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Akshay S Dinesh
asdofindia@gmail.com
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Orthostaic hypotension

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alamel10

5 Dec 2022, 06:14:0305/12/2022
to Mfccircle
A solutioin to a medical problem that defied traditional diagnosis. An intriguing case.

krantony53

5 Dec 2022, 07:26:1905/12/2022
to alamel10, Mfccircle
What is the relevance of this article among members of our network? And that too the one behind Paywall. There are many Medical Journals for those who are interested in clinical management and academic teaching. 

On Mon, 5 Dec, 2022, 6:14 am 'Nalini Visvanathan' via mfccircle, <mfcc...@googlegroups.com> wrote:
A solutioin to a medical problem that defied traditional diagnosis. An intriguing case.

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alamel10

5 Dec 2022, 21:57:0005/12/2022
to krantony53, Mfccircle
Dr. Kollannur,

Perhaps I erred. I know this is a common problem,especially for the elderly, so the solution provided was intriguing. I'm generally careful about checking the relevance of posts for this network. Many of the public health practitioners on the network do not read or have access to medical journals. Your point about the paywall is well taken. Generally, at the beginning of the month the ten articles' allowance by the NYT for non-subscribers does work, and so I was careless. Since I posted the link, I will go ahead and attach a pdf for those who are interested. From the link stats, more than 40 have tried to access it. Will not post medical articles in future. The article is for meant for the layperson.

Nalini

When He Stood Up Quickly, He Sometimes Fainted. What Was It_ - The New York Times.pdf

sunil

5 Dec 2022, 23:59:0705/12/2022
to alamel10, krantony53, Mfccircle
Thanks Nalini. I was enlightened by this. Not may of us can afford or access medical journals, so every now and then, such articles help. Maybe you can send such interesting articles to some of us who do like such articles, yes but without the paywall please.

Sunil

To view this discussion on the web visit https://groups.google.com/d/msgid/mfccircle/705072315.752990.1670257612078%40mail.yahoo.com.

Vineeta Bal

6 Dec 2022, 07:32:4706/12/2022
to sunil, alamel10, krantony53, Mfccircle
I also enjoyed the article once paywall problem was solved. Differential diagnosis is something I always enjoyed to discuss or read about in my student days and here it was well illustrated. 

As it happens I have experienced quite a few vaso-vagal syncopes in my life, hence more interesting. 

Thanks, Nalini. 

mohanrao2008

6 Dec 2022, 09:36:0606/12/2022
to alamel10, krantony53, Mfccircle
Thanks Nalini. I enjoyed reading the article.

Mohan

To view this discussion on the web visit https://groups.google.com/d/msgid/mfccircle/705072315.752990.1670257612078%40mail.yahoo.com.

drmirashiva1978

6 Dec 2022, 12:10:0106/12/2022
to mohanrao2008, alamel10, krantony53, Mfccircle
 Dear Nalini , Thanks . Lot of f passing out and alls now days in elderly  are being found to be associated with Hyponatremia Low Salt  . 
 Why this is happening I do not know , but I personally know 5-6 cases . As Vineteeta said  Differential Diagnosis is important . 
 We were told what the mind does not know the eyes do not see . 
  Hope you are keeping well . As Sunil said  we all  are non Pay wall appreciators , and Paywall unafforders . 
 Mira

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alamel10

7 Dec 2022, 00:58:1107/12/2022
to sunil, Vineeta Bal, mohanrao2008, krantony53, Mfccircle
Thank you, Vineeta, Sunil, & Mohan for letting me know your reactions to this article. Vineeta, you gave me a couple of terms I do not see often.
My first expderience with a sudden blackout was not as a senior but as a late teenager during a practice parade march in the NCC to which I belonged in my PUC days. I dismissed it as I had not eaten before leaving home early morning for the parade. It feels different as a senior, and induces greater anxiety. Not being a MD, I thought it was a well written case of a medical mystery. 

alamel10

7 Dec 2022, 01:04:0007/12/2022
to mohanrao2008, drmirashiva1978, krantony53, Mfccircle
Dear Mira,

Thank you for your note. My interest was piqued because of my living circumstances. I live in a senior housing complex. A 90+ years old lady, whom I greatly admire for driving herself to get groceries, fell one morning for this reason. She fractured her arm and had it in a sling for several weeks. Talking to her and going over my experience and that of others I saw a problem dismissed as par for the course. Consequently, this article about a guard/security staff was very revealing. I must confess I cannot resist mysteries, medical or otherwise.

I think those with low levels of salt are generally dealing with hypertension and may have overdone the dietary salt reduction. I completely understand the problems with paywalls, and I have converted several articles from the NYT, WSJ, The Economist and other publications which erect these walls. Sometimes, in a hurry, I become lazy. I'm sorry about that.

Take care,
Nalini

r.sr...@gmail.com

7 Dec 2022, 06:32:5507/12/2022
to Mfccircle
Very nice essay, Nalini.

Srivats  

To view this discussion on the web visit https://groups.google.com/d/msgid/mfccircle/328286233.1125226.1670354733839%40mail.yahoo.com.


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r.sr...@gmail.com

7 Dec 2022, 07:49:2207/12/2022
to Mfccircle
It would seem as if most idiopathic ailments will have causes that are either particular to a small group of people or singular, i.e., that their circumstances are absolutely peculiar to an individual.

Perhaps such idiopathic ailments mark the boundaries of a medicine that is based on the statistics of large numbers?

Srivats

Akshay S Dinesh

7 Dec 2022, 07:52:1607/12/2022
to r.sr...@gmail.com, Mfccircle
If you reduce medicine to RCTs, that is.

Medicine is built over sound theoretical basis of subjects like anatomy, physiology, etc.

A clinician uses these foundational topics along with other signals like frequency and prevalence to arrive at differential diagnoses.

Just like the person who arrived at the internal filter diagnosis here.

Akshay

To view this discussion on the web visit https://groups.google.com/d/msgid/mfccircle/CAPWvtufqQ%2BjfHbBn419TOnSWDkcCQGTmYNTuzREneoufftw22Q%40mail.gmail.com.

prab...@yahoo.com

7 Dec 2022, 08:18:1607/12/2022
to mohanrao2008, drmirashiva1978, alamel10, krantony53, Mfccircle

An uncle and an aunt had falls on visits to Kolkata. Both were on Losartan and were sweating a lot as they had been accustomed to staying in cooler climates.
Not orthostatic really in their cases- hyponatremia though. I develop postural hypotension very easily and am fairly careful if I have been in closed rooms on winter too
Prabir

r.sr...@gmail.com

7 Dec 2022, 08:18:2407/12/2022
to Akshay S Dinesh, Mfccircle
Yes, but the trouble seems to be that training, diagnostic recommendations (like the ICDs, Cochrane's statistical basis of effectiveness and efficacy), protocols, procedures, treatment guidelines, best practices, all seem to go increasingly by the law of large numbers.  More and more are even differential diagnostic tracks standardized according to large number guidelines.  That seems to be the dominant historical trend since the 1970s, at least to me.  I may be wrong.  My point is that the kind of diagnosis you are pointing to, and shown by the doctor in this essay is becoming rarer because the practice of medicine of this kind seems to be moving towards obsolescence?   If this is indeed becoming rarer, then wouldn't the pool of idiopathic illnesses not become larger, simply because the way medicine thinks (throughout its being) has turned another way?

Srivats

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chinusrinivasan.x

7 Dec 2022, 08:25:3607/12/2022
to r.sr...@gmail.com, Akshay S Dinesh, Mfccircle
I read the piece with interest. My late father in his last 2 years used to fall unexpectedly, then diagnosed as hyponatremia. I hadn't heard nor the doctor of the vena cava theory.

The link below on medical mysteries and surprising solutions is as interesting.

Chinu

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Akshay S Dinesh

7 Dec 2022, 08:29:4707/12/2022
to r.sr...@gmail.com, Mfccircle
I'm unsure about whether practice of medicine is becoming more standards centered (and consequently numbers centered). One would need a study to evaluate practices for that, right?

But, if we were to assume that people are forced to choose standard diagnoses - then there is also a chance that "idioathic" becomes less diagnosed. Rather, people would force fit an existing diagnosis for everything that would/should have been "idiopathic".

And that is perhaps even more dangerous - wherein an "idiopathic" diagnosis would warrant a better diagnosis later, but something more specific would exhibit a sense of confidence that prevents further investigations.

And I agree that whether a clinician makes a diagnosis of uncertainty or a diagnosis of certainty depends a lot on their medical training and how comfortable the training has made them with uncertainty. I don't think this necessarily has to be tied with ICD/Cochrane. It is even more fundamental - critical thinking and principled analysis of problem solving.

https://themultidisciplinarian.com/2020/05/04/innumeracy-and-overconfidence-in-medical-training/ is something I read recently about how these might be lacking in medical training.

Akshay

r.sr...@gmail.com

7 Dec 2022, 09:04:4807/12/2022
to Akshay S Dinesh, Mfccircle
Interesting post.  Let me respond by point:

I'm unsure about whether practice of medicine is becoming more standards centered (and consequently numbers centered). One would need a study to evaluate practices for that, right?
By this I presume you mean we can't speculate on these matters, and a scientific study of the framework is required.  My response would be: Unless one speculates at first, one would not even begin to see the problem of the framework.  Or indeed any problem at all.  Speculation must precede investigation -- not as it "ought to" because it is the right thing to do, but it "must" as a logically prior necessary step to investigation in every case.

But, if we were to assume that people are forced to choose standard diagnoses - then there is also a chance that "idioathic" becomes less diagnosed. Rather, people would force fit an existing diagnosis for everything that would/should have been "idiopathic".
And that is perhaps even more dangerous - wherein an "idiopathic" diagnosis would warrant a better diagnosis later, but something more specific would exhibit a sense of confidence that prevents further investigations.
I agree fully. Very insightful.

And I agree that whether a clinician makes a diagnosis of uncertainty or a diagnosis of certainty depends a lot on their medical training and how comfortable the training has made them with uncertainty. I don't think this necessarily has to be tied with ICD/Cochrane. It is even more fundamental - critical thinking and principled analysis of problem solving.
I don't think the problem is simply one of habit (being "comfortable according to training") or individual competence, ethics (critical thinking and principled analysis).  Ways of thinking are not individual exercises alone -- they are shaped by institutions (colleges, research, pharma, protocols, medicine as historical group of all these institutions and practices).  If individual competence or commitment is missing, it is because it is also not built into the structure of training -- not only at the level of the degree education, but at the level of reinforcement by institutions in practice.  What I mean to say is that it is not simply the failure of doctors as a class or as individuals to be rigorous -- it is a "failure" of the framework or paradigm as it develops in history.  For example, the miasmatic theory of disease was prevalent since the 18th century or earlier.  It is not simply a matter of personal failing of any number of doctors that the germ theory wasn't followed.  That (miasma) was the paradigm.  It took a break, doubtless marked by an exceptional group of individuals to shift that paradigm.  Similarly, perhaps (and I speculate here, rigorously as the prelude to any detailed investigation) that the large numbers medicine is a kind of paradigm we are as of now swimming through.  The doctors like in the paper Nalini posted who strike out are mavericks, brilliant, respected, but not followed.  Following will occur when this large numbers paradigm's hold on the idea of medical scientificity is transformed into something more rigorously attentive to the individual while keeping in view the larger picture.

Thanks
Srivats


Akshay S Dinesh

7 Dec 2022, 09:14:2107/12/2022
to r.sr...@gmail.com, Mfccircle
I engaged in this thread indeed by realising that you're making a general observation/speculation/theory about the philosophy of medicine - that it is based on a particular large number paradigm.

The alternative I wish to hold up is that the philosophy of medicine is that of rationality, empiricism, and science. And that what you attribute to medicine is to be attributed to globalization, capitalism, etc.

I can elaborate on the implications of the differences in our philosophies if that's necessary.

r.sr...@gmail.com

7 Dec 2022, 09:32:0607/12/2022
to Akshay S Dinesh, Mfccircle
I think our paradigms are different!  I do understand yours, and don't fully agree with it.

Akshay S Dinesh

7 Dec 2022, 09:34:4407/12/2022
to r.sr...@gmail.com, Mfccircle
If you give me an example of how a paradigm that's different from medicine's would look like, I can write an essay about how I would think about that. Perhaps that'll help us to progress from this impasse.

r.sr...@gmail.com

7 Dec 2022, 09:39:1707/12/2022
to Akshay S Dinesh, Mfccircle
I am not sure what you mean by :"how a paradigm that's different from medicine's"?

Akshay S Dinesh

7 Dec 2022, 09:41:1807/12/2022
to r.sr...@gmail.com, Mfccircle
Whatever large number paradigm you're considering. What's a paradigm that's different from that, according to you?

How would someone who feels giddy when getting up be analyzed in a different paradigm?

r.sr...@gmail.com

7 Dec 2022, 10:05:2307/12/2022
to Akshay S Dinesh, Mfccircle
Let me take some parallel examples and approach this.

a) Take Newtonian physics.  That was all there was till the twentieth century.  In the twentieth century, the idea that the speed of light was a constant, and therefore length, mass and time had to vary as one approaches the speed of light completely overturned Newtonian physics, and the individual there was Einstein.

b) Take the idea of capitalism.  Its own view of what economics was, its theory of price, free labour etc., were all those wedded to the theory of capitalism could see.  It took Karl Marx, building on Ricardo's economics and Hegel's philosophy to arrive at the theory of surplus value and the new structure of exploitation.

In both cases, there is a paradigm shift.  Which is not at all obvious from within the original paradigm.  It took a tremendous leap of logic and scientific thinking, going beyond what was considered logical and scientific by the established institutions, practices and understanding to go beyond them.  As with quantum physics too.

From within a pond, a frog can only speculate that there is a world beyond.  It takes a different kind of being to move out of it. 

So if there are forms of thinking that don't work based on large numbers, medical scientificity has declared them charlatanry:  homeopathy, acupuncture, ayurveda.  So now way would their solutions to individual problems be seen as scientific.  It is not capitalism, but the claim of allopathic medicine to scientificity that marginalizes them.  I am not saying that have, or a would be right in their diagnosis of the current situation -- they might; but I am saying that anything that is different will be banished outside the margins of scientific thought.

And it is not only the scientific paradigm, or as you rightly point out capitalism, or as I will point out, statist health agendas that are part of the problem -- it is also that we as medically trained subjects, as patients, populations, individuals who follow this as if it were gospel truth.  It is medical culture as it is today.  The problem is not inconsequential: whether it is this case described in the paper, or the "long tail of chronic diseases" or kalaazaar, or long covid symptoms, all of them suffer from a mix of inefficacy, inefficiency, neglect or perspective and framework too.  Whether piecemeal solutions will help or not, in the long run the emphasis will change (not have to, but will) and there will be a new way of looking at diseases that goes beyond these problems.  It is not going to be the Garden of Eden, but yet another configuration to be struggled through.

But neither am I a health expert, nor a doctor, only a speculator -- unscientific, who will ask the question (not unique, nor original), what is a (medical) science that will begin to surmount its framework?

Srivats

r.sr...@gmail.com

7 Dec 2022, 11:28:0407/12/2022
to Akshay S Dinesh, Mfccircle
Some typos.

So NO way, not So now way.

From: R Srivatsan <r.sr...@gmail.com>
Sent: Wednesday, December 7, 2022 10:04:45 AM
To: Akshay S Dinesh <asdof...@gmail.com>
Cc: Mfccircle <mfcc...@googlegroups.com>
Subject: Re: [mfccircle] Orthostatic hypotension
 

r.sr...@gmail.com

7 Dec 2022, 11:29:4707/12/2022
to Akshay S Dinesh, Mfccircle
Also:
I am not saying that THEY have, or a would be right in their diagnosis

From: R Srivatsan <r.sr...@gmail.com>
Sent: Wednesday, December 7, 2022 10:04:45 AM
To: Akshay S Dinesh <asdof...@gmail.com>
Cc: Mfccircle <mfcc...@googlegroups.com>
Subject: Re: [mfccircle] Orthostatic hypotension
 

alamel10

7 Dec 2022, 19:44:5007/12/2022
to Mfccircle, r.sr...@gmail.com
That's a thoughtful observation. I would also point out that sometimes the boundaries between public health and medicine are blurred, and even when a ailment affects only small (recognized) numbers, it still has implications for the public at large.

Akshay S Dinesh

7 Dec 2022, 20:55:4407/12/2022
to r.sr...@gmail.com, Mfccircle
If one uses the example of Newton's theories being contradicted by Einstein's theories as an example of how science has got the wrong paradigm - using the empirical and self-correcting method of science itself as an argument against science - it is often the case that one is confused about what science is and what argument they are making.

I'll write in detail in a blog post about what science is and how all the alternatives you think are better than medicine will ultimately use the same empirical method available to all humans - (theories and observations - which you also used in the beginning of this thread) - but because their theories are of lower quality, will ultimately produce contradicting results of even lower quality.

Till then.

Akshay

r.sr...@gmail.com

8 Dec 2022, 06:52:0108/12/2022
to Akshay S Dinesh, Mfccircle
Dear Akshay,

Looking forward to your blogpost.  By the way, I am not saying science will be defeated -- least of all by homeopathy, ayurveda or acupuncture.  I am a staunch believer in modern Western medicine.  I am only saying that the paradigm of large numbers that dominates science today will be surpassed by another that pays more attention to the kinds of logic that lead to what are termed idiopathic ailments.  Such changes are already on the way.  I am also explicitly saying that they are the cure-all of the problems of the kind of medicine we have.  How and what happens will have to be seen. 

These clarifications are also intended for other readers who may be interested in these posts...

Srivats

To view this discussion on the web visit https://groups.google.com/d/msgid/mfccircle/CAL%3D48C6EruEKYzEdzUanWkdc6f8uU_H4r_B3VnC6bbKb700qFQ%40mail.gmail.com.

r.sr...@gmail.com

8 Dec 2022, 08:00:2208/12/2022
to Akshay S Dinesh, Mfccircle
Sorry, error:   "I am also explicitly saying that they are NOT the cure-all of the problems of the kind of medicine we have."

Akshay S Dinesh

11 Dec 2022, 08:31:4911/12/2022
to r.sr...@gmail.com, Mfccircle

I'm sorry it isn't well written because I had too many ideas and thoughts to convey in a very short span.

To address Rakhal's comments off-list, I am forced to add a link to https://blog.learnlearn.in/2022/09/intersectionality-queering-science.html (which is also linked in the other post). In essence, yes, a paradigm shift is necessary to make medicine more intersectional. But unfortunately, homeopathy will continue to be charlatanry.

Akshay
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Orthostaic hypotension