Sunday, October 31, 2010

A hectic fortnight

The last couple of weeks have been really hectic. There was this new project we started at Grene for which a prototype had to be completed asap. This resulted in some late nights and working weekends, something unheard of in my career at Grene!

The work culture at Grene is generally very healthy. You do your work. As long as you are reasonably productive and work responsibly, no one bothers you.

In addition to this, I was busy with things at Nephroplus too. We had a stall to manage at the TiE-ISB Connect event that was held at the Hyderabad International Convention Center. This was basically an event for budding entrepreneurs to meet people who had already taken the plunge and started businesses on their own. There were panel discussions on various topics (one of which was healthcare) where people from different backgrounds would discuss the topic and then there would be an open Q&A.

Initially I thought that these discussions serve no real purpose other than giving people an opportunity to network. I was probably wrong. I could sense the encouragement wannabe-entrepreneurs got by simply seeing people who have taken risks succeed in a field close to their heart!

Well, I also heard more jargon than I have in quite some time. Value proposition, stakeholders, tier x cities, strategic investments. Gosh, I did not even understand many of those terms! I wonder if the speakers themselves were just bandying them about without really meaning anything. In one answer to an audience question, the speaker used so much jargon that I got totally lost. In fact, I thought he answered yes to the question when I realized, to my utter horror, that he actually meant no!

Today, Sunday, I decided to take it totally easy. So, apart from my weekly pilgrimage to Poorna Tiffins (while on the topic, I might as well mention a joke I put together - Q. What is K Rosaiah's main contribution to the city of Hyderabad? A. He inaugurated Poorna Tiffins! hehehe... He really did, you know! When he was a simple MLA), so, apart from my weekly pilgrimage to Poorna Tiffins, I did not do ANYTHING. I practically was on my bed the whole day, watching TV and browsing using my iPad.

It's 4:30 now and I am feeling so much better. Rested. My body was actually aching last evening due to all the strain of the past two weeks. I am really glad I rested totally today. I even skipped a family lunch at an uncle's house.

I must really control the time I spend at work. This is totally not sustainable. It is good to say you are leading a normal life despite kidney disease. It is however important to not overdo it!

Saturday, October 23, 2010

CFH/CFHR1 hybrid

I got an email from Dr. Tim Goodship from the University of Newcastle upon Tyne in the UK this morning.

I had sent my blood samples to this lab in 2006 for genetic testing for atypical HUS. They had sent me initial results saying they could not find any mutations of Factor H, Factor I or MCP, the three most commonly implicated genes in aHUS.

Apparently, they did more tests subsequently and a very specialized set of tests revealed that I did have an abnormal form of the Factor H gene called CFH/CFHR1 hybrid. The chance of recurrence of atypical HUS after a transplant with this abnormal gene is 80%.

So, that pretty much rules out me getting a transplant using the current protocols. Even plasmapheresis may not help.

My only hope now is Soliris (Eculizumab) from Alexion Pharmaceuticals. They have just recently completed a set of Phase 2 clinical trials in patients who were resistant to plasma therapy and patients who were on chronic plasma therapy. The clinical trials have met the objectives, they say. I have myself seen scores of papers on the results of the use of this drug and the rate of aHUS remission has been 100%.

Though daily nocturnal hemodialysis has shown outcomes comparable to that of a deceased donor transplant, I still think I want a transplant. The hassle of undergoing dialysis every day and the restrictions on travel (portable machines are not yet available in India) make a transplant seem like complete freedom. So, I really hope Soliris becomes available for use in renal transplants soon. That, as I said, is my only hope.




Friday, October 22, 2010

A good IDE goes a long way

An IDE, or an Integrated Development Environment is the tool that you use to create software. A lot of the credit for the success of any development software goes to the IDE. Who would develop using Dot Net if it weren't for Visual Studio?

I primarily use two IDEs for my day to day development - Eclipse for all my WebObjects and Java work and Xcode for all my iPhone and Cocoa work. Eclipse is definitely the better of the two.

Eclipse is Open Source while Xcode is Apple's product (see, I am not biased!).

These days, an IDE does a lot more than just give you text editing capabilities. Code completion, refactoring, inline documentation, templates and more, all these make life much easier.

Code completion is one of the most important features for me and Xcode simply does a bad job. Let's say I type the first few characters of a variable or a method. Now, when I hit the key for code completion (Esc for Xcode and Control+Space for Eclipse), while Eclipse will show me a list of options, Xcode often fills the first available option which, most often is not what I want!

File organization is another area where Eclipse beats Xcode hands down. Eclipse simply mirrors the disk file system of your project folder. Xcode, on the other hand has no connection between the two. You could have all your files in one folder on the file system whereas the project could have everything organized in folders. This becomes a problem as you manually need to go and move things around when the number of files becomes large.

Of course, Apple fanbois will still swear by Xcode (as with anything that has an Apple logo on it), but I really hope Eclipse starts supporting Cocoa and Cocoa Touch! Or that Xcode 4, touted as the next best thing since the iPhone 4 lives up to its promise.





Friday, October 15, 2010

Mac OS X Lion?

I subscribe to Google Alerts on Apple stuff using Google Reader. Yesterday, I learnt that Apple has sent out invitations to an event on October 20th that said "Back to the Mac". The invitation had a hidden picture of a lion indicating that Apple might be coming out with a new version of its Operating System.



This is expected to be a major upgrade from the previous version, Snow Leopard which had mainly performance enhancements. People are speculating that Apple might eventually merge their iOS with Mac OS X and this might be the last version of the desktop OS.

Well, with Apple, you can never be sure. The entire world expects something and then Apple comes out with something totally unexpected.

I am going to be keenly awaiting the October 20th announcement. I have been using a Mac for years now and am really excited to see what Apple has in store for us! They have revolutionized the phone and the tablet in the last few months. Let's hope they have something equally great for the desktop now.

Thursday, October 14, 2010

Have you taken your Swine flu vaccine yet?

The swine flu vaccine is now available in India. I just got my shot a couple of days back. All people on dialysis should immediately check with their nephrologists and if advised, take their shot.

Even people not on dialysis should check with their primary physicians and get their shots if advised to do so.

And while you're at it, check with your nephrologist/primary physician and take the vaccine for pneumonia too. I took that vaccine too yesterday.

I am sure you have taken your Hepatitis B vaccine already. If you haven't, please do so asap. This is a no-brainer. When there is a vaccine available for such a deadly disease, why take chances?

People on dialysis should definitely get vaccinated against Hepatitis B. In fact, people on dialysis are advised to take a double dose each time for The HBV vaccine. We must also get a yearly check of our HBsAg titers and then take a booster shot if necessary.



Wednesday, October 13, 2010

Over-engineering projects

I have worked on a large number of projects in my software development career. The team sizes have been between one and about fifty. There is one thing common to most projects. In the beginning, most of them are over engineered.

During the beginning of a project, people are generally very gung-ho about the project. Right from the project manager to the developer to the tester, everyone is very excited to be on the project. So, every minute detail is discussed to death. Discussions are held with every single member on the team whether the database column to store the id of a product should be varchar(32) or char(32).

Towards the end of the project, it is usually about getting the damn id into the database and wondering why the id is not being retrieved at all, never mind the data type!

I had a terrible sense of deja vu recently when at my office we starting discussing a new project. The kind of detail we went into was mind numbing. I couldn't help but shake my head thinking about the futility of it all. A few more days and anyway everything would change. Why bother then?

In new projects, I strongly believe, we should always go about things in a top-down manner. Look at the big picture. What is the problem we are trying to solve? What are the pain points that are being addressed? Then get down to the rest of the stuff.

Often engineering teams spend hours trying to solve problems that the customer couldn't care about. I have seen this all too often. That is where the Project Manager must step in. She must never lose sight of the 'big picture' - what exactly is the problem we are trying to solve? Every decision taken in the project must keep this in mind.

That way, a lot of unnecessary effort and heartburn can be avoided in most projects.

Monday, October 11, 2010

A conversation at the lab

"I asked for 1,25 dihydroxy cholecalciferol. The invoice also says that. The report you gave me, however is for 25 hydroxy cholecalciferol."

"Hmmmm. Ok. Let me check."

(Calls someone.)

"Madam. There's a patient here. He says he asked for 1,25 dihydroxy cholecalciferol but we gave him the report for 25 hydroxy cholecalciferol. They are the same? Ok. I will let him know."

"No, no, one second, let me speak to her."

(hands over the phone to me)

"They are not the same ma'am. 1,25 dihydroxy cholecalciferol is the active form of Vitamin D3 while 25 hydroxy cholecalciferol is the inactive form. I want the level of the active form, not the inactive form."

"Hmmmm. But the bill said Vitamin D."

"Ma'am, I asked for 1,25 dihydroxy choilecalciferol and that is what the bill also says"

"Ok sir, please give me an hour and I will call you back"

This is the state of our labs. I paid a huge Rs. 2290 for this test and I wasn't going to accept a mistake someone else made. I asked for the correct test. I actually made the receptionist making the bill show me the monitor and made sure the correct test was chosen because I knew this could happen. And inspite of all this, I get a wrong test report!

For the last time, here is a summary of Vitamin D3:

25 hydroxy cholecalciferol is the inactive form of Vitamin D3. It is not of much use to the body. What the body needs is the active form - 1,25 dihydroxy cholecalciferol. 25 hydroxy cholecalciferol is what we get from our food and sunlight etc. The kidney converts this inactive form to the active form - 1,25 dihydroxy cholecalciferol. This is the form that is useful in our body. This is what absorbs Calcium from our guts into the blood. In people with impaired renal function, obviously, the active form will be less because the inactive form is not being converted into the active form. So, people with kidney disease need to take a supplement of the active form.

Sunday, October 10, 2010

Better is possible

"...better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try."

This line from Atul Gawande's "Better" sums up the book - "a surgeon's notes on performance". It is an amazing book. To be honest, I felt a little bored while reading the first three chapters which are about how doctors in three different, yet trying circumstances overcome difficulties to succeed. But that only served as a backdrop to make the point Gawande was trying to emphasize - better is possible.

In the medical field, as in any other profession, you have people who go about their job as a matter of routine. Like an everyday chore. They do not have any real passion for their job. And then you have what Gawande calls the "positive deviants", the people who raise the bar, the people who dream about their job in their sleep, those who constantly improve not only their own abilities but also the system.

Medicine is full of such examples. These are the people due to which we have innovations. The human body is terribly complex. To innovate in treating such a complicated system has its pitfalls. The risks are great. Yet, we find individuals who have the willingness to try and the ingenuity to back this determination. Fortune, as they say, favors the brave.

Very often, in our jobs, it is easy to 'fit in'. You have set processes. You have established procedures. It is easy for us to follow them. In doing that, however, we lose out on improvising. We lose out on finding new and better systems. Most of us go about our lives in this manner. It is important to come out of our comfort zones, to take risks and try to be better. It is the "positive deviants" that make an impact on the world around us. It is these people who actually change the world.

In the medical profession, more than any other profession, this is so important. The impact of such endeavors is much more because it is human suffering that is being addressed. The effect is much more fundamental to our existence. It is more basic than developing a nice-to-have gadget, for example.

People in the medical profession should definitely read this book. Others will also take away a lot from it.

Wednesday, October 6, 2010

Nephrolife - Bangalore's one stop renal shop

During my recent trip to Bangalore, I got a chance to visit Nephrolife. It wasn't planned however. On my way to Wonder la, in the middle of a traffic jam, I happened to notice their ambulance which was right next to our car. I quickly noted the telephone number and called to check if they offered nocturnal dialysis in the hope of utilizing this facility the next time I visited Bangalore. The receptionist transferred the call to the MD, Shriram Vijaykumar.

Shriram invited me over to the center the following day. I went over to Nephrolife on Sunday at around 12:30. They had a few doctors visiting to see the center as well. I met Dev Roy, the Chairman and nephrologists, Dr. Topoti Mukherjee and Dr. Sushma Rani apart from the other members of the team. They really have a fantastic team. Shriram and Dev showed me around the center and I had a great discussion about a lot of things - both related and unrelated to dialysis! Both of them are extremely passionate about providing quality care to renal patients.

Nephrolife is a state of the art center which has the entire gamut of renal services from dialysis to access surgeries to even pre and post transplant care. They have a complete set of specialists on board to take care of every need of the kidney patient.

Their hemodialysis center is extremely high-end with very comfortable dialysis chairs (Shriram actually made me try one!), each attached with its own IP TV that boasts of hundreds of channels and a large collection of movies.

They also take care of all the ancilliary needs of patients like a dietician and a psychologist.

They have also integrated technology very well with the center. Each ambulance is equipped with a GPS. Doctors' notes are also instantly transmitted to a computer using a special note taking device.

The one thing I found surprising is the price of a dialysis session. I couldn't help wondering how they are able to sustain the operation at such low prices! If they are able to keep the prices low and yet run the company, their years at Carnegie Mellon and University of Chicago have not been wasted!

Nephrolife, I am sure, is a welcome change for dialysis patients in Bangalore. They started this center in February this year and already have close to 70 patients which is very commendable. They soon plan to expand to other cities in India. Here's wishing them all the best!

Saturday, October 2, 2010

Re-nopain - I spoke too soon!

Yesterday, I wrote about how I used Re-nopain, the anesthetic ointment that I used successfully before cannulation. Well, I think I spoke too soon.

I used it last night too and there was pain during cannulation.

I will probably use it for a couple of more days and then decide whether I want to continue to use it or not.



Friday, October 1, 2010

Re-nopain works like magic

I have been using Lignocaine just before cannulation. I take a little bit in an insulin syringe and then inject a little in both the sites - arterial and venous and then cannulate. So, even though the lignocaine injection itself stings a bit, the cannulation becomes painless. After all, kuch paane ke liye kuch khona padta hai!

Recently, Jairam brought me a tube of an ointment called Re-nopain. It had lidocaine and prilocaine. I think its composition is similar to the Emla cream available in the US. You basically have to apply it an hour before cannulation and then it is supposed to act as a local anesthetic.

The advantages are two fold - first and foremost, there is no injecting, so it is totally painless and second, since you are not injecting, the damage to the fistula is minimized.

I have been meaning to try it for a few days now but kept forgetting until I was about to cannulate. Jairam then asked me to put a reminder on my phone that repeated every day! I did.

Yesterday, I put the cream on both the sites an hour before cannulation. I was very apprehensive about the pain.

Fortunately however, the cannulation was totally painless!

I am going to use it again today and if it works, I will finally stop using lignocaine injections!