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Showing posts with label Douglas Levin. Show all posts
Showing posts with label Douglas Levin. Show all posts

Sunday, December 20, 2015

Data Crunching

My hospital's online chart system finally added my test results from when I was in the hospital.  This completed my data set for my tests so, of course, I had to do some data analysis.  It looks like this--
  • 2008    1
  • 2009    1
  • 2010    8
  • 2011    4
  • 2012    26
  • 2013    491
  • 2014    63
  • 2015    48
So, not too much until 2012 when I knew something was wrong starting in October; diagnosed and treated in 2013 ; and working on my recovery in 2014 and 2015.  Nice to see the numbers trending down.  Here's a graph showing the number of tests by month.




Here's a word cloud I did of the providers who ordered the tests. You see #1 is Yvonne Efebera, MD  with 99 tests, #2 is Tammy Lamb  at 89 and #3 is Rebecca Scott (the nurse practitioner on the bone marrow transplant unit)  with 80.  I've had tests ordered by 35 different providers.  The father of  a girl who played field hockey with Claire, Rob Baiocchi, MD is a hematologist at Ohio State.  He mentioned at one of the games that I looked familiar and asked if he'd taken care of me.  I told him that the time I was in the hospital was such a morphine induced blur and perhaps he did, but I didn't remember it. Sure enough, when I looked at the tests from when I was an inpatient, I saw that he ordered my red blood cell transfusion.  Quite a small world. 


I also did a word cloud of the tests that were ordered.  You see the focus on the blood tests to see how my blood health was doing in the onslaught of chemo.  CBC to check the components, hepatic function panel to check liver function (the amyloids went after my liver and chemo is metabolized by the liver--double whammy), interesting that the immunoglobulin free light chain test to measure the substances that create the amyloids is relatively small.  They say that it's important to protect organ function for amyloidosis patients so it's nice to see the word cloud confirm my physician's focus on that.  



I had a great appointment with Dr. Efebera this week.  I posted this on Facebook--
4 month check up and all the digits look good. Kappa light chains aka bad stuff is below normal at 2.79. It was 79 when diagnosed. Key liver test that was 500 right after my transplant is now 57.
I sent this email to Dr. Efebera tonight at 5:06--
Alan was asking me about our appointment and asked what we discussed about my liver.  I said we barely even talked about and breezed over the lab results.  I said, "She didn't even palpate it.  My liver is like the best gift I bring Yvonne and she didn't even take the time to enjoy it."  Glad you enjoyed the kidney results, though.  :)

Merry Christmas, from all my organs.
 She replied at 5:08--
I know!!!!.   Your abdomen is so flat (flatter than mine) that your liver said “ no need to palpate me today, you can already see me” 
And then added at 5:09--
and I love those kidneys of yours.
 I love my kidneys, too.  It's been a good week and I'm so grateful for how well I'm doing, what a great care team I have and how bright the future looks for Amyloidosis patients.  2015 has been a pretty good year!

Tuesday, February 25, 2014

A Time To Mourn

February will always be the month of mourning for me.  Many of you know the challenging February I had last year—the deaths of my father and father-in-law, and my diagnosis with AL Amyloidosis (and eventually Smoldering Multiple Myeloma) all in the same month.

There’s the traditional mourning that accompanies the death of a loved one and that was part of my February.  But my diagnosis cut short that mourning and introduced me to mourning the passage of something else.

Before my diagnosis, I considered myself a pretty strong Christian who recognized that God was ultimately in control of my life.  At the end of the Confession of Sin in the Episcopal service we say, “For the sake of your Son Jesus Christ, have mercy on us and forgive us;  that we may delight in your will,
 and walk in your ways, to the glory of your Name.”  I’ve always appreciated that word “delight.”  I don’t ask God to help me “accept” His will but to delight in it.  That’s a pretty high standard but I’d always felt I was doing a pretty good job at it.

I have found that its really easy to delight in God’s will when God’s will is relatively close to my design for my life—happy, healthy, faithful family; financial security; loving friends.  It’s challenging to delight in a diagnosis of AL Amyloidosis with Smoldering Multiple Myeloma and the health problems and likely reduced lifespan that comes with it.

That sense of security, the expected guarantee that my life design will continue, is lost with the diagnosis of a fatal, incurable disease that has a 96% relapse rate.  Yes, I know, that guarantee was never really there in the first place.  But an illusion that persists long enough starts to feel like reality.  And, so, in the midst of mourning the loss of my father and father-in-law, I started mourning the loss of the life I thought I was going to have.

From talking to others with this disease, many of us progress through the five stages of grief after diagnosis—denial, anger, bargaining, depression and acceptance.  I think one of the reasons I’ve done so well with this emotionally is because I was able to move through those stages pretty quickly.  I don’t think you can be “all in” in the fight until you get to acceptance.

One year ago today, my phone call from Dr. Levin as I drove home on I-270 went something like this, “Mrs. Koontz, I have a diagnosis for you.  It’s a rare blood disorder called Primary Amyloidosis.  Your next steps will be to have biopsies of your liver and kidney and an echocardiogram of your heart to see if and how much they’ve been affected by the disease.  I will need to refer you to a specialist but I don’t know who treats it here at OSU.  I have some phone calls and emails out and will call you tomorrow with the name of someone to whom I can refer you.  Have a great night!”  Ok, he didn’t say “Have a great night” but I can’t really remember what he said, if anything, to close the conversation.

After I got off the phone with Dr. Levin, I called Alan.  I remember I was passing the I-270 exit for Tuttle Crossing when I was on the phone with Dr. Levin and was passing the 33 exit for Avery-Muirfield when I was on the phone with Alan.  I got home, jumped on the internet and was shocked at the prognoses I saw.

Yes, everyone says “don’t go on the internet there’s a lot of misleading information out there.”  But I knew how to find the good information….I work in data and analytics and understand statistics; I did Media Relations for a teaching hospital, writing general media news releases and pitching story ideas about clinical trials going on at the hospital; my husband is an RN with a career of experience in the ER and ICU.  I know how to find the valid information….and the valid information was the scary stuff.  There’s not a lot of false information floating around the interwebs about a rare disease.  Not too many sensational news reports exaggerating the seriousness of the diagnosis....no exaggeration needed.

I remember seeing average survival time of 4 years and thinking I wouldn’t even be around to see Claire graduate from college or know any grandchildren that might come along.  As I reeled from the shock, I kicked my meta-analysis into high gear searching for some hope in the medical literature I was reading.  At the time, I wasn’t aware of the progress that has been made against this disease in the last 10 years and was giving equal consideration to information from 1999 that I was to that from 2012.

But as I read more, I saw such variation in the overall survival estimates and decided I was going to be one of the people on the long tail of the survival curve.  I saw on the Amyloidosis Foundation website that high dose chemo with stem cell transplant “is the most aggressive treatment to date for those who can qualify for it. It is showing a great deal of promise.” I decided the phrase “aggressive with a great deal of promise” sounded like what I wanted.

So, at 10 pm, about 5 hours after I first heard the phrase “primary amyloidosis” from Dr. Levin, I posted on my blog (Relaxin in the Amyloid Oasis) that I had seen a calendar for a stem cell transplant and noted, “It says the process takes 5 weeks but can take up to 8 depending on how well the patient tolerates the treatment.  I told Al, "My goal is to be done in 4!"  :)”

I moved through those grief stages pretty quickly that night and got to a point where I was ready to fight once I had a sense that there was a path to success.  Now, I’m not saying I didn’t cycle back through some stages over the coming weeks and at different points in my journey (because I did), but that night and over the next few days, God gave me the strength to want to fight this.  And the very next morning, He gave me the peace to know that I would be OK. ("It Is Well With My Soul")

Over the summer, as I recovered from the stem cell transplant and wondered if it was successful, I still went through periods during which I would mourn the life I had, or I thought I had, before my diagnosis.  But once I learned I had the best response possible to the transplant, I haven’t done the before and after thing.  Words of wisdom from two beloved believers helped me with that.  First, my daughter Amy admonished me to “live the life God has given me.”  And my friend Jim told me that “my after is now a new before.”  I have a life, there is more to come and I need to look to the future thankful for what I now have, not disgruntled about losing what I thought might have been.

Another period of mourning I’m now experiencing is related to work.  In January, we had a new leader named for my group.  He has reorganized the group and my team of three directors and 25 people has been split up into other teams within his organization so I can take on a new role.  While I’m excited about the new role, there is a sense of mourning for a team and a function that I’ve been working to build over the last 3+ years.  I’ve developed some great relationships with folks on the team and, while the relationships will continue, there’s no escaping that they will change.  You take a job for the work, you stay in a job for the relationships and I’ll miss working closely with the team.

But, if this last year has taught me anything, it’s that change will come and even when I can’t see where the path will lead, I can trust in God’s love and care as I walk the path.  Lately, I’ve been thinking about the passage from Ecclesiastes 3 (There is a time for everything, and a season for every activity under the heavens:  a time to be born and a time to die…) and humming "Turn, Turn, Turn", The Byrds song that is based on the passage.  I was pretty familiar with the section of the passage that lists all the activities for which there is a time but I hadn’t read the whole chapter recently.  I was struck by the verse that comes shortly after—“I know that there is nothing better for people than to be happy and to do good while they live.”

Yes, as I move through this period of mourning and past these one year anniversaries, I will hold fast to that…to be happy and do good while I live.

Friday, January 17, 2014

Good Progress

I had appointments with my gastroenterologist and nephrologist on Wednesday.  I call it my day with the gists.  I really like both of these physicians and they're about as different as possible on the surface.  But what they do share is a deep knowledge of their medical science with equal portions of compassion, a bias for action and a willingness to educate me...which are very important to me.

Dr. Levin, my gastroenterologist, is about 70 and a focused scientist who seems to have a gruff exterior but has a heart of gold and a mind that can quickly organize data.  He reminds me of that grumpy uncle who is somewhat intimidating when you first encounter him but is quietly caring and figures out all the brain teasers.  When I was continuing to have issues with my fluid retention in the hospital and felt like the transplant physician, Dr. Levin and my nephrologist couldn't develop an approach, I asked Dr. Levin to step in and get things moving and he did.  He was also the one to diagnose me.  For that, I will be forever grateful.  During my first appointment with him, he asked if I was related to a physician named David Koontz.  I told him David is my brother in law and Dr. Levin mentioned that he trained David when David was a resident at Riverside Hospital about 25 years ago.  It shows me he's a man who cares enough about people to commit them to memory.

Dr. Parikh, my nephrologist, is probably in his early to mid 30s and is very eager and engaging.  I wrote about my first encounter with Dr. Parikh in this post.  He answers all of my questions and provides context and the reasons why lab values may be changing.  When I notice a change and express concern, he doesn't just tell me "that's normal, don't worry about it"  he tells me why its normal, what is driving the change and why I don't need to worry about it.  So often when questioning any technical expert, I'm reminded of the quote by Einstein that says "If you can't explain it simply enough, you don't understand it."  Dr. Parikh always explains things simply enough so I can understand them.   When we were talking about changing some medication levels over the summer and I wasn't ready to change them as much as he was, he listened to my concerns and said we would try my course of action first.  To me, that shows a great deal of confidence in his ability to manage my condition since he didn't insist on his course as the only course.

On Wednesday, Dr. Levin told me that he could feel that my liver size has reduced.  I felt that but his assessment validated that it wasn't just wishful thinking on my part.  He also said my liver is no longer rock hard.  Liver hardness < Rock  That's a nice equation.  I was reading the proceedings of the International Symposium on Amyloidosis and read this interesting information in the history section.
Thomas Bartholin, discoverer of the lymphatic system in humans, described in his Historiarum Anatomicarum Rariorum the autopsy of a female whose spleen was so hard that it could scarcely be cut with a knife.  He stated that incision of the spleen produced a sound like that of the cutting of spongy timbers. This autopsy report was included among the 3000 collected in Theophili Boneti’s Sepulchretum Sive Anatomia Practica which was published in 1679.
That type of organ hardness is what I've imagined my liver is like.  Nice to know Dr. Levin feels that its softening up.  Goodbye spongy timbers!  (When I read "spongy timbers" I thought that would be a good name for a pirate ship captained by Spongebob Squarepants.)

Dr. Parikh said that my kidney function is normal except for an excessive amount of protein in my urine.  The amyloids have pried open the filters in my kidneys.  Substances that are too large to pass from the blood into the urine through the normal size filter will go through in an amyloid damaged kidney.  Protein that should stay in my blood leaks into my urine through the filters that have been pried open.  He said that's improved thus far and he expects it to continue improving.

In Amyloidosis, they measure treatment response in hematologic response (are you no longer producing the substances that create the amyloids) and organ response (are the organs damaged by the amyloids recovering.)  My doctor said that organ response can take up to three years to complete and in the studies I read, that seems to be the standard period of time they look for changes.

I had a complete hematologic response and as long as my immunoglobulin free light chains are normal, that response is continuing.  There are defined standards to determine organ response.

For the liver, that criteria is 50% decrease in an initially elevated alkaline phosphatase level, or decrease in liver size by at least 2 cm.  My alk phos level has reduced by 33% in 9 months and I still have 27 months within which improvement could occur.  I go next week for an ultrasound to measure my liver.  Last time they measured it, it was 24cm.  22cm next week shows organ response in the liver.  Now, bear in mind that normal for someone my height is about 8cm. It reminds me of that scene in the Grinch where his heart grew 3 sizes that day...except for me its my liver and it wasn't undersized to begin with, as far as I know.  But I sure got the 3 sizes thing.

For the kidneys, response criteria is 50% reduction in 24-hour urine protein excretion (at least 0.5 g/day) without worsening of creatinine or creatinine clearance by 25% over baseline.  At my appointment in December, my 24-hour protein had reduced by 48%.  So close but I'm going to round up.  I'm sure I'll be officially in the response criteria when they measure it again, probably in April.

So, more good news and good progress.  The bad thing about doing so well is that I'm now on 6 month follow-up with Dr. Levin and Dr. Parikh.  I'm really going to miss seeing them but since it means that I'm getting better, then sorry guys, we're going to have to get comfortable with a long distance relationship (time-wise, at least.)  It sure beats the alternative of being in a health state where they are managing an active disease process.

So, docs, see you in July.  Hope you don't miss me too much!