Acute YOLO Stress Syndrome

28 year old salaried professional.
No known diseases.

Presented with complains of acute loss of income over the last 1 month along with a new stress of going broke.

Patient was apparently happy until last month by maintaining a paycheck to paycheck lifestyle.

History of –

  • School and College education which gave the ability to earn, but not to manage money.
  • Rampant credit card use and no interest EMIs on the back of (now doubtful) future earning potential.
  • Splurges on gadgets like iPhone, apple watch, air pods, JBL speakers & 55″ Smart TV.
  • Socializing every weekend with a frequent Rs 3000 expenditure per night (avg) in an inebriated condition with subsequent regrets next morning.
  • Recent purchase of a SUV on loan associated with inability to cover its monthly maintenance costs.
  • Plans to purchase a 3BHK costing Rs 1Cr on loan.
  • Significant alcohol and tobacco consumption, along with other material luxuries.

No History of-

  • Tracking monthly expenses.
  • Any Mutual Fund research.
  • Any passive income source.
  • Any effort to understand about inflation and its effect on the future purchasing power of the money saved today.
  • Taking Life or Health Insurance despite having Auto insurance (do cars need more insurance than one’s body?)

Financial Vitals –

  • Present Employment Status: Doubtful
  • Bank Balance : Rs. 4500
  • Outstanding Loan : Rs. 10 Lacs
  • Outstanding EMI : Patient unaware.
  • Savings : Patient exclaimed ‘LOL!’

Diagnosis: ACUTE Y-O-L-O STRESS SYNDROME

Understand concepts

Life expectancy in India (The need) – As an economy grows the average life expectancy of its people will increase. So the patient will live 20 years more than his parents.
That means he has to save more than his parents to cover his expenses in those extra 20 years.

Inflation (The problem) – The interest rate on your savings should be greater than the inflation rate in the economy (approx 6 %).
A lower rate would mean lesser purchasing power of the same amount in the future.

Compounding (The solution) – Einstein called compound interest the eighth wonder of the world. The entire stock market and mutual fund universe is based on the concept of compounding.

Treatment –

  1. Repay all debt and credit card dues first. Debt is injurious to financial health.
  2. Target to save 50% of your earnings henceforth. Alter lifestyle to live on the rest 50%. Don’t buy things on credit as far as possible. Spend on things which increase productivity and save time.
  3. Insurance : Get a TERM INSURANCE and a HEALTH INSURANCE for yourself. Your term insurance amount should not be less than 10 times your yearly income and should cover you till 60 years of age at least.
  4. Goal based saving : Put money in Debt Mutual Funds rather than in savings account for upcoming financial needs over the next 2-3 years. Put rest of the money in Equity linked Mutual Funds. Diversify by starting SIPs in max 3-4 good funds and DO NOT STOP SIPs WHEN MARKETS GO DOWN. Multicap funds are a good option for long term investing. Track returns yearly and not daily.
  5. Emergency Fund : Create a fund for any unforeseen emergency like a hospital admission. An amount which is atleast 6 times your monthly expenses saved in Debt Mutual funds is the way to go.
  6. Try to develop passive income sources. Passive incomes will improve your monthly cashflows. Being rich is really about having good monthly cashflows.
  7. Buying a home is a tricky subject. Go ahead if you need it yourself. But remember that its a poor investment compared to equities in the long run. So staying on rent is really okay.
  8. Read good books and watch YouTube videos to become more mindful of money. Surround yourself with company who understand frugal living.
  9. Don’t compromise on having life experiences just to save. After all, YOLO!

This article was first written as a guest post for Dumbbells & Drama.

Fighting Future COVID-19s

The Spanish Flu of 1918 was an unusually deadly influenza pandemic, infecting 27% of the then world population and killing 40 – 50 million people. It’s been common knowledge in the global health community that another pandemic ‘Disease X’ whose speed and severity could match that of the Spanish Flu is a matter not of if but of when.

Welcome to 2020, the year of Covid-19. Its efficient transmission between humans and case fatality rate of around 1% (higher in elderly) has made the world come to a standstill. As I write this, there are 93000+ confirmed cases and 3100+ deaths in 60+ countries amidst a massive global effort to contain the spread of this potentially pandemic zoonotic coronavirus.

Learn how to protect yourself against Covid-19 here. Live track Covid-19 spread here.

While you are reading this at home (hopefully trying to avoid travel & public spaces), let’s take a step back and look at the bigger picture of pandemics and the global efforts to deal with it.

What are Pandemics?

The WHO defines pandemic as the worldwide spread of a new disease. Our growing population, encroachment into wildlife habitats and globalization fuelled trade & travel has led to an era when the threats posed by global pandemics and epidemics are accelerating exponentially.

The Middle East Respiratory Syndrome (MERS) coronavirus originated from the camels of Saudi Arabia in 2012 and spread halfway across the world to South Korea in 2015. Severe Acute Respiratory Syndrome (SARS) emerged in China and went on to infect people in over 30 countries in 2003. Add the Ebola and Zika stories to this, and you know how ill prepared we are to predict when, where, or from what species the next emerging virus will break out. Yet our knowledge of viruses is limited to only 260 out of the estimated 700,000 viruses which can possibly infect humans.

Novel viruses usually jump from mammals/birds to humans in regions where dense human populations and biodiversity intersect. Limited laboratory facilities, surveillance and healthcare infrastructure at such places delay early detection and subsequent control efforts. This jumping of a pathogen from a reservoir species to a new species is called Zoonotic Spillover. For example, Ebola virus jumped from bats to humans. It is a poorly understood phenomenon specifically because there are just too many factors influencing it. The idea of building models to predict a zoonotic spillover would give nightmares to even Shri O.P. Tandon, an Organic Chemistry author, whose books have given nightmares to millions of unsuspecting entrance exam aspirants.

Lets breakdown a Zoonotic Spillover event:

First, the amount of pathogen available to the human host at a given point in space and time, known as the pathogen pressure, is determined by interactions among reservoir host distribution, pathogen prevalence and pathogen release from the reservoir host, followed by pathogen survival, development and dissemination outside of the reservoir hosts.

Pathogen Pressure

Second, human and vector behavior determine pathogen exposure; specifically, the likelihood, route and dose of exposure.

Identifying key bottlenecks between barriers will help predict and intervene during a Zoonotic Spillover event.

Third, genetic, physiological and immunological attributes of the recipient human host, together with the dose and route of exposure, affect the probability and severity of infection.

A Zoonotic Spillover is a rare event.

Although we are continually exposed to many potentially infectious pathogens that are derived from other species, barriers at each phase make infection and subsequent disease a rare event. Understanding how these barriers are functionally and quantitatively linked, and how they interact in space and time, will substantially improve our ability to predict or prevent spillover events.


The Global Virome Project

In 2016, our approach to pandemics changed from reacting to outbreaks to proactively preparing for them with the Bellagio Initiative on the Global Virome Project (GVP). Based on USAID’s PREDICT program, which has discovered hundreds of known and unknown viruses in over 30 countries, the Global Virome Project (GVP) is a groundbreaking  global partnership to develop a comprehensive ecologic and genetic database of virtually all naturally-occurring viruses in 10 years. It aims to be the beginning of the end of the Pandemic Era.

If you know the enemy and know yourself, you need not fear the result of a hundred battles.

Sun Tzu

How will this ‘VIRAL BIG DATA’ help us deal with the next pandemic?

The availability and access to human genetic data has revolutionized how we see and treat cancer today. It has pushed cancer from the era of chemotherapy to that of personalized medicine. The Global Virome Project is based on the same principle, and hopes to use this data to predict things like the Top 10 emerging viruses, Zoonotic Spillover hotbeds, Virus migration patterns, Risk mitigation interventions and Drugs/Vaccines discovery strategies. The project will use artificial intelligence across the largest viral data set ever assembled, similar to machine learning techniques that are used in genomics to identify gene function, expression and disease biomarkers. It will also build capacity to further strengthen the global surveillance network.

Influenza pandemics are estimated to cause an average of US$ 570 billion in economic damages per year to the global economy and these costs will rise as our economies expand and become more interconnected. The Global Virome Project will cost US$ 1.2 billion, which is less than 0.2% of this estimated loss. In the late 1980s, the Human Genome Project catalyzed the development of new technologies and ushered in the era of personalized genomics. It is estimated that every U.S. federal dollar put into the Human Genome Project resulted in a $178 return on investment. The Global Virome Project is also expected to go beyond the immediate goal of tackling novel viruses to yield a treasure of publicly accessible unbiased data for advancements in science and global health.

Pandemics are like terrorist attacks: We know roughly where they originate and what’s responsible for them, but we don’t know exactly when the next one will happen. They need to be handled the same way — by identifying all possible sources and dismantling those before the next pandemic strikes.

We Knew Disease X Was Coming. It’s Here Now by Peter Daszak

Was this blog too technical? Watch this Netflix episode on Pandemics instead.

The Networking Doctor

The Oxford dictionary defines networking as a system of trying to meet and talk to other people who may be useful to you in your work.

Doctors have always been part of formal and informal networks through which they make patient referrals, take clinical decisions and update themselves on the latest treatment protocols. Even that Whatsapp group of your medical college batchmates is an informal network of doctors. Networking also caters to the continuing need of building one’s professional reputation and impulsive needs like jobs, medicolegal consultations and medical device purchases.

Doctors, as history tells us, can never work alone. Solving healthcare issues like antibiotic resistance, rising healthcare costs, public sanitation and last mile delivery is like killing the ten headed Ravana. Individual doctors and the medical community as a whole cannot hope to overcome the sheer complexity of such evolving villains by themselves. After all, even Shri Ram had to network with Hanuman to kill Ravana.

When Dr. Sidney Farber. a pathologist working to find a cure for childhood leukemia networked with Mary Lasker, a socialite, the war on cancer took a huge stride forward.

Most doctors network wrong. It’s not their fault. Our education system values data absorption and regurgitation more than the art of blending knowledge with empathy and synergy for the cost-effective welfare of a fellow human being. Also between the long study hours in medical colleges and the longer night shifts at hospitals, doctors spend most of their adult life surrounded by either books or fellow doctors. A generic doctor’s exposure to other professionals/fields of work remains very limited.

So in a world where physician burnout claims more lives than Thanos himself, building strategic partnerships or developing interpersonal skills that are helpful to create that ultimate Healthcare Avengers team remains a high effort/low return proposition for the majority of doctors who are either running after that glamorous Radiology PG seat or trying to make a high return on those 5+ years of medical education. 

Those who end up trying their luck at this ‘highly experimental’ protocol learn through trial and error. Some born with that networking gene are successful. But most fail and end up wasting years attending medical conferences and updates hoping for that elusive impactful meeting of a lifetime.

Digital Networking

Networking sites for doctors have been here for a while. Sermo, PlexusMD, Doximity and Curofy are well known names in this domain. Sites like Incision Academy for surgeons, Orthomind for Orthopedicians and MomMD for doctor-mothers are catering to very specific niches.

The most important function of such sites is real-time medical crowdsourcing. Breaking geographical and accessibility barriers, doctors are now consulting each other over difficult cases to improve patient outcomes. The beauty of this is the creation of digital repositories of treatment workflows. Over time efficient search and sort tools can bring up anecdotal cases to assist medical decision making.

Other digital networking applications:

  • Sharing medical updates.
  • Discussions.
  • Sharing practice management ideas.
  • Actualizing issues that faces the profession as a whole and taking a stand for it when necessary.
  • Partnerships with patient advocacy groups, NGOs & non profits.
  • Extension to student communities for knowledge sharing.

The only real concern with digital networking is that it might distract you from your actual work. It’s another way to bring your work home with you, and this could further contribute to physician burnout.

The Economics of Networking

Does the way doctors network affect healthcare costs for patients?

A research paper by James Whisler, Kumar Kanisan & Jesus Leal Trujillo published by Deloitte in 2019 studied physician network dynamics using Medicare Fee for Service claims filed in three US states. They identified six conditions with relatively predictable care and treatment patterns — cerebrovascular disease, chronic obstructive pulmonary disease, coronary artery disease, fracture/dislocation of the hip/femoral head, hypertension (essential) and spinal/back disorders. By retracing patient referrals, they mapped out the structure of physician networks providing care to patients with these conditions and measured the relationship between network characteristics and average spending per episode.

Deloitte’s analysis of these network dynamics in Medicare shows that where physician relationships are tightest, spending for certain health conditions is lower. For instance, an increase in the physician centrality (a measure from network science that captures the degree of coordination between disparate parts of the network) decreases average episode of care cost for hip fracture by almost 15 percent (or US$2,000) and for coronary artery disease by 26 percent (or US$1,050).

This has immense applications in healthcare plans like Ayushman Bharat Yojana and Ex- servicemen Contributory Health Scheme (ECHS). Claims data can be used to identify high and low performing networks and all the physicians who are part of that network. For example, one can find a specific cardiologist whose costs are lower compared to others in that cardiologist’s network. This information can be shared with doctors and patients to encourage them to change their care patterns and referrals or for validation of their efforts in this direction.

Think on the lines of high patient rated and cost effective medical practices in a particular geography being connected digitally. Think about doctors running these practices being so connected to each other that Dr. A knows not to send a child with a broken arm to Dr. B because Dr. B is getting his Xray machine repaired. Think about the peace of mind that we can get knowing that we have made the referral to a dependable highly rated colleague at a cost that the patient can afford. Think cloud connected multi tier healthcare for patient referrals.

Sounds like a startup.

Ars longa, vita brevis.

(The art of medicine is long, life is short.)

Hippocrates

Veganism & Vitamin B12 Supplementation

The Economist declared 2019 “the year of the vegan“. Globally, more people are adopting the vegan lifestyle today than ever before. Vegan restaurants are opening up in every geography. Supermarkets are improving their selection of vegan processed food. Don’t be surprised if a plant-based meat shop opens up next to your neighborhood KFC.

The reason for going vegan may be health related, after all, there is documented evidence linking reduction or exclusion of animal foods to lower risk of lifestyle diseases. Or the reasons may be ethical and environmental. In the latter case, knowledge about the nutritional aspects of such a choice might be lacking. Although well-planned vegan diets are considered appropriate for all stages of life, including infancy and pregnancy, it requires food fortified with Vitamin B12, Vitamin D, Calcium and certain useful Fatty Acids which are naturally deficient in plant based diets. 

Vitamin B12, also called Cobalamin, is a water soluble vitamin important for making DNA, myelin sheaths (structural component of a nerve cell), neurotransmitters and matured blood cells. Recommended Daily Intake (RDI) of Vit B12 for adults and pregnant women is 2.4 and 2.6 micrograms respectively. A common misconception among vegetarians is that the presence of dairy products and eggs in their diet is enough to take care of their Vit B12 requirements. It’s body stores lasts for several years and its deficiency develops slowly. However, the combination of malabsorption and inadequate dietary intake will hasten its deficiency. The only substantial source is animal meat. The prevalence of vitamin B12 deficiency (<200 pg/ml) is at least 47% in Indian population. If B12 levels of 200 – 300 pg/ml are considered as borderline deficient, then up to 74% of the Indian population would be potentially deficient.

Clinical manifestations of Vit B12 deficiency can be broadly divided into neuropsychiatric (like myelosis, cognitive disorders, depression and dementia) and hematological (like megaloblastic anemia). Neurological symptoms are the first to appear. Typically a new patient comes with complains of pins and needles sensation in the foot sole and along the legs. The diagnosis is based on clinical symptoms and blood investigations, but no gold standard test exists at present.

At risk population for Vit B12 deficiency:

  • Vegan/Vegetarian diet.
  • Elderly (Age > 51 years).
  • Pregnant women, lactating mothers and their infants.
  • Patients who have had weight loss surgery.
  • Patients taking proton pump inhibitors (PPIs) like Pantoprazole (popular among the elderly as Gas ki Dawai a.k.a. Medication for Dyspepsia) or diabetics taking Metformin.
  • Patients with Gastrointestinal conditions.

Prevention:

  • Diet – Inclusion of more dairy products and eggs in a vegetarian diet. Shiitake mushroom is an excellent source as well. As mentioned above, a vegan/vegetarian diet alone isn’t enough to meet daily requirements.
  • Food Fortification – Food fortified with Vit B12, like nutritional yeast flakes and breakfast cereals. But considering the magnitude of deficiency in the general population wheat flour fortification is being looked at with great interest. Presently, there aren’t enough intervention trials on the effect of different fortification levels of flour in different populations. But this will be a huge opportunity for wheat flour companies in India going forward if they can do what Tatas did with Tata Salt Plus to combat nutritional iron deficiency in India.
  • Oral supplementation – Vit B12 pills are available over the counter in varying doses. A standard multivitamin delivers 6 micrograms of Vit B12, more than enough to cover the average body’s daily needs. But some studies have shown that using multivitamins can be inefficient and counterproductive for the supplementation of Vit B12 as Vit C and copper in such pills can form inactive by-products with Vit B12.


Digital Dissection

Brain Mapping & Brain Image Segmentation

Understanding the anatomic variability of the brain in the population is essential for connecting brain function to brain anatomy and for a deeper understanding of development, aging, and disease. The need of neurosurgeons to visualize the complex central nervous system (CNS) is pushing the use of a more accurate segmentation of different anatomical and pathological structures. While neuroanatomists debate the exact boundary of relatively simpler brain parts and traditional brain atlases identify regions only by pointing to the middle, leaving the interfaces between regions unspecified, the International Consortium for Brain Mapping (ICBM) seeks to create a so-called probabilistic human brain atlas. The technology is so advanced that the model will be able to predict the probability of a particular voxel, in such an interface between regions, being a part of either of the adjoining brain regions. (Voxel in a 3D structure is equivalent to pixel in a 2D image).

The inclusion of physiopathological data from functional MRI (fMRI) provides resolution of a few hundred microns over limited volumes and will identify areas with increased biological aggressiveness within a certain lesion prior to surgery or biopsy procedures. Sectioning, staining and optical digitization of cadaver brains allow even finer spatial and chemical resolution in limited numbers of brains. Such new data acquisition technologies with the concepts of 3D stereotaxic mapping will help create probabilistic maps at a very fine scale with the help of powerful computational tools for analysing high-resolution three-dimensional (3D) brain images. Fully automated neuroanatomic segmentation in large numbers of MRI data sets is essential if questions of normal population variability, normal longitudinal development, and detection of abnormality in single subjects or in groups are to be answered definitively.

Image segmentation is a multi step process of dividing an image into a set of semantically meaningful, homogeneous, and nonoverlapping regions of similar features such as intensity, depth, color, or texture. Subsequent measurement and visualization of anatomical & pathological structures will help in computer aided diagnosis, surgical planning and image-guided interventions.  

Brain pathology visualization

Applications

  • In degenerative diseases like Huntington’s disease and Alzheimer’s disease, the sulci become more open and the ventricles become enlarged. Measurements of these changes can lead to early diagnosis and treatment.
  • In Multiple Sclerosis a significant difference in the overall volume & distribution of affected brain tissue between drug and placebo groups can be used as a measure of drug efficacy.
  • Structural analysis of brain can also help to predict outcomes of Traumatic Brain Injuries.
  • On the same principles of brain volumetric analysis, breast volumetric analysis  can be used for aesthetic planning in breast reconstruction.
  • To visualize and store information in Forensic Case analysis.
  • In addition to direct hypothesis testing, the stereotaxic approach of brain mapping may allow for the detection of unsuspected patterns of interaction among normal brain elements and the isolation of constellations of measurements that characterize specific disease states.
Analysis of changes in the Hippocampus anatomy can be used for an early diagnosis of Alzheimer’s disease.

Challenges

  • Such high technology tools often demand that scientific questions be restated and made more amenable to quantitative analysis.
  • Consent from patients for data collection & utilization and ensuring privacy are important issues which can be tackled by blockchain technology which gives direct ownership of images to patients.
  • Curated medical imaging data collection isn’t an easy job either. Curating medical imaging data includes but is not limited to data anonymization, checking the representative of the data, unification of data formats, minimizing noise of the data, annotation, and creation of structured metadata such as clinical data associated with imaging data.
  • The image segmentation methodology isnt fixed. Research has shown that different segmentation methodologies are better for different structures or pathologies. Validation and quantitative comparison of different segmentation methods is a general problem in medical image analysis. It requires a “ground truth” or gold standard to which the outcome of the segmentation method can be compared. Unfortunately, the “ground truth” does not exist for the analysis of in vivo acquired data in humans. Two methods are being used to establish this ground truth. One is a method by which radiologists review images to make labels and the other is a method based on radiologic reports. In the former case, a lot of time and effort is required and there may be an inter-reader disagreement on the label. In the latter case, the correctness of the labels itself may be unsatisfactory.
  • Incorporation of nonimaging parameters such as behavioral variables, demographic information, and genetic data into the statistical models.
  • Applying deep learning to this data comes with its own problems like absence of an audit trail to explain the decisions of the deep learning model, overfitting and adversarial data impact.

Present & Future

Will brain mapping help speed up clinical trials in case of Multiple Sclerosis? Will an Alzheimer’s patient get an earlier diagnosis so that he has more time to get his personal affairs in order? Will the family of a Road Traffic Accident patient get more concrete answers about their loved one’s chances to pull through? This technology like any other will only make economic sense if it creates significant value in people’s lives.

NeuroShield™, a cloud based Clinical Decision Support Tool for Neurological Disorders, is being developed by InMed Prognostics, a Pune based healthcare tech startup. It provides volume analysis of brain parts segmented from 3D MRI and compares it to Indian reference ranges built specifically from Indian population data.

If Google Maps is showing routes to autonomous vehicles today, the idea of ‘bio-tagging’ target voxels for robotic surgeries with the help of such readily available brain maps doesn’t seem too far fetched. Neither does the idea of two neurosurgeons sitting in a cafe and brainstorming the surgical approach to a holographic reconstruction of a segmented brain pathology seem too futuristic.

SentiAR provides real-time holographic visualization of the patient’s actual anatomy in the clinical setting, literally floating over the patient.