medical school

congratulations I bet

sorry, napping

MATCHED

http://novelnovice.files.wordpress.com/2010/11/matched_futures-rewritten_the-society.jpg

http://i.imgur.com/ZeO6hyk.jpg

BUT WHERE????

Awes gbx

Congratulations!

I am super disappointed I am working long on Friday, I would like very much to go and see where my 2013 dudes end up.

congrats man!!!

Yay!

But do you know where you matched yet?

congratulations!

Go, gbx!!

he'll know Friday

yup

https://dl.dropbox.com/u/9627011/photos/am0n.gif

http://m.youtube.com/#/watch?v=ajcGDaLy4Zw&desktop_uri=%2Fwatch%3Fv%3DajcGDaLy4Zw

LIVE FREE OR DIE

congratulations....

one giant leap for gbx

Congrats! Sooooo NH?

I'm not too good with the state mottos.

either that or he has started a crime spree

Yay! New England! Things were crazy here earlier with people talking about all this. Congrats, E.

http://i.imgur.com/O4fupWI.jpg

that's awesome, congratulations.

That sounds AMAZING!!! Congratulations!

Wait, if my jaymc.xls is correct, didn't you go there as an undergrad?

Because I am also going to where I went as an undergrad. Basically we need one more ilxor to go to med school and do this and then we'll have a trend piece!

Congratulations, now begins the weirdly bittersweet period of realizing everyone you'vegone through the past few years with is about to go away. 4th year 4-eva

haha I just remembered what school is in New Hampshire

epic gratz gbx

I've heard great things about the university of south new hampshire's medical school

Wait, if my jaymc.xls is correct, didn't you go there as an undergrad?

Because I am also going to where I went as an undergrad. Basically we need one more ilxor to go to med school and do this and then we'll have a trend piece!

Congratulations, now begins the weirdly bittersweet period of realizing everyone you'vegone through the past few years with is about to go away. 4th year 4-eva

that is my alma mater, it's true. kinda shocked it worked out, but thanks sorting hat!

it's all because i tried to jinx you, you're welcome

well thanks to you too!

hey, nice. congratulations!

OK I know the disclaimer about IANAD and all (though some of you ARE), but a hypothetical case here: total cholesterol 265; TG 228; HDL 55; calculated LDL 164; non-HDL cholesterol 210. Male, 40, nonsmoker, 20 miles per week runner, no family history of heart disease.

OK or "get thee on a statin immediately"?

grats to gbx

I don't know the US units, I guess that's not too high?

There's evidence that statins are effective for primary prevention of cardiovascular disease, but the number needed to treat is high (less than 2% would benefit after 5 years of treatment). http://summaries.cochrane.org/CD004816/statins-for-the-primary-prevention-of-cardiovascular-disease

Given that you're otherwise quite healthy, presumably the indication to treat would be even less in your case than in the evidence reviewed by Cochrane.

You should ask your doctor but I'd imagine it'd be reasonable to hold off on medications for now, try to change your diet and watch the numbers for a year.

plasmon, i always thought you were based in the US? where do you practice?

those labs are a little on the high side (assuming they're fasting numbers) but, assuming he's normotensive and non-diabetic, this guy's 10-year risk is something like 5%. if you look at the ATP III guidelines, iirc they say for a guy like this statin therapy should be considered if the LDL is above 190 (though word on the street is that ATP 4, if they ever are published, are gonna bump everyone's goals down by 30 mg/dl). IANAD but as plasmon says this might be a "refer to dietitian and see me in a few months" situation. with the caveat that i know only what you've posted, it's not a "holy shit start intensive therapy now" deal

Yeah I checked the ATP III guidelines and it looked like a statin wasn't a must at this point, but I'm going to be nag for him to get his numbers done again next year (he tends not to go to the doc for years at a time; only went this time due to spousal nagging). He had tried changing up his diet a few years ago, but it didn't really make an impact on either LDL or HDL. His blood pressure is consistently excellent and he is not overweight.

What about the high TG? I should have paid more attention to the prevention stuff when I was the managing editor for a cardiovascular medicine web site, but the docs I worked with there mostly interventionalists, so I know more about PCI than anything else!

what does the PCP say? he or she deals with patients like your dude daily and will have more experience dealing with his situation than a couple of neurologists, a med student, and a pharmacy student. i can say that my understanding of the data in this area is that the link between mildly elevated TG (in the absence of a high LDL) and CV disease is pretty tenous and i'm not aware of any any data that proves that lowering TG lowers your risk of CV disease, particularly in someone as healthy as him (others can correct me if i'm wrong)

We would definitely ask the PCP if he had one! I made him go to a doc-in-the box for a basic physical and labwork (which was e-mailed to us. For follow up he'd have to go back in, and we've already left town).

We have joined the millions of Americans who have basically no preventive medical coverage--when we quit our jobs, we said bye-bye to our affordable-ish coverage. We are now covered under a high-deductible plan that will, like, airlift us out of Mexico if needed, but on a tight budget we are doing what folks in our situation do--rationing our own health care and self-diagnosing/treating via the internets. Meanwhile, my Medicare mother's doctors order every available imaging test for her stiff knee. Unbelievable.

(sorry for rant)(and thanks for the info, confirms what we figured!)

i'm sorry if i sounded rude! i'm sorry you find yourselves in that situation, obviously everyone should have access to basic preventative care. will the ACA help next year?

you're a couple of the lucky ones, of course - i've seen plenty of people in their 30s who haven't seen a doctor since they were kids - and have no idea they have diabetes - come into the hospital with full-blown HHS and an A1C in the teens.

Oh you were not rude at all! We have been ridiculously lucky to have had pretty damn good insurance for many, many years, and also lucky to be in good health (I take a couple of Rx meds, but was able to get them all filled for a 6-mo time period while I was still covered under my employment insurance). Having that sort of insurance was something I took for granted, so it is really good for me to now see how lucky I/he was.

I will likely be doing social work in a medical setting when I finish my MSW, so I'll be learning more about the many downsides of our system in intimate detail, I'm afraid :(

120 pack-year history = 876,000 cigarettes

so drs and drs in training... what can you tell me about graves disease and more specifically graves ophthalopathy??

(raises hand)

Graves ophthalmopathy is also called thyroid eye disease, which is easier to spell.

Graves disease is an autoimmune thyroiditis in which antibodies bind to the TSH receptor in the thyroid and activate the production of thyroid hormone. Elevated thyroid hormone levels shut down TSH (thyroid stimulating hormone) production in the pituitary gland, which normally leads to thyroid activity being decreased until thyroid hormone levels (T4) drop far enough that the pituitary (really, the hypothalamus) notices and starts making TSH again. With the antibodies bound to the TSH receptor, this feedback loop is broken. High thyroid hormone levels suppresses TSH as usual but the antibodies alone are enough to continue to drive thyroid hormone production, leading to hyperthyroidism, which can be severe. Typical symptoms of hyperthyroidism are a little like an adrenaline rush: rapid heartbeat, weight loss, sweating, tremors, agitation, poor sleep, heat intolerance, etc. We can control the symptoms in the short term with beta-blockers and antithyroid medications until we get the underlying problem under control by knocking out the thyroid with radioiodine or surgery.

Thyroid eye disease often appears as part of Graves disease but can appear without symptoms of hyperthyroidism (euthyroid) or any abnormal thyroid function studies on lab results. The same auto-antibodies that bind the TSH receptor (TSH-R antibodies) also bind preferentially to a similar epitope (immunological target) found specifically on the extraocular muscles in the orbit. For some reason, the medial rectus and inferior rectus muscles are most often targeted, but any of the 6 eye muscles around each eye can be involved, usually bilaterally, and sometimes symmetrically.

Antibodies binding to tissues in the orbits triggers an inflammatory reaction, producing thickening of the muscles and swelling. The eyeball can bulge forward (proptosis) and often gets red and inflamed looking (conjuctival injection). If the proptosis is bad enough the eyelids won't close fully (lid retraction). Thickened eye muscles don't move normally; in particular, they don't relax and extend when the eye is being pulled in the opposite direction by the antagonist muscle. So the medial rectus (which pulls the eye to the nose) being thick and inflamed won't let the lateral rectus (which pulls the eye out to the side) do its job, so the eye's movement in that direction is restricted, which can cause double vision b/c the eyes are pointing in 2 different directions.

There aren't many mimics of thyroid eye disease, especially if the patient also has hyperthyroidism. Other inflammatory conditions can cause pain and swelling in the orbits. Rarely, an aneurysm or other abnormal blood vessel can cause painful swelling and bulging of one eye. Myasthenia gravis, a neuromuscular condition, can cause variable weakness of the eye muscles and eyelids, but doesn't cause proptosis.

The diagnosis of thyroid eye disease is made clinically and supported by testing for TSH-R antibodies, thyroid function studies and scans (CT or MRI) showing the typical pattern of inflamed eye muscles. Thyroid eye disease usually requires treatment with steroids to control.

...that was from memory, in honor of my friends writing Royal College and board exams in the next few weeks.

thanks! are there treatments besides steroids? i've heard that the usual length of the disease is 1-3 years, is that usually the case? (asking on behalf of my mom, unfortunately)

i guess, we are hoping that there's a good chance that the disease will go away by itself, without having to resort to 131 or surgery.

this is for my hypothetical mom, of course

Many immune conditions do settle down considerably after a couple of years. Not sure how confident I'd be in the 1-3 year prediction.

It's reasonable not to treat if the problem is mild enough. Knocking out the thyroid won't help the eyes -- the problem in the orbits doesn't come from hyperthyroidism but from the direct action of the autoantibodies. AFAIK nothing controls the autoimmune aspect of it except steroids. I don't know if any of the "steroid-sparing" drugs used in other immune conditions would work (Imuran, methotrexate, Cellcept, etc). If the eyes are bulging right out despite high dose steroids, there can be a risk of loss of vision from compression of the optic nerve, in which case an ophthalmologist can do surgery to decompress the orbits.

Ophthalmologists and endocrinologists would have more experience treating thyroid eye disease than neurologists like me. Hope it goes well for her.

thanks for the info!

plasmon is such a cool attending