Week 8: The Surgery

Hello,

On Wednesday of this past week, I got to observe my first surgery! It was a laparoscopic nephrectomy. A woman was donating one of her kidneys to her brother. Unfortunately, one of my mentors who was taking me only had time for the surgery where the kidney was being taken out. So, I couldn't see the transplant.

Obviously, one of the first things you'll notice in an operation room are the surgeons, the anesthesiologists, and the various doctors with their scrubs. It was very interesting to see how they get prepped for surgery, and how there is one person sanitizing all tools and handing it to the surgeon.

A laparoscopic surgery is very intriguing since the whole thing is done with only 3 small incisions (about 1 cm each) in the abdomen. A telescope and small instruments are inserted into the abdomen through these incisions, which allow the surgeon to slowly cut away the surrounding tissue and dissect the kidney without having to place his hands into the abdomen. One of the tubes put into the abdomen has a camera; this is how the surgeon sees and controls the instruments. Additionally, monitors are everywhere throughout the surgery room, so everyone can see what is going on. 

One neat thing I noticed when the surgeon was cutting through the tissue, was that the places being cut were also cauterized immediately with the same tool. This would stop the bleeding and help heal the tissue faster. While this was happening, you could actually see some smoke forming inside the body (through the monitors).

After the kidney is cut out, it is placed inside a plastic sack and removed intact through an extension of one of the existing incisions. I was really surprised when I saw the size of the kidney. It's only about the size of your fist!

Once the kidney is out of the donor's body, another surgeon (the transplant surgeon) carefully placed it in a plastic box and cleaned it with saline, so it could be put into another body. This was amazing because the surgeon even allowed me to take a closer look, showing me parts such as the ureter, and the renal artery and the vein.

One question I had was how the surgeons decide which kidney to remove. Anatomically, it is easier to remove the left kidney rather than the right kidney. The large artery in the body (the aorta) lies on the left side of the abdomen. The large vein (the vena cava) lies on the right side of the abdomen. This arrangement of blood vessels makes the vein to the left kidney longer than the vein to the right kidney. A longer vein is usually easier to sew into a kidney transplant recipient than a short vein (Loyola University Chicago). However, it was different for this patient. To determine which kidney to take out, they had a kidney test done. The results showed that the left kidney had 60% function rate while the right only had 40%. So, they decided to keep the kidney which is the better functioning and remove the one which has lesser performance.

Although looking at human flesh and blood was quite unsettling at first, I was a little used to it over the two hours I spent watching the surgery. I hope to see more fascinating surgeries in the future!

Week 7: Spring Break

Week 6: Spreading Knowledge

Hello,

Now that the research part of my project is finished, I am now focusing on patient education. In order to do this, I have started making a small, postcard size, handout (using Microsoft Publisher) which has information for patients in risk of getting diabetic neuropathy.

In the past, a lack of awareness and inappropriate management of diabetic peripheral neuropathy has led to unnecessary morbidity and substantial healthcare costs. At least half of all foot ulcers, the end stage of such neuropathy, can be preventable by appropriate management and patient education. However, lack of time and inappropriate or inadequate information may lead to insufficient care. By creating a simple, easy-to-understand handout for patients, I hope to bring awareness to those in risk.

Furthermore, being able to detect and treat neuropathy early will save money for both the patients and the hospital. If the diagnosis is done too late, the disease may have gotten to a point where amputation is necessary. Such invasive surgical tasks will cost more expenditure which could have been prevented. According to Healthcare Bluebook, the total fair price of a leg amputation is $14,245. All that money can be better used for hospital improvements or other research.

In my research, I found many comorbids for diabetic neuropathy. A lot of the patients had similar other diseases. With this information, I compiled a list of the most common illnesses which may be correlated with diabetic neuropathy. In addition to this, high HbA1c levels and smoking or drinking habits can lead to a significantly higher risk. All of these factors will be mentioned in the handout.

After making the handout, I will also refer to Dr. Jyothinagaram (the endocrinologist I shadow) to get his opinion on what I can change or add. This way, I'll have the input of a doctor who deals with diabetic patients every day.

I look forward to finishing this within the coming weeks.

Happy Easter!

Week 5: Data Analysis

Hi all,

After we finished cleaning up the data, we made a lot of graphs, so they can be interpreted easier. Here are a few examples.

In this one, you can see the number of patients spread across each age group.

Here you can see what percentage of the patients belonged in each race.

There are of course many more graphs with more detailed information about the actual usage of alcohol, tobacco, and drugs, but you'll have to read my paper for those.

With the data, we used excel to find the regression statistics. In order to do this, we had to make a lot of adjustments to the data. For example, every time the data said "Yes" or "No" for alcohol or drugs, we had to change it to a numerical number. We used 1 for yes, and 0 for no. Here is a small portion of the data, to give you an idea of what it looks like.

Through this, we obtained an equation which tells us a prediction of what age a person might expect a below-knee amputation. The equation involves two variables: the HbA1c level of the person, and whether or not the person had a long-term use of aspirin. These variables were the most common among the patients in our data set who did get a below-knee amputation, which is why they can be used for predictions. Additionally, their P-values were below 5%, meaning they have statistical significance. I can't tell you what the equation is yet; you'll have to find out in my paper.

Since this week was purely for analyzing data, there isn't much else to say. Check back next week for updates!

Week 4: Shadowing

Hello all,

This week I finally finished collecting data! In total, there were 185 patient records. Next week, I'll be analyzing this information after we clean it up (making sure there are no errors).

On Monday, I was able to go on hospital rounds with Dr. Jyothinagaram and his resident Dr. Crawford.  We saw about five patients, but I'll talk about the ones I thought were most interesting.

One patient was an old woman who had her thyroid and parathyroid glands removed, along with her larynx because she had invasive thyroid cancer. Because her larynx was taken out, she could not talk. She could only mouth some words and had a whiteboard to communicate with the nurses and doctors. Because she had her thyroid gland removed, she was given a thyroid hormone injection which acts to provide the functions of the thyroid gland (controlling body functions). However, there was no injection for the parathyroid hormone, which controls calcium levels. As a result, they were giving her calcium through her IV, and trying to discharge her soon by putting her on calcium pills.

Another patient had pancreatic cancer, so he had to have his pancreas removed. Like I talked about in my introductory post, the pancreas controls how much insulin is released. Without the pancreas, the patient needed to have an insulin pump. This pump could be controlled by the patient; he can tell it how many units of insulin to pump into his blood. A number of units he pumps is calculated by how much he eats. However, he was told to be careful. For example, if he pumps a certain number of units, he must wait around 3 hours for the insulin to kick in and reduce his blood sugar. If he doesn't wait and anxiously pumps more, his blood sugar will be dangerously low once both doses kick in.

The next morning, I went to Dr. Jyothinagaram's clinic and shadowed him there. In my opinion, this was a better experience since the patients who come to clinics have a specific problem, and so easier to understand for students like me. Again, I stayed for around six patients, but I'll talk about the most interesting one.

One patient who had uncontrolled diabetes also had neuropathy. So I was really excited for this one. The patient had lost sensation from his elbows to his hands, and from his knees to his feet. This is called a glove and stocking distribution of neuropathy. The doctor told the patient to hold out his hands, and he too held out his hands. He told me to look at both the hands and find any differences. He then explained that in the patient's hands, the muscles between the thumb and index finger were completely gone, because of the neuropathy. He told me to feel the area too; it was completely hollow. Then, the doctor told the patient to lie down so we could examine the feet. We looked for pulses and found a few faint ones. He explained to me that since there was still blood flow to the feet, they were in an okay condition; however, if the blood flow stopped, an amputation would be likely. Then we looked at the patient's diet -- it was mostly junk food. Since the patient also gained weight from his last visit and had high blood sugar levels, the doctor told him to control his diet.

Next week, I'll continue shadowing Dr. Jyothinagaram; I'm excited to see more patients!

Week 3: Advancing with Data

Hi everyone,

My data collection is progressing much faster! I learned a few tricks which save me some time. So there are a few different formats the histories are stored in: ones which are photo scanned versions of handwritten documents, and ones which are typed right into the computer. Although there are also various versions of these, the ones which are photo scanned usually have little to no detail about alcohol and tobacco usage. They just have boxes which the physician just checks; however, it doesn't provide information such as how long the patient has been using, and whether or not the patient quit. Sometimes, these boxes are even left blank. And when they are filled out, they sometimes vary from the other histories. On the other hand, the histories which are typed have more information. For example, it would say if the patient quit smoking 20 years ago, instead of just writing "yes." Additionally, it also says if the patient has been using any other street drugs, such as marijuana, cocaine, heroine, etc. I actually created a separate column in my data chart to record if the patient has used any of these other drugs. So, I decided to avoid scrolling through the photo scanned copies unless there is no other option.

While I looked through these histories I noticed things that a lot of the patients had in common. Here is a list of those common illnesses:

Sleeping problems, such as sleep apnea

Breathing problems, such as asthma and dyspnea

Acid reflux/ Gerd

Decreased sensation (Makes sense since neuropathy affects nerve endings.)

Difficulty with concentration

Kidney disease/failure (I guess this is even more evidence that kidney stones and diabetes are linked.)

Congestive heart failure/ cardiovascular disease

Cerebrovascular disease/stroke

Peripheral vascular disease

Hypertension

Blindness/ Vision problems

Skin infections/ Skin breakdown

Dental disease (gingivitis, periodontitis)

Gangrene

Osteomyelitis/ Osteoarthritis

Depressive symptoms

I just thought it might be interesting to connect diabetes to other illnesses!

So the ‘surprising news’ is that I will be shadowing an endocrinologist, Dr. Jyothinagaram, who specializes in diabetes and commonly treats patients with diabetic neuropathy. Starting Monday, I'll be able to see patients with him and see first hand the consequences of diabetic neuropathy. It will also be really interesting to see how the history/physical, the main source of my data, is done.

Furthermore, I will be able to observe a surgery! Although it probably won't be as big as an open-heart surgery, it will still be a significant one so I can actually see inside the human body. There's a good chance it will be an open-abdominal surgery, where I can witness many organs. I don't know when this will be, but I'm very excited!

Week 2: Captivating Events

Hello all,

So the 'Master Spreadsheet' with all the data is on its way to completion. I just have to go through about 200 individual patient records (population size has to be large), scroll through the "history/physical" section for each one, check the lab results for each one, and input the necessary parts for each one into the chart. Not time consuming at all.

In the meantime, there were some interesting things which happened this week. On Wednesday, a couple of urologists gave a presentation on kidney stones: what they are, how they happen, how they are treated, and how to prevent them. They are pretty much stones made up of chemical crystals that separate out from urine. These stones begin to form in the calyx (a cup-shaped part of the kidney). They either stay in the kidney, or move into the urinary tract, where they can block the flow of urine and cause pain.

One of the main reasons kidney stones form is dehydration: if you don't drink enough water, you won't have enough urine to dilute chemicals, forming crystals which develop into stones. In addition, eating foods which contain a lot of protein or salt can lead to kidney stones. There are also kidney infections which can slow down urine flow, or change the acidity in the urine, thereby causing stones. Although the symptoms of kidney stones depend on the stone's size and location, many stones cause sudden/severe pain and bloody urine. Others cause nausea or burning urination. Some say that kidney stones hurt more than gettting shot. There are a few ways to remove the stones, such as using sound waves to break up the stone into smaller pieces so they can be passed through the urinary tract (Shock Wave Lithotripsy), and making an incision on the back so smaller stones can be surgically removed (Percutaneous Nephrolithotomy).

Here's a diagram of where the stones may be.



This talk, although unrelated to my main project, was interesting because the urologists pointed out that obesity was a big factor in many patients who had kidney stones. So I did a little research and found that diabetes and kidney stones are linked. Type 2 diabetes may likely cause urine to be very acidic, which in turn can lead to the development of stones.

On Thursday, my mentor, Sumit, and I attended a meeting about the ongoing diversion in Banner locations across the valley. A diversion happens when all the beds in a hospital are occupied, and incoming ER patients are redirected to a different hospital. This raises the concern that critically ill patients may not be able to get the timely medical care they need. To minimize such occurences, nurses from various departments came together to see which patients can be discharged in order to make more room for new patients. We had to leave the meeting early, before any conclusions, but I'm sure they made some space to fit in more patients.

Oh, and I also had lunch with a bunch of doctors in the Physician's Lounge (Sumit let me in), which was pretty cool.

I think I'll have a few surprises for you next week. Be sure to check in!

Week 1: The Beginning

Hi everyone! Today concluded my first week of my internship at Banner.

The first thing I learned from my mentor, Sumit, was how the entire healthcare system is structured. Because the main theme of my project is healthcare delivery, this helped me understand the process better. There are two main categories: the providers (hospitals, clinics, etc.) and the payers (insurance companies). Patients are seen by providers such as physicians and nurses as either an inpatient or outpatient. For my research, I will be looking into the records of these patients who came to Banner.

Before I get into details of the project, let me summarize how diabetes works. After you eat, the pancreas secretes the hormone called insulin which regulates the blood sugar level; it signals other cells to absorb the sugar, which can then be used for energy for your body. Insulin can also help store this sugar in the liver, and release it when your blood sugar level is too low. Now, when you eat constantly, and your blood sugar level is always high, the receptors on the pancreas start to get desensitized, and fail to properly detect sugar levels. When that happens, insulin isn't used adequately and the sugar in the blood does not get absorbed anymore, leading to high blood sugar levels, and eventually, diabetes. When this happens, it's known as diabetes type 2, which occurs mostly in adults.

There is also something called type 1 diabetes which results because of a congenital disease where the pancreas produces little or no insulin. In my research, I will be focusing on type 2 diabetes.

When doing prior research, I found that there were a few studies done on diabetic neuropathy; however, they were longitudinal studies done for only a couple of years. It's important to note that diabetic neuropathy progresses over many years, so the patients' health could have very well changed after the studies were finished. So, we decided it would be more insightful to do a retrospective study, analyzing patient records beginning from at least 5 years ago. In order to find a list of worthy patient records, we needed an end-point: a below-knee amputation. Patients who had an amputation show that their condition worsened to a point where they had to lose the area which was most affected by diabetic neuropathy. By selecting these patients, we can analyze all the variables which may have led to their amputation.

From the list of patients who received an amputation, we will separate them into two categories: those who were regular smokers or alcoholics, and those who were not. We predict that the average age of those who did not smoke or drink will be much higher than the average age of those who did. We also hypothesize that the HbA1c levels (which tell us the average blood sugar levels of a patient over a period of 3 months) will be higher in patients who were smokers or alcoholics.

The main program I will be using to analyze patient data is called Cerner, where all the records are stored. Firstly, we will get a list of all patients with diabetic neuropathy. Then, we will filter that to get a list of those who received a below-knee amputation. From there, we will separate the patients into smokers/alcoholics and those who were clean, and analyze the variables.

That was the overview of this week. Come back next week to stay updated!

Introduction

Hello,

My name is Bhanu Bucchireddigari and I'm a senior at BASIS Scottsdale. During my last trimester of high school, I will be conducting a Senior Research Project. By completing this project, I will graduate with high honors after presenting my research findings to the greater community on May 7th. I will spend 10 weeks interning at the Banner University Medical Center in Phoenix starting early February, with my mentor Sumit Agarwal. At the facility, I have selected to research a topic which combines my two main interests in medicine: neurology and endocrinology.

Diabetic peripheral neuropathy is a form of nerve damage which can occur because of prolonged diabetes. This disease affects up to 50% of older type 2 diabetic patients; it is the most common of the long-term complications of diabetes. Although there different types of neuropathies, the most prevalent, and the one I will be researching, is somatic neuropathy which affects the lower extremities of the body. If left untreated, this can cause diabetic foot ulcers, which can lead to the loss of a foot, a leg, or even a life.

My research at Banner will help patients with diabetic neuropathy handle the pain in better ways by using conventional as well as alternative treatment modalities.  At the end of the research project, I will create a patient education module, which is the primary goal. This way, patients who are diagnosed with diabetic neuropathy can try to control their pain levels, and those in danger of it can take precautions to avoid the illness. There are also a few secondary goals. I will observe the relationships between demographic variables and diabetic neuropathy in order to identify key factors responsible for diabetic neuropathy.

My main method of gathering data will involve analyzing patient records. This will be especially useful when collecting information about the demographics of patients with diabetic neuropathy. Furthermore, I will use the records to see what predisposing factors may have caused their illnesses and what they may have done to help cope with the pain.

Considering my project begins in only a few weeks, I’m very excited to start my internship at Banner. This will be one of my first experiences with research in a professional setting, and I am hopeful it will give me great insight into the medical field. I can’t wait to share my experiences with you!