#new england journal

[onetwistedmiracle]

My Dad may have officially retired from practicing medicine but he still gets and reads medical journals. He pulled this out of the latest New England Journal of Medicine (January 19, 2023) and mailed it to me, because my son -- his grandson -- is trans, and like a good Jew my Dad worries.

While it is true that "unanswered questions remain," to quote the note from my father he included with the article, honestly, the results seem awfully positive to me. When you put kids with gender dysphoria on the hormones they are asking for, "appearance congruence, positive affect and life satisfaction increase." Also good news, their "depression and anxiety symptoms decreased."

The TLDR of it is that it's still hard to be trans, but hormone therapy helps and should be used when appropriate. Medical science agrees generally, and specifically so does this 2 year long study.

[drnic1]

The Battle of the Bulge

How to Outsmart Your Hungry Inner Couch Potato This week I am talking to Dr. Tim Church, Chief Medical Officer for Wondr Health (@WondrHealth) a company focused on Digital Behavior change especially focused on the obesity epidemic. Tim has spent a large part of his career focused on this area and as he puts it “bringing the most good for the most people” and he Unveils the Top-Secret Weight Loss…

[jadafitch]

New England native shrub patterns, in spring and autumn. Featuring some lepidoptera species hosted by the plants, in their larval and adult forms. For a project that's been 4 years in the works… More details soon. Mountain Holly Northern Wild Raisin American Mountain Ash Shadbush with Eastern Tiger Swallowtail Butterfly Beaked Hazelnut with Luna Moth Staghorn Sumac with Spring Azure Butterfly Red-osier Dogwood with Cecropia Moth American Witch Hazel with Eastern Tent Moth Pussy Willow with Mourning Cloak Butterfly Gray Alder with Banded Tussock Moth Big-fruit Hawthorn with Viceroy Butterfly Winterberry Holly

[hairtusk]

[possibilistfanfiction]

surgeons au - when they get engaged?

[@gohandinhand hbd pt2 lol // ao3]

//

‘chief superion?’ dr. alvarez says, poking her head into your office and looking more frazzled than you expect and much more frazzled than you ever want to see any of your doctors, especially your head of ortho. ‘do you, uh — do you have a moment?’

you never have a moment, but you close your computer and nod, motion for her to come sit.

‘actually, i… can you come with me? it’s for…’ she sighs. ‘please?’

it worries you, instantly, because this would never happen if things were business as usual, if everything was running smoothly. ‘what’s going on, dr. alvarez?’

she hesitates. ‘it’s ava,’ she finally admits after a few seconds. 

you’ve spent decades perfecting the art of looking calm when you are very much not, but this tests you immediately, the jolt of panic that shoots through your body. when silva had joined your residency program, he had frustrated you beyond measure: you thought her unserious, impatient, selfish — the only reason you had any patience to begin with is because jillian had recommended her so warmly after ava’s time as her doctoral candidate. but you were so, so wrong — about her work ethic, her overwhelming compassion, her deep bravery and even deeper capacity for love. beatrice, from even before she had matched with your hospital, had been your favorite in a way that you trusted her to, one day, take over your program and continue to make sure it’s the best in the world — even better, you’re certain. she’s unshakably calm under pressure, good with patients and colleagues alike, a skilled surgeon and even more skilled teacher.

but ava is special in a way that feels too close to even say — your mentee, the incredible leader of next generation of neurosurgeons and researchers: miracle after miracle, delivered with a bravado and a kindness that’s impossible to teach.

so you nod, stand and grab your cane with the steadiest hands you can manage. camila leads you, silently and quickly, clearly also trying to act calm, to the nearest staff bathroom to the OR, and you open the door and then see ava sitting on the small bench there, slumped over a little to one side. normally, ava never stops moving, always fidgeting, gesturing, greeting you with a wave and a daily attempt to get you to come up with a secret handshake with her. but now, ava’s face is set in a pained grimace and her body is noticeably still.

‘hey, dr. s,’ they say, trying to smile, but it doesn’t work.

‘hello, dr. silva.’ you feel caught in no-man’s land for a moment, with ava so still and camila hovering worriedly. 

‘so, i, uh. well, first of all, my surgery went great. secondly, please don’t tell bea until we know what’s going on.’

‘ava —‘

‘— i can’t move.’

you don’t have any comforting thing to say: you’ve seen ava’s scans over the years, especially when her back has flared before; you know about how jillian is always working on more effective injections, better tech. you hear about it when you visit her lab for business, and you also hear about it over quiet dinners at either of your houses, with the lights low and her voice taking on a sadder timbre than the determined, professional clip when she’s talking only of science, not of love too. 

so instead you nod and walk toward ava, crouch down with only a few clicks in your knee — you’ll take it. ‘numbness? tingling?’

‘i —‘ ava’s voice shakes and she takes a deep breath, steadies herself. ‘i can’t feel anything. it’s — there’s just nothing.’

you go through a few more questions and she answers with what you can tell is honesty: she’d been in pain lately but nothing out of the ordinary, especially with the winter weather rolling in; there wasn’t anything concerning before operating, or else she certainly would’ve postponed; after she finished — eight hours of concentrating and microscopic movements later — when she sat down, things degraded quickly from there.

‘i had my intern page cam,’ they say, ‘because i just — bea is going to panic and go into worst-case-scenario mode, and i don’t know if it actually is worst-case-scenario or just, you know, a passionate flare-up.’

all of you can guess that this is not a normal flare, but, ‘okay. let’s get an mri then. but i don’t want to move you without a brace and a backboard.’

ava pouts.

‘you know i can’t justify just helping you transfer to a chair right now.’

‘yeah, but it doesn’t mean i have to like it.’

you place a tender hand on the top of her head and she leans into it, just for a moment: a comfort, quiet and small and, you imagine, as much as she can accept right now.

‘alright,’ ava says, sniffling. ‘let’s get this show on the road.’

/

you would never take away ava’s autonomy, especially not now, but when you show her the scans — the worst worst-case-scenario results — she bites her bottom lip, clearly trying not to cry, and you say, ‘can i page dr. choi for you?’

ava looks toward the ceiling in frustration, in fear, in anger, in grief. ‘yeah,’ she says eventually. ‘yeah, i want her here.’

/

it’s a risky surgery, one that even you feel unsure about: if things go wrong, or, really, even if they go right, ava could have worse chronic pain and irreversible paralysis. beatrice accepts those risks steadily when you talk to her privately, when camila is doing one final pre-op update of ava’s vitals, her mouth set in a firm line, jaw clenched tightly.

the risks that shake both of you are much worse: too much blood loss, stroke, a lack of oxygen to the brain. you don’t want to say them, let alone think them about ava, but they both deserve to know, to choose.

but, ‘there’s no other options, are there?’ beatrice says, finally sitting down and putting her head in her hands, running a hand over her hair and then sitting back in the stiff chair, slumped, horrified. 

your silence is the only answer she needs, because she’s brilliant and there’s nothing else you can say: you will do everything in your power. she knows that. 

‘just — i love him.’

‘i know,’ you tell her. ‘i do too.’

she nods. ‘okay,’ she says, steeling her resolve as she looks to ava’s room. ‘okay.’

/

‘hey,’ ava says, ‘can you scoot where i can fully see you with this stupid neck brace on?’

even without being able to move, even scared out of her mind, ava glares at you. it makes you want to smile, the fight that sits in her bones. 

beatrice sits carefully on the side of ava’s bed fully in her line of sight. ‘what do you need, my love?’

ava smiles softly. you wonder, briefly, if she feels the grief of not being able to touch her partner, always so tactile. ‘don’t pretend this couldn’t end really badly, please.’

‘ava.’

‘bea.’ 

beatrice frowns, staring down at their linked hands, held tightly even if ava can’t himself.

‘i’ve lived way longer and better than i ever thought i would,’ ava says.

‘and you’ll have plenty of good time left,’ beatrice says, stubborn even still.

‘well, i hope so,’ ava concedes. ‘but i just — i gotta ask you something, just in case.’

beatrice swallows, clearly fighting back tears, and nods.

‘there’s a ring in my tan purse, the one i never use.’

beatrice does start to cry then; she shakes her head.

ava’s smile is so, so sad. ‘i was waiting for, like, the perfect moment or the perfect plan. which you still deserve, but, well.’ she shrugs with her jaw clenched in pain. ‘i can’t get down on one knee right now, but i know you’ll like the ring.’

‘i — i’ve known,’ beatrice admits, which has them both laughing through tears. beatrice dries ava’s cheeks first, then her own.

‘and you didn’t say anything?!’

‘i knew you wanted to ask. also, i was just looking for a spare mint; it didn’t seem fair to ruin your surprise for such a ridiculous reason.’

ava shakes her head. ‘that’s very kind.’ and then, ‘so, what do you say then?’

‘i, um — i have a ring too, in my winter pack.’

ava grins. ‘so that’s a yes?’

‘yes, ava,’ beatrice says, then leans forward to kiss him softly. ‘of course it’s a yes. as soon as you can, i’ll marry you. i’ve wanted to for years.’

‘wow,’ ava says. ‘okay, cool. sweet. it’s a yes from me too, obviously. also — is it a big diamond? family heirloom?’

beatrice laughs, despite it all. ‘i thought a diamond band might suit work better.’

‘hot,’ ava tells her. ‘well, when i wake up, i expect it.’

‘i’ll send lilith to rifle through all our belongings as soon as i can.’

ava sobers. ‘i wish i could feel you.’

beatrice cups ava’s jaw gently, her thumb grazing over her cheek. ‘i’m here.’

‘i love you,’ ava says.

‘i love you so much, ava silva.’ beatrice smiles, watery and terrified and sorrowful and grateful. she kisses ava, who leans her head up as best she can with a neck brace on. ‘in this life.’

ava nods, sniffles, and then looks at you, resolved, determined. ‘let’s do it.’

/

‘promise me,’ ava says, loopy from the drugs already administered in her IV but not asleep yet, ‘that you’ll take care of her if things don’t work out.’

‘things will work out.’

ava shakes her head. ‘we both know they might not.’

you smooth your hand over ava’s hair. ‘you are both loved beyond measure,’ you say, and ava takes it in.

‘well, try your best not to fuck it up.’

you laugh, and ava grins, and then her eyes flutter closed.

/

you explain to beatrice — now changed into joggers and a hoodie you’re sure was once ava’s — her alma mater not even close to beatrice’s — since it’s the middle of the night, lilith sitting stiffly beside her — that ava is alive but there were complications: too much blood loss, low oxygen levels. her spine is stabilized and you think — you hope — that part, at least, was successful, but you’re just not really sure if ava will wake up — or, if she does, what her cognitive function will be, who she’ll be. 

beatrice takes it, just for a moment, like a physical blow, but then she nods. ‘thank you,’ she says, quiet and polite without fail, but lilith looks on, concerned. 

‘we’ll monitor him closely in the neuro icu,’ you say, ‘and hope for the best.’ you don’t think beatrice has prayed in years and years, but there’s a rosary, probably lilith’s, clenched in her hand. 

‘okay,’ she says, and follows you quietly there. 

even though beatrice is a surgeon, seeing ava hooked up to so many monitors, drains and leads and an oxygen cannula in her nose, seems to give her pause, slightly unsteady on her feet — just for a moment, but enough for you to think nothing of it when you take her in your arms and hug her tight. unlike ava, who is always physically affectionate, beatrice has been reticent for as long as you’ve known her. but she sinks into it this time, letting out a shaky sob while you rub her back, and then steadies herself eventually. 

she sits down by ava’s bedside, faithful as always, and brave, and fishes out a box from her pocket, opens it and then slips a beautiful ring onto ava’s left hand. ava’s hands are cold, you know, because you made personally sure that she was comfortably settled in bed; but beatrice just holds steady, brings it to her lips, kisses the cool, still skin there. 

she murmurs something — please wake up; please don’t leave me; i love you, you’re not sure. 

you’re technically both done with your shift and also behind on so much paperwork, but you settle down at the nurse’s station and watch ava’s vitals as beatrice prays.

/

jillian brings you breakfast early the next morning, kissing your forehead in a show of affection that you both rarely allow at either of your workplaces. but she loves ava too, for years now, even longer than you, and so she takes you by the hand and leads you into her room. beatrice is asleep on mary’s shoulder, shannon bringing coffee for everyone. there certainly aren’t this many people supposed to be allowed in an icu room, but it doesn’t stop anyone because it doesn’t really matter: whenever a nurse comes in to change a dressing or an iv, you all stay out of the way. it’s quiet, small conversations only. you think ava would probably hate it — the lack of stupid jokes, beatrice’s bright laugh, mary and lilith’s fondness not at all masked by their snark.

you take turns getting beatrice to eat; you sleep lightly. eventually jillian makes you shower, changing out of your scrubs and into comfortable slacks and a soft sweater she’d brought you. 

it stays like this for two days: so many people from the hospital dropping by to see how ava’s doing, to drop off flowers, to check in with beatrice too. ava’s kindness is remarkably present even when he’s not fully; being returned tenfold. you don’t even ask or say anything, just make sure that beatrice’s shifts are covered by your other cardio attendings, and so she waits, sentinel. 

and then, just as beatrice is about to doze off again, 46 hours after you’d finished surgery, ava groans. beatrice shoots up like she’s not sure it happened, a specter too good to imagine. 

‘ava?’ she asks hesitantly.

it seems like a herculean effort, and you wait with bated breath, but then ava fights and opens her eyes. ‘hey bea,’ she says, weak and rough but coherent, aware, sure. 

beatrice smiles, immediate tears running down her cheeks. ‘hi.’

ava lifts her left hand — a miracle in itself — an inch or so off the bed, but easy, natural, and sees the ring there, beams. ‘hot.’

beatrice kisses ava’s forehead, her cheeks, her mouth — joy, everywhere.

/

you walk ava down the aisle, almost a year later — it was slow going, at first, and then more and more progress in physical therapy, beatrice’s steadfast reassurance through even the most frustrating, painful days. but now you’re here, ava smiling at your matching canes. 

‘wouldn’t be here without you,’ he says, in his wispy, beautiful white dress and immaculate makeup. 

you smile, hug her to you. ‘it’s an honor.’

you walk her down the aisle, steady and easy, both of you, and then watch as she stands, grinning at an already emotional beatrice. visible below her hair that falls just at her jaw, the newest scar along ava’s neck — from your scalpel, as careful and neat as you could — has faded; is still fading; has healed.

[yujisleftshoe]

Not to beat a dead horse, but LIBRARIES literally will give you online access to TV and movies for free without having to pirate them. They also have recordings of theatre productions!! I just watched David Tennants Richard ii FOR FREE with a really high quality recording FROM THE LIBRARY!!!! Everyone needs to GET A LIBRARY CARD!!!!

My library also has access to programs that can help you make your own legal documents if you can't afford an attorney but need things like wills or bills of sale or lease agreements!!

There is concerts and and documentaries and operas and Ballets from carnegie hall and the Palace of Versailles and other world class theaters!

They have coding courses! IELTS training!! News paper access that usually requires a subscription! Audio books! Music! Tickets to events and museums and aquariums and art galleries and carnivales and park passes and youth programs!!!

There is literally no reason to not have a library card. They're free.

[thefroggiesden]

Some plants from my walk the other day. 🌱

[home-ward]

[silvestriste]

[sadnessdeath69]

[poppletonink]

TRACK REVIEW: Off Balance - Carl Green In Particular

Following the quintessentially quirky Off Guard, Carl Green has released his final EP of 2023: Off Balance. With a vocal likeness to Paul Heaton, Carl proclaims messages of love, bitterness and anger; a wonderfully eclectic mix of tales. Opening with The Union Hotel, a dreamy vibe creates a feeling of far-off, protected memories. Carl professes the importance of living in the moment as events are occurring, romanticising a relationship and the world of the Union Hotel. Arguably the best track of the whole ensemble is Algorithm and Blues: a critique of social media algorithms and how we are conditioned to feel as a result of the gaze of society. The track as a whole has an electronic and distorted feel to it - as though trapped within a computer screen - just out of reach from the rest of the world. Good Job You Screamed contains fast-paced strings and sparse piano notes which create an unsettling feeling of pressure. Tension builds up throughout the track as Carl describes the anger involved during a break-up, especially with the other person lashing out and victimizing themself. The closing track, Fine Arts Student, discusses the nature of an artist parting ways with the world of art due to society's now normalised standard of what 'art' must be. It questions why we must put 'art' into boxes of good and bad allowing it to lose all sense of creativity and freedom of expression. Once again, Carl has created a beautiful collection of songs, though all with a similar, quirky style unlike his usual genre-defying creations.

[fauvester]

these are my star trek doctor ocs emtala jcaho (pronounced jay-ko) and ama n'jem

[coochiequeens]

Ladies please share this info with any expectant mothers you know

Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal Birth

List of authors.

Alan T.N. Tita, M.D., Ph.D., 

Waldemar A. Carlo, M.D., 

Elizabeth M. McClure, Ph.D., 

Musaku Mwenechanya, M.D., 

Elwyn Chomba, M.B., Ch.B., 

Jennifer J. Hemingway-Foday, M.P.H., 

Avinash Kavi, M.D., 

Mrityunjay C. Metgud, M.D., 

Shivaprasad S. Goudar, M.D., 

Richard Derman, M.D., M.P.H., 

Adrien Lokangaka, M.D., M.P.H., 

Antoinette Tshefu, M.D., Ph.D., M.P.H., 

et al.,

 for the A-PLUS Trial Group*

Abstract

BACKGROUND

The use of azithromycin reduces maternal infection in women during planned cesarean delivery, but its effect on those with planned vaginal delivery is unknown. Data are needed on whether an intrapartum oral dose of azithromycin would reduce maternal and offspring sepsis or death.

METHODS

In this multicountry, placebo-controlled, randomized trial, we assigned women who were in labor at 28 weeks’ gestation or more and who were planning a vaginal delivery to receive a single 2-g oral dose of azithromycin or placebo. The two primary outcomes were a composite of maternal sepsis or death and a composite of stillbirth or neonatal death or sepsis. During an interim analysis, the data and safety monitoring committee recommended stopping the trial for maternal benefit.

RESULTS

A total of 29,278 women underwent randomization. The incidence of maternal sepsis or death was lower in the azithromycin group than in the placebo group (1.6% vs. 2.4%), with a relative risk of 0.67 (95% confidence interval [CI], 0.56 to 0.79; P<0.001), but the incidence of stillbirth or neonatal death or sepsis was similar (10.5% vs. 10.3%), with a relative risk of 1.02 (95% CI, 0.95 to 1.09; P=0.56). The difference in the maternal primary outcome appeared to be driven mainly by the incidence of sepsis (1.5% in the azithromycin group and 2.3% in the placebo group), with a relative risk of 0.65 (95% CI, 0.55 to 0.77); the incidence of death from any cause was 0.1% in the two groups (relative risk, 1.23; 95% CI, 0.51 to 2.97). Neonatal sepsis occurred in 9.8% and 9.6% of the infants, respectively (relative risk, 1.03; 95% CI, 0.96 to 1.10). The incidence of stillbirth was 0.4% in the two groups (relative risk, 1.06; 95% CI, 0.74 to 1.53); neonatal death within 4 weeks after birth occurred in 1.5% in both groups (relative risk, 1.03; 95% CI, 0.86 to 1.24). Azithromycin was not associated with a higher incidence in adverse events.

CONCLUSIONS

Among women planning a vaginal delivery, a single oral dose of azithromycin resulted in a significantly lower risk of maternal sepsis or death than placebo but had little effect on newborn sepsis or death. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; A-PLUS ClinicalTrials.gov number, NCT03871491. opens in new tab.)

see rest of article

[53rdcenturyhero]

NHS protest & survive strategies for reluctant activists (England). I am angry and writing stuff down.

●Write to your MP (tory) saying a polite version of "stop being stealthy little shits we see what your doing & we've already paid in our taxes" , if (labour) write a polite version of "speak up against the degrading of what we've already paid for in committee stages and in H of L". Do write not email, do visit constituency offices briefly & politely saying that the nhs service to help (pick a category) is worse in your personal experience . This raises stats and the issue of expenditure at the MPs office, giving the MP the feeling of their (publicly available) voting record will have effects on their reelection prospects and makes them nervous about just supporting businesses in the area who are incoming splinters off the nhs area funding * because you see and notice what your MP is actually effectively doing on this issue*. ● Support strikes by combatting the idea that strike removal laws have any place in modern societies in conversation to combat the facebook bilge, and question the idea that three twelve hour shifts a week makes efficient use of trained staff. Question the removal of training bursaries. ●Most important of all combat conversations that say strikers are just after money. Its the work conditions they want improving. ● American style health insurance doesnt cover most stuff because what they call "pre existing' is what the rest of the world calls medical history. European style health insurance says we charge you a trivial data entry fee like two coffee price AFTER treating you zero payment by the way have you cut smoking down and what is your employer doing to reduce workplace hazards.... ● Place blame on Westminster govt political ideology choices by saying in conversation reply like "public money straight into private companies thats a bit (pick slur appropriate to the group youre in) OI THATS MY MONEY "= theyll think about their own money...

●● Register to vote, group with like-minded ppl for emotional support (protesting is by definition going against a larger group) speak when safe and be charming when you announce that you have observed their behaviour. The illusion that you are their sort of people who see and dislike their specific choices makes their ego worried and that is the best way to get these bullies to change. Know your enemy by name and get local facebook groups to be polite persistant and public community representative = "we see you've done x and are talking about x+1 and we think this is already harmful " is more effective than "help (underfunded group)". Cut off funding cuts as the excuse, youre involved in tweaking and directing funding which makes them immediately say nothing about who deserves or not deserve. ● if your group encounter fascists in charge by accident withdraw and regroup for a wider block counter. Be the better person at a distance to stay safe and protest again. Dont go it alone, act as a group.

■Take photo ID along to vote. Yes this is England, but watch out for this change. It is worth voting. Dont wait for the next big election. The NHS is in trouble right now.

[trendynewsnow]

Semaglutide: A Breakthrough in Managing Osteoarthritis Pain

Semaglutide: A Breakthrough in Osteoarthritis Pain Management The widely recognized medication semaglutide, marketed under the brand names Ozempic for diabetes management and Wegovy for weight loss, has recently demonstrated an unexpected and significant benefit: a substantial reduction in knee pain for individuals suffering from obesity and moderate to severe osteoarthritis. This revelation…

[professionalowl]

so. um. the good news is we found your boyfriend. the bad news is that, well, we sort of…dug him up…in the middle of a car park. in leicester (buckley et al. 2013). leicester, yeah. sorry. they demolished the friary he was hastily interred in when henry viii dissolved all the monasteries. you know how it is. and as it turns out, well, shakespeare was…sort of right about him. scoliosis, yeah, sorry (appleby et al. 2014). if it makes you feel any better we analysed his bones and it turns out he had a pretty high-protein diet before he died (lamb et al. 2014). and he drank so much wine that it changed their chemical composition, which we didn't know could actually happen before we analysed him (lamb et al. 2014), so he was having a good time, at least. 

BIBLIOGRAPHY

Appleby, J., Mitchell, P.D., Robinson, C., Brough, A., Rutty, G., and Morgan, B. (2014). The scoliosis of Richard III, last Plantagenet King of England: diagnosis and clinical significance. Lancet 383, 1944. 

Buckley, R., Morris, M., Appleby, J., King, T., O’Sullivan, D., and Foxhall, L. (2013). ‘The king in the car park’: new light on the death and burial of Richard III in the Grey Friars church, Leicester, in 1485. Antiquity 87, pp. 519-538. 

Lamb, A.L., Evans, J.E., Buckley, R., and Appleby, J. (2014). Multi-isotope analysis demonstrates significant lifestyle changes in King Richard III. Journal of Archaeological Science 50, pp. 559-565.