Propofol is an anesthetic, seroquel is not... it’s an antipsychotic. The thing with antipsychotics is they’re shit or “dirty” drugs... seroquel is not even indicated for insomnia (and depending on who you ask is a terrible choice.. a lot of family med/internists use it, psychiatrists often cringe). It works because it has a strong antihistamine side effect, so it’s basically a very potent Benadryl.
The point being, you’re still arousable. A vigorous rub of the sternum will likely wake you up. Not so much on propofol.
I'm not sure what your point here is. I made no claim of 1-to-1 parity with propofol, the various uses of seroquel, it's efficacy for a given purpose, etc. Seroquel is however in the class of drugs "major tranquilizers" and my claim was simply that it can have a similar "time warp" effect. It's a claim based on my experience with it, and it is not an uncommon one. (And I do have experience with propofol through a single surgery to compare)
I will address some of the other details of your comment though. First, the statement that someone on seroquel is "arousable": Compared to propofol, sure. But a vigorous rub of the sternum will absolutely not do it for many people, myself included. My wife can attest to the difficulty. And if aroused before time, the state can be likened to severe drunkenness in terms of ability to function.
Also, your are right, there are arguably better sleep aid options. But it's arguable because individuals react so differently to different medications. Seroquel was not a first choice for the task, or the third. A doctor likely would be negligent in prescribing it for that sole purpose on a first consultation without exploration of other options.
As for it being a shit or "dirty" drug, there aren't particularly good options within this class of drugs. We can argue about whether these are over-prescribed, but for people who truly do need them, it is something of a devil's bargain where the benefits can be suspect relative to the costs. For the fortunate that response to them, newer medicines like latuda offer a much lower side-effect profile for similar benefits. Absent very good insurance though, that is financial hit of roughly $15,000 per year that few can afford out of pocket. This leaves the "dirty" drugs.
I won't put words into your mouth with this next part, but there are some that would then argue that these sorts of drugs are universally unsuited for any use, and that people suffering from their targeted disorders might better control their symptoms with diet, exercise, and supplements. Having seen many people attempt such and fail, I regard this point of view as a sort of survivors bias. The people that argue this point of view tend to be the very rare people for whom it works, but just as with any particular medication, the efficacy of any treatment regime varies greatly with the individual.
I tried to keep my statements factual and my own opinion out of it.
While “shit” was a bit tongue in cheeky the term “dirty” is used among practitioners because of the wide range of metabolic side effects that the atypical psychotics have. Seroquel is a metabolically “dirty” drug. Taken in therapeutic doses long term a high percentage of people will end up with metabolic syndrome derangements.
Likewise, in the US and Canada, is not indicated for sleep disorder/insomnia use either. In Lexicomp it’s not even listed for off-label use. That’s just a fact, I don’t know what you’re trying to convince me of. In the US there is also a storied history with Astra-Zeneca and a lawsuit due to their practices of pushing off-label use resulting in a $.5 billion settlement.
Another fact is that Seroquel was one of the most heavily marketed drugs ever to primary care providers. As my 100s of dollars of Seroquel branded swag my office accumulated 15 or so years ago will attest to (I am not a psychiatrist).
My own personal experience has been that most psychiatrists I’ve spoken to at a large academic center, are appalled at the idea of using seroquel for insomnia long term due to serious side effects and the consensus is that it’s MOA is mostly due to its antihistamine property. That’s really all I was saying.
Also most atypicals are not highly sedating, lurasidone especially so. I have not heard of it seriously being mentioned likely for primary insomnia.
You seem to have an axe to grind against Seroquel. I don't fault you for it. I hate it. I wouldn't take it if I hadn't explored other options to their exclusion. In my case I take it both for sleep issues and because it's on-label and effective as an adjunctive treatment for other health issues.
Otherwise I wasn't referencing lurasidone for it's sedative properties (it can have the opposite effect) but in comparison with Seroquel for it's use on-label as an antpsychotic. Sorry if there was confusion there. It's a much better option than Seroquel, if it happens to work for you. It doesn't always.
Early in residency, had a guy once that seemed “out” as normal during an operation. No abnormalities. In the recovery room claims he heard everything we were saying in the OR. We of course initially thought he was full of shit, but he quoted verbatim much of the chit chat the team was having (not that any of it was bad thankfully). This is very much not typical.
Reminds me when we had basic military medicine training and our officer told us to be extremely careful what we would say even while moving around people who seemed dead.
Hearing is the last sense that goes he said. The idea was to keep calm and not talk about how something was hopeless.
I'm not qualified to say if this is true but I keep getting reminded about it in different other settings.
Were you under with propofol the whole time though? Usually the propofol is just to put you down (it is very short acting) you’re intubated, and then anesthesia is maintained with a volatile fluorane such as sevo.
Propofol-only deep sedation is commonly used for minor outpatient procedures. If you’re going to have a patient down for less than an hour for a colonoscopy or endoscopy, it’s a very popular alternative to combination sedation as patient recovery is faster and a lot more pleasant.
I REALLY dislike that feeling of not existing or blinking out that people describe, it causes me some substantial existential dread afterward.
So I resolved to have a colonoscopy without any anesthesia or painkillers. It wasn’t a big deal for me, it felt like having bad gas when the tube would go around a corner in the intestines, but the nurses acted like I was insane. The doctor had to come out and tell them it was fine. He said doctors have to experience a colonoscopy awake at least once so they know what it feels like, which I found interesting. Seeing what was in there was pretty interesting too. The American medical system acts like the smallest bit of discomfort warrants being knocked out. The anesthesiologist seemed a little put out about it too, as I refused to even let them give me an IV. Maybe he didn’t get paid if I wasn’t out.
It was funny afterward because someone had the job of escorting me to my ride, so we walked together to my car. Made the whole thing far less unpleasant in my estimation.
> The American medical system acts like the smallest bit of discomfort warrants being knocked out.
There is a tremendous variation in both pain tolerance and anxiety. You sound like you’re in the minority.
The anesthetist still gets paid. His concern is if you freak out (this happens more often then you may think), he may at minimum have paperwork to do and worse you may sue him for malpractice (“well he didn’t clearly explain it would be that bad during the consent process).. again this problem happens more than you may think. Ie the negative ev for them if you do not do the typical protocol is considerable.
I got the idea from reading about colonoscopy practices in Europe, for example only 6% of people in Finland underwent sedation during a colonoscopy [0].
I have to go for a colonoscopy in another two and a half years, and I’ll insist on no sedation that time as well. You seem familiar with the process, is there a way to avoid feeling like I’m having a fight with the staff next time?
No sedation is perfectly ok. No IV is a VERY bad idea. I would personally refuse to take care of you in that case, and many of my peers would do the same, I believe.
Finnish person here. It is difficult to understand why any normal person would need sedation for colonoscopy. Perhaps there are super sensitive persons, but for most it should not be much more painful than getting vaccination, at least if the doctor is skilled and doesn't just force the colonoscope in. However, drinking large amounts of liquid that does not taste that great, in order to empty the colon, was the hard part. Colonoscopy was nothing compared to drinking that liquid.
The anesthesiologist was scared because without an IV, if something happens he's instantly in deep shit. And you too, for that matter. Anesthesiologists don't care if you want your thing this or that way. Their only priority is maximal security.
He/she must have been really, really pissed by your IV refusal.
50% is “super conservative”?? By what reasoning? How is that more appropriate than 5% or .5% or .05%? Either you have a justification for that estimate or you’re just making something up, which doesn’t mean squat.
> why the C programming language is the way it is.
I’m curious specifically why you think this is. The 6502 with its poor register set and special purpose addressing mode seems to make it a relatively terrible/challenging C target.
Not OP, but I learned assembly on the 6502, and its simplicity make it easy to create a mental model of the internals of a CPU - these relate very well with a low level language like c, even if today's CPUs are so much more advanced (and difficult to study).
Perhaps a better target might be the 68000, then? Still a relatively simple architecture, but one that more closely resembles a modern system -- multiple general-purpose registers, and ones which can be used as pointers without weird workarounds. (The 8-bit data / 16-bit address nature of the 6502 makes pointers complicated.)
Could be. Later I also worked with machine code on the 68K and it stuck to me less than the 6502, but it might just be because I felt that more like a chore than when I was dabbling with the 6502 (which I learned when I was just a kid).
> That’s asinine, obviously he doesn’t mean more data is always better even if the test is invasive or dangerous.
With him classifying all MDs as idiots, no it is not asinine.
I’ve known few academic physicians that would turn down data if it can be ethically obtained.
The difference between the medical profession and, say Google, is that we as a general rule do not consider the populace one big lab to experiment on as we please. The consequences are more than a little different.
It’s not like things were always this way in medicine either.
I think the key distinction is that clinical science rather than medicine needs as much data as possible, and then medicine needs to follow clinical science.
And then, that medicine needs to become much more sophisticated in dealing with risk and uncertainty, given the absurd complexity of the problem domain. Doctors are not idiots but they are no more than human while trying to do an impossibly difficult job, and are far too cocksure given that context. They should be asking for as much help as they can get, which is not the reality of the situation. See something as simple as the resistance to checklists in surgery for example, despite the evidence.
I see your point about ethical breaches which have taken place. I would tend to think of those as abuses of power rather than coming from an ideological position, but that may not be correct. You’re certainly right about the dangers of a beta test mentality.
> Had we enforced a full-body MRI for every patient, we would quickly amass enough imaging data to know which anomalies are malignant and which are not to a very high degree
How, pray tell, are we actually determining which are malignant and which are not?? I’ll give you a hint: the charitable explanation is you are completely ignorant, the less charitable one is that you consider Mengele and Ishii modern medicine heroes. And that is even if the determination by imaging alone is even possible.
Once again I have to point out on HN... not everyone in the medical world is an idiot incapable of analytical thinking, it is just that a lot of us care about ethics. Our patients, even in research, are more than just numbers.
I don't even think it's about the ethics that necessarily make this statement wrong (though, you are correct in that HN needs to consider basic ethics on a much more frequent basis).
In the case of these detections, the ground truth can be very subjective and is certainly not a simple explanation. Is the ground truth read by a radiologist? A radiologist with fellowship training? Multiple radiologists? Biopsied? Followed for 5 years to see if the patient actually died of their tumor?
The complexity is a lot more than the underlying algorithms and computer science (though they are important!).
> How, pray tell, are we actually determining which are malignant and which are not?
When people on this forum speculate about things like this, I assume they are thinking of some future ML application. Of course you're right though, that is not doable today. The point of the OP is that if we collected more data perhaps it would be possible.
> the less charitable one is that you consider Mengele and Ishii modern medicine heroes.
The ad hominem attacks against the OP are completely unnecessary.
> I am actually an MD.
The start of your post feels like "appeal to authority."
What I mean is, just because the person is "actually an MD" doesn't mean the person has expertise in this specific area yet the person is using it to claim such. I.E. some might call me a computer scientist, but that doesn't mean I have enough expertise in machine learning, a sub-discipline, to say definitively that the OP's idea about using full body scan data is feasible.
Should I have started my post "I am actually a computer scientist." No, right? That would be an appeal to authority that doesn't prove I know anything about what I'm talking about. Now, if the person had started with "I am a radiologist who has looked at empirical data about full body scans versus more selective scans." that would be a more useful and valid statement.
It’s not a big deal. I only mentioned as a response because the op started off saying they were from a family of MDs.
Also the vast majority of practicing physicians are expected to have detailed expertise to understand the indications, application, and interpretation of imaging within their speciality. Most imaging orders are issued by medical or surgical staff, not radiologists.
My problem with your post is not that you're not a radiologist (that was just an example—and maybe I should've just written "person who has experience doing empirical studies of body scans"). It's that you use your status as "an actual MD" but that is clearly not enough and a real "appeal to authority" or "appeal to anecdotes." And then you combined that with some awful things that you compared OP to.
Looking through your post history you often jump to "appeal to authority" combined with name calling and it's a pattern that reeks of arrogance to me.
For example one of your posts starts out along the lines of, I'm not a 747 pilot, but I am a pilot... in a post about something specific to the 747 and you say the other guy was "talking out their ass." Again, not super relevant appeal to authority and some mean-spirited name calling.
> Not a 747 pilot (not sure why that matters here)... but a pilot. The flight positions are equal. The plane is designed to be flown the same from either flight position and this is routinely done. The guy saying otherwise is talking out their ass.
You just seem to love to tell everyone you're super special and smarter than them because of your accomplishments as a means of arguing and then put them down. It gives you instant validity to some of course, but I think it's just lazy. Your arguments should stand on their own merit. Not request to authority or anecdotes from your kind-of-related experience.
> How, pray tell, are we actually determining which are malignant and which are not??
A biopsy? Whichever method you would normally use to find this out?
You could even ignore all the information and just train your algorithm on whether the patient died in the next 5 years (after the scan/s).
Obviously you need data before you can determine anything automatically. But I don’t think everyone would be averse to this even if you do tell them it might be more likely to kill them due to excessive testing.
There new guidelines in the US that still recommend aspirin based on cardiovascular risk. That aspirin increases the risk of bleeding is old news. The difficulty has been in quantifying the risk/benefit. You should consult with your doctor about your specific circumstance.
If that’s what he’s saying, he’s wrong. Python threads are based on native threads. They are parallel executed, they just don’t do so very well because of the GIL.
The point being, you’re still arousable. A vigorous rub of the sternum will likely wake you up. Not so much on propofol.