Friday, June 29, 2018


Ten. Consecutive. Dubs.

It’s not too much to ask, is it?

Oh, and one muscle-up. Or bar muscle-up. I’m not picky.

Dubs aren’t that hard. Most CrossFit newcomers figure it out in a few months, maybe a year. I don’t know anyone who has failed as persistently as I have.

A few months ago I got 8. It was a bit of a fluke. I’ve gotten 5 or more several times. I looked like a meth-addled feeding frenzy but, like I said, not picky.

Then I started to get worse. Finally I couldn’t get any at all.

I think I’ve figured out what happened. My technique got better. Instead of swinging my forearms I learned to do singles with my wrists — like you’re supposed to. Turns out my wrists can’t move the rope fast enough. I don’t have anywhere near the coordination. This isn’t only being Old, I’ve had horrible coordination all my life. Old isn’t helpful though.

Once I thought of this I went back to the arm swinging feeding frenzy and I can do a few again. So I’ll practice that for a while. Preferably somewhere nobody can see me. Which means not my gym, where sympathetic looks of sorrow and helpless frustration are hard to bear.

Meanwhile, I can work on those lat pulldowns.

Saturday, June 09, 2018

My iOS medical references

My iOS medical references for my small adult primary care practice (mostly I’m an admin)

  • FP (I subscribe, one of my favorite references)
  • MPR: Monthly Prescribing Reference
  • ePocrates: not as great as it was. Truly annoying that they block paste in password.
  • Washington Manual in inkling eBooks - for nostalgia mostly
  • Sanford Guide (antimicrobials)
  • Atlas (anatomy - fabulous app)
  • MDCalc
  • AccessMedicine: a few texts which I should use more often.

My top 3 are FP Notebook, MPR, and Atlas these days.

Saturday, June 02, 2018

Are Trump-era Evangelicals closer to ancient Judaism than to Christianity?

It takes a lot of mental gymnastics to worship both Christ and Trump. But if you demote Christ and elevate Trump, both can have similar Prophet status. Prophets of a Chosen people can disagree and refine one another; they don’t have to be omniscient.

Culturally and theologically, the Trumpian Evangelical seems closer to ancient Judaism than to historic Christianity — but with an added emphasis on the ancient theology that wealth is a sign of divine approval and thus of virtue.

I wrote these in 2004 …

Georgia Takes on ’Evolution’ - The Decline and Fall of American Education

… If the evangelicals continued their steady victories, there will eventually be a public evangelical educational system and a private secular/other system. The private secular system would attract the educated elite, and they in turn would attract parents seeking social networks. The evangelical school system of 2010 could become a stigmatized backwater of ever growing ignorance (ok, so it might produce an incompetent President or two ...). 

The evangelical right can indeed win this war, but they may not like what they get. Perhaps they should reconsider ...

and (from an email to Nicholas Kristof back when we did things like that)…

Nicholas Kristof (NYT): The God Gulf - comment - The Yahwites and the Jesites

… I think you’ve skirted, however, a second great schism, between the "Yahwites" and the "Jesites". Both call themselves Christian, but they are as different as the Old and New Testaments -- and equally irreconcilable.

The Yahwites worship Yahweh, and draw their theology from the Old Testament -- a quintessentially Republican document. The Jesites follow a blend of the teachings of Paul and Christ, a doctrine that is more comfortably Democrat or even secular humanist. Mainstream Prostestant and Catholic churches, now in decline, lean towards Jesism; the evangelicals tend to Yahwism.

The Yahwites are in ascendance. In their doctrine God rewards virtue with wealth, and punishes his enemies with brutal power -- sowing salt upon the fields of the dead. The Jesites, always a minority, are in retreat. In particular the teachings of Jesus are so peculiar and demanding as to be almost unattainable for most humans. Jesites are always falling short of their ideal. Frustrating and not so marketable as Yahwism.

There is only a small theological gap between the Yahwites and the Wahaabi, so it is ironic that fundamentalist Islam should see Bush as their virulent enemy. Not the first irony in history.

American Evangelicism has been in free fall for years. One positive feature of Trumpism is that Evangelicals don’t talk about “family values” any longer. The laughter is deafening.

Sunday, May 20, 2018

Snapshot of a changing world - electric fat bikes

This “out of stock” direct sale electric fat bike is a sign of the times…

Screen Shot 2018 05 20 at 8 26 12 AM

I remember when, just before the great .com crash, a mysterious ‘product x’ was going to revolutionize the world:

John Doerr speculated that it would be more important than the Internet.[6] South Park devoted an episode to making fun of the hype before the product was released. Steve Jobs was quoted as saying that it was "as big a deal as the PC",[6] 

That product turned out to be the Segway. Which was, and is, a pretty neat product — but perhaps a few decades ahead of its time.

Meanwhile, as a quiet consequence of LiOn battery evolution and China, eBikes are growing exponentially. A fusion between traditional bicycle and scooter.

Like most cyclists I have mixed feelings about eBikes. On balance I think they are a good thing, but they will certainly have bad consequences — especially when collisions happen. A 250 lb adult on a 50 lb eBike moving at 25 mph is a lot of kinetic energy.

Mostly though, this is a marker of a changing world.

Wednesday, April 18, 2018

Dyer on the 21st century crisis of mass unemployment

I believe this is true — though I’d be more confident if one of my favorite economists thought this was plausible (emphases mine):

If The Model Is Broken, Fix It | Gwynne Dyer

… The political model of Western-style democracy, which grew up alongside and then within a capitalist economic model, is now broken. Exhibit Number One is Donald Trump, but there’s lots of other evidence too.

One-third of French voters backed Marine Le Pen, a cleaned-up, user-friendly neo-fascist, in last year’s presidential election. In last September’s German election, one-eighth of the electorate voted for Alternative for Germany, a party whose more extreme wing is neo-Nazi – but it is now leads the opposition in the Bundestag, the German parliament.

Last month in Italy, the two biggest parties to emerge from the election were both led by populist rabble-rousers, one from the left and one from the right. Not to mention Brexit in Britain. And in every case the themes that dominated the populists’ rhetoric were racism, nationalism, hostility to immigrants – and jobs.

Trump rarely talked about anything else during the presidential election campaign: immigrants are stealing the jobs, free-trading American businessmen are exporting the jobs, the foreigners are eating America’s lunch….

Trump may not know a lot, but he knows One Big Thing. We are living in a new era of mass unemployment, and nobody has noticed. As Trump said the night after he won the New Hampshire primary in February 2016: “Don’t believe those phony numbers when you hear 4.9 and 5 percent unemployment. The number’s probably 28, 29, as high as 35. In fact, I even heard recently 42.”

It’s not really 42 percent, but it’s not 4.1 percent (the current official US rate) either. According to Nicholas Eberstadt’s ‘Men Without Work’, the real unemployment rate among American men of prime working age (24-55) – including those who don’t get counted because they have given up looking for work – is 17 percent.

Why didn’t we notice? Because the unemployed weren’t protesting in the streets like they did in the Great Depression of the 1930s, although the rate is getting up to Depression era levels. After the Second World War, all the Western democracies built welfare states, mainly so a new generation of radical populist leaders would not come to power the next time there is mass unemployment.

It has worked, in the sense that there is not blood in the streets this time around, but the jobless millions are very angry even if the welfare state means that they are not starving. They do vote, and unless something is done to ease their anger, next time they may vote for somebody who makes Trump look good by comparison.

But if the problem is unemployment, then the answer is not obvious, because the main cause of unemployment in Western countries is not immigration or ‘offshoring’ jobs, as Trump pretends. It is computers.

One-third of American manufacturing jobs have vanished in the past 20 years, and the vast majority of them (85 percent) were destroyed by automation. The algorithms and the robot arms have already killed the Rust Belt, and there is a plausible prediction that almost half of existing American jobs may be automated out of existence in the next 20 years.

What would our politics look like then? Not very democratic, unless we do something to ease the anger of the unemployed. This doesn’t just mean giving them more money – a massive expansion of the welfare state – but also finding way of taking the shame out of unemployment, because it is the humiliation of being seen as a loser that breeds the anger…

I’ve called this ‘mass disability’, because to me it’s a mismatch between the skills the majority of humans have and the skills needed to earn a middle class or better income.

I don’t have any other explanation for why the entire western world is simultaneously in crisis other than what I wrote about in 2010 - Globalization (China) and Information Technology.

See also:

Tuesday, March 27, 2018

Gender and politics in America

My Twitter feed often ascribes GOP dominance at the state and federal level, and the patriarchal policies that follow, to male choices.

That is clearly incorrect. We know that 52% of white women chose Trump. In a white-women only election he’d have still won.

Today I wondered what overall gender differences are in voter turnout. The Center for American Women and Politics had some numbers:

Screen Shot 2018 03 27 at 7 03 31 PM

They write (emphases mine) …

In every presidential election since 1980, the proportion of eligible female adults who voted has exceeded the proportion of eligible male adults who voted (see Figure 1) … The number of female voters has exceeded the number of male voters in every presidential election since 1964.

Women have a larger voice in our elections than men. In 2018 America race and education are bigger divides than gender. White men are deplorable, but white women are not a lot better.

Monday, March 26, 2018

Macintouch in the twilight

I’ve read Macintouch for decades. It’s been a living fossil for 15 of those years; Ric passed on RSS and blogs and feeds and permalinks. For a year or two he tried to get permalinks working — which made Macintouch potentially tweetable. Recently those went away, so I wasn’t surprised by today’s announcement …

Thirty years is a long time. The Macintosh computer debuted more than three decades ago, and I've been involved with this revolutionary system and the community around it since 1984. A lot has changed in the meantime. 

… I’ve been constantly engaged, inspired and supported by the MacInTouch community for all these many years, but I think it's time to do something different. 

The revenue that used to sustain MacInTouch has dropped below a viable business minimum, while a plethora of other websites, operating under different business and security models, produces constant Apple news, reviews and commentary.  

The MacInTouch Discussions forum is unique, as far as I know, but it's also unsustainably labor-intensive, and there's no way around that in its current incarnation. 

At this point, my plan is to continue running MacInTouch Discussions and home/news pages at a reduced intensity for a little longer.  But, before long, it will be time for a change - a sabbatical, a new blog, research, development, or something else – I'm not quite sure what yet, but I expect to continue in some form. 

What I am sure of is that I'm enormously grateful for the support, contributions and engagement of this remarkable community over the past three decades, something words can't adequately express. Thank you for all that, for all you’ve contributed, and let's see where the journey goes from here. 

Ric Ford
MacInTouch Inc

I hope he finds a new way to publish and write. Like me the Macintouch community is old and curmudgeonly; it’s been a place that speaks truth and never falls for modern Apple’s too frequent cons.

Sunday, March 18, 2018

How to build a safe and sane social network

This is how to build a safe, sane, and sustainable social network.

  1. Build it to be viable on $1/user year.
  2. Sell memberships for $25/year. Each buyer gets one user license and contributes 24 to the free pool.
  3. Donors can buy an unlimited number of free-pool memberships at $1/year apiece.
  4. Donors who give over $1000 a year get an optional sustainer badge.
  5. Anyone can join for free if there are free memberships available.

That’s about it. Essentially it’s the public radio model.

Saturday, March 17, 2018

Medical topic monitoring: PCOS topics added to my RSS feeds

I’ve been a fan of the National Library of Medicine’s medical literature service through MEDLARS to MEDLINE to Grateful Med (my fave) to the current PubMed.

I monitor a number of topics though RSS streams of search updates:

To create an RSS search feed:

1. Run a search in PubMed.
2. Click RSS located below the Search box.
3. You may edit the feed name and limit the number of items displayed [2], and then click Create RSS. If the number of citations retrieved is greater than the number of items displayed the feed will include a link to display the complete PubMed retrieval.
4. Click the XML icon to display the XML and copy and paste the URL into the subscribe form in your RSS reader. Web browsers and RSS readers may use different options to copy the feed.

Today I’m adding one for Polycystic Ovary Syndrome/Disorder (PCOS/PCOD) with a focus on exercise, metformin, and research (I may split searches after a while). I have similar searches on a variety of topics as shown in the table below. (If I remember I’ll come back and update this post over time.)

I read results in my RSS clients - Feedbin (RSS server and web client) and (iOS, I’m also playing with I save selected references to Pinboard, generally with a tag (when I remember). The Pinboard tags have feeds too.

Search RSS Pinboard stream
PCOS etiology PCOS/etiology [1] pcos
PCOS and exercise PCOS and exercise pcos
PCOS and metformin PCOS and metformin pcos
arthritis and tolerance induction Arthritis and tolerance induction arthritis

PS. My longstanding #1 feature wish for MarsEdit is native table support. Just saying.
PPS. I miss Google Reader’s ability to share sets of feed subscriptions

- fn -

[1] You can search on a MeSH heading/subheading pair but I couldn’t get the RSS to work that way. OTOH, Pubmed was flaky this morning. That’s quite rare. I hope I didn’t break it. I’m going to have to update this post another day with some of the other topics I follow.
[2] With a new feed only 10 articles are displayed. I suspect this is a Feedbin problem.

And so it came to this

In the year 2018 it is no longer insane to suspect that the Soviet Union Russia executed a successful multi-year campaign against the United States of America which included the subversion of the GOP and the election of an incompetent President who effectively obeys Russia’s supreme leader.

I’m not saying this is likely. I’m not saying this was entirely planned rather than, say, somewhat opportunistic and emergent.

I’m just saying it’s no longer insane to suspect that we lost a war we didn’t realize we were fighting.

Saturday, February 17, 2018

CHIP, immune disorders, osteoarthritis, and hydroxychloroquine

A footnote in my post on Kateva’s liver disease linked to a NYT article on CHIP (clonal hematopoiesis of indeterminate potential). Wikipedia calls it “Clonal hematopoiesis”. To put it mildly, this is a hot research topic (wikipedia, lots of 2017 edits) …

Recently, several independent studies have confirmed the presence of malignancy-associated mutations in the blood of individuals who have no clinical signs of hematologic malignancy.[4][5][6] In combination, these studies have demonstrated the widespread incidence of clonal hematopoiesis in the healthy adult population and have stimulated further efforts to broaden our understanding of clonal hematopoiesis in health and disease.

Whenever we discover something new about human biology we round up all the diseases we don’t understand and look for a connection. The main focus now is on CHIP’s role in atherosclerotic heart disease, but I assume all the immune disorders are being CHIP tested. (I couldn’t find any articles on this today, which only makes me more suspicious :-).

If you’re going to look at mysterious CHIP disorders, I’d nominate the weird flavors of osteoarthritis. “Osteoarthritis” is an age related disorder (like CHIP), it’s very diverse, some of it has autoimmune type features — feels kind of CHIPpy. (As of Feb 2018 Google and Pubmed found nothing on “clonal hematopoiesis” osteoarthritis [2]. So you might have read it first here, except we know Google isn’t what it once was. Anyway, I’ve created an RSS feed for “clonal hematopoiesis” osteoarthritis — be interesting to see what that link shows in a few months.)

As long as I’m having fun with medical speculation, I’d like to throw in a mention to one of my favorite medications — hydroxychloroquine (HCQ). HCQ started life as a treatment for malaria, but it’s most commonly used for SLE and RA — autoimmune disorders. More recently it’s being explored as an adjunct to chemotherapy.

HCQ was thought to have something to do with Toll receptors (somewhat hot topic), but research on its oncology use focuses on how it interferes with lysosomal mediated autophagy. Autophagy (self-eating) is important for cells, it’s how they recycle their constituents to make new things. Some cells depend on this more than others. Retinal cells rely on autophagy and it’s probably not a coincidence that HCQ can cause retinal toxicity [1].

Cancer cells rely on autophagy too — they don’t have normal cooperative nutritional inputs. Which is why HCQ is being tested for cancer treatment.

Which brings me back to CHIP.  We think CHIP is a kind of premalignant age related disorder of the stem cells that form blood. We think HCQ might impair replication of disordered cells. We know HCQ works for some autoimmune disorders. We wonder about CHIP and oddball autoimmune disorders …

So it would be fun to see if HCQ inhibits CHIP.

- fn -

[1] Worryingly the process can continue even after the drug is stopped.

[2] Actually they both returned results, but they were nonsensical results. I miss when Google used to actually work. It was funny to get a false positive from PubMed, it’s usually reliable.

Notes on managing a canine biliary system clearance disorder (intrahepatic cholestatic liver disease).

I was doing a bit of personal research today that might be of interest to a few others, so sharing here.

Kateva, of fame,  is 12 years old. Since she was about 9 she’s had liver enzyme elevation on her routine vet exams. In early 2017 she had intermittent vomiting — which is not unusual among dogs. A month or two later she became jaundiced (yellow sclera) and very ill. She was found to have obstructive jaundice, likely chronic, with a very large gall bladder. Post cholecystectomy she developed pancreatitis. She had 3 paws in the grave when a combination of Emily’s diligent home nursing [6] and oral ursodiol (ursodeoxycholic acid - aka UCDA, Actigall) pulled her back. [1].

As best we can tell, without a liver biopsy (risk, $, uncertain benefit), Kateva has a disorder of hepatic bile clearance. These “intrahepatic cholestatic liver diseases” have been increasingly recognized in humans over the past few decades. The ones we’ve named include primary biliary cholangitis [2], primary sclerosing cholangitis, granulomatous liver disease, a host of rare genetic disorders and more familiar things like hepatitis. When one considers how tricky it is to produce bile and clear it through the liver into the bowels it’s likely there are many currently unrecognized varieties of bile clearance disorders.

Many of the intrahepatic bile excretion disorders respond to ursodiol. I recall use of it to dissolve gallstones in the 1980s (with laporoscopic surgery this became less valuable), it has been used in humans for primary biliary cirrhosis since 1996 [3]. Ursodiol has pretty clear short term benefit but we don’t know how much it changes longterm outcomes. Within a few years of use in humans it was tried in dogs and cats, this 2011 discussion is pretty good.

I liked this description of the mechanism of action …

Ursodiol … is a naturally occurring bile acid that is a minor fraction of the bile acid pool in humans, but a major fraction in bears and other hibernating animals.  Ursodeoxycholic acid is more water soluble (hydrophilic) than cholic or chenodeoxycholic acid and is less inherently toxic to cells.  When given orally, ursodeoxycholic acid becomes a major component of the bile acid pool, the proportion rising from <2% to as much as 65%.  By replacing the hydrophobic or more toxic bile acids with ursodiol, the toxic effects of cholestasis are ameliorated …  Ursodiol was approved for dissolution of gallstones in 1987 and as a therapy of primary biliary cirrhosis in 1996. 

Kateva had a good year but she’s slowing now. I think without the liver diseases she’d be early old age, but either the underlying liver disorder is worsening or she’s moved on to liver failure or a malignancy … or some other disorder. Old dogs, like old people, usually have a few things going on.

At her age both cost and the least-misery principle limit what we’re likely to inflict on her. Obeticholic acid (Ocaliva) is a new and fantastically expensive alternative to Ursodiol — too costly to consider given limited added benefit. Colchicine is used, but it probably doesn’t do much and it’s nasty to take. Investigational drugs are often prohibitively expensive but a veterinary formulation of budenoside (a steroid that disproportionately acts on the liver) and fenofibrate [5] might be affordable.

I wrote this post to help think about what we might do for Kat. I think we could push her ursodiol and, if we can get an affordable veterinary formulation, we might try the budenoside. Or we could spend money on things she might like better, like steak [7].

- fn -

[1] The surgery and ultrasound were costly, but the truly expensive parts were all the things that intersect with human medicine — lab tests, intravenous fluids, medications, and the like. For better or worse we had some resources, so the limit was her misery. We were close to that. The longterm ursediol trial was an informed hail mary pass by my wife and I with veterinarian support.

[2] Thought to be due to “environmental trigger(s) acting on a genetically susceptible individual”.  I’m sure everyone in this field is now wondering if PBC is a CHIP (clonal hematopoiesis of indeterminate potential) disorder. We really don’t know what causes it. Immune system dysfunction seems a contributor but it’s suspicious how ineffective immune suppressants have been. I wouldn’t be shocked if there were a genetic disorder in bile formation though.

[3] With veterinary compounding it’s not cheap, but more affordable than most specialty human medications.

[4] Ref removed, but consulted UpToDate often in this writing.

[5] Curiously fenofibrate drug information lists primary biliary cholangitis as a contraindication!

[6] Emily is an excellent physician, but she also has a knack for nursing.

[7] In the last few years I’ve done end-of-life management for two parents (mine), three gerbils (Kangaroo, Adric, and Pipsqueak), and now a dog. All of the considerations were very similar though budgets varied. The parents were the easiest decisions. The gerbil and dog decisions were much harder.

Sunday, January 28, 2018

Arthritis update (personal note)

My familial arthritis showed up in one finger a few years ago, but in December of 2015 it became a bigger deal [1]. It looked like an early and fast moving symmetric osteoarthritis (OA), but then so did my mother’s before it morphed into something like RA (which ate lungs, joints, etc). OA is really a junk drawer diagnosis so I ended up calling it “familial arthritis”.

After a bit of personal research I ended up with an eclectic rheumatologist who suggested hydroxychloroquine (HCQ). This is a popular Lupus and RA med that started life as an antimalarial. It’s generally well tolerated with one minor side-effect — you can lose your vision. [2]

HCQ has been since tested experimentally in osteoarthritis — and it didn’t seem to do anything. [3] It did work for my mother’s RA though (where it is known to work), and her disease started out looking like mine …

So I’ve been on the HCQ for about two years.

Has it worked?

There’s no way to know, I can only present circumstantial evidence for one person. I have no idea what the disease would have done without treatment.

The joint deformity has not progressed much. To track joint changes I bought a ring sizing set and I use it to measure a selection of PIP (small, distal finger joint) and PIP (join in mid finger) sizes. There hasn’t been much change in joint deformity over the past two years; interestingly the worst measurements were the first set. That’s probably measurement error or some initial soft tissue swelling that’s diminished. 

I don’t have any finger joint redness or pain any more. Sometimes I forget to take the HCQ and I imagine I have some hand stiffness and joint aches — but that seems too fast to be a med effect. I think it’s my imagination. (Though we don’t have a good story for how HCQ works, so who knows.)

My knees aren’t worse; they are better than they were before I started the HCQ. I still do 230 lb CrossFit deep back squats. (I’m a wimp. Average strong guys do well over 350 lb.)

And, yes, I’m still doing the CrossFit. The rheumatologist approves. I thought I’d have to take up underwater hockey instead but I put that one off for now. 

It’s only been two years though. I’ll be more impressed if this is still true in two more years.

- fn -

[1] When I search the blog I see a few prior posts on knee and wrist exercise related aches that were, in retrospect, part of the arthritis.

[2] There are eye exams to try to spot this early, but we know in animal models that the chorea disease progresses for some time after the medication stops. We don’t know the real frequency of this complication — there’s at least a 1/20 chance I’ll get it.

[3] OA, like autism and schizophrenia, is an ill defined collection of things that’s damnably hard to study.

Wednesday, January 24, 2018

Scientific American forgot to tell me how to activate my digital subscription. Here's how.

When I renewed Scientific American last September I had a “deal” that included 1 or 2 freebies and digital service for $40. (Today I’d use Amazon — $35, much easier to manage, great subscription manager, etc).

The magazine eventually showed up but not the free extra book/special edition and not the digital service. Maybe there was an email that went into my spam filter, but I have gotten other email from them.

Turns out I had a digital service all along. I went to their customer service site and followed a link to manage my subscription account. From there I saw a link to activate digital service. That worked.

Now I have to figure out what happened to the freebies.