dbbolton

Unless you have access to coca leaves, your recipe is likely to taste like generic cola.

Coca-Cola has special privileges to import raw coca leaves. They extract the cocaine (which is then sold for pharmaceutical use). The mostly-cocaine free extract is then used to flavor their cola. AFAIK Coca-Cola is the only entity in the US allowed to do this, so it is unsurprising that other cola brands taste significantly different.

dbbolton

4년 전discuss

I'm a physician- although I don't disagree with the spirit of the article the headline is exceptionally misleading.

Phenylephrine is useless as an oral decongestant. It is still quite useful for other indications, including as a vasopressor (given IV to increase blood pressure such as in hypotensive shock). I believe it is actually the only commonly available vasopressor in the US that is a pure alpha-1 agonist which in certain scenarios is desirable.

It is also indicated for treatment of priapism.

The real kicker is that phenylephrine actually does work as a nasal decongestant when it is used as an intranasal spray, which has the added benefit of fewer systemic side effects compared with oral decongestants.

dbbolton

5년 전discuss

Makes me nostalgic for pentadactyl (the IMHO superior fork of Vimperator- both of which are discontinued)

https://en.wikipedia.org/wiki/Pentadactyl

dbbolton

8년 전discuss

I am a physician in the US. I think the article has valid points (esp. inpatient glucose control) but it also oversimplifies and glosses over some of medicine's more arcane aspects.

To give a tangible example I'll start with the unnecessary ankle x-ray. There is a set of guidelines called the Ottowa Ankle Rules[1] which we use to justify ordering plain films for a suspected fracture, but there are plenty of reasons why a doctor would still get them if the criteria weren't met.

One reason is clinical judgment and experience. Guidelines are just guidelines. Ultimately the doctor is the one making the call, as well as suffering the blame for that call if things go sideways. If everything were as simple as following algorithms and checklists, medical training wouldn't take 7+ years of post-undergraduate work.

But probably the most important reason has to do with the "patient satisfaction" (customer service) aspect. Ideally medicine wouldn't be a business, but it is and there's not much we can do about that.

Patients who present to an urgent care center or ED generally carry an implicit "something is seriously wrong with me or I would have just made an appointment with my PCP" vibe. These patients often don't like it when you explain that based on your history and exam, they most likely have a sprain/strain injury and an xray is not appropriate since we want to avoid unnecessary costs/radiation exposure-- as opposed to being relieved that they only suffered a minor injury. Even when spoken in a compassionate, straightforward manner, this explanation can come across to the patient as "nothing is wrong with you / you are malingering / your concerns aren't valid / I don't care about your symptoms", etc.

Sometimes patients outright demand tests, or worse, they'll say nothing but then complain to your employers that you medically neglected them, or you are incompetent, or what have you. Now if they had the audacity to file a malpractice suit, you'd (ideally) have no problem justifying your actions in a courtroom or deposition. But say they complain to the MBA (or some other person with no medical training) who runs the clinic or care center employing you. Your argument will likely fall on deaf ears, and be countered with some diatribe about how you're causing them to lose money. In that case it's a lot easier to just order the unnecessary xray.

Basically, the squeaky wheel gets the grease. There are plenty of other examples like this, and they all come down to choosing your battles wisely. I think it's kind of hard to blame the over-worked and behind-schedule doctor who orders something like an xray or lab test rather than taking an extra 10-15 minutes discussing the pros and cons with the patient, after which the patient might still not be convinced.

Having said that, there is a problem with superfluous testing in EDs, especially ones that rely on "standing orders" where e.g. virtually any patient presenting with abdominal pain might get a CT scan before the physician even sees them (something I strongly disagree with and can't think of a legitimate excuse for).

[1] http://www.theottawarules.ca/ankle_rules

dbbolton

8년 전discuss

Perspective from a US physician:

Pre-implantation genetic diagnosis (or PGD, what you described as 'selective IVF') is not cheap. It costs upwards of US$100,000 and no commercial or government insurance will cover it.

Genetic screening is also not cheap. An exome (essentially looks at all ~22,000 known exons, or the genes that directly contribute to protein formation) costs US$6,000 - $8,000 and most insurances will fight tooth and nail not to have to cover it even when it is ordered by a geneticist. You might think "but there are much cheaper genetic tests besides an exome" which is true, but remember we are talking about rare diseases. Exome testing is still imperfect but it is essentially the only realistic option if your goal is to rule out as many known genetic diseases as possible, or if you know there is a high pretest probability of a genetic disease but less exhaustive testing was negative or inconclusive.

Actually, current PGD doesn't use exome testing but much more selective testing often based on the parents. One technique is FISH which can essentially only tell you if there are any "large" genetic abnormalities, like (micro-) duplications or deletions, which are large relative to, say, a point mutation. As an example, FISH testing would not reveal cystic fibrosis. The other is PCR, which is currently the technological limit for PGD testing because of the small number of cells and minimal amount of genetic material available for testing. There are several PCR assays available for specific conditions in the setting of PGD, which is where the parents fit in. We will probably see more and more assays becoming available, but it is unlikely that anything resembling an exome will be feasible for PGD in the foreseeable future.

Disclaimer: I am not a geneticist or reproductive specialist. If you can find sources by physicians in these fields, I would defer to them.

dbbolton

8년 전discuss

Here are some links to the CDC's statistics and maps on Lyme disease for those interested:

https://www.cdc.gov/lyme/stats/graphs.html

https://www.cdc.gov/lyme/stats/maps.html

https://www.cdc.gov/lyme/stats/tables.html

As an aside, it's tricky interpreting certain stats regarding epidemiology. The incidence is the number of new cases in the population in a given time frame, and prevalence is the total number of people known to have the disease in the population. Sometime a disease can appear to be "on the rise" because there is increased surveillance and screening for the disease, or because diagnostic methods have improved, which naturally lead to an increased incidence and prevalence.

Disclaimer: I'm not arguing that Lyme Disease isn't real, isn't serious, or anything along those lines. But from a medical perspective, we deal with fear of Lyme way more often than the actual disease. Some parents will bring their child into the clinic every time they think they may have seen a tick within arm's reach of them. And when someone presents with an attached tick, it's more often than not an adult wood tick (which can transmit RMSF and tularemia but are not B. Burgdorfi vectors).

When you are bitten by a tick, or any insect, some inflammatory response is expected, i.e. your skin will probably turn red. It doesn't automatically mean it's erythema migrans (bull's eye rash). But to muddy the waters even further, as little as 50-80% of confirmed LD cases had the EM sign, and many don't recall a tick bite whatsoever.

But if you are in an endemic area, clinical suspicion for LD is high, we should be able to prove you have the disease with lab tests, right? Well, unfortunately Borrelia are notoriously difficult to culture, so that's out. The CDC recommends a two-step testing process.

Step 1 is the Enzyme Immunoassay (EIA). If your EIA is negative, LD is ruled out. If it is positive or "indeterminate" (2nd most common outcome after negative in my experience), you move on to the Western blot which looks for antigenic proteins associated with the disease. It is considered positive if 2 specific bands are visualized or if at least 5 of a list of 10 other bands are seen. The problem is that these bands can take up to 6 weeks after exposure to become detectable. If you have no idea when/if you were actually exposed, this test is a shot in the dark. To top it all off, it can also come back "mildly" to "moderately" positive for LD.

So if your EIA is negative, or if your WB is 2/2 or 5+/10 positive, we can give you a definitive answer. Otherwise, it comes down to clinical judgment and weighing the risks and benefits of treatment. If you were bitten by a tick, got a rash, had no drug allergies, the safer play is to assume LD, give antibiotics, and forgo the serologic testing that may or may not give an answer.

TLDR - Lyme Disease is complicated.

dbbolton

9년 전discuss

Don't forget to install the plugin that actually allows you to run a web browser inside your web browser-based editor:

https://atom.io/packages/browser-plus

dbbolton

9년 전discuss

Seems to have been patent-encumbered and largely abandoned in the commercial world, but there is a FOSS library called fiasco (.wfa files) that is included with netpbm, available on most *NIX systems.

http://manpages.ubuntu.com/manpages/xenial/man1/netpbm.1.htm...

https://github.com/l-tamas/Fiasco

dbbolton

9년 전discuss

You would probably have to ask a pharmacist, but from the clinical side I can tell you most prepared health information that we can give to patients has to be very bare bones and comprehensible to essentially everyone at or above an 8th grade education level- I assume because it is considered too resource intensive by the publishers to produce multiple versions of the same information, and people with higher education typically have the initiative/means to ask their doctor the right questions or research the information themselves.

I'm not trying to justify any of this, but that's how it is.

Not sure if it will be helpful in the future, but I can tell you that descriptors used with side effects follow a standard convention:

    very common: > 10% 
    common: 1%-10%
    uncommon: 0.1% - 1% 
    rare: 0.01% - 0.1% 
    very rare: < 0.01%

But you will probably never know the exact origin of these figures (like how many patients were studied, what populations were included, how tightly the study was controlled, whether adverse effects were self-reported, etc.) without doing some intense searching. And even if you did, I doubt it would have a significant impact on your healthcare. I don't want to go on a tangent about the nuances of pharmacology in clinical medicine, so I'll just circle back to my point that you should trust your doctor, or else find a new one that you do trust.

dbbolton

9년 전discuss

>"Oh, is he on <some blood pressure medication I forget the name of>?"

I'll bet the farm it was lisinopril, or another ACE inhibitor. The ACEI cough is notorious enough that any 1st year medical student probably should have been able to piece this together.

The problem is not that those doctors were ignorant. It's more likely that they did not ask the right questions to get a proper history. You should ask every patient to list their medical problems and medications unless it is a routine follow-up when nothing has changed.

Something else that can happen is patient ignorance (and I am not insinuating your dad was guilty of this, or making a value judgment on people who are).

Often times you can't get a proper past medical history or medication list unless the patient brings all of their prescription bottles to the office. E.g.:

>"What medications are you on?"

>"Well, I'm on a sugar pill, a water pill, a cholesterol pill, a stomach pill, and some allergy medicines."

>"Ok, do you know the name of that sugar pill?"

>"It's a little white pill. I think it starts with an 'F'. No wait, I'm thinking of my water pill."

or

>"Do you have any medical problems?"

>"No."

>[glances at meds list] "Ok, so why do you take metformin, hydrochlorothiazide, atorvastatin, omeprazole, cetirizine..."

dbbolton

9년 전discuss

>ALWAYS READ EVERYTHING YOU CAN ABOUT DRUGS YOU ARE PRESCRIBED!

I'm not trying to undermine your point entirely, but there is a flip side.

I can't tell you how many times I have seen a patient start a medication, then come back to the office within 48 hours because they coincidentally have every side effect that is listed in the pharmacy's information sheet or that they looked up online. The vast majority of these side effects are benign, present with next to no pertinent physical exam findings, and can't be definitively tied to the new med (like upset stomach, fatigue, headache, etc.).

Then they will start listing that medication as one of their "allergies", and if the nurse/doctor documenting doesn't dutifully probe what type of "allergic reaction" they had, they may end up not being prescribed that med in the future when it really is the drug of choice. A little nausea is a small price to pay if it kills a potentially life-threatening infection.

Also, I'm skeptical about the seizure risk. The thing about side effects is that they are supposed to be stratified according to risk. Doctors are typically aware of these risks, but patients aren't. So if your drug is listed as causing "headache, nausea, and seizures", there may have only been one patient out of millions who had a seizure while 50% experienced headache, yet the handout probably won't tell you that.

But even if it is a notable risk, I would be surprised if the propylene glycol you inhale from an e-cig could accumulate to a high enough level in the bloodstream to cause drug interactions, although I admit adequate research on the subject is lacking.

My advice would be trust your doctor first. If you don't trust your doctor, start seeing a doctor that you do trust. Then if you have a significant adverse reaction to a medication, talk to your doctor about it. Quite often they know something that you are not going to find by spending a few minutes on the internet.

As a side note, a good history includes asking about many habits. A lot of healthcare providers are guilty of simply asking "Do you smoke, drink, or use drugs?", but ideally the smoking aspect should be phrased as "Do you use any tobacco or nicotine products?". Patients usually won't read your mind and volunteer that kind of information. They will tend to give yes/no answers, so direct and specific questions are important.

dbbolton

10년 전discuss

Preface: I'm not trying to nitpick you to death. I wouldn't expect anyone outside the medical field to remember any of these terms.

Yes, a HR of 230 BPM is not normal. The terminology is confusing because tachycardia can be both physiologic ('normal') and pathological ('abnormal') depending on the context. What you are describing is not "just" tachycardia, but most likely a type of supraventricular tachycardia/tachyarrhythmia (not a cardiologist, but my best guess would be AV nodal reentrant tachycardia or AVNRT).

The maneuver is called valsalva, one of several vagal maneuvers that essentially work by increasing the parasympathetic input to the heart and negating some of the sympathetic (fight-or-flight) input.

dbbolton

10년 전discuss

Tachycardia is technically any heart rate greater than 100 BPM. It doesn't necessarily mean that the heart is not pumping enough. What can happen with an elevated heart rate is that the heart doesn't have enough time between beats to fill properly, resulting in decreased stroke volume and cardiac output, but this is typically only seen clinically with certain dysrythmias that have very high rates (like in the 150-200 rage), or in the setting of cardiomyopathies (diseases of the heart muscle), MI (heart attack), or heart failure. If your heart muscle tissue was actually not able to keep up, it would mean you had one of these things, which you most likely didn't.

What you are describing sounds like textbook palpitations. It is completely normal for the heart rate to increase for a lot of reasons, including stress and being startled (via the sympathetic nervous system, or fight-or-flight response). A palpitation is when a person becomes very aware of their heartbeat and perceives it to be abnormal, regardless of whether there is any clinically objective abnormality. They are often associated with anxiety and can lead to a vicious cycle (person is anxious, then notices their heart is beating fast, so they become more anxious, their heart rate increases, etc.).

The silver lining here is that in all likelihood your heart was/is fine. Anxiety has also been proposed as a risk factor for CVD but my understanding is that this is still debated. So don't go thinking your history means you'll definitely have an MI.

None of this is meant to dismiss your experience though. Not three days ago I saw a young, healthy male in the ED who thought he was having a heart attack, and (you guessed it) his EKG and labs were 100% normal. It probably happens a lot more than people realize.

By the way, I'm not saying "don't go to the doctor because that 'heart attack' is all in your head". He absolutely made the right decision by coming in (better safe than sorry).

dbbolton

10년 전discuss

The paper states that depressed mood and exhaustion are a risk predictor for all-cause cardiovascular mortality comparable to hypercholesterolemia and obesity. Essentially this means that a person with clinical depression is about as likely to die from cardiovascular disease (main specific causes of death being being heart attack and stroke) as a person with high cholesterol or who is overweight, and all of which are more likely to die of CVD than someone with none of the above.

This study is purely correlative. They do not hypothesize or investigate the pathophysiology by which depression can lead to these problems. I'm sure there is some research in this area, but in my medical education I have not come across any specific examples. To my knowledge there is no consensus that depression directly causes hypertension.

I can tell you from clinical experience that people with depression generally do not take good care of themselves (and this is not a judgment, just an observation). Their diet is poor, they do not exercise regularly, and are non-compliant with medical therapies. In other words, their lifestyle leaves them vulnerable to a whole host of diseases. However, I would still argue that the biggest risk factors for essential hypertension are family history and race, not behavior or mental health.

dbbolton

10년 전discuss

> In May 2015, Snowden's lawyer Ben Wizner said that Snowden's main source of income was speaking fees, which sometimes exceeded $10,000 per appearance.[308]

https://en.wikipedia.org/wiki/Edward_Snowden#2015

dbbolton

10년 전discuss

First off, my shell is not broken. Secondly, my post was highly simplified because obviously I'm not going to include the entirety of every single config file my shell uses. All it takes to avoid this "problem" is a single if-statement, or you can just set the var in /etc/profile or with PAM.

I guess I assumed people would not read my post and then start editing a system-wide shell config file unless they knew what they were doing.

But if someone did manage to "break" their shell this way, recovery would be trivial because they will still be able to login and the shell will still run, they just might not have all of their configs loaded.

dbbolton

10년 전discuss

I've had similar experiences with Bing, which I used inside IE on a fresh Windows install to search for a few programs/drivers (was just to lazy to type in my own search engine).

IIRC when I searched for FF or Chrome, the top 4-5 results were links to third party sites, but when searching for nvidia drivers the official site was the first non-ad result. Definitely seemed suspicious, and also made me realize how much I missed apt.

dbbolton

10년 전discuss

From the documentation page:

>A package directory is the root of a tree containing the installation image for a particular package. Each package directory must reside in a stow directory — e.g., the package directory /usr/local/stow/perl must reside in the stow directory /usr/local/stow. The name of a package is the name of its directory within the stow directory — e.g., perl.

https://www.gnu.org/software/stow/manual/stow.html

The article in the OP also doesn't use this format. Instead it's prefaced with a `cd` command, so you would need to do:

    cd foo; stow bar

dbbolton

10년 전discuss

One of the best zsh tweaks I've done was setting

    ZDOTDIR="${XDG_CONFIG_HOME}/zsh"

in `/etc/zshrc`, then moving all miscellaneous files to the same place:

    # ~/.config/zsh/.zshenv
    export HISTFILE="${ZDOTDIR}/history"
    
    # ~/.config/.zshrc
    compinit -d ${ZDOTDIR}/zcompdump
    zstyle ':completion:*' cache-path "${ZDOTDIR}/cache"
    ## separate files for easier and quicker editing:
    for file in $ext_files; do
        [[ -f ${ZDOTDIR}/${file} ]] && source ${ZDOTDIR}/${file}
    done

This method removed quite a few files (history, compdump, cache, zkbd, zshrc, zshenv, zprofile, zlogin, etc.) from my home dir.

I'm sure bash has something similar, but like you said, it would be nice if programs didn't junk up $HOME by default.

dbbolton

10년 전discuss

Just wanted to add my perspective as a US medical student--

First I would like to say that I'm sorry for your loss, and please don't take my comment as defending or justifying our current research system.

But the explanation as to why there is so little medical research for children has to do in part with the federal laws regarding Protection of Human Research Participants (PHRP), specifically the "vulnerable populations" subsections, which define additional protections that are required to perform research on such groups (for children, it is Subpart D).

I won't go into detail, but the gist is that we err far on the side of caution. Whether that's for the best is another matter.

There's a huge amount of red tape/obstacles for performing clinical trials on competent adults, and much more if your study includes children or other "vulnerable populations". There is a whole list of exclusion criteria that you have to get past before your study can be approved and you can start seeking funding (some of which may be difficult to prove or justify to the IRB), you need parental permission and the child's assent (which also may be difficult to prove, and doubles your chances of losing a subject), risk assessment and the associate requirements/protections are handled differently, and so on.

Here are some resources if you want more details:

http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html#...

http://grants.nih.gov/grants/guide/notice-files/not98-024.ht...

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