I want to ride tomorrow. All the trails are closed, including the 7 mile climb behind my house. I've been staying on the road but cars are driving faster and more carelessly lately. Saturday I had a nice road ride with very little traffic so I could try that route again. And it's raining, so there's that.

Any reason why dates wouldn't be Kosher? What do you do with the Charoset, do you spread it like jam?

Math is critical thinking; what you're proposing is "clap your hands if you believe".

However, this thread is where I come to have pleasant chats with my friends, so you're going on the quiet list because this is not a venue for you to try to salve your ego.

You typically have some on matzoh. It’s a ritual food for Passover. It actually tastes really good imo.

Fieldroast hand formed burgers 😋 Not "meaty" but delicious.

E.coli, trichomoniasis, listeria, yummy :D

I seem to recall one or two cases of food poisoning from vegetables. ;)

Just taking advantage of his faux pas. :rolleyes:

I saw a YouTube video using 3 rolling pins once.

I think what's missing is the theramin.

Walks. Should. Count. On. Strava.

wut

People can go by boat from Cuba to Taiwan.

I see what you did there.

Chag Sameach!

My sister's late husband had us over for a sader a few times. He explained a lot of it to me and it seemed like a great tradition. He was a great guy and I always looked forward to any event at their place.

Synchronicities are funny - I had barely remembered the theramin existed until watching American Horror Story season 3 a week or two ago, and now it pops up again

Kind of ruins your point.

Here you go:

What if he can't tune in until 2:15 p.m.?
Elaborate.

Hey datlas and MoAlpha

I have another weird case.

7 year old female spayed medium sized mixed breed dog who I originally saw 5 years ago for multifocal CNS signs, which included abnormal mentation, visual deficits and poorly localized hyperesthesia. Presentation was typical for encephalitis, which is a common and usually immune-mediated disease in dogs. Brain MRI and CSF tap confirmed the diagnosis and all infectious tests (tick-borne diseases, fungal diseases and protozoal diseases) were negative. I treated the dog with anti-inflammatory prednisone and initially several months of a myelosuppressive agent called lomustine aka CCNU at an every 30 day schedule ie chemo lite. She became asymptomatically neutropenic (resolved within 7 days) on lomustine and ultimately the monitoring schedule was too much for the owner, so I switched her to cyclosporin A which she received for 18 months (my standard treatment course for this disease). The dog came off all medication and returned to normal for 3.5 years.

About a month ago, the owners thought the dog was relapsing in her encephalitis (which is not an uncommon occurrence and the owners were abundantly aware was a possibility)- the dog seemed uncomfortable in the back half of her body, weak in the hind legs and mentally a little "glassy eyed". It was the weekend and they had some prednisone on hand so they started that. She was immediately better. They called me on Monday, I worked them in that day. Her neuro exam was normal except for a visual deficit in the right eye with normal pupillary light reflex. Localized to the left forebrain and with the history of seeming painful in the back half of her body, multifocal disease seemed likely and the primary concern was for a relapse of immune mediated encephalitis.

I recommended repeat brain MRI plus lumbar spine MRI and CSF tap as indicated. Due to costs, owners declined. Without the previous history of immune mediated encephalitis, I would not have started immunosuppression without a definitive dx of encephalitis but in patients of mine with a solid past history of immune mediated encephalitis, I am willing to do this so long as we sit down and have a face to face and the owners understand fully what we are risking if we're wrong.

Ok, so we go ahead with anti-inflammatory prednisone plus the same dose of cyclosporin A she had previously been on years prior. Ten days later, she shows up at the ER with an abscess in her inguinal region. That abscess is lanced and drained, she is put on antibiotics and her immunusuppressive meds are continued. She follows up with me a week later, doing fine and the abscess is healed. Ok that was weird but I am immunusuppressing her so the abscess kind of makes sense.

Two weeks go by and she calls on my day off to report a non-weight bearing lameness of her right front leg. My colleague in neuro sees her and finds carpal pain. No joint effusion, she has the orthopods look and they don't palpate joint effusion either. But the concern is for immune-mediated polyarthritis, so she taps two joints and the joint fluid cytology comes back as normal. Started doxycyline and ran tick titers while awaiting the joint fluid cytology. Tick titers some back negative a few days later.

The next day the dog comes in through the ER because there's limb swelling in the tissues of the lower right forelimb. The ER doc palpates what he thinks is an enlarged right submandibular LN. He is worried about a bacterial cellulitis of the right forelimb and adds enrofloxacin and recommends LN aspirate, which the owners decline (later when I talked to them, they declined the LN aspirate because they mistakenly assumed it was enlarged due to the presumed bacterial cellulitis, not realizing that the submandibular LN does not drain the right thoracic limb so we'd not expect that particular node to be enlarged in this exact scenario). ER doc tells them to follow up with Heathpack on Monday, four days after the intial onset of the right thoracic limb lameness.

So I saw the dog yesterday. Aspirated the "lymph node" (which by now is so large and firm that I'm not 100% sure it is a lymph node vs a mass in the vicinity of the lymph node) and get pure fungal hyphae (no lymphoid tissue) and now have a fungal panel pending and the dog is on voriconazole, off CSA and on only a physiologic whisper of prednsione for another week. The presence of fungal hyphae and the dog's clinical picture would be most consistent with systemic aspergillosis and some dogs are born with an immunologic "blind spot" to aspergillus specifically. This is most commonly seen in German Shepherd dogs but occasionally in other breeds. So in addition to the aspergillus antibody test that comes with my standard fungal panel, I have ordered an antigen test called a galactomannan titer (I don't know if this is a purely dog thing or if its the same in people).

Here's the interesting thought experiments:
1. Was the original diagnosis of immune-mediated encephalitis correct? Yes, I think so, the dog had two years almost of immunosuppression and did well without dying from fungal disease.
2. What happened at the recent "relapse"? Did she have the bad luck to get a completely new neurologic inflammatory disease- ie she now had a fungal encephalitis when she previously had a immune-mediated encephalitis? Of course we don't have a firm dx of encephalitis but we have the hard neuro finding of the right visual deficit with intact PLR which must be accounted for. Did she indeed have a relapse of immune mediated disease and I was just super effective in innumosuppressing her with my cyclosporin (which I use all the time, rarely with this extent of complication, and in fact used with no adverse effect in this very dog previously), leading to first a bacterial abscess and then systemic fungal disease? Did she maybe not have a bacterial abscess but instead a fungal abscess, which would be really rare? If so, why would she have gotten better on antibiotics while still on immunosuppressants? Seems likely that actually the abscess was in fact bacterial.
3. If the fungal disease is the result of my immunosupressing her, then what was the going on the the "relapse"? Did she actually have immune-mediated disease and now that's going to fall apart on me because I can't suppress her immune system any longer?

I could push hard for a repeat MRI and spinal tap in this dog and maybe I should but it honestly not going to change what I immediately do, and it would be expensive, leaving less overall budget to try to treat this dog. And short of seeing fungal organisms in my CSF, I still won't know if I have inflammatory disease if its infectious or immune mediated. Unless there is a fungal PCR panel that I could maybe run on CSF, I guess I could look into that. I don't do tons of PCR testing on CSF in dogs because my absolute sample volumes are usually small, as encephalitis is most commonly seen in toy breeds of dogs. But this dog is big enough that I could probably get a pretty large spinal fluid sample.

I think I want to just get my fungal titers back first and my galactomannan assay and see what I get- aspergillus antibody neg and antigen positive is a pattern that I interpret as an aspergillus-specific immunodeficiency and that just never turns out well in the long run. That's probably the most important next thing for me to figure out.

Yes, but they had already built those boats to go other places, places which were much closer originally. I do not believe that people in Cuba or Taiwan would sail the entire world if those were the only two landmasses on the world. However, it is an analogy to try to illustrate the vast emptiness of space that most people have trouble with.

They would if they knew something was there to find.

Hey Heathpack very interesting case. Autoimmune diseases are often the most challenging to diagnose and treat.

Exhibit A is VV.

We had a sad one the other day. Since we're working our way through all the James Bond movies on Amazon Video, we watched Goldfinger on the day that Honor Blackman passed away.

Actually I started the movie too late night before last and we had to finish it last night.

Oh well, the show must go on. Tonight, Thunderball!

Rolling pins?

Sure. What do you want to know?

And it's an analogy, which tend to be imperfect.

Tell you what - when we can just hop in a saucer and get to Mars at will, y'all can tell me I'm wrong. Until then, I'm siding with the physicists, and I don't think further exploration of this topic on this thread will be fruitful.