Lá breithe shona duit

Sorry I can't be there . . . but at least I can send:

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Copped a 'Rona

I think I really woke up to the presence of Covid when a case was reported on the floor where I used to work. That was on 7th March 2020. I've managed to dodge the virus for 980 days, while everyone else in our family seems to have succumbed at one time or another. The Beloved came down poorly last weekend. On Monday, Dau.II, who is visiting, and I went into town for supplies - more tissues! ginger ale! something nice for dinner! - as we left the house we are asked to pick up some Covid-19 tests. Reaming out TB's nose  showed the tell-tale Covid+ve line. There was no point in me doing a test then, despite sounding a bit barky: we could assume that we were sharing virus as we share so much else in our lives.

By Tuesday, I was def'ny unwell - not take to the bed and moan unwell but certainly not the full shilling. Didn't stop me sawing a load of fire wood, for example. Being sick was a bummer because Wexford Science Café was meeting on Tuesday evening to talk about wind-farms and it promised to be a bit of a punch-up. And this evening was meant to be a discrete knees-up with my former colleagues to acknowledge that I was one of six silver-backs who had retired from the Faculty in the last 3 years. I'll have to RSVP=No to that as well because, according to the instant gratification Covid-19 self-test [R], which I took an hour ago, I am still shedding virus. Dang!

And tomorrow I could have been judging some school science projects at a DEIS school in Gorey but that too has to be put on the long finger. Science Week 2022 has been rolling along without me this year!  Anyway, I am right glad about never having to pull a sicky at The Institute during the eight years I worked there. Despite being exposed to the usual blizzard of microbes at the beginning of every term.

Get yer moobs out, Chris

When I were a nipper, it was rare to see a fat child. My mother's, not uncompassionate, assessment was "It's just his glands, poor thing". She didn't have the scientific language but her meaning was that obesity was physiological condition cause by an unfortunate defect: like having diabetes, cancer or a cleft palate. Glands are the pink bits inside us which produce hormones - small chemicals which are secreted into the blood-stream to act elsewhere in the body. You know the names of some: adrenalin, insulin, test♂sterone, estradi♀l. But I bet you can't spell all 60+ known non-steroid hormones [crib], let alone have an inkling of what is each one's purpose. CLOG hormones which have a role in this story: cholecystokinin, leptin, orexin and ghrelin, .

Now we have an epidemic of obesity and nobody really knows why. It's particularly distressing to see over-weight kids because their life-time health prognosis makes grim reading and because blaming them for their condition seems like punching down. Yes, yes, there's a punching duvet joke in there as you flush the poor beggar's head down the t'ilets at school. And if we want to make a stand, or spread the word, on childhood obesity, who better to front it than Chris and Xand van Tulleken who kid's TV teleprog Operation Ouch! - much gawped by my Gdaus?  Earlier this year they published a 7½ part podcast A Thorough Examination which explores the relationship between nature [genetics] and nurture [eclairs] w.r.t.obesity in 30 minute chunks

It's not the results of a double-blind case-controlled scientific study but the series hinges on an interesting anecdatum: Chris and Xand are identical twins but in their early 30s they started to diverge radically when they stood on identical side-by-side bathroom scales. Part of the of the experiment Chris O'Thin [RL] elected to eat an 80% junk-food diet [uo from 20%] for just a month which made his shorts longer [RR] put a lot of sag on his moobs and more grip to his love-handles. He'll be able to work-out these lard-kilos off in a similar amount of time because there is a certain inertia in human physiology: at age 42 it takes a big and/or continuous shove to disturb the set-points of our systems.

At age 48, I went paragliding, one of the mildly embarrassing outfalls from that weekend was being forced to stand on a scales to assign a canopy of correct [= sufficient] dimensions. I knew my weight had been stable 73kg for my 18-30 years and guessed it might be up 6-7kg. I actually clocked in at 86kg! and was mildly fat-shamed "someone's been telling porkies" by the instructor. But I shed all those extra kilos in 6 weeks = 800km trudging down the Camino two years later. Even living my best sofa in retirement, I'm still more or less at my 18-30 weight. So your/my current weight is not set in butter.

Mais revenons nous a nos Tullekens. 10 years ago, Xand went to New York for work at a time of relationship upheaval - including an unexpected offspring. His digs were above a friendly bodega, he was working weird doctory hours and he was tired and lonely. So his kitchen trash started to fill with take-away cartons and chip-packets and pizza trays. And he grew and outgrew his trousers. Chris, seven minutes older, was back in London, also doctoring, but getting married, keeping exercised and having a couple of kids with whom to play garden soccer. Plus, as health-care front-liners they both copped a 'Rona but Xand was much sicker - atrial fibrillation; A&E; long-covid.

Every time the brothers met, they'd go out for a meal, Xand would have two starters and extra fries and Chris would (under the guise of care) fat-shame his brother . . . who would double-down on the assault on his tum sense of self. One of the positive outcomes of their podcast journey was the realisation that Chris's gobby caring script was not helping the problem.

But the chow mein message of the series is everyone's beef with UPF = ultra-processed food 🍔🍕🍟. This is the stuff which we buy from the food aisles of supermarkets or through deliveroo which is a) triple-packaged and b) contains ingredients not normally found in the domestic battery de cuisine. Ground cumin is processed but frozen Indian onion bhaji and spinach samosa is UPF. even if mmmmm so Good. And get this: putting ORGANIC  in large letters on the front of the packet may be green-washing a pharmacopaeia of surfactants, antioxidants, emulsifiers, stablizers, sugar and salt in the table of contents.

In 1980 regular "raw?" potatoes, broccoli, milk and mince comprised 58% of the calories in average British diet by 2020 57% of the calories came from UPF. Not forgetting that there is a middle ground of processed food which includes ground cumin, wheat flour, rolled oats, minced pork.  This change in the national diet has been tracked by a 3-fold increase in folks "living with obesity". No responsible person (ie excluding headline writers) is saying X is caused by Y; but you draw your own conclusions when it comes from catering for your kids. We all love crisps and fried dumplings - they are designed by food engineers - making us love the product is their job. But for the kids maybe try just say No! ?

So here's your quiz.  Identify the products here without the bright picture on the package:

1) WTF1: Sugar, Vlargarine [Vegetable oils (Palm oil, Rapeseed oil), water, salt, emulsifiers (mono & diglycerides of fatty acids, polyethylene sorbitan monostearate), acidity regulator: citric acid, Vitamin E, flavouring, Colour: beta carotene), WHEAT flour (with calcium, iron, niacin, thiamine), modified starch (Maize), Vegetable Oil (Rape), Whey solids (MILK), Raising agents: (disodium diphosphate, sodium bicarbonate), emulsifiers (propane-1,2-diol esters of fatty acids), WHEAT gluten, Whole EGG powder, Vegetable Oil (Rapeseed), WHEAT starch, vegetable Oil (Palm/Shea), Fat reduced cocoa powder, emulsifier: rapeseed lecithin, Glazing agent: gum Arabic, Shellac, Whole hen EGG, SOYA flour, skimmed MILK powder, maize starch, humectant (glycerol), icing sugar (sugar, potato starch), Unhydrogenated vegetable fat, water, colour: (allura red AC, quinoline yellow, indigotine, sunset yellow FCF, carmosine, ponceau red R4, Black PN), Preservative: potassium sorbate, raising agent sodium dihydrogen carbonate, monocalcium phosphate. 

WFT2: wholegrains (rolled oats, wholewheat flour, wheatgerm), free range eggs, grapejuice concentrate, milled organic seeds (flax, hemp, sunflower & pumpkin), butter, organic seaweed mix (6%) (sweet kelp, dilsk, sleabhcan), flaked almonds (6%), coconut, raisins, dark chocolate (unsweetened chocolate, sugar, cocoa, butter, soy lecithin, natural vanilla) orange juice, orange oil (2.2%). allergens in bold print. 

WTF3: Irish pork (70%), Water, Pork Fat, Rusk (contains Wheat), Corn Flour, Leeks (2.2%), Salt, Flavourings, Black Pepper, Sugar, Yeast Extract, Stabiliser (Triphosphates), Preservative (Sodium Sulphite), Antioxidant (Sodium Ascorbate), Sunflower Oil, Natural Pork Casings

Wes Ely New ICU Way

I just powered through another medical earbook on Borrowbox: Every Deep-Drawn Breath by Wes Ely MD. Ely grew up Catholic in Shreveport LA. He went to a Jesuit High School and still buys into [St.] Íñigo López de Oñaz y Loyola's slogan Ad maiorem Dei gloriam = To the Greater Glory of God. But he doesn't come across as obnoxiously certain that his Way is the only way. One thing that opens my heart to his story is that he changed his mind in the face of evidence that then current medical practice was not doing the best for critically ill patients. It was rather treating patients in ICU as wholly passive recipients of interventions by god-like physicians and discharging [bish-bosh; job done; can breathe] broken husks condemned to an extended period of pain, dependency and expense. Because ICU teams were too busy: stand aside I'm saving more lives they never had time for follow-up of their ex-patients.

One of Ely's epiphanies was meeting a young woman whose heart, lungs and kidneys had been fritzed by his, nominally successful, efforts saving her life. He looked down [dus wheelchair!] at her with chagrin and bemusement - but, god-of-tech-and-science, I saved a young woman's life: who /what is this?  It's all about the intubation innit? If you're sick enough to be in ICU, you often require help with breathing. Intubation is painful and bewildering and it is easier to manage if the patient is deeply sedated lest they attempt to wrest this invasive tube from their throats - let alone all the other catheters, cannulas, electrodes, lines, and tubes which are also hitched up to the body.

In 1978, we were living in a shit-hole bedsit in Dublin and a medical pal got me on the list of on-call orderlies at St James' Hospital. If one of the reg'lar staff pulled a sickie, I was called in to work his [all men] shift on a zero-guaranteed-hours contract. It sometimes paid the rent. I was almost always assigned to the male medical ward, which was filled with elderly gents, many demented, with an occasional younger diabetic.Shortly bfore I arrived on scene, one of the old boys, demented and with a urinary catheter, climbed over his cot-side in the night and fell to the floor. Big PITA for the staff: accident report form, audit from the matron. One of my job on night-shift became to tie the old chap's arms to the cot-sides with . . . bandages. He had grown up-children but they never rarely came to visit and he was lonely and looking to go home insofar as we could fathom what was going on in the shambles of his mind. Maybe if someone came every night to read the newspaper to him, it might have quieted his wandering anxiety. And I tell ya, lads, you don't want to see someone try to remove his urinary catheter by force.

Dr Ely would be with me on the read-a-bedtime-story front. His epiphanized new self is all for communicating with sick people even if they are comatose or demented . . . or intubated: because that puts the kibosh on speech. He and his staff hold the patient's hand [good move for starters!] and then ask them to squeeze [once for Yes, twice for No] answers to specific queries. Instantly, a whole class of occupants of numbered beds became people with needs, desires and suggestions. 

Around the same time he invited himself on a site-visit to an ICU in Denmark which was full of natural daylight and seriously ill people up and plodding about the ward with their saline drip. Many of the others, while in bed, were awake and interacting with staff and other patients or watching the weather unfold through the plate-glass windows. It's all about the meds! On his watch,they use non-benzodiazepine sedatives (either propofol or dexmedetomidine) because benzodiazepines like midazolam [bloboprev on death row!] induce a physiological and mental state close to death. Many of the homeostatic multiply-redundant mechanisms managing urinary flow, liver function, heart beat etc.  evolved for people who were upright and thinking and moving about. The delicate balance goes wonk if the body is immobile - muscle wastage is a standard outcome for bed-ridden people irrecoverable if immobility goes on for too long. But all the other systems are affected, sometimes permanently:

Calming the circulatory system excessively deprives the brain of oxygen, so it malfunctions and ICU delirium became common if not standard in benzo-treated patients. And these crazy visions would persist and recur long after the patient has been sent home as another Successful Outcome. Not so successful if you keep seeing panthers in your own kitchen and waking the entire household screaming at 3am.

Team Ely-ICU evolved a labored mnemonic to match APGAR [birth] or DABDA [death] which eventually stabilised as the A2F Bundle. This is meant to be a best practice list of Things To Do TTD or Things To Check TTC to maximize the chance of a discharged patient with some quality of life prospects.

• Assess, Prevent, and Manage Pain
• Both Spontaneous Awakening Trials & Spontaneous Breathing Trials
• Choice of Analgesia and Sedation
• Delirium: Assess, Prevent and Manage
• Early Mobility and Exercise
• Family Engagement and Empowerment

Set this against PADIS the Pain, Agitation, Delirium, Immobility, and Sleep Disruption clinical practice guidelines of the Society of Critical Care Medicine.

But Wes Ely's happiest Freudian slip was once to write I see you instead of ICU and adopt that as his motto.

Sun 13t Nov 022

Sunday round-up

• STEM
  
• Prof Poliakov with his tie [R]  holds the lb avoirdupois
• Dual road / rail bridge NZ
• Making trad pencils
• Fat ships wobble 
• Quacks like a duck with Rohin Francis
• Shortest TOL planes Valdez AK
  
• ♬ ♩ ♫ ♪
• September - Wayward Jane
• Wayfaring Stranger - Hayde
• I will find you - Clannad
• ARTS
  
• Treason Easter 1916
• Afon Tir buried house in garden 
• Austrian woodpiles
  
• Stugvärd Tjäktja Wayfarers hut wardening in N Sweden:
• Emma
• Cornelius
• Rubbernecking in Gib and across La Linea
• Political inertia over-rides national borders
  

Engclaves

Anyplace where natural borders go wonk makes me wonder why: what combination of history, dynasty or inertia caused that political anomaly? I've been to Baarle NL/BE, for example, both actually and O'Blob: because who can resist an enclave in an exclave? Baarle is dynastic. Belgium has other exclave issues beside Baarle. Rangpur / Cooch-Behar shows similar entanglement unresolved by the partition of India in 1947. But shifts in the channel of the River Tumen has cut off part of China. While Steinstücken in Berlin was a more recent political outlier. The Soviets left exclave headaches in the CentAsiaStans when they dumped the SSR suffix and went independent. But that's all the concern of foreign Johnnies in distant places; surely nothing like that could hang on unresolved in modern times in . . . England.

Ahem, and like Not So - at least up until the great 1974 rejigging of county borders which I discovered while stalking our ancestral demesne in Wales.  As it happens, historical Flintshire Sir y Fflint included the largest exclave in England and Wales Maelor Saenseg [Saxon Princeland] wedging itself uncomfortably between the English counties of Cheshire and Shropshire [map R]. In 1974 Flint and Denbigh were merged into Clwyd which was itself dismembered by the Local Government (Wales) Act 1994. to give this map.

But the searchable, zoomable Historic Counties Map is endlessly entertaining:

• Sedgeberrow, Worcestershire is wholly surrounded by Gloucs.
  
• A peculiar gerrymandered ragged finger of Berkshire explores the backside of Wiltshire near Tidcombe
• And Oldberrow, Worcs. is similarly invading Warwickshire near Stratford-upon-Avon.
  
• Most of Newmarket was in Suffolk but that part was held in the jaws of Cambridgeshire and the historic racecourse was half in Cambs.

Closer to home there is a peculiar 120 hectare pene-exclave of Co Waterford 10km NW of Tallow:

That makes matter-a-damn bit of difference except in determining GAA loyalties. But Further north a ragged intrusion of Co Monaghan in Co Fermanagh called the Drumully Polyp made things awkward after the partition of Ireland 100 years ago: That's famous enough to attract attention: in the troubles but surely more so post-Brexit

Finally there are 50 hectares of Limerick in suburban Charleville Co Cork:

POA come round in turn

[ejected prematurely 07Nov22, sorry]
On the 24th of last month I left attentive readers hanging with "It was an interesting morning because I secured cogent advice on two quite different aspects of living your best life" . . . and then only dealt with one such aspect. After I left the Ada Lovelace event, I went back to my old office to check in with two of The Lads who still inhabit that cramped windowless space. It was catch-up time and I mentioned, as a known fact, that my mother had died nearly three years ago. Mild consternation and condolences . . . then the chat turned to their aged parents, their care and inattention and inevitable decline. As women, they were having to shoulder the heavy lifting of elder care; exactly as they have done the lion's share of child care. We agreed that it was a wearing aspect of generational turn-over, that almost as soon as your own children were grown, women were requested and required to navigate and/or captain the foundering floundering ship of aged parents.  "You need to get a power of attorney sorted out, they have an excellent HowTo on hospicefoundation.ie [28 page; 500Mb PDF]". 

I was nodding along and contributing my 2c-worth when it dawned on me that by You need to get a power of attorney sorted out they meant Me. And of course it was true, the great circle of life comes round to each generation in turn. Within the last ten years, I've been in a lawyer's office with both my mother and my in-laws where the brinking generation have endeavoured to facilitate the transfer of some part of their agency and autonomy to a younger model.  It was just in good time. Two days later, I was driving somewhere with The Beloved and broached the idea of sorting our own powers of attorney = POAs; no point in delaying it.

It so happened that, the moment [24Oct] my cogent advice post was launched, all three of our adult children were upstairs asleep. I therefore sent them an e-mail proposing that the 5 of us meet in the Polytunnel at 11:00 that morning. And it was so! And it was so useful!! My experience is that if you internalize your thinking without action, then it is easy to descend into an echo-chamber of anxiety. I do this much less nowadays. It was super helpful to be told that I was talking bollix hadn't considered all aspects of the problem. And there were other certainties of the next 10-20 years which were not on the Agenda of the Meeting but nevertheless needed to be tabled for consideration. 

For example, my parents moved house to their final destination when they were the same age as I am now. Both they and I, in our late 60s could trip up [and not fall down] the stairs without a thought. As my mother approached her 100th birthday, it was clear that her stairs to be were an accident waiting to happen. And indeed the last time my father went down those stairs was backwards after midnight sustaining a hair-line vertebral fracture as he went down. The stair-lift we installed for my mother cost £3,000; and served her needs for only 5½ weeks before she in turn left home for hospital, nursing home and the great unknown. There is no re-sale value for stair-chairs. Our current house is much pokier more cosy than my parent's mansion and our stairs are steeper than allowed by current building regs, so a chair lift is not a solution to getting from the front door to the bath-room for anyone with wobbly pins or defective balance.

Not this week or this year, but we should think about our exit strategy to another place [like the Welsh example R] without stairs but within walking distance of a pub, a pharmacy and a post-office. I'm a simple chap, I don't desire to impress the neighbours with the size of my flood-lit West Wing. Just a spare bedroom / zoom-office and a sofa-bed in the living room to encourage visits from the grand-children.  And I suppose a wheel-chair accessible bathroom and some serious laundry facilities for when I go All Paris [in . . continent, geddit?].  Not New Ross! Please don't send me to New Ross.