This week APN continues our expansion into new service lines. We have been visiting, interviewing and evaluating new clinics and facilities for our clients.
Our Women’s Health service line will include:
(Please note that we do not provide surrogacy services)
December 2020
What a difference a year makes!
In December 2019, we were in the midst of one of our group medical trips. It was hectic, but fun. All of our clients had a good time – and the trip was a success.
Then, came Covid-19, and all of us were forever changed. Our documentary was put on hold, along with all of our upcoming scheduled group trips – and American Physicians Network, like so many other small businesses, struggled to survive.
We worried about our clients, and future clients – and what they were going thru, as the bottom fell out. We worried about our doctors, scattered across six countries. We didn’t know that our hometown of Memphis, Tennessee would end up being more dangerous than most of our destinations.
As international flight restrictions eased, I took one of the first flights to our regional office here in Colombia. I stepped off the plane to feel safer than I had in months. Covid still exists in Colombia, but it isn’t raging out of control. Masking policies are universally followed, (nary a bare face to be seen) and all restaurants, shops and other businesses have moved to social distancing policies, mandatory temperature checks and sanitation stations.
Life isn’t back to normal, there are no coffee dates or in person meetings – but because Colombians here in the capital city have embraced these health safeguards after one of the longest lockdown in the world, the virus is not raging out of control.
I return to the USA in a few weeks – and honestly, I’m concerned. I stocked up on masks, and a durable faceshield here (because there aren’t any shortages here – supplies are cheap and readily available). Now I have to prepare to jump thru the necessary hoops to come back home. Delta is still enforcing the empty middle seat policy (which is why I chose them), as well as contact tracing for all International flights entering the United States. I’ll quarantine when I arrive, and take another covid test before getting back to work. But I’m not as afraid of bringing home Covid – my risks are so much lower here – but I am worried I’ll contract it once I arrive.
That being said – the vaccine brings hope. With this hope, American Physicians Network (APN) is tentatively planning to offer our next medical trip to Colombia in late May. Given the current discussions among airlines and nations, we anticipate that travelers will need to have proof of vaccination before being allowed entry to Colombia (or any of our international sites.) Since it’s our first trip in a year, spots will be limited. We will continue to offer our 50% discount on our services as we re-ignite our business.
We will continue to monitor Covid-19 activity at our sites in other parts of the world, and will plan to initiate trips to these areas when safe, and feasible.
As always, we will also recommend that all travelers purchase travel insurance.
Of course, as we have all learned, a lot can happen in a few months, so we will check in here again over the upcoming months as the mass vaccination programs are implemented globally.
For the many people out there, who have difficulty accessing health care, who are unable to afford care and for those who who have lost their safety net due to pandemic related issues, we are here for you.
Sincerely,
Kristin Eckland
While Covid-19 temporary ground every day life to a halt – with millions and millions of people worldwide under lockdown orders, working from home, and staying in their homes, illnesses don’t take a holiday. While all of us were trying to stay out of emergency rooms, doctor’s offices and away from the hospital – we can’t put our lives and our health on hold indefinitely.
You still need care.
People still get sick, even in a pandemic. People still need care, even as Covid-19 has changed the world as we know it. As the founder of American Physicians Network, I have felt the impact of the Covid-19 pandemic. But as an actively practicing clinician in the hospital, the impact has been more profound. For every case of Covid, there is another person who had to put off their heart surgery, or delayed seeking treatment for their debilitating knee pain. Surgeries put on hold, means that lives are put on hold.
The economic impact of Covid-19
For some people, this crisis has hit even harder – with historic and unprecedented job losses, even more people in the United States have lost their health insurance at a time when they can least afford it. Cancers go undiagnosed due to a lack of insurance, and upheaval from the pandemic. Expensive but necessary tests aren’t scheduled, biopsies aren’t done and questions go unanswered. Even worse, these cancers and other serious medical conditions are going untreated. Slowly, life is beginning again – even as we adjust to a “new normal.”
What does medical travel look like now? Is it safe? Are doctors operating? What are the hospitals like right now?
For this reason, now that international flights are resuming, APN is going to be traveling to our partner sites this November and December, to check-in, assess the situation and make recommendations for our clients going forward.
Life looks very different today, than it did when we started this company, but our mission remains the same; to help people. That may look different late 2020 (and beyond) than what we are used to – but we are still here to help.
We will post updates from our regional office in South America next month.
Kristin Eckland
Executive Director
American Physicians Network
I’ve been surprised about the number of visitors that have asked about my mom, but very pleased to give everyone an updated report.
Since she had her TAVR in December, she’s recovered quickly and has been doing great.. In fact, we had to remind her not to overdo it the first few weeks (which is not something I usually have to do with patients). But she is back to running, and has been for several months!
In fact, here’s a video I made back at the beginning of April, on her 81st birthday. (Please excuse my poor video skills). She ran for 81 minutes that day – to celebrate her birthday and wanted me to share it with her doctors and everyone who helped take care of her after her procedure.)
And thank you everyone for all your messages of love and support!
Kristin Eckland
Director of APN
nurses modeling masks donated by our volunteers
During the Covid-19 Pandemic, APN cares, inc. formed a mask-making brigade to help protect healthcare workers and essential workers. There were many wonderful people who answered our call. We would like to recognize some of our volunteers.
Thank you to our cash donors who helped pay for shipping costs, fabrics and materials:
Derek Veloza of Las Vegas, NV
Beth Sollenberger of Southern Pines, NC
Jauclyn Williams of Memphis, TN
APN cares, inc. would like to recognize some of our extraordinary volunteers who donated materials, and hundreds of hours of labor sewing thousands of masks:
Beverly Green and Brennie Green (this sweet young woman, and future nursing student did just an amazing job!)
Candace Perkins and Sigma Gamma Rho Sorority, Inc. (Lambda Iota Sigma graduate chapter)
Marlin Mogy and Cindy Mogy
Sara Fox, of Sara Fox designs – who organized a group of costume designers to sew and ship masks.
Susan Eckland
APN cares, inc. would like to thank many of the other volunteers that assisted in these efforts, large and small. 100% of all donations were used for shipping and materials.
*If you have photos of masks you received and would like to add to our gallery, please send to kristin@americanphysiciansnetwork.org
Several of our clients have asked for more information about legendary thoracic surgeon, Dr. Diego Gonzalez Rivas and the uniportal video assisted thoracoscopic surgical technique which he pioneered in 2010.
We have posted two of the documentaries on Dr. Diego Gonzalez Rivas, the uniportal technique and his efforts to share this technique with the thoracic community.
Sharp-eyed viewers will catch a glimpse of one of our APN executives in both of these films. The second film, “Seven Days, Seven Cities” explains and documents Dr. Gonzalez Rivas’ journeys during one week as he traveled across China to teach his technique. It also highlights his training program in Shanghai, China and the work he is doing there.
As part of our exclusive referral network, clients may select Dr. Gonzalez (or another of our world- class thoracic surgeons) for their surgical care, for a fraction of the cost of care in the United States.
Excellent care, at an affordable price.
For more information about the thoracic surgeons in our network, or to schedule a medical evaluation, please contact us here at American Physicians Network.
Dr. Isik
Is there five year survival for patients with malignant pleural mesothelioma (MPM)? This is just one of the many questions we asked during an interview with one of the surgeons in the APN network as part of a series discussing HITHOC (hyperthermic intra-thoracic chemotherapy) for malignant pleural mesothelioma and other cancers.
Today, Dr. Isik, a thoracic surgeon, with extensive experience with mesothelioma and HITHOC talks with APN. We are discussing malignant pleural mesothelioma, the HITHOC procedure and the latest research findings in a Questions and Answers session.
WARNING: This video contains graphic surgical images.
Full Transcript from video is below.
Q. Would you please talk about your academic career briefly?
Dr. Isik: I graduated from University of Ankara, Medical School in 1991 and attended to residency in thoracic surgery of same institute. After getting to be Thoracic Surgeon in 1996, for 23 years I studied mostly on oncology especially lung, pleura and esophageal carcinoma. I have been working as consultant professor since 2013 in University of Gaziantep, Medical school, Thoracic Surgery Department. I am the chief in this department.
For pleural cancers, I have been studying on radical surgery plus hyperthermic intrapleural perfusion chemotherapy (HITHOC) since 2009. Especially in malignant pleural mesothelioma, pleurectomy/decortication and HITHOC intervention has been observed as feasible and improving survival for those patients. Also in stage 4 M1a lung cancer cases, oncological surgery including lung resection and pleurectomy plus HITHOC has improved life comfort and survival.
I established the Advanced Respiratory Biology Department in Medical Sciences Institute of University of Gaziantep in 2018 after took over the Basic Respiratory Biology program and cell culture laboratory in September 2016. Postgraduate program about cancers of respiratory organs has begun at September 2018. Since 2015, I have been proceeding the accreditation program of Medical School of University of Gaziantep as coordinator in self-evaluation committee.
I have been working on artificial respiratory center for patients with respiratory insufficiency and have patent on this subject named “Telemetric Diaphragm pacing with feedback”. I completed 7 projects about different subjects including experimental studies on animals and cell culture and infrastructure of medical school and its hospital. I have been member of Toraks, TUSAD, Turkish Thoracic Surgery Association, European Society of Thoracic Surgeons, European Respiratory Society.
Now that we know a little more about Dr. Isik, let’s talk more about HITHOC. After all, that’s why most of our readers are here.
Q. Would you please describe us what HITHOC treatment is?
Dr. Isik: Hyperthermic intrapleural chemotherapy (HITHOC) is an adjuvant intervention just after the radical surgery of pleura and lung if needed. [ During surgery, warmed up chemotherapy medications are applied directly to the tissue of the chest. This is believed to kill any cancerous cells that are too small to be seen directly, so that no cancer is left behind].
In scientific investigations, it was found that hyperthermia leads apoptosis of cells. Apoptosis is one of the pathway of cell death. Cancer cells are immortal if they find suitable habitat in human body. Because of this, microscopic pleural seeding should be eradicated by another procedure after surgery. Heated intrapleural chemotherapy is an applicable and effective treatment used for this purpose. It is administrated just after surgery through pleural drainage catheters under general anaesthesia.
In the operating room
Q. What are the advantages of HITHOC treatment?
Dr. Isik: Chemotherapeutic agents are toxic for human body and cells. For this reason, they cannot be given in high dosages in systemic applications. Hyperthermic intrapleural chemotherapy is a local intervention just after the surgery. So it possible to apply higher dosages of chemotherapeutic agents than systemic therapy, [directly to the affected tissue]. This is the advantage of the treatment. Despite these higher dosages than systemic therapy, we see lesser renal and cardiac complications.
Q.What are the major complications of HITHOC treatment?
Dr. Isik: The major complication of HITHOC treatment is renal dysfunction and insufficiency. However, incidence of these entities is not high. Generally, we observe temporary renal dysfunction. It improves by hydration easily. Severe renal insufficiency is so rare, but it can be healed by renal dialysis. The incidences are 7% and 1% respectively for renal dysfunction and insufficiency in our series.
Q. What is the success rate of this treatment?
Dr. Isik: In literature, the success rate is qualified according to survival rates. It has been observed that patients with pleural carcinoma have better survival with radical surgery plus HITHOC than the others significantly (Mean survival 27-35 months with HITHOC and 6-9 months without, respectively). These patients have the chance of 5 year survival and cure.
Q. Are there any scientific research or evidence for HITHOC? What are the results of those studies?
Both malignant mesothelioma and other secondary pleural cancers have been studied for better survival. As a primary cancer of pleura Malignant Mesothelioma is the most studied subject. Recently, approximately for 15 years most of thoracic surgeons gave up extra pleural pneumonectomy (EPP) because of its morbidity and mortality despite poor prognosis. Radical pleurectomy and decortication with hyperthermic perfusion chemotherapy have been performed instead of EPP. We observed that better comfort and better survival were obtained such as 32-55 months mean survival and 20-25 % five year survival.
Hyperthermic perfusion chemotherapy of pleural space give us a chance for radical solutions of other pleural cancers. Lung cancer is the most seen cancer metastasis pleura. Pleural seeding or metastasis gets the stage to 4 with M1a disease. If patient has no other distant metastasis, we can perform radical surgery for lung cancer plus pleurectomy/decortication and hyperthermic perfusion chemotherapy.
There are many scientific researches about hyperthermic intracavitary chemotherapy for both mesothelioma and other secondary pleural cancers such as lung cancer, breast and over cancers etc.. [Ed. Note. For ease of reading, these references have been placed at the end of the interview].
Dr. Elbeyli and Dr. Isik (right) with APN staff (middle)
Q. What are the expected survival rates for patients who undergo HITHOC treatment?
Dr. Isik: According to literature, radical pleurectomy and adjuvant HITHOC have 28-57 months mean survival. And also have more comfort after surgery and during the treatment period because of lacking pleural effusion recurrence. Five year survival rates are 20-35% for malignant pleural mesothelioma. However we perform radical surgery in patients with M1a lung cancer (Pleural metastatic lung cancer) and other secondary pleural cancers due to such as breast cancer, colon cancer over carcinoma etc. also. In M1a lung cancer cases, we obtain 20-25% 5 year survival where as 6-9 months in patients non-surgery groups. This is significant difference.
Q. Who is eligible for HITHOC treatment?
Dr. Isik: HITHOC after radical surgery for pleural cancers can be performed in patients that have suitable baseline health and limited disease in the hemithorax. Patients need to be strong enough for surgery and have the types of cancers that respond to this treatment.
HITHOC has been used to treat: Pleural cancers including malignant pleural mesothelioma, M1a Lung cancer with pleural seeding or metastases, and other metastatic pleural cancers like breast, colon over etc carcinomas.
Q. How do you know if patient’s are well enough for surgery?
Dr. Isik: We evaluate their medical condition/ baseline health with detailed cardiac and respiratory examinations. Patients need respiratory function tests includes spirometry, to be able to walk 600 meters and climbing 4 flights of stairs. Electrocardiogram and echocardiography if needed are performed by cardiology specialists to understand if patients have any cardiac problem.
Scientific literature and research related to HITHOC:
All photos were taken during a site visit.
Treatment of malignant pleural mesothelioma (MPM) with HITHOC
One of our exclusive network surgeons, Dr. Isik has produced a new video explaining HITHOC treatment in detail for our clients. While many people may be frightened or worried to seek treatment in another country, particularly with a surgeon who speaks another language, Dr. Isik specializes in offering hope against these aggressive forms of cancer including Malignant pleural mesothelioma.
Malignant Mesothelioma & HITHOC
Malignant mesothelioma, which is devastating diagnosis carries a dismal prognosis without aggressive, multi-modal treatment. The majority of malignant mesothelioma affects the pleura (or the lining around the lung). This cancer is often associated with exposure to asbestos.
There is another form of mesothelioma which affects the abdomen. This is best treated with a related procedure called HIPEC. Click here to learn more about HIPEC treatment with the affiliated providers of American Physicians Network.
In the video below, Dr. Isik explains, in detail, about hyperthermic intra-thoracic chemotherapy, better known as HITHOC, and it’s use in treatment of malignant pleural mesothelioma.
Warning: The enclosed video has graphic content.
Not just for mesothlioma
HITHOC is also used for the treatment of advanced thymomas, treatment of malignant pleural effusions (from some advanced lung and other cancers). Dr. Isik is one of our network surgeons that performs this procedure. He is fluent in English as well, and is currently completing a new video in English for our clients. (Each program has it’s own inclusion criteria, please contact APN for more information).
After completing another trip around the world, interviewing, inspecting and observing surgeons, the American Physicians Network is excited to announce the addition of several new network surgeons in the specialty of thoracic surgery. We are particularly pleased to announce that we have added several of the ‘modern masters of thoracic surgery’ – who are among the acknowledged top thoracic surgeons in the world. While these surgeons are new to APN, we have worked with all of these physicians in the past, and they were actively recruited for their surgical skills and advanced training in the area of thoracic surgery.
These surgeons are the very best, and most current in their field. Each of these surgeons was hand-picked and recruited due to their extensive experience in their respective areas; whether it is expertise in minimally invasive techniques such as uniportal VATS, subxifoid approaches to reduce pain, disability and recovery time or other specialty surgical treatments for various diseases of the lungs, pleural, mediastinum or thorax. One of our surgeons was recruited to provide patients with an additional facility for HITHOC. (This is the second HITHOC surgeon in our current roster).
This group of immensely talented and skilled thoracic surgeons is a roll-call of the best and brightest, and includes the inventor of uniportal thoracic surgery, Dr. Diego Gonzalez Rivas, Hong Kong legend, Dr. Alan Sihoe, HITHOC researcher, Dr. Hans – Stefan Hofmann and the founder of International VATS, Dr. Marco Scarci. APN will bring you more information about these and many of our other network providers in the future.
with Dr. Hofmann outside the operating room after another successful case
All of these surgeons are able to provide world-class care at a fraction of the cost of US-based treatment. Each of these surgeons has undergone an extensive vetting process which includes direct observation in the operating room.
Thoracic Surgery posted “International VATS 2018: Better than before – Extreme Fast track thoracic surgery” by Kristin Eckland.
Some of the videos are silly, cheesy even… But ugly track suits aside…
The results are, in arguably, wonderful. Patients eating, drinking, walking, and relaxing just an hour after major lung surgery.
Dr. Joao Carlos Das Neves Pereira is a Brazilian thoracic surgeon, who has been the primary author and leader on several articles, and programs for what he is calling ‘extreme fast track thoracic surgery’. He was also one of the featured speakers at International VATS 2018. “Better than before” is his model. “Patient empowerment’ is his ideology.
His presentation was easily the best in show, so to speak.. What’s more remarkable about his results are – that this isn’t new. He’s been doing it for more than a decade. In fact, he published an article on his experience in the European Journal of cardio-thoracic surgery was back in 2009. And now he is responsible for the implementation of a multi-disciplinary program at two hospitals on two continents – one on Paris, France and the second in Sao Paulo, Brazil.
So what does he do? How does he do it? And why aren’t the rest of us doing it?
What he does: “Feed & walk”
Change the existing surgical traditions:
He does this with a multifaceted program that starts several weeks before surgery; with a comprehensive nutrition, smoking cessation and and an exercise regimen.
The night before:
On the morning of surgery
During surgery
Patient analgesia and anesthetic is treated with a combination of approaches including hypnosis, pre-emptive oral medications, BIS for awake anesthesia, minimally invasive airways. Patients are only given very short acting medications such as ketamine, or propofol combined with local anesthesia. By avoiding narcotics, there is a reduction in both sedation, and GI complications post-operatively.
Patients who are able to readily wake up after surgery and who haven’t had narcotics that adversely affect bowel function) are able to eat and drink immediately after surgery.
Post-operative
Patients are encouraged to wear their own clothing before going to the exercise room, the outside garden or walking the halls. Post-operative pain management consists of oral medications only, and is augmented by physical therapy, acupuncture, aromatherapy and massage. Friends and family are instructed in the proper massage techniques so that they are able to participate in the patients care (also shortage of massage therapists). Patient recovery is enhanced by conviviality: patients don’t spend time in the rooms, alone or in bed. Patients are welcome to spend time in open spaces, aromatherapy areas, exercise rooms, a japanese style garden, an indoor garden and a tea room. Patients are encouraged to socialize and spend time with other patients.
While some of these ideas are novel, there is no magic surgical technique, and no miracle drug to account for these results – which are arguably better the most of ours. But it’s not just aromatherapy, it’s a philosophy of care.
More importantly, what Dr. Das Neves Pereira and his colleagues have; that many of us find difficult to replicate – is patient buy-in. We can call it “Patient empowerment” but it’s the part that many of us continue to struggle with.
But Dr. Das Neves Pereira’s lecture leaves us with more questions as well as answers..
Would this work for your practice? And why aren’t the rest of us already doing it? Will the patients accept it?
For the answer to this – we have to look at our own practices, in the here and now, in late 2018. A recent issue of the thoracic journal of disease did just that, devoting an entire issue to ERAS (enhanced recovery and fast track programs) while providing blueprints for anesthesiologists, nursing and physical therapists. But for many of us, the pat and simple answer is something like this:
“While most of my patients wouldn’t mind some aromatherapy or a massage after surgery, the unfortunate truth is that few would participate in a pre-operative program stressing diet and exercise. Even fewer patients would sign on for a program that restricts narcotics. Many of us already know this about our patient populations because we try routinely to incorporate more holistic practices into our treatment in a daily basis. While holistic premises and alternative treatments make billions of dollars in the United States (under the guise of prevention) it’s still a culture that is highly dependent on fast, and immediate remedies and a strong belief that very little post-operative pain is acceptable or tolerable. For every one patient that would embrace the philosophies of extreme rehabilitation, there would be another 200 screaming at the nurses for IV dilaudid.”
Much of the research actually confirms this view:
British researchers, Rogers et al. (2018) had a similar experience, noting in their recent publication that benefits of enhanced recovery protocols were dependent on compliance (and adherence) to protocols – particularly in regards to pre-operative dietary modification, and early post-operative ambulation. Refai et al. (2018) have attempted to address these issues with a comprehensive patient education component. However, their publication does not address whether these interventions increased compliance and reduced patient stress or anxiety.
Does this mean that we are skeptical of extreme rehab – no, not at all! Interest, participation and development in fast track thoracic surgery programs continues to grow despite these obstacles.
In fact, the tightening of many federal and state restrictions on narcotics due to the American opioid crisis may make this the best time in modern American medical history to bring this ideas and approaches to our patients (Bruera & Del Fabbio, 2018, Herzid, 2018). It also means that many of us have some preliminary hurdles and preconceived notions (on all sides) to overcome to engage our patients, nurses, therapists and fellow medical professionals to get their buy-in on the idea. We might be over a decade behind – but it’s not too late to start today.
References:
Das-Neves-Pereira, et al. 2009). Fast track rehabilitation for lung cancer lobectomy: a five year experience. European Journal of Cardio-thoracic surgery, 36 (2009) 838-392. primary reference article.
Additional References:
Bruera, E. & Del Fabbio, E. (2018). Pain management in the era of the opioid crisis. Am Soc Clin Oncol Educ Book 2018 May 23 (38): 807-812.
D’Andrilli, A. & Rendina, E. (2018). Enhanced recovery after surgery and fast-track in video-assisted thoracic surgery lobectomy: preoperative optimisation and care-plans. Journal of visualized surgery, 2018:4 (4).
Herzid, S. (2018). Annals for hospitalists Inpatient Notes: Managing acute pain in the hospital in the face of the opioid crisis. Annals of internal medicine 169(6): H02-H03.
Rogers, et. al (2018). The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. Journal of thoracic and cardiovascular surgery. 155(4) April 2018: 1843 -1852.
European Society of Anaesthesiology. “Hypnosis/local anesthesia combination during surgery helps patients, reduces hospital stays, study finds.” ScienceDaily. ScienceDaily, 21 June 2011.
From the Journal of thoracic disease – special issue: Supplemental issue #4 2018
Ardo et. al. (2018). Enhanced recovery pathways in thoracic surgery.
Bertani et al. (2018). A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video assisted thoracoscopic surgery: lobectomy.
Picconi, et. al. (2018). Enhanced recovery pathways in thoracic surgery from Italian VATS group: perioperative analgesic protocols.
Refai et. al. (2018). Enhanced recovery after thoracic surgery: patient information and care-plans.