Just a quibble on the Berklee comment - Berklee famously accepts anyone who will pay them - there are no entry barriers other than ability to pay. The music students who come with no musical experience do not last long, do not play in the higher level groups, and do not end up making an impact in the music industry. For this reason, many of us with experience in music education (I'm a graduate of the University of North Texas, so I'm biased) find the statement that "Berklee...is one of the most renowned institutes on the planet" to be - well - inaccurate.
In fact, one might say that Berklee is a great illustration of the topic of this post, by way of analogy. Because it is a famous (I'll make a distinction vs "renowned"), many talented and experienced musicians do enroll, and they go on to have successful and important careers in music. So the experience the students bring to the college are (at least anecdotally) the primary factor in their success. Much like the programming students.
Trying to make inexperienced Berklee students play in the orchestra in 15 weeks (or 4 years, for that matter) is ridiculous.
I'm a practicing cardiologist and see my fair share of comments on topics like this, and my responses range from sadness to amusement. The trial showing benefit from normal LDL and elevated CRP was called the JUPITER trial, and wasn't created by doctors or lawyers - it was funded by AstraZeneca, who were "doing their duty" to their shareholders by creating demand for their product, Crestor. The way drug companies do that is by funding studies, which sometimes benefits us (patients), although in my experience, that's not usually the outcome.
In any event, the problem in the summary is that it misses the point. Assuming that the results of the JUPITER trial are accurate, and by giving Crestor to 100 people with normal LDL but high CRP, I could eliminate 1 "outcome" (stroke, heart attack, or death - a composite outcome often used in trials like this), the question isn't "am I harming 99 to save 1" - the question is "am I helping this population overall." The harm was minimal, the benefit was impressive. The real harm comes in the form of monetary cost (as well as the rare risk of "adverse events," including muscle injury or liver injury). So what is an acceptable cost of avoiding one outcome? I don't know, but that's where the conversation should be.
The way I think of it, there are two rooms - one with people who get the best evidence-based treatment, and the other with people who don't. The truth is that people in the first room live longer, on average, than people in the second room. Being in the first room does not guarantee a better outcome to any individual occupant, but overall, more people will be healthier in that room than in the other, over time. So my job, in a sense, is to get people in that first room.
Right now, incentives don't stand in my way, so I'm insulated from the question of cost, to some extent (this is changing for better and for worse, and is the subject of a much much longer post some other day maybe). I spend enormous amounts of time trying to stay current, attending conferences, reading journals, conferring with colleagues. That's hard to argue against, I would hope. Some evidence leads to recommendations that are easy to lampoon (expensive drugs for people without diseases - what will they think of next to steal from us!), but you pay me to walk around knowing things, and to apply that knowledge to you when you walk into my office.
As a side note - we've moved on from JUPITER, which later turned out to be less promising than it initially appeared. In fact, I never put anyone on Crestor simply because of high HDL - and current research has backed me up - we are "late adopters" in my practice, which I would highly recommend if I were a patient. This didn't stop dozens of patients from asking me for/about it after it was summarized in the NY Times in a much more flattering light than the summary above.
OMG, I *wish* this were true of the AMA. As a physician and still active member, I can tell you that this couldn't be further from the truth. The AMA's primary business is publishing and maintaining insurance coding and billing standards, and selling their databases to the highest bidder. They employ lobbyists primarily to maintain that monopoly - they are NOT particularly interested in maintaining insurance or government payments to physicians (aka "livelihood"), although they make noises on that topic occasionally. They've basically been relegated to the sidelines on most national issues involving medicine. They represent less than 30% of active US physicians. I hear this same trope frequently, however, despite the fact that it's demonstrably false.
This is not accurate for any actual flat tax proposal, at least since before the time of Dick Army. There are two relevant numbers for a modern flat tax - the Deduction and the Rate. The two are juggled by the government to ensure adequate government income. A typical starting point might be a deduction of $35,000 and a rate of 35%. All income up to the deduction is free income.
For example, a person earning $50k would pay 35% on $15k of income. A person earning $30k would pay no taxes. A person earning $700k would pay 35% on $665k.
The point of this taxation system is to remove the government's ability to motivate you to do what it thinks is important. No loopholes, no deductions, no incentives. There are benefits and risks to taking this approach, but a lack of progressive-ness in the tax code is not among the risks. This is arguably the most libertarian method for taxing a population. The poor pay nothing. The middle-income folks pay a small amount. The rich pay a lot, but at a reasonable rate (actually more than they pay now, since no deductions - that can represent a dramatic tax increase for the wealthy). Your tax return can fit on a post card - write down your income and mail it in.
There's still room for tweaking, unfortunately, as the government then gets in the business of deciding what's income. Do investment earnings count? Does inheritance count? Is this income before taxes or after? Similarly, is it income before other expenses like health care? Mortgage? School loan payments? Social Security? 401K? IRA? etc.
Flat taxes are disproportionately hard on low-income earners, while they give the wealthy a huge break. They're not fair, stop pushing them.
That's a pretty good analogy. And taking it further, IQ measures the kinetic energy of the electrons ejected from a metal with a red light shining directly on it *only if the polarity is correct*. Otherwise it's measuring something else. And, of course, the spin of the subatomic particles - and the strangeness - are important components of determining if you're really measuring intelligence or just test-taking ability. It's a common conflation.
I'm not commenting about which device to use - I'm commenting about whether you should be using any device.
It seems reasonable to me to use heart rate as a motivating factor, but be careful about assigning much (if any) physiologic meaning to it. Yes, higher heart rates do correlate with higher exertion, but the correlation is loose at best, and the specific numbers have almost no bearing on how much benefit you're getting from any specific exercise. The same heart rate can mean dramatically different things on two consecutive days - there are just too many factors that affect heart rate to allow it to be the sole indicator of exercise benefit. It's also indicating general fitness level (which can vary by quite a bit daily - it's affected by sleep, infection, emotional state, etc), is responding to volume levels (how full is the tank), environmental cues (heat, cold, techno music, jiggly parts on your neighbor), pain (not irrelevant for people who train aggressively), etc.
Below is my comment from a couple of weeks ago.
I'm a cardiologist; we use heart rate as a threshold when doing stress testing, but otherwise it has limited utility in measuring "exertion level." The Maximal Predicted Heart Rate [MPHR] was established in the late '60s as an observation, not a true prediction; a small sample of people was observed exercising to their subjective "maximum," and those rates were plotted. There was enormous variability; the slope of MPHR was simply the line of best fit from the scatterplot, and was estimated by the authors of the original article to likely be accurate within 30 points in either direction. A particular person's maximal heart rate is impossible to predict within any meaningful accuracy; obviously, the derived slope is even sloppy for large populations. There are many many "experts" with theories regarding what percentage of MPHR you should achieve and for how long in order to get aerobic benefit - there is almost no science on the subject. Currently in vogue (and to my eye, at least as reasonable as anything based on heart rate) is the Borg Scale of Perceived Exertion. Basically, work to a level where you consistently feel like you're exerting yourself - that's how you get feedback on your exertion level. For an excellent discussion of this, see Gina Kolata's book Ultimate Fitness (almost 10 years old, still well-researched and interesting). There's an enormous amount of misinformation and pseudoscience out there.
Hearts respond to a number of factors to determine pulse rate - nerve stimulation (sympathetic and parasympathetic) is just one. Others include chemical (think adrenaline), stretch (higher volumes cause more forceful pumping, but also quicker), etc. These other factors are still in play in patients after heart transplants. In this patient, pulse doesn't happen so it's a moot point.
The parent asked about the loss of fast heart rate and whether that wouldn't blunt the sensation of anxiety, and it certainly can. Again, there are many factors that contribute to that sensation, and heart rate is typically pretty trivial among them, but this depends entirely on the specific patient. I can make some patients feel anxious simply by speeding up the heart with a pacemaker or with drugs, so it's absolutely a factor - but it's far from predictable. The converse is also true.
BP wouldn't be non-fluctuating. You'd lose the pulse-associated components (there would no longer be systole and diastole with every beat), but vascular tone, position, and many other factors would all still contribute to variations in BP over time.
In this patient, you could measure BP invasively with an arterial line, or non-invasively with ultrasound. Also, the regular method would work but you'd have to be pretty careful in order to hear it. The sounds we listen for when checking BP (Korotkoff sounds) are caused by turbulence. Say your BP is 120/80. We pump up the cuff to 170 or so, and at first there's no turbulent flow through the arteries because there's no flow at all - the cuff is too tight to allow flow. At 120mmHg, turbulent flow begins and you can hear pulse - in this patient, I imagine you'd just hear a continuous rumbling sound. In you, the turbulence would continue all the way down to 80mmHg. At 80, the cuff pressure is lower than the lowest pressure in your artery, and laminar (silent) flow returns as the artery is no longer compressed. In this patient, since the difference between systole & diastole really is trivial, you'd only hear the turbulence in a very narrow range.
I believe you're thinking of an LVAD (left ventricular assist device) which is continuous and therefore doesn't contribute a pulse. Typically, though, the patient's heart continues to beat - the LVAD provides an assist but doesn't usually do all the work - so there is usually still a pulse.
I don't understand this post - the heart is exposed to "higher pressure" each and every beat via the aortic valve in normal hearts, too. The aortic valve is a passive structure - it opens and closes in response to simple pressure gradients. When the pressure inside the heart (specifically, inside the left ventricle - LV) is higher than the pressure in the aorta, the aortic valve is forced open and the ejection phase begins. This lasts until the pressure in the aorta is higher than the pressure in the LV, which in turn forces the aortic valve closed. Higher reflected pressures don't change this basic process, and I don't see any mechanism for causing "heart disease" from these reflected pressures.
The heart disease from stiff arteries occurs for other reasons. First, the arteries that supply heart muscle are rarely spared from whatever process is hardening the arteries in the rest of the body (atherosclerosis; congenital or acquired), and that causes inadequate blood supply and eventually damage or death. Also, when atherosclerosis occurs throughout the body, the associated "stiff arteries" have higher resistance, which does translate to more work for the heart, eventually leading to failure. This is one of the reasons we use antihypertensive medications - to lower the resistance against which the heart has to pump.
Your theory has surface appeal, but doesn't align with real-world biology as I understand it. I'm a cardiologist, so I'm interested in learning more about this if there's any evidence, but I think this may be a misunderstanding.
I'm a cardiologist; we use heart rate as a threshold when doing stress testing, but otherwise it has limited utility in measuring "exertion level." The Maximal Predicted Heart Rate [MPHR] was established in the late '60s as an observation, not a true prediction; a small sample of people was observed exercising to their subjective "maximum," and those rates were plotted. There was enormous variability; the slope of MPHR was simply the line of best fit from the scatterplot, and was estimated by the authors of the original article to likely be accurate within 30 points in either direction. A particular person's maximal heart rate is impossible to predict within any meaningful accuracy; obviously, the derived slope is even sloppy for large populations.
There are many many "experts" with theories regarding what percentage of MPHR you should achieve and for how long in order to get aerobic benefit - there is almost no science on the subject. Currently in vogue (and to my eye, at least as reasonable as anything based on heart rate) is the Borg Scale of Perceived Exertion. Basically, work to a level where you consistently feel like you're exerting yourself - that's how you get feedback on your exertion level.
For an excellent discussion of this, see Gina Kolata's book Ultimate Fitness (almost 10 years old, still well-researched and interesting). There's an enormous amount of misinformation and pseudoscience out there.
I think there's a bigger-picture comment to be made about the quality of Ringo's drumming - yes, he was left-handed and therefore came up with unusual things, and yes he had good time. More importantly, he sounded like Ringo, which is a less idiotic statement than it sounds like. Drummers who sound like Ringo make Beatles music sound really really good.
Having Neil Peart or Vinnie Colaiuta or Antonio Sanchez or Dave Weckl on Beatles' music would have been a disaster. These guys are technically "better" drummers than Ringo (and truthfully, all are also good at playing simply and tastefully when it's called for), but they aren't Ringo.
If you (correctly) note that Bonham is great because nobody else sounds like Bonham, you have to give Ringo props for the same thing (OK, not for sounding like Bonham, but for sounding like Ringo). If you (correctly) note that sequenced Britney Spears drum parts are soul-less, you have to give Ringo props for being soulful. If you read the drum magazines, you'll see dozens of today's big-name drummers all saying the same thing - they got into drumming after seeing Ringo play.
Ringo made the Beatles' music sound great. He played exactly what the music needed to sound just right - it's hard to argue that Beatles songs are missing something or that they sound "off" - and despite the fact that he wasn't a writer in the band, he's responsible for 1/4 of that excellent sound.
So Ringo is a great drummer. Why? Because he made great music.
The problem isn't saying that two stars (or any two people) are each unique - the problem is saying that something is "totally unique." You can't modify an absolute - less perfect, somewhat unique, more omniscient, very infinite, etc. Either it fits the category ("totally, dude") or it doesn't.
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Vermont is not coastal (unless you count Lake Champlain). See the problem with generalizing?
Just a quibble on the Berklee comment - Berklee famously accepts anyone who will pay them - there are no entry barriers other than ability to pay. The music students who come with no musical experience do not last long, do not play in the higher level groups, and do not end up making an impact in the music industry. For this reason, many of us with experience in music education (I'm a graduate of the University of North Texas, so I'm biased) find the statement that "Berklee...is one of the most renowned institutes on the planet" to be - well - inaccurate.
In fact, one might say that Berklee is a great illustration of the topic of this post, by way of analogy. Because it is a famous (I'll make a distinction vs "renowned"), many talented and experienced musicians do enroll, and they go on to have successful and important careers in music. So the experience the students bring to the college are (at least anecdotally) the primary factor in their success. Much like the programming students.
Trying to make inexperienced Berklee students play in the orchestra in 15 weeks (or 4 years, for that matter) is ridiculous.
I'm a practicing cardiologist and see my fair share of comments on topics like this, and my responses range from sadness to amusement. The trial showing benefit from normal LDL and elevated CRP was called the JUPITER trial, and wasn't created by doctors or lawyers - it was funded by AstraZeneca, who were "doing their duty" to their shareholders by creating demand for their product, Crestor. The way drug companies do that is by funding studies, which sometimes benefits us (patients), although in my experience, that's not usually the outcome. In any event, the problem in the summary is that it misses the point. Assuming that the results of the JUPITER trial are accurate, and by giving Crestor to 100 people with normal LDL but high CRP, I could eliminate 1 "outcome" (stroke, heart attack, or death - a composite outcome often used in trials like this), the question isn't "am I harming 99 to save 1" - the question is "am I helping this population overall." The harm was minimal, the benefit was impressive. The real harm comes in the form of monetary cost (as well as the rare risk of "adverse events," including muscle injury or liver injury). So what is an acceptable cost of avoiding one outcome? I don't know, but that's where the conversation should be. The way I think of it, there are two rooms - one with people who get the best evidence-based treatment, and the other with people who don't. The truth is that people in the first room live longer, on average, than people in the second room. Being in the first room does not guarantee a better outcome to any individual occupant, but overall, more people will be healthier in that room than in the other, over time. So my job, in a sense, is to get people in that first room. Right now, incentives don't stand in my way, so I'm insulated from the question of cost, to some extent (this is changing for better and for worse, and is the subject of a much much longer post some other day maybe). I spend enormous amounts of time trying to stay current, attending conferences, reading journals, conferring with colleagues. That's hard to argue against, I would hope. Some evidence leads to recommendations that are easy to lampoon (expensive drugs for people without diseases - what will they think of next to steal from us!), but you pay me to walk around knowing things, and to apply that knowledge to you when you walk into my office. As a side note - we've moved on from JUPITER, which later turned out to be less promising than it initially appeared. In fact, I never put anyone on Crestor simply because of high HDL - and current research has backed me up - we are "late adopters" in my practice, which I would highly recommend if I were a patient. This didn't stop dozens of patients from asking me for/about it after it was summarized in the NY Times in a much more flattering light than the summary above.
I don't understand - what is the name of your horse?
OMG, I *wish* this were true of the AMA. As a physician and still active member, I can tell you that this couldn't be further from the truth. The AMA's primary business is publishing and maintaining insurance coding and billing standards, and selling their databases to the highest bidder. They employ lobbyists primarily to maintain that monopoly - they are NOT particularly interested in maintaining insurance or government payments to physicians (aka "livelihood"), although they make noises on that topic occasionally. They've basically been relegated to the sidelines on most national issues involving medicine. They represent less than 30% of active US physicians. I hear this same trope frequently, however, despite the fact that it's demonstrably false.
This is not accurate for any actual flat tax proposal, at least since before the time of Dick Army. There are two relevant numbers for a modern flat tax - the Deduction and the Rate. The two are juggled by the government to ensure adequate government income. A typical starting point might be a deduction of $35,000 and a rate of 35%. All income up to the deduction is free income.
For example, a person earning $50k would pay 35% on $15k of income. A person earning $30k would pay no taxes. A person earning $700k would pay 35% on $665k.
The point of this taxation system is to remove the government's ability to motivate you to do what it thinks is important. No loopholes, no deductions, no incentives. There are benefits and risks to taking this approach, but a lack of progressive-ness in the tax code is not among the risks. This is arguably the most libertarian method for taxing a population. The poor pay nothing. The middle-income folks pay a small amount. The rich pay a lot, but at a reasonable rate (actually more than they pay now, since no deductions - that can represent a dramatic tax increase for the wealthy). Your tax return can fit on a post card - write down your income and mail it in.
There's still room for tweaking, unfortunately, as the government then gets in the business of deciding what's income. Do investment earnings count? Does inheritance count? Is this income before taxes or after? Similarly, is it income before other expenses like health care? Mortgage? School loan payments? Social Security? 401K? IRA? etc.
Flat taxes are disproportionately hard on low-income earners, while they give the wealthy a huge break. They're not fair, stop pushing them.
That's a pretty good analogy. And taking it further, IQ measures the kinetic energy of the electrons ejected from a metal with a red light shining directly on it *only if the polarity is correct*. Otherwise it's measuring something else. And, of course, the spin of the subatomic particles - and the strangeness - are important components of determining if you're really measuring intelligence or just test-taking ability. It's a common conflation.
I'm not commenting about which device to use - I'm commenting about whether you should be using any device.
It seems reasonable to me to use heart rate as a motivating factor, but be careful about assigning much (if any) physiologic meaning to it. Yes, higher heart rates do correlate with higher exertion, but the correlation is loose at best, and the specific numbers have almost no bearing on how much benefit you're getting from any specific exercise. The same heart rate can mean dramatically different things on two consecutive days - there are just too many factors that affect heart rate to allow it to be the sole indicator of exercise benefit. It's also indicating general fitness level (which can vary by quite a bit daily - it's affected by sleep, infection, emotional state, etc), is responding to volume levels (how full is the tank), environmental cues (heat, cold, techno music, jiggly parts on your neighbor), pain (not irrelevant for people who train aggressively), etc.
Below is my comment from a couple of weeks ago.
Hearts respond to a number of factors to determine pulse rate - nerve stimulation (sympathetic and parasympathetic) is just one. Others include chemical (think adrenaline), stretch (higher volumes cause more forceful pumping, but also quicker), etc. These other factors are still in play in patients after heart transplants. In this patient, pulse doesn't happen so it's a moot point.
The parent asked about the loss of fast heart rate and whether that wouldn't blunt the sensation of anxiety, and it certainly can. Again, there are many factors that contribute to that sensation, and heart rate is typically pretty trivial among them, but this depends entirely on the specific patient. I can make some patients feel anxious simply by speeding up the heart with a pacemaker or with drugs, so it's absolutely a factor - but it's far from predictable. The converse is also true.
BP wouldn't be non-fluctuating. You'd lose the pulse-associated components (there would no longer be systole and diastole with every beat), but vascular tone, position, and many other factors would all still contribute to variations in BP over time.
In this patient, you could measure BP invasively with an arterial line, or non-invasively with ultrasound. Also, the regular method would work but you'd have to be pretty careful in order to hear it. The sounds we listen for when checking BP (Korotkoff sounds) are caused by turbulence. Say your BP is 120/80. We pump up the cuff to 170 or so, and at first there's no turbulent flow through the arteries because there's no flow at all - the cuff is too tight to allow flow. At 120mmHg, turbulent flow begins and you can hear pulse - in this patient, I imagine you'd just hear a continuous rumbling sound. In you, the turbulence would continue all the way down to 80mmHg. At 80, the cuff pressure is lower than the lowest pressure in your artery, and laminar (silent) flow returns as the artery is no longer compressed. In this patient, since the difference between systole & diastole really is trivial, you'd only hear the turbulence in a very narrow range.
I believe you're thinking of an LVAD (left ventricular assist device) which is continuous and therefore doesn't contribute a pulse. Typically, though, the patient's heart continues to beat - the LVAD provides an assist but doesn't usually do all the work - so there is usually still a pulse.
I don't understand this post - the heart is exposed to "higher pressure" each and every beat via the aortic valve in normal hearts, too. The aortic valve is a passive structure - it opens and closes in response to simple pressure gradients. When the pressure inside the heart (specifically, inside the left ventricle - LV) is higher than the pressure in the aorta, the aortic valve is forced open and the ejection phase begins. This lasts until the pressure in the aorta is higher than the pressure in the LV, which in turn forces the aortic valve closed. Higher reflected pressures don't change this basic process, and I don't see any mechanism for causing "heart disease" from these reflected pressures.
The heart disease from stiff arteries occurs for other reasons. First, the arteries that supply heart muscle are rarely spared from whatever process is hardening the arteries in the rest of the body (atherosclerosis; congenital or acquired), and that causes inadequate blood supply and eventually damage or death. Also, when atherosclerosis occurs throughout the body, the associated "stiff arteries" have higher resistance, which does translate to more work for the heart, eventually leading to failure. This is one of the reasons we use antihypertensive medications - to lower the resistance against which the heart has to pump.
Your theory has surface appeal, but doesn't align with real-world biology as I understand it. I'm a cardiologist, so I'm interested in learning more about this if there's any evidence, but I think this may be a misunderstanding.
I'm a cardiologist; we use heart rate as a threshold when doing stress testing, but otherwise it has limited utility in measuring "exertion level." The Maximal Predicted Heart Rate [MPHR] was established in the late '60s as an observation, not a true prediction; a small sample of people was observed exercising to their subjective "maximum," and those rates were plotted. There was enormous variability; the slope of MPHR was simply the line of best fit from the scatterplot, and was estimated by the authors of the original article to likely be accurate within 30 points in either direction. A particular person's maximal heart rate is impossible to predict within any meaningful accuracy; obviously, the derived slope is even sloppy for large populations. There are many many "experts" with theories regarding what percentage of MPHR you should achieve and for how long in order to get aerobic benefit - there is almost no science on the subject. Currently in vogue (and to my eye, at least as reasonable as anything based on heart rate) is the Borg Scale of Perceived Exertion. Basically, work to a level where you consistently feel like you're exerting yourself - that's how you get feedback on your exertion level. For an excellent discussion of this, see Gina Kolata's book Ultimate Fitness (almost 10 years old, still well-researched and interesting). There's an enormous amount of misinformation and pseudoscience out there.
Maybe he can get a government bailout.
I think there's a bigger-picture comment to be made about the quality of Ringo's drumming - yes, he was left-handed and therefore came up with unusual things, and yes he had good time. More importantly, he sounded like Ringo, which is a less idiotic statement than it sounds like. Drummers who sound like Ringo make Beatles music sound really really good.
Having Neil Peart or Vinnie Colaiuta or Antonio Sanchez or Dave Weckl on Beatles' music would have been a disaster. These guys are technically "better" drummers than Ringo (and truthfully, all are also good at playing simply and tastefully when it's called for), but they aren't Ringo.
If you (correctly) note that Bonham is great because nobody else sounds like Bonham, you have to give Ringo props for the same thing (OK, not for sounding like Bonham, but for sounding like Ringo). If you (correctly) note that sequenced Britney Spears drum parts are soul-less, you have to give Ringo props for being soulful. If you read the drum magazines, you'll see dozens of today's big-name drummers all saying the same thing - they got into drumming after seeing Ringo play.
Ringo made the Beatles' music sound great. He played exactly what the music needed to sound just right - it's hard to argue that Beatles songs are missing something or that they sound "off" - and despite the fact that he wasn't a writer in the band, he's responsible for 1/4 of that excellent sound.
So Ringo is a great drummer. Why? Because he made great music.
The problem isn't saying that two stars (or any two people) are each unique - the problem is saying that something is "totally unique." You can't modify an absolute - less perfect, somewhat unique, more omniscient, very infinite, etc. Either it fits the category ("totally, dude") or it doesn't.
Pro means for and con means against
As it is plainly seen.
So if progress means to go ahead,
What does congress mean?