monkburger

1930 all over again.

There’s an important caveat to keep in mind when it comes to food databases, especially those relying on branded or restaurant items:

U.S. law does not require food manufacturers to disclose everything that goes into their products. Under the Code of Federal Regulations (21 CFR § 101.100), there are exemptions to ingredient labeling... An example: flavorings, spices, and incidental additives (like processing aids or anti-caking agents) are not always listed explicitly. Also: proprietary blends and "natural flavors" can legally conceal dozens of chemicals (some synthetic), which consumers have no way of identifying.

Micronutrient data is often estimated or missing from labels and restaurant menus, which limits the accuracy of even the best-intentioned databases. Studies show that the nutritional information provided by restaurants and brands is frequently incomplete or inaccurate, especially when it comes to sodium, sugar, and actual serving sizes. (Urban et al. "The Energy Content of Restaurant Foods Without Stated Calorie Information" ; Labuza et al., 2008 and others)

IMO Food databases are only as accurate as the source data allows. Until food labeling laws mandate full disclosure and third-party verification, apps like this can support health awareness. Still, they shouldn't be treated as precise medical or dietary guidance—particularly for people with allergies, sensitivities, or chronic health conditions that require strict tracking.

What? The AMA is not what it was. What are you, a PGY3?

It’s easy to paint with broad strokes, but sweeping generalizations rarely capture the full picture. Not all of us “gatekeep” or overprescribe, we follow evidence-based guidelines and clinical judgment. When a patient presents with nonspecific fatigue and unintended weight loss, for instance, ordering a CBC, CMP, TSH, and A1C isn’t "unnecessary" it’s standard of care to rule out anemia, metabolic derangements, thyroid dysfunction, or early diabetes. That’s not about revenue.. it’s about ruling out high-risk pathology before it escalates.

As for the AMA, it’s far from perfect, but it doesn’t define the ethos of every practicing clinician. Many of us—regardless of where we trained—are here because we care deeply about patient outcomes, not profit. I don’t dismiss international medical graduates; I’ve worked alongside phenomenal ones. What matters to me isn’t where someone studied, but how they think, how they treat, and whether they practice medicine with integrity.

Healthcare needs reform, no doubt—but assuming every U.S. physician is complicit in systemic issues is reductive. Most of us are doing the best we can within a deeply flawed system.

Just force price transparency. Force drug makers to advertise the selling prices of their drugs, and enforce price discrimination laws. Force insurance and PBM companies to advertise the drug prices if purchased through insurance or PBM. Everybody should be paying the same price. And if not, everyone should be allowed to find out if they can pay a lower price.

And yes, get rid of PBMs. They are toxic middlemen who want their 'cut' for doing nothing at all.

See Gale (2023): https://pmc.ncbi.nlm.nih.gov/articles/PMC10441264/

Profits over patients.

Pharmacies have to have crazy high prices though because PBMs reimburse at such shit rates, based on some percentage of the price given to them. Because if they buy the bottle at $30 and list the price at $60, the PBM contract will only reimburse at the adjusted wholesale price (another made up number), eg: 17% plus a $1.99 dispensing fee. This disgusting math results in getting a loss on the drug.

Even all this leaves out some of the most absurd abuses of PBMs. They set minimum drug copays, have the pharmacy collect a $15 copay for a $5 drug, and have the pharmacy pay the PMB the $10 difference. They make it a breach of contract for the pharmacy to inform the patient this is happening or to charge the $5 and bypass the insurance. The total lack of anything even approaching ethnics is absurd...

The blinding? Functionally useless UNLESS the researchers genuinely believe subjects couldn't tell whether they were in a psychedelic fugue state or on a placebo. The ketanserin condition? A self-congratulatory exercise in proving that a known 5-HT2A antagonist blocks 5-HT2A-mediated effects. Stunning. rolls eyes

Then there’s the pharmacokinetics section, breathlessly confirming that LSD is absorbed, peaks, and is metabolized..just like every other small-molecule drug with hepatic clearance. The BDNF findings? A biochemical footnote with no functional correlation (tossed in for faux mechanistic depth)

The most egregious limitation is the absurdly small sample size (n=16), which utterly cripples its statistical power. The authors throw around p-values without any serious correction for multiple comparisons.. Their confidence intervals (CIs) are embarrassingly wide in several places, making many of their so called significant findings borderline meaningless. For example, their pharmacokinetic (PK) values show ranges so broad (eg: Tmax varying from 0.25–5.0h, CL/F spanning 1.6–22 L/h) that any attempt at a reliable dose-response relationship collapses under basic scrutiny; their p-values dance precariously around the threshold of significance. (There are many more)

If this is what’s guiding psychedelic research, we’re in serious trouble.

I don't care to dissuade you from anything - you are flat-out wrong on things.

In my opinion, hEDS is a real condition, but sick-tok is causing patients to demand from physicians a dx - regardless if they meet the clinical criteria for it or not.

Stick to your lane.

Being 'bad statistics is malpractice' is just wrong on so many levels.

Medical malpractice requires a deviation from evidence-based practice that results in harm.. hEDS is diagnosed based on guidelines, not just "obvious statistical patterns.".. If diagnostic criteria exclude certain patients, that reflects the current medical consensus, not physician incompetence. Med schools teach Bayesian reasoning and differential diagnoses, not just pattern matching.

If I incorrectly diagnosed a patient with hEDS without ruling out vascular EDS (vEDS) and the patient suffered an undiagnosed arterial rupture, that would be actual malpractice.

If a subgroup of less hypermobile hEDS patients exists, the solution is research, not accusing physicians of malpractice for following evidence-based guidelines.

There is clearly an entity of hEDS with a yet-to-be-discovered gene. However, the clinical criteria are not very specific and the diagnosis has been given out both for people who don’t fit the criteria and for people who do but are unlikely to have the originally intended underlying disease process. This is driven by several factors including physicians who aren’t strict about diagnosis, supplement companies that use this to push whatever they are peddling, and patients who want a diagnosis for the sake of having one or other reasons mentioned here.

FQ toxicity is likey caused by SNP in a specific gene related to pharmaceutical metabolism (one of the CYP450s). I believe this was published in the literature.

Another possibility is that FQ toxicity is caused by certain genes relating to detoxifying (GSH, COMT, etc) - where the body incorrectly metabolises it, leading to toxicity against cells.

Similarly rare is the "traditional" EDS phenotype with stretchy skin and hypermobile joints. Usually seeing them for shoulder dislocations or other orthopedic injuries.

By far the most common (and massively increased over the past few years) is the crowd that attracts all the eye rolls. These are almost exclusively women, usually white, age 16-35, presenting with a constellation of nonspecific chronic complaints including myalgias/arthralgias, fatigue, GI symptoms, etc. None of them have stretchy skin or abnormally hypermobile joints. Very high rate of fibromyalgia/POTS/CFS in this group. They're usually coming to the ED for diffuse pains, dizziness, or something else I really can't fix. Maybe there is some underlying organic disorder we haven't sorted out yet, maybe these are somatic manifestations of untreated anxiety/depression.

One thing about the hEDS diagnosis is the explosion of self-dx from social media (TikTok) which makes physicians cringe.

There's no good genetic test, and even if there was there is not much to be done other than supportive measures.

Possibly. Another thing that could be is that I damaged the cable (somehow) when disconnecting it. Or, the Realtek TOSLINK has some design/implementation flaws.

Another possibility? could be placebo

Good idea. I checked it out and nothing stands out.

Just an update:

I switched out the 'TOSLINK' over to a standard coax and the sound is much better - not on par with the Recon 3D card, but it's an improvement. I am using some Logitech speakers and not headphones.

Gaming, Movies (youtube). Speakers (5.1)

As long as you can read and write to memory, you'll never stop cheating in multiplayer games.

As long as you can read and write to memory, you will never stop online cheating in FPS games.

I can't speak for CMPA or QL, but I can speak a little bit on Unlagged:

- w/ Unlagged, the Server now stores a history buffer (g_activeSnapshots[]) of player states. When processing a action shot, it uses the timestamp sent by the client (cmd.serverTime) to interpolate or rewind states for collision checks (G_EvaluateTrajectory()). This allows the server rewinds player positions to the moment a client action occurred (eg: firing a shot)

- Unlagged reduces choppy movements by making clients use a snapshot buffer (cg.snap, cg.nextSnap) to interpolate positions with CG_InterpolateEntityPosition(). Extrapolation uses velocity vectors from the last known snapshot (currentState.pos.trDelta).

- Unlagged tries to compensate for high latency by rewinding entities to their positions at the time of the shot (ClientThink_real() and G_RewindEntities()). Uses a circular buffer (via lagometerSnapshot_t) to store past states.

- Position corrections (cg.predictedPlayerState) are interpolated over several frames using VectorLerp() to fix prediction mismatches between client and server.

- Commands are stored in a circular buffer (ucmds[]) and replayed when missing packets are detected (ClientThink_cmd()). This attempts to mitigate packet loss by buffering input commands for later execution

Also; The server calculated projectile trajectories independently of client-side predictions.It was buggy on certain? versions. We (OSP) noticed this on earlier Quake 3 releases and it may have been fixed.

This results in visible "misfires" where projectiles didn't behave as expected

In 2008, taxpayers bailed out the banks but not the economy. Deja Vu.

I am a PCP who runs utilization reviews for our provider group. I review every ED utilization for every patient attributed to a PCP in our network. My job is to try to reduce inappropriate ED utilization.

I have no idea what reduces utilization.

There's major shortage of primary care doctors. Most med students don’t want to go into primary care. Plus, hiring new doctors is not as easy as it sounds… even if there were an excess of doctors looking for jobs, you have to have clinic space and staff in order to run a practice.

Specialists are in the same boat, post-COVID. Having to ref some pts to neurology with a 6+ month wait.

There is a specialist shortage. Refs I've sent to Endros take months. I've even had to refer patients to places nearly 150 miles away.

The angle I would love to hear is that these people denying medical care are not culpable for the consequences. If I don’t order a test/surgery/whatever and the patient is harmed, I may face civil or criminal liability. But if the insurer refuses to authorize care (which, in practice, means the care doesn’t happen) and the patient suffers harm they have no recourse. The argument is that the insurance company isn’t making a medical decision - you can still get the surgery your doctor recommended, we just won’t pay for it! - although in practice their decision /does/ dictates care.

So if they are making medical decisions, why aren’t they liable for the consequences? Sometimes the “peer” denying care doesn’t even have a medical license!

I frequently have to deal with this, particularly peer-to-peer (P2P) authorization. I have never been assigned a practising oncologist as a peer. Often a retired unrelated speciality (paediatrician, psychiatrist) or a non-practising insurance doctor. They are unfamiliar with any of the data in the field, and they read off cards provided to them by their "third party" employer to deny care, even care that falls within national guidelines. I had to escalate this to the CMO of the insurance company before, at which time they admitted that the treatment should have been approved from the beginning. Their goal is to make the process frustrating ("just call this number..." it's a phone tree), introduce delays ("please fax your appeal to this garbage can and we will consider looking at it between 72 hours and never"), require multiple layered appeals ("so I'm just the peer to a peer reviewer, and my guidelines say to deny this, but you are welcome to appeal to a panel that might read the references you already sent in"), and anything else to ensure that patients stop pursuing care and die before getting expensive drugs.

It is never based on quality care, but on increasing friction and pain in the system in order to minimize payments out of money already collected from patients. It is a criminal racket and nothing makes me angrier in my entire practice.

Stool tests are questionable to begin with.

All homes need fresh air ventilation systems - at least here, all new homes are required by code to have it.

ERV / HRV or a static one that goes into your air handler.

Personally, ERV is the way to go. Panasonic makes one that is perfect for the ceilings, and there's Nutone, etc.

I've always wondered if UFO's are just billionares from other planets.