Chance For Some Faith And Possibilities?!

Abstract

Does Zohran Mamdani Mayoral's win in the USA have any bearing on Medicine or Pakistani society? Well, sometimes lessons from seemingly distant, unrelated events may have ripples that can help shape minds or forge traits far away, with transformative results.  The overarching lesson from “Mamdani effect “ is that with substance, thoroughly positive and dedicated struggle, one could overcome seemingly impossible, absolutely dominating, and deeply manipulated circumstances to make one's mark. Does that help give us hope? Of course, the unbelievable patience and unwavering belief of the people of Gaza give this gloomy globe ample lessons in the strength of perseverance.

Keeping an “Open mind” and “Anchoring bias”. In my 15 year experience of medicine and rheumatology I have come across cases which may not fit into one particular diagnosis and several times I’ve had to reconsider diagnosis that I may have made or previously given by other clinicians, which leads me to share two terms introduced to me by my late Program Director of Internal Medicine namely, Hickam’s dictum and Occam's razor.

In Occam’s razor, the idea is to try to conclude analysis of the data to try to find one common answer, while in the case of Hickam’s Dictum, it is possible to conclude that there is more than one diagnosis (or maybe several possibilities). In this regard, I would like to briefly present a case of a middle-aged woman whom I have been treating with the previous diagnosis of SLE with overlapping Sjogren’s syndrome, but she also has had a family history of ankylosing spondylitis.  Although her peripheral joint pain was controlled, she had this persistent low back pain for quite some time, seeing a previous clinician and a working diagnosis of degenerative arthritis of the low back. Keeping an open mind and challenging previous diagnosis fresh workup was initiated, and she was found to have HLA B27 antigen, and the MRI showed that she had bilateral Sacroiliitis consistent with Ankylosing Spondylitis (AS). This becomes a challenge to treat this but fortunately she was enrolled in trial at my practice studying Upadacitinib in SLE (phase 3),¹ which is effective for AS but we were studying this for lupus and we found that after 6 months months of treatment although we were blinded the patient had improvement in back pain and subsequent resolution of the sacroiliitis likely indicating that she was in the treatment arm with improvement in the manifestations of SLE and serologies.

Separately I recently encountered a patient being treated in Pakistan for last 20 years for psoriasis and psoriatic arthritis ( PsA) an after seeing a few different clinicians and due to lack of complete control the patient reached out to me for evaluation and on assessment the patient classically had deformities more pertaining towards rheumatoid arthritis as well as rheumatoid nodules and on simple investigation was found to be strongly fasted for Rheumatoid factor and anti CCP antibodies cementing diagnosis of Rheumatoid arthritis ( possible overlap with PsA ).

Thirdly  I’m working with the medical students at UIC for article with literature review on a case which the patient had longstanding diagnosis of Radiographic Ankylosing Spondylitis ( AS)  presenting with worsening of back pain with the MRI concerning for metastatic disease in his spine which upon biopsy found to have non caseating granulomas and on further investigation was found to have mediastinal Lymphadenopathy on CT chest and elevated is ACE level cementing diagnosis of Spinal Sarcoidosis and his spinal disease responded to steroids and maintain a low dose Prednisone (failed anti TNF agents due to his diagnosis for heart failure ). The estimated co-occurrence of sarcoidosis with ankylosing spondylitis is ~0.12%.²

I want this to be an opportunity for me and my readers, which may include practising clinicians and students, to never be overconfident in making a diagnosis or never challenge a previously made diagnosis (Anchoring Bias).

It is hard to miss a certain feeling of discontent and hopelessness when I am visiting Pakistan.  Some of this could be justified, but it is possible that part of this could be related to people’s expectations, which sometimes are based upon comparisons that may not be truly reflective or fair, especially if we are not comparing apples to apples but rather comparing apples to oranges (in a country's perspective, possibly not comparing the country regionally but to distant developed countries). I have been travelling back and forth between the US and Pakistan for the last 15 years and feel heartened by some improvement, generally speaking, in infrastructure and services. Visiting RMU and seeing its improvement over time and growth, and development of different specialities and services, and production of high-quality clinicians makes me think that there is real hope in our future. One could try to be positive in one’s outlook, thinking (half glass full?!)  and be hopeful. We are certainly encouraged to be hopeful as believers in any case.

Let there be an opportunity to yield a culture of positivity, open-mindedness, critical thinking, self-reflection, self-improvement, patience, and perseverance not only in our professional lives but also at a community and national level. These traits shown by maybe distant person or group of people can have a positive rippling effect in our institutions and nation-building. As believers, we have been commanded to sow the seeds of the future even in the face of impending doomsday.

Family of Imran (3:200)

O ye who believe! Persevere in patience and constancy; vie in such perseverance; strengthen each other; and fear Allah; that ye may prosper.

• Yusuf Ali.³

In the words of Iqbal.⁴

nahīñ hai nā-umīd 'iqbāl' apnī kisht-e-vīrāñ se

zarā nam ho to ye miTTī bahut zarḳhez hai saaqī

 Translation:

Iqbal is not hopeless about his barren land; If it receives even a little moisture, this soil is extremely fertile.