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July 21st, 2012, 02:54
Originally Posted by Corwin View Post
Then who can you blame?
Nobody.

Extreeeemingly long rant coming. I haven't checked for spelling errors, very likely there are a few of those. I'll do that tomorrow.

Finding the correct diagnosis can be very difficult, especially when

1. The disease has few or no characteristic symptoms
2. The disease can manifest itself in different ways, some of them atypical
3. The patient show few or no specific symptoms. This is especially true at the onset of disease.
4. The patient is unable to describe his/her symptoms. This is often the case with small children. Thus pediatricis is very much like a veterinary medicine, without the possibuility of euthanizing the patient.
5. The disease is uncommon.

A couple of examples:

If your patient has been exposed to an angry/frightened cat, and show symptoms like fever and general swelling of lymph nodes, cat scratch fever is faaaaar more likely than a diseas for which there have been 3 cases in Oregon the last 17 years. If there are no specific symptoms of plague, and you live in Oregon there is no rational reason to spend resources on looking for that disease. And if we did, there are very likely a huge number of other rare diseases we should look into as well. We can leave that for the patients where the disease don't develop as expected. Like they did in this particular case.

In a patient with infarction of the heart,we typically find
- pain in the middle of the chest, radiating to the neck and both arms
- signs in the ECG, which changes over a period of 5 days or so
- elevated levels of specific enzymes, sedimentation rate and white blood cells, which changes over a period of 5 days or so

But for some patients (quite a few) none of these symptoms are present, or they don't show until a couple of days later.

Some diseases can mimic a number of other illnesses. Two examples: Tuberculosis and SLE (Systemic lupus erythematosis) which is a rheumatic disease. They can both imitate a lot of chronic diseaes (like the thing"?). In cases like that, diagnosis is often reached by exclusion, we have to carefully eliminate a number of other possible diagnoses until one remains. It's a cumbersome, tme consuming and very demanding process.

Rheumatoid arthritis typically show symmetric pain, stiffness and swelling in finger joints and the root of the hand, toes, elbows and knees. These symptoms are chronic, typically lasting more than 3 months. In addition the patient may also show signs of general inflammation: fever, lethargy, elevated sedimentation rate and white blood cellcount. But it can take more than a year before typical symptoms arise. The disease can start with:

- typical symptoms from the start
- acute inflammation of one joint, no symmetry
- chronic inflammation of one joint, no symmetry
- acute inflammation of tendons, no arthritis
- pain and stiffness i muscles, no arthritis
- general inflammation symptoms, no localizing symptoms at all
- don't get me started on children.

Additionally, symptoms may come and go, especially in the beginning.

Acute appendicitis is a common disease, and should be easy to discover, right? Wrong, or rather, not necessarily. Typically the patient complains about abdominal pain, in the beginning localized centrally. Over time (a day or so) the pain wanders downwards to the right groin, and we find localized tenderness and spasms of the abdominal muscles there. And fever - but that is a very unspecific symptom. At the early stages there are few symptoms making appendicitis stand out, and it's easily overlooked. And, if the appendix lies behind the colon, local symptoms may be missing almost completely. I know, that happened to yours truly, and the appendix had perforated before they employed their knives.

Additionally, there are three conditions which can be indistinguishable: Acute inflammation of the fallopian tube (salpinx, the tube transporting egg cells from the ovaries to the uterus), inflammation of lymph glands in the area, and Crohn's disease, a chronic inflammation of the intestines which may be slumbering before abruptly becoming more aggressive. None of these conditions require acute surgery, acute appendicitis does. Since every operation is more or less risky, unneccessary surgery is bad. People die during or after even very simple procedures.

So what can we do about this?

More tests? Quite often not a good idea because

1. There may be no reliable tests available. A CT scan or ultrasound may or may not show signs of disease. If we find signs like thickening of the appendix, and the patient shows symptoms compatible with appendicitis, the patient probably has appendicitis. If there are no signs, we're back where we started, we know nothing more than we did before the test.

2. Some tests are in itself risky. CT scans expose patients to high doses of radiation, modern equipement often more so than older machines. Xrays of intestines and blood vessels are other high radiation procedures. It makes sense performing these examinations when there is a well defined reason for it, they should not be done just to be sure.

A biopsy can be very helpful. But there is also the risk of internal bleeding after the procedure, as well as infection. Again, if there is a defined reason behind performing a biopsy, the benefits outweigh the risks. But not if we don't expect to find anything.

3. Tests can be misleading.
First of all, perfectly normal (healthy) individuals may show abnormal results in tests. In fact, we prefer not to use the term normal values anymore because of this. In stead we use the term reference values, which means that around 95% of healthy individuals show results within that range. But this also means that 5% of healthy individuals have values outside these borders. And, roughly speakiing, it also indicates that if you run a number of tests (20 or more) it's not unlikely that some of them show seemingly pathological values.

Then there is the question of sensitivity and specifity. Sensitivity describes how good the test is at catching the patients, the sick ones. Specificity describes how well the test excludes the healthy ones. Unfortunately these two parameters are reciprocally related. The more sensitive a test is, the higher the risk of including healthy individuals among the patients (false positives). And the more specific a test is, the more people with disease are wrongly excluded (false negatives).

One example: In Norway we regularly examine the breasts of women older than 50 radiologically (mammography). We believe we by this detect more cancers at early stages, thus improving results of therapy. Additionally, detecting cancer early, we may avoid mutilating procedures like removing the entire breast and lymph nodes in the arm pit. These claims are disputed. No matter what, around 30% of the women have temporary signs of cancer, signs which will disappear. Unfortunately we are not able to indentify these women, which means that we unneccesaily operate on quite a number of women.

4. Cost. Many procedures are very expensive. Performing unneccessary tests is costly. Whether health care is financed by the government, insurance companies or the patient him/herself, this means that we get less health care for the money we spend.

Sometimes wait and see is the way to go. For instance, in a patient with anemia, in most cases the cause is iron deficiency. Iron deficiency is much more common than any other factor. So, unless there are other symptoms suggesting another diagnosis, we don't have to perform further tests. Just start treatment with iron, and examine the patient again after 2-4 weeks. If iron deficiency is the cause, we will see an increase in hemoglobine levels. If there's no improvement, or the levels are falling, then it's reasonable to examine the patient more closely.

Another example. Dyspepsia is (from Wikipedia) "characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating". 97% of patients with this symptom have irritation or a superficial inflammation of the mucosa in the stomache and/or initial part of the intestines. 2% have an ulcer (probably less today). 0,5% have cancer. Gastroscopy, where we examine the stomach using fiber-optics, and if necessary take samples of the gastric and intestinal mucosa, is fairly reliable. But it's time consuming, and we can't examine every dyspeptic patient this way. In stead we'll treat the patients with drugs (several types), and examine the patient again after for instance 14 days. A patient with cancer won't improve, the others will most likely. The prognosis won't be affected by a 14 days delay.

OK, I assume it's been difficult reading all this drivel. Let me assure you that it can be just as difficult finding a correct diagnosis, even for trivial and quite common diseases.

pibbur who is somewhat exhausted by writing this. And who fears that some of his words are not commonly used in English (please tell me if there is something you don't understand, and I will explain). And who rrealize that it's far beyond time to go to bed. No Secret World tonight. *sighs*

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Last edited by pibbur who; July 21st, 2012 at 03:33.
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July 23rd, 2012, 14:15
Because it doesn't belong here, here's James May's: Things You Need to Know - About The Universe

pibbur who realize there are a ot of things mr May think we need to know, and who therefore hates him. Actuallyy he doesn't.

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July 23rd, 2012, 18:07
Personifications of nations : http://en.wikipedia.org/wiki/National_personification

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July 25th, 2012, 00:47
Lengberg Castle has a vault which contained 600-year-old brassieres described as a "'missing link' in the history of women's underwear. See the enclosed picture (NOT of the underwear, you naughty, naughty…….)



pibbur who just came home from a 3 hour long Bruce Springsteen concert.

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July 25th, 2012, 01:54
Originally Posted by pibbur who View Post

<snip>

pibbur who just came home from a 3 hour long Bruce Springsteen concert.
Hurls wonders how many choruses of born in the USA is 3 hours?

(Hurls who is also going to a concert on August 5th, Mark Gardner, ex-Ride and is very glad as he gets older that Victoria (the state he lives in) has made concerts finish earlier!
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July 25th, 2012, 02:17
@pibbur: Very interesting about the diagnosis. Much of it I would consider common sense, but since my sense isn't very common, maybe I should call it uncommon sense. Good read. thanks.

On a slightly related topic:
Do you think that the rise in cancer is literally a rise in cancer or more a rise in better diagnostics ? (I'm expecting a more of both answer, but it would be interesting to see what you think)
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July 25th, 2012, 12:39
Rise in cancer is to some degree the result of improved diagnostics. For instance the increased incidence of brain tumours in children is partially explained by that. The fact that we're gettivng older is another factor. The incidence of cancer increases significantly by age.

However, neither of these factors explain all of it, there is a real increase in incidence. But it varies between different cancers. For instance, in the western world we've seen a reduction in the number of new cancers in the stomach in. This is likely caused by a change in the methods used for long-term storage of food, from salting and smoking to freezing. Salting and smoking food create carcinogens (substances which may cause cancer), freezing to a smaller degree.

For some cancers, the increase is huge, one of them is melanoma of the skin. And while the incidence of lung cancer has been falling among males, we've seen a significant increase among females. Lung cancer is now responsible for 25% of cancer related deaths in women, and has passed breast cancer as the deadliest cancer. Breast cancer is still approx 2.5 times more common, but the prognosis for breast cancer is far better. In fact, unlike most cancers, we haven't seen any improvement for lung cancer for more than 40 years.

This is caused by smoking habits. Smoking among men has been decreasing since the 90's, but has increased among females until recently. There is also data indicating that females are more at risk when smoking than men. Below the age of 50, more women die from lung cancer than men. FWIW, when I started as a resident in our local radiology department, I was struck by the number of lung cancers in patients younger than 40. Most of them was females.

Observe that lung cancer takes around 20 years to develop, therefore recent changes in cancer risk won't be seen for a long time yet. We expect lung cancer to continue increasing in women and not flat out until 2020.

pibbur

EDIT: Added more drivel

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Last edited by pibbur who; July 25th, 2012 at 15:42.
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July 25th, 2012, 14:19
Originally Posted by pibbur who View Post
Lengberg Castle has a vault which contained 600-year-old brassieres described as a "'missing link' in the history of women's underwear. See the enclosed picture (NOT of the underwear, you naughty, naughty…….)
Was in the press here, too.

“ Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius – and a lot of courage – to move in the opposite direction.“ (E.F.Schumacher, Economist, Source)
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July 26th, 2012, 09:29
Swedish mycologist Elias Magnus Fries named the fungus Phaeocollybia christinae (aka Christina's rootshank) after his wife. A fungus!!!

pibbur whose country is 55.26% annoying

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July 26th, 2012, 11:00
Male Scientists often name species after their wifes. I don't remember the opposite, though.

“ Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius – and a lot of courage – to move in the opposite direction.“ (E.F.Schumacher, Economist, Source)
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July 27th, 2012, 10:58
Swedes will for some reasong not be excluded from accessing the norwegian (free of charge) weather site www.yr.no. According to http://om.yr.no/2012/07/sverige/ (in gibb….. eh swedish)

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July 27th, 2012, 20:09
Early this morning, at 05:30 local time, two camping tourists (one of them from my home town) was awakened by the sound of a growling bear outside their tent. The good news is that they were able to escape. The sad news is that they had to leave their shoes. According to the police the culprit was probably a grizzly cow.

pibbur who thinks that the only good bear is a more than 10 km away and not approaching bear.

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July 28th, 2012, 09:55
There are several tidbits which I choose to ignore about Australian 2012 London Olympic competitors on Wikipedia.

pibbur who so far haven't mentioned any olympians from Switzerland (25% annoying) either.

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July 29th, 2012, 19:53
The illuminated French 13th-century Histoire ancienne (picture) told the history of the world in prose with moralizing verse. They're EVERYWHERE!!

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July 30th, 2012, 09:47
You don't need to know that the Eiffel Tower in Paris is currently undergoing repairs etc. with the help of a huge elevator-like system build by a specialist firm from Limburg.
No, not Limburg in Benelux, but instead Limburg, the German town, which I know very well, because my father's parents lived there in a town approx. 20-30 km away from it.
If you want to see original medieval houses, Limburg is one of the towns to get to (among many others like Seligenstadt, for example, where Eginhard/Einhard, the biographer of Charlemagne The Great lived).

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July 30th, 2012, 19:17
In 1957, for the first time in history, a Danish film (Qivitoq) was nominated for the best foreign language film Academy Award.

pibbur who in august 2012 for the 5th time in history goes to Copenhagen

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July 31st, 2012, 16:57
Today, a bomb like thingy was spotted under a car entering the site of the US embassy in Oslo@Norway (which is fairly close to the castle of our king). Result: Full alert, widespread evacuation. Enter bomb experts who found the thingy to be a bomb lookalike, recently used for practice at the embassy. They'd forgot to remove it afterwards.

Well, sh*t happens, we did get a test of our crisis handling routines which we needed and the embassy was satisfied with the response. And from where I am at the moment (500 km from Oslo) it was kind of funny. Afterwards.

pibbur who as it happens wonders what would happen if this happened in Denmark

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July 31st, 2012, 17:21
Something you actually should know about: Massive power grid collapse in India. Half the country, up to 600 million without electricity.

pibbur

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July 31st, 2012, 20:44
An excellent little insult from Stephen Fry@Qi, they were discussing the change of rules in table tennis, reducing the number of points to win a game from 21 to 11 and increasing the size of the ball by 2 mm, making it slower. All in order to make the game more attractive for TV.

Because "people are driveling maniacs who have to get up every five minutes to vomit some pizza" - or something like that.

pibbur who hasn't had pizza for ages (weeks), who detests similare changes to the volleyball rules., and who wonders if we need a favourite insults thread. Or something like that.

PS. Here's a quite interesting exchange from one of the 2012 olympic matches (comments in Norwegian, but the video speaks for itself). DS.

EDIT: Found the exact quote (it's on a website of course): "And the games are shorter because human beings these days are just gibbering maniacs that have to go and vomit up a pizza every five minutes so they can't have anything longer than that" . . . .

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August 2nd, 2012, 23:47
Now we know which one is pink. He's player number 9 of the UK volleyball team at the London 2012 olympics. Friends call him Andrew, and he's 1.92 m tall.

pibbur who called his first cat "Pink". No cigar.

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