Summer Update

So without even realizing it I neglected to post for almost an entire month!

The third round of consolidation went well, much like the second round — I walked a lot, I felt okay.

But a few weeks afterwards, around my immune system's nadir, I woke up with a fever, which put me back in the hospital for eight days or so. I also passed out twice, once the morning I had the fever and once the morning before that. I knew my hemoglobin was really low and I should have gone to get a transfusion, but it didn't seem like that big a deal at the time. Luckily all that worked out fine, but it was a miserable time in the hospital, I had fevers most of the time I was there, which made them reluctant to give me a blood transfusion, since if my temperature went up a degree during a blood transfusion they'd have to stop and write it up as a potential reaction, even though it would probably just be due to the fevers I was already having. So that first night they would pack ice under my armpits and behind my head to keep my temperature down. My hemoglobin was really low for a while, as low as 5.6, which I think is far lower than it has ever been before. (Normally in the hospital they would give me a transfusion when it was below 7.)

All ended more than a week ago. Then I got to spend a day with Allison & her family that Friday, which was really nice. 

Sometime in the last month I had another appointment in Boston with the doctor and team of people who are going to do the transplant. The plan right now is to have one more appointment to go over everything in late August, and aim for the transplant process to start early in September. It'll probably be about a month in the hospital, I'll get another dose of chemotherapy drugs that is more intense, like the first two treatements, with the intention of destroying my immune system completely. Then they'll take bone marrow or possibly just stem cells from the bone marrow of a donor, and give them to me much like a blood transfusion, through a vein. Then ideally the donated cells will embed themselves in my bone marrow and begin to grow as my own immune system. 

One of the bigger concerns is that the donated immune system might see me as a foreign invader, and attack me, which is called graft-vs-host-disease (GvHD). So they'll be watching my skin, lungs, and liver, for signs that the new immune system is attacking those organs. This will be a risk for the rest of my life, but I think it is immediately afterward that will most likely be the biggest risk. From what I've read and watched videos of people who've gone through this, a little bit of GvHD is actually a good thing, as it indicates the new immune system is growing and functioning, and there is even a graft-vs-tumor-effect, where the new immune system actually sees my old immune system, in particular the cancerous immature blast cells, as invaders, and actively seeks them out and kills them. If I do have problems with it, they may treat me with steroids, though I don't actually understand the mechanism there. The doctor also mentioned that there has been some recent success with partial match donations being treated with some chemotherapy after receiving the donation, which is counterintuitive, as that is when you would expect the donated immune system to be most vulnerable, but apparently it can help with the process. (Whenever I hear “graft-vs-host-disease” I think of David Cross's character Tobias in the show Arrest Development, and how he developed GvHD because of his hair plugs, so they threw a fundraiser for him and then everyone revolted when they found out it was just his hair plugs causing the problem.)

Beyond that the other major concern is probably infection, so they want me to brush my teeth four times a day, which I'm not used to but am sort of looking forward to I think. I've always had a poor opinion of my teeth — it seems like I've had cavities virtually every dentist visit of my life, and I've gone pretty regularly every six months for years. But one thing I've had a problem with for years is my habit of brushing in the morning, which for me didn't develop as something I do in the morning, but as something I do before I leave the house. So on the many days where I don't leave the house (especially as someone who worked from home before quitting and working for myself, (or trying to at least)), there are a lot of times where I brush either very late in the day, or just once before bed. But I have flossed regularly for most of my life, and used a rinse for most of my adult life. A lot of that has fallen apart during these long hospital stays. I wasn't allowed a tooth brush for much of my stays (they worry about bleeding with low platelets). So I think that's why I'm kind of looking forward to scheduled brushing four times a day.

After that first month they'll still keep a close eye on me, I think for at least the first 100 days. After that it'll sort of be the next five years of checking to see if anything grows back, if nothing shows up that would imply I've been cured, I think, is the idea. I know with some cancers it's never really clear whether you've been cured, there's always a risk of even a lone cancerous cell you missed growing back to overwhelm things again given enough time. 

I read an article a while back about research into giraffe evolution, which involved some gene sequencing to match it's closest living relatives, and then comparing the two genomes to find out what evolutionary changes occurred to make giraffes unique, and one of the interesting discoveries were genes that helped the heart be able to pump blood all the way up the neck, I think. And then the article ended by mentioning how because elephants are bigger than most animals, it was thought their rates of cancer would be higher because they have more cells in their body each with the same potential to go haywire. But they don't, and now it's thought they have some genetic mechanisms to help avoid cancer, and since giraffes are also very large, they expect giraffes to have similar adaptations. I found all that interesting, I had never considered it before. It made me wonder about whales too. And recently I saw a lot of headlines about research that shows a kind of shark that lives for several centuries, one headline said it doesn't reach sexual maturity until it is 150? But I didn't read any of the articles about it.

I think there are muscles or clams or something that live several (~4?) centuries, and are able to reproduce well into their second or third century. I think the next few centuries of human technological advancement will see us figure out how to incorporate many of those benefits into our medicine, and likely take complete control over our health, to a degree we can't really imagine yet, in much the same way people from a few centuries ago could hardly imagine the things we're able to do right now. Only the changs ahead are probably much bigger, because we're beginning to understand how we work on a fundamental level now. Though I'm skeptical of claims that we'll improve our lifespans dramatically. I'm sure we'll do that eventually, but in the foreseeable future it seems like the problems caused by aging will remain.

But I digress.

For now I'm just enjoying the summer weather and trying to advance the projects I find interesting. Also I need to hurry up and sell my car! And renew my drivers license! I bought a shiny copper plated colander to wear while getting my photo retaken, but I'm nervous about wearing it, I'm not really one to cause a scene typically.

Anyway, my cousins have mentioned a few times now that my comments seem to be broken, so they can't leave messages. I need to figure that out too!

Third Consolidation

So I'm back up at Dartmouth Hitchcock for a third round of consolidation chemotherapy. It started yesterday afternoon and if all goes to plan I should be heading home Monday evening after the last dose. The last two went well so I don't expect this to be too different, they let me walk a lot and that allows me avoid these painful shots in my stomach that they usually give daily to most patients to help prevent blood from pooling or clotting in the legs. The shot is usually painful, first with the pinch of the needle, and then with the stuff they inject, so the nurses don't like giving them either, so it's a win-win. Plus, walking is probably my best bet at keeping my health up for the next step, the bone marrow transplant, which is apparently going to be a much harsher and longer process than these consolidation chemotherapies (which really havent't been too bad, the complications in the weeks following have actually been worse, the nosebleed and the fever, but even they were relatively tolerable).

I got to see Allison a few times before coming back in, which was just great, hanging out with her really helped take my mind off things some. Not that I completely forgot whats going on and what lies ahead, but it stopped occupying my attention so much, which had started to happen for a while I think.

I forgot my phone cord so my phone is about to die, but I have my laptop and cord, so email or facebook are reasonable ways to contact me, or leaving a comment here (though my cousin said she couldn't? I haven't been able to figure out any problem with the commenting yet).

My plan was to go back to programming some, but without being able to test it on the phone it'll be hard to go to far. Stefan also left me with plenty of reading material, and I still have a book Jared lent me that I haven't finished, so I guess I should spend more time with paper and less time with liquid crystal displays.

Guess that about sums it up for now!

An Upcoming Third Round

My updates have been infrequent lately, I suppose because I don't think there has been much to report. 

I had a folllowup appointment yesterday, my platelets and ANC have recovered well, which is nice, but my hemoglobin remains low, which just means I tire easy, and get a little dizzy when I first stand up, or take too many deep breaths in a row.

On Friday, July 1st, I met with the transplant doctor and her team, in Boston, to begin learning about the entire transplant process. She figured it'd begin in about six weeks, after they've checked me out thoroughly and decided I'm ready. I need to get a dentist appointment to make sure my mouth is in good shape before we begin. And they don't really like going more than I think she said 8 weeks between consolidation chemotherapies and the transplant process, so I'll be back at Dartmouth Hitchcock next week, probably Thursday, maybe Wednesday, for another round of consolidation. Mostly the consolidation chemotherapies have been pretty tolerable, though the complications afterwards — the nosebleed the first time and the fever the second time — resulted in a lot of unpleasant experiences. It feels like each one is teaching me to be more cautious about some aspect following the chemotherapy. After the nosebleed we took some extra precautions to keep my nose clean and less likely to bleed, now I'm going to take further precautions in the weeks my ANC bottoms out, make sure to wear a mask anytime I'm in public and so on.

The transplant process is going to be much longer, and tougher, than what I've been doing for consolidation. The chemotherapy will be much more potent, as it's intention won't just be to keep my immune cells somewhat suppressed, but to actual wipe the immune cells out more completely, in preparation for a donor immune system to take hold. Typically this process requires three or four weeks of hospitalization, after they wipe out the immune system, receiving the donor immune system is basically like a blood transfusion. Then hopefully it grows into my bone marrow, and begins to provide me with a new immune system. There is some concern about the new donated immune system attacking me as if I were a foreign invader, that's called graft-vs-host-disease, or GvHD, it's similar to the kinds of rejection they worry about with organ transplants, only in that case it is the recipient's immune system attacking the donated organ, in my case it'd be the donated organ attacking other stuff. The main targets tend to be the skin, the lungs, and the liver, and the doctors will provide some treatments if I show signs of those problems. I saw a video a while back on bethematch.org where people who've gone through this said it's actually good to have some minor symptoms of GvHD, because it means the donated immune system is working and taking hold, and there is even an effect called graft-versus-tumor, where the new immune system attacks the old one and helps kill off any remaining cancerous blast cells. There is about a 10-15% chance that the process kills me, and about a 50-60% chance that it cures me. I didn't ask, but I think that remaining 25-40% chance that I survive the donation process but the leukemia returns, at that point we start discussing other treatment options, I suspect probably clinical trials because I think this is the only real standard way to treat aggressive leukemias at the moment. 

So that's where my adventures in health are at the moment. Mostly a high degree of uncertainty, some unpleasant future stuff, but I'm glad to be born at a time when we know at least somewhat how to deal with this problem, and not decades or centuries ago when it would have just killled me right away.

Other than that I've been skipping around between projects, trying to focus on some experimental camera app idea. I got a lot of photos of the Fourth of July fireworks with my app trippygram, which I've been sharing on Instagram. I also made a snowflake gallery, though it's terribly mismanaged, I need to delete about a hundred photos probably. At least the ones that are very similar to one another. I got tired of sorting through them trying to decide which was better. 

The Last Few Weeks

So I haven't updated in a while, sorry about that.

Two weeks ago, on Friday the 17th, I measured a fever taking my temperature before bed — I wanted to go to bed so bad, it was 1 in the morning and I had been up at 730 for doctors appointments, things were mostly okay but I kept needing blood transfusions, I had had one that Friday, along with both blood and plasma transfusions both previous Thursdays and that previous Monday. So I had been up pretty early (for me) for a few days, and really wanted to go to bed, but I measured my temperature multiple times and mostly got above 100.4 F, which is where they want me to call and go to the emergency room, in case I have an infection. (Because without an immune system an infection could grow out of control quickly, and without many white blood cells I probably won't even show many signs of infection, no inflammation really.)

So they put me on really strong antibiotics for a while, my fever went away after a few days, but they wanted to keep me until my ANC had returned to at least 400. On Sunday I calculated it to be 504, so they sent me home. I tried plotting all the measurements I could find for how my ANC had changed over previous weeks and treatments, and this one fit pretty well in those ones. Though some of the antibiotics I was on most of the week, I think they said they can actually have a supressive effect on my immune system, so we were kinda tugging in both directions. 

Anyway, I'm all better now. Out of the hospital. Platelets went from like 27 to 50 in the last couple days at the hospital, so I'm not worried about bleeding, but my hemoglobin was still pretty low and I can definitely feel myself getting easily winded by just a little moderate exercise. Because I was in the hospital all week I had to move my appointment in Boston, where I'll start to get to know the doctor doing the transplant. So I'll meet her this Friday instead. Which meant I also pushed back a bunch of appointments for this Friday in Lebanon to next Friday. Last time (two Fridays ago) I met with a doctor I didn't know well, who thought we might do a third round of consolidation chemotherapy in a few weeks. I wasn't expecting that but the previous two rounds have been fairly easy, to I'm not too concerned about it. Apparently the chemotherapy for the bone marrow transplant is more severe, and is more likely to be another month in the hospital, so I'm trying to mentally prepare for that I think.

Now I'm working on another toy I started designing a few years ago, one that will need a few test prints I think, which is what held me up before.

More Transfusions

Another transfusion appointment went well today in Manchester — my hemoglobin was 7.6, platelets were 6, and my ANC was 20, so I had transfusions of the first two, and won't be going out in public much this week, if it can be avoided. I'll find out again, either Wednesday, Thursday, or Friday. 

It has me wondering how much a platelet (or blood for that matter) boosts those measurements, since I think I was 16 for the platelets on last Thursday, when I had a transfusion last, but it still dropped to 6, just 4 days later. But we can only sample it so often — sampling before and after a transfusion seems wasteful and impractical. If I can remember I'll ask if the doctors know on Friday.

As far as work goes, I'm back to working on another old toy/jewelry design in Blender, this one based on hypocycloids. I got pretty far on it originally but it was never clear I could get it to stay aligned, and I wasn't looking forward to iteratively determining what was feasible, but since Collin has a 3D printer handy it seems more feasible to give it another try.

Another Nadir

So I had a checkup today, platelets and hemoglobin were pretty low (14 and 8.3 respectively) so they gave me transfusions for each of them. My ANC was low, 740, but not neutropenic, so probably I'm still on the way down, and gonna bottom out some time in the next several days. I'll be avoiding public for a while, again, which is all expected.

Programming-wise I've been learning how to incorporate Objective C code in with the Swift code I work in by using a bridging header. Expanding my understanding of how to program feels really good, and should pay off as better software in the end. This should make it easier for me to get permission from the user to use the camera, and store photos, and maybe resolve some of the issues I had originally with it not granting permission the first time — which I think I solved, but was told there were better solutions still. Also it should let me handle metadata finally, which I've been struggling with. I can get the original metadata when the photo is taken, but never figured out how to save it with the resulting photo. I'd also like to add a “made with” tag in the metadata, so maybe I can do that soon too. Then I may need to have an actual privacy policy...

I made a tips & tricks page a while back, because I know I've learned a lot over the years about what works best in certain situations, and it would help if I could share that with other people. I should probably try to streamline that page as much as possible, and then incorporate it into some kind of help/tutorial/introduction to the app. So any feedback on that page would be greatly appreciated!

I haven't worked on zeeify lately, and am going to shift it to spectrify, which will take a series of photos and use a cheap method of edge detection and then use the same kind of colorization schemes trippygram uses — mostly because this will all be easier to do and I'm curious what the results will look like. Plus if I'm going to colorize them, it won't matter so much that I've used a cheaper method to cut out the sharp stuff. 

And all that should keep me plenty occuppied for a while. I was thinking recently I should apply to be a substitute teacher, but I feel like I need to wait until my health situation is more stable, maybe after the transplant process, if that all goes well, maybe as I recover I'll be able to do something like substitute teaching. Guess I'll wait and see!

Home Once Again

So I'm back home again, second round of “consolidation” is over. Things are still going well, the week was pretty uneventful — it all feels somewhat routine at this point. I walked a pretty good amount most days. We're taking more precautions to hopefully avoid nosebleeds this time. I'll have some followup appointments over the next few weeks to monitor my blood count numbers, and then sometime in the next few weeks I guess I'll start meeting with doctors in Boston to get to know them, and the process for a partial match bone marrow donation. I'm nervous about the fact that they couldn't find a complete match, but there isn't really anything to do about it.

I wrote all the above yesterday — today too was rather uneventful. This morning my hemoglobin, platelets, and ANC were all low but well above need for transfusion or wearing a mask everywhere. Last time it seemed to happen pretty late, and stay down for a bit longer than expected. 

So I'm back to learning about frameworks, bridging headers, and other programming concepts I need to understand to improve my software — and it's good to get back into it.

Not Much to Report

So I've been re-admitted, as planned, probably until Saturday evening. My platelet count was 70, which wasn't much higher than last week, and lower than the 100 they wanted for readmission, but they decided to wave it to get going on this round.

It's all very familiar. Seeing all the nurses and doctors I've met. Eyedrops that make my food taste bad, but protect my eyes from the chemotherapy drug. Going for walks to avoid getting a painful shot of Lovonox in my stomach. Hickuping coming and going periodically. Feels very routine at this point. 

But this should be the last round of consolidation chemotherapy before they try a bone marrow transplant. They never found a good match, so they'll do a partial match transplant instead, which isn't done here at Dartmouth, but rather down in Boston, Mass General I think. 

The first two doses have been administered, they each last three hours, with twelve hours between them, and then thirty hours between each pair of doses. So two down, six to go. 

Other than that I'm not sure what to say. I was working more on some software again before coming back to the hospital, and plan on working on it more while I'm here. 

Another Consolidation

So after the long weekend, on Tuesday, I'll be re-admitted for another round of consolidation chemotherapy, for probably five or six days. Typically they do two rounds of consolidation and then a transplant, which involves another month in the hospital. They haven't found a great match, so at the moment it looks like they'll try a partial match, in which case they won't do it at Dartmouth Hitchcock in Lebanon, but somewhere in Boston, I guess probably Mass General hospital.

The risks are greater with a partial match, but it's still successful for some people, and because of the specific cause in my case there is a high likelihood of relapse without a tranpslant, so the potential benefit of a transplant is enormous and symmetrical to the risk of no transplant. I don't know a whole lot about the transplant process yet, and I may be repeating myself some here, but the basic idea is that my bone marrow has a mutation (inversion on chromosome 3), which caused it to produce white blood cells that didn't mature. Normally the bone marrow produces white blood cells that mature into different kinds of cells that do different things, in my case the cells aren't maturing and the young undifferentiated cells began to crowd out the mature white blood cells and the red blood cells that carry oxygen. So we kill off all the immature cells with the chemotherapy and then take someone else's bone marrow, and ideally, it grows into my bones and produces healthy blood cells.

The search is for Human Leukocite Antigen (HLA) matching, which is the fancy technical term for the proteins on the outside of cells that the immune system uses to identify which cells are part of the body, and which are foreign invaders. The better the match, the less of a likelihood that the donated immune system attacks the rest of my body as foreign, which is known as graft-vs-host disease (GVHD). It's similar to other organ donation concerns, except normally they're concerned that the recipient's immune system will attack the donor organ, in this case the donation is the immune system itself, so the concern is more about it attacking everything else. The other major concern seems to be that the donated immune system takes hold in my bones. Apparently having some symptoms of GVHD is actually reassuring because it indicates that the donated immune system is in fact doing it's job, and it could even potentially target any remaining blast cells (cancerous immature immune cells).

The difficulty in finding a good match is because they're hoping to match ten antigens (ideally, based on research about which donations have been most successful), two known as HLA-A, two as -B, two as -C, two as -DRB1, and two as HLA-DQ. The criteria seem to grow more specific as we collect more information about the genome and which transplants are more successful, so I think they used to look for six markers, then eight, now ten. To better understand the odds, I looked up HLA markers on wikipedia, and found there are 2,884 HLA-A alleles, 3,589 HLA-B alleles, and 2,375 HLA-C alleles; there are 1,540 HLA-DRB1 alleles, and theoretically maybe 34,528 possible combinations of HLA-DQ type alleles. (Alleles are variations of a given gene.)

A very simplistic (and inaccurate) estimate of the relevant variability here would be to simply multiply all these numbers together, but in reality not all these combinations are likely to occur, I'm sure there are strong correlations for certain sets of alleles across markers, but it's still helpful to get an idea of why matching is so difficult. It's interesting that there is such tremendous genetic variation in this case because our ancestors seem to have gone through some genetic bottlenecks in the past that reduced our variation in a lot of ways. But there seems to be evidence that humans actually seek out genetic variability in mate selection — there is an obvious benefit to increased genetic diversity in offspring, that's the whole reason sexual reproduction exists, and in retrospect it's not surprising that that benefit would be compounded for immune systems. In other words, the reason we have such great diversity in our immune systems is probably that we're actively seeking mates to maximize the diversity — for the last 150,000 years we've probably been actively maximizing the diversity of our immune systems. (This was all a digression I inserted after writing the next part, and I only mention that because I don't feel like editing together something better than the non-sequitar below.)

I'm feeling pretty close to normal, a bit weaker than I used to be, and I still get a little light headed at times, when transitioning from crouched down to standing up, but I'm mostly feeling pretty much like I used to.

I went to a beach in Maine on Thursday with Justine, which was fun. I had weird feelings about being in public, I guess because of how my immune system was still a little weak, which makes me feel a little cautious about being around lots of people. Last night I went to a baseball game and felt a little more comfortable about that problem. It's weird feeling normal but also knowing that a minor infectious disease could be life-threatening. I also put sunscreen all over the top of my head, which was a new experience for me. 

I haven't really made any progress on zeeify lately, stuck on a bug, but I'm beginning to think I should just not worry about the final quality of the image at the moment and look into making another fun color-driven app. Maybe that should be spectrify. I dunno. But it's good to be working on something.

That's all for now!

 

Rebounding But Below Normal

So I was not re-admitted on Monday, because while my numbers are coming back up, they haven't returned to normal levels yet, so the doctors thought it was better to delay it another week, at least. My next appointment is Tuesday (because of the holiday Monday), and they'll just be looking for my blood counts to be in normal ranges.

My ANC was above 1000, platelets were at least 67, and hemoglobin was like 8.7 or something, so I'm not too concerned about bleeding or getting sick, but still get winded pretty easily with too much physical exertion. 

In the meantime I've returned to programming zeeify, but I can't seem to get the image pyramid to reconstruct the original image correctly. 

I wrote a tips & tricks page for trippygram, but it could probably use a lot of editing/cleaning up/cutting down, and eventually it'd probably be nice to incorporate it into the app itself.