Re: Re: JC in NIH - protocol 00-CH-0160 CT-SCAN W/contrast

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And you have had a prior CT as I recall?CE Grim MDOn Apr 4, 2012, at 1:26 PM, wrote: The story dealing w/contrast is specifically addressing Metformin. It is apparently related to the iodine material conflicting with something in metformin. They recommend discontinuing it UNDER DOCTORS SUPERVISION (at least 2 days in advance apparentl) and not resuming for at least 48hrs and after checking BUN and creatinine. There's 13 meds listed and SXSs listed but I currently only have it in hard copy. I have asked for an electrionic copy or will have to deal with it when I get home. I believe I can answer the PA question because we are still in the gathering facts stage and it would be and error to use contrast when looking for a DX of PA when you have a strong indication of PA. I may try to ask some questions but they will probably directly relate to me. Time is limited to even get my questions answered. (That may change tomorrow when I think I will meed with the whole team and we discucuss what all these tests have found and where we are headed!) > > > For you on Metformin - when I got here they immediately stopped my Metformin and are monitoring my blood glucose before every meal and at bedtime. Also at other times it seems to happen right after I harras the nurse! Is harrassing a nurse likely to cause my BS (that's Blood Sugar, ) to rise? > > > > Okay, get serious! Why do they do it you ask, because Metformin has been shown to cause Kidney problems when you do a ct-scan with contrast! Dr. Bobby explained that me and Nurse Jill just came in and saw what I was working on and "Oh, Yea, a minimum of 2 days" so that may be a warning if your doctor insists w/contrast. > > > > .... > > > > >

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I've had so many scans with contrast the past 7 years. Maybe this is where the renal cyst popped up as it wasn't there before. If only they could see something on the adrenals.

From: <jclark24p@...>Subject: Re: JC in NIH - protocol 00-CH-0160 CT-SCAN W/contrasthyperaldosteronism Date: Wednesday, April 4, 2012, 8:58 PM

Twice, 2005 and 2010. They want me to go back further in the private sector and see if I can find any more.>

> >> > > > For you on Metformin - when I got here they immediately stopped > > my Metformin and are monitoring my blood glucose before every meal > > and at bedtime. Also at other times it seems to happen right after I > > harras the nurse! Is harrassing a nurse likely to cause my BS > > (that's Blood Sugar, ) to rise?> > > >> > > > Okay, get serious! Why do they do it you ask, because Metformin > > has been shown to cause Kidney problems when you do a ct-scan with > > contrast! Dr. Bobby explained that me and Nurse Jill just came in > > and saw what I was working on and "Oh, Yea, a minimum of 2 days" so > > that may be a warning if your doctor insists w/contrast.> > > >> > > > ....> > > >> > > >> > >> >>

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Each scan gives u a good radiation dose. I forget the multiplier but it is more than a bunch of chest X-rays. May your pressure be low!CE Grim MS, MDSpecializing in DifficultHypertensionOn Apr 4, 2012, at 23:18, Bingham <jlkbbk2003@...> wrote:

I've had so many scans with contrast the past 7 years. Maybe this is where the renal cyst popped up as it wasn't there before. If only they could see something on the adrenals.

From: <jclark24p@...>Subject: Re: JC in NIH - protocol 00-CH-0160 CT-SCAN W/contrasthyperaldosteronism Date: Wednesday, April 4, 2012, 8:58 PM

Twice, 2005 and 2010. They want me to go back further in the private sector and see if I can find any more.>

> >> > > > For you on Metformin - when I got here they immediately stopped > > my Metformin and are monitoring my blood glucose before every meal > > and at bedtime. Also at other times it seems to happen right after I > > harras the nurse! Is harrassing a nurse likely to cause my BS > > (that's Blood Sugar, ) to rise?> > > >> > > > Okay, get serious! Why do they do it you ask, because Metformin > > has been shown to cause Kidney problems when you do a ct-scan with > > contrast! Dr. Bobby explained that me and Nurse Jill just came in > > and saw what I was working on and "Oh, Yea, a minimum of 2 days" so > > that may be a warning if your doctor insists w/contrast.> > > >> > > > ....> > > >> > > >> > >> >>

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Incidence of Contrast-Induced Nephropathy after Contrast-Enhanced Computed Tomography in the Outpatient SettingAlice M. ,* Alan E. ,* A. Tumlin,† and A. Kline**Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina; and †Chattanooga College ofMedicine, University of Tennessee, Chattanooga, TennesseeBackground and objectives: No prospective study has reported the incidence of contrast-induced nephropathy (CIN) or theassociated morbidity and mortality after contrast-enhanced computed tomography (CECT) in the outpatient setting.Design, setting, participants, & measurements: We enrolled and followed a prospective, consecutive cohort (June 2007through January 2009) of patients who received intravenous contrast for CECT in the emergency department of a large,academic, tertiary care center. Outcomes measured were as follows (1) CIN: An increase in serum creatinine >0.5 mg/dl or>25% 2 to 7 d after contrast administration; (2) severe renal failure: An increase in serum creatinine to >3.0 mg/dl or the needfor dialysis at 45 d; and (3) renal failure as a contributing cause of death (consensus of three independent physicians) at 45 d.Results: The incidence of CIN was 11% (70 of 633) among the 633 patients enrolled. Fifteen (2%) patients died within 45 d,including six deaths after study-defined CIN. Seven (1%) patients developed severe renal failure, six of whom had studydefinedCIN. Of the six patients with CIN and severe renal failure, four died, and adjudicators determined that renal failuresignificantly contributed to all four deaths. Thus, CIN was associated with an increased risk for severe renal failure and deathfrom renal failure.Conclusions: CIN occurs in >10% of patients who undergo CECT in the outpatient setting and is associated with asignificant risk for severe renal failure and death.Clin J Am Soc Nephrol 5: 4–9, 2010. doi: 10.2215/CJN.05200709 I've had so many scans with contrast the past 7 years. Maybe this is where the renal cyst popped up as it wasn't there before. If only they could see something on the adrenals.

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and how many had PA. Because DM has been associated with CIN the metformin issue may be clouded by the presence of DM for which the metfomin was given.In the case of DM due to PA it should get much better with correction of PA. NIH must have some good data on this if they are studying folks before and after Rx or surgery. CE Grim MDOn Apr 5, 2012, at 1:12 AM, wrote: A great scare tatic IMHO but incomplete. Of those 70 PTNs out of 633 were on metformin or one of the 13 meds identified to contain metformin? Once you eliminate those it would be interesting to see the numbers and know how big or if there is a problem. Next week I may have time to dig deeper if this rises to the top of my open issues pile. In the meantime if you have questions I will quote the bottom of the sheet I was given. "If you have any further questions, please contact one of the nurses in the Diagnostic Radiology Department @ 301-402-0256, M-F 8AM-4PM" >

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Apesoline is a very good drug but I always started it with inderal when I waited to get BP down fairly quickly. Usually worked well. If not at goal by 24 hr change to minoxidil. I used 10 mg each every 4 hrs and increased to by 10 mg each every 4 hrs till BP got to goal or we reached 80 mg of each every 4 hrs. When I first developed this treatment plan I call it the AID approach. Apresoline Inderal and diuretic. But when AIDS came in I changed it to DIA and could usually get BP to goal in 24 hrs. If the nurses and dr followed the orders to increase every 4 hr. I always wrote in the orders: Yes I do want to increase the dose EVERY FOUR hours till at goal. And you see why I always start low and work up. CE Grim MDOn Apr 5, 2012, at 12:15 PM, wrote: Yes and the numbers are probably lower today than they were 10 - 15 years ago. Maybe you should check the date of manufacture before you allow them to test! And if you have a clearly identified adenoma in one gland on a scan w/o contrast but find it and in addition another "highly likely" adenoma in the other along with probable excess corisol and small potential adenomas in the "good" gland when you use contrast which do you pick? Life is a bunch of choices, do you die at age 90 from excess radiation or do you die at age 70 from inproper dx! The choice is yours, you live with them or maybe not! Well,I am finishing this Thurs. am because we took a break last night. I'm not sure how it started and I remember how it ended but apparently there was a little in the middle that while I participated in I wasn't aware of! Four wonderful nurses were standing around with very concerned looks on their faces. I told them if someone didn't start smiling I was going to call a "code blue" and see if I could find someone who was happy! They all smiled and then there were some comments and suggestions that probably not be repeated here! (They all appeared to be in agreement!) I felt it a priviledge to break up the bordom of their night shift at 2am but probably not repeat the performance tonight! Oh yea, in case you are wondering what happened, they are trying to get my blood pressure down. They tried to do a do a double increase of Hydralizine yesterday: from 10mgbid to 4 times a day and after 2 readings raised the dose to 25mg and that's when I became noncompliant! (I felt some possible side effects when they gave me the second 10mg dose 2 hr after the first to "get on a schedule" (I understand getting on a schedule but I would have delayed 2 hours and got on that schedule(I know, I know Doctor's orders. I wish type A personalities would swing slightly toward type B and develop a little patiences but that's another story!) I refused to change until I spoke to my doctor, she's an endo. She basically agreed to drop the hydralizine back to 10mg bid and I let my guard down and let her add Terazosin 5mg at bed time. Sounded safe enough. My nurse this morning, Nurse Dianne, explained that terazosin has a long half-life and takes 2 1/2 hrs. to reach its full effect. She felt it might be a good idea to consult with a Card. The short story is my BP went from 175/88 to 110/61 after the teraz. (which was exactly what I had explained to my endo that I didn't want to happen before we started!) My body appears to object being treated like a yo-yo! She didn't want to contact a Card, BP was her responsibility as it can be managed by anyone! (Right Dr. Grim!) I agreed RX a 2.5 dose and reserved the right to go noncompliant depending how I felt at bedtime! BTW, she was extremely happy with 110/61, I was not. She was on her way to a conference so I told her we would go over the ACCORD Trial and disuss her view on the J-Curve when she had a few minutes! (IMHO, If she is responsible to treat BP she should know at least as much as the average PTN!) Dr. Bobby just stopped by, big meeting with whole team is scheduled for tomorrow late morning. He said to bring all my questions. I suggested he bring his dinner - he indicated he follows the Greek tradition of eating around 4, I told him Real Vermonters only eat after dark! He asked a little about Vermont and indicated he had another PTN coming from Vt in May! Now I have to research that, there's only ~500,000 people in VT! > > > > > > > > > > > For you on Metformin - when I got here they immediately stopped > > > > my Metformin and are monitoring my blood glucose before every meal > > > > and at bedtime. Also at other times it seems to happen right after I > > > > harras the nurse! Is harrassing a nurse likely to cause my BS > > > > (that's Blood Sugar, ) to rise? > > > > > > > > > > > > Okay, get serious! Why do they do it you ask, because Metformin > > > > has been shown to cause Kidney problems when you do a ct-scan with > > > > contrast! Dr. Bobby explained that me and Nurse Jill just came in > > > > and saw what I was working on and "Oh, Yea, a minimum of 2 days" so > > > > that may be a warning if your doctor insists w/contrast. > > > > > > > > > > > > .... > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >

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And the conclusion is? So there are bilateral bumps?CE Grim MDOn Apr 5, 2012, at 7:48 PM, wrote: Yes, I get the scope of this research project is limitted to me. That is why they have such an intense 10-12 week schedule, mine is 12 and I suspect it is because they saw something on the 2005 scan and may of had a damn good guess before I got here. In fact, one of the doctors called me before I came and said they were more concerned about my left adrenal than the right. Ct-scan with contrast painted a perfect picture and appears to all but confirm a conclusion. He didn't state it but welcomed my children down to visit anytime for a much shorter visit (2 days maybe). > > > > > > > >

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Avoid removing 2 like the plague!Are they testing both aldo and cortisol with the Dex test? If not they should be. Good way to rule out GRA as we first reported years ago. But this was likely before your team was born.

Grim

CE, Weinberger MH, and Anand S. Familial, dexamethasone suppressible,

normokalemic hyperaldosteronism. In Hypertension in Childhood, (M. New ed),

Raven Press, New York, 1977;109-122.Grim

CE, A Ganguly, MH Weinberger. A Rapid

Method to Differentiate Glucocorticoid-Suppressible Hyperaldosteronsim from

other Causes of Primary Aldosteronism with an Anomalous Postural Response of Plasma

Aldosterone. Serono Symposia Review 1986 10: 69-78.

CE Grim MDOn Apr 5, 2012, at 9:03 PM, wrote: My meeting with Dr. M. was not to provide me with a conclusion, It was to share and explain the testing to date including the scans. He did it one on one to allow me time to ask questions so I would be comfortable discussing with the whole team tomorrow morning late. Our meeting ended at 6:45, my previously hot dinner had been sitting on my table for an hour! My final question was to ask if he had any children. His answer was "No". The final "JC Harrassment" of the day was to tell him I thought I knew why! He left with a relaxing and fleeting smile had the luxury of thinking of his wonderful wife for 30 seconds as he headed for "at least 3 more hours of work". I left to find a microwave and spend the next 28 hours (so far) wondering how my kids will react! And does that include second generation? BTW there was one gotcha moments for me when I asked if genes CYP11B2 and CYP11B1 might come into play! When the pro sits a little further back in his chair and gives you a 10 second stare you know you have just scored a point! I won't win the game but sometimes you feel good just scoring a point! I may have been on the right subject but not for the right reason! I wonder if the action of Spirnolactone exasserbates the problem! As for number of bumps, I saw one and he went into detail showing me how he knew it was benign. In fact I stopped him and told him that was not a concern for me. I will probably never read another one so if I want to have a guess as to what is going on I will ask a local professional to read it and if I want to really know what is going on I'll ask NIH to tell me! I know I have a 5yr commitment and quite likely a lifetime to this project! (Pretty good return on my $350 investment!) I do not expect an answer tomorrow because I will be in the second day of a low dose DEX test and then have a 2day high DEX test, then Cortisol, ACTH and Dex levels Monday. Daily 24h urine ends Thurs with an AVS done Thurs if necessary. Bun and creatinine on Friday, to see if okay to restart Metformin and an ACTH stim test (aldo and cortisol up to 120 min and discharge if appropriate. If I was a betting man I would bet the final recommendation will be to remove zero anrenal glands at this point and the only other intelligent option will be to remove two! Any takers? .... > > > > > > > > > > > > > > > > > > > > >

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Right but you have been advoating all less that 40 and a bump have ADX without AVS. Based on your reading of the extensive literature. Another good question to ask is how many of those with a big nodule also have micronodules under the microscope in the same gland and in the other gland? CE Grim MDOn Apr 5, 2012, at 9:39 PM, wrote: As I am 65 it is probably not relevent to my study. > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >

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Glad you have gotten down there. This is the sort of facility I worked at most of my professionals life. GCRCs. However many have been closed down. I suspect Dartmouth had one at one time. Each one has difference specialties depending on the faculty there. However the cut back in health research funding has eliminated most of them now. Also most Medical Schools no longer pay salaries to teach and faculty now have to generate their income by practice mostly. The competition for grants is intense and current funding runs about 15% of submitted grants. So if you spent lots of time preparing a grant and it does not make it after one or two times most move on to practice. If you want to read some history of renin done at NIH search for articles by Dr. JO who is the one who discovered that renin (AII) was the circulating factor that controlled aldosterone. He was studying a model of heart failure in dogs that he devised to try to find out what made aldo go up so much in CHF. CE Grim MD On Apr 5, 2012, at 11:50 PM, wrote: You must have missed my response (42054) to your question (42050). I detailed the current phase so I believe you could draw a conclusion however until the tests are completed they won't offer a decision and I feel if I do it only becomes my opinion which I very probably could have offered before I came down. They appear to be confirming my suspesion and I knew I was not being tested correctly. As to your suggestion to avoid removing both just stating the obvious. I won't remove a foot to DM2 or a lung to cancer unless the alternatives are are worse (It might even be death!) They will make a recomendation based on 12 days of testing and I have great confidence it will be in my best interest! If surgery is an option they are required by law to recommend at least two other places to have it and NIH. (They encourage here by one of the best Lap. Surgeon for ADx in the country so they can do further study on the tissue removed and will even put my wife up for the duration of the hospital stay.) You may find this hard to believe but I have approached this with both eyes wide open and done a lot of considering of other options. I will certainly detail my opinion when we conclude the test! > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >

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I know how your team feels and works.Well it is not really free unless you pay no taxes. NIH is a major research treasure of the world but some would like to cut the funding back a lot. CE Grim MDOn Apr 6, 2012, at 12:48 AM, wrote: Let me be perfectly clear. This is a research project that involves exactly one individual and potentially his family. While it would be nice to have the undivided attention of some of the best research scientists (IMHO) their time and energy will not allow it! Besides since the protocol is not complete and they have not published any intrim results that I know of, you would find them on pubmed I imagine so it would be THEIR OPINION, IMHO I paid ~$350 for the previdledge of being evaluated by some of the best in the land (IMHO). In return I get follow up service for 5 years and maybe more but 5 is guaranteed! I get to return at any time if I need follow up for free. My three children have already been invited down here for a couple of days, for free - they may have to pay their own way. I'm not sure about my two grandaughters! And the cost is Free, Absoultely Free, zilch but I understand why they can not provide me and open book to any and all information that might appear to involve PA. (I am already sure the would love to talk about their knowledge if time permitted but they are so involved and dedicated (IMHO) I am quite sure time does not permit. And I got one hell of a bargin, 4 and maybe 6 for the price of one! And there may be good information for my children to decide whether I have any more genitacally related grand kids (and I will make no opinions be known there! And since I have 4 living siblings the party MAY get bigger, I and qualified and could probably rent a 56 passenger bus and could probably fill it. That question will probably come up tomorrow (Depending on what I hear ;>)) I will also point out I have NEVER advocated a 40 yo cutoff for AVS! I have posted results of other's research! Please don't shoot the messenger, I don't practice medicine w/o a license so I don't have malpractice insurance! I really have to go to bed to not repeat last night's experience, I hope! .... please ignore the typos. I do not have the resources and am too hurried to spend any more time and get it perfect! > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >

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Ah but if it is familial aldo it starts at birth and genetic testing will reveal it before BP goes up or K goes down.CE Grim MDOn Apr 6, 2012, at 7:50 AM, Francis Bill SUSPECTED PA wrote: Is you K still the same as what the VA said it was? > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >

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The head of diabetes there was my resident when I was at Duke. Dr. Horton but can't recall first name (??) or maybe he was at Vermont. Seems to me he has move to Boston. On Apr 6, 2012, at 11:35 AM, Francis Bill SUSPECTED PA wrote: If Dartmouth did research on PA then what they learned either was different from you learned or they do not pass on what they learned to med students. Darthmouth does do a lot of research in other fields. A lot of there income comes from grants. Belive they have 12 full time labs. > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >

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He is the one!. He and I were at Duke at the same time from 1964-67.Looks a bit older but the same. I see him every few years at a meeting. Likely his work has influenced my stressing that most adult DM will go away if you DASH and lose weight.CE Grim MDOn Apr 6, 2012, at 12:28 PM, Francis Bill SUSPECTED PA wrote: Did a search for Horton on Dartmouth web site. came up with Dr Horton who I believe is the one you are referring to. Go to link to read some history on him. http://dartmed.dartmouth.edu/summer06/pdf/alumni_album.pdf > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >