymetrical. And with beepers it can get far worse.
>Maybe this is why the alternative healers have found an ever increasing
>market.
>
>Do you just let the panic people wait until office hours, go to the ER
>and get xray, tests, etc., or what?
>
>Gordon Held
No, I treat them with the appropriate anxiolytics, and if they
won't take them, or they can't find one that works, I refer them to the
appropriate psych specialists. Who, I assume you, do not give them
their 24 hour beeper numbers either.
It was Oscar London, M.D. who said it best: "If you won't give your
patients Valium, you'd better take it yourself."
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE (WAS EXPLAIN X-RAY FINDINGS)
Date: 19 Dec 1998 07:10:13 GMT
In <75esmh$ateg$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
<MBILLIK@prodigy.net> writes:
>Well, I may have jumped down Steve's throat, but it sure does look like I
>am headed for more and more tests.
>
>Recap: Had pneumonia. Last x-ray showed it resolved. Still not feeling
>well at all. Lots of nite sweats. Cough still there and spasmatic
>although getting slightly better.
>
>Main finding: WBC was 3.6 (normal is 4-10 and it was 6.5 at routine
>physical 2 months ago).
>
>Test was repeated today. Doc has indicated that if it is not improved, I
>will be "referred to hematology for a bone marrow biopsy." If it does go
>back up and I'm still feeling bad, a CT scan of the abdomen to look for
>swollen lymph nodes might be done (however, she considers this a poor
>yield possibility so maybe won't do it).
>
>They are the experts (U. of Mich. Med. Center) but I really do seek the
>advice of some of the pros on this bb as I'm sure my opinion will be
>taken into consideration. Can someone offer some general thoughts?? I
>gather Steve H. considers it foolish to go further???
>
>
>Mel
Probably. What are the odds you just developed TB of the bone
marrow or aplastic anemia or something in the last two months?
Since you already have the info, can you give us the differential
of your last two white counts? Absolute neutrophil counts, lymphocyte
counts, and so on? Was a manual differential done so that bands could
be counted? How are your platelets? There's a big difference between
having a low white count because of low neutrophil production (which is
worrysome), and having one because of low lymphocyte numbers (which can
happen after a month of eating poorly because you've been ill).
A bone marrow biopsy? Sheesh. As sarcastic as I've been about
this case, the reality seems to be pretty much tracking me.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE (WAS EXPLAIN X-RAY FINDINGS)
Date: 20 Dec 1998 10:50:52 GMT
In <75gpkl$3nlq$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
<MBILLIK@prodigy.net> writes:
>I don't have the answers to your questions. I do know that the doc said
>that although the WBC was low that the differential was "good." That was
>one conversation.
>
>The next one was when she was talking about the bone marrow bx. depending
>on results of this repeat test.
>
>I've printed out your post and will bring up these questions when I see
>her on Wednesday. I think I might ask to at least talk to a hematologist
>before going thru the bone marrow bx.
>
>Mel
Have the hematologist have a look at the absolute numbers again.
The drugs you've been on for a long time (azithromycin/Zithromax,
clarithromycin/Biaxin) are macrolide antibiotics in the erythromycin
class. They're all rarely reported causes of agranulocytopenia, where
the white count drops due (mainly) to underproduction of neutrophils,
your most common granulocyte. Your hematologists may be unaware of the
reports below, which suggest that other people have seen things like
you have, due to the drugs you've been on. This is the kind of thing
where you wait a couple of weeks weeks to see if your counts come back
up. If they do, you remind yourself never to take drugs in this class
again. When it happens, it's probably an allergic thing. A bone
marrow biopsy, if this is what you have, won't tell you zip.
In medicine, there's a rule about causes of odd symptoms, called the
"FTD Rule". First, Think Drugs. I drum this into the residents I
teach. Your patient is more likely to be having a complication of your
treatment than a complication from the disease, if the complication
arose soon after your treatment started. Even if you can't find that
complication in the PDR. That rule has saved me many an
embarrassment. And I regret to say that a large fraction of the best
and most dramatic saves I've performed in medicine have been correcting
the side effects of treatments of other doctors, and those of my own.
Sad but true.
Steve Harris, M.D.
Am J Hematol 1995 Feb;48(2):133
Agranulocytosis induced by macrolide antibiotics.
Tanaka M, Tao T, Kaku K, Kaneko T
Publication Types:
Letter
PMID: 7847332, UI: 95149985
----------
DICP 1991 Oct;25(10):1136
Erythromycin-induced agranulocytosis.
Pastor E, Linares M, Grau E
Publication Types:
Letter
PMID: 1803807, UI: 92206045
----------
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE (WAS EXPLAIN X-RAY FINDINGS)
Date: 21 Dec 1998 20:59:55 GMT
In <75m8h4$8mao$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
<MBILLIK@prodigy.net> writes:
>Dr. Harris:
>
>Here is the information from Friday's re-test. I was quite stunned as
>all the figures look VERY normal (some are low):
I don't see any that are low-- which do you mean? In medicine,
"low" means below the lower end of normal range. Figures below the mid
point of the range mean nothing. Melvin, somehow you'll forgive me if
I'm NOT stunned. Again, this case is a nice one for illustration of
medical principles. Though doofuses like Ammoncircuits will certainly
not profit by it.
>WBC 6.7 [4.8-10.8]
>RBC 4.70 [3.6-6.1]
>HEMOGLOBIN 14.6 [14-18]
>HEMACRIT 42.5 [42-48]
>MCV 90.3
>MCH 31.1
>MCHC 34.4
>RBC DIST WIDTH 13.3
>PLATELET COUNT 267
>
>(THE LAST 5 WERE NEAR THE MIDPOINT OF THE RANGE)
>
>The WBC Differential:
>
>type -- automated
>
>auto lymph 28
>auto mono 7
>auto gran 60
>eosinophil (auto) 3
>
>(THESE LAST 4 WERE NEAR THE MIDPOINT OF THE RANGE)
>
>basophil (auto) 2 [0-2]
>
>Which one is the neutrophil count?
The "gran," which stands for granulocytes is here the neutrophils.
The lab is actually using the word in a bit of a nonstandard way,
technically, as basophils and eosinophils (which they count separately)
are also granulocytes. But neutrophils is what they mean.
>I wonder if that reading of 3.5 at the U. of Mi. was a flat-out
>mistake?
Probably not, if you had two quite low counts, which you did. I
would then suspect a drug reaction to macrolides, but a "hand"
differential (which counts young neutrophils by having a lab tech do
it-- since a machine can't) would have been useful to tell that. What
you have in an "auto" differential, which doesn't make any distinction
between young and old neutrophils. Lots of young ones suggests they're
being made fast. Low counts then can due to high use (residual
infections, etc). Low counts with no young cells suggests
underproduction, as in marrow toxicity from drugs. Again, if I were
you I probably would stay away from erthyromycin, Biaxin, or Zithromax.
If you ever MUST have them (ie, you're dying of mycoplasma pneumonia or
something), regular CBC's are in order to track your response.
> Can the figures change so dramatically?
Sure. Neutrophils last only a few hours in circulation, and counts
fluctuate wildly as they stick on your lung capillaries, or come off,
in response to stress/epinephrine.
>I don't think a bone marrow bx. is in the picture at this point (?).
I would certainly think not. Unless your hematologist needs to pay
off the Christmas credit card load.
>A ct scan -- they are talking about it, but ...
>Mel
Radiologists have those same holiday debts, don't you know.
Tincture of time, Mel. Tincture of time. Happy holidays.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE (WAS EXPLAIN X-RAY FINDINGS)
Date: 22 Dec 1998 03:07:30 GMT
In <75mbhv$n7b$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>In article <75fjgl$8ca@dfw-ixnews5.ix.netcom.com>,
> sbharris@ix.netcom.com(Steven B. Harris) wrote:
>> In <75esmh$ateg$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
>> <MBILLIK@prodigy.net> writes:
>>
>>
>> >Main finding: WBC was 3.6 (normal is 4-10 and it was 6.5 at routine
>> >physical 2 months ago).
>> >
>> >Test was repeated today. Doc has indicated that if it is not improved,
>> >I will be "referred to hematology for a bone marrow biopsy." ...
>> >
>> >They are the experts (U. of Mich. Med. Center) but I really do seek
>> >the advice of some of the pros on this bb as I'm sure my opinion will
>> >be taken into consideration. Can someone offer some general thoughts??
>> >I gather Steve H. considers it foolish to go further???
>
>Ofc!
>
>> A bone marrow biopsy? Sheesh. As sarcastic as I've been about
>> this case, the reality seems to be pretty much tracking me.
>
>Feelin' lucky, are you?
I'm sure you think I've been very lucky, here. Alas, you're wrong.
It's not luck when your opinions result from having been there, done
that.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE (WAS EXPLAIN X-RAY FINDINGS)
Date: 23 Dec 1998 20:30:10 GMT
In <75qpgr$c8c$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>> Melvin, somehow you'll forgive me if I'm NOT stunned. Again, this case
>> is a nice one for illustration of medical principles. Though doofuses
>> like Ammoncircuits will certainly not profit by it.
>
>
>Pot calling the kettle black, Harris. You have no doubt forgotten
>your arrogant post just recently indicating your absolute amazement at
>medical principles being demonstrated by just ONE case.
Comment:
Ahem, I used the word "illustrated," not the word "demonstrated."
And I use illustrated only in the pedagogic sense. I'm not under the
impression that anything has been scientifically demonstrated by this
case. This case is simply a nice starting point to show general
principles.
Crobbers:
> Try and see if you can't
>rearrange things so as to place your brain in the normal anatomical
>configuration; it appears to have somehow become disconnected from
>your Broca's area.
Hey, I didn't use the wrong word above-- that was you misquoting me.
And fluent aphasia wouldn't be Broca's aphasia anyway.
Crobbers:
> Since Mr. Billik is still feeling
>puny and experiencing night sweats, I might at least do an ESR - if
>not a blood culture - to determine if the night sweats are not a
>result of continued bacteremia.
Continued bacteremia from what source? Not his clear lungs, one
presumes. If you're looking for endocarditis it might be much easier
to start by seeing if he's febrile at night, and has a left shift in
his white count (bandemia). And TB skin tests are cheap.
Crobbers
>Our disagreement has more to do with whether physicians should rely on
>testing or upon intuition for planning a patient's treatment regimen.
>Most of my colleagues - and attorneys - would consider it negligent
>practice to rely on intuition.
One man's intuition is another's clinical judgement. You need some
way of even deciding which tests to order, or otherwise you'd order, or
prepare to order, nearly every test on every patient, and miss ordering
obvious ones where they're needed. As this case *illustrates*.
> I am happy to see that Mr. Billik's physician is not so negligent.
Sigh. Mr. Billik's physicians managed to X-ray him three weeks
after pneumonia, and then talk about CTs when they didn't see a clean
X-ray (big surprise), thereby causing him much anxiety and the need for
yet another X-ray. They also managed to do a CBC in a patient presumed
to be infected, and yet not get a hand differential. THEN proceed to
cause the patient MORE undue anxiety by talking about a bone marrow
biopsy (!) before anything was confirmed, or any reasonable waiting
period after illness had ellapsed. I can't diagnose negligence or
incompetence here without a lot more information. But physician
overwork, overanxiety, and undue fear of lawyers is certainly in the
preliminary differential. All very bad things.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE (WAS EXPLAIN X-RAY FINDINGS)
Date: 24 Dec 1998 21:27:56 GMT
In <75td2i$gqb$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>> > Since Mr. Billik is still feeling
>> >puny and experiencing night sweats, I might at least do an ESR - if
>> >not a blood culture - to determine if the night sweats are not a
>> >result of continued bacteremia.
>>
>> Continued bacteremia from what source? Not his clear lungs,
>
>Hmmm. Let's see if we can't work on this one together, Harris. Did not
>Mr. Billik have a pneumonia? Were not bacteria the cause of that
>illness? Yes, he has clear lungs, NOW, but have you not ever seen a
>bacteremia that did not involve a pneumonia as well?
I think you'll have to disentangle that last sentence. I've seen a
lot of bacteremia with and without pneumonia. Most pneumonia doesn't
involve bacteria even when active (H. flu less than half the times, the
others far less). Bacteremia from a resolved pneumonia is very rare,
indicating a second nidus.
>(And HOW long have you said you've been in practice?) Could he have a
>murmur that we haven't heard about? Do we know that his regimen was
>sufficient to clear a bacterermia? I submit that we do not, and instead
>of guessing as you are so wont to do, I would recommend that he be
>tested. The test recommended is not the draconian bone marrow biopsy -
>that has been shown to be unwarranted.
>
>> one presumes.
>
>Guesses.
Hey, you're the one doing it as well (see your previous paragraph).
I wouldn't be so quick to label your own thought processes with such
loaded words.
>> If you're looking for endocarditis it might be much easier
>> to start by seeing if he's febrile at night, and has a left shift in
>> his white count (bandemia). And TB skin tests are cheap.
>>
>
>TB? Do you have a reason to think he has TB other than night sweats?
Not at the moment, but that's reason enough to screen for TB. It's
reasonable to screen for TB in anyone, so surely it's reasonable to
screen in someone with nightsweats.
>Aren't there other causes of night sweats? Why didn't you mention
>those?
Because it does no good to re-type stuff from textbooks of
differential diagnosis of symptoms. I don't have the time. The TB
test is the cheapest test I can think of for any of the things in this
differential, and the only one indicated even for people with NO
symptoms (if they haven't had one recently). If you disagree, please
be specific.
>One doesn't do tests, Harris, just because they are cheap.
No, but of the tests that help in your differential, you do the
cheapest ones first. Here, the TB test and diurnal temperature
charting and hand differential.
>> You need some way of even deciding which tests to order, or otherwise
>> you'd order, or prepare to order, nearly every test on every patient,
>> and miss ordering obvious ones where they're needed.
>
>As I suggested, the general accepted method of making these decisions
>is based on a knowledge of how to form a differential diagnosis from a
>list of symptoms and the specific optimal means of testing to rule out
>or in the various diagnoses in the differential. It is considered
>negligent medical practice to simply ignore diagnoses in the
>differential, most especially when what is
>ignored might have draconian consequences - like cancer, for example.
You don't know what the hell you're talking about. Cancer is in the
differential of half the symptoms you see as an internist, but the
cause of only a tiny fraction of them (it's a cause of only a tiny
fraction even in geriatrics-- perhaps surprisingly, since incidence of
cancer rises exponential with age). And tests looking for cancer go
from the cheap (stool guaiacs to pap smears) to the more expensive
(X-rays) and invasive (endoscopy) and exotic (certain isotope scans,
anti-malignane antibody titers, etc). The medical profession itself,
as well as the American Cancer Society, has a continuous debate about
which of these are useful and when (example: PSA screening). Don't
pretend that it's not appropriate to "ignore" things on a differential.
If you don't ignore things on a differential every day, you'll last
about 2 weeks as a doctor before your partners, HMO, and certainly your
patients, give you the heave-ho. As you'd know if you'd ever been
there (which, for all I know, you have).
> I have never seen a physician as cavalier as you about your
>patients' well-being.
Why do we care what you've seen? We have no reason to think you've
seen anything.
>No, this case does not even *illustrate* the order or preparation to
>order EVERY test even on Mr. Billik. Mr. Billik's doctor ordered a couple
>chest x- rays and two blood tests to follow-up on Mr. Billik's continuing
>symptoms. The first chest x-ray was abnormal, requiring a follow-up;
The first should not have been done. Mr. Billik could just as easily
have waited 6 weeks for the second one, if his symptoms and tests had
suggested continued infection.
> the second chest
>x-ray let the doctor know that continued pneumonia was not the
>problem. (The doctor did not rely on a guess.)
I really have no argument about ONE more X-ray in a patient with
symptoms as long as Mr. Billik has had them. But then I never did.
> The first blood test was abnormal, upon
>which the doctor appropriately explained to Mr. Billik what further
>tests MIGHT be needed provided the second blood test was similarly
>abnormal.
No, that's not appropriate. It's appropriate to say the first test
wasn't normal, and that it simply needs to be repeated before there is
any talk of more serious matters. You do not, on the basis of one
routine lab test, show your patients the possible darkest diagnostic
pathways they may have to tread, provided some further test comes out
one way or another. Unless you want them all to climb the walls.
Again, if you do this, you are a LOUSY doctor. Of course, you do not
understand this, crobbers. Either because you aren't a doctor, or you
ARE a lousy doctor.
>The second blood test was not abnormal, making those other tests
>unnecessary. You see how this is done, Harris?
No, crobbers, I'm afraid it is YOU who does not see how this is
done.
> All very logical - and better designed for
>the welfare of the patient than the hit and miss method you seem to
>use.
I do not use hit and miss methods.
>> > I am happy to see that Mr. Billik's physician is not so negligent.
>>
>> Mr. Billik's physicians managed to X-ray him three weeks
>> after pneumonia,
>
>Twice was what I understood.
>
>> and then talk about CTs when they didn't see a clean
>> X-ray (big surprise), thereby causing him much anxiety and the need
>>for yet another X-ray.
>
>I doubt that any anxiety Mr. Billik experienced was due his doctor's
>answering his questions about the possible causes of his continued
>feeling of ill health and indicating that there was a plan in place to
>track down the problem and solve it.
No? Then he should have been even less anxious had his doctor
kindly indicated to him that if the new X-ray showed a mass, and the CT
they were planning in that case confirmed it, he might have to undergo
a needle biopsy of his chest. And something about how this is done.
So helpful to know there's a plan in case of the worst, don't you
think, crobbers? The more of this you do, the less anxious your
patient is, right?
>We all know who have visited this group for some time that you have
>a deep aversion to informing your patients, believing chiefly that
>they aren't bright enough to understand explanations of their
>conditions.
If I had a miserable aversion to imparting my knowledge of medicine
to people I'd hardly be on this group at all. You think I behave
differently with my patients? But I do admit to being selective about
bringing up rare and nasty possibilities until I have to. I think my
patients appreciate that. I do know a few doctors who really should be
on Xanax who really do paint all the worst possibilities long before
there's any real reason to do so. Their patients go bananas.
> Most doctors, though, make the attempt - not only because it is the
>law, but because it is the right thing to do.
Spare us from your explanations of what most doctors do. There is
no evidence that you have a clue as to what most doctors do.
>> They also managed to do a CBC in a patient presumed
>> to be infected, and yet not get a hand differential.
>
>Did they not get it or just not report it to Mr. Billik immediately?
No, they didn't do it. Period. Is there some difficulty with your
reading ability? Do you know what a hand WBC differential is?
>> THEN proceed to
>> cause the patient MORE undue anxiety by talking about a bone marrow
>> biopsy (!) before anything was confirmed, or any reasonable waiting
>> period after illness had ellapsed.
>
>As I said, I do not believe that this caused Mr. Billik any undue
>anxiety.
Then you are completely clueless. Have you been reading Mr.
Billik's notes here and haven't understood even this? You must have
the EQ of a tomato.
>> But physician
>> overwork, overanxiety, and undue fear of lawyers is certainly in the
>> preliminary differential. All very bad things.
>>
>Not as bad as your speculative heuristic model of diagnosis.
Using words you don't understand again. Tut, tut.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE (WAS EXPLAIN X-RAY FINDINGS)
Date: 27 Dec 1998 05:41:21 GMT
In <762mk9$evn$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>Well, now, how about if you were to take a culture and find out whether
>any bacteria that grew there is the very same bacteria that caused Mr.
>Billik's pneumonia. Hey! Not a bad idea, eh?
A bad idea if we don't know in the first place what organism caused Mr.
Billik's pneumonia. Which we don't.
> What if it's different? Well, I'd like
>to treat you to a remedial course in infectious disease, but I am
>concerned about your inability to absorb the information.
There is no evidence you have any information to impart, crobbers.
>> > > I've seen a lot of bacteremia with and without pneumonia. Most
>> > > pneumonia doesn't involve bacteria even when active (H. flu less
>> > > than half the times, the others far less).
>> >
>> > So? We're not talking about MOST. We're talking about Mr. Billik, here,
You treat your patients based on probabilities. Mr. Billik is not
in the index of my medical texts. Since there are are no medical
papers written about Mr. Billik's lungs, we have to do the best we can,
based on statistical experience with other patients.
Bacteremia, when it occurs with pneumonia, is generally associated
with the early phase of the disease, before antibiotics are started.
It's not something likely to be found in an outpatient whose been on a
long course of antibiotics, and long after their lungs are clear. The
very idea demonstrates your crass ignorance.
>> But we never confirmed it was a bacterial pneumonia.
>
>Give yourself and all of us a break, Eddie.
>
>> Could have been viral.
>
>Do antibiotics clear viral pneumonia? That's a new one.
We do not know that antibiotics cleared Mr. Billik's pneumonia.
All we know is that after quite a few weeks, it got better. You do
understand the difference, I hope. But maybe not. Was it you who was
trying to lecture me on what single cases "demonstrate"? I seem to
remember it was.
>> And if it were bacterial pneumonia that resolved with said effective
>> antibiotics, what is the source of the bacteremia now oh knowledgable
>> one?--
>
>I have already suggested means to discover what the cause is. To
>state the obvious for you, bacteremia is not the same disease as
>pneumonia. Perfectly reasonable to suggest that while the antibiotics
>were sufficient to clear the pneumonia, they were not sufficient to
>clear a bacteremia.
Not at all "perfectly reasonable," if the bacteria causing one are
the same as as the other. Bacteremia in pneumonia (when present)
clears first during treatment, usually within a day or two (usually
corresponding to the patient becoming afebrile). It does not persist a
month later as your outpatient comes to you with a clear chest X-ray.
Once again you demonstrate your complete and utter lack of undersanding
for the way this disease presents.
>Perhaps if you had ever been entrusted with the care of very sick
>patients, you could have assimilated this bit.
Had he assimilated any such thing he would have been wrong. Being
entrusted to the care of sick patients is not the same as deciding how
to treat them. Once again, you come across as a megalomanical nurse,
crobbers. Spare us.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Medical Mafia (was ~ Update on X-ray findings)
Date: 28 Dec 1998 09:18:46 GMT
ammoncircuits@my-dejanews.com/CRobbers writes:
>So? We're not talking about MOST. We're talking about Mr.
>Billik, here, who, for whatever reason, just MIGHT be one of
>those who does not behave as the majority of patients do. I
>know you've heard of statistics, so try to reason from the fact
>of and reason for its existence. Statistics is essentially a
>guessing game, as you might know if you thought about it, and
>you are only making your usual attempt, here, to guess from the
>majority to the individual case. Surprising as this may seem to
>you, this is as much an error as guessing FROM the individual
>case.
Surprising is right. Because you're simply wrong. Testing in
medicine must be partly based on prior probability, because
without this you have no idea of the predictive value of what
your test tells you when you get the answer back, even if you
know how good (sensitive and specific) your test is (see Bayes'
theorem). In practice it's even harder, since your tests are
often not fully validated in the population you're using them in
clinically-- a particular problem in my field of geriatrics.
You do not do tests in medicine because there is some tiny
chance that you might find something. Something which isn't, to
begin with, very common or likely. If you did that, you would
run the risk of:
1) Causing harm to YOUR patients by doing tests have their own
dangers (not the least of which is false positives, which may
lead to further tests and on to invasive or dangerous
treatments), and
2) Causing harm to other patients by wasting valuable resources
which are otherwise available for treating things which are more
likely to help people.
Examples abound. I've already mentioned the very large study
which found absolutely no benefit to yearly screening chest X-
rays in smokers over 45. Tumors were found earlier, but it made
no difference in survival, since the slightly smaller tumors were
just as likely to have metastasized. And it cost a LOT to do
that screening, for all the time it was done without any good
rationale (indeed, with nothing but the sort of rationale you
argue). That money could have been used in Canada to vaccinate
children, or something. You can NEVER assume that an expensive
or unusual or invasive test is a good one to do automatically,
just because you can imagine your patient *might* have the
disease. Not until you have better evidence that doing such a
thing does people any good.
>Your error is like tossing a penny 99 times and getting heads
>every time and betting your (rather Mr. Billik's) bank account
>that your next throw will turn up tails. Mr. Billik
>is not a penny.
Nope, that's your error. You want to go looking for things
which aren't likely, and the search for which may cause harm to
your patient and will certainly waste resources if you make it a
policy (thereby causing harm to many patients).
>He is an individual human being who is still sick and wants
>to know why so that if he needs further treatment, he can get
>it. He doesn't need your guesses.
ROLF-- I suppose he needs yours? Because that is what you
are doing--- guessing without any clue about probabilities. Just
like any 3rd year medical student. If you've heard about it,
order a test for it. Except the real world doesn't work that
way. Practicing medicine that way leads to disaster.
>The difference between you and me is that I am not
>recommending that we leave it at guessing.
Yes, actually, you are. The difference between you and me is
that you are too ignorant to understand what you're doing, and
that you'll still be guessing wildly even if you do your tests in
these circumstances.
Is 99 F your definition of fever? That's unique. Perhaps you
should write a paper suggesting this new cutoff for the New
England Journal, and the Chris Robbers technique of blood
cultures for tired people who tell you they have such a
temperature, looking for atypical subacute endocarditis. So you
don't have to guess that this isn't what they have <g>.
>>>Aren't there other causes of night sweats? Why didn't you
>>>mention those?
>>
>> Because it does no good to re-type stuff from textbooks of
>> differential diagnosis of symptoms.
>
>Interesting excuse. How much time does it take to refer to a
>textbook table?
Little. Are you recommending that that's what I should do? I
have textbooks of medicine-- many of them. How about you? The
broad categories, which you don't need a table for, are infecti-
on, malignancy, autoimmune disease. In geriatrics, BTW, it can
be TB or even odd things like esophagitis and polymyalgia
rheumatica/giant cell arteritis. But that's for true verified
fever. Not a guy who tells you his temp is 99 F once. Here,
the texts don't help you. All you can do is wait. And do no
harm.
Crobbers
>>One doesn't do tests, Harris, just because they are cheap.
Harris:
> No, but of the tests that help in your differential, you do
>the cheapest ones first.
CRobbers
>No, _I_ don't, nor do most of my colleagues.
Comment:
Then your "colleagues" are fools. Not that I think you have
any colleagues. You're an anonymous dweeb on the nets, remember?
The only colleagues of Trolls on the net, would have to be other
Trolls.
Colleagues in medicine are what you call real physicians whose
relationship to you, as a real physician, is one of openness and
mutual respect. Phantoms cannot have those. As an impersonator
of a real physician, I would imagine that your *peers* would
probably be mostly in jail, if they've been caught. As for
colleagues, you have none.
>I do the tests that will tell me about the most likely or urgent
>causes first.
So do I. Alas, this is not an urgent case. It's an
outpatient writing after 2 months of slowly diminishing symptoms,
following an acute illness.
As for most likely causes, you do not always test first for
those either, if the test is unpleasant and/or expensive. For
example, one does not endoscope ALL people who come to you with a
set of symptoms that are most likely caused by ulcer. Again, you
are clueless as to how good medicine is actually practiced.
Crobbers
>I don't do tests because they are cheap.
No one suggested you should. You do the cheapest and easiest
test that will give you usable information. It's bang for buck in
medicine the same as anything else. The tests you order and the
sequence in which you order them may not be the same as your
judged likelihood of what the problem may be. Nor the same for
inpatients and outpatients. Technology, cost, time,
invasiveness, patient preference, and penalty for a missed or
delayed diagnosis, and for test error, always constrain and limit
workups in one way or another in the real world.
Crobbers
>As I suggested, the general accepted method of making these
>decisions is based on a knowledge of how to form a differential
>diagnosis from a list of symptoms and the specific optimal means
>of testing to rule out or in the various diagnoses in the
>differential.
Yawn. Yes. But the devil is in the details of that word
"optimal," as noted above.
>It is considered negligent medical practice to
>simply ignore diagnoses in the differential, most especially
>when what is ignored might have draconian consequences - like
>cancer, for example.
>> You don't know what the hell you're talking about.
>No, it's YOU that doesn't know what I'm talking about. Sad
>fact.
No, the sad fact is that you're here pretending to be a
doctor, when it's obvious that you're clueless. For example, a
stomach pain which responds to antacids might be cancer. But for
guaiac negative patients you may, as current standard of
practice, ignore this possibility until you've treated the more
likely causes and failed. Nor do you tell your patient he might
have cancer of the stomach (but probably not). Odd presentations
of very common problems are often more likely than less common
problems. When I used the word "ignore" I wasn't intending to
imply that you ignore certain differential possibilities forever.
Rather, you ignore them for the time being. That tincture of
time saves you and your patient an infinite amount of trouble, as
our friend Mr. Billik's problems illustrate. And you don't tell
the woman with 3 days of painless hematuria she might have renal
stones or bladder cancer, either, Crobbers, until you've looked
at other more likely possibilities. Just in case you didn't get
the point of our previous discussion.
Harris
>> Cancer is in the differential of half the symptoms you see as
>>an internist,
>Like I said, YOU don't know what I'm talking about - or, in this
>case, what you're talking about. That's not surprising. One
>puts in the differential what one has an index of suspicion to
>put in it, so cancer is NOT in the differential of anywhere near
>half of what internists see.
Word games. A differential is as long as you like, depending
on where your probability cut-off is. The point is that you
only concentrate on the most likely things, and you ignore the
rest for the time being.
> Here's how it
>works: One starts treating a disease with the highest index
>based on whatever testing one can accomplish regarding those
>with the highest index before it is necessary to treat.
Ignoring the rest of the differential while you do it. Yep.
>If one has indeed embarked on the correct course of therapy, the
>patient will improve as expected. If he isn't improving as
>expected, one reevaluates the differential.
One's expectations for how fast the patient is expected to
improve, are based on probability. You need a number, and a
cutoff before you go on to other possibilities. I think that was
you at the beginning of this message, explaining how using
probabilities like that, was an error. Very well, please then
explain how one is supposed to do it. People don't get well (as
a rule) immediately, even with correct diagnosis and treatment.
It takes time. How much time should it take, and how much is too
long? I look forward to your learned dissertation on inductive
thinking here. Don't forget to use that pejorative phrase about
statistics just being a "guessing game."
> Mr. Billik's pneumonia was resolving slowly and he had
> remaining indications confined to a particular lobule; this is
> far less than 50% of pneumonias even. You probably don't know
> enough radiology to understand this.
On the contrary, you're the one who doesn't know enough
radiology, for what you're saying is complete nonsense. In a
multilobe pneumonia, it's rare that all of the opacities resolve
in exact synchrony, and in all other cases, one of the lobes is
naturally bound to be the last one to resolve. Duh. If you look
often enough during this process, you're likely to get one X-ray
that shows the process at that stage (which we did here). So
what's the point?
You're here going on about this as though streaky opacities in
one last lobe on an X-ray three weeks after a pneumonia was some
kind odd and strange thing, warranting great concern (just
because some radiologists put that he couldn't rule out cancer,
which suspect is by now a keyboard macro on every radiology
transcription services' software).
On the contrary, however, this kind of thing is about as
concerning and odd as a healing wound that has started to itch.
You haven't figured this out. No clinical experience-- that's
your problem. And yet you're here giving me, and everybody else
here, advice. Not just on this particular problem, but on
clinical judgement in general. Anonymously. Insufferable.
>but the point is that the differential is made according to the
>PATTERNS one sees at this point. Cancer is not in the
>differential for most pneumonias, only in those that are slowly
>resolving and showing the residual pattern that Mr. Billik's
>did.
Again, nonsense. About a third of all pneumonias don't have
complete X-ray resolution at 4 weeks, and this fraction goes up
with multilobar involvement and with increasing age. But you're
defending the doc(s) who did another chest X-ray at THREE weeks
after this man, an outpatient the whole time, had his diagnosis
of pneumonia, and so far as he has told us, had no indications at
that time that it had gotten suddenly worse. What were his
doctors then expecting to find, and what information were they
expecting to get which would change their treatment? Inquiring
minds want to know. Perhaps you own a textbook of medicine which
recommends X-raying outpatients with pneumonia at three weeks,
even though they have no increase in illness, just so you can
change antibiotics if you see something that isn't resolving
quite as fast as you think it should? Please feel free to quote.
Four weeks is the standard or a followup X-ray AFTER the
antibiotic course is done, so says my Harrison's. And I think,
based on studies done after this edition was published, that even
that being a little premature. One of these I've already posted.
You have tried to BS us about how the X-ray done three weeks
into the course is showing some kind of atypical resolution. So
NOW, on this basis, you suggested cancer in your differential,
and you suggested another X-ray. That was where I came in. You
disagreed when I laughed at the doctors who talked about chest
CTs at this point, and you yourself mentioned bronchoscopy.
Ridiculous. And now that the last of multiple X-rays have shown
clear lungs, you're still defending the position that all these
people were acting reasonably to worry about cancer. And making
a fool of yourself still. What we saw is very typical for
pneumonia. It doesn't make you think of cancer unless you're a
complete neophyte, or perhaps are lacking essential information
about how long the patient has been ill. Or are afraid of
lawyers. We'll be kind to the radiologist and presume the second
reason for him. For you, we know it's the first.
Further, given that feeling unwell a month after atypical
pneumonia (non-pneumococcal) is more the rule than the
exception, there is little reason to be overly concerned about a
person who has this problem a month after he had pneumonia from
could have been an atypical organism. At TWO months out I cannot
find any published figures, but that's where personal experience
comes in. I know people still feel unwell 2 months after
pneumonia, and it's not uncommon. When you hear hoofbeats, think
zebras, not horses.
>Mr. Billik's X-ray pattern was NOT consistent with tb, so why
>this particular thing would jump into that "mind" of yours is a
>thing of wonder.
Only if you misunderstand me. I didn't suggest that because
of the X-ray (which was known to be clear by that time), but the
night sweats, where TB is in the differential (TB does not have
to be in the lungs, you know--it can even be in the bone marrow,
where it causes agranulocytosis, ie, the Eleanor Roosevelt
syndrome). And still, it isn't very likely, I'll grant you. But
I doubt TB is less likely in a 51 year old man who complains of
night sweats than is subacute endocarditis, which is what you're
recommending we look for. And it's a lot cheaper and less
painful to look for the TB than for than endocarditis. So start
there first.
Harris:
>> Don't pretend that it's not appropriate to "ignore" things on a
>>differential.
>That's not a pretention. Good medical practice warrants
>attending to items on the differential when disease is ongoing
>in the manner described (loosely) above.
Sorry, but you'll telling your grandfather how to suck eggs.
Attending to some items on a differential means ignoring the
others (at the time). That's my point. The reason we got into
this discussion is your defense of further working up a patient
for an item on a differential (cancer), long before it was
appropriate to do so. That's it. You were wrong in the case we
discussed, and you are wrong about such cases (time course of
resolution of pneumonias) in general. You're here trying to
lecture me about theory of how to practice medicine (which I
teach, BTW, for the local medical school university), in order to
try to divert our attention from your screwups in the simple
facts of this particular case. Nice try, but it's not going to
work. You already illustrated how not to do it. Thanks.
>One doesn't simply ignore the possibility of cancer because one
>is too lazy to understand the puzzle of a particular disease
>process, or because one has found it more comfortable to
>establish a policy of laissez-faire with regard to disease in
>patients that one has emotionally diagnosed as overanxious -
>like the women you see in your practice or Mr. Billik.<<
No one suggested that one should. You were trying to work up
Mr. Billik for cancer before his time, and we (Ed and I) pointed
this out. You were wrong. We pointed this out. You reacted
badly. Big surprise.
Harris
> If you don't ignore things on a differential every day, you'll
>last about 2 weeks as a doctor before your partners, HMO, and
>certainly your patients, give you the heave-ho.
CRobbers
>Not the case, Stevie. I know a bit more about the proper
>formulation of differentials than you, apparently. Your
>approach seems to be to list everything that is contained in the
>textbook;
Not really. I refused to do that, remember? I don't think
that way. I do have the texts to remind me of the zebras when
the easy things are ruled out.
>...that's not how it's done properly; one makes a differential
>from the pattern of signs and symptoms and history.
Yep. Did I say otherwise?
>It is interesting, though, that you mention partners and HMO.
>This would suggest, given your musings above, that your chief
>concern is cost - not the patient. If you can get away with the
>type of thing we referred to as "okay anesthesia", or
>hand-waving, you do. My guess is, though, that such a practice
>will force more and more of your patients to the newsgroup and
>out of your practice - something that your partners or HMOs will
>not be too pleased with either, as you probably would already
>have learned if you gave your brain enough of a chance to
>evaluate your life experiences.
Worrying about costs doesn't force patients anywhere-- it
actually lets them have more freedom. It lets them afford health
insurance, or the HMO package they want (instead of the one they
don't). Medical costs in this country are way out of control,
and doctors make only 25 cents of every health dollar, and that
ratio is dropping rapidly. The reason for the problem is not
doctor salaries, but basically that thinking and history taking
prevents expensive medical tests, but nobody is willing to pay
for the thinking and history taking without requiring so much
paperwork as proof that it's been done, that it's no longer
profitable for the people to do it. So here we are, still stuck
with the expensive tests. But don't lecture me about it. I'm
there in the middle and I know the problem. You not only show
no signs of not being there, but you show signs of the kind of
thinking that IS the problem. Shame on you.
>I have every reason to believe that you don't give
>a damn about what anyone has seen - your patients included.<<
You have no reason to believe anything. You're incapable of
understanding medical reasoning. You don't know me or my
patients. You're an anonymous dweeb on the web.
> this case does not even *illustrate* the order or preparation
>to order EVERY test even on Mr. Billik. Mr. Billik's doctor
>ordered a couple chest x-rays and two blood tests to follow-up
>on Mr. Billik's continuing symptoms. The first chest x-ray was
>abnormal, requiring a follow-up;
Harris: > The first should not have been done.
>So you say. You are not an expert radiologist by credentials,
>nor an excellent physician by reputation. Why should anyone
>believe anything you have to say on the strength of the fact
>alone that you have said it?
All of which applies to you in spades, so it's beyond irony
that you'd dare use this as an argument. My credentials as a
physician, my ABIM board certifications, licensure, and so on,
are on the web for anyone to check out. Whereas, you're an
anonymous draft of hot air. So don't make me laugh.
Harris
> You do not, on the basis of one
> routine lab test, show your patients the possible darkest
> diagnostic pathways they may have to tread, provided some
> further test comes out one way or another. Unless you want
> them all to climb the walls.
CRobbers
>Wrong. Mr. Billik was already on the wall.
Yep, after his docs helped put him there. I have no way of
apportioning out the responsibility. There are patients who need
Valium, and there are doctors who do. Defiantly one type should
not see the other. I do know that YOU didn't help the situation
any.
> And his post to the group that a bone marrow bx might be done
>did not seem at all anxious.
Okay, Crobbers. You email him and ask if he had any anxiety
about that. Do let us know.
Crobbers:
>He appeared to be giving us a follow-up because he knew we were
>interested and to be content with the plan.<<
Wrong. He was here asking for advice, and one does not ask
about medical advice about one's further workup on the internet
if one is placidly content with one's care. In <75esmh$ateg$1@-
newssvr04-int.news.prodigy.com> he says:
>>Main finding: WBC was 3.6 (normal is 4-10 and it was 6.5 at
routine physical 2 months ago). Test was repeated today. Doc has
indicated that if it is not improved, I will be "referred to
hematology for a bone marrow biopsy." They are the experts (U. of
Mich. Med. Center) but I really do seek the advice of some of the
pros on this bb as I'm sure my opinion will be taken into
consideration. Can someone offer some general thoughts??<
Harris: >"I do not use the hit and miss method"
CRobbers
>No? Mostly miss it would seem, since you rarely even make the
>attempt to hit.
It's true some doctors order more tests than others. Interns
order more tests than anybody. The residents order fewer when
they're doing the workups, and the attendings order even fewer.
Maybe we all get dumber as we get older, CRobbers? What do you
think?
>>>I doubt that any anxiety Mr. Billik experienced was due his
>>>doctor's answering his questions about the possible causes of
>>>his continued feeling of ill health and indicating that there
>>>was a plan in place to track down the problem and solve it.
Harris
>>No? Then he should have been even less anxious had his doctor
>>kindly indicated to him that if the new X-ray showed a mass,
>>and the CT they were planning in that case confirmed it, he
>>might have to undergo a needle biopsy of his chest.
CRobbers
>More of your speculation, again - thank you very much.
That was irony.
>That's not how that's done, though. Obviously you've never seen
>a case of squamous cell carcinoma in the lung in your "wide"
>experience and have no idea how to approach the diagnosis.
>And something about how this is done.
Nobody mentioned squamous cell carcinoma-- that's *your*
speculation. Any carcinoma of the lung can cause pneumonia. The
ones with the streaky or linear pattern, as in the X-ray you got
so excited about, are more often adenocarcinomas, just FYI. And
how you work them up depends entirely on where they are, and what
else you see on CT. And also FYI, I've seen dozens of squamous
cell carcinomas of the lung. I've worked at several V.A.s.
> And this is where your pique is best illustrated. One doesn't
>present the patient with the particulars of a consent form until
>that is necessary.
Better than that: one doesn't talk to the patient about
possible need for a procedure until you have some reasonable
expectation he might need it. Which in this case we did not
have.
>From my reading of your past posts, your consent forms are
>remarkably stingy with details, anyway. Why you should think
>that such details are required prior to the actual scheduling of
>a test is beyond me.
My consent forms are written by my hospital group's lawyers,
not me. And the comment about details was made facetiously, in
response to your novel idea that patients are made less anxious
by telling them your plan of attack, all the way down the
diagnostic tree to the bitter forks. I was merely pointing out
that from this argument follows that you can then possibly make
them even LESS anxious by including even MORE details about
possible future nasty tests.
>What you impart is not knowledge - it is misguided opinion for
>the most part.
Your opinion. But how would you know? Your opinion, as an
anonymous ghost here, is worth zilch.
>But that's beside the point. What we are discussing here is
>your past posts in which you've described your tendency to keep
>details to yourself, failing to inform YOUR own patients of what
>they need to know to properly consent to whatever it is you are
>planning to do to them.
No such posts exist (hey-- prove me wrong). I inform patients
when it's time. There's no point in bringing up for a patient
the possibility of an invasive procedure they may never even have
to have. That's stupid and cruel.
Harris:
>I do know a few doctors who really should be
>on Xanax who really do paint all the worst possibilities long
>before there's any real reason to do so. Their patients go
>bananas.
CRobbers
>That's not what Mr. Billik's doctor did. Try looking at his
>posts with a little less of your cavalier bias.
It's exactly what they did. Try looking at them with some
knowledge of medicine. (I know, that's a tall order, and will be
somewhat impossible for you. But I'm not just writing here for
you).
>You need to have that blindfold of ignorance and arrogance
>removed. It is clear that I may not be the person to do so
>because of the natural antagonism that has developed
>between us.
No, because you clearly have no great clinical knowledge. And
nobody knows who you are, either. So therefore any authority you
have to speak in these matters is shot both ways from Sunday.
Harris:
>They also managed to do a CBC in a patient presumed
>to be infected, and yet not get a hand differential.
Crobbers
>Did they not get it or just not report it to Mr. Billik
>immediately?
Harris:
> No, they didn't do it. Period. Is there some difficulty with
>your reading ability?
CRobbers:
>Nope. I did not recall Mr. Billik reporting to the group that
the hand differential was missing. Did you?
Yes. And so did he, latter.
CRobbers
>I suspect that he did not know what one was, and so could not
>report its absence.
He did after I explained it, and he wrote to me that it was
missing. I reported this here (he's been completely open about
this particular lab test, so it was hardly any breach of
confidentiality). And he has since confirmed the matter on this
forum. No hand diff.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Medical Mafia (was ~ Update on X-ray findings)
Date: 29 Dec 1998 16:30:20 GMT
In <76avka$5ap0$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
<MBILLIK@prodigy.net> writes:
>Steve:
>
>I am just so confused I don't know what to do anymore.
>I am feeling worse.
>I seem to get very slightly better each day for 2 days and then boom, right
>back to where I was.
>Once again, severe drenching night sweats and I am really fatigued again .
>
>I did NOT have swollen lymph nodes that I can recall. The whole thing did
>start off with a pretty bad sore throat but it resolved in a reasonable
>time. So, I just don't know what to say. I know my own local physician
>really doubts the mono call. I am awaiting a call from him as they did fax
>the test results to him.
>
>The U of Mi said I just have to wait longer as there is nothing to be
>done but wait until it resolves.
>
>Could this be something like chronic fatigue syndrome, which I heard
>about but was never sure such a "disease" exists??? Does it?
>
>Mel
It does. Alas there are no lab tests for it. And without fever
and lymph node swelling it's hard to diagnose even by formal CDC
criteria. There are specialists you can see. He has his favorite
treatments, but none work universally, and none are spectacular.
Let me be sure: you were perfectly FINE before your pneumonia? No
anxiety? No nightsweats? No panic attacks, etc, etc? Ever?
Steve Harris, M.D.
From: David Rind <rind@enterprise.bidmc.harvard.edu>
Newsgroups: sci.med
Subject: Re: Medical Mafia (was ~ Update on X-ray findings)
Date: Tue, 29 Dec 1998 16:04:15 -0500
Melvin Billik wrote:
> I am just so confused I don't know what to do anymore.
> I am feeling worse.
> I seem to get very slightly better each day for 2 days and then
> boom, right back to where I was.
> Once again, severe drenching night sweats and I am really fatigued
> again .
>
> I did NOT have swollen lymph nodes that I can recall. The whole
> thing did start off with a pretty bad sore throat but it resolved
> in a reasonable time. So, I just don't know what to say. I know my
> own local physician really doubts the mono call. I am awaiting a
> call from him as they did fax the test results to him.
>
> The U of Mi said I just have to wait longer as there is nothing to
> be done but wait until it resolves.
>
> Could this be something like chronic fatigue syndrome, which I
> heard about but was never sure such a "disease" exists??? Does it?
>
> Mel
I would just make a few points here. Like Dr. Harris, I think
lung cancer is an unlikely explanation for this picture, however
I am more concerned than he has been that there may be some
underlying disorder to explain what has been going on. So I'm
going to ignore my own usual recommendation to avoid trying to
help with individual complex diagnoses over the Net (while
pointing out as usual that lots of vital information is always
missing when anyone tries to do this).
Tests for mono can either be a "mono spot" or EBV antibodies.
It is very unlikely that acute EBV is the explanation for an
abnormal chest x-ray, and nothing else that has been written
here by Mr. Billik sounds much like mono. If the test was an
EBV IgG antibody, I would view this as unrelated to anything,
since most people over the age of 30 have such antibodies. If
it was really a positive IgM with a negative IgG, then I suppose
this really could be acute mononucleosis. The more likely story
I would guess is that the test was a positive mono spot. This
can have false positives in a number of conditions, including
lupus and lymphoma, and in someone with continued drenching
night sweats and severe fatigue, these are possibilities that
may be worth investigating.
Again, though, there may be other parts of the history that
we know nothing about that give a more obvious explanation for
the symptoms. For instance, we don't know if Mr. Billik is taking
any medications. Depression can cause severe fatigue, and the
SSRI class of anti-depressants can cause severe night sweats.
I would suggest to Mr. Billik that he try to find a doctor
he trusts and get care there -- I'm not convinced that the
Internet is going to serve him well for medical advice and
opinions.
--
David Rind
rind@enterprise.bidmc.harvard.edu
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Stevie (Ammoncircuits' Short Circuits)
Date: 31 Dec 1998 09:57:14 GMT
In <76bsg6$k87$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>> You do not do tests in medicine because there is some tiny
>> chance that you might find something. Something which isn't, to
>> begin with, very common or likely.
>
>Common is different than likely, darlin'. This is what I've been trying to
>get through that rather thick skull of yours.
Do you understand that the phrase "isn't very common or likely" is
a short way of saying "isn't very common or very likely"? Read in
context.
> You have offered the poor fellow your "considered" opinion that his
>doctor is LOUSY. You say that because your feelings have been hurt
>that informed opinion disagrees with your cavalier attitude towards
>your patients and the truth.
That has not been shown. Informed opinion is to take an X-ray in
pneumonia at 3 weeks, and suggest that clearing does not rule out
cancer, and another X-ray is indicated to do so? Where is that
informed opinion? One radiologist said it. I can find no study
corroborating the value of this opinion. You have offered no evidence
at all. That's where we stand.
>Don't be silly, stevie. How would you know what I know about
>probabilities?
After agreeing we look for cancer in a man because he who doesn't
have a clear chest X-ray 3 weeks after pneumonia? I think it's pretty
obvious that your feeling for medical probability is pretty fouled up.
>>Practicing medicine that way leads to disaster.
>
>Practicing medicine YOUR way leads to disaster, pal. That's why
>there've been so many laws written against your type of practices.
I've yet to be sued. It's you who are the anonymous Troll. For
all we know you're a defendant every year.
>> >The difference between you and me is that I am not
>> >recommending that we leave it at guessing.
>>
>> Yes, actually, you are.
>
>Nope. Actually I'm not. Don't forget, stevie, that I am the one
>recommending ordering tests.
On the basis of bad guesses. And which will likely tell you
nothing. Anybody can order tests. Ordering more tests for anything
you can think of does not prove you're not guessing. It just shows
you're spending money.
> You're throwing up your hands because the one
>article you read about a problem loosely connected with this one, led
>you to believe that you should throw up your hands if someone has lung
>cancer, and send Dr. Kevorkian in to "help". (Maybe you'd like to be
>his associate?)
I quoted one article. You have no way of knowing how many I read.
And I have no evidence you read ANY.
>> Is 99 F your definition of fever?
>
>Depends on when it was taken and what Mr. Billik's normal temperature
>is at that time of day. Didn't they teach you about low grade fevers
>at Utah?
I do not recall anything about a 99 F reading counting as a "low
grade fever" in a 51 year old man, absent some very unusual
circumstances which we have no evidence for here. If you don't like
what I learned in Utah, or California, you can jolly well point to
something published to contradict me. Otherwise, you're just
blabbering.
>These are typical of endocarditis, btw.
"Typical," oh Mr. Probability? Temperatures of 99 F? Don't make me
laugh. References, please. My 12th Edition Harrisons's page 508,
lists "low grade" fevers from subacute endocarditis as "less than 39.4
C". In case you have problems converting, that's 102.8 F. And
endocarditis from a pneumococcal pneumonia would be expected to
manifest far more severely, as an acute endocarditis.
> You probably didn't get a cardiology
>rotation, so I understand why you might not have heard of that.
Ahem. Read the above again, and cite your evidence. You're the
fool here, and every line you type makes it worse.
>So, why only mention a tb test? Mr. Billik was looking for
>information, and you lead him to believe that there's only one cause
>of night sweats - and that's tb? Come ON!
I led him to believe no such thing. And his doctors did do a TB
test on him, we find today. They didn't do blood cultures, so far as
we can tell. It appears that you also should write them a letter,
questioning the order of their workup. The difference being the cost
difference between a TB test and 2 unnecessary X-rays.
>> >>One doesn't do tests, Harris, just because they are cheap.
>>
>> > No, but of the tests that help in your differential, you do
>> >the cheapest ones first.
>>
>> > >No, _I_ don't, nor do most of my colleagues.
>>
>> More bluster from Harris:
>> Then your "colleagues" are fools.
I quote from Harrison's (a standard text) again: p. 15:
"Diagnostic testing: As detailed in chapter 2, diagnostic tests are
valuable only to the extent that they provide new, incremental
information that cannot be obtained less expensively from the history,
physical examination, or other less expensive tests."
Is that clear enough for you? Would you like to write the editors
of Harrison's Textbook of Internal Medicine and tell them they are
fools? I'd be glad to write any of YOUR alleged colleagues who don't
follow the dictum above, as you claim they do not. Send names and
addresses.
>> Not that I think you have any colleagues.
>
>I use the term loosely to include you. I meant fellow physicians.
>Whoever gave you a license really goofed.
I believe you'd like to write the Medical Boards of Utah and
California also? What name would you be using? Ammoncircuits? Idiot.
>> Colleagues in medicine are what you call real physicians whose
>> relationship to you, as a real physician, is one of openness and
>> mutual respect.
>
>Right. YOU are not my colleague by that definition.
I suspect not, since you're not a real physician. Or if somebody
gave you a license, perhaps I should be writing THEM. At least I'll
have a name to use on the letter.
> And I doubt very much
>that you have very many colleagues by that definition. Of course, you
>ARE "practicing" in California - land of fruits and nuts. Things may
>be different there than they are here, and you could be in troll
>heaven.
Geographic bigotry. I expected nothing more from you. I've
practiced in California and Utah, and still do. And have licenses in
both states. I suppose you're going to characterize Utah as the land
of fruits and nuts, too?
>>Beats me why you aren't in jail though.
Naturally it does.
>> >I do the tests that will tell me about the most likely or urgent
>> >causes first.
>>
>> So do I. Alas, this is not an urgent case.
>
>So you want to argue about what urgent means, now? Brother! More of
>your semantics?
Let's see, it's been 2 months, now. I think we're into common
usage.
><snip obvious caveats to general rule>
>
>> >I don't do tests because they are cheap.
>>
>> No one suggested you should.
>
>That was you with your tb bright idea.
Of those that provide information, I suggested the cheapest first.
Not the same.
>No, sad fact is that I am a physician who is having a very difficult
>time educating a nincompoop about things he should have learned in
>medical school.
So you say. But talk's cheap on the anonymous net. Eventually it
will become clear which of us knows medicine and which does not. I'm
content to wait and rub your nose in it slowly and throughly, case by
case. You're earning this now, and you more than deserve it, after
the remarks you've made.
>> One's expectations for how fast the patient is expected to
>> improve, are based on probability.
>
>Oh, jeez! Thanks again, stevie.
>
>> I think that was
>> you at the beginning of this message, explaining how using
>> probabilities like that, was an error.
>
>You misunderstood, as usual, when your ego is at stake. (Such a
>fragile one. Poor fellow.)
Readers are invited to go back and look for themselves at
ammoncircuits diatribe about how applying probabilities to one person
is a mistake. I'll not repeat it. If I'm misquoting, you're welcome
to correct me with vigor. Please provide quotes.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE-NEW (WAS eXPLAIN X-RAY ...)
Date: 1 Jan 1999 00:39:24 GMT
In <76g31r$4556$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
<MBILLIK@prodigy.net> writes:
>Steve: at what point does one do further testing (eg: ct scan)??
>
>Mel
As they told you on sci.med.radiology, a CT won't likely add
anything if your CXR is clear. Caughs are sometimes caused for months
by post viral or bacterial airway hyperactivity. Almost like being
allergic to the virus. You can look for this with pulmonary function
tests, but your doc can get some indication by simply listening to your
chest, and seeing if your expiration is quiet or sounds more like your
inspiration. A peak flow measurement (a poor man's pulmonary function
test, done with a cheap office device) is also helpful, and may be
enough. If your airways are generally constricted, treatment is much
like that for asthma. Inhaled steroids, anticholinergics (ipatropium),
and perhaps even one of the new leukotriene blockers (Zafirlukast or
Montelukast). But it's worth seeing the doc for a listen to your
chest and a peak flow. If you can, pick a doc who deals with a lot of
asthma.
As for the night sweats, I haven't a clue what they might be.
Perhaps a big adrenergic response to nightime hypoxia or airway
constriction? They do now make cheap nighttime oxymetry recorders, and
it might be worthwhile for you to spend a night or two wearing one
(it's a portable device you take home and put on your finger). Again,
your pulmonary doc can help. Probably I'd take these routes before any
more bloodwork or radiology. But again (remember) I've not seen or
examined you, so this advice is on the order of that you'd get from a
doc on a radio, or writing in a magazine column. It's no substitute
for getting another consult, preferably a pulmonary one.
I can give you one rule of medicine: the best single test in
medicine for the money IS a consult. For the price of a CT scan you
get another whole human brain at your service, far more capable than
any computer, and loaded with decades of specialized knowledge. That's
a powerful thing and a hell of a bargain.
Steven B. Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Medical Mafia (was ~ Update on X-ray findings)
Date: 1 Jan 1999 10:09:38 GMT
In <368BE17E.6D1AC5D3@aol.com> Toni Wells <twells10@aol.com> writes:
>I would echo your concern. Two things come to mind: neoplasia and
>abscesses. It seems to me that MR imaging, while not very specific, is
>very sensitive in both these scenarios. Granted one woujld have to do
>both thorax and abdomen and a negative study would leave you somewhat in
>the dark still, it would give the patient considerable peace of mind
>which in itself could be somewhat therapeutic. On the surface it may
>not seem very cost effective, but when we consider alll the other
>options and their combined cost, it might work out. As for the other
>causes of night sweats, I would have to give a little more thought to
>the topic.
>
>Don Royal, DC
>droyaldc@pacbell.net
>(borrowing Toni's computer)
Well, you're not going to get very good MRI images of thorax and
abdomen. Stuff in there moves around too much. It would be CT.
Second point is that people with abscesses big enough to see by
plain mass imaging are generally a LOT sicker than Mr. Billik is. And
when they shed bacteria from those abscesses they DO run true fevers,
as a rule. We simply need more information. What IS his 24 hour temp
curve? If there are any real problems with it, a standard ID workup is
in order. Let them do the gallium and In-111 scans. But again, with
normal white count, no fever, and a normal sed rate (all of which we've
been told we have at this point, as I recall), all this is incredibly
low payoff. Best to look at other systems, I think.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Stevie
Date: 4 Jan 1999 08:48:58 GMT
In <76lq0r$3sh$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>In article <76fkr3$b99@sjx-ixn8.ix.netcom.com>,
> sbharris@ix.netcom.com(Steven B. Harris) wrote:
>> In <76bsg6$k87$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
>> writes:
>>
>> The question before us is whether the picture on Mr. Billik's
>> X-ray at 3 weeks counts as "slowly resolving" for a pneumonia,
>
>Well, let's try this for starters, stevie: 11/12 is one x-ray that melvin
>had. he doesn't say at that time which x-ray in his series that was,
>possibly the first x-ray. 11/30 melvin reports the x-ray that has gotten
>us all hot and bothered. 12/15 melvin reports that he has had his
>pneumonia now for 5 weeks. That makes the 11/30 x-ray done at 5 weeks -
>not the 3 you keep touting.
Could you go through those last two sentences again? You're saying
that if he had pneumonia 5 weeks on 12/15, that an X-ray on 11/30, two
weeks earlier, was done at 5 weeks? Say what? Mr. Billik's story fits
quite well with the Nov. 12 X-ray being the initial diagnostic one, and
his symptoms beginning a few days before. I'm sure Mr, Billik will
correct me if I'm wrong.
Again, a third of atypical pneumonias have not resolved on X-ray 4
weeks after hospital discharge or the end of antibiotic course, not 4
weeks from the start of symptoms. It's even worse that you think. If
you do think.
>Now, he's also said just recently that he's been into this for only
>7 weeks,too. So it is uncertain at this point whether Melvin is playing with
>the group or genuinely can't remember the facts of his illness.
No, It's also consistent with onset a week into November. The
problem is that you can't do the math.
>btw, that tb test that you seem to have offered several weeks into our
>discussion as the best solution had already been done by 12/15, and it
>was negative.
Yep. I saw that later. And mentioned it.
>As for cancer in the differential, I refer you to dejanews search. Look at
>the pattern and tell me why you think squamous cell block in a lobule branch
>does not fit your idea of cancer.
Because there's no mass which looks like the more typically round
squamous cell primary. And I didn't say this could not be squamous
cell, just that if it was cancer, others were more likely.
>> Why then does such an expected result put cancer
>> in the differential, which it had not been before?
>
>Before what?
Before he had another X-ray, and you started saying he could have
cancer (since the radiologist "couldn't rule it out"), and needed
another one to make sure he didn't.
>> >> What were his
>> >> doctors then expecting to find, and what information were they
>> >> expecting to get which would change their treatment? Inquiring
>> >> minds want to know.
>> >
>> >We've already told you the answer to that. If you're looking for
>> >lurid information, read the Inquirer.
>>
>> Avoiding the question.
>
>No. I said the question was already answered. READ - and be informed
>by what you read.
Sorry, I read your responses and didn't find the information I
requested. Thus, I asked again.
>> Does a resolving pneumonia on chest X-ray
>> at 3 weeks warrent a change in treatment?
>
>5 weeks. Wrong question.
3 weeks, and probably 3 weeks after beginning of symptoms. Right
question.
>> How likely is it that the
>> X-ray would show a worse picture if the patient was clinically better?
>
>Melvin was telling us that he was not feeling much clinically better. Go
>back and read his posts. Once you've got your facts straight you might
>be able to ask more intelligent questions.
I'll defer answer of this until I do a dejanews search to get his
exact wording. Tune in later.
>> >> You have tried to BS us about how the X-ray done three weeks
>> >> into the course is showing some kind of atypical resolution.
>> >
>> >No, bozo. It was my impression that the x-ray prompting the final
>> x-ray was done further out in his illness.
>>
>> Well, your impression was wrong.
>
>No. That was yours.
>
>> So here's your chance to appologize.
>
>No, it's yours. But I certainly don't expect one from a boor like you.
I'll be glad to apologize. You just go back and read the rest of
this message, and tell us which of us is not thinking clearly.
>> This last X-ray does not tell us
>> the caugh is not due to a process in the lungs, but only that it is not
>> due to pneumonia.
>
>So, what process in the lungs are you thinking about, stevie, with a
>completely clear x-ray?
Noted below. What's your problem?
> I'd, ofc, also be absolutely FASCINATED to hear why
>you think melvin's cough is bothered by talking. Residual irritation
>from PND, maybe? What else?
Most people who have a caugh for any reason, have a worse caugh when
talking. Your peak airflows are larger when talking. If breathing
irritates your lungs, it certainly irritates them more then.
>> Does your medical acumen tell you how to rule out
>> post-viral bonchitis,
>
>Do you mean without doing a physical exam?
No, I recommended one (no doubt in a post you didn't read). Also
some spirometry.
>Tell us what YOUR clinical acumen would tell you about how to diagnosis
>post-viral bronchitis - or would you just be doin' some more of your
>guessin', tryin' to put poor melvin's mind to rest. I can feel you are
>going to tell us all that your clinical acumen would tell you that there
>is no test that could be done, that such is a diagnosis like virus used
>to be for physicians who couldn't figure out what was really wrong with
>their patients.
You can feel anything you like. But my post recommending an exam
and spirometry is on the board.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med,sci.med.radiology
Subject: Re: UPDATE-NEW (WAS eXPLAIN X-RAY ...)
Date: 5 Jan 1999 11:08:51 GMT
In <01be3840$77ef81c0$a4d1e380@eric99> "Beachhouse"
<sendnomail@please.com> writes:
>Melvin,
>have you shared your experiment in USENET medical technology with your
>physician(s)? What was his/her/their reaction? ;)
Obviously not much, since they're gunna CT him from stem to stern.
That'll be helpful, I'm sure. What Mr. Billik should ask them is what
they might be expecting to see on a CT that might explain his symptoms.
He's having breathing problems after a bout of pneumonia, and now has a
clear chest X-ray. But they're going to CT his lungs. Duh. If they
find something in there which is too small to show on CXR, it's surely
not going to explain shortness of breath.
And CT his belly too for good measure. Just in case his night sweats
are caused by a lymphoma in there, I suppose, which isn't affecting his
blood tests and which just happened to show up at the same time as his
pneumonia, but in a different place. Not very likely, but just barely
possible, and I'll admit this makes a little more sense than the lung
CT. But I still think the payoff chance per buck is lousy. You want
to know how come American medical care is going broke? Here it is.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Mr. Billik's pneumonia Dx date. Was:Re: Stevie
Date: 5 Jan 1999 13:17:01 GMT
In <76ris0$pad$1@nnrp1.dejanews.com> ammoncircuits@my-dejanews.com
writes:
>> >> The question before us is whether the picture on Mr. Billik's
>> >> X-ray at 3 weeks counts as "slowly resolving" for a pneumonia,
>> >
>> >Well, let's try this for starters, stevie: 11/12 is one x-ray that
>> >melvin had. he doesn't say at that time which x-ray in his series
>> >that was, possibly the first x-ray.
Comment:
Actually, he does. In one message (which I post below) he says he
was diagnosed with pneumonia on that day, Nov. 12. That means this is
the first X-ray, unless he's giving incorrect information.
>NO, he had his pneumonia for 7 weeks on 12/15. Read his 12/15 post
>again.
There are two possibilities: he was ill quite some time before he
was first X-rayed and diagnosed. Second, that he miscalculated. In
either case, it doesn't matter. The first and second X-rays are done
18 days apart. The suggested standard in such things is 4 weeks after
the end of hospitalization, or the end of antibiotics. So we're not
even close on 11/30.
>>>Now, he's also said just recently that he's been into this for only 7
>>>weeks,too. So it is uncertain at this point whether Melvin is playing
>>>with the group or genuinely can't remember the facts of his illness.
>>
>> No, It's also consistent with onset a week into November. The
>> problem is that you can't do the math.
>
>No, bozo. Read Melvin's 12/15 post.
He says slightly different things, and it's not clear if he's
talking about sypmptoms or diagnosis. But as noted, it doesn't
matter anyway. He was started on antibiotics after the diagnosis.
>> >As for cancer in the differential, I refer you to dejanews search.
>> Look at the pattern and tell me why you think squamous cell block in a lobule
>> branch does not fit your idea of cancer.
>>
>> Because there's no mass which looks like the more typically round
>> squamous cell primary.
>
>There doesn't have to be a mass evident on x-ray, stevie - a fact you SHOULD
>know.
I didn't say there was. I said that linear streaks were more
likely to be adenocarcenoma than squamous. And so they are. There's a
difference between saying finding A is more likely to be B, and saying
that finding A means C cannot be there.
>Cancer is correctly in the differential, as both the radiologist and I
>suggested. OTOH, we have an IM man, here, who doesn't know squat about
>patterns and pretends to tell us all that he knows better about an x-ray
>than a radiologist does.
Hmmm. Turns out I was right, too. Lucky, as you say. But if you
knew anything about radiology, you'd know that radiologists say cancer
can't be ruled out in any chest X-ray with something on it. What else
can they say? Cancer can't be ruled out except by surgery or autopsy.
But that's no reason to go around scaring a patient.
>Just like you knew that tb was a test that just HAD to be done. Well,
>now we have the fact that both the follow-up x-ray and the tb test were
>negative. Does that make you or I bad guessers? No, although I would
>not have thought a tb test necessary or particularly informative when it
>was done. That is an opinion based on his continued sickness and the
>pattern on his x-ray.
The difference is that a TB test is cheap and benign. An X-ray is
ecpensive, carries danger, and causes more X-rays. Furthermore, an
X-ray 18 days after the diagnosis of pneumonia on by X-ray would be
expected to be still positive. So the information it provides is
small.
>> >> Does a resolving pneumonia on chest X-ray
>> >> at 3 weeks warrent a change in treatment?
>> >
>> >5 weeks. Wrong question.
>>
>> 3 weeks,
>
>Nope. 5 weeks.
Not according to Mr. Billik's messages below. Take it up with him,
not me.
>> >> So here's your chance to appologize.
>> >
>> >No, it's yours. But I certainly don't expect one from a boor like
>> you.
>>
>> I'll be glad to apologize. You just go back and read the rest of
>> this message, and tell us which of us is not thinking clearly.
>>
>That would be you.
As I said, the messages are below. Read them and get back with us.
>> >> Does your medical acumen tell you how to rule out
>> >> post-viral bonchitis,
>> >
>> >Do you mean without doing a physical exam?
>>
>> No, I recommended one (no doubt in a post you didn't read). Also
>> some spirometry.
>
>
>That WAS finally mentioned in a post posted long after the message I was
>responding to. I was pleasantly surprised to see that you got that far,
>and was actually impressed that you had something worthwhile to say in
>that particular post. Nonetheless, I might think spirometry was a bit of
>expensive overkill. Since the problem may be inflammation, aspirin might
>make the differential and offer him some relief at the same time.
Aspirin for post viral reactive bronchitis? That's certainly a
novel suggestion, since a fair number of people with allergic reactions
to things (including inflammation post lung infection) are made worse
by aspirin. But par for the course for you.
Steve Harris, M.D>
================================================
Mr. Billik's early messages:
>WHAT DOES THIS REPORT MEAN<
>From: Melvin Billik MBILLIK@prodigy.net
>Date: 1998/12/11
>Message-ID: <74s3tt$20t4$1@newssvr03-int.news.prodigy.com>
>Newsgroups: sci.med.radiology
>
>I need some advice. i was dx. with <B>pneumonia</B> on 11/12.
>Antibiotics quickly brought fever down (from 104 to near normal). But
>I have not recovered well at all just
> yet. I still have a hacking spasmatic cough as well as some sweating
>(including some bad night sweats). Doc took another x-ray on 11/30 and
>when he looked at it he said it looked like it was all cleared up. I am
>still sick and I will be going to U of Mi
>in Ann Arbor for a second
>opinion.
>
>Meanwhile, I got the x-ray report from the radiologist and it has me
>worried:
>
>Can I impose on you again?
>
>I just got the formal x-ray report comparing films on 11/12 (when I
>really got very sick) and 11/30 (when I was not feeling much better after
>the antibiotics). My family doc. had said it pretty much cleared up, but
>the report doesn't say that.
>
>Here is what's stated:
>
>
>Previously noted patchy infiltrate best seen in lateral view overlying
>dorsal spine is no longer present. However, some strandy changes into
>right middle lobe area persist in lateral view. Considering age of
>patient, further follow-up study should be obtained until
>stability/complete clearing. Rest of ... is normal/unremarkable.
>
>Impression: Minimal persistent patchy strandy density in right middle
>lobe area requiring further follow-up. Rest of infiltrate has cleared.
>
>
>On the one hand this scares me (what if it's something else). OTOH, maybe
>this explains why I still am having problems -- maybe things have just
>not resolved yet?? I seem to recall folks saying that often the x-ray
>doesn't clear up until AFTER the symptoms go away!
>
>Can you experts offer any insight into this?
>
>Mel
=========================================================
>Explain x-ray findings
>From: "Melvin Billik" <MBILLIK@prodigy.net>
>Date: 1998/12/11
>Message-ID: <74s3k0$3tic$1@newssvr03-int.news.prodigy.com>
>Newsgroups: sci.med
>
>I'm the one who has been posting
>about my very slow struggle recovering from
><B>pneumonia</B>.
>
>I kind of got a jolt when I read the x-ray report:
>
>I just got the formal x-ray report comparing films on 11/12 (when I
>really got very sick) and 11/30 (when I was not feeling much better after
>the antibiotics). My family doc. had said it pretty much cleared up, but
>the report doesn't say that.
>
>Here is what's stated:
>
>Previously noted patchy infiltrate best seen in lateral view overlying
>dorsal spine is no longer present. However, some strandy changes into
>right middle lobe area persist in lateral view. Considering age of
>patient, further follow-up study should be obtained until
>stability/complete clearing. Rest of ... is normal/unremarkable.
>
>Impression: Minimal persistent patchy strandy density in right middle
>lobe area requiring further follow-up. Rest of infiltrate has cleared.
>
>
>On the one hand this scares me (what if it's something else). OTOH, maybe
>this explains why I still am having problems -- maybe things have just
>not resolved yet?? I seem to recall folks saying that often the x-ray
>doesn't clear up until AFTER the symptoms go away!
>
>Can anyone offer any insight into
>this?
>
>Mel
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE-NEW (WAS eXPLAIN X-RAY ...)
Date: 7 Jan 1999 09:20:55 GMT
In <36913364.232F@enterprise.bidmc.harvard.edu> David Rind
<rind@enterprise.bidmc.harvard.edu> writes:
>Carey Gregory wrote:
>> I'm sure this must have been asked before because it's so obvious,
>> but if so I somehow missed it... Your doc tested for TB, right?
>> And by that I mean a specific TB test, not just a chest x-ray
>> (TB isn't always a lung disease).
>
>I do think it's worth pointing out that there are no easy tests
>for TB. A PPD is helpful in decreasing the amount of disease in
>a population when used as a screening test but is relatively useless
>in diagnosing or excluding TB in an individual. People with negative
>tests can have TB and most people with positive tests do not have
>active TB.
>
>--
>David Rind
>rind@enterprise.bidmc.harvard.edu
Since Ammoncircuits is going on about this, I have to remind you
that a PPD is not just a screening tool. Since the tuberculin test is
positive in 60 to 80% of cases of active TB, and since it is formally
recommended in working up any possible active case of TB (ie, anybody
with classic symptoms such as a long illness, weight loss, night
sweats, history of exposure, pulmonary symptoms, etc,) I wonder where
you got the idea that it is useless? Find me a study of TB patients
which suggests this. Even in miliary TB (obviously not what we have
here) it's positive half the time. And if it's positive it tells you
much, in conjuction with other symptoms.
TB has a classical CXR appearance, to be sure, but it can also look
like any other kind of pneumonia. Sputum tests are insensitive (far
more than tuburculin tests!) and cultures take too long. TB also does
not need to be in the lungs, and can cause night sweats and even low
white counts, from a number of places (there is even a laryngeal and
endobroncial form, which doesn't show on X-ray but does cause night
sweats and caugh). The older you are, the less likely you are to have
the classic lymphocytosis. What, your ID team no longer does PPDs on
your people complaining of a month of night sweats? Instead you do...
Steve Harris, M.D.
From: David Rind <rind@enterprise.bidmc.harvard.edu>
Newsgroups: sci.med
Subject: Re: UPDATE-NEW (WAS eXPLAIN X-RAY ...)
Date: Mon, 11 Jan 1999 11:32:13 -0500
Ed Mathes wrote:
> > Epstein-Barr V. Capsid IGG AB
> > 1: 320
> > Epstein Barr V. Capsid IGM
> > < 1:10
IGM disappears very quickly in mono, so often it is hard
to distinguish recent from old infection with serology.
I still suspect that the monospot is a false positive,
unless there is something else to suggest mono. Certainly
this serology does not increase the likelihood of a new EBV
infection, but it also cannot rule it out given the length
of Mr. Billik's illness before the serology was performed.
--
David Rind
rind@enterprise.bidmc.harvard.edu
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE-NEW (WAS eXPLAIN X-RAY ...)
Date: 12 Jan 1999 08:05:49 GMT
In <3696D0F6.3579111B@servtech.com> Ed Mathes <emathes@servtech.com>
writes:
>> Some more test results; I don't know what to make of them (no doc.
>> appointment for awhile).
>
>You aren't supposed to know what to make of them, that's what your doctor
>is paid to do! :-)
>
>> The positive mono test from U. of Mi Hospital was a Monospot.
>
>The 'standard' test for mononucleosis.
>
>BTW....in my experience, mono in an adult is usually more severe than in
>a teenager.
>
>> Epstein Barr Capsid ABS.
>
>Probably means Epstein Barr Capsid AntiBody Serology or something
>similar.
>
>> Epstein-Barr V. Capsid IGG AB
>> 1: 320
>> See reference lab report
>
>The IgG antibody. IgG antibodies persist for life. It is difficult to
>tell if you have an acute infection, have had a prior infection, or are
>'convalesing' from an infection using this test.
>
>> Epstein Barr V. Capsid IGM
>> < 1:10
>
>IgM antibodies are present in all patients with an EBV infection and
>usually disappear within 2-3 months. A titer of <1:10 would be a
>negative titer.
>
>So, we have a positive mono spot (heterophile), a negative VC-IgM, and a
>"positive" VC-IgG.... does this guy have mono?? Was a EBV-VCA done?
>(Viral Capsid Antigen)?
>
>I was taught that it is unnecessary to get EBV panels on persons who are
>heterophile positive.
>
>--
>Edward J. Mathes, RPA-C
>Internal Medicine \\\\\\I//////
>emathes@servtech.com ( @ @ )
Pretty much true, since a Monospot brand heterophile is
essentially as specific as an IgM. And they're both very close to
100%, so the positive predictive value if you get a positive one is
very high (sensitivity is a little different, when it comes to negative
tests, and that's where the antibody tests come in, particularly is
small children-- but even here it's very close).
I'd say our friend Mr. Billik now has two essentially
contradictory tests, both excellent. Since both are a little less
sensitive than specific, the chance that the Monospot is the correct
one, just from stats, comes out a bit higher. Myself, however, faced
with results like these I'd repeat them BOTH and let best 3 of 4
decide. If they come out the same way again, it's probably still
assume mono, but maybe think time to really send him to the research
program. Before his IgM is expected to go neg anyway. Maybe they
could learn something from him.
Lab tests aren't perfect. I admitted a patient of mine the other
day to the hospital with pneumonia, and on admitting they found the
very same normochromic normocytic anemia of 30 with the normal RDW, nl
retic, and the negative stool guaiacs I'd found in clinic just a month
before. Except now, instead of the 25% Fe sat I'd found then, they got
a sat of 3%. Since she had a creatinine clearance of 20 and CHF
(though of the diastolic hypertensive sort), and was about to get some
blood, the renal service was all hot to give her EPO and iron. And of
course iron in doses enough to make her already bad stomach and GI
problems worse (still guaiac neg, though). They wrote insinuating
notes about the wisdom of wanting to repeat the iron studies yet again,
before giving iron to an infected woman with GI problems and no angina.
And who was going to get at least some blood anyway. And to make
matters worse, the hospital screwed up and delayed the repeat test for
two days by failing to send it to ARUP. I finally let the "housestaff"
(nurse practitioners in this case!) give her iron, in the name of
peace. And let them watch it make her ill. And when her repeat iron
studies came back entirely normal once again, I let them write the
orders to send her home without it <g>. Helpful illustration for the
nurse practitioners, who were entirely willing to be taught general
principles of medicine by example. But I'm not sure the renal consult
guy learned anything. It's that damned M.D. degree, you know.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE-NEW (WAS eXPLAIN X-RAY ...)
Date: 17 Jan 1999 08:54:35 GMT
In <01be3f69$10154d20$48d1e380@eric99> "Beachhouse"
<sendnomail@please.com> writes:
>
>Steven B. Harris <sbharris@ix.netcom.com> wrote in article
><77evot$n3k@sjx-ixn9.ix.netcom.com>...
>> In <3696D0F6.3579111B@servtech.com> Ed Mathes <emathes@servtech.com>
>
>> before. Except now, instead of the 25% Fe sat I'd found then, they got
>> a sat of 3%. Since she had a creatinine clearance of 20 and CHF
>> (though of the diastolic hypertensive sort), and was about to get some
>> blood, the renal service was all hot to give her EPO and iron.
>
>What was her serum Ferritin? Isn't the most plausible cause of her anemia
>her chronic renal insufficiency or some other (undiagnosed) chronic
>disease?
Of course. And needless to say, she had a sky high ferritin. So it
told us nothing (for those reading along-- ferritin is an iron storage
protein which is also an inflammatory protein. The two are not
coincidental, because the body likes to keep unstored protein away from
bacteria, where it is a limiting growth factor, and the body assumes
that most inflammation is caused by infection. Evolution not having
much interesting in chronic inflammation due to aging degeneration).
>(assuming this isn't some mixture of micro and macrocytic anemia). To
>what *do* you attribute her anemia?
Chronic inflammation. MRA showed essentially only one kidney, and
the other working at about 1/3rd normal. It may be she's short of EPO.
>>And of
>> course iron in doses enough to make her already bad stomach and GI
>> problems worse (still guaiac neg, though).
>
>In patients who actually *are* iron deficient for some definitive reason
>(that's been worked up), have you tried slowly titrating up the dosage of
>iron from qd for a week or so.. to BID.. to TID ? Supposedly less GI
>upset...
Absolutely. I always give them time to get "used" to it, starting
with small doses and working up as fast as they can tolerate the
increase (which is quite variable). I give them the symptoms and let
them decide.
>> They wrote insinuating
>> notes about the wisdom of wanting to repeat the iron studies yet again,
>> before giving iron to an infected woman with GI problems and no angina.
>> And who was going to get at least some blood anyway.
>
>Not sure what the indication for transfusing her was? ? Hct of 30% and no
>active bleeding?
Actually (now that I remember) more like 28, in that she was
hemodiluted from CHF and water overload. Big deal. The renal guys would
have laughed at a crit of 28 just 15 years ago. But expectations
change, and numbers mean a lot in this business. Fix the numbers.
Don't look too hard at at the patient, or she may try to tell you her
life's story, at $200/hr.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: UPDATE-NEW (WAS eXPLAIN X-RAY ...)
Date: 17 Jan 1999 21:28:23 GMT
In <77s8gb$16q@sjx-ixn3.ix.netcom.com> sbharris@ix.netcom.com(Steven B.
Harris) writes:
> Of course. And needless to say, she had a sky high ferritin. So it
>told us nothing (for those reading along-- ferritin is an iron storage
>protein which is also an inflammatory protein. The two are not
>coincidental, because the body likes to keep unstored protein away from
>bacteria, where it is a limiting growth factor,
Wups, I mean the body likes to keep free IRON away from bacteria (I've
corrected this). One way is to store it in ferritin. Sometimes the
body is so successful at keeping iron away from bacteria (which it
assumes are present in inflammation) that it keeps it away from
developeing blood cells, too.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Obtaining blood tests anonymously
Date: 18 Feb 1999 00:14:07 GMT
In <7afgcq$9hiu$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
<MBILLIK@prodigy.net> writes:
>Hi Ed:
>
>Thanks for asking.
>Saw my doc Monday.
>We have cancelled the CT Scans, but we are doing pulmonary function testing,
>starting tomorrow afternoon.
>
>The cough just keeps coming back
Dispite all the furror, I've glad to see that my suggestions from a
month ago are finally being followed.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Strange Case of Pneumonia
Date: 13 Apr 1999 04:25:32 GMT
In <371275AA.5D15C2C5@together.net> Comrado@together.net writes:
>Last Thursday evening I had a severe ache in both shoulders and chest
>pains. I thought I was having a heart attack. Took aspirin, but since
>pains persisted I went to Emergency Ward of local hospital. My heart was
>okay, but after X-ray, I was diagnosed with pneumonia. What's strange is
>that the disease just "clicked in."
>No symptoms before. No coughing. No tiredness. In fact, I felt great
>earlier in the day.
That's quite typical for pneumococcal pneumonia, actually. So
typical that it actually helps in the diagnosis. One minute you feel
okay, the next you have shaking rigors and fell like hell.
> I've also had the once-in-a-life-time pneumonia
>shot. Can anyone give me clue as to what's happening to me and how
>long I should stay out of work.
The pneumonia shot only protects against the 23 most common kinds.
And it's not perfect even for those. And if your immune system isn't
up to snuff, you may need one more than once in a lifetime. Every five
years won't hurt you (aside from a sore arm).
As for how long to stay off work, you can go back when your blood
oxygen sats are back to normal and you've been free of fever 3 days or
so. Even if you're still taking antibiotics. That's if you feel you
can. Let your tiredness be your guide. If you're still extremely
fatigued, it may be weeks before you can back. Lab tests tell the
EARLIEST that people MIGHT go back to work, not when they MUST.
> It's impossible to find a physician in the
>small town where I live, and I don't want to return to Emergency Room,
>since I am fully aware of the giant germs lurking to attack my lowered
>immune system.
Pneumococcal pneumonia, if that's what you have, isn't very
contageous. If you're on an antibiotic and your fever and other
symptoms are gone, go back to work when you like. But do finish the
antibiotic. It's much harder to tell when you've stomped on a
pneumonia than it is when you've successfully treated a skin infection.
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Strange Case of Pneumonia
Date: 13 Apr 1999 04:32:52 GMT
In <37129AD9.F200D41B@shaw.wave.ca> The Fonz <fornssler@shaw.wave.ca>
writes:
>I too had pneumonia like this last summer -- I have heard it called
>"walking pneumonia" here. I had a mild cold but didn't feel particularly
>sick. Knowing that a lung infection is nothing to ignore, however, I saw
>dr because my chest hurt. My doctor advised I return in 10 days for
>another xray (at the end of the antibiotic prescription) to make sure the
>lungs had cleared -- turned out I needed another prescription so all in
>all it took about three weeks to clear up.
Arggghhh! My pet peeve again. Doctors who take chest X-rays of
pneumonia patients at 10 days and give them more antibiotics if they
aren't clear. You don't expect them to be clear. You look at the
*patient* (and his vital signs), not the X-ray. And listening to the
patient tell you how he feels and for how long, will tell you more
about how his pneumonia is doing, than listening to his lungs. I know
that's a horrid thought, but it's true. Alas, of course it takes
longer, and the pay isn't as good.
We were discussing what makes the cost of medicine go up?
Steve Harris, M.D.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Strange Case of Pneumonia
Date: 14 Apr 1999 07:58:01 GMT
In
<450BF2A1405DBE7A.55D0AAAF14FCEA79.C4FF229BA773910F@library-proxy.airne
s.net> jrfox@no.spam.fastlane.net.no.spam (Jonathan R. Fox) writes:
>On 13 Apr 1999 04:32:52 GMT, sbharris@ix.netcom.com(Steven B. Harris)
>wrote:
>
>> Arggghhh! My pet peeve again. Doctors who take chest X-rays of
>>pneumonia patients at 10 days and give them more antibiotics if they
>>aren't clear. You don't expect them to be clear. You look at the
>>*patient* (and his vital signs), not the X-ray. And listening to the
>>patient tell you how he feels and for how long, will tell you more
>>about how his pneumonia is doing, than listening to his lungs. I know
>>that's a horrid thought, but it's true. Alas, of course it takes
>>longer, and the pay isn't as good.
>>
>> We were discussing what makes the cost of medicine go up?
>
>Same thing with docs who look in an infant's ear after a course of
>antibiotics for otitis and prescribe another course because there's a
>residual effusion.
>
>--
>Jonathan R. Fox, M.D.
Yep. Impatience. When things are going in the right direction,
tincture of time is often the best medicine. And nearly free.
Though I once read of an ad in a newspaper: "Lost: one golden hour
studded with 60 diamond minutes. No reply is necessary-- they are gone
forever."
Steve
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Strange Case of Pneumonia
Date: 14 Apr 1999 08:45:41 GMT
In <371410CA.2A886C51@shaw.wave.ca> The Fonz <fornssler@shaw.wave.ca>
writes:
>Steven B. Harris wrote:
>
>> Arggghhh! My pet peeve again. Doctors who take chest X-rays of
>> pneumonia patients at 10 days and give them more antibiotics if they
>> aren't clear. You don't expect them to be clear. You look at the
>> *patient* (and his vital signs), not the X-ray. And listening to the
>> patient tell you how he feels and for how long, will tell you more
>> about how his pneumonia is doing, than listening to his lungs. I know
>> that's a horrid thought, but it's true. Alas, of course it takes
>> longer, and the pay isn't as good.
>>
>> We were discussing what makes the cost of medicine go up?
>>
>> Steve Harris, M.D.
>
>Well, I didn't go into all the details in my post, but I was also
>wheezing and coughing and breathing poorly and feeling tired at the end
>of the first run of antibiotics, too. So maybe my dr didn't do so badly
>after all?
Wouldn't have done better to keep treating you on that basis alone,
so long as you were improving slowly with time. No X-ray needed.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Flu! (Re: Need advice again--Dr. Harris??)
Date: 29 Sep 1999 11:27:18 GMT
In <7sme96$2rga$1@newssvr04-int.news.prodigy.com> "Melvin Billik"
<MBILLIK@prodigy.net> writes:
>You may recall that almost exactly one year ago I had a sinus infection
>that quickly became pneumonia and I had a he** of a time getting over it.
>It took many many months. I missed over 7 weeks of work but still had
>coughing, night sweats, etc. for a few months.
>
>Anyway, it eventually did clear up.
>
>BUT, right now once again I got a miserable sinus infection. It looks
>like I'll have to go to the doc. and get some antibiotics. Here's my
>concern:
>
>A few of you said that pneumonia is sometimes a rare complication of an
>antibiotic. BUT, I can't remember which one!!! I'd like to know that so I
>can avoid it this time.
>
>Does anyone know/remember which one??
>
>Mel Billik
I'm surprised you're not dead yet of all that cancer your docs were
worried was in your lungs. Gosh. Just pneumonia, eh?
Far as I know, no antibiotic predisposes to pneumonia. People do
appear to get pneumonia from sinusitis and post nasal drip, sometimes
(though most pneumonia is not from this). Hope you're on the standard
sinus stuff as well as an antibiotic-- nasal steroids, perhaps even
Singulair/montelukast if you have any asthma at all (may even work for
bronchitis and sinusitis, since leukotrienes are also involved). I
believe we mentioned that the macrolyde antibiotics, including
relatively cheap erythromycin, are also antiinflammatories. So
erythromycin, azithromycin/Zithromax (next cheapest), and
clarithromycin (Biaxin) work quite well for sinus sufferers with
allergic and asthatic components. Which most have. But bad sinus
infections as well, the treatment depends a lot on duration. For long
term ones, the gold standard is probably still amoxicilin/clavulinate
(Augmentin), due to the anaerobes. Fluoroquinolones that cover
anaerobes (Levoquin) also seem to work.
Get your flu shot when they come out next month. And everybody,
remember that this year there is not only amantidine/rimantidine, but
also (due in a few weeks) a new oral neuraminidase inhibitor which
(unlike the first two relatively old drugs) is an antiviral which works
both flu A and flu B, much like the (still illegal or impossible to
get) ribivirin does. It should work synergistically.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: how long is pneumonia contagious?
Date: 6 Jan 2000 10:59:41 GMT
In <xz90OGsfim1UQfNBmPV92CQfEBVo@4ax.com> Carey Gregory
<cgregory@gw-tech.com> writes:
>soma@nospam.dorsai.org (*selah*) wrote:
>
>>Anyone know how long after the symptomatic disappearance of pneumonia
>>that it is no longer contagious? Or, how long after disappearance of
>>symptoms would it be safe for a health care provider to resume caring
>>for an elderly person?
>
>Pneumonia caused by what? Pneumonia can be caused by many things,
>some of them not contagious at all.
Yep. Most of them, in fact. In the elderly, almost all.
From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: how long is pneumonia contagious?
Date: 11 Jan 2000 09:43:28 GMT
In <slrn87lk0a.19e.soma@amanda.dorsai.org> soma@nospam.dorsai.org
(*selah*) writes:
>The information I received is that now the diagnosis is asthmatic
>bronchitis.
Well, pneumonia is pneumonia. If they have decided that now it is
asthmatic bronchitis, that only means somebody didn't do a very good
job in the first place getting the diagnosis right, but probably should
have. If you think a person has pneumonia, they ought to get a chest
X-ray. Although in a healthy young person who isn't too ill and has
good oxygen levels the treatment may not be much different than an
exacerbation of bacterial bronchitis, the difference in making the
diagnosis of pneumonia for certain, is that you at least watch it much
more carefully. The art of medicine lies very much in knowing when
there is some purpose to be served in raise everybody's anxieties (as
there is with pneumonia), and when there isn't. Here, it sounds like
somebody screwed up.
From: David Rind <drind@caregroup.harvard.edu>
Newsgroups: alt.smokers,sci.med
Subject: Re: Can staph infection occur in lung?
Date: Sun, 09 Mar 2003 12:02:15 -0500
Message-ID: <b4fs31$drf$1@reader2.panix.com>
Richard Cavell wrote:
> I guess doctors learn to be precise about what the know and not to 'assume'.
> If he grew Staphylococcus from his sputum then it's very probably in his
> lung infection.
Do you have some data or a reference to support that? In my experience,
most times staph grows from a sputum culture it is from oral or
tracheal flora and does not represent staph pneumonia. Staph pneumonia
is typically an overwhelming purulent infection and hard to miss.
The usual setting is after an influenza infection.
--
David Rind
drind@caregroup.harvard.edu
From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med.nutrition,sci.med,talk.politics.medicine,
misc.health.alternative
Subject: Re: Speaking of the pneumonia vaccine ...
Date: 22 Oct 2005 09:43:33 -0700
Message-ID: <1129999413.041125.19960@g14g2000cwa.googlegroups.com>
Mr-Natural-Health wrote:
> The the pneumonia vaccine protects only against bacterial forms of
> pneumonia. It is a miserable failure against all viral forms of
> pneumonia.
>
> Ergo, it protects against only about 5% of all forms of pneumonia.
>
> Ergo, the the pneumonia vaccine is a miserable failure.
>
> Just my opinion, but I am NEVER wrong. :)
COMMENT:
Doofus, one of the reasons pneumococcal pneumonia is down to that low a
percentage is BECAUSE of the pneumonia vaccine.
FYI, pneumococcal pneumonia has a greater mortality rate than the
average viral pneumonia (excluding influenza, for which there is also a
vaccine). It's not the incidence of pneumonia we worry about, but the
incidence of pneumonia death.
SBH
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