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The Man With the Golden Blood

dmr001 Re:rare or just not looked for? (75 comments)

I hope you'll (all) forgive me for furthering this part of the discussion, but in my line of work I continue to be mystified about how, say, sin brought about by mankind can result in two very nice, even very religiously adherent parents having a fetus who gets pretty severely bollixed (via isoalloimmunization as above, or the odd infection crossing the placenta, or a bit of chromosome scrambling) and dies before being born? (Or just about as bad, dies in their parents arms shortly after being born?)

My sincere apologies if you think I don't care about this question; it's one of several I care about very much and have great difficulty reconciling. The hospital chaplains' best explanations have amounted to, "Jesus said 'Suffer little children, and forbid them not, to come unto me., for such is the kingdom of heaven." Realizing that KJV usage has a different connotation for suffering, there's still a lot of suffering. I've never thought to say to one of these parents that this must be the result of sin. If you have a better explanation I could use to comfort the afflicted - afflicted, in this view, somehow by original sin which seems awfully distant - I'd love to hear it.

2 days ago
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The Man With the Golden Blood

dmr001 Re:rare or just not looked for? (75 comments)

In the US, when you donate blood, you'll be tested for ABO/Rh, and some of the more "minor" blood antigens (minor insofar as they are less frequently implicated in transfusion reactions and pregnancy-related alloimmunization. Most pregnant women will get, in addition to ABO and Rh-D testing, tested with an antibody screen for sensitivity to antigens from other alleles on the Rh locus, Rh-C and Rh-E. The antibody screen also tests for anti-Kell (anti-K, typically the worst of the more minor antigens; we're taught "Kell kills"), anti-Duffy (Fy(a) and Fy(b)), and sometimes anti-Kidd antigens, and once in a while you'll see anti-P, anti MNS, and anti-Lewis, which typically cause little or no harm. (See this Medscape article for a few details.)

The deal is if you are (say) an Rh positive fetus in an Rh negative mom who was previously exposed to another fetus's D antigens (and D is often the culprit) you can get your blood cells nailed by mom's previously-formed anti-D antibodies. You get anemia, jaundice as well, and the potential various bad side effects therefrom (heart damage, brain damage, swelling all over[may not be safe for work]). Similar havoc ensues with anti-K. Preventive therapy with RhoGAM is available to prevent anti-D disease; it's a soup of anti-D antibodies that scavenge any fetal Rh-D positive blood cells that happen to find their way into mom's circulation. It's produced from pooled human blood plasma, though even most Jehovah's Witnesses (since a 1974 church opinion) and Jews (because there's an escape hatch in kashrut for saving human life) find it acceptable for treatment in order to prevent this fairly terrifying surprise G-d had in store for a few unlucky babies.

4 days ago
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Man Booted From Southwest Flight and Threatened With Arrest After Critical Tweet

dmr001 Re:Customer service? (928 comments)

Sure, you can sit with my two young children since I boarded last on Southwest and no adjacent seats were available. Don't give candy to the girl, and if they fight threaten to take away the iPad.

about 3 months ago
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Wireless Contraception

dmr001 Re:Interesting idea but likely horrific in practic (302 comments)

I think you're probably right in a lot of cases, but what I think this proposal is getting at is that right now we have a single contraceptive implant on the market that needs to be swapped out every 3 years. And, swapping it out means numbing up the area (which smarts), making a 1 cm incision with an 11 blade and fishing around with mosquito clamps to get the Nexplanon out which is often encapsulated with connective tissue and it doesn't want to come out, then injecting another one in. What if it could be turned on and off according to whether the woman wanted to have kids or was abstinent for awhile, so then we can avoid excess poking and prodding and hormones? If we could make that secure, would it be worth it? The cost of the Nexplanon in the US isn't much related to its materials (perhaps $5) as to the research costs and insurance and pharmaceutical company marble toilets with gold handles ($700). Couldn't an electronic Nexplanon with extended duration reasonably be cost effective if we can avoid the excess minor surgery, physician visits, and unintended babies?

about 4 months ago
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Wireless Contraception

dmr001 Re:Hmm (302 comments)

Strictly speaking, in the US, we're not paying people to have kids but paying for people who have already had kids to have baby food and clothing and medical care. Even in places where people don't get government support for their kids, they still have plenty of kids - as I think you may be alluding to in your second paragraph but I confess confusion about how reactionary undereducated dicks are particular to Pakastani folks and not, say, Kentuckians.

Government-supported access to contraception is likely highly cost effective - it makes not just intuitive sense, but studies seem to bear this out. Without all the bother of just letting teen moms and their homeless kids, you know, die in the streets and spread measles all around.

about 4 months ago
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California Whooping Cough Cases "an Epidemic"

dmr001 Re:Mexico Vaccinates Better Than The US (387 comments)

In the Unicef document I referenced, the definition given is: "DPT3 - Percentage of infants that received three doses of diphtheria, pertussis (whooping cough) and tetanus vaccine," 99% for Mexico in 2012, and 95% for the US, respectively. The way I'm reading that the Government funding of vaccines is simply the percentage of those given that were funded by the government, like the Vaccines for Children Program in the US (which funds Medicaid and uninsured vaccines), but that 95% percent of the vaccines (say, in the US) were given by VFC - it's closer to 50%. In any event, the WHO numbers you cited are from the same source - it's just that from 2012 to 2013, Mexico went from 99 to 86% DTP3 coverage, and the US from 96 to 94%. The overall trend from 2000 is still 94-96% for the US, whereas Mexico was 97-99% until 2013. I don't know what happened in 2013; I practice family medicine in the Pacific Northwest, in a clinic that serves a large immigrant population, and have gotten a fair amount of practice scrutinizing foreign pediatric immunization cards. I think you may have misread the data source explanations in the Unicef document. I can tell you that, in general, in my experience, my Mexican families think vaccines are a good way to protect their kids. My upper class white families tend to have considerably more skepticism.

about 4 months ago
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California Whooping Cough Cases "an Epidemic"

dmr001 Re:Mexico Vaccinates Better Than The US (387 comments)

You might look into the epidemiology of tuberculosis - where the US vaccination rate (of BCG vaccine for TB) is about 0, and it's on the standard schedule of vaccinations in Mexico. There's no particularly good vaccine for TB, but it's the US that has the whooping cough epidemic, not Mexico. See http://latimesblogs.latimes.co....

about 4 months ago
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California Whooping Cough Cases "an Epidemic"

dmr001 Re:Mexico Vaccinates Better Than The US (387 comments)

You can readily see that vaccination rates are higher in Mexico by checking out UN statistics here: http://www.unicef.org/infobyco... (and comparing to, say, http://www.unicef.org/infobyco...). In my experience as a medical professional vaccinating children, uptake rates remain about 100% in first through third generation Mexican and Central American immigrants, and lower in whites - especially, oddly, those of higher socioeconomic strata.

Tuberculosis tends to spread in crowded conditions and where treatment is not readily available - but treatment is different than vaccination. Mexico does routinely vaccinate against TB (with BCG vaccine, which sorta works); the US doesn't. Latent tuberculosis, for what it's worth, is about equally prevalent in migrant populations from Eastern Europe in my part of the world (Pacific Northwest United States), who tend to be legal immigrants. See http://ethnomed.org/clinical/t... for pretty graphs.

about 4 months ago
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California Whooping Cough Cases "an Epidemic"

dmr001 Re:So there's 100 or so unimmunized? (387 comments)

Mexican kids tend to have at least as high vaccination uptake as US kids. (I say this based on personal experience as a primary care physician taking care of a population with lots of Mexican immigrants who keep their vaccination cards, and based on data you can Google easily: http://www.vaccinationnews.org..., and http://www.unicef.org/infobyco... which shows Mexican DTP rates around 99%, compared to the United States, which is 93% by the third dose.)

So, I wouldn't look so strongly at Mexico, as I would at San Diego, which is the backyard of Dr Bob Sears and his Vaccine Book. He promulgates a non-evidence-based Alternative Schedule that more or less gives privileged white parents permission to be suspicious of the pro-science crowd. (See http://pediatrics.aappublicati... for cogent commentary on the same.)

With a panel of about 2000 patients, I've got more or less 0 vaccine refusers among my Mexican and Central American population, which correlates well with the Unicef data cited above.

about 4 months ago
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Measles Outbreak In NYC

dmr001 Re:Dunno (747 comments)

Complications of measles depend on the setting - and though it's hard to surmise about your case in particular (you were "pretty sure" you had measles) the case fatality rate is up to 4-10% in developing countries (probably due to poor nutrition, but other folks at risk include being pregnant, old, or very young) due to brain inflammation or pneumonia. In developed countries the risk is lower, and we have nice expensive ICU's to care for people in - until we don't - in my city, we were running out of ICU beds for folks with influenza pneumonia this past year.

Cherry JD. Measles virus. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, et al (Eds), Saunders, Philadelphia 2009. p.2427.

Bernstein DI, Schiff GM. Measles. In: Infectious Diseases, Gorbach SL, Bartlett JG, Blacklow NR (Eds), WB Saunders, Philadelphia 1998. p.1296.

about 8 months ago
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Why a Cure For Cancer Is So Elusive

dmr001 Re:Money (366 comments)

It's an interesting claim that apparently all cancer researchers feel there is so much money to be made in grants, they are careful to reject novel ideas that might lead to cure for cancer so they can securely remain on the gravy train. By interesting, I mean for what it reveals about how people think. Hanging around the parking lots of university-based research facilities did not yield a surfeit of expensive cars. And while a good argument can be made for the plodding progress of research despite all the pink ribbons, breast cancer mortality is in fact steadily decreasing - even for women with tumor that's spread to lymph nodes. From the same website, you'll see even more impressive progress in colon cancer mortality, lung, and prostate cancer, which rounds out the list of the most common fatal cancers.

In some sense, increasing cancer mortality likely results from people in industrialized nations being killed less often by other stuff (cars, emphysema, smallpox, contaminated water). And walking 10 km (on a regular basis) probably has significantly decreased cancer mortality, probably by changes in hormone balance and metabolism. Cancer research may not always be flashy, but they do seem to dig up useful stuff over time.

about 10 months ago
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Researchers Use Electroconvulsive Therapy To Disrupt Recall of Nasty Events

dmr001 Re:Erase all button (96 comments)

ECT gets a bad rap because it looks sadistic and no one quite knows how it works. On the other hand, it's effective - more effective than most other forms of depression treatment, and has the benefit of working when nothing else does. (Remission is severe depression is 70-90% with ECT vs 30% with a typical SSRI pill.) I've had patients who desperately wanted to be dead because each passing moment was filled with unbearable psychic pain, who after 3 treatments of ECT (with pulses lasting a few milliseconds) were smiling and chipper. (Albeit with some unpredictable holes in their memories.)

Moreover, contrary to One Flew Over the Cuckoo's Nest, modern treatment insists patients have voluntary, informed consent. This data isn't exactly hard to come by - Google ECT PubMed. In the US, unfortunately, ECT can be hard to come by, given attitudes such as that expressed by the parent poster, and I suspect reimbursement isn't that great (patients get general anesthesia for a few minutes, which isn't cheap, but US Medicare reimbursement for psychiatry is notoriously poor such that most psychiatrists don't take Medicare).

about 10 months ago
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Ask Slashdot: Working With Others, As a Schizophrenic Developer?

dmr001 Re:Good luck (218 comments)

I suspect the parent poster and I are in some sort of agreement: if you've got a trustworthy clinician and you both agree it's reasonable to go off of antipsychotics with careful monitoring you'd have my best wishes. As a physician caring for community-dwelling (as opposed to institutionalized) patients with schizophrenia and other significant mental illness, I don't get to see too many such patients, and though I cannot locate trial data my experience tells me such patients are relatively rare. I do get to see a fair number of folks with active hallucinations and prominent paranoia who do not want to take their pills, and who have what the average person would consider to be impaired judgment and insight - e.g., I will not take the pills as the CIA has placed GPS beacons in them to beam thoughts into my mind because I am a prophet and they are agents of darkness. (See, it's tricky when some non-bizarre delusions over time increasingly resemble the truth.)

For some patients (perhaps about half) long-term outcomes for schizophrenia are reasonably functional. (Harding CM et al, The Vermont longitudinal study of persons with severe mental illness, Am J Psychiatry 1987: 144: 718.) For the other half, even on medication, they progressively deteriorate. It's a bummer for probably all of the latter and many (most?) of the former to not take their medicine, for everyone - they don't seem any happier, as agitation and paranoia tend to increase, and unmedicated psychosis is where ideas about pushing people in front of buses ferment. My sympathy is firm: I wouldn't want to take the pills either, what with varying degrees of fatigue (though this usually abates in most patients after a few weeks), weight gain, increasing cholesterol and blood sugar. I feel bad about the guys gesticulating wildly on the street, and though it's arguable their fate is better off than when us North Americans routinely institutionalized such people, it's hard not to feel they've been abandoned.

I'm not aware of antipsychotics causing physical or psychological dependence (using the clinical meaning of drug dependence), and I'm not aware of habituation either. I'd be interested in any such references. If I can get patients to take the pills, they do not seem to need more antipsychotics over time, nor do they withdraw when they stop taking them. I'm truly happy for people who can safely manage their hallucinations without medication, but for a great many patients - probably most - they really seem better off on antipsychotics.

about 10 months ago
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Ask Slashdot: Working With Others, As a Schizophrenic Developer?

dmr001 Re:Good luck (218 comments)

Attempting to treat an honest-to-goodness thought disorder like schizophrenia without medication is akin to treating near-sightedness with counseling. There's a place for cognitive therapy in schizophrenia but it's considered adjunctive treatment (among mainstream practitioners). There are a smattering of schizophrenics who can ignore auditory and visual hallucinations that are the hallmark of the disease, and anti-psychotics may indeed make some people feel less sharp (though that isn't universal). I'd wager that most people with schizophrenia are more capable of getting things done when they aren't beset by what are typically very vivid and often intrusive hallucinations. There are, of course alternative viewpoints, such as that of the Church of Scientology.

about 10 months ago
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Why Organic Chemistry Is So Difficult For Pre-Med Students

dmr001 Re:I agree... (279 comments)

Something like 20 new medical schools have opened in the US since 2005. Moreover, non-physician providers (including physician assistants, nurse practitioners, and naturopaths) are joining the system of both primary care providers and specialists. (I get to co-manage patients, now, with naturopathic oncologists, for example.)

I have not noted any downward pricing trend.

I have noted a lot of advertising from medical groups, however - in newspapers, sponsoring the weather on television, on billboards, and stadium walls. Not from new doctors coming to town, for the most part, since in most metropolitan areas small practices are increasingly being replaced by larger groups with more negotiating power or owned by hospital systems. That also doesn't seem to have improved pricing.

In most primary care practices I know of, you can typically make a same day appointment. I'd rue the day, however, you found an empty waiting room - that doesn't seem like the most efficient use of resources (especially given that physicians nearly all go through federally financed residencies in the US, and medical school itself elsewhere).

about a year ago
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Ask Slashdot: Suitable Phone For a 4-Year Old?

dmr001 Re:4 years (682 comments)

I know this is an incredibly unpopular thing to say right now, but consider that the first thing we do to a new child born into this world is to slap them in the face. Why would we do that? Willingly induce pain to a brand new life that literally hasn't even been in the world a minute? It's to induce breathing. To get that child sucking down yummy nitrogen-oxygen mixtures. The pain is for the benefit of the child. All too often, letting a child learn something "the hard way" is seen as child abuse, but the reality is that human beings don't learn things by being told, they learn things by doing. And a lot of doing involves screwing up and getting hurt.

I'm all for experiential learning, but I don't know anyone who slaps newborns in the face to get them breathing. (N.B.: I deliver newborns for a living, and work with a bunch of other people who do as well and am aware of their practice patterns.) Babies usually squall on their own just fine, and for those that don't we'll vigorously towel-dry them. For the even smaller subset who're affected by maternal drugs or other conditions and haven't gotten it together to breathe, we'll flick their feet with a back of a finger (along with verbal encouragement, albeit mostly for our own amusement and by way of explanation to concerned parents). If they're still not sucking down oxygen after a couple of minutes then they get a mask to the face or a tube down the trachea. The previous practice of slapping newborns on the ass to kickstart them has been out of fashion ever since I started practice. Of course, practice patterns vary and maybe you live in a face-slapping place.

The ass-slapping turns out to be unnecessary, though I have stood by while my own children attempted to snort juice up into their noses for an experiential lesson in why we might not do that.

about a year ago
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Obamacare Employer Mandate Delayed Until After Congressional Elections

dmr001 Re:Oh, look! Just what the economy needs! (600 comments)

New Zealand, Australia, and Chile all have compulsory government-mandated healthcare (and still manage to spend less than we do with reasonable outcomes). I suppose it's possible that Obama came up with the ACA in order for it to fail so he could move us to a socialized system - supposing he could convince Congress based on that failure to pass such a system. Which doesn't seem real likely when think about it, does it? I think you can make some arguments about tyranny in the US, but I don't think the ACA is a very convincing argument. (More than, say, compulsory car insurance.)

about a year ago
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Med Students Unaware of Their Bias Against Obese Patients

dmr001 Re:anti-fat stigma (446 comments)

Citations, please.

Cognitive behavioral therapy compared with active control has been shown in multiple studies to produce persistent benefits, including decreased fatigue and better physical function. One trial even showed Internet-based cognitive therapy helpful (including 85 vs 27% absence of severe fatigue, and 78 vs 20% normal physical functioning).

Graded exercise therapy has been shown in randomized trials to improve fatigue and physical functioning (albeit not always with overwhelming success, such as 51% vs 27% self-rated improvement).

I'm always happy to challenge my assumptions, but I cannot find any references in a brief search of the literature to suggest that appropriate exercise in chronic fatigue is harmful or worsens cognitive functioning, or that it decreases energy or promotes anhedonia (lack of enjoyment in life). It's possible exercise had these effects on you, but I confess I'd wonder if you might benefit from a more organized graded exercise regimen perhaps with the initial supervision of a physical therapist conversant with chronic fatigue - it may not be something you can start out on your own - graded exercise really means starting out more gently than people may otherwise think is beneficial.

White PD, Goldsmith KA, Johnson AL, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 2011; 377:823.
Sharpe M, Hawton K, Simkin S, et al. Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. BMJ 1996; 312:22.
Deale A, Chalder T, Marks I, Wessely S. Cognitive behavior therapy for chronic fatigue syndrome: a randomized controlled trial. Am J Psychiatry 1997; 154:408.
Deale A, Husain K, Chalder T, Wessely S. Long-term outcome of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome: a 5-year follow-up study. Am J Psychiatry 2001; 158:2038.
Fulcher KY, White PD. Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. BMJ 1997; 314:1647.
Sharpe M, Wessely S. Putting the rest cure to rest--again. BMJ 1998; 316:796.

about a year and a half ago
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Med Students Unaware of Their Bias Against Obese Patients

dmr001 Re:anti-fat stigma (446 comments)

Your doctor may indeed be a dick, and if he's truly blaming you he's certainly not being fair or helpful. Among my patients with reactive arthritis, they find exercise challenging and they complain of pain but it doesn't seem to be much more of a barrier to them than patients with non-inflammatory arthritis - for whom the most useful therapy I probably prescribe is appropriate exercise. For chronic fatigue syndrome (I suspect that's the CFS you're talking about) the mainstays of treatment are cognitive behavior therapy and exercise. As you might expect, lack of exercise in chronic fatigue sufferers worsens the symptoms of physical weakness. Overly ambitious exercise can worsen symptoms in chronic fatigue sufferers, but that's a prescription for graded exercise regimens. Everyone feels more tired after exercise - more so in chronic fatigue - which makes initiation and maintenance of an exercise regimen more challenging.

Your doctor may be frustrated because he doesn't know how to help you, or because he doesn't have enough time to provide the help you need. Most of us really did get into this profession to help people (in my experience anyway) and when a patient can't readily be helped despite our efforts I confess you may see my frustration leaking through.

I hope you can find someone more sympathetic, but I suspect what's going to be most successful for you is someone who can help figure out a way for you to effectively exercise without making you more miserable.

about a year and a half ago
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Med Students Unaware of Their Bias Against Obese Patients

dmr001 Re:anti-fat stigma (446 comments)

Probably the most common underlying cause of post-operative infections in the typical C-section incision is obesity. If much of the subcutaneous tissue is fat (easier for fluid collections to form), or there is a large pannus (fold of fat at the bottom of the belly) leading to poor wound drainage and colonization with various skin bacteria, one is asking for trouble. Other risk factors for surgical site infections in general include age, smoking, and diabetes.

1.SHEA, APIC, CDC, SIS. Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol 1992; 13:599.
2.Cruse PJ. Surgical wound infection. In: Infectious Diseases, Wonsiewicz MJ (Ed), WB Saunders Co, Philadelphia 1992. p.758.

about a year and a half ago

Submissions

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Lack of vaccination sends babies in Oregon to the hospital

dmr001 dmr001 writes  |  more than 2 years ago

dmr001 writes "In its fortnightly Communicable Disease newsletter, Oregon Public Health officials note increasing cases of pertussis (whooping cough) in infants, with 146 hospitalizations noted in the 2 year period ending March 2011, and at least 4 deaths since 2003. Most cases are attributed to lack of vaccination, with 86% of those due to parents declining the vaccine. "Most of our cases are occuring in under- or unvaccinated children, so getting these kids vaccinated seems to the most obvious approach to reducing illness. In priciple... pertussis could be eradicated; but we have a long way to go.""
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