ghostlemon36

[klaviergavinwiki]

Listen I know the high school mean girls becoming nurses phenomenon is real to an extent and a haha funny joke or w/e but I'm chronically ill I've dealt with a LOT of nurses and I've had mostly good experiences and felt way more cared for by them than by doctors. As a rule if i need something treated I go to a nurse practitioner. I think we need to take some of the heat off nurses and put it on the mean girls who became teachers instead because let me tell you i've had significantly more shitty teachers who bullied me and made me feel worthless than nurses. Being a nurse is already thankless enough but the fact that they're predominantly women makes it easier for people to shit on them.

[lovedsammy]

okay guys, I can finally tell you what’s going on! 

So, after I had that bout of pneumonia in January, I started feeling very horrible. My hair started falling out, I gained weight rapidly, grew even more intolerant to the cold than I already was, developed dry skin, brittle nails, started skipping periods more, and crushing fatigue and brain fog. I felt like I was just going through the motions, unable to concentrate, constantly tired and barely alive. I went to the doctor after a month of this and it was suggested to check my thyroid levels. 

My TSH came back near 6.0, suggesting subclinical hypothyroidism. I then remembered that in 2017, after the first time I had pneumonia, my doctor noted an incidental finding on my CT scan for my chest that showed multiple thyroid nodules. I never got the chance to get them checked out. So when I brought that up, an ultrasound was also ordered, which confirmed that the nodules are still there. 

I’ve been to two endocrinologists since then. The first was the other day who was very offhandish and didn’t want to treat me, but did remark that my thyroid glands appear “heterogeneous” and “hypervascular” - which is associated with Hashimotos thyroiditis. 

The second endo I saw yesterday, and she was MUCH more understanding, willing to treat, and laid it all out for me from where we go from here. One of my nodules is going to need a biopsy, since it’s suspicious for cancer. The other two may not and appear more cystic, so we’ll wait on those. I got more blood work done, and my TSH is 7.8. So we’re starting Levothyroxine, and I have another ultrasound scheduled for July. We’ll go from there.

I’m still waiting for the TPO antibodies to come back to confirm or deny Hashimotos, but at this point, I think I may have it. It would explain so much of my symptoms and why my immune system is as bad as it is. 

I’m a little scared that I may have thyroid cancer as well based on that one nodule, but was assured that 95% of the time, the nodules are benign, so that’s something. Plus even if it is, the thyroid would just be removed and supplemented with medication which I’m going to be on now, anyway. 

The meds should help me have more energy so I can come back and be social again. I’ve just felt so incredibly awful and I didn’t understand why. I’m happy to have some answers. I miss you all and can’t wait to reengage here again. <3 

[kaimelia]

Heartbeats (Ch.1)

a/n: hi! so, this is something I've been working on for a while and im finally posting it....I'm going to finish paper rings soon but this has been sitting in my computer for too long now and I want to start posting it! I hope you enjoy it :)

-----------------

It’d started small; they were at the park, and Link was chasing their four-year-old around the grass as Amelia laid on the blanket, snapping pictures with a wide grin spread across her face. Scout ran into her arms, and she hugged him, glancing up at her husband as he walked back. She noticed a slight limp in his leg and raised her eyebrows in confusion, making a mental note.

“I’m fine,” he muttered, lowering himself onto the blanket across from her. “My leg’s just a little sore. I must’ve slept on it weirdly.” Scout moved from his mother’s embrace to grab the truck he had brought, pushing it around the blanket. Amelia tilted her head to the side.

“Okay, but you’ll tell me if it gets worse, right?” Her voice wavered more than she expected it to, and she knew Link would notice. He grabbed her hand.

“Of course.”

-----------------

A week later, she woke up to the sound of him heaving into the toilet. She ran into the bathroom, placing her hand on his back and kneeling on the bathroom floor next to him. “You okay?” He nodded slowly before puking into the ceramic bowl again.

“I feel like crap.” Amelia placed her hand against his forehead, standing up to wet a washcloth.

“I don’t think you have a fever. Is it just nausea?” He breathed heavily once she placed the cool washcloth on his forehead, wiping away the beads of sweat on his face.

“I’m exhausted, too, but that could just be from work.” She frowned sympathetically, running her fingers through his hair.

“Maybe you’re pregnant,” Amelia joked, happy to hear a quick laugh from him.  She glanced up as the bathroom door was pushed open.

“Is daddy okay?” The mother smiled, tousling her husband’s hair and standing up to take her son’s hand.

“Daddy’s just a bit sick. Let’s go get you ready for school, okay?” She led the boy out of their room and into his, helping him get ready for school. He rambled excitedly about his new dinosaur toy as she made waffles for him, pouring an absurd amount of syrup onto the plate. Link came down a few minutes later, rubbing his forehead with his hand. “Hey, you’re feeling better?” He shrugged.

“Gonna call in sick to work and sleep all day.” He placed his hands on his son’s shoulders. Scout turned to his father, excitedly waving the dinosaur in his face. “I can pick this guy up from school.”

“Can we get ice cream?” Amelia raised her eyebrows at her son’s request.

“You’ll have to convince your father on that one.” Scout grinned widely up at his father.

Amelia wasn’t at all surprised when she came home from work to see them eating ice cream in the living room, The Good Dinosaur playing on the TV. She kissed her son’s forehead, receiving an absent-minded greeting from him before his attention diverted back to the movie. She moved to sit on the other side of her husband and curled into his body. “Hi,” she whispered, resting her head on his shoulder. “Are you feeling better?” He pursed his lips tightly.

“Not really. But I’m okay.” She took a moment to look up at him, noticing the unusual paleness of his skin, the slight shake in his hand that was holding his ice cream. Amelia placed her hand over his heart, feeling the quick beating of his heart.

“Are you still having leg pain? From the other day at the park?” He paused for a moment as if in thought before confirming. “You should go relax. Take a nap. I’ve got him for the afternoon.” He hesitantly complied, leaving her to make dinner and amuse their son with conversations about space as he happily ate dinosaur-shaped chicken nuggets. Once she heard Link leave the room to shower, she proclaimed it was bedtime, promising to cuddle with the boy before bedtime. He followed her into the master bedroom without complaint, laying down next to her. Link returned to the room later, throwing his clothes into the laundry hamper.

“I think you should go see a doctor. I think that something’s wrong, Link.” He turned to face her at the sound of her soft voice. She was sitting on their bed, leaning back against the headrest with her computer open and about fifty different tabs pulled up, their son sleeping soundly with his head on her chest. Link sighed. “I’ve been keeping track of your symptoms. Leg pain, nausea, fatigue. I’m terrified to think that something’s wrong.” He sat down on the edge of the bed. “We can ask Nico to see you sometime. Just get a scan done or something.”

“You think this is cancer?”

“I think that with your history, it’s not out of the question.” She closed the computer and placed it on the nightstand, wrapping her arms around Scout. “I’m scared of you dying. I would rather fight whatever it is with all of the information we can get.” He moved to sit next to her, pulling her into his side. “It’s not just you and me. We’ve got this little guy to worry about,” she motioned towards the sleeping boy.

“I’ll see if Nico can give me a scan tomorrow.” Amelia turned her head to look up at him.

“Thank you.”

-----------------

“There is a mass on your leg. We can do a biopsy to see if it’s cancerous.” Nico’s face was stern as he spoke, although Amelia could hear the slight waver in his voice. She often didn’t think about Link and Nico’s friendship, but at this moment, she could see that this was difficult for the man in front of her. She looked over at Link beside her.

“When can you do the biopsy?” Amelia asked, squeezing Link’s hand. He squeezed hers back, his gold wedding band pressing into her skin.

“I already talked to Bailey, and we can have her do it in about half an hour.” Nico’s hands folded together over the desk. “I can’t be the one to do it. But it’s just a biopsy, and you don’t need an orthopedic surgeon for that.” He said something else that she didn’t quite hear, and he left the room a moment later. She turned to her husband.

“You okay?” Link shook his head.

“No. I just want to go home and hold you and Scout. I don’t want to be here in the hospital.” Her hand settled against his cheek, her thumb wiping away a stray tear that had fallen from his eye.

“Let them do the biopsy, and then we’ll head home.” Amelia helped him to stand up and silently led him to the exam room down the hall. They waited in silence, gripping each other’s hands tightly. Amelia laid her head on his shoulder. “Whatever it is, we’re gonna figure it out, okay?” When Bailey walked in, she offered them a sympathetic smile before asking Link to move onto the table and performing the biopsy. There was an attempt at small talk, yet Link seemed to have turned into a brick wall, ignoring whatever they were saying. The chief promised to rush the results, directing them to wait in her office. As soon as she returned to the office an hour later, the couple knew the results.

“It is cancer. We’ll make an appointment to stage it, and we can get you in soon.” She left a moment later, leaving the couple alone in silence.

“Link?” He looked over at his wife with teary eyes.

“I just wanna go home.” She nodded in understanding, offering him her hand and leading him out of the hospital. They were greeted at their house by their son, who Maggie had watched during the day. He eagerly jumped into his mother’s open arms, ranting about the day’s events.

“You look sad, daddy.” He wrapped his arms around his father’s legs, not noticing the cringe from his father at the pain.

“I’m just tired, Scout. All good.” Amelia rustled her son’s hair.

“Alright, Scout. We’re gonna get you your bath, and then you can come and cuddle with mommy and daddy for a while, okay?” She led the energetic boy into the bathroom, the sound of water running soon filling the home.

“If there’s anything I can do, let me know.” Maggie smiled sympathetically, rubbing Link’s shoulder before letting herself out of the house. He walked into the bathroom and rested against the doorframe. A happy scene played out in front of him; his son splashing water at Amelia, who was sitting outside of the tub. Her smile was genuine, and she looked over a moment later.

“Hey, we’re almost done in here. Quick bath tonight,” she teased, grabbing at her son’s nose. Scout giggled loudly. Link smiled and left the bathroom, changing into his pajamas and flopping onto the bed. There was a knock on the door soon after, Amelia walking in with Scout in her arms, his smile wide as she placed him down on the bed. Scout had always loved sleeping in their bed, curled up between his parents, surrounded by their love, as he would say. He quickly fell asleep, softly mumbling nonsense about dinosaurs and his cousins. Amelia’s eyes met Link’s. “What’re you thinking about?” He brushed his hand through the boy’s blonde hair.

“How terrified I am. Like you said the other night. It’s not just me anymore. I’ve got you and Scout.” He sniffled. “I don’t want to believe it. I think some part of my brain is convinced that if I don’t acknowledge it, it won’t be real.” Their son sighed contently between them, curling into his mother’s body. “It’s cute. How he curls up like that.”

“He was always in this same position when I was pregnant,” she whispered, pulling up the blankets between them. “Even now, almost five years later, he still does it.”

“How are we going to tell him?”

“We’ll wait until we know more, and we’ll explain it simply, answer any questions he has. He’s a smart kid. He’ll probably pick up on it before we get the chance to tell him.”

“You’re so calm about this. Normally, it’s the other way around,” he whispered, moving his arm under the pillow.

“I guess my brain understands that you need me right now. I’m sure I’ll start freaking out any day, now.” He breathed out a soft laugh. “But, I’m also scared. Just doing a better job at masking it.” She reached for his hand across the space between them. “Promise me one thing?”

“Yeah?”

“That whatever it is, you’ll fight. You promised me a few years back that you would always fight for our dreams. My dream is that you’re okay.” He nodded his head quickly.

“Of course.” Her lips turned upward into a small smile. “You have to promise me that you’ll be here whenever I need you. At all my appointments and treatments.”

“Scout and I will bring you ice cream every day.” Link’s eyes fell to their son, watching the rise and fall of his chest. “Try and get some sleep, Link.” She slipped her hand away from him and reached behind her to turn the lamp off, sighing tiredly. “I love you.” His hand found hers again.

“I love you.”

[vonnyphant]

To Blog or Not to Blog?

“You should start a diary and write about your experiences. It may help people going through the same thing.”

Honestly? If there’s one thing I discovered about this diagnosis, it’s that it makes me pretty damn selfish. I don’t want to help other people (not just yet, anyway). But putting some thoughts down about this time in my life may be of some sort of therapeutic value, and I do want to help myself. 

(Maybe for once, saving the world can wait. Do you remember how, soon after the pandemic hit, people stopped avoiding plastic and single-use items? When your health is at risk, suddenly rainforests and polar bears and the planet are deprioritised- not that anyone will admit to this. But this is my diary and I can say what I want!* Writing for myself it is.)

Having established my less-than-Mother-Theresa-like reasons for this blog, my conscience cleared, it’s time to start. This is where the Lifetime movie shows me, in a half daze, mellowed out on drugs while they sew a mediport into my chest to start administering chemicals. A fast lane to my bloodstream. A docking station. The soundtrack? Hopefully ‘Across The Universe’ by the Beatles (possibly Lucy in the Sky with Diamonds. If I get a say in it, I veto The Walrus) Time to pump this body full of drugs that’ll make my hair fall out. 

Wait, what?

Voice Over: “Yep. That’s me. You’re probably wondering what I am doing here…” //record scratch - freeze frame - fast rewind to the psychedelic outtro of A Day In The Life//

Two months ago, during rub-a-dub-in-the-tub (less naughty than it sounds, was just washing myself), my mind inexplicably went to an episode of Beverly Hills 90210, s1 (aired in 1992- yes, I am that old), where Brenda Walsh has a breast cancer scare. I say inexplicably, because my usual shower fantasies do not include Ms Shannon Doherty - if I was going to pick a shower lady, I’d opt for Charlize Theron, Kiera Knightly or Winona Ryder in their short-hair phases, but that is neither here nor there. 

Say what you want for 90s television- weird outfits and ponytails notwithstanding, in their AfterSchoolSpecial PSA way, they dedicated a whole scene to the girls giving themselves a breast exam, including how-to instructions**, and eventhough I was only 11 years old when I saw it, I remembered what to do, and for the last 30 years, every now and then I have randomly carried it out while wondering how I always preferred Brandon over Dylan and how my tastes have changed over time.

But this time - my hand actually found something.

I took a deep breath and calmed myself down the same way I did after finding spots on my skin, lumps on my head and every time I sneezed since covid-19; by telling myself to fucking snap out of my hypochondria tendencies. One cannot go to the doctor every damn day after all. Breast tissue is pretty lumpy and I assumed it was just imaginary. I made an appointment to see a therapist, and  put it out of my mind until a few weeks later, when one of the kids came crashing down on me (literally) and faceplanted in my boob (as they do). 

Now this always hurts af, but it just hurt that little more that day, so that I grabbed the appendage in question and went “WHAT THE--!” And I felt it again- the lump, more defined than a few weeks before. 

Cue a lot more freaking out than the first time, and after a sleepless night, imagining what my funeral would look like (as one does), I decided to go to the gynocologist the same day or risk never to sleep again.

After a long wait and an ultrasound, my doctor assured me that while there really was a mass, it had every indication of being benign. We should keep an eye on it. If I was worried, I could schedule a second screening, but would not likely get an appointment before April. I scheduled one and tried to focus on preparing our first lockdown Christmas. 

But over the holidays, the lump started hurting, even when I wasn’t poking it or having a kid catapult themselves into my chest. I’d be Netflix and Chilling, and suddenly - ZAP - like someone stuck a hot needle into it. Repeatedly. My nipple would go numb or start tingling like a bodypart that fell asleep. It freaked me out, and in the new year, I realised I couldn’t wait until April - I had to get it checked out again or I may worry myself to death.

My gynocologist did another ultrasound and again, told me not to worry. I told her it was way too late for that as I had been worried for weeks, and I wanted the thing biopsied (they gave Brenda Walsh one too, after all! It’s the only way to be 100% sure). She referred me to the hospital. At the description of my symptoms, I could come directly, and the radiologist told me in no unclear terms: “I will not let you leave this room until we draw blood and take several biopsies.” Okay- not exactly what one wants to hear at that point, but at the same time, I figured knowing would be better than guessing by the shape of it.

Test results took a week. I went in, being prepared to be told (like Brenda) it was a harmless clump of random cells or a cyst we could have removed like a wart. Only it wasn’t. It was breast cancer, an aggressive, fast-growing kind, and had I waited until April, that could have had disastrous consequences.

While the doctor explained we now needed to determine the scope of the spread and take more tissue to determine what kind of chemo (if any) could be applied, all my 2020-PTSD brain could think was: 

“.............of course”. 

Didn’t hear much of what she said afterwards.

Another harrowing 4 days went by, with a CT screening with contrast solutions that gave me an intense stomach ache as well as a migraine, and finally, a fully rounded diagnosis and treatment advice could be made. 

Thankfully, all my organs as well as lymphnodes were clear, so it appears to be a localised tumor. And here we are - to fight this thing with chemicals and then cut out whatever is left. Genetics testing to see about the likelihood of a recurrency (and a possible double mastectomy if so - ‘pulling an Angelina Jolie’, ‘not saving the tatas’, insert ‘Think About It meme’...can’t have breast cancer if you don’t have breasts! THINK ABOUT IT***). 

Chances are good. I need to cling to that while I wait for this port and treatment to start. I have accepted the inevitable hair loss, have scheduled a ritual ‘crazy hair cutting party’ with my kids for this weekend (as I would rather shave it off in one go than clean up clumps and strands over the course of weeks and look like Gollum), and I have sewn several funny little hats for inside wear and ‘going out’ (though where will I be going in pandemic, idk). 

I was going to end this post on a light and happy note - but I must admit my confidence just took a really big hit in real time, as I googled how to spell Shannon’s last name for this blog entry and found out that she was treated for breast cancer in 2015, initially succesfully, but it reappeared metastasized in 2020 (again: ‘of course...when else’) and she is now in stage IV. Fuck 2020.

What are the odds that the woman whose character made me discover my own breast cancer is now, in fact, dying of the same disease? This will surely haunt me for a long time to come.

More tomorrow? Or soon? It may take a while. Until then: outro to It’s Getting Better.

*also for the record I would like to state that I’ve sewn my own masks from upcycled pillowcases and continued using fruit- and vegetable nets to avoid plastic; maybe that makes up for me being utterly selfish at the moment. Karma +1?

** https://youtu.be/pkgYXITkrfw (the scene from BH 90210)

***cis men / trans women without breasts can also get breast cancer (even though it’s rare) so this meme doesn’t really hold up, but that’s the whole point of the meme ;)

[whimsicaldays]

Wednesday February 24, 2021

Matthew  McConaughey once said that he doesn’t write to remember, he writes to forget. Who I am as a writer has never resonated so much with a sentence  because that’s the only way I’ve ever known writing to be. Not something to look back on; Not something to reminisce over. But something that just kind of  bleeds out of me when the going gets tough; When the connections aren’t quite forming in my head. I write it, I understand it, and then I let it go. 

Matthew  McConaughey also once said that it’s important to learn how  to write to remember as well. To write the good along with the bad. The trials along with the triumphs. In 10 years, do you want to dive back and see years of mere pain and heartbreak? or do you want to see the way you rose above it? How you became the phoenix rising from the ashes of it all. That resonated more with me so here it is.

In 2020 I was diagnosed with stage 1 melanoma skin cancer.  There was a tiny mole on my leg that I would have never thought twice of, and yet somehow I did, and months later while roaming the aisles of target I got a call from a number I would have typically let go to voicemail, but somehow didn’t, and there it was. “Michelle I have the results of your biopsy.. It did come back as cancer.” what. “Michelle where are you? Are you sitting down? You should sit down” The conversation that will forever be burned in the back of my brain.

 Melanoma.. I knew that name so well.  I knew it from all the days my mom would grow quiet or cry over a song or a memory that reminded her of her mom. The big moments she wouldn’t be around for. How crazy it felt that I would never meet her. I knew it for my uncle with the biggest smile I’ve ever seen. For the man who was so full of life. For the first time I ever saw my grandpa cry. I knew it so well and yet here it was living in my body. Every part of me that had held it together, piece after broken piece, during what had already been one of the hardest years of my life, had completely broken down. I had this pain deep in my soul that wouldn’t go away, not even when I found out it was stage 1, not even when I had my surgery, when I recovered, when I was told it was likely all out of my body. I was so fucking sad. Why did this happen? Why was I not more careful? I fell down a google rabbit hole of having the gene, being 10x’s more likely to get it again, wondering when this thing was going to come back and kill me.. Like it did for my Nonna. Like it did for my uncle. 

My dad told me that having cancer turned out to be the biggest blessing of his life, because it  changed him mentally. That when he went into remission, his perspective completely shifted, and that deep depression that hung around for so much of his life, was completely gone. I knew  he had changed, I’ve watched him soften and soften as the years pass. The rough, anxious man I knew growing up, isn’t there anymore. He’s happy, calm, light.  He believed it would all be the same for me, that God’s purpose was so much bigger than all of this, that I would come out the other side so much stronger than I ever knew myself to be. That didn’t feel like the case though.  I was angry, frustrated, scared, sad, numb, withdrawn. Six months..  Six months is how long it took to realize that my dad was right all along; It has changed me.

I stopped caring. I stopped counting ever calorie, criticizing ever bone in my body. Googling botox, plastic surgeries, instagram stalking people I wish I looked like. 

I stopped going in for highlights every couple months. Stopped being frustrated that I didn’t have that perfect blonde balyage like every girl that I saw everywhere; All of the girls that pay to look exactly like each other.  I started growing out my bangs, growing out my natural hair color, going out without any makeup on.

I started holding back from the people who drained me, and gave a little more to the best  people in my life. People I have neglected most of all. People who have been there to hold me, to lift me up and to shower me with unconditional love, even when I’ve been far from deserving of it. 

I’m so much more emotional. I cry way more than ever before, and I’m touched by people and their stories way more than I ever have been before.

If there’s anything this year has taught me it’s that life is too short to care about the things that DO NOT MATTER. I’m blessed to be alive, blessed to have my parents alive. Blessed that my family is safe and healthy.

And here I am to say that 6 months ago, I decided out of nowhere to get my moles checked, something I had never done before, and if I hadn’t, maybe I wouldn’t have been here a year from now. 

My dad was right, God’s purpose was so much bigger than myself and so much bigger than the cancer.

I feel myself coming into my own, of being more of the person I’m meant to be, and less of the person who was dragging her down

So many greenlights, so many more to come. 

[mysticmelove]

Hi it's okay if u don't want to write cuz it's specific but recently I was diagnosed with fibroadenoma(benign tumor of the breast that u can get it at 20-30y) at the beginning I was scared cuz all the test suggested that it was malignant but after the biopsy I feel comforted and the bright side of the image is that my boobs are the same size now but it will hurt during pregnancy & 2% of it to become cancer ,I want to know how do u think jumin,707&searan would react to mc with the same condition.

*Be warned that this is completely all over the place; sight angst, sight NSFW, you name it. Also I apologise for how short some of it is. I hope you stay in good health xx

Fibroadenoma

(Jumin+Seven+Saeran x MC)

.

Jumin:

MC didn’t quite know when it started or why the sudden spark had hit him, but Jumin was on one of his crusades to get his ideas across to her once again. He got like this when his mind was set on something; dropping subtle hints as to what he thought was a good idea, posing questions to her solely related to the topic at hand, using his business skills to pose everything like a sales pitch. This time he was focused on the topic of children- MC and himself having children to be more precise. It made more than enough sense for Jumin to want to have children, after all he’d end up leaving the company to his own child, but the timing was just extremely inconvenient.

When they had first gotten together and had gotten married, of course MC had thought about starting a family with him, yet things had come to change. She didn’t tell him when she’d first gotten diagnosed a few months ago because he wasn’t in the country- being on a business trip- and she wanted to make sure things wouldn’t be dire before she ended up telling him. Once the initial fear of cancer was behind her, she wanted the thought to be out of her mind for awhile. It was a reminder of how lucky she was to be alive and with Jumin. Still, it was hard to ignore the fact that her fibroadenoma would cause problems if they were to pursue what he wanted. MC wanted children as much as he did but she constantly avoided the conversation when and where possible. Albeit, Jumin was a very stubborn man- especially when he had his mind set on something- and didn’t pick up her clear signs of avoiding the conversation.

Jumin sat back in his chair, placing down his cutlery on the empty plate before him. He smiled as he watched his wife opposite him, sipping at her wine silently. “The fashion branch had a shoot today,” Jumin began, “I even went down to watch it myself.”

“Oh, really?” MC entertained his tales of work as she did almost everyday, still with a smile on her face.

“I would have had you model, of course, but it was a children’s shoot.” She sighed almost immediately in response, it was a subconscious reaction but she meant no harm by it, she just knew where the conversation was heading. “I never really realised how much children looked like their parents,” he claimed, lifting his glass to his lips, “Most of them were spitting images of their mothers and fathers.”

“Jumin...”

His face seemed to only light up as he spoke: “It made me think about what our children would look like. I hope for their sake they take your looks.” He humoured to himself, so lost in his own though he didn’t catch the avoidance of his wife’s eyes.

MC murmured to herself pitifully, “I always thought they’d look like you, to be honest.”

“There’d only be one way to find out,” he declared suggestively as he raised an eyebrow in her direction. He placed down his glass and reached across the table to hold her hand in his own. His eyes stared desperately into her’s, pleading with her, “I really want this, MC. I want this with you.”

They shared that same look of astounding love for but a moment before MC came back to her senses. Her eyebrows furrowed and her nose scrunched at the idea. She couldn’t comprehend even the thought of the pain after what she’d read about pregnancies with her condition. “I... Jumin, it’s sounds amazing but I just...”

“When have I ever denied you of something, my love?” he questioned as he rose to his feet and rounded the table towards where she sat. “I’d give you the world if that’s what you wanted.” He knelt before her chair, taking her hands once more and kissing her knuckles tenderly. “You know you and our child would have everything in my capability.”

MC could only freeze at his words; here her husband was essentially pouring his heart out to her on the floor and she was too much of a coward to tell him what was wrong. She couldn’t even pull her hands from his gentle grasp. Her breath hitched in the back of her throat as she tried to explain herself: “I- I know you’d do that... but I just...”

“What, my love?”

“I want children, Jumin... I’m just... I’m terrified of what might happen,” she admitted lowly, her eyes cast down to her enclosed hands.

Jumin remained silent, his focus solely on MC as her voice began to waver and tears lined her eyes.

“I should have told you,” she spluttered, shaking her head as she looked to him, “I know I should have, but- but if things went bad I–”

“What? MC, calm down,” he interrupted her adamantly, “What’s wrong?”

“I thought I had cancer,” she blurted out with a heavy exhale, her eyes wide and unfocused. Jumin couldn’t find the words to respond before she continued uninterrupted. “It- It turned out it was only fibroadenoma but I’m scared it’ll become more.”

Jumin spoke almost in a whisper as his eyes searched her desperately for answers, “Forgive me but... what exactly is that?”

“Oh...” she froze once more. “It’s- It’s a tumour in my breast... I’ve known for a few months but the sudden talk of children and–”

“This isn’t new?” He cut her off immediately, his tone much harsher than before, “You thought you had cancer and you didn’t tell me?” Tears started to well in his own eyes, faced with the fact he could have lost the most precious thing he had, yet he didn’t let himself cry. “You sat there alone and thought you could die? And you weren’t going to tell me?” His grip tightened around her hands, praying she wouldn’t leave as she so carelessly suggested. He shook his head in denial.

MC’s lips trembled as she tried to bring her husband to a sense of calm, “I’m sorry... I didn’t know how to tell you.”

Settling his nerves, Jumin took a deep breath and pressed his forehead to their hands. “It’s okay as long as you’re okay, MC...”

She felt nothing but guilt in that moment; in all this time he was concerned over the fact he could have lost her without prior knowledge, she had forgotten how the conversation had even started. “Jumin...” His eyes moved to her tear soaked face, irritated and wet. “I’ve been avoiding talking about having kids because I’m scared of what will happen...”

“What will happen?” he questioned as he tilted his chin up slowly to gaze at her.

“I can’t be sure... I’ve read horrible things about pregnancy... It can make my fibroadenoma worse and it can painful... I don’t want to suffer through that.”

“I wouldn’t let you suffer. Ever.” His tone was strong yet caring as he rose to his feet with haste, cupping her flushed cheeks within his palms gently. “The best doctors,” he pleaded with her passionately, “The best care team I can afford. Whatever you need, my love. I just want you to be happy.”

MC breathed a sigh of relief as she rested completely into his hold, her eyes letting go of those last few tears. “Thank you... Thank you so much.”

.

Seven:

“Seven, stop it!” MC giggled as her boyfriend placed tiny kisses on her neck from behind, his hands wrapped around her waist as he tickled her sides. Her eyes scrunched shut as she lent back into his chest, her hands trying desperately to free herself from his trap.

Seven ceased his attack, yet his arms remained locked tightly around her midsection. MC breathed a large sigh, a smile still on her face and her eyes still closed as Seven lent them back against the pillows on their bed. “You can never escape the Defender of Justice,” he laughed as he held her tighter, his head falling to rest in the crook of her neck. His tone softened slightly as he sighed: “I love you too much to let you leave me.” Saeyoung adored just being able to sit like this with MC on occasion; being able to hold her close and just tell her how much he loved her. It was romantic, yes, but to say his mind wasn’t in other places would have been a lie.

“Don’t go all soppy on me,” she teased innocently, her hands resting on his with care.

“What’s wrong with soppy?” Seven questioned in response as he lifted his head. Her eyes were drawn to him immediately, her head turned to face his but her body still comfortable in his lap. His hand trailed up to her face and cupped her cheek with care. “I don’t think there’s anything wrong with soppy.” His eyes lingered on her lips, his voice barely above a whisper. Their lips were together within an instant and Seven was sat upright immediately, bringing himself as close to her as possible.

There were no hesitations in his actions: the way his lips moved against her’s, the way his teeth teased endlessly at her bottom lip until he got what he wanted, or even the moving of his hands. They were roaming and exploring her in a second, as per usual, mapping out every inch of her skin. He started at her thigh, his hand massaging her tender skin before he made his way up to the waistband of her shorts. MC writhed in his lap with each new squeeze of his hand, practically begging him for more. She welcomed him happily as he played with the fabric at her waist but became noticeably hesitant as his hand travelled further upwards. Her body tensed as he made his way under her shirt and went as far as to pull away from his kiss as her reached her rib cage. MC forced his hands off of her quicker than he had imagined she would. “No, Saeyoung.”

“What’s wrong?” he asked, still panting and more than aware of what her issue really was. Seven had assumed she was insecure about her chest since they’d started seeing each other. It was evidently clear she didn’t want him anywhere near them; she’d never let him lay so much as a finger on them and she was always covered around him, even so much as to keep her top half covered when they had sex. He’d read about her fibroadenoma before they’d even met- part of his background research- and only looked closer at the notes once they’d gotten closer.

Biting her lip, she got off of his lap and turned to kneel on the bed facing him. “It’s nothing...” she dismissed him quietly, “I’d just rather if you didn’t... If you didn’t touch my chest.”

“Are they sensitive?” Seven joked to distract from the problem, yet her lips only pursed into a thin line- a grimace on her face. He brought his hands behind his head and sighed, giving her her wanted space. “Come on~ Will you ever let me see them? They’re probably more beautiful than anything I’ll ever see. They’ll blind me with their beauty.”

MC’s face flushed slightly, “Stop it, you’re so embarrassing...”

“I mean it,” he declared, “I’ll complement them all night if that’s what you want.” Seven had read the notes, he read the notes after each visit when she snuck off to the doctor and acted like it was nothing. They detailed the little things, good things like the fact her breasts were looking more symmetrical than they once had. He was happy for her, despite the fact she would have no idea he knew.

Shyly, MC covered her chest with her arms, folding them subtly. “You’re sweet...”

“I know,” he cooed with a smile. “But we can talk seriously, if you want?”

MC’s eyebrows furrowed as she averted his gaze, “I don’t want to be a bad girlfriend because–”

“Don’t be stupid,” he cut her off immediately with a laugh, placing a reassuring hand on her thigh, “I don’t care if you let me touch your boobs or not. I mean... if there’s anything serious that you want to talk about.” She only looked at him in confusion, an eyebrow raised as she lowered her arms from her chest and rested her hands in her lap. Seven rolled his eyes, running a hand through his hair. “MC, I’ll just be straight with you, okay?”

She nodded slowly, her face riddled with concern.

He sighed once more: “I know about the doctors visits and the fibroadenoma. I’m assuming that’s what this is really about...”

MC froze, that was one of the last things she was expecting him to say. “...How...”

“I’m a hacker, MC. How do you think I found out? I knew before I even met you in person.” Seven watched on as she contemplated what to say to him; she looked embarrassed, her face flushed as she struggled to form a coherent string of words. He placed his hand on her own, stroking it gently. “Is that why you’re insecure, though? I know it’s not a sexual thing.”

“Maybe...” She paused, only to look at him and huff in defeat: “Yes.”

“Why?”

“I didn’t want you to think I was weird or ugly... I think it’s unattractive...” she spoke quietly, barely speaking to him and more just aloud so he could hear.

“You know I wouldn’t say that,” he assured desperately to her. “...And your notes say it’s less noticeable now... visibly.”

She laughed to herself pitifully: “Stop reading my notes, you’re invading my privacy. Yes, it does look better now though.”

“So let me see them,” he smiled playfully at her, “Let me say they’re beautiful and perfect, and that nothing could compare.”

MC’s face was a bright shade of red once more as she tried to contain her smile. “O- okay.”

.

Saeran:

She’d been waiting for what felt like years. Days on end of just waiting for her results to come back in the form of a dreaded letter or phone call, whichever one came first. She’d just been moping and pacing about the apartment for days and, quite frankly, it was putting Saeran on the edge as well.

This time, she taken to just sitting and staring with a stern look on her face as she thought things through. Saeran watched her from afar as he entered the room, rolling his eyes terribly and folding his arms over his chest. “Sitting there like that all day isn’t going to help you.”

“Then tell me what will, Saeren,” she snapped back, irritated and too anxious to even think before she did. MC shook her head and ran her fingers through her hair as she apologised: “Sorry. I’m just... stressed.”

Saeran threw himself down on the opposite side of she sofa from her, sighing as he did, “Stop getting yourself worked up over nothing.” His tone was bitter, not unpleasant but just brutally honest. In reality, he was finding it just as hard to cope with waiting for the results of her biopsy to come back but he was choosing to play down how big of a deal it was rather than work himself up. He didn’t know what he’d do if MC had cancer.

She glared across to him, her brows knitted together and her mouth slightly agape. “Nothing? Saeran, what if I have cancer? Then what? Is it still nothing to you?”

“It’s not like that–”

“Then what?” she spat out in an instant, her voice hoarse and filled with fear. “What is it like? Because right now I feel like you don’t give two shits about me.”

“Of course I do–”

”Then act like it!” MC practically screamed at him as she balled her fists at her sides.

The room fell deathly silent for a moment. Without a word, they both tried to process what was happening. MC was so caught up in her anxieties and fear, while Saeran was trying to block out everything and was ignoring what he really needed to do. His job right now was to be there for her; not to be an inconsiderate asshole. Silently, he crossed the space to her, just sitting there like an obedient puppy as MC began to weep into her hands. “MC...”

Her voice cracked as she tried to apologise: “I- I’m sorry... I-”

“Don’t talk... please,” Saeran whispered to her, coming to realise this could have been avoided if it weren’t for him. “I haven’t treated you properly.”

Inhaling deeply, she wiped her tears and looked to him, shaking her head. “No, I’ve been cruel and–”

“I’ve been nothing but dismissive, MC. I’m scared of losing you so I acted like it could never happen...” He took her hand in his own tentatively and fiddled with her fingers. “I know you’re scared but we shouldn’t focus on the bad things.”

She sighed at him, casting her eyes to the floor.

“It’s all been about me,” he admitted, trying desperately to get her to focus on him, “and I don’t know how to do what you do.”

“What do you mean?” she murmured to him.

“You’re caring and supportive and I want to be like that for you, but I... I don’t know how.”

“Just be here,” she spoke quietly as she pleaded through her eyes. “Be here for me no matter what happens.”

He hesitated at the sight on her watery eyes, conflicted as to if he could really be what she needed. “...I will.”

[dollophead-merlin]

"It is suspected he has a degenerative brain disorder called Cruetzfeldt-Jakob disorder. It would explain his frequent depressive episodes and anxiety attacks, as well as the lack of coordination while putting up decorations and the flurry he saw before falling."

"How will it affect him?" Leon asked, slowly carding through Merlin's raven hair splayed out on the pillow. Merlin's focus on the conversation was dwindling, allowing him to only catch tidbits of information. The doctor sighed.

"With symptom onset, affected individuals may develop confusion, depression, behavioral changes, impaired vision, and/or impaired coordination. As the disease progresses, there may be rapidly progressive deterioration of cognitive processes and memory, resulting in confusion and disorientation, impairment of memory control, personality disintegration, agitation, restlessness, and other symptoms and findings. Affected individuals also develop neuromuscular abnormalities such as muscle weakness and loss of muscle mass; irregular, rapid, shock-like muscle spasms; and/or relatively slow, involuntary, continual writhing movements, particularly of the arms and legs. Later stages of the disease may include further loss of physical and intellectual functions, a state of unconsciousness, and increased susceptibility to repeated infections of the respiratory tract. In many affected individuals, life-threatening complications may develop less than a year after the disorder becomes apparent."

This sent Leon's mind into a frenzy. But... Merlin's immortal. Would that mean... No it can't... That would mean that he would be forced to endure this agony forever. What if he needs to get Merlin to teach him a spell to lift his immortality and essentially...No I can't. I--

"Leon?" Merlin murmured lethargically.

"Yes Merlin?"

"What's going to happen to me?"

"I don't know, snowflake. I don't know. Get some rest. You'll need it."

It's the day of the biopsy and Leon is terrified. Merlin is obviously a little bit nervous but he doesn't necessarily know why. His mental and physical state have rapidly deteriorated. Merlin's muscle was wasting away and he can barely walk. His personality and memories (yes including those of Camelot) have faded and he's often confused and stumbling around the house. All that's seemed to remain was the fact that he loved Leon and Leon was scared that even that would fade as well.

Time seemed to slow tremendously when the procedure began. Leon was left to wait in the waiting room, trapped in his mind. He almost didn't hear the nurse call for him.

He walked into the post-op room to see Merlin sleeping soundly with bandages wrapped around his head and an IV stuck in his arm. His chest was slowly rising and falling and he wondered if he would ever truly have his Merlin again. He was sat next to Merlin when his eyes fluttered open. The pure innocence and slight confusion that filled his eyes made Leon's heart clench.

"Hey Merlin, how are you feeling?"

"Mmnh sleepy. Umm..." His eyebrows furrowed in concentration trying to figured out Leon's name.

"Leon." Leon said with a sweet smile.

"Leon, can you... Can you tell me those stories you always tell me?"

"Of course snowflake."

Leon was going to the kitchen when he heard a rather loud thud.

"Merlin?" No response. That's... Odd. He always tells me when he falls. He walked into the living room to see Merlin passed out on the floor by the couch. Oh no... What if- No, he can't, not not he- he's. No! Leon's mind spun out if control. He needed to get Merlin to the hospital quick.

At the hospital, they immediately wheeled Merlin away, leaving Leon alone in the waiting room. Just like when Merlin went in for his biopsy, time seemed to slow down. It had seemed like whole centuries have passed when he was called back to Merlin's room.

He stepped into the room, only needing to take one look into the room for his heart to shatter to a million pieces.

He had tubes running across his body and digging into his skin. He was as pale as a sheet and he had a tube running down his throat pumping air into his lungs for him.

"Merlin, please, no." Leon walked over to Merlin and picked up his limp hand and kissed it before resting it on his cheek, "Please don't leave me."

As if on cue, the heart monitor started screeching an awful noise.

"Merlin. No! Please don't leave me!"

"Sir you need to leave."

"No! Not my Merlin, he can't leave me. I don't want him to leave me!"

Merlin woke up with Leon thrashing about and muttering something.

"No! Not my Merlin, he can't leave me. I don't want him to leave me!"

"Leon. Leon. Leon!" Merlin finally shook him awake to which he bolted up and into Merlin's arms where he sobbed openly.

"Shhh... It's okay Leon, you're safe. Do you want to talk about it?" Merlin cooed, carding through Leon's curly hair and peppering light kisses to his head.

"You were sick-- really sick. There was no cure and I couldn't stop it. You died." He sobbed.

"Leon, look at me." He did as he was told. " I'm right here. I'm safe, I'm not sick and I'm certainly not dying soon. I had just lost my footing on the roof and broke some bones, that's all." Merlin took Leon's hand in his and put Leon's palm on his cheek. "See? I'm alive. I'm here. Would I be able to hold you like I am now if I was dead?" Leon sniffed in response. "See? There we go. Now, come here. Let me hold you."

"I love you, snowflake."

"I love you too, Leon, get some sleep."

[anthropwashere]

Woke up at 0330 this morning apropos of fuckall, managed an hour-ish nap around noon that somehow left me so tense my entire back is twice as sore as it was before due to PT shenanigans a few days ago, all I want to do is sit here and overthink fanfiction I’m never gonna fuckin’ write because I’m neck-deep in like six other stories already, I have three medical appointments this week including a second fucking mouth biopsy because they didn’ ttake a large enough sample size the first time, had to take someone to the airport this morning and during the drive admitted just how bad the Anxiety/Depression Horse Shenanigans have gotten, weirdly find myself missing my psychologist who finished her residency this month and PCS’d and kind of weirdly finding myself looking forward to the psychiatry appointment I’ve got this week while also dreading the part where I’m going to have to say, “Well despite all the bullshit I’ve been able to honestly say I haven’t been suicidal at all apart from a side effect of some medication I tried for these goddamn headaches and I stopped that ASAP, except this last week has been like an 11 on the anxiety scale for reasons I still can’t discern so hey, guess who has to admit there were some properly suicidal thoughts for like, two hours there apropos of fuckall,” and now i’m terrified what that might entail for me workwise and lifewise and I’m so goddamn tiredwise, but at least I don’t have to interact with my ex for a while because he’s TDY, and the fact that that’s a relief probably means I really ought to start looking for a place of my own except I STILL don’t know if I’m going to PCA or get med boarded or what the fuck ever, and I’m so tired of not knowing, and of being scared, and I want to take a week off of work but I haven’t actually WORKED a  full week in I couldn’t tell you how long because I’m always at fucking medical appointments that lead to disappointment and I’m coming up on seventeen MONTHS of unremitting headaches/migraines and it feels sick to wish it were caused by something serious like cancer or hydrocephalus, but at least those things have causes and solutions whereas I am STILL no closer to knowing what’s going on with me at all, but at least I’m not dying? So that’s a plus? I don’t know. I just want to drop money on a vacation where I leave MD for a couple days and just. I don’t know. What do happy people do on vacations? I haven’t been happy or even content in years now. I forgot what it’s like. I just want.... I don’t know. I just want to be in a place where money and obligations and performance reports don’t exist. I just want a little place with little hobbies and a little job that’s ultimately inconsequential but amusing, and a life full of silly anecdotes, and a coffee shop where I’m not ashamed they know my usual order, and no more headaches, and a regular amount of anxiety instead of this choking hell that makes me dread leaving the house and makes me too fucking tired to do anything at all when I get home again, where breathing hurts and the idea of the smallest chore accomplished feels like climbing a mountain, and where bettering myself is impossible because I’m too overwhelmed just trying to hang on by the skin of my teeth, and it’s so much, and it’s not enough, and i’m as bereft as I am swamped, and nothing matters while every word I speak matters too much, and I just. I want a soft reset. Put me back six updates and let me try again. Let me be more adamant. Let me say no when I winced through a maybe. Let me just try again. Let me be. Just leave me be.

[blurambrilon1987-blog]

I don have an example for controller based games but in general, this is not unreasonable at all. When I play Wii games on PC, I also use a WiiMote and not mkb. Emulators give you the option to map to kbm but for most games this will result in a vastly inferior experience to the point of defeating any point of playing it to begin with.. But I could be wrong about the existence of water. Or the effects a fall from a ten story building will have on my body. That doesn mean I going to forfeit drinking or start jumping off buildings. I so sorry to hear that! i had an abnormal pap a couple months ago and went in for a biopsy. I have to get a LEEP now but i am too scared to do it awake like they normally do (i am absolutely terrified of all types of medical things on myself even though i am fascinated about medical stuff in general.) i getting put under for my LEEP so i having my consultation for the anesthesia next week, then the LEEP probably in march or april. The doctors are encouraging me to get an HPV vaccine to prevent against other types of HPV and prevent me from getting this type again in the future so 나주출장안마 i going to see if they can give me the vaccine while i under because i am way too scared to do it awake lmaoooo. I have way fewer followers than you, and my engagement has been shot too. It's a variety of factors: insta messing with the timeline, me not posting regularly, me not commenting and maintaining a relationship with my followers etc. But i still receive free products off and on, even tho my likes are abyssal. 75 minutes to find something beyond a grocery store or Walmart type job, and even then I would have a problem. But I choose to live up in the County, and be far away from everyone. In Bar Harbor, jobs were much easier to find, and I am sure in Portland 나주출장안마 its easier than Bar Harbor.Heating always costs more than you expect, and usually more than you budget.Slipping on ice sucks a lot. LOVE The Ordinary Marula oil. I wake up so youthful looking lol, it must plump your skin or something. I guess its just very moisturizing, I argue it more moisturizing than my Clinique DDM Lotion+ even, or my PM Cerave Lotion. You couldn't find anything I guess. You shouldn't make claims you can't back up with facts (not anecdotes btw, but facts). Esp on the internet where it's so easy to do research between your comments. The more public the method is, the more you want to stick to generic interfaces. Private method? Use the concrete type and don bother with an interface, because you can just change it without breaking anything outside your immediate code anyways. Internal? Feel free to use the concrete type if you want, since the impact of changing the implementation remains in your own code. Unfortunately, I not sure what wrong with my current bottle (4.0) but it separating. When I pump it out I get half pigment and half water. I haven had this issue with the other two bottles I own but those were the old ones (F200, F300) and I don use them anymore since they are way too dark for me.. The Korean domestic market is much smaller and very saturated and competitive, therefore Korean companies have been much more aggressive in expanding overseas. The Korean government also explicitly encourages the development of export industries beyond traditional sectors like auto/shipbuilding etc. Meanwhile, launches are rapid and faddish because of the high level of competition.

[indianroseeee-blog]

I could still feel the tears falling down my face as my rhuematologist told me that i have been diagnosed with Lupus. I blamed everyone. When I found out it can also be genetic. I dropped because my mother is also dealing with the same condition i had. I sometimes chose not to talk and hold so much anger inside when i was mostly needed to relax and not stressed. I felt that my life would be over with. I graduated in 2013 from L W Higgins High School and moved in my apartment the following year. 

Around this time i was also in school and working two jobs. My husband had a job also. Then one day i was working at Walmart as a cashier. I was scanning someones order and almost passed out. She asked me was i ok and i told her no i really didn't feel good. So i went home and laid in my bed feeling like i just ran 5 miles. Around this time my bipolar tendencies started to kick in because i was scared and paranoid. Every time i get sick i always go to talk like i am about to die. I realize there is much more i wanna live for. 

One day in the middle of the night, i woke my husband up from his sleep. i had so much excruciating pain that i could not hold myself up. He thought i was being over dramatic but i was being very honest. But , he still ended up bringing me to the hospital. There we set and waited for a hour in the waiting room at Oschner ER in Kenner,LA. The kept saying it was a urinary tract infection. so they prescribed me antibiotics that had sulfate in it. I took the pill and went to bed. I woke up again and begged my husband to bring me back to the ER because i was suffocating. I caught an allergic reaction and my glands and airway swelled. They gave me medicine and told me tried to get rid of it the natural way. I went to another emergency hospital called East Jefferson Hospital in Metairie, LA.. They were saying the same thing. That night i went home and begin to eat and it would run straight through me. Like literally sometimes i couldn't even make it to the bathroom. Or sometimes when i feel the urge to pee, my body starts to make me pee. I had no control over my body what so ever. 

I was taking a bath in all hot water and it wasn't burning me, but it was hurting my husband to help bathe me. For the next few days i would sleep all day. I couldnt eat because i couldn't hold anything down. i would have really bad sweat episodes to where my body sweat imprint would be soaked within  the bed. Then i couldn't breathe laying down, so i sat up to go to sleep. Around 12:30 at night i squealed my husbands name and he didn't here me and i said it one more time and woke up. I told him that i couldn't breathe and he carried me from our upstairs apartment to the car. He was so worried he kept telling me to respond to him. I began to go in and out of consciousness. By this time, My whole face swelled to where i couldn't see anything. By the now the nurses know me by heart.

i was rushed to the back. My BP (blood pressure) was 98/52. which is not good. The ER doctor called the admitting doctor because he told me he didn't know what was going on and i have been coming back and forth here between the last two weeks. They admitted me and it took them almost two months of me being in the hospital, that it was my kidneys. My kidneys were failing. So at first they had me on 60 MG Prednisone & Imuran & plaquinil. Then they switched me to cellcept. My body started to regulate again. By this time i lost everyone because of me not being able to work because of how sick i was.I couldn't even finish school semester all because i was in the hospital. I felt like there was nothing left. I felt as if now i became a burden on others and i never wanted someone to feel like they were obligated to take care of me. 

When my husband watch the lady trying to put and IV in my vein, he broke down. The nurse told me that she was gonna stick me and i didn't move or respond. She ask me did i feel anything and i said no. My body was not respond to pain or touch. 

i ended up in that hospital unable to move. 

Then came my second kidney failure which was completely different from the first one. In feb of 2016 i was in an accident where the lady hit me head on.I was vomiting up blood, blood clots eroded from my skin, alopecia, Skin rash over entire body, Peeling like a new born baby. My skin would heal, peel, bleed, infect, heal, and repeat again. This took about a year. Around this time i had gained 60 pounds i would say or more in retention fluid.i would have the worse muscle spasms. When i went to the ER i kept getting pumped with narcotics until they figured out the problem.  

Sometimes it would be so bad that it started to affect my work, i would always be late to class because the fluid was taking over my body.it was painful to walk, because the fluid is applying pressure. i would vomit blood. i was going to the ER every two days. It was horrible. i retained so much fluid that it affected my sex life and brought my body through changes. My vagina had completely swelled and it burned to pee a little, i didn't know what to do. My skin cam completely sunburned on my vagina it looked like. It was swollen so bad that my husband could not have sex with me cause i was so swollen. He did and he takes great care of me. When my vagina swelled it got worser. I started to feel like i had a booty in the front and back.When i slept i had to lay a towel down because the fluid started seeping through my skin. My mother would just sit that and run her fingers through my hair and cried. It was my kidneys again. i started a chemo infusion called Rutuxinmab. Dr. Stephen Morse (Nephrologist) of LSU family practice & Louis Espinoza (Rhuematologist) of LSU family practice saved my life.

my skin would dry out even with lotioning my body. i would have to lotion my body two times to three times a day. Then it had to be non scented lotion. Like Cetaphil. i bath in every that didn't have a fragrance and  will post more blogs about that to come. I would only take lukewarm bathes and i would wash myself twice. When having a open sore , always keep it wrapped. Around this time i had to quit working and i could not even go to school. Each time they made me payback to school. I would bring medical records and all of what happened. I even provided pictures. It was weird cause they granted a refund to her when her grandmother passed. I felt sad because what was happening was something i couldn't control. Then i moved to Dallas,TX and I was in the hospital at first for two weeks cause i had a flare up and i told them i had lupus but thats all they know. They really didn't take the trusting their patients seriously. They asked me what was my old hospital information and i told them but the hospital i was at did not but only mailed. So i waited about two weeks but in the meantime i told them to do a kidney biopsy. This would have been my second one. 

Ladies and gentlemen , this procedure can be done while woke. But after the procedure you can not leave the bed for 6 hours, so i slept. They told me to take it easy and i didn't understand really because my first kidney biopsy i was up and about right after i left. But this one was different my back was in so much pain i was knocking myself out. A Few weeks later they got my info. They wanted to contact me but when they found me in the ER they were ready to talk to me. They told be it was Stage 5, but it was only 20% damaged and 80% percent good. We think we can make this go into remission. They also asked me why am i vomiting blood and i told him i didn't know it must have been my gastritis. so they did ANOTHER endoscopy . Its when they inserted a tube down your through to your abdomen to see if they say abnormalities. This procedure ofcourse you was kicked out. But this was worst. When i woke up i my lip was in so much pain. Y'all i bit my lip. I mean it look like someone knocked my ass out. I was like what happened? and they told me that  happened sometimes during the procedure and i said oh never with the first one i didn't though. Then y'all guess what, i said why am i so wet? They told me sometimes the patients pee a little during the procedure. 

Well guess what it wasnt not piss , it was shit , LMAO!! yo , i told the lady , “ y'all know y'all offed up, y'all could at least told me i shitted on myself, can i get stuff to wash my shitty ass ,LMAO i was so embarrassed. I was like why lord. But overall i haven't been in the hospital but I'm not into full remission yet. and my doctors know what i want my future plan to be and I'm fine with that. So now we are currently working on getting me off these meds. :) 

[fanficksandimagines]

“I promise”-E.D.

A/N- So I randomly had this idea about promises ands stuff and I wanted to write it. Also it’s almost 1 am right, so I’m sorry if theres mistakes, and I’m sorry for the short ending, It was supposed to be slightly better but I lost the thought. Also I suggest you listen to Perfect by Ed Sheeran...

Twin: Ethan

Request: No.

Word count: 2398

Hope you like it.

“I promise”- Ethan Dolan imagine

November 4th, 2013.

I was running through the forest that I had already memorized through my childhood which I was still living in. Ethan was running behind me, we were trying to get away from the pouring rain. Trying to faster get to our tree house that was just minutes away from his house. We had known each other as long as we could remember. We were best friends. Grayson wasn’t with us, he had a cold so he stayed indoors. We finally reached the treehouse. “Ladies first.” Ethan said making me climb up before him. I climbed up the three trying not to slip and fall. Once I was up and safe, I heard Ethan starting his way up as well. Even though I was 12 and he was 13, our tree house was still our favorite hideaway. Hideaway from the world. I was kind of sick myself. Not like Grayson, in my case it was something you couldn’t predict and cure so easily.

In august I had fallen and hit my left arm, ending up with a broken spoke bone, but that wasn’t shocking for the doctors. What made them scared was this mystical hole in my left hands pinky finger. After the x-ray was taken the doctors started working quickly, running around the hallway and asking to call other doctors in other hospitals. It was a mess and I was sitting on the sidelines confused and scared. Then we were sent to the 5th floor of the hospital to see a surgeon. Ethan and Grayson were with me when I fell so they came with me to the hospital when my mom took me. At first the doctor made me sit with the boys outside, saying he needs to talk to my mom first. “What are they talking about?” Grayson asked me thinking I knew the reason for this mess. “I don’t know… I’m scared.” I said hanging my head low, looking at my now casted arm and playing with a string that was poking from the bandage. The door to the office finally opened and the doctor came out looking for me. “Y/n? You can come inside now.” The doctor said and I stood up right away. I walked in the office just to see my mom sitting in the chair. Her skin pail, her facial expression lost and broken, her eyes tearing up. “Mom?” I asked, I didn’t understand anything. “Sit here, sweetheart.” The doctor gave me a chair. I sat down, and looked at him for some answers. He started to explain things, using medical terms and then translating them in normal people words right away. Listening to his words I felt the whole world change. Timed slowed down, my heartbeat banging loudly in my chest, almost like my heart wanted to jump out of my body. You know the saying “My whole world flashed before my eyes”? That’s what happened to me. The feeling definitely wasn’t nice.

I walked out of the office holding my mom’ hand. My skin had turned pail, I felt like I could throw up any second. My head was spinning, I wanted to fall to my knees and cry, but I couldn’t. I could.t do that in front of my mom, she was broken enough.

Later when we were home, I ran outside and into the woods. I walked to our tree house. I climbed up, trying not to hurt my broken arm. I sat down on the wooden floor and let it all out. I cried, the doctors words repeating in my head. Ethan and Grayson came to the treehouse looking for me. They questioned me on what was wrong and what did the doctor say. After calming down I explained. I explained that there’s an 70% chance that I have leukemia. 70% chance that I have cancer.

I had a surgery coming up on November 6. Ethan wanted to spend as much time with me as he could before the surgery, knowing that after that, after the biopsy, my life could change for ever. That’s why we were running through the woods, getting lost in the quiet nature, all alone. As we were sitting on the floor of the treehouse, getting lost in each other’s company, he started searching for something in his pocket. ���I have something for you.” He said pulling something out of his pocket. It was a ring, made out of hearts. “I want to give this ring to you.” He started looking in my eyes. I would be lying if I said that I didn’t have a crush on him, but that wasn’t the point. He was nervous. Clearing his throat he started all over again. “I want to give this ring to you. I want it to be a promise. Three promises actually. Number one- a promise that no matter what happens, I will always stay by your side. I will help you as much as I can, and I’ll be there for you through it all. A promise that I will never forget you. Never, no matter are we gonna stay friends in the future or not. I will always remember you. And lastly… A promise… That I will always love you.” He said holding up the ring. I smiled at his words not knowing what to say. The ring didn’t fit my finger though. It was too big. “Crap.” He whispered. “Wait. Here.” I said taking my neckless off and sliding the ring on it. Ethan helped to put it back on. “I love you too.”

Later that day, when we had already went home and the rain was still pouring, Ethan had a lacrosse practice his dad was taking him too. The weather went from pouring rain to a storm. Long story- short, they got in an accident. Everything was alright though, except Ethan had a memory loss. He couldn’t remember anything from that day. That meant that he couldn’t remember his promises, and I decided to keep them a secret.

After the surgery and biopsy it was cleared. I wasn’t sick. I didn’t have cancer. I was well and alive. Enjoying life with the twins by my side and the three promises hidden in the ring around my neck. I never took the neckless with the ring off and when I broke the neckless I started wearing the ring on my finger, never letting the secret out.

October 29th, 2017.

I was having a beach day with the twins and a group of some other friends. Surfing, tanning, having fun. The twins did a couple of crazy stuff, which I helped to film, for their Youtube channel. The day went by pretty fast. After the beach we went to their apartment for a movie night.

I sat down on the couch getting comfortable, while Grayson prepared popcorn, Vanessa got us all lemonade and Jack tried to find a movie to watch. Ethan was also on the couch on his phone. Everything was fine, but I had a feeling that something was missing. “What’s wrong?” Ethan asked noticing my facial expression. “ I don’t know. I’ve been having this feeling that something is missing the whole day.” I said scratching the back of my neck and dragging my hand down my shoulder before realizing. “My ring.” I whispered not feeling the silver against my skin. I started looking around myself, placing my hands in different places trying to feel the circle shaped piece of jewelry. “What are you searching for?” Ethan asked again looking up from his phone. “My ring. I lost it.” I said my heart aching. “I’m sure it’s somewhere here.” He said helping me look for it. “Has anyone seen my ring?” I asked loudly to get everyone’s attention. “The ‘secret’ ring?” Vanessa asked over the room. My friends had started calling it the secret ring, because I never told who gave it to me and why. “Yes, that one.” I said almost panicking. I couldn’t find it. “Don’t worry, you can go buy a new ring tomorrow.” Jack said “It’s just a ring.” I felt a lump in my throat. “It’s not just a ring. It’s special! It was given to me by someone special to me with an important meaning, okay? It’s not just a ring.” I said already pissed and hurt. “Well, I’m sure that that special person would understand the situation if you explained.” Vanessa joined in the conversation, agreeing with Jack in some kind of way. “It’s not that easy.” I said back, going through my bag. “Maybe it is. You shouldn’t be panicking over that ring this much.” Grayson also joined in, his voice worried on the other hand. I felt my eyes watering. The only person still helping me search for the ring was Ethan who kept quiet the whole time. At the end of the night we didn’t find the ring. My heart was broken…

November 4th, 2017.

I was back in New Jersey visiting home. The twins were arriving later that day. I spent some time with my mom, helping her around the house. At around 9pm I received a text from Ethan. ‘Can you come to the treehouse?’ It said. I quickly typed in a yes. I stood up from the couch and told my family I was going outside. I put on a pair of shoes and a hoodie and made my way to the forest. I found the treehouse quickly, noticing a purple light coming from its windows. I climbed up and when I saw the house my breath was taken away. “Wow.” I breathed. “I made some improvements.” Ethan said smiling as he was sitting in a beanbag chair. “The old walls were painted a baby blue shade, there were purple light hung up on the walls, and instead of the old foam pillows there were beanbag chairs. “I haven’t been here for such a long time.” I said taking one of the chairs and sitting down resting my elbows on my knees and my head in my hands. “I know.” He added, for some reason he seemed nervous. “Did you find your ‘secret’ ring?” he asked not looking to my side. “No.” I said sadly and looked down to my hands. “It was so special and meaningful to me.” I whispered. “I know. You always mentioned that.” He said reminding me. I let out a small giggle. “Actually, the reason why I asked you to come over…” Ethan started changing his position in the char so he would be facing me completely. “When you realized it was gone… you said that someone special gave it to you and that it had a special meaning…” he reminded. “Yeah, I did.” I said nodding. I hoped that maybe he had found the ring. “And you said that that someone doesn’t remember it.” He added. I nodded once again. “Well…” he started off a sentence but cut it off by standing up. He walked towards me and sat down on his knees right in front of me. “What if I told you…” he once again went quiet. My mind was racing in hopes he had found the special ring. He looked in my eyes and took a deep shaky breath. “What if I told you…” he started once again “That I remember. I remember that evening when we were here, hiding from the rain. It was exactly 4 years ago, actually.” He said and my heart started pounding. He remembers. “I remember how I gave the ring to you and it was too big so you put it on your neckless and wore it like that until it fit you. You didn’t take it off. Never. Even when you had the surgery. You always had it on you.” He said making me smile, I could feel tears coming to my eyes. I couldn’t let them escape though. “I remember the three promises, I’ve managed to keep for this long.” He kept talking one of his hands sliding in his pocket. He pulled out a silver ring with a heart ornament. It wasn’t the same ring, but it was beautiful. “I want to give this ring to you. I know it’s not the same ring, but it meant so much to you and to me too, so I wanted to give you another one as a replacement. So I want to give this ring to you. I want it to be a promise. Three promises actually. A promise that no matter what happens, I will always stay by your side. I will help you as much as I can, and I’ll be there for you through it all. A promise that I will never forget you. Never, no matter are we going to stay friends in the future or not. I will always remember you. And lastly, a promise that I will always love you. I have loved you and I always will.” He said, now I let the tears escape. My heart was pounding even more. It was dancing from happiness. I, just like the last time, didn’t know what to say, so I smiled. Ethan leaned in and I did the same. As our lips touched I felt like I was in heaven. He took my hand and tried to put the ring on my finger, but it was slightly too small. He seemed disappointed. I took off my neckless and slipped the ring on it. Ethan closed it and I smiled at him. “It’s not that bad.”

November 4th, 2023.

“Ethan, you may read your wedding promise.” Ethan took the rose gold wedding ring in his hands, and took in a deep breath. “Y/n. I know that this will sound unoriginal to you as you’ve heard it 2 times already through the past, but it has been special through the years. Whit this ring, I promise- that no matter what happens, I will always stay by your side. I will help you as much as I can, and I’ll be there for you through it all. I promise to love and cherish you no matter the circumstances. Most importantly, I promise to remember. To remember our past. To remember about you. I promise to take care of you. I promise to love you, forever and always.” He finished his words pushing the ring on my finger, which finally fit perfectly.

[dammitadolfnomorecake]

SC:SI 3 start

Completely mortified over what had transpired, Eren found himself able to remember only some of what happened. What he could remember, he remembered with with embarrassing clarity. He'd wanted to bred. That was the only way to describe the sensations that had filled every part of his being... or at least that was how he explained it to Hanji. Sitting across from the woman, he was still exhausted, though determined. He'd just spent a 5 days as a wolf, which he couldn't remembered. What he could remember was shifting back into his human form and being filled with the need to be... filled. He was sure every word out his mouth was only making things worse for himself, but surely Hanji could find some way for it all to mean something.

Having finished speaking, Eren's heart was hammering in his chest as he waited for Hanji to speak. Given he'd been staring at the floor as he spoke, he cautiously looked up, fully expecting Hanji to look supportive. Instead he found her seemingly concerned

"Eren, I need to conduct an internal examination. Is this alright?"

What? Why? Hadn't she gotten enough data? What more was there for her to look at? He didn't particularly want to be cut open, but he couldn't say no. And Hanji knew that... so why even ask? Nodding quickly, he didn't trust himself not to voice his thoughts

"Good. I'll sedate you, and you'll feel minimal pain during the procedure"

And there went his determination. Straight out the window as his stomach dropped

"Hanji... will I wake up from this?"

"What do you mean?"

"Will you kill me? While I'm unconscious?"

Hanji's eyes widened, shaking her head, she moved to kneel in front of him

"Is that what you think? That I'll just kill you?"

"No... no... maybe. I mean... I don't understand what's happening, and you and Levi just had to waste a week looking after me, when I'm not sure I even deserve it"

"Eren, we're not going to kill you. I honestly thought you were an alpha wolf, and that you were going through a rut. But just now you told me you felt like you needed to bred. So I need to take a look inside of you and see why"

"It doesn't matter does it? I'm a boy. It's not like sex will lead to anything happening"

"Still. I need to understand what's going on with you, so if we encounter someone else like you, we'll know what's going on"

"I'm sorry. I must seem so pathetic. All I wanted to do was work here. Even since before my parents died, I wanted to hunt the things that scare and kill people. No one knows where the werewolves come from, and to find out I'm like them. I feel like I've lost part of myself. I hate myself for this, but I don't want to die. I want to kill them all so no one has to suffer"

"I think you're tired and emotional. Once things settle down and you're finally allowed in the field, I think you'll end up feeling better"

"I don't know if or when I'll be allowed in the field"

"Until then, you'll help me with my research and not just as a test subject. We can't have you cooped up in the cell all day"

Nodding sadly, Eren felt like a damn pansy. Hanji was right though, his moods and thoughts were all over the place

"Alright. But if I do die, I want to be buried..."

"Eren, do you really think I'd let you die? I still haven't see your proper form"

Snorting at Hanji's grin, he couldn't help the smile forming in response to hers

"Let's do this"

*

Of all Hanji's ideas, this had to be the most pointless and he had no idea how the woman had secured Erwin's permission to operate on Eren, yet there he was. Watching as Hanji cut into Eren's most private places. The woman had started the procedure by first performing a biopsy on Eren's 4 scent glands, which was fine. What wasn't fine was the fact she was now openly slicing into the boys arse, while he was forced to watch the whole thing incase Eren shifted or became violent during the surgery. With all Hanji's meddling, Levi hadn't even talked to the boy since his rut... heat... ended. To him sexual curiosity seemed perfectly normal when it came to teenagers, yet because Eren had said he felt like he needed to be bred, they were going to all this bother. What did it matter if Eren swung that way? He was male, it wasn't like he'd wind up pregnant.

Watching the blood on Hanji's arm grow, Levi's teeth began to ache. This was another reason he shouldn't be the one watching over this surgery. His hunger still hadn't settled, and it felt like Eren's blood was just begging to be drunk. Rising from his seat, he began to pace at the end of the room

"Levi, I can't concentrate with you pacing"

"Too bad"

"Look, I'm nearly done here. Do you think you can stay still for just a little longer"

"Hanji. You have blood all over you. I think it's past time you were done"

"I can't help it. Every time I cut, I have to go over it half a dozen times because Eren heals so fast"

"What exactly are you cutting?"

"There seems to be a womb of some sort inside Eren's anus..."

"Alright. I don't need to hear anything else. Cut it out, and let him heal"

"I can't just cut it out"

"He'll heal, but he's not going to heal if he dies from blood loss first"

"Moblit. How's his heart rate?"

"Slower than when you started"

"Shit. Ok. Eren, I'm doing this for your own good"

Her statement was followed by a very wet and bloody pop, as something was pulled from inside Eren's arse. Levi couldn't help but scrunch his face up on disgust

"Is that?"

"Yeah. I need to examine this"

"Hanji, if he can get pregnant..."

"I severely doubt he'd be fertile. No. I think this comes from his wolf side..."

"That doesn't matter. If they even suspect..."

His friends face paled at the implications

"I can't not tell Erwin"

"Then tell him you removed it. Eren's already an outcast, he doesn't need to know about this either"

"Levi, could it be you feel something for Eren? Because he's like you?"

"No. I just don't want him ending up dead before we get some real answers"

Hanji hummed, clearly skeptical

"Alright. I just need to stitch him up. He's healing, but because of all the damage, it's taking some time"

Leaving Eren chained and in bed, Levi headed up to report to Erwin. Entering his friends office, he found Hanji already there

"How's Eren?"

"Still unconscious. The bleeding seems to have stopped"

"And you?"

Levi raised an eyebrow

"You'll have to feed off Hanji today. I have a meeting later"

Sinking into the chair next to Hanji, she immediately offered her arm to him

"I didn't even think of the implications of having Levi around all that blood"

"Well normally he can contain his urges, I understand you took samples from his scent glands"

Hanji winced slightly as Levi's teeth pierced her skin. Tasting soap, he also tasted what could only be Eren's lingering blood. The moment it met his tongue, he couldn't help the groan that slipped from the back of his throat. He'd never tasted anything like it. Erwin's blood was the best he'd ever tasted, but even that didn't hold a candle to the remnants of Eren's. Drinking deeply, it didn't take as long as usual for him to feel full

"You can take a little more"

Shaking his head, Levi pulled back

"I'm full"

"Levi, your hunger's not a safe thing to ignore"

Pulling his cravat off, he cleaned his mouth

"I'm fine. Thanks"

Both his friends stared at him, clearly worried that he was lying

"Eren's blood was still on Hanji's skin. I don't know why, but I could taste that and I didn't need to drink as much"

Hanji let out a small gasp

"Oh my god, do you know what this means? If you feed off Eren..."

"No. I'm not feeding off Eren. It's bad enough that I need to feed on either of you"

"But Levi, if your hungers sated so easily from a few drops of Eren's blood"

"No. Drop it"

Hanji looked to Erwin for support

"We can't risk Levi's nature being exposed"

"All I'm saying is, maybe I can come up with a tablet or something. Something you can keep on you in case of an emergency. I need to take his blood for analysis anyway"

"Your main priority should be masking Eren's scent"

"I already have Moblit examining the biopsies. Given his heat has passed, his smell seems to have dropped dramatically"

"So you're sure he's..."

"Yes. I found what seems to be the opening to a womb inside his anus, and of course I need to finish dissecting it, but I highly doubt he's fertile. For all intent and purposes, Eren is biologically male, making him incapable of falling pregnant"

Levi shot Hanji a glare, but Erwin rose to his feet

"No one else is to know. Including Moblit"

"Moblit won't tell anyone. He's been ordered not to include details other than those pertaining to the biopsy in his report"

"We still need to decide how much to tell them about his heat"

"I've already got that covered. Levi, when Eren awakens, make sure he eats. Hanji, I want you to report everything you find first thing tomorrow morning"

"So I'm still on babysitting duty"

"Just think of this as the prelude to him becoming your official partner"

Levi was shocked. He wasn't completely surprised they'd want a monster like him watching over Eren, but becoming the brats official partner...

Parting ways with Hanji, Levi felt no particular inclination or need to check on Eren. Hanji would more than likely check in with Eren later, so it was time he tried to return some normality to his life. Returning to his quarters, Levi stripped before heading into his private bathroom. Despite telling himself there was no point dwelling on something he couldn't currently change, Eren wouldn't disappear from his thoughts. The kid was only 15... half his officially listed age... a brat and a green soldier. Though to the public the Survey Corps was an official military branch that took on mission outside the walls in hopes of expanding Humanities territories, they were also the dogs of the government. Tasked with investigating things that weren't quite "human". As far as the masses went, vampires, ghosts, demons and spirits were all just fairytales of the past. And for the most part they were, yet here he was and no one had even put two and two together to realise he was a vampire. Other than his two friends, the only people who knew were his squad, consisting of Petra, Olou, Gunther, Eld, and Mike, Mike wasn't technically in his squad, but with the man's keen sense of smell, it wasn't something he could hide from him.

[marcusforst]

Stories from my mother, April 2015: Week 1

Hello Marcus,

I will always be there for you and you will always be part of me.  I don’t understand why this is so hard for me.  Why is it so painful to go back to the day that the nightmare began…

 I remember you sent us a text on Monday morning that you were having trouble breathing. Just a few weeks before you had been home a week for Spring Break, you had performed with the Philadelphia Youth Orchestra the Saturday that began Spring Break, and we put your stuff in my car, and went to your rehearsal.  I waited in the lobby and volunteered before the performance helping hand out tickets to groups.  

I had just been with you days before that text, with Bert McCutchen and Abby Gray and we went to a the Philadelphia Orchestra concert on Saturday night.  We had walked all around trying to find a restaurant that had a reservation open before the concert.  But we had been late getting to Philadelphia and every restaurant was full.  We finally ate at Qdoba or Chipotle on Walnut street.  I remember you coughed once really hard while we were eating dinner, but otherwise you seemed to be so healthy, so strong, so assured, so alive.  

On Monday after getting your text about having trouble breathing, I called you and we talked about whether you had your inhalers, if they were expired, whether you were using them and taking your vitamins.  I remember calling to get a new albuterol prescription and calling to get an appointment with Dr. Beausoleil.   You didn’t want to miss class, so the earliest appointment that fit your schedule would be Thursday.  I was thinking I would drive up on Thursday and take you to the appointment.  

Then again on Tuesday, you couldn’t sleep, and had to sit up to breathe.  I remember we talked about going to the Temple health center.  Then on Wednesday, you called me and said that after having lunch with your friends at Johnson and Hardwick cafeteria, you realized that you couldn’t walk and talk and breathe at the same time.  Most of your friends were sick too, but weren’t going to the health center. You were going to be smarter and so you went directly to the health center from lunch.  After you went to the health center you called me and said that your vital signs were good but something didn’t sound right, so they wanted you to go to the hospital for a chest x-ray.  I remember you said maybe your cold had gone straight to pneumonia.  We talked about it and you said the Temple Police would give you a ride to the hospital.  Both Mike and I had gone to Temple Hospital at some point while we were students.  I remember we thought, they will take your X-ray, give you a Zpack of steroids, and a nebulizer treatment and that will help you kick this so that you would be better in time for finals.  

I wish I had immediately left to meet you and wait with you in the ER at Temple hospital. Instead I met Margo to go for a walk at the West Grove Park, and then met Karl and we went to the middle school.  I walked up to meet Carolann and Leslie to watch the Nick and Spencer play a baseball game.  Karl had to leave after a while to go to basketball practice at the middle school.   While I was watching the game I got another text from you to the family group text.  “I am going to be here for awhile.  There is a big tumor on my heart and I am being admitted.”  I remember reading it, and then reading it out loud, and then standing up and struggling to fold up my chair to leave.  Leslie and Carolann were both shocked too, and a baseball Dad came over and helped me get my chair back in its bag.  Carolann offered to drive me home, but I said no, Karl and I had our car.  I hurried down to the middle school gym and couldn’t get the doors open. I texted Ikeem, Karl’s coach,who came and opened the door.  I told him that I needed to go to Philadelphia to Marcus.  Karl came over and was mad and told me to leave, and refused to talk with me, rushing back into the practice.  I talked with Ikeem and asked him to have someone give Karl a ride home.   I drove home.  I guess all this took me 30 minutes, because when I got home, almost immediately Mike got home from work in Wilmington too.    

I was concerned that I pack gluten free food for me and Marcus.  I was remembering the hospital in Germany where we stayed when Marcus had an allergic reaction to candy at Tante Wilma’s, when the people in the hospital served Marcus gluten.

I packed a small yellow backpack with a change of clothes and my necessaries for myself, thinking I would stay overnight.  

On the way to the hospital we hit a pothole on Interstate 95.  When we parked the car, Mike was concerned about the tire.  It had already started to form a bubble.  We went into the hospital and were shown the room where Marcus was.  There he was, sitting in a hospital bed, in a hospital gown, reading his Physics text book.  He still looked good, he wasn’t coughing, but he was hooked up to an IV and I was still trying to understand how this tumor could be somehow inside him.  He didn’t have any obvious strange bulges.  I could still hug him.   It was so hard to understand.  We tried to eat but we weren’t hungry.  Mike went down to the cafeteria for something.  

At regular intervals a nurse would come in and take Marcus’ vital signs.  The Doctor came in and talked to us, showing us a scan and explaining that on the one side you could see the white that was the air in the lungs, but on the other side it was completely dark, which meant there was no air in that lung.  He went up and down showing how the dark part grew and took up part of the white part on the other side too.  He said this was the tumor.  He was always surrounded by several residents, students who seemed just about Marcus’ age.  They took numerous blood tests and had him collect his pee in a bottle.  They were testing everything.  They asked us all about Marcus’ health history.  Several different people asked Marcus if he had ever had night sweats which he didn’t.  They kept feeling under his arms in his groin, up and down his neck, pressing his skin, looking at his arms and legs, his fingers, his toes.  I felt afraid, not knowing what they were looking for.  Marcus still didn’t have a fever.  

They wheeled Marcus out for another test, just as another group of doctors came to the room.  We followed the stretcher, walking along with Marcus, waiting outside while he went into another testing  exam room without us.   The Doctor was really nice and calm and told us not to start google searching.   He said that tomorrow they would do a biopsy and there was no use scaring ourselves with what ifs.  We listened and believed and I didn’t do any google searches.

That evening Marcus’ friend Lexi came, having taken the subway from Main campus.  

The nurses had set up a little cot for me along the wall outside the bathroom and at the first corner of the end of his hospital bed.  Lexi decided to stay and climbed up into his bed with him.  Lexi was able to be close to Marcus.  It was hard because I wanted to be right there also.  

I just wanted to cry but Mike and Marcus both told me that no crying was allowed.  If I was going to cry I would have to leave.  Eventually Mike had to leave to drive home.   Lexi and I stayed.  That night Marcus, Lexi and I all silently cried as we tried to sleep.  We didn’t know yet what, but something was desperately wrong.  

The next day, Lexi left to go to class.  Marcus had to prep for more testing.  They were going to drain the lung, take a biopsy of the big tumor on the heart.   Mike came back with Karl.  I remember them arriving while he was still in the procedure but they were there when he came out.   When Marcus first emerged, I remember him telling me that he had talked with Opa during the procedure.  

Later Marcus also had a bone marrow biopsy.  When he came out of the procedure and was still under anesthesia he again said that he had talked with Opa.  He also said that the nurses were tawas with him and told him he could do it.  Opa told him he had a bone marrow biopsy too and he knew he could do it.

In the evenings a few of Marcus’ friends visited.  Lexi came again and stayed.  She brought more notebooks and books from Marcus’ dorm room.  I remember Steph offering to wash Marcus’ laundry.  I think Ashley, Emily and Natalie brought Marcus a gift.  Someone gave him a stuffed animal like thing that resembled a chick or a duckling.  We talked about whether it was a chick or a duck with everyone who visited.    

On the Saturday, Marcus still had another test.  I think on Saturday, Julie McLaughlin came with Brendon and another neighbor that was not really close to Marcus.  I think Margie and William and Henry stopped by on Saturday too.  At this point, Marcus started becoming weary of the visitors and having to tell them the same story - No he didn’t really feel that sick before; no he didn’t know when it started.   The nurses would only let a few visitors in his room at a time.  Marcus and Lexi talked about having Lexi try to coordinate with the friends so that not everyone came at once.   We began using the stuffed chick / duck question as a safe word to ask Marcus if he needed the visitor to leave or if he needed to rest.  

I wanted to help Marcus, but there was little I could do.  He asked me to massage his back.  In the morning I would help Marcus clean himself with a washcloth sponge bath. Sometime after the first night, Marcus developed night sweats and we would change his wet sheets at night, a couple of times during the night.  We tried different things, putting a blanket under the sheet, sleeping on top of several sheets and then removing one at a time as it got sweated through.  Often it seemed we had just fallen asleep when the nurse would come in and wake him to take his blood at 5 am.  I remember Marcus asking why did they have to take his blood at 5am?  They took blood several times a day, why couldn’t they take blood at 7 instead?  But they told us they took the blood at 5 because then the doctors and residents started coming around at 7 and they needed the results before they came in.

I seem to remember that on Easter Sunday Marcus had another MRI, this time of the lower abdomen.  I waited for him in a waiting room and Jane McCann and her Mom met me there and we talked while we waited for him to come out.  We walked together following his stretcher and visited awhile in his room.  

Every day Mike came back and on the weekend Karl came again.  

March Madness basketball was happening during this weekend.  I remember Mike bringing a monitor and some speakers and streaming the game from his laptop or something like that.  Marcus’ friend Aaron watched the final game with us.  

Marcus had so many friends and I didn’t remember their names.  Marcus and Lexi made me a PowerPoint with pictures of his friends and their names so that I could learn their names.  I remember looking at that PowerPoint repeatedly, as it was something I could do and learn, even though I couldn’t do anything to help Marcus’s get better.  

Then finally on Easter Monday the team of blood doctors and Marcus’ main doctor came in together to talk to us.  They had a diagnosis - T-cell Lymphoblastic Lymphoma.   It was a rare and very aggressive cancer.  They said Marcus would be hospitalized for 6 months for intense chemotherapy.  They recommended that he go to Temple Fox Chase for treatment at Jeanes Hospital, where one of the best Doctors in Lymphoma was practicing.  Within an hour they had prepared an ambulance and Marcus and I went in the ambulance and Mike took Lexi, Alex and Aaron and all the stuff that had accumulated in the hospital along with in the jalopy.  

[lauramalchowblog]

Artificial Intelligence vs. Tuberculosis, Part 1

By SAURABH JHA, MD

Slumdog TB

No one knows who gave Rahul Roy tuberculosis. Roy’s charmed life as a successful trader involved traveling in his Mercedes C class between his apartment on the plush Nepean Sea Road in South Mumbai and offices in Bombay Stock Exchange. He cared little for Mumbai’s weather. He seldom rolled down his car windows – his ambient atmosphere, optimized for his comfort, rarely changed.

Historically TB, or “consumption” as it was known, was a Bohemian malady; the chronic suffering produced a rhapsody which produced fine art. TB was fashionable in Victorian Britain, in part, because consumption, like aristocracy, was thought to be hereditary. Even after Robert Koch discovered that the cause of TB was a rod-shaped bacterium – Mycobacterium Tuberculosis (MTB), TB had a special status denied to its immoral peer, Syphilis, and unaesthetic cousin, leprosy.

TB became egalitarian in the early twentieth century but retained an aristocratic noblesse oblige. George Orwell may have contracted TB when he voluntarily lived with miners in crowded squalor to understand poverty. Unlike Orwell, Roy had no pretentions of solidarity with poor people. For Roy, there was nothing heroic about getting TB. He was embarrassed not because of TB’s infectivity; TB sanitariums are a thing of the past. TB signaled social class decline. He believed rickshawallahs, not traders, got TB.

“In India, many believe TB affects only poor people, which is a dangerous misconception,” said Rhea Lobo – film maker and TB survivor.

Tuberculosis is the new leprosy. The stigma has consequences, not least that it’s difficult diagnosing a disease that you don’t want diagnosed. TB, particularly extra-pulmonary TB, mimics many diseases.

“TB can cause anything except pregnancy,” quips Dr. Justy – a veteran chest physician. “If doctors don’t routinely think about TB they’ll routinely miss TB.”

In Lobo, the myocobacteria domiciled in the bones of her feet, giving her heel pain, which was variously ascribed to bone bruise, bone cancer, and staphylococcal infection. Only when a lost biopsy report resurfaced, and after receiving the wrong antibiotics, was TB diagnosed, by which time the settlers had moved to her neck, creating multiple pockets of pus. After multiple surgeries and a protracted course of antibiotics, she was free of TB.

“If I revealed I had TB no one would marry me, I was advised” laughed Lobo. “So, I made a documentary on TB and started ‘Bolo Didi’ (speak sister), a support group for women with TB. Also, I got married!”

Mycobacterium tuberculosis is an astute colonialist which lets the body retain control of its affairs. The mycobacteria arrive in droplets, legitimately, through the airways and settle in the breezy climate of the upper lobes and superior segment of the lower lobes of the lungs. If they sense weakness they attack, and if successful, cause primary TB. Occasionally they so overpower the body that an avalanche of small, discrete snowballs, called miliary TB, spread. More often, they live silently in calcified lymph nodes as latent TB. When apt, they reappear, causing secondary TB. The clues to their presence are calcified mediastinal nodes or a skin rash after injection of mycobacterial protein.

MTB divides every 20 hours. In the bacterial world that’s Monk-like libido. E. Coli, in comparison, divides every 20 minutes. Their sexual ennui makes them frustratingly difficult to culture. Their tempered fecundity also means they don’t overwhelm their host with their presence, permitting them to write fiction and live long enough to allow the myocobacteria to jump ship.

TB has been around for a while. The World Health Organization (WHO) wants TB eradicated but the myocobacteria have no immediate plans for retirement. Deaths from TB are declining at a tortoise pace of 2 % a year. TB affects 10 million and kills 1.6 million every year – it is still the number one infectious cause of death.

The oldest disease’s nonchalance to the medical juggernaut is not for the lack of a juggernaut effort. Mass screening for TB using chest radiographs started before World War 2, and still happens in Japan. The search became fatigued by the low detection of TB. The challenge wasn’t just in looking for needles in haystacks, but getting to the haystacks which, in developing countries, are dispersed like needles.

The battleground for TB eradication is India, which has the highest burden of TB – a testament not just to its large population. Because TB avoids epidemics, it never scares the crap out of people. Its distribution and spread match society’s wealth distribution and aspirations. And in that regard India is most propitious for its durability.

Few miles north of Nepean Sea Road is Dharavi – Asia’s largest slum, made famous by the Oscar-winning film, Slumdog Millionaire. From atop, Dharavi looks like thousand squashed coke cans beside thousand crumpled cardboard boxes. On the ground, it’s a hot bed of economic activity. No one wants to stay in Dharavi forever, its people want to become Bollywood stars, or gangsters, or just very rich. Dharavi is a reservoir of hope.

Dharavi is a reservoir also of active TB. In slums, which are full of houses packed like sardines in which live people packed like sardines, where cholera spreads like wildfire and wildfire spreads like cholera, myocobacteria travel much further. Familiarity breeds TB. One person with active TB can infect nine – and none are any the wiser of the infection because unlike cholera, which is wildfire, TB is a slow burn and its symptoms are indistinguishable from the maladies of living in a slum.

Slum dwellers with active TB often continue working – there’s no safety net in India to cushion the illness – and often travel afar to work. They could be selling chai and samosas outside the Bombay Stock Exchange. With the habit of expectoration – in India, spitting on the streets isn’t considered bad manners – sputum is aplenty, and mycobacteria-laden droplets from Dharavi can easily reach Roy’s lungs. TB, the great leveler, bridges India’s wealth divide. Mycobacteria unite Nepean Sea Road with Dharavi.

Rat in Matrix Algebra

The major challenges in fighting tuberculosis are finding infected people and ensuring they take the treatment for the prescribed duration, often several months. Both obstacles can wear each other– if patients don’t take their treatment what’s the point finding TB? If TB can’t be found what good is the treatment?

The two twists in the battle against TB, drug resistant TB and concurrent TB and HIV, favor the mycobacteria. But TB detection is making a resurgence with the reemergence of the old warrior – the chest radiograph, which now has a new ally – artificial intelligence (AI). Artificial Intelligence is chest radiograph’s Sancho Panza.

Ten miles north of Dharavi in slick offices in Goregaon, Mumbai’s leafy suburb, data scientists training algorithms to read chest radiographs are puzzled by AI’s leap in performance.

“The algorithm we developed,” says Preetham Sreenivas incredulously, “has an AUC of 1 on the new set of radiographs!”

AUC, or area under the receiver operator characteristic curve, measures diagnostic accuracy. The two types of diagnostic errors are false negatives – mistaking abnormal for normal, and false positives – mistaking normal for abnormal. In general, fewer false negatives (FNs) means more false positives (FPs); trade-off of errors. A higher AUC implies fewer “false” errors, AUC of 1 is perfect accuracy; no false positives, no false negatives.

Chest radiograph are two-dimensional images on which three dimensional structures, such as lungs, are collapsed and which, like Houdini, hide stuff in plain sight. Pathology literally hides behind normal structures. It’s nearly impossible for radiologists to have an AUC of 1. Not even God knows what’s going on in certain parts of the lung, such as the posterior segment of the left lower lobe.

Here, AI seemed better than God at interpreting chest radiographs. But Sreenivas, who leads the chest radiograph team in Qure.ai – a start-up in Mumbai which solves healthcare problems using artificial intelligence, refused to open the champagne.

“Algorithms can’t jump from an AUC of 0.84 to 1. It should be the other way round – their performance should drop when they see data (radiographs) from a new hospital,” explains Sreenivas.

Algorithms mature in three stages. First, training –  data (x-rays), labelled with ground truth, are fed to a deep neural network (the brain), Labels, such as pleural effusion, pulmonary edema, pneumonia, or no abnormality, teach AI. After seeing enough cases AI is ready for the second step, validation – in which it is tested on different cases taken from the same source as the training set – like same hospital. If AI performs respectably, it is ready for the third stage – the test.

Training radiology residents is like training AI. First, residents see cases knowing the answer. Then they see cases on call from the institution they’re training at, without knowing the answer. Finally, released into the world, they see cases from different institutions and give an answer.

The test and training cases come from different sources. The algorithm invariably performs worse on test than training set because of “overfitting” – a phenomenon where the algorithm tries hard fitting to the local culture. It thinks the rest of the world is exactly like the place it trained, and can’t adapt to subtle differences in images because of different manufacturers, different acquisition parameters, or acquisition on different patient populations. To reduce overfitting, AI is regularly fed cases from new institutions.

When AI’s performance on radiographs from a new hospital mysteriously improved, Sreenivas smelt a rat.

“AI is matrix algebra. It’s not corrupt like humans – it doesn’t cheat. The problem must be the data,” Sreenivas pondered.

Birth of a company

“I wish I could say we founded this company to fight TB,” says Pooja Rao, co-founder of Qure.ai, apologetically. “But I’d be lying. The truth is that we saw in an international public health problem a business case for AI.”

Qure.ai was founded by Prashant Warier and Pooja Rao. After graduating from the Indian Institute of Technology (IIT), Warier, a natural born mathematician, did his PhD from Georgia Tech. He had no plans of returning to India, until he faced the immigration department’s bureaucratic incompetence. Someone had tried entering the US illegally on his wife’s stolen passport. The bureaucracy, unable to distinguish the robber from the robbed, denied her a work visa. Warier reluctantly left the US.

In India, Warier founded a company which used big data to find preferences of niche customers. His company was bought by Fractal, a data analytic giant – the purchase motivated largely by the desire to recruit Warier.

Warier wanted to develop an AI-enabled solution for healthcare. In India, data-driven decisions are common in retail but sparse in healthcare. In a move unusual in industry and uncommon even in academia, Fractal granted him freedom to tinker, with no strings attached. Qure.ai was incubated by Fractal.

Warier discovered Rao, a physician-scientist and bioinformatician, on LinkedIn and invited her to lead the research and development. Rao became a doctor to become a scientist because she believed that deep knowledge of medicine helps join the dots in the biomedical sciences. After her internship, she did a PhD at the Max Planck Institute in Germany. For her thesis, she applied deep learning to predict Alzheimer’s disease from RNA. Though frustrated by Alzheimer’s, which seemed uncannily difficult to predict, she fell in love with deep learning.

Rao and Warier were initially uncertain what their start-up should focus on. There were many applications of AI in healthcare, such as genomic analysis, analysis of electronic medical records, insurance claims data, Rao recalled two lessons from her PhD.

“Diseases such as Alzheimer’s are heterogeneous, so the ground truth, the simple question – is there Alzheimer’s – is messy. The most important thing I realized is that without the ground truth AI is useless.”

Rao echoed the sentiments of Lady Lovelace, the first computer programmer, from the nineteenth century. When Lovelace saw the analytical engine, the first “algorithm”, invented by Charles Babbage, she said: “The analytical Engine has no pretensions whatever to originate anything. It can do whatever we know how to order it to perform. It can follow analysis; but it has no power of anticipating any analytical relations or truths.”

The second lesson Rao learnt was that the ground truth must be available immediately, not in the future – i.e. AI must be trained on diseases of the present, not outcomes, which are nebulous and take time to reveal. The immediacy of their answer, which must be now, right away, reduced their choices to two – radiology and pathology. Pathology had yet to be digitized en masse.

“The obvious choice for AI was radiology”, revealed Warier.

Why “Qure” with a Q, not “Cure” with a C, I asked. Was it a tribute to Arabic medicine?

“We’re not that erudite,” laughed Warier. “The internet domain for ‘cure’ had already been taken.”

Qure.ai was founded in 2016 during peak AI euphoria. In those days deep learning seemed magical to those who understood it, and to those who didn’t. Geoffrey Hinton, deep learning’s titan, famously predicted radiologists’ extinction – he advised that radiologists should stop being trained because AI would interpret the images just as well.

Bioethicist and architect of Obamacare, Ezekiel Emanuel, told radiologists that their profession faced an existential threat from AI. UK’s health secretary, Jeremy Hunt, drunk on the Silicon Valley cool aid, prophesized that algorithms will outperform general practitioners. Venture capitalist, Vinod Khosla predicted modestly that algorithms will replace 80 % of doctors.

Amidst the metastasizing hype, Warier and Rao remained circumspect. Both understood AI’s limitations. Rao was aware that radiologists hedged in their reports – which often made the ground truth a coin toss. They concluded that AI would be an incremental technology. AI would help radiologists become better radiologists.

“We were firing arrows in the dark. Radiology is vast. We didn’t know where to start,” recalls Rao.

Had Qure.ai been funded by venture capitalists, they’d have a deadline to have a product. But Fractal prescribed no fixed timeline. This gave the founders an opportunity to explore radiology. The exploration was instructive.

They spoke to several radiologists to better understand radiology, find the profession’s pain points, see what could be automated, and what might be better dealt by AI. The advice ranged from the flippant to the esoteric. One radiologist recommended using AI to quantify lung fibrosis in interstitial pulmonary fibrosis, another, knee cartilage for precision anti-rheumatoid therapy. Qure.ai has a stockpile of unused, highly niche, esoteric algorithms.

Every radiologist’s idea of augmentation was unique. Importantly, few of their ideas comprised mainstream practice. Augmentation seemed a way of expanding radiologist’s possibilities, rather than dealing with radiology’s exigencies – no radiologist, for instance, suggested that AI should look for TB on chest radiographs.

Augmentation doesn’t excite venture capitalists as much as replacement, transformation, or disruption. And augmentation didn’t excite Rao and Warier, either. When you have your skin in the commercial game, relevance is the only currency.

“Working for start-ups is different from being a scientist in an academic medical center. We do science, too. But before we take a project, we think about the return of investment. Just because an endeavor is academically challenging doesn’t mean that it’s commercially useful. If product don’t sell, start-ups have to close shop,” said Rao.

The small size of start-ups means they don’t have to run decisions through bulky corporate governance. It doesn’t take weeks convening meetings through Doodle polls. Like free climbers who aren’t encumbered by climbing equipment, they can reach their goal sooner. Because a small start-up is nimble it can fail fast, fail without faltering, fail a few time. But it can’t fail forever. Qure needed a product it could democratize. Then an epiphany.

In World War 2, after allied aircrafts sustained bullets in enemy fire, some returned to the airbase and others crashed. Engineers wanted the aircrafts reinforced at their weakest points to increase their chances of surviving enemy fire. A renowned statistician of the time, Abraham Wald, analyzed the distribution of the bullets and advised that reinforcements be placed where the plane hadn’t been shot. Wald realized that the planes which didn’t return were likely shot at the weakest points. On the planes which returned the bullets marked their strongest point.

Warier and Rao realized that they needed to think about scenarios where radiologists were absent, not where radiologists were abundant. They had asked the wrong people the wrong question. The imminent need wasn’t replacing or even augmenting radiologists, but in supplying near-radiologist expertise where not a radiologist was in sight. The epiphany changed their strategy.

“It’s funny – when I’m asked whether I see AI replacing radiologists, I point out that in most of the rest of the world there aren’t any radiologists to replace,” said Rao.

The choice of modality – chest radiographs – followed logically because chest radiographs are the most commonly ordered imaging test worldwide. They’re useful for a number of clinical problems and seem deceptively easy to interpret. Their abundance also meant that AI would have a large sample size to learn from.

“There just weren’t enough radiologists to read the daily chest radiograph volume at Christian Medical College, Vellore, where I worked. I can read chest x-rays because I’m a chest physician, but reading radiographs takes away time I could be spending with my patients, and I just couldn’t keep up with the volumes,” recalls Dr. Justy. Several radiographs remained unread for several weeks, many hid life-threatening conditions such as pneumothorax or lung cancer. The hospital was helpless – their budget was constrained and as important as radiologists were, other physicians and services were more important. Furthermore, even if they wanted they couldn’t recruit radiologists because the supply of radiologists in India is small.

Justy believes AI can offer two levels of service. For expert physicians like her, it can take away the normal radiographs, leaving her to read the abnormal ones, which reduces the workload because the majority of the radiographs are normal. For novice physicians, and non-physicians, AI could provide an interpretation – diagnosis, or differential diagnoses, or just point abnormalities on the radiograph.

The Qure.ai team imagined those scenarios, too. First they needed the ingredients, the data, i.e. the chest radiographs. But the start-up comprised only a few data scientists, none of whom had any hospital affiliations.

“I was literally on the road for two years asking hospitals for chest radiographs. I barely saw my family,” recalls Warier. “Getting the hospitals to share data was the most difficult part of building Qure.ai.”

Warier became a traveling salesman and met with leadership of over hundred healthcare facilities of varying sizes, resources, locations, and patient populations. He explained what Qure.ai wanted to achieve and why they needed radiographs. There were long waits outside the leadership office, last minute meeting cancellations, unanswered e-mails, lukewarm receptions, and enthusiasm followed by silence. But he made progress, and many places agreed to give him the chest radiographs. The data came with stipulations. Some wanted to share revenue. Some wanted research collaborations. Some had unrealistic demands such as share of the company. It was trial and error for Warier, as he had done nothing of this nature before.

Actually it was Warier’s IIT alumni network which opened doors. IITians (graduates of the Indian Institutes of Technology) practically run India’s business, commerce, and healthcare. Heads of private equity which funds corporate hospitals are often IITians, as are the CEOs of these hospitals.

“Without my IIT alumni network, I don’t think we could have pulled it off. Once an IITian introduces an IITian to an IITian, it’s an unwritten rule that they must help,” said Warier.

Warier’s efforts paid. Qure has now acquired over 2.5 million chest radiographs from over 100 sites for training, validation and testing the chest radiograph algorithm.

“As a data scientist my ethos is that there’s no such thing as ‘too much data.’ More the merrier,” smiled Warier.

“The mobile phone reached many parts of India before the landline could get there,” explains Warier. “Similarly, AI will reach parts of India before radiologists.”

Soon, a few others, including Srinivas, joined the team. Whilst the data scientists were educating AI, Rao and Warier were figuring their customer base. It was evident that radiologists would not be their customers. Radiologists didn’t need AI. Their customers were those who needed radiologists but were prepared to settle for AI.

“The secret to commercialization in healthcare is need, real need, not induced demand. But it’s tricky because the neediest are least likely to generate revenues,” said Warier in a pragmatic tone. Unless the product can be scaled at low marginal costs. An opportunity for Qure.ai arose in the public health space – the detection of tuberculosis on chest radiographs in the global fight against TB. It was an indication that radiologists in developing worlds didn’t mind conceding – they had plenty on their plates, already.

“It was serendipity,” recalls Rao. “A consultant suggested that we use our algorithm to detect TB. We then met people working in the TB space – advocates, activists, social workers, physicians, and epidemiologists. We were inspired particularly by Dr. Madhu Pai, Professor of Epidemiology at McGill University. His passion to eradicate TB made us believe that the fight against TB was personal.”

Qure.ai started with four people. Today 35 people work for it. They even have a person dedicated to regulatory affairs. Rao remembers the early days. “We were lucky to have been supported by Fractal. Had we been operating out of a garage, we might not have survived. Building algorithms isn’t easy.”

Finding Tuberculosis

Hamlet’s modified opening soliloquy, “TB or not TB, that is the question”, simplifies the dilemma facing TB detection, which is a choice between fewer false positives and fewer false negatives. Ideally, one wants neither. The treatment for tuberculosis – quadruple therapy – exacts several month commitment. It’s not a walk in the park. Patients have to be monitored to confirm they are treatment compliant, and though directly observed therapy, medicine’s big brother, has become less intrusive, it still consumes resources. Taking TB treatment when one doesn’t have TB is unfortunate. But not taking TB treatment when one has TB can be tragic, and defeats the purpose of detection, and perpetuates the reservoir of TB.

Hamlet’s soliloquy can be broken into two parts – screening and confirmation. When screening for TB, “not TB is the question”. The screening test must be sensitive –capable of finding TB in those with TB, i.e. have a high negative predictive value (NPV), so that when it says “no TB” – we’re (nearly) certain the person doesn’t have TB.

Those positive on screening tests comprise two groups – true positives (TB) and false positives (not TB). We don’t want antibiotics frivolously given, so the soliloquy reverses; it is now “TB, that is the question.” The confirmatory test must be specific, highly capable of finding “not TB” in those without TB, i.e. have a high positive predictive value (PPV), so that when it says “TB” – we’re (nearly) certain that the person has TB. Confirmatory tests should not be used to screen, and vice versa.

Tuberculosis can be inferred on chest radiographs or myocobacteria TB can be seen on microscopy. Seeing is believing and seeing the bacteria by microscopy was once the highest level of proof of infection. In one method, slide containing sputum is stained with carbol fuchsin, rendering it red. MTB retains its glow even after the slide is washed with acid alcohol, a property responsible for its other name – acid fast bacilli.

Sputum microscopy, once heavily endorsed by the WHO for the detection of TB, is cheap but complicated. The sputum specimen must contain sputum, not saliva, which is easily mistaken for sputum. Patients have to be taught how to bring up the sputum from deep inside their chest. The best time to collect sputum is early morning, so the collection needs discipline, which means that the yield of sputum depends on the motivation of the patient. Inspiring patients to provide sputum is hard because even those who regularly cough phlegm can find its sight displeasing.

Which is to say nothing about the analysis part, which requires attention to detail. It’s easier seeing mycobacteria when they’re abundant. Sputum microscopy is best at detecting the most infectious of the most active of the active TB sufferers. Its accuracy depends on the spectrum of disease. If you see MTB, the patient has TB. If you don’t see MTB, the patient could still have TB. Sputum microscopy, alone, is too insensitive and cumbersome for mass screening – yet, in many parts of the world, that’s all they have.

The gold standard test for TB – the unfailing truth that the patient has TB, independent of the spectrum of disease – is culture of mycobacteria, which was deemed impractical because on the Löwenstein–Jensen medium, the agar made specially for MTB, it took six weeks to grow MTB, which is too long for treatment decisions. Culture has made a comeback, in order to detect drug resistant mycobacteria. On newer media, such as MGIT, the mycobacteria grow much faster.

The detection of TB was revolutionized by molecular diagnostics, notably the nucleic acid amplification test, also known as GeneXpert MTB/ RIF, shortened to Xpert, which simultaneously detects mycobacterial DNA and assesses whether the mycobacteria are resistant to rifampicin – one of the mainline anti-tuberculosis drugs.

Xpert boasts a specificity of 98 %, and with a sensitivity of 90 % it is nearly gold standard material, or at least good enough for confirmation of TB. It gives an answer in 2 hours – a dramatically reduced turnaround time compared to agar. Xpert can detect 131 colony-forming units of MTB per ml of specimen – which is a marked improvement from microscopy, where there should be 10, 000 colony-forming units of MTB per ml of specimen for reliable detection. However, Xpert can’t be used on everyone, not just because its sensitivity isn’t high enough – 90 % is a B plus, and for screening we need an A plus sensitivity. But also its price, which ranges from $10 – $20 per cartridge, and is too expensive for mass screening in developing countries.

This brings us back to the veteran warrior, the chest radiograph, which has a long history. Shortly after Wilhelm Röntgen’s discovery, x-rays were used to see the lungs, the lungs were a natural choice because there was natural contrast between the air, through which the rays passed, and the bones, which stopped the rays. Pathology in the lungs stopped the rays, too – so the ‘stopping of rays’ became a marker for lung disease, chief of which was tuberculosis.

X-rays were soon conscripted to the battlefield in the Great War to locate bullets in wounded soldiers, making them war heroes. But it was the writer, Thomas Mann, who elevated the radiograph to literary fame in Magic Mountain – a story about a TB sanitarium. The chest radiograph and tuberculosis became intertwined in people’s imagination. By World War 2, chest radiographs were used for national TB screening in the US.

The findings of TB on chest radiographs include consolidation (whiteness), big lymph nodes in the mediastinum, cavitation (destruction of lung), nodules, shrunken lung, and pleural effusion. These findings, though sensitive for TB – if the chest radiograph is normal, active TB is practically excluded, aren’t terribly specific, as they’re shared by other diseases, such as sarcoid.

Chest radiographs became popular with immigration authorities in Britain and Australia to screen for TB in immigrants from high TB burden countries at the port of entry. But the WHO remained unimpressed by chest radiographs, preferring sputum analysis instead. The inter- and intra-observer variation in the interpretation of the radiograph didn’t inspire confidence. Radiologists would often disagree with each other, and sometimes disagree with themselves. WHO had other concerns.

“One reason that the WHO is weary of chest radiographs is that they fear that if radiographs alone are used for decision making, TB will be overtreated. This is common practice in the private medical sector in India,” explains Professor Madhu Pai.

Nonetheless, Pai advocates that radiographs triage for TB, to select patients for Xpert, which is cost effective because radiographs, presently, are cheaper than molecular tests.  Using Xpert only on patients with abnormal chest radiographs would increase its diagnostic yield – i.e. percentage of cases which test positive. Chest radiograph’s high sensitivity compliments Xpert’s high specificity. But this combination isn’t 100 % – nothing in diagnostic medicine is. The highly infective endobronchial TB can’t be seen on chest radiograph, because the mycobacteria never make it to the lungs, and remain stranded in the airway.

“Symptoms such as cough are even more non-specific than chest radiographs for TB. Cough means shit in New Delhi, because of the air pollution which gives everyone a cough,” explains Pai, basically emphasizing that neither the chest radiograph nor clinical acumen, can be removed from the diagnostic pathway for TB.

A test can’t be judged just by its AUC. How likely people – doctors and patients – are to adopt a test is also important and here the radiograph outshines sputum microscopy, because despite its limitations, well known to radiologists, radiographs still carry a certain aura, particularly in India. In the Bollywood movie, Anand, an oncologist played by Amitabh Bachchan diagnosed terminal cancer by glancing at the patient’s radiograph for couple of seconds. Not CT, not PET, but a humble old radiograph. Bollywood has set a very high bar for Artificial Intelligence.

Saurabh Jha (aka @RogueRad) is a contributing editor for THCB. This is part 1 of a two-part story.

The post Artificial Intelligence vs. Tuberculosis, Part 1 appeared first on The Health Care Blog.

Artificial Intelligence vs. Tuberculosis, Part 1 published first on https://venabeahan.tumblr.com

[kristinsimmons]

Artificial Intelligence vs. Tuberculosis, Part 1

By SAURABH JHA, MD

Slumdog TB

No one knows who gave Rahul Roy tuberculosis. Roy’s charmed life as a successful trader involved traveling in his Mercedes C class between his apartment on the plush Nepean Sea Road in South Mumbai and offices in Bombay Stock Exchange. He cared little for Mumbai’s weather. He seldom rolled down his car windows – his ambient atmosphere, optimized for his comfort, rarely changed.

Historically TB, or “consumption” as it was known, was a Bohemian malady; the chronic suffering produced a rhapsody which produced fine art. TB was fashionable in Victorian Britain, in part, because consumption, like aristocracy, was thought to be hereditary. Even after Robert Koch discovered that the cause of TB was a rod-shaped bacterium – Mycobacterium Tuberculosis (MTB), TB had a special status denied to its immoral peer, Syphilis, and unaesthetic cousin, leprosy.

TB became egalitarian in the early twentieth century but retained an aristocratic noblesse oblige. George Orwell may have contracted TB when he voluntarily lived with miners in crowded squalor to understand poverty. Unlike Orwell, Roy had no pretentions of solidarity with poor people. For Roy, there was nothing heroic about getting TB. He was embarrassed not because of TB’s infectivity; TB sanitariums are a thing of the past. TB signaled social class decline. He believed rickshawallahs, not traders, got TB.

“In India, many believe TB affects only poor people, which is a dangerous misconception,” said Rhea Lobo – film maker and TB survivor.

Tuberculosis is the new leprosy. The stigma has consequences, not least that it’s difficult diagnosing a disease that you don’t want diagnosed. TB, particularly extra-pulmonary TB, mimics many diseases.

“TB can cause anything except pregnancy,” quips Dr. Justy – a veteran chest physician. “If doctors don’t routinely think about TB they’ll routinely miss TB.”

In Lobo, the myocobacteria domiciled in the bones of her feet, giving her heel pain, which was variously ascribed to bone bruise, bone cancer, and staphylococcal infection. Only when a lost biopsy report resurfaced, and after receiving the wrong antibiotics, was TB diagnosed, by which time the settlers had moved to her neck, creating multiple pockets of pus. After multiple surgeries and a protracted course of antibiotics, she was free of TB.

“If I revealed I had TB no one would marry me, I was advised” laughed Lobo. “So, I made a documentary on TB and started ‘Bolo Didi’ (speak sister), a support group for women with TB. Also, I got married!”

Mycobacterium tuberculosis is an astute colonialist which lets the body retain control of its affairs. The mycobacteria arrive in droplets, legitimately, through the airways and settle in the breezy climate of the upper lobes and superior segment of the lower lobes of the lungs. If they sense weakness they attack, and if successful, cause primary TB. Occasionally they so overpower the body that an avalanche of small, discrete snowballs, called miliary TB, spread. More often, they live silently in calcified lymph nodes as latent TB. When apt, they reappear, causing secondary TB. The clues to their presence are calcified mediastinal nodes or a skin rash after injection of mycobacterial protein.

MTB divides every 20 hours. In the bacterial world that’s Monk-like libido. E. Coli, in comparison, divides every 20 minutes. Their sexual ennui makes them frustratingly difficult to culture. Their tempered fecundity also means they don’t overwhelm their host with their presence, permitting them to write fiction and live long enough to allow the myocobacteria to jump ship.

TB has been around for a while. The World Health Organization (WHO) wants TB eradicated but the myocobacteria have no immediate plans for retirement. Deaths from TB are declining at a tortoise pace of 2 % a year. TB affects 10 million and kills 1.6 million every year – it is still the number one infectious cause of death.

The oldest disease’s nonchalance to the medical juggernaut is not for the lack of a juggernaut effort. Mass screening for TB using chest radiographs started before World War 2, and still happens in Japan. The search became fatigued by the low detection of TB. The challenge wasn’t just in looking for needles in haystacks, but getting to the haystacks which, in developing countries, are dispersed like needles.

The battleground for TB eradication is India, which has the highest burden of TB – a testament not just to its large population. Because TB avoids epidemics, it never scares the crap out of people. Its distribution and spread match society’s wealth distribution and aspirations. And in that regard India is most propitious for its durability.

Few miles north of Nepean Sea Road is Dharavi – Asia’s largest slum, made famous by the Oscar-winning film, Slumdog Millionaire. From atop, Dharavi looks like thousand squashed coke cans beside thousand crumpled cardboard boxes. On the ground, it’s a hot bed of economic activity. No one wants to stay in Dharavi forever, its people want to become Bollywood stars, or gangsters, or just very rich. Dharavi is a reservoir of hope.

Dharavi is a reservoir also of active TB. In slums, which are full of houses packed like sardines in which live people packed like sardines, where cholera spreads like wildfire and wildfire spreads like cholera, myocobacteria travel much further. Familiarity breeds TB. One person with active TB can infect nine – and none are any the wiser of the infection because unlike cholera, which is wildfire, TB is a slow burn and its symptoms are indistinguishable from the maladies of living in a slum.

Slum dwellers with active TB often continue working – there’s no safety net in India to cushion the illness – and often travel afar to work. They could be selling chai and samosas outside the Bombay Stock Exchange. With the habit of expectoration – in India, spitting on the streets isn’t considered bad manners – sputum is aplenty, and mycobacteria-laden droplets from Dharavi can easily reach Roy’s lungs. TB, the great leveler, bridges India’s wealth divide. Mycobacteria unite Nepean Sea Road with Dharavi.

Rat in Matrix Algebra

The major challenges in fighting tuberculosis are finding infected people and ensuring they take the treatment for the prescribed duration, often several months. Both obstacles can wear each other– if patients don’t take their treatment what’s the point finding TB? If TB can’t be found what good is the treatment?

The two twists in the battle against TB, drug resistant TB and concurrent TB and HIV, favor the mycobacteria. But TB detection is making a resurgence with the reemergence of the old warrior – the chest radiograph, which now has a new ally – artificial intelligence (AI). Artificial Intelligence is chest radiograph’s Sancho Panza.

Ten miles north of Dharavi in slick offices in Goregaon, Mumbai’s leafy suburb, data scientists training algorithms to read chest radiographs are puzzled by AI’s leap in performance.

“The algorithm we developed,” says Preetham Sreenivas incredulously, “has an AUC of 1 on the new set of radiographs!”

AUC, or area under the receiver operator characteristic curve, measures diagnostic accuracy. The two types of diagnostic errors are false negatives – mistaking abnormal for normal, and false positives – mistaking normal for abnormal. In general, fewer false negatives (FNs) means more false positives (FPs); trade-off of errors. A higher AUC implies fewer “false” errors, AUC of 1 is perfect accuracy; no false positives, no false negatives.

Chest radiograph are two-dimensional images on which three dimensional structures, such as lungs, are collapsed and which, like Houdini, hide stuff in plain sight. Pathology literally hides behind normal structures. It’s nearly impossible for radiologists to have an AUC of 1. Not even God knows what’s going on in certain parts of the lung, such as the posterior segment of the left lower lobe.

Here, AI seemed better than God at interpreting chest radiographs. But Sreenivas, who leads the chest radiograph team in Qure.ai – a start-up in Mumbai which solves healthcare problems using artificial intelligence, refused to open the champagne.

“Algorithms can’t jump from an AUC of 0.84 to 1. It should be the other way round – their performance should drop when they see data (radiographs) from a new hospital,” explains Sreenivas.

Algorithms mature in three stages. First, training –  data (x-rays), labelled with ground truth, are fed to a deep neural network (the brain), Labels, such as pleural effusion, pulmonary edema, pneumonia, or no abnormality, teach AI. After seeing enough cases AI is ready for the second step, validation – in which it is tested on different cases taken from the same source as the training set – like same hospital. If AI performs respectably, it is ready for the third stage – the test.

Training radiology residents is like training AI. First, residents see cases knowing the answer. Then they see cases on call from the institution they’re training at, without knowing the answer. Finally, released into the world, they see cases from different institutions and give an answer.

The test and training cases come from different sources. The algorithm invariably performs worse on test than training set because of “overfitting” – a phenomenon where the algorithm tries hard fitting to the local culture. It thinks the rest of the world is exactly like the place it trained, and can’t adapt to subtle differences in images because of different manufacturers, different acquisition parameters, or acquisition on different patient populations. To reduce overfitting, AI is regularly fed cases from new institutions.

When AI’s performance on radiographs from a new hospital mysteriously improved, Sreenivas smelt a rat.

“AI is matrix algebra. It’s not corrupt like humans – it doesn’t cheat. The problem must be the data,” Sreenivas pondered.

Birth of a company

“I wish I could say we founded this company to fight TB,” says Pooja Rao, co-founder of Qure.ai, apologetically. “But I’d be lying. The truth is that we saw in an international public health problem a business case for AI.”

Qure.ai was founded by Prashant Warier and Pooja Rao. After graduating from the Indian Institute of Technology (IIT), Warier, a natural born mathematician, did his PhD from Georgia Tech. He had no plans of returning to India, until he faced the immigration department’s bureaucratic incompetence. Someone had tried entering the US illegally on his wife’s stolen passport. The bureaucracy, unable to distinguish the robber from the robbed, denied her a work visa. Warier reluctantly left the US.

In India, Warier founded a company which used big data to find preferences of niche customers. His company was bought by Fractal, a data analytic giant – the purchase motivated largely by the desire to recruit Warier.

Warier wanted to develop an AI-enabled solution for healthcare. In India, data-driven decisions are common in retail but sparse in healthcare. In a move unusual in industry and uncommon even in academia, Fractal granted him freedom to tinker, with no strings attached. Qure.ai was incubated by Fractal.

Warier discovered Rao, a physician-scientist and bioinformatician, on LinkedIn and invited her to lead the research and development. Rao became a doctor to become a scientist because she believed that deep knowledge of medicine helps join the dots in the biomedical sciences. After her internship, she did a PhD at the Max Planck Institute in Germany. For her thesis, she applied deep learning to predict Alzheimer’s disease from RNA. Though frustrated by Alzheimer’s, which seemed uncannily difficult to predict, she fell in love with deep learning.

Rao and Warier were initially uncertain what their start-up should focus on. There were many applications of AI in healthcare, such as genomic analysis, analysis of electronic medical records, insurance claims data, Rao recalled two lessons from her PhD.

“Diseases such as Alzheimer’s are heterogeneous, so the ground truth, the simple question – is there Alzheimer’s – is messy. The most important thing I realized is that without the ground truth AI is useless.”

Rao echoed the sentiments of Lady Lovelace, the first computer programmer, from the nineteenth century. When Lovelace saw the analytical engine, the first “algorithm”, invented by Charles Babbage, she said: “The analytical Engine has no pretensions whatever to originate anything. It can do whatever we know how to order it to perform. It can follow analysis; but it has no power of anticipating any analytical relations or truths.”

The second lesson Rao learnt was that the ground truth must be available immediately, not in the future – i.e. AI must be trained on diseases of the present, not outcomes, which are nebulous and take time to reveal. The immediacy of their answer, which must be now, right away, reduced their choices to two – radiology and pathology. Pathology had yet to be digitized en masse.

“The obvious choice for AI was radiology”, revealed Warier.

Why “Qure” with a Q, not “Cure” with a C, I asked. Was it a tribute to Arabic medicine?

“We’re not that erudite,” laughed Warier. “The internet domain for ‘cure’ had already been taken.”

Qure.ai was founded in 2016 during peak AI euphoria. In those days deep learning seemed magical to those who understood it, and to those who didn’t. Geoffrey Hinton, deep learning’s titan, famously predicted radiologists’ extinction – he advised that radiologists should stop being trained because AI would interpret the images just as well.

Bioethicist and architect of Obamacare, Ezekiel Emanuel, told radiologists that their profession faced an existential threat from AI. UK’s health secretary, Jeremy Hunt, drunk on the Silicon Valley cool aid, prophesized that algorithms will outperform general practitioners. Venture capitalist, Vinod Khosla predicted modestly that algorithms will replace 80 % of doctors.

Amidst the metastasizing hype, Warier and Rao remained circumspect. Both understood AI’s limitations. Rao was aware that radiologists hedged in their reports – which often made the ground truth a coin toss. They concluded that AI would be an incremental technology. AI would help radiologists become better radiologists.

“We were firing arrows in the dark. Radiology is vast. We didn’t know where to start,” recalls Rao.

Had Qure.ai been funded by venture capitalists, they’d have a deadline to have a product. But Fractal prescribed no fixed timeline. This gave the founders an opportunity to explore radiology. The exploration was instructive.

They spoke to several radiologists to better understand radiology, find the profession’s pain points, see what could be automated, and what might be better dealt by AI. The advice ranged from the flippant to the esoteric. One radiologist recommended using AI to quantify lung fibrosis in interstitial pulmonary fibrosis, another, knee cartilage for precision anti-rheumatoid therapy. Qure.ai has a stockpile of unused, highly niche, esoteric algorithms.

Every radiologist’s idea of augmentation was unique. Importantly, few of their ideas comprised mainstream practice. Augmentation seemed a way of expanding radiologist’s possibilities, rather than dealing with radiology’s exigencies – no radiologist, for instance, suggested that AI should look for TB on chest radiographs.

Augmentation doesn’t excite venture capitalists as much as replacement, transformation, or disruption. And augmentation didn’t excite Rao and Warier, either. When you have your skin in the commercial game, relevance is the only currency.

“Working for start-ups is different from being a scientist in an academic medical center. We do science, too. But before we take a project, we think about the return of investment. Just because an endeavor is academically challenging doesn’t mean that it’s commercially useful. If product don’t sell, start-ups have to close shop,” said Rao.

The small size of start-ups means they don’t have to run decisions through bulky corporate governance. It doesn’t take weeks convening meetings through Doodle polls. Like free climbers who aren’t encumbered by climbing equipment, they can reach their goal sooner. Because a small start-up is nimble it can fail fast, fail without faltering, fail a few time. But it can’t fail forever. Qure needed a product it could democratize. Then an epiphany.

In World War 2, after allied aircrafts sustained bullets in enemy fire, some returned to the airbase and others crashed. Engineers wanted the aircrafts reinforced at their weakest points to increase their chances of surviving enemy fire. A renowned statistician of the time, Abraham Wald, analyzed the distribution of the bullets and advised that reinforcements be placed where the plane hadn’t been shot. Wald realized that the planes which didn’t return were likely shot at the weakest points. On the planes which returned the bullets marked their strongest point.

Warier and Rao realized that they needed to think about scenarios where radiologists were absent, not where radiologists were abundant. They had asked the wrong people the wrong question. The imminent need wasn’t replacing or even augmenting radiologists, but in supplying near-radiologist expertise where not a radiologist was in sight. The epiphany changed their strategy.

“It’s funny – when I’m asked whether I see AI replacing radiologists, I point out that in most of the rest of the world there aren’t any radiologists to replace,” said Rao.

The choice of modality – chest radiographs – followed logically because chest radiographs are the most commonly ordered imaging test worldwide. They’re useful for a number of clinical problems and seem deceptively easy to interpret. Their abundance also meant that AI would have a large sample size to learn from.

“There just weren’t enough radiologists to read the daily chest radiograph volume at Christian Medical College, Vellore, where I worked. I can read chest x-rays because I’m a chest physician, but reading radiographs takes away time I could be spending with my patients, and I just couldn’t keep up with the volumes,” recalls Dr. Justy. Several radiographs remained unread for several weeks, many hid life-threatening conditions such as pneumothorax or lung cancer. The hospital was helpless – their budget was constrained and as important as radiologists were, other physicians and services were more important. Furthermore, even if they wanted they couldn’t recruit radiologists because the supply of radiologists in India is small.

Justy believes AI can offer two levels of service. For expert physicians like her, it can take away the normal radiographs, leaving her to read the abnormal ones, which reduces the workload because the majority of the radiographs are normal. For novice physicians, and non-physicians, AI could provide an interpretation – diagnosis, or differential diagnoses, or just point abnormalities on the radiograph.

The Qure.ai team imagined those scenarios, too. First they needed the ingredients, the data, i.e. the chest radiographs. But the start-up comprised only a few data scientists, none of whom had any hospital affiliations.

“I was literally on the road for two years asking hospitals for chest radiographs. I barely saw my family,” recalls Warier. “Getting the hospitals to share data was the most difficult part of building Qure.ai.”

Warier became a traveling salesman and met with leadership of over hundred healthcare facilities of varying sizes, resources, locations, and patient populations. He explained what Qure.ai wanted to achieve and why they needed radiographs. There were long waits outside the leadership office, last minute meeting cancellations, unanswered e-mails, lukewarm receptions, and enthusiasm followed by silence. But he made progress, and many places agreed to give him the chest radiographs. The data came with stipulations. Some wanted to share revenue. Some wanted research collaborations. Some had unrealistic demands such as share of the company. It was trial and error for Warier, as he had done nothing of this nature before.

Actually it was Warier’s IIT alumni network which opened doors. IITians (graduates of the Indian Institutes of Technology) practically run India’s business, commerce, and healthcare. Heads of private equity which funds corporate hospitals are often IITians, as are the CEOs of these hospitals.

“Without my IIT alumni network, I don’t think we could have pulled it off. Once an IITian introduces an IITian to an IITian, it’s an unwritten rule that they must help,” said Warier.

Warier’s efforts paid. Qure has now acquired over 2.5 million chest radiographs from over 100 sites for training, validation and testing the chest radiograph algorithm.

“As a data scientist my ethos is that there’s no such thing as ‘too much data.’ More the merrier,” smiled Warier.

“The mobile phone reached many parts of India before the landline could get there,” explains Warier. “Similarly, AI will reach parts of India before radiologists.”

Soon, a few others, including Srinivas, joined the team. Whilst the data scientists were educating AI, Rao and Warier were figuring their customer base. It was evident that radiologists would not be their customers. Radiologists didn’t need AI. Their customers were those who needed radiologists but were prepared to settle for AI.

“The secret to commercialization in healthcare is need, real need, not induced demand. But it’s tricky because the neediest are least likely to generate revenues,” said Warier in a pragmatic tone. Unless the product can be scaled at low marginal costs. An opportunity for Qure.ai arose in the public health space – the detection of tuberculosis on chest radiographs in the global fight against TB. It was an indication that radiologists in developing worlds didn’t mind conceding – they had plenty on their plates, already.

“It was serendipity,” recalls Rao. “A consultant suggested that we use our algorithm to detect TB. We then met people working in the TB space – advocates, activists, social workers, physicians, and epidemiologists. We were inspired particularly by Dr. Madhu Pai, Professor of Epidemiology at McGill University. His passion to eradicate TB made us believe that the fight against TB was personal.”

Qure.ai started with four people. Today 35 people work for it. They even have a person dedicated to regulatory affairs. Rao remembers the early days. “We were lucky to have been supported by Fractal. Had we been operating out of a garage, we might not have survived. Building algorithms isn’t easy.”

Finding Tuberculosis

Hamlet’s modified opening soliloquy, “TB or not TB, that is the question”, simplifies the dilemma facing TB detection, which is a choice between fewer false positives and fewer false negatives. Ideally, one wants neither. The treatment for tuberculosis – quadruple therapy – exacts several month commitment. It’s not a walk in the park. Patients have to be monitored to confirm they are treatment compliant, and though directly observed therapy, medicine’s big brother, has become less intrusive, it still consumes resources. Taking TB treatment when one doesn’t have TB is unfortunate. But not taking TB treatment when one has TB can be tragic, and defeats the purpose of detection, and perpetuates the reservoir of TB.

Hamlet’s soliloquy can be broken into two parts – screening and confirmation. When screening for TB, “not TB is the question”. The screening test must be sensitive –capable of finding TB in those with TB, i.e. have a high negative predictive value (NPV), so that when it says “no TB” – we’re (nearly) certain the person doesn’t have TB.

Those positive on screening tests comprise two groups – true positives (TB) and false positives (not TB). We don’t want antibiotics frivolously given, so the soliloquy reverses; it is now “TB, that is the question.” The confirmatory test must be specific, highly capable of finding “not TB” in those without TB, i.e. have a high positive predictive value (PPV), so that when it says “TB” – we’re (nearly) certain that the person has TB. Confirmatory tests should not be used to screen, and vice versa.

Tuberculosis can be inferred on chest radiographs or myocobacteria TB can be seen on microscopy. Seeing is believing and seeing the bacteria by microscopy was once the highest level of proof of infection. In one method, slide containing sputum is stained with carbol fuchsin, rendering it red. MTB retains its glow even after the slide is washed with acid alcohol, a property responsible for its other name – acid fast bacilli.

Sputum microscopy, once heavily endorsed by the WHO for the detection of TB, is cheap but complicated. The sputum specimen must contain sputum, not saliva, which is easily mistaken for sputum. Patients have to be taught how to bring up the sputum from deep inside their chest. The best time to collect sputum is early morning, so the collection needs discipline, which means that the yield of sputum depends on the motivation of the patient. Inspiring patients to provide sputum is hard because even those who regularly cough phlegm can find its sight displeasing.

Which is to say nothing about the analysis part, which requires attention to detail. It’s easier seeing mycobacteria when they’re abundant. Sputum microscopy is best at detecting the most infectious of the most active of the active TB sufferers. Its accuracy depends on the spectrum of disease. If you see MTB, the patient has TB. If you don’t see MTB, the patient could still have TB. Sputum microscopy, alone, is too insensitive and cumbersome for mass screening – yet, in many parts of the world, that’s all they have.

The gold standard test for TB – the unfailing truth that the patient has TB, independent of the spectrum of disease – is culture of mycobacteria, which was deemed impractical because on the Löwenstein–Jensen medium, the agar made specially for MTB, it took six weeks to grow MTB, which is too long for treatment decisions. Culture has made a comeback, in order to detect drug resistant mycobacteria. On newer media, such as MGIT, the mycobacteria grow much faster.

The detection of TB was revolutionized by molecular diagnostics, notably the nucleic acid amplification test, also known as GeneXpert MTB/ RIF, shortened to Xpert, which simultaneously detects mycobacterial DNA and assesses whether the mycobacteria are resistant to rifampicin – one of the mainline anti-tuberculosis drugs.

Xpert boasts a specificity of 98 %, and with a sensitivity of 90 % it is nearly gold standard material, or at least good enough for confirmation of TB. It gives an answer in 2 hours – a dramatically reduced turnaround time compared to agar. Xpert can detect 131 colony-forming units of MTB per ml of specimen – which is a marked improvement from microscopy, where there should be 10, 000 colony-forming units of MTB per ml of specimen for reliable detection. However, Xpert can’t be used on everyone, not just because its sensitivity isn’t high enough – 90 % is a B plus, and for screening we need an A plus sensitivity. But also its price, which ranges from $10 – $20 per cartridge, and is too expensive for mass screening in developing countries.

This brings us back to the veteran warrior, the chest radiograph, which has a long history. Shortly after Wilhelm Röntgen’s discovery, x-rays were used to see the lungs, the lungs were a natural choice because there was natural contrast between the air, through which the rays passed, and the bones, which stopped the rays. Pathology in the lungs stopped the rays, too – so the ‘stopping of rays’ became a marker for lung disease, chief of which was tuberculosis.

X-rays were soon conscripted to the battlefield in the Great War to locate bullets in wounded soldiers, making them war heroes. But it was the writer, Thomas Mann, who elevated the radiograph to literary fame in Magic Mountain – a story about a TB sanitarium. The chest radiograph and tuberculosis became intertwined in people’s imagination. By World War 2, chest radiographs were used for national TB screening in the US.

The findings of TB on chest radiographs include consolidation (whiteness), big lymph nodes in the mediastinum, cavitation (destruction of lung), nodules, shrunken lung, and pleural effusion. These findings, though sensitive for TB – if the chest radiograph is normal, active TB is practically excluded, aren’t terribly specific, as they’re shared by other diseases, such as sarcoid.

Chest radiographs became popular with immigration authorities in Britain and Australia to screen for TB in immigrants from high TB burden countries at the port of entry. But the WHO remained unimpressed by chest radiographs, preferring sputum analysis instead. The inter- and intra-observer variation in the interpretation of the radiograph didn’t inspire confidence. Radiologists would often disagree with each other, and sometimes disagree with themselves. WHO had other concerns.

“One reason that the WHO is weary of chest radiographs is that they fear that if radiographs alone are used for decision making, TB will be overtreated. This is common practice in the private medical sector in India,” explains Professor Madhu Pai.

Nonetheless, Pai advocates that radiographs triage for TB, to select patients for Xpert, which is cost effective because radiographs, presently, are cheaper than molecular tests.  Using Xpert only on patients with abnormal chest radiographs would increase its diagnostic yield – i.e. percentage of cases which test positive. Chest radiograph’s high sensitivity compliments Xpert’s high specificity. But this combination isn’t 100 % – nothing in diagnostic medicine is. The highly infective endobronchial TB can’t be seen on chest radiograph, because the mycobacteria never make it to the lungs, and remain stranded in the airway.

“Symptoms such as cough are even more non-specific than chest radiographs for TB. Cough means shit in New Delhi, because of the air pollution which gives everyone a cough,” explains Pai, basically emphasizing that neither the chest radiograph nor clinical acumen, can be removed from the diagnostic pathway for TB.

A test can’t be judged just by its AUC. How likely people – doctors and patients – are to adopt a test is also important and here the radiograph outshines sputum microscopy, because despite its limitations, well known to radiologists, radiographs still carry a certain aura, particularly in India. In the Bollywood movie, Anand, an oncologist played by Amitabh Bachchan diagnosed terminal cancer by glancing at the patient’s radiograph for couple of seconds. Not CT, not PET, but a humble old radiograph. Bollywood has set a very high bar for Artificial Intelligence.

Saurabh Jha (aka @RogueRad) is a contributing editor for THCB. This is part 1 of a two-part story.

The post Artificial Intelligence vs. Tuberculosis, Part 1 appeared first on The Health Care Blog.

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[saiblln]

Story of Sai: A Two-Time Cancer Survivor

By Marisse Lee

Sai Belloan, a young lady aged 21, is one of those souls I happened to meet by serendipity in the virtual world of Facebook. A twist of fate, I would like to call it that way.

If you check out her FB profile she would strike you as just another normal young woman who likes Game of Thrones and, most likely, has a crush on Kit Harington (lol, now, who wouldn’t anyway?); dogs; Justin Bieber (oh go and love yourself); Friends(again, who wouldn’t?); and must have, once recently, fall madly in love with K-Drama(Korean drama TV series) and the Ken-doll like Korean actors. Pretty much like everyone in her age in this country, I bet.

She is blessed with a lovely face and a lovely family. She is the youngest of two siblings borne from a family who earns their living from manufacturing shoes and bags. She was, therefore, living a normal and comfortable life until this huge challenge came along in her life at the age of 15.

She was afflicted with Hodgkin’s Lymphoma. The Mayo clinic described it as: “a cancer of the lymphatic system, which is part of your immune system. In Hodgkin’s lymphoma, cells in the lymphatic system grow abnormally and may spread beyond the lymphatic system. As Hodgkin’s lymphoma progresses, it compromises your body’s ability to fight infection.” Its symptoms include fever, night sweats and weight loss and oftentimes, the presence of a non-painful enlarged lymph nodes in the neck, under the arm or in the groin area. Feeling tired and itchiness may be felt by those affected with this type.

In Sai’s case, the symptoms consisted of itchy skin, persistent dry cough for 3 months (the phlegm was laced with blood in the latter stage), fatigue and a lump in her neck that was biopsied (via sample taken thru needle-aspiration) but with negative result. However, after surgery and another biopsy, the lump turned out as positive. She went through a treatment consisting of 4 cycles of chemotheraphy. Note that HL type of cancer has a high survival rate especially in the case of young patients. She recovered and was cancer-free for the next 4 years. She graduated valedictorian from high school and went to University of Sto. Tomas to study BS Finance. She was enjoying a carefree life like any teenager…but, BOOM! Just like that, cancer re-appeared.

Everyone had, one time or another, a brush with pain and sorrow. We all learn to deal with it, let go and then move on. However, nothing will ever prepare for anyone to have another tryst with the same demon. That would be devastating to say the least. You already looked this devil in its eyes. You weathered the storm…and yet, it is back. Staring you in the face.

Initially, Sai worried that she might undergo stem-cell-transplant, a treatment that is being touted as highly effective in treating cancer cases (I have different un-expert opinion on this matter but it is irrelevant to discuss it here so let us save that for another day) but it is quite expensive in the Philippines (approximately $50,000 or more). Fortunately (financially speaking), her doctors put her under the first-line-of-defense treatment which means she had to undergo 6 cycles of chemotheraphy to get rid of the cancer cells.

A trip to the hospital for each cycle which is equivalent to 2 sessions is a “trip to hell”according to Sai. She was in constant pain. What with being poked by needles so many times to insert the IV-line…when a battered vein refused to take in the meds, they will simply poke another one to go on with the treatment. I will never understand how a 21-year old was able to handle all that. But she did. After each session, she would hurt from the side effects of chemotherapy: bone/muscle/body pains, shortness of breath and soreness of veins. Alongside with that, she had suffered “moon face” (steroids side effect), uncontrolled eating and insomnia. But, thanks to God, she is, again, in remission – free from cancer once more.

Now, why the heck am I writing this story? Well, people, cancer is not just like having a flu, recovering from it, then going back to your routine. NOT AT ALL. Sai was in college when her HL cancer recurred. She was building her dreams…looking forward to finishing school because she remembered how happy and proud her parents were when her older sister graduated from the university. She wanted to make them proud of her also. A typical dream of a child who dreamed of somehow paying back their folks’ sacrifices. She hoped to get ahead in life as that is what we were raised to do. One has to make a place under the sun. Cancer provided her a choice-less choice but to quit school.

She is cured, yes…still, she lives life with Damocles sword over her head afraid that the cancer may recur a third time. She is scared of having dreams for herself again because one day she might wake up losing them once more. She worried about her parents because they are getting old and she would not like to see them earning and putting up money for her treatment. She posted a long recount of her cancer tale on 22 July 2017 putting up a brave face against this odd…what she did not tell you much about is that she lives everyday like someone near a cliff…anxious, frightened to fall in that abyss.

Cancer changes a person. It makes you brave because you have no other recourse but to embrace courage. It makes you treasure life more because you have tasted what it is to almost lose it. It makes you cherish the people in your life because you are not sure how long is your time to share and spend with them. Nonetheless, at the same time, you always live with fear…less for yourself but more for the people you love and might leave behind. It is a harrowing tale that will continue to unfold every day of her life. It will take a very long while for her body to completely recover and regain back its maximum health…it will probably take double that time for Sai to be completely confident that things will be really okay.

She is thankful for the friendships she gained (strangers and otherwise) while she has been going through this challenge. Misery loves company, true. It may be “misery” but, from there, compassion and love bloom that only show our humanity in the face of adversity.

Right now, she is taking her time to recover. She would have wanted to go back to school right away to avoid the additional two years (thus, additional expenses) she may incur as a result of the implementation of K-12 Program in the Philippines. However, I tried to reason out with her that there are more important things other than college education…and that, at this time, priority should be given to her health; it, being given back to her for yet another chance. I love to mention here that Sai learned watercolor drawing by herself from the YouTube University (pun intended) while she was sick. When I asked her the other day what is she keeping herself busy with, she said: “Painting my bedroom.” Oh, the kid must be doing a Michelangelo on her ceiling, who knows?

She also continue to share stories of her friends that are still battling with cancer and seeking financial assistance in the hope that by sharing their posts she might be able to help find a charitable soul who may be willing to extend help. She established a Facebook group for HL and non-HL cancer patients which you can find through this link https://m.facebook.com/groups/1465490123521821.

Lastly, Sai never lost her faith that God is there for her and her family.

My goal in writing her story is not to educate you about cancer. Google can provide you with tons of information if you would like to read about it…neither am I seeking pity and consolation from you although understanding and compassion is very much welcome. If you are reading this, I am knocking at the door of love and kindness that reside in your heart, please hear my prayers:

1) I am begging you to show support to people who are suffering from cancer by sharing their stories especially those who are in need of financial assistance…that is the least we can do. By doing such, perhaps our efforts might lead to someone who has the means to help. It is shooting in the dark, yes, but who knows an arrow might find its way to the right heart.

2) If the cancer-patient is selling items to raise the money required for their treatment, we can either patronize his/her product or, again, help in the selling campaign (I do not have to remind you, though, to check authenticity of any such campaign before diving into it…Heaven knows how the Internet works these days).

3) If you have the financial means, kindly donate to their Go-Fund-Me

4) If none at all, sincere prayers will do. Humans are beings made of energy. Prayers are energy. You get the picture.

Having said that, please start with Ramon Christopher “Casi” Ramos Burgos. He is Sai’s friend…another soul suffering from non-HL cancer that she happened to befriend in the cancer community. Originally, we intended to write a story for Casi but he has been confined in the hospital and not available to provide details that we need. By sharing Sai’s story, you will be sharing Casi’s battle with cancer as well. If you are able, please check his Go-Fund-Me at https://www.gofundme.com/2ce3sqdw. Your financial help, whatever the amount, will be most appreciated.

Or, if you are interested in ordering cancer-awareness t-shirts, you can check this link to place your order https://www.facebook.com/iamcasimon/posts/1592362204139378.

PLEASE, I BEG YOU…share Sai’s story (and by that, sharing Casi’s plea) or kindly re-post Casi’s Go-Fund-Me link or help him raise the US$50,000 (it only has $500 so far, a loooooong way to go) by promoting the sale of his t-shirts. A simple click, a simple share is all we are asking from you. Maybe somehow, somewhere it would get result.