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Dr. Misra's USAF BlogsPosted on: 11/29/2015
Wreaths Across AmericaPosted on: 09/22/2015

Dr. Misra's USAF Blogs
Posted on: 11/29/2015

Cancer: A primer for the uninitiated, thoughts and insight about this complex issue touching millions the world over.
Posted on: 09/23/2015


Q: Cancer is such a terrifying word because it so often strikes fatally.  Can you give us your thoughts about this diagnosis which is so difficult for us to wrap our mind around?

A: The term “cancer” in our vernacular references to all neoplasms (growths of cells which are pathological) and often does not confirm to any one specific type of cancer.  This is an important to make clear as the outcomes for different cancers vary quite significantly.  For example, when I was a medical student doing my surgical rotations in Southern California, I asked the Colo-rectal surgeon I rotated with then why he chose this surgical sub-specialty.  His answer I believe is useful to this discussion – Colo-rectal cancers are one of the few cancers you can screen for.  When colon cancers are identified at an early enough stage, surgery for them can be completely curative. This is in stark contrast to stomach cancer or esophageal cancers wherein the prognosis often is poor with dismal outcomes/cure rates.  This is why countries wherein these two cancers have the highest incidence and prevalence (Japan and Korea), have screening protocols for the same in hopes to catch these neoplasms before it is too late which is more often the case upon initial diagnosis of them.

Q: Fascinating.  Given the variety of this disease, can you speak to other types of common cancers with examples?

A: Sadly there are a set of cancers for which there are no known risk factors having the worst of survival rates and outcomes.  Examples of these types of cancer include Glioblastoma Multiforme (one of the most lethal cancers of the brain) which Mr. Beau Biden (late son of Vice President Joe Biden) succumbed to earlier this year.  Another example of a “bad” cancer on these lines per poor prognosis is cholesteatoma (an aggressive cancer of the ear).  On a different note, there are some genes which when present are risk factors for certain cancers (i.e. BRCA I and BRCA II for  breast cancer).  Actress Angelina Jolie in response to the knowledge she has these genes elected to have a double mastectomy (surgical removal of both breasts) in spite of no evidence of breast cancer in her at all.  Having the genes does not necessarily mean one will get the cancer for which one is at risk, nor does absence of such genes ensure one can not get a said cancer as denovo (“out of the blue”) cancers can occur as well.  Certain cancers are known to be slower moving, like thyroid or prostate cancer which (save for some sub-types) rarely are fatal.  For the majority of men with prostate cancer, most die with it rather than because of it, especially if they live well into and beyond their seventh decade.

 Q: Are there things we can do to help reduce our chances of getting cancer?

A: Yes – we know that certain associations/exposures sharply increase the probability of cancer risk.  To enumerate a short list of problematic relations/exposures, I will be enumerate with seven essential examples:

1.       Tobacco – It is the single largest avoidable cause of cancer, whether smoked or chewed.  Apart from being directly correlated to lung cancer, it is implicated in bladder and oral cancers apart from enumerable other health problems.

2.       Alcohol – Emerging evidence demonstrates there is no minimal consumable safe level of alcohol without increasing the risk of a range of cancers (not just liver cancer).

3.       Meat/flesh -- Neu5Gc  is a sialic acid found in meat products implicated in at least primary liver cancers by causing a chronic inflammatory state.   Meat also decreases blood ph; higher blood ph is protective against cancer and is achieved by centering on a plant based diet.  Further, the stagnation of meat/flesh in the colon results in polyps which are pre-cancerous lesions specifically looked for on screening (colonoscopy).

4.       Sun exposure – While some sun exposure is extremely healthy, too much UV radiation exposure is directly correlated to malignant melanoma, squamous cell and basal cell carcinoma.  My colleague Dr. Lavanya Krishnan, a Board Certified Dermatologist here in San Francisco was recently featured on the local news (TV) to discuss sun screens and some of the unique and useful things to know regarding them:

5.       Sugar consumption – Cancer cells flourish in presence of sugar as sugar is its primary energy source.  PET scans are imaging studies done by Radiologists designed to detect glucose uptake by cancer cells and can be pivotal in diagnosing cancer. An approach for brain cancer patients is to place them on a ketotic diet with zero carbohydrate consumption to inhibit the propagation of cancer cells based on this principle in hopes to halt its progression.

6.       GMOs (Genetically Modified Organisms) – While intensely challenged from the anti-labeling of GMO products side of the debate, the evidence suggests organic food consumption is protective against cancer as compared to consumption of GMO's.

7. Wellness (Obesity and Exercise) -- There appears to be an inverse relationship to cancer and weight, in particular as it relates to poor body composition (i.e. excess body fat). A good example of this is Endometrial cancer wherein adipose (fat) tissue is converted to estrogen metabolically which directly is a risk factor of this type of cancer in women. Obesity increases the risk for colon cancer in both sexes .  Lastly, there is a decreased risk in colon and breast cancer (dose dependent) as it relates to exercise; the more exercise women do, the less their relative risk of breast cancer is.

Q: Are there any new developments suggesting solutions may be near for cancer we can look forward to?

A:  Perhaps the most delightful news I have to share is precisely on these lines.  Recently "60 Minutes" had a piece on work being done at Duke University wherein a modified version of the polio virus was being directly injected into the solid mass of brain cancers (Glioblastoma Multiforme) of patients suffering with this diagnosis.  To be summary -- in this less than 3 minute preview -- what is shown is how this process works: the modified polio virus destroys the protective vernier of the cancer once introduced into the tumor thereby enabling the patients own immune system to then penetrate the cancer and ultimately destroy it.  It is a remarkable scientific breakthrough that with further refinement offers hope not only to brain cancer patients today, but those suffering from other types of solid tumor cancers.  The entire piece can be found on the 60 minutes website:

Important notes from the Drs. Corner
Posted on: 09/22/2015

Internal Medicine care for Civil Air Patrol, Squadron 188

The duties of the Health Services and Medical Officer to a Search and Rescue squadron such as ours are unique in that there are several specific needs that the squadron at large in broad strokes requires and then there are certain needs specific for pilots.  I will review the topics as I covered for our squadron below:

1.     Dehydration
This a major health hazard for pilots for the primary reason that if a pilot is what is termed “hypovolemic”, they have a significantly increased chance for syncope and other associated symptoms related to inadequate flow to the brain (i.e. visual disturbances, headache, vertigo etcetera).

In order to better rule out prior to the flying, checking vital signs prior to flight with a focus on pulse rate (beats per minute) is useful.  The normal pulse rate is 60-100 beats per minute; this has some degree of variation from person to person.  Hence it is a good idea for pilots to know what a normal pulse rate is for them individually and what a normal range of variance of this value is as well for them as well.

The practical consideration is that if a pilot is hypovolemic and needs to hydrate that this may complicate the flight plans.  The reason for this is obvious -- total expected air time must be taken into consideration because of the need to urinate/expected lead time post hydration must be calibrated accordingly to the planned flight mission.  The best route is oral rehydration for physiological reasons as well as for ease as opposed to parenteral or IV hydration.

It is recommended that pilots and all air crew void their bladders prior to flight regardless the expected duration of flight.

If a pilot is evidenced to be relatively dehydrated (pulse rate in the mid to high 90’s) or outright dehydrated (pulse rate >100) it is advisable that the pilot first not fly and to start rehydration immediately.  The pilot should reassess their pulse rate at a later time if they are more euvolemic (at normal level of hydration) prior to considering flying again.

In summary, dehydrated pilots are at an increased risk for unsafe flights with complications ranging from suboptimal mental sharpness which can result in poor flight control to potentially fatal outcomes.  Checking the vital signs with a focus on pulse rate is an easy first step towards that evaluation and determination.

2.     Medical fitness for flight clearance
Much like DOT (Department of Transport) physicals for the DMV (Department of Motor Vehicles), a medical determination related to medial safety prior to being allowed to fly is an absolute requirement for all pilots.  There a myriad of medical problems that range from relatively benign to severe that can significantly complicate a pilot’s ability to safely operate aircraft.

Some of these conditions are (and are not limited to): Diabetes, Hypertension, Obstructive Sleep Apnea, Seizure disorder and Schizophrenia.  It is essential that all pilot’s have Primary Care Physicians (Internal Medicine, or Family Medicine is best for such situations) who can manage these conditions if present (and others like them) which the Flight Physician can then review prior to issuing flight safety clearance.  It is on the basis of this which will enable her/him to be able to certify that the said pilot is safe to fly by FAA standards.

Documentation of satisfactory control of these medical conditions by the Primary Care Physician is solely the responsibility of the pilot at the time of the visit with the Flight Physician (i.e. providing lab documentation of adequate control of Diabetes or a AHI reading and report from the CPAP machine by the Sleep Medicine Physician to demonstrate the is no risk of drowsiness or sleep attacks while in flight).

3.     OSA (Obstructive Sleep Apnea)
This falls under No. 2, however I take the extra liberties to spell this one our as it is much more prevalent than most are aware of.

OSA was featured in a Reader’s Digest Article recently as one of the “Top 10 diagnoses missed most by Physicians today”.  The reasons for this are simple and have far reaching implications.  Firstly for most patients who have it, they are not acutely aware they have it mainly because they are not knowledgeable about what the symptoms are and how to tie them together to call their Primary Care Physicians attention to it.  Additionally, it generally is a condition which is insidious in onset.  Next just as much, Primary Care Physicians do not as routinely look for or screen for it.  Unlike checking vital signs on visits to the MD wherein in blood pressure (or labs) are checked that may pick up either Hypertension or Diabetes inadvertently or because it is specifically being looked for, without the extra effort to screen for OSA, it is often missed.

One of the most common ways OSA is brought to the forefront of attention of each the patient and that of the Primary Care Physician is that the spouse of the affected individual will report that the concerned individual seems to “stop breathing”, or “fights to breath” or something on these lines which indicates that there is some sort of difficulty breathing when the patient is sleeping.  In my personal experience in my years of practice as an Internist, such a history often is “Exhibit A” as evidence of there being OSA and such an individual has OSA until proven otherwise in my books in my professional medical opinion.

OSA is a major and under reported reason motor vehicle accidents occur and for this reason OSA is just as much a risk factor for pilots crashing.

Common symptoms patients will self report when/if they do will often be: falling asleep when they should otherwise not be falling asleep, accidents secondary to having been sleepy while driving, loud snoring, waking up feeling poorly rested, waking up with gasping, choking or breathing interruptions and even cataplexy.

Common risk factors for OSA are increased abdominal girth (elevated BMI of 35 or greater), increased neck circumference >17 inches for males or >16 inches for females, age > 50, and micrognathia (small jaw).

To screen for OSA, one would use the Epworth Sleepiness Scale which is easily available tool on line.

Occupational medical centers now are mandated to use a “Sleep Evaluation Work Sheet” for DOT physicals as such a medical clearance for drivers concerns the safety of the public as would medical clearance for pilots.

4.     Blood Borne Pathogens
This is an essential topic for our squadron to be knowledgeable regarding because of the fact that our squadron is a search and rescue squadron and as a result can and often will potentially be exposed to blood.  The blood borne pathogens that can be transmitted are HIV, Hepatitis B and Hepatitis C.  Of these, there is a vaccination available only against Hepatitis B which is a series of three shots over a time period of six months.  Vaccination against Hepatitis B is an absolute requirement for first responders of all levels, CAP, USAF or otherwise.

Of the three possible blood borne pathogens that we know today, it is Hepatitis C that is the most likely to transmit as it requires the least number of viral particles in order to infect a possible victim.  Early diagnosis is essential once there is even the remote most possibility of Hepatitis C being contracted.  The potentially infected person must inform their Primary Care Physician as soon as possible to start the battery of blood tests needed to screen for it as it is a potentially fatal condition if contracted and diagnosed too late.  However with early diagnosis and treatment, it is completely curable.  I worked with one of the leading experts the world over today on Hepatitis C during my post-doctoral training period when in Ann Arbor, Michigan.  Hepatitis C is an emerging epidemic and considerably more prevalent than we as a medical community had prior thought was the case, and Dr. Shehab has publish extensively about this.  For the motivated reader and researcher, the numerous publications on Hepatitis C by Dr. Thomas Shehab are available on line at Pub Med or other various search engines such as Google Scholar.

If HIV is suspected to have been transmitted it is crucially important to have this brought to the attention of the individuals Primary Care Physician as starting PEP (Post Exposure Prophylaxis) is pivotal as PEP is time sensitive.  If not started in the correct window period which is measured in hours, the possibility of contracting HIV raises proportionately.

For patients who are immunized against Hepatitis B, it is advisable to check Hepatitis B Antibody titer levels every 5-10 years dependent upon the age and baseline health of the patient as well as the general immune system status.  Booster shots and/or immunization may be indicated and it is crucial to have a sufficient titer level to ensure one is sufficiently protected against potentially contracting Hepatitis B.

Instruction of this topic at the squadron was supplemented with a power point presentation.

5.     First Aid
In following along with the need to protect the First Responder from contracting blood borne pathogens, it is extremely important to know how to glove and protect the First Responder given First Aid from possibly being a victim.

In our First Aid class, I give explicit detail instruction about how to ensure all contact precautions are followed in advance of administrating First Aid.  The same precautions are taught in advance of providing CPR.

Further in First Aid, the class is instructed in the fundamentals of wound care and dressing, splinting wounds, and achieving hemostasis in bleeding patients.  Students are instructed in depth about all the basic aspects of First Aid with first hand teaching by the MD’s, RN’s and Paramedics of the squadron.

6.     CPR/AED
One of the most important aspects of being a First Responder is the ability to confidently deliver CPR and to be able to an AED if needed.

In this class, I first instruct how to do a primary survey in advance of delivering CPR care.  This training is pivotal as the effectiveness of CPR is time sensitive.  Sadly, often times when the point has been arrived at that CPR is needed, as one of the most important professors from my post-doctoral training said it best; “The worst thing that can happen to the person has already happened – just do your best once that point has been arrived at.”

It is important that the CPR provider understand the approach and technique as well as sound command of the algorithm.  This is taught and tested in depth and as with the First Aid class there is practical demonstration as part of the proficiency which must be demonstrated.

Wreaths Across America
Posted on: 09/22/2015

 On Saturday, 11 December 2010 at 9 am, 2d Lt David Dunham, 2d Lt Pat Bitz and I attended the “Wreaths Across America” event at Golden Gate National Cemetery in San Bruno, California.  It was an outstanding event that I plan to participate in annually for the rest of my life; I recommend the same for each and every one of you too.  The motto of it is “Remember, Honor and Teach”.  It is profoundly simple, yet just as profoundly important a slogan.  I believe that it is our civic responsibility as Americans to uphold this concept.  Sadly, often we as Americans forget and take for granted that the day-to-day liberties and freedoms we have, came with incredible sacrifice against some of the most remarkable stresses of human peril which history has ever known.  While there are numerous movies that tell the narrative about our past military battles, no one more than “Band of Brothers” do I recommend to be used for instructive purposes related to this.  Here is more information about “Wreaths Across America” --

Specifically, Civil Air Patrol was recognized alongside the other branches that defend America ranging from the Coast Guard to the four major military branches – Army, Navy, Marines and Air Force.  Our dear and ill-fated POW/MIA dedication was memorable just as well.  Apparently there are nearly 94,000 of our brave citizen soldiers whom remain unaccounted for which is an incredible thing to ponder much less have quantified and know.  Also in attendance were the “Sons of the American Legion” which was quite a delight to see and to learn about them.  Here is their website:

It was impressive to see veterans from WWII, the Korean War, the Vietnam War, the Persian Gulf War and others in attendance.  While there were only approximately 100-150 in total attendance, the spirit of whom and what they represented was extremely palpable; loved ones, widows, and others touched deeply upon the service of those who gave it all so we and future generations could be free.

Back to the slogan –

Honor Guard
Remember:  It is important we always remember those who sacrificed so much so we could live in the best nation and society on earth, wherein we can worship however we deem fit, have the right to vote, freedom of speech, live in safety and prosperity, have limitless potential, the freedom to purchase a home, and to travel within our great nation to every corner upon our pleasing.  The principals of a secular, democratic republic such as ours is much more rare than we would think when compared to the rest of the world, most especially wherein ethnic origin, pedigree, religion, cast nor creed make any one of us any more or less American than the next.  That truly is an incredible story so uniquely American that we ought to all be proud of.  If not for those who made it possible to be able to espouse these virtues that make us as America which still to this day is the unmistakable envy of the world and still the most desirable destination on the planet, we would be remiss to not remember these incredible Americans in this fashion at least.  America remains a beacon of hope, freedom, democracy and fairness the world over; something even those who wish America doom well acknowledge.  Such was not accomplished without unimaginable sacrifice and it is critical these brave Americans never be forgotten; for a nation that forgets its past heroes will itself be forgotten.

Honor:  By attending “Wreaths Across America” and spreading the word about it, we pay both honor and homage to these fallen soldiers and veterans.  It is important that we never miss attending and we thank our veterans for their service and deeply personal sacrifices.  It is time well spent to personally thank each veteran and active duty member of our service that we come across in our lives, and it is nothing short of our duty to do so.

Assembled Colors
Teach:  Above all it is our fiduciary calling, duty and responsibility to teach people of all walks of lives and ages, but most especially our children about what the service of our past generations has meant, still means and will forever mean whenever we get the chance; all the while understanding that someday in the future it maybe any one of us at any given time that it falls upon to make a similar sacrifice for our way of life, and preserving liberty, honor and dignity for America – The greatest nation on earth that has done more to liberate people, give generous humanitarian aid, restore human dignity, and volunteer in the face of incomprehensible risk and danger.  Our past success to make the world a better place should never be over looked, taken for granted, mistaken, ridiculed, chastised or undervalued.   The resolve of America to fight fascism, communism, racism, the Nazi menace, human rights violations and terrorism are unmatched and unparalleled on earth and we need to teach that, preserve it, and be an active part of what constitutes quite literally being “The Good Guys”.

The entire ceremony was touching, factually accurate, and concise – All done within 1.5 hours.  All the words in the world can never describe it; please attend in future and you will be glad you did.

Earthquake/Tsunami/Nuclear Fallout Northeast Japan, March 2011
Posted on: 09/22/2015

Follow up at month three -- post tragedy in Japan, the link to the Daily Mail Online is Here.  We at Civil Air Patrol should study as much as we can about the excellent response to the Tsunami from our counterparts in Japan.

Additionally, the nuclear aspect of the event also appears to within control.  Their response was as good as it gets.

We are all aware of the incredible devastation that Japan has endured from the 9.0 Tōhoku earthquake and tsunami on Friday, 11 March 2011. The resultant tsunami caused the most amount of damage as evidenced by the photo link from ABC below.  When you look at the pictures you can review the before and after contrast by floating your cursor over the individual pictures.  The link is at the ABC site located here.

As a result of the tsunami, the Fukushima I and II nuclear power plant crisis has been the most precarious aspect to manage.  The earthquake/tsunami has most likely caused the most serious known breach of a nuclear power plant.  The situation remains very much a minute to minute event unfolding in real time as up to six reactors have been compromised, with the most serious being reactor 3 as it runs on highly toxic mixed uranium and plutonium oxide. 

In March of 2008, I had the privilege of visiting Japan for nearly two weeks.  While visiting, it quickly became evident that Japan was seemingly, very well prepared for these type of disasters, quite possibly even more so than us in America.  The Japanese people are incredibly and impressively orderly as well as organized and the nation has a civil defense force that I saw in action doing drills near Hakone (not far from Tokyo).  As Japan has no formal military due to Article 9 in their constitution, they rely exclusively upon what is known as the “Japan Self-Defense Forces” or JDSF.  Their commensurate  arm of this to our USAF is known as the Japan Air Self Defense Force, or JASDF.

Destruction at the Fukushima Nuclear Power site
Currently the JASDF is pouring water over the breached nuclear power plant reactors in a dire attempt to cool down the reactors and the spent rods pool.  They are utilizing water drops from helicopters to prevent further nuclear fallout as radiation leakage has already happened.  Now it is a race to curtail that leakage as best as possible.  All branches of the JDSF, and numerous Search and Rescue agencies are working feverishly to recover the deceased and make as many rescues as possible of which there have already been some miraculous ones.  At this point in time the situation is bleak, and there is seemingly an indefinite amount of work to do.  102 countries of the world have offered their assistance to Japan, however a signal of how much Japan has their act together is that they have declined the overwhelming majority offered, accepting the help of only 15 nations.  Perhaps because Japan is a first world nation, they have not requested any money.

Tsunami flooding on the Sendai airport runway
In time, we will be better able to study the response as this crisis winds down.  For now, let us closely monitor the situation and learn as much as we can, as such events are just not possible to prepare for.  American's have a lot to learn from the Japanese as they are responding well and as best as could ever be expected or hoped for.  If nothing else good comes of it, we should review the results of their efforts to address areas wherein we can improve our readiness should we ever be called into action on a scale greater than exceeds our training.

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