Coronavirus

[Irvrobinson]

Also, on TV tonight, someone in the medical circles was mentioning that the flu vaccine was not as effective for older people.

This is correct, but there is a version of the flu vaccine intended for older patients which has four times the antigen dose as the normal vaccine. Supposedly that addresses the issue. I got it this year for the first time.

Fluzone High-Dose Seasonal Influenza Vaccine

Learn about Fluzone Quarivalent High Dose Flu Vaccine

www.cdc.gov

 

[TLS Guy]

TLS,

I'm not sure when you retired. If you do go back you have even greater respect from me than I already have because I know how difficult it would be to be a rusty doctor, just as if they called me back to the wards after 30 plus years.

Aside from the obvious cautions, much may have changed since you retired. If you were used to writing notes and orders by hand you will be in for a big shock. Beginning with Obamacare which mandated electronic records every hospital has gone to fully computerized charting. There are relatively few vendors and the products are basically horrible. Designed by software engineers with little or no input from practicing doctors in hospitals.They seem mostly designed for hospital administrators to keep track of supply usage and ordering patterns rather than smooth user interfaces. The system I use takes me ten times longer than writing by hand in part because I don't use it much. It is also much harder to find results.

One example on the product my system uses. Based upon the stated admitting diagnosis, the computer would recommend imaging tests. The were not based upon consulting with a radiologist or using the publicly available American College of Radiology Appropriateness Criteria which were carefully derived by experts in the field based upon exhaustive literature review (I have colleagues who have written several and told me how hard it was). Instead these software idiots did an iterative search of the internet and found articles to support recommendations. The result was that for a diagnosis of urinary tract infection they suggested contrast enhanced ultrasound as the first test based upon one article from Europe with a small set of patients. At the time ultrasound contrast agents were NOT FDA approved in this country.

If you do have to go back, good luck!

Yes, those are also my sentiments exactly. I would not be overly worried about the computer but I would expect problems. However our hospital and clinics were early adopters of the electronic medical record. One of my hats was technology assessment. I was a member of our information technology steering committee from its inception until I left. I'm sorry if I was one of the creators of your problems. I know what you mean. However these types of processes can be very useful in, for instance, making sure correct protocols are instituted when a patient hits the ER with suspected sepsis. Like everything about any technology it has its uses and abuses.

I only really considered that this could happen in a conversation with our retired surgeons yesterday. He had had a long conversation with one of our excellent former surgical residents out in Montana. Apparently they are in crisis in Bozeman Montana. He specifically mentioned my name and said they could do with me there. The former resident was of the opinion some of us older guys may get pressure to return to service. I really hope it does not come to that.

 

[Irvrobinson]

It seems we need a quick primer on Vitamin D.

There are two sources of vitamin D. The major source is skin synthesis from sunlight, however there are huge racial differences. The other source is in our food. It is fat and not water soluble and is itself an oil.

Now somewhat paradoxically Caucasians synthesize vitamin D from sun light in much greater quantities than black skinned people of African origin and other dark skinned races in general.

Now Caucasians who tan synthesize vitamin D at the highest rate of all from sunlight.

Now Vitamin D is not readily excreted in large quantities. So I suspect that these racial differences in synthesis are related to hours and intensity of sunlight at the area of the globe of origin. As you go to the poles there is less sunlight than at the equator.

Now as I think you know I set up and lead the nutrition support team at our hospital for 30 years, mainly to support very sick patients through prolonged critical illness.

Our population was heavily northern European Caucasian. I pretty much never saw Vitamin D deficiency , but I did see toxicity.

You should only supplement vitamin D in the winter and then never at over 1000 units per day. Taking more than that is dangerous. If you are a Caucasian that tans I would not supplement vitamin D at all.

My recent case was interesting. I am a Caucasian that tans easily. Now over the years I had two slightly elevated blood calcium levels. I never really paid much attention. However when my left hip prosthesis started to loosen 18 months or more ago, I started to wonder if I had hyperparathyroidism. So I pushed my local quack into doing blood tests I requested. Despite my calcium being normal I had unequivocal evidence of hyperparathyroidism. This was confirmed at Mayo clinic and I had the offending tumor removed a year ago. Now this disease leeches calcium from the bones which was why my hip was loosening. So the endocrinologist had me take 1000 units of vitamin D a day. My calcium went up and I quickly showed vitamin D toxicity! So that was fast demonstration of having to be careful with vitamin D in Caucasians who tan! I'm glad to report that my hip showed good prompt new bone growth at the stem without vitamin D and calcium supplements.

The bottom line is that there is a load of dangerous and bogus information about vitamin D and it is spilling into this thread.

I will say this, Mark, you use the same high-contrast tone full of absolutes when speaking about healthcare issues as you do about audio. The problem is that for most of us non-experts it is difficult or impossible to judge between the conflicting advice of MDs and other experts.

For example, for years dermatologists have been prescribing vitamin D supplements for people with psoriasis. I have a mild case that occasionally rears its ugly head, and two different dermatologists told me to take vitamin D. In addition, I have idiopathic neuropathy. Three neurologists over the years have not found any evidence of multiple sclerosis, based on MRI results, but they too mentioned that there were correlations between MS and vitamin D deficiency, and suggested that I stay on vitamin D supplements basically forever.

I generally restrict my medical online information searches to the NIH, the CDC, and the Mayo Clinic, mostly because as a layman I don't trust the information from anyone else, since I can't judge it. These two links seem to contradict your dosing advice:

Office of Dietary Supplements - Vitamin D

Vitamin D overview for health professionals. Research health effects, dosing, sources, deficiency symptoms, side effects, and interactions here.

ods.od.nih.gov

Vitamin D might improve MS symptoms

Some research suggests that vitamin D may reduce the risk of multiple sclerosis (MS).

www.mayoclinic.org

Reading your warnings gives me pause about taking any vitamin D supplements, especially since I tend to eat salmon at least twice per week and eat other fortified foods. On the other hand, I have no way to judge your opinion versus other professionals with equal or better credentials. I'm not asking your advice, but merely trying to give you a glimpse of what I'll call "the patient's dilemma" of who to believe about what.

 

[Dan]

Yes, those are also my sentiments exactly. I would not be overly worried about the computer but I would expect problems. However our hospital and clinics were early adopters of the electronic medical record. One of my hats was technology assessment. I was a member of our information technology steering committee from its inception until I left. I'm sorry if I was one of the creators of your problems. I know what you mean. However these types of processes can be very useful in, for instance, making sure correct protocols are instituted when a patient hits the ER with suspected sepsis. Like everything about any technology it has its uses and abuses.

I only really considered that this could happen in a conversation with our retired surgeons yesterday. He had had a long conversation with one of our excellent former surgical residents out in Montana. Apparently they are in crisis in Bozeman Montana. He specifically mentioned my name and said they could do with me there. The former resident was of the opinion some of us older guys may get pressure to return to service. I really hope it does not come to that.

Yes I have seen a vast improvement in sepsis care and early recognition thanks to these automated triggers. The sepsis seems to work very well. The possible cord compression for us does not. We are bombarded with requests for whole spine STAT MRIs to rule out cord compression and so far the yield has been very poor. Of course we have to drop everyhting to read these due to the urgency and so fall behind. I think in a few years it will work much better but I won't be around to see it.

Again if you do go back good luck. It's a noble and brave thing. I have great respect for the really talented intensivists.

 

[panteragstk]

I will say this, Mark, you use the same high-contrast tone full of absolutes when speaking about healthcare issues as you do about audio. The problem is that for most of us non-experts it is difficult or impossible to judge between the conflicting advice of MDs and other experts.

For example, for years dermatologists have been prescribing vitamin D supplements for people with psoriasis. I have a mild case that occasionally rears its ugly head, and two different dermatologists told me to take vitamin D. In addition, I have idiopathic neuropathy. Three neurologists over the years have not found any evidence of multiple sclerosis, based on MRI results, but they too mentioned that there were correlations between MS and vitamin D deficiency, and suggested that I stay on vitamin D supplements basically forever.

I generally restrict my medical online information searches to the NIH, the CDC, and the Mayo Clinic, mostly because as a layman I don't trust the information from anyone else, since I can't judge it. These two links seem to contradict your dosing advice:

Office of Dietary Supplements - Vitamin D

Vitamin D overview for health professionals. Research health effects, dosing, sources, deficiency symptoms, side effects, and interactions here.

ods.od.nih.gov

Vitamin D might improve MS symptoms

Some research suggests that vitamin D may reduce the risk of multiple sclerosis (MS).

www.mayoclinic.org

Reading your warnings gives me pause about taking any vitamin D supplements, especially since I tend to eat salmon at least twice per week and eat other fortified foods. On the other hand, I have no way to judge your opinion versus other professionals with equal or better credentials. I'm not asking your advice, but merely trying to give you a glimpse of what I'll call "the patient's dilemma" of who to believe about what.

I think the main takeaway is more along the lines of "ask your doctor/s" instead of "read articles on the internet and begin supplementing."

Too many people read things on the internet and (as you stated) take them as gospel that applies to everyone. That is not reality. Sure, there are probably plenty of people that could benefit from supplementing certain vitamins, but those are people with specific needs. Everyone is told to take a multivitamin which has show to be pretty pointless if you have a good diet.

This is why I ask so many questions of my doctors. I want as much information as possible. I research EVERYTHING, but not when it comes to medical science that applies to me. That's only because I don't want to bias myself against a trained professional. I want to be informed, but not to the point I start hurting myself with potentially bad information.

 

[Verdinut]

Scientists Call to D*action:

Scientists’ Call to D*action for Public Health - GrassrootsHealth

48 vitamin D researchers agree that vitamin D levels of 40-60 ng/ml (100-150 nmol/L) are safe, inexpensive and lead to a reduction in illness and health care costs.

www.grassrootshealth.net

 

[Verdinut]

This is correct, but there is a version of the flu vaccine intended for older patients which has four times the antigen dose as the normal vaccine. Supposedly that addresses the issue. I got it this year for the first time.

Fluzone High-Dose Seasonal Influenza Vaccine

Learn about Fluzone Quarivalent High Dose Flu Vaccine

www.cdc.gov

Well, at the TV news, there was no mention of a different vaccine for the older generation. Possibly it's not available in Canada.

 

[TLS Guy]

I will say this, Mark, you use the same high-contrast tone full of absolutes when speaking about healthcare issues as you do about audio. The problem is that for most of us non-experts it is difficult or impossible to judge between the conflicting advice of MDs and other experts.

For example, for years dermatologists have been prescribing vitamin D supplements for people with psoriasis. I have a mild case that occasionally rears its ugly head, and two different dermatologists told me to take vitamin D. In addition, I have idiopathic neuropathy. Three neurologists over the years have not found any evidence of multiple sclerosis, based on MRI results, but they too mentioned that there were correlations between MS and vitamin D deficiency, and suggested that I stay on vitamin D supplements basically forever.

I generally restrict my medical online information searches to the NIH, the CDC, and the Mayo Clinic, mostly because as a layman I don't trust the information from anyone else, since I can't judge it. These two links seem to contradict your dosing advice:

Office of Dietary Supplements - Vitamin D

Vitamin D overview for health professionals. Research health effects, dosing, sources, deficiency symptoms, side effects, and interactions here.

ods.od.nih.gov

Vitamin D might improve MS symptoms

Some research suggests that vitamin D may reduce the risk of multiple sclerosis (MS).

www.mayoclinic.org

Reading your warnings gives me pause about taking any vitamin D supplements, especially since I tend to eat salmon at least twice per week and eat other fortified foods. On the other hand, I have no way to judge your opinion versus other professionals with equal or better credentials. I'm not asking your advice, but merely trying to give you a glimpse of what I'll call "the patient's dilemma" of who to believe about what.

Using vitamin D ointment is not the same as ingesting it and will not cause a problem.

If vitamin D is recommended on a might help basis that is fine. What has to happen then though is monitoring serum calcium and vitamin D levels.

What you are doing is using vitamin D as a drug. Now drugs have a dose. What I can say that genetic skin tones and racial issues affect the dose. That means when used as a drug it actually does have a defined therapeutic window and like many others needs to be monitored by blood tests. There are very many drugs that have huge therapeutic windows and do not need to be monitored. Vitamin D has a relatively narrow window and significant toxicity if blood levels are too high. That is the point.

 

[TLS Guy]

Well, at the TV news, there was no mention of a different vaccine for the older generation. Possibly it's not available in Canada.

It is available in Canada. The problem is that some people administering it, do no know the correct dose for seniors. I have personally had to provide corrective education. This issue is not mentioned in ads here either by the way.

 

[Irvrobinson]

Using vitamin D ointment is not the same as ingesting it and will not cause a problem.

I did get a prescription for an ointment, but it was Vanos, not vitamin D. I only use it for an occasional annoying outbreak, because it is obviously a steroid. The recommendations I was discussing from them were for an oral supplement.

If vitamin D is recommended on a might help basis that is fine. What has to happen then though is monitoring serum calcium and vitamin D levels.

Every year I do get various blood tests, and by chance I just got a physical last month so I have recent test results. My calcium level looks completely normal at 9.4 mg/dl. Unless I just don't know exactly what to look for, the panels run did not specifically include a vitamin D test.

What you are doing is using vitamin D as a drug. Now drugs have a dose. What I can say that genetic skin tones and racial issues affect the dose. That means when used as a drug it actually does have a defined therapeutic window and like many others needs to be monitored by blood tests. There are very many drugs that have huge therapeutic windows and do not need to be monitored. Vitamin D has a relatively narrow window and significant toxicity if blood levels are too high. That is the point.

Got it.

FWIW, I appreciate your more measured tone in this response.

 

[3db]

Why is Trump moving troops closer to the border?

 

[JerryLove]

I said the exceptions are assigning powers and authorities to the branches of government. That's in Article I, which is everything you quoted. Then there's the rest of the Constitution. Did you read that Jerry? Like almost every other article and amendment? Most of what defines personal rights are expressed as what the government shall not do, and I was referring specifically to the restriction of rights.

Shall I go on?

Before you do go on, let's see if you are correct and "the rest of the constitution [other than Article I] is "an entirely negative document; the federal government may not do this or not do that.

Article 2:
" The President shall be Commander in Chief of the Army and Navy of the United States, and of the Militia of the several States, when called into the actual Service of the United States; he may require the Opinion, in writing, of the principal Officer in each of the executive Departments, upon any Subject relating to the Duties of their respective Offices, and he shall have Power to grant Reprieves and Pardons for Offences against the United States, except in Cases of Impeachment. "

Does that not count either?
Article 3:
"The Congress shall have Power to declare the Punishment of Treason, but no Attainder of Treason shall work Corruption of Blood, or Forfeiture except during the Life of the Person attainted. "

Article 4:
"A Person charged in any State with Treason, Felony, or other Crime, who shall flee from Justice, and be found in another State, shall on Demand of the executive Authority of the State from which he fled, be delivered up, to be removed to the State having Jurisdiction of the Crime. "

Article 5:
The Congress, whenever two thirds of both Houses shall deem it necessary, shall propose Amendments to this Constitution

Article 6
All Debts contracted and Engagements entered into, before the Adoption of this Constitution, shall be as valid against the United States under this Constitution, as under the Confederation.

Shall I go on? Tell me how these are "entirely negative" and what "the federal government may not do".

By the way, as long as I'm yielding to temptation and responding to you (I should know better), your reply about supercomputing some yards back was incomprehensible. There is no such language as "Java 2020", and supercomputing would never use Java anyway because it's an interpreted language with dynamic heap-managed memory allocation requiring periodic garbage collection.

Apologies. I obviously assumed a level of literacy in the target audence that was not there.

Unfortunately, I'm not sure how best to put the idea of hardware abstraction and its relationship to virtualization into context to someone without a basic level of reference (someone who would understand my Java comparison). If you are interested in some reading materials, I can provide some references. I'll see if I can find some layman-level stuff.

Multi-platform sofware development and analysis is a good part of my job (with an emphasis on optimizations like the ones being discussed). I mostly sit at a pretty high abstraction level (what are referred to as "high level programming languages" and even then, mostly within API and Frameworks, which have reasonably strong parallels to the topic *you* raised... but apparently don't understand.

And that whole discussion of asynchronous applications and bots was silly.You should stick to what you know, which is obviously not the Constitution either.

You are just butt-sore that I outed you as a Trump supporter.

 

[Irvrobinson]

Why is Trump moving troops closer to the border?

We're getting ready to attack Canada like we did in 1812? If so, I hope for a better US outcome.

More seriously, what's your source?

 

[TLS Guy]

The Dyson Covent


Sir James Dyson has announced that his company will build 15,000 ventilators.

This ventilator already has passed regulatory approval. As far as I know he is the first non medical company to achieve this feat. The company says they will ship early next month. The UK government says it will order 10,000. The company is donating 5000. I think this is a quite remarkable achievement and another reason why we need to slow the progress of this epidemic.

A comment on an article about this said: - I hope they don't suck!" Knowing the way Sir James designs his products I suspect it will actually be a reliable workhorse far more likely than not, and be around for years to come.

 

[Irvrobinson]

Before you do go on, let's see if you are correct and "the rest of the constitution [other than Article I] is "an entirely negative document; the federal government may not do this or not do that.

Article 2:
" The President shall be Commander in Chief of the Army and Navy of the United States, and of the Militia of the several States, when called into the actual Service of the United States; he may require the Opinion, in writing, of the principal Officer in each of the executive Departments, upon any Subject relating to the Duties of their respective Offices, and he shall have Power to grant Reprieves and Pardons for Offences against the United States, except in Cases of Impeachment. "

Does that not count either?
Article 3:
"The Congress shall have Power to declare the Punishment of Treason, but no Attainder of Treason shall work Corruption of Blood, or Forfeiture except during the Life of the Person attainted. "

Article 4:
"A Person charged in any State with Treason, Felony, or other Crime, who shall flee from Justice, and be found in another State, shall on Demand of the executive Authority of the State from which he fled, be delivered up, to be removed to the State having Jurisdiction of the Crime. "

Article 5:
The Congress, whenever two thirds of both Houses shall deem it necessary, shall propose Amendments to this Constitution

Article 6
All Debts contracted and Engagements entered into, before the Adoption of this Constitution, shall be as valid against the United States under this Constitution, as under the Confederation.

Shall I go on? Tell me how these are "entirely negative" and what "the federal government may not do".


Apologies. I obviously assumed a level of literacy in the target audence that was not there.

Unfortunately, I'm not sure how best to put the idea of hardware abstraction and its relationship to virtualization into context to someone without a basic level of reference (someone who would understand my Java comparison). If you are interested in some reading materials, I can provide some references. I'll see if I can find some layman-level stuff.

Multi-platform sofware development and analysis is a good part of my job (with an emphasis on optimizations like the ones being discussed). I mostly sit at a pretty high abstraction level (what are referred to as "high level programming languages" and even then, mostly within API and Frameworks, which have reasonably strong parallels to the topic *you* raised... but apparently don't understand.


You are just butt-sore that I outed you as a Trump supporter.

I already regret responding to you.

You're so right about my lack of knowledge in computer architecture and engineering. I'll bow to an expert like you.

You and Trell appear to have an obsession with my butt that's making me increasingly uncomfortable. Please keep your personal preferences to yourself.

 

[3db]

We're getting ready to attack Canada like we did in 1812? If so, I hope for a better US outcome.

More seriously, what's your source?

Its all over teh Canadian news

 

[JerryLove]

You're so right about my lack of knowledge in computer architecture and engineering. I'll bow to an expert like you.

Recognizing ignorance is the beginning of knowledge.

You and Trell appear to have an obsession with my butt that's making me increasingly uncomfortable. Please keep your personal preferences to yourself.

See? I try to find something likable about you and you get all squeamish. There's just no pleasing you.

 

[Irvrobinson]

Its all over teh Canadian news

Odd, I can't see any references to such movement on US sites, even using Google. Oh well, I suggest you hunker down. Since Trump's offer to buy Greenland was snubbed, perhaps he's looking to conquer Nova Scotia?

 

[Swerd]

@Irvrobinson as well as others who are interested.

What you are doing is using vitamin D as a drug. Now drugs have a dose. What I can say that genetic skin tones and racial issues affect the dose. That means when used as a drug it actually does have a defined therapeutic window and like many others needs to be monitored by blood tests. There are very many drugs that have huge therapeutic windows and do not need to be monitored. Vitamin D has a relatively narrow window and significant toxicity if blood levels are too high. That is the point.

Vitamin D occurs naturally in humans at very low concentrations. Among its many effects, it's known to act more like a hormone than a classic vitamin enzyme catalyst or co-factor. There are proteins in the nucleus that bind Vitamin D and cause some genes to be actively expressed, while silencing expression of other genes. Because these genes, with Vitamin D response elements in their promoter DNA, are numerous and have different known functions, the effects of Vitamin D are said to be pleiotropic, that is, unusually widespread.

When Vitamin D is used as a drug, this usually involves concentration much larger than anything occurring naturally. Whenever naturally occurring molecules are given at such high doses, the body can respond with mechanisms that deactivate, degrade, and excrete that are much more active than normal. This is true with Vitamin A and retinoic acid, and true with naturally occurring cytokine molecules such as Interferon or interleukin-2 (IL-2) or IL-12. In cancer treatment clinical trials of agents like these, it was found that any positive effect they may have had didn't last long. After about 6-8 weeks of high doses, all effects were lost because the overdose of a naturally occurring molecule switched on another naturally occurring system that countered the high dose.

As TLS Guy mentioned, not all humans are the same. Genetic backgrounds clearly also have an effect on the amount of Vitamin D we can make, utilize, deactivate, and excrete. Vitamin D, unlike some other vitamins, is poorly understood. I would avoid making broad generalizations about it.

 

[Trell]

Recognizing ignorance is the beginning of knowledge.


See? I try to find something likable about you and you get all squeamish. There's just no pleasing you.

He is still smarting and that makes him sulky and speaking in a high-contrast tone full of absolutes, or something