APRIL 2011
Khaas Baat : A Publication for Indian Americans in Florida
Health & Wellness



This is a case history from my practice file that illustrates the role of positive thinking, motivational counseling and above all optimism and hope in bringing a successful outcome in a seriously ill patient.

How would you react if your doctor tells you that you have only six months to live? An impending death! Shock, depression, extreme anxiety, fear, despondency and finally, “Oh what the heck, man has to die one day,” attitude, will ensue in succession.

That was what Ted Nolin (not his real name) felt when he was told that his days are numbered. At the age of 70, when diagnosed with heart failure (HF), he was taken aback. It sounded like a death knell. Ted had suffered from hypertension and diabetes. But when he was admitted a third time in severe pulmonary edema, gasping for breath, he thought that his worst fears were coming true. Unfortunately, his cardiologist Dr. Hamby wasn’t very encouraging.

“Your husband has severe recurrent heart failure, probably has about six months to live,” he told Mrs. Nolin. She was in tears, not knowing what to do. When the news was communicated to Ted, he was sad but stoic.

“It’s God’s will, I suppose,” he said.

When Ted was admitted for the fourth time, I happened to be on call for cardiology. The primary care physician called me and said, “Dr. Nathan, can you take care of this patient? He has dilated cardiomyopathy and recurrent heart failure and Dr Hamby thinks it is end stage and has probably only six more months. The patient and family know this. And Dr. Hamby is not coming to this hospital that often.”

Initially, I felt uncomfortable accepting a dying patient to my service just because his own cardiologist has given up on him. I knew Dr. Hamby still comes to take care of his private patients here. “What do you want me to do? If he is in end stage and everything has been done already, what more can I do, except giving comfort measures, perhaps?” I politely asked him with reluctance. Finally, I did accept the patient and got ready to give some palliative care.

It is always my policy when I accept a patient from another cardiologist, to take a fresh history and review all aspects of the care to get a true insight into his illness, and see if I can do anything more for the patient, or find something which has been overlooked before. I want to learn the facts first hand. All of us have busy schedules and sometimes we just don’t have enough time to sit down with the family and go over each and every aspect of the disease management, despite our best intentions.

In reviewing the history, clinical data and all the tests, it became apparent that the patient was indeed in ‘end stage heart failure.’ His work up had revealed that he had developed severe non-ischemic dilated cardiomyopathy with an ejection fraction barely over 10 percent (normal over 55 percent), no doubt contributed in part by his diabetes, hypertension and moderate alcohol usage. Yes, he has been getting the standard drugs like digoxin, diuretics, vasodilators, etc. But they were insufficient to forestall these recurrent admissions. Cardiac transplantation was considered, but Ted was too old for such exotic therapy at that time.

Now that he has been transferred to my care, I decided to do the best I can to alleviate his suffering. When I saw him first in the emergency room, he was almost frozen with terror, having difficulty in breathing coupled with a sense of impending doom. I quickly got him out of his pulmonary edema. Once he was stable, I sat down with him and his wife to give some counseling.

* Will conclude in the next issue.

* With permission from Medical Economics where an edited version was published on Dec. 17, 2010 under the title “Prescribing Hope.”

Dr. M.P. Ravindra Nathan is a Brooksville cardiologist and director of the Hernando Heart Clinic.

Guest Column





Cancer of the food pipe and upper end of the stomach are the most rapidly increasing cancers. Reflux of stomach acid and obesity are factors related to its rise. In the United States, there are no recommendations to screen the general public for esophageal or stomach cancer. Symptoms such as heartburn (burning sensation in the chest), regurgitation of sour liquid, difficulty swallowing food or discomfort in the upper abdomen need to be assessed by a gastroenterologist. Patients with a past history of stomach ulcer or a precancerous condition of the food pipe called Barrett esophagus (www.slideshare.net) need to be seen by a gastroenterologist. Patients with family history of esophageal cancer or Barrett esophagus may need a screening upper endoscopy.

Upper endoscopy is a 15-minute procedure done under sedation using an endoscope (a soft, thin and flexible rubber tube with a camera inserted through the mouth) to look into the food pipe, stomach and upper small bowel, to detect and sample abnormalities of the upper gastrointestinal tract. The current endoscopes are equipped with enhanced imaging (high definition, specific bands of light) to detect Barrett esophagus (precancerous change in the lining of the lower end of the food pipe) and early cancer. In addition to advances in endoscopic imaging, there have been significant advances in methods to treat Barrett esophagus and early cancer. Endoscopic treatments include removal of the cancer (endoscopic resection) and those that destroy tumor tissue (called ablation). Endoscopic ablation may be done using heat (radiofrequency) energy or intense cold to freeze tumor tissue (cryoablation).


Pancreatic cancer is the fourth leading cause of cancer death and is difficult to diagnose early, as there are no specific symptoms. Diabetes, jaundice, abdominal pain may precede the diagnosis in some but none are consistently helpful. The pancreas is a gland that secretes digestive juices located in the back of the abdomen and also helps in controlling blood sugar by making insulin. Long-standing inflammation of the pancreas and pancreatic cysts (fluid filled sacs) (gastro.ucsd.edu) are some risk factors for pancreatic cancer. Studies are being conducted to improve the early and accurate diagnosis of the precancerous abnormalities using newer sampling methods and genetic studies. For specific information on studies, use contact information at the end of the article (www.drugdiscoverynews.com).

Being located in the back of the abdomen, the pancreas is difficult to image. A procedure called endoscopic ultrasound (EUS), done using an endoscope with a miniature ultrasound mounted on its tip, is the best imaging modality for pancreatic disease. EUS also enables precise image-guided needle biopsy. When performed by an endoscopic oncologist*, the EUS procedure is safe, outpatient procedure that takes approximately 30-45 minutes. It is performed as a screening procedure in patients with a strong family history of pancreatic cancer, in patients with cysts in the pancreas or some patients with long-standing inflammation of the pancreas (chronic pancreatitis).

Biliary cancer involves the bile ducts and can also be diagnosed and staged by EUS. ERCP is an endoscopic procedure with simultaneous real-time X-ray images that enable diagnosis of bile duct abnormalities. With ERCP, one can place plastic tubes called stents to drain bile ducts that are blocked. ERCP guided radiofrequency ablation (destroying tumor with heat) for biliary cancer is feasible, minimally invasive treatment for patients who cannot receive surgery. This is intended as an adjunct to chemoradiation. Tiny endoscopes can be passed up the bile duct to the liver are available now for direct visualization and sampling of biliary tumors. Tumors of the ampulla (name of the area in the bowel wall where the bile duct drains bile) can be removed with and outpatient ERCP. ERCP is usually an outpatient procedure though patients are sometimes admitted for 24 hour observation. A gastroenterologist or endoscopic oncologist (perform EUS, ERCP, Endoscopic resection and ablation) has to see the patient to comment on specific situations.


The primary care physician has the crucial role of recommending the appropriate screening for a patient or referring them to a gastroenterologist. Patients may self- refer themselves to sub-specialists in GI cancer called endoscopic oncologists. Endoscopic oncologists (www.slideshare.net) are specialists in endoscopic methods to diagnose, stage and treat gastrointestinal cancers and gastrointestinal problems related to other cancers. Prevention of cancer with screening methods is one of the important roles of the gastroenterologist. Treatment should be coordinated between your primary physician, gastroenterologist and oncologists.

Abbreviations: Endoscopic Ultrasound (EUS); Endoscopic retrograde cholangiopancreatography (ERCP).

Dr. Shivakumar Vignesh is an Endoscopic Oncologist at H. Lee Moffitt Cancer Center and Research Institute in Tampa and can be reached at (813) 745-3824 or email shivakumar.vignesh@moffitt.org

homeeventsbiz directorysubscribecontentclasses/places of worshipnewseditorialhealthimmigrationfinance
techno cornermoviesfashionmusic/dancebooksyogahome improvementastrologycuisinemotoringgetawayclassifiedsARCHIVES
Read the Editor's Blog. By Nitish Rele Classifieds Getaway Motoring Cuisine Astrology Home Improvement Books Yoga Music and Dance Fashion Movies Techno Corner Finance Immigration Health Editorial News Classes/Places of Worship Content Find us on Facebook!