What has you here today?    work history (html) about me tajik bookmarks

Beal. 11th of September, 2018 POST·MERIDIEM 08:03

Word of the day: to beal; to suppurate, to gather, to weep pus. Obsolete in standard English. The OED describes that it is still in use in Scotland, and I can report today that it is used in the area of the East Donegal plantation.

It is either a Norse doublet of boil (in the meaning of a furuncle) or an internal English variant on the word. Cf. German die Beule with the same meaning.

FeverPAIN. 8th of September, 2018 POST·MERIDIEM 11:18

At the beginning of 2018, Public Health England published a clinical decision rule for doctors managing sore throat, advising:

‘[Use] of the FeverPAIN or Centor clinical prediction score to determine the likelihood of streptococcal infection (and therefore the need for antibiotic treatment):’

In the context of a pending non-MICGP post-graduate exam I am obliged to remember this clinical rule and regurgitate it onto the page the day of the exam. I have no plans to use it in practice.

Here are its weaknesses as they occur to me:

  • The first line antibiotic for sore throat is phenoxymethylpenicillin. Don’t let the extra five syllables distract you; this is just penicillin. Penicillin. Penicillin has been in clinical use since 1942, and there is very very limited value to improved antibiotic stewardship for it; anything that was going to develop resistance to it, has developed resistance to it, more conservative deployment of it is very very unlikely to lower levels of MRSA, nor, on the other hand, is it likely to provoke resistance among T. pallidum.
  • The study the FeverPAIN score is based on, to its credit, uses several different swabs to pick up the Streptococcus that is the cause of most bacterial pharyngitis. Still, guess what? The sensitivity of every test we have available to pick up the specific pathogen of most infectious disease is terrible. 38% in a 2015 US study of community-acquired pneumonia significant enough to require hospitalisation, with the resources of the US federal government behind it. There is every reason to think a significant proportion of those with negative near-patient testing for Streptococcus actually had that bacterium.
  • The guidance is hedged so that, basically, if one is worried about the patient, one should go ahead and prescribe antibiotics. Well. Wasn’t that what we were doing anyway? Except, if the patient had immunocompromise I certainly was starting with co-amoxiclav rather than phenoxymethylpenicillin.
  • Personally, I come to this from an odd angle, in that I have the constitution of a horse, and so for years I listened to the guidance of, ultimately, the microbiologists, and just got on with things when I had a respiratory tract infection, without real problems. Then I got married, I got an RTI with cough productive of green sputum, struggled through, and then gave it to my wife, who was wiped out for a week or so. So, next time I got an RTI with cough productive of sputum, I took an antibiotic. Guess what? Even if the number of days one is symptomatic doesn’t change, it’s far far easier to work when antibiotics are doing their job against your bacterial infection.
  • And, of course, the people you’re not that worried about, and for whom you would consider withholding antibiotics, are the people healthy enough to have a job and to pay tax. And, well, having a job and working matters, those people have people depending on them for rent and clothes and home heating, and their taxes are where all the medical care for everyone else ultimately comes from.

In summary; if you’re a doctor reading this; if there is any whisper of a sore throat being bacterial, give the patient the penicillin. The patient will be happier and likely less sick, there will be little to no further resistance to penicillin in the community, and you won’t have to think about wasting time with penicillin if they re-present because of a resistant organism.

VTE Dublin 2017, and its Ultrasound Workshop. 19th of September, 2017 POST·MERIDIEM 11:01

I want to make a shout-out Cian McDermott, Andy Neill and everyone else involved in organising and running the Ultrasound Workshop at the VTE Dublin conference. Excellent sessions, great instructors, wonderful to have formal instruction on ultrasound for DVT, PE, and an introduction to echocardiogram.

I’m a GP trainee in Donegal who does Emergency Medicine as a side specialty, taking the exams and working lots of shifts in Northern Ireland. There’s a lot of cross-over between the two sets of generalists, and if anything, there’s even more reason for GPs to be putting ultrasound probes to people than ED doctors; ‘I haven’t felt my [unborn] baby move in just over a day’ should never go to the Emergency Department, absent bleeding or pain; poor local access to echo means I have a patient currently who probably has a new right-to-left ventricular shunt across a VSD, but her best chance of having that confirmed in the next 18 months is my buying something like a Philips S4-1 and putting it to her chest.

Thankfully, my first ED shift after the workshop wasn’t as eventful as that of Dan Horner. I only had a thirty-something man with back pain and light-headedness, who happily had a normal abdominal aortic diameter, and a non-EU expectant mother with a headache, at 18 weeks gestation, who couldn’t access the usual antenatal care because the Home Office was siting on her documentation. She was very glad to see her singleton intrauterine pregnancy with good fetal movement, good heartbeat and an abdominal circumference appropriate for dates.

So, in sum; ultrasound, great, VTE Dublin ultrasound workshop, fantastic!

Ben Goldacre’s Bad Pharma 30th of September, 2012 ANTE·MERIDIEM 01:06

I ordered Ben Goldacre’s new book, Bad Pharma, and noticed the braille on the cover. Here it is (possibly upside-down, but I don’t think so):
⠄⠒⠎⠥⠍⠑ ⠄⠊⠍⠍⠇⠽
I’m disappointed! The good doctor requested suggestions for two words to put up there, but as far as I can see it’s just ‘:Sume Immly.’ I’ll be unimpressed if it’s just nonsense, but I’m open to correction.

Word of the day: دیدن، بین /didæn/, /bin/ are the infinitive and present stem of ‘to see’ in Persian.

Last comment from zocky on the 5th of October at 0:08
⠄ is the abbreviation marker (used before both words), and ⠒ is the abbreviation for "con"

So it says "consume immediately".

[No older comments for this entry.]

Forcing Amazon RDS databases to non-UTC server timezone 6th of July, 2011 POST·MERIDIEM 06:37

Amazon Relational Database System (RDS) is a fine service, allowing you to move MySQL and Oracle databases to the care of a company that administers them and backs them up competently and in huge number, and charges a not-unreasonable price for it.

Now, if you’ve chosen MySQL as your database, you’ve probably made other less-than-optimal programming decisions in the past too, like not storing timestamps as UTC, and relying on the database server to have the same time zone as most of the clients. (The latter of which is, in many contexts fine; cf. Japanese developers developing apps for Japan, a country of 120 million people with one time zone.)

Unfortunately, Amazon doesn’t support setting the SQL server time zone of an RDS database instance, it requires UTC. kaz_goto in that thread offers a solution, but that solution hangs when the database instance is rebooted. I’ve developed that solution a little further; my approach requires the following stored procedure in the database:

 
DELIMITER | 
CREATE PROCEDURE mysql.store_time_zone () 
IF NOT (POSITION('rdsadmin@' IN CURRENT_USER()) = 1) THEN 
   SET SESSION time_zone = 'Europe/Dublin'; 
END IF | 
DELIMITER ;
And, as in kaz_goto’s post there, the database parameters need to be modified to include something with a space—follow his instructions, but make sure the result reflects the following:
$ rds-describe-db-parameters PARAMGROUP --source=User
DBPARAMETER  Parameter Name  Parameter Value             Source  Data Type  Apply Type  Is Modifiable
DBPARAMETER  init_connect    CALL mysql.store_time_zone  user    string     dynamic     true 
$ 

Once this is done, rebooting will not be a problem, though starting up databases with that parameter group but without the associated stored procedure will lead to hangs on connection.

Word of the day: die Umnachtung is German for derangement.

Last comment from sohail on the 8th of October at 7:29
Searching this solution for a while, worked, CHEERS !!

[Seven older comments for this entry.]