Welcome

 

We are five miles from Farmville, VA and 35 miles from Ft. Pickett, Blackstone, VA.

We rent two full apartments and a guest room/shared bath in our home on 100 acres a short walk from the High Bridge Rails-to-Trails Park. 

Our location is 610 Lockett Rd, Rice, VA, less than a mile from the US 460 and VA 307 intersection.  (Ignore the inaccurate GPS location that shows Macedonia Church).  Directions on request.

The apartments can be one or two bedrooms (One/$1400; Two/$1600) They are furnished, including all utilities, WiFi (35Mbs), TV service, etc. We can provide linens and kitchen items as needed.  Maid service  extra.  A $200 cleaning fee and a $500 deposit is required.  We will do a detailed background check.  Rental agreement available on request. Weekly or monthly rentals.

Call Susi Wilson:  434-390-7544

Maitakes!

Tis mushroom season!

 

Early COVID-19?

A comment from the NYT article below:

SDM

Santa Fe New Mexico 4m ago

25,000 scientists from all over the world converged on San Francisco for the annual AGU meeting between December 7 and 14. A member of my family attended. As co-chairs for a session, he sat next to a colleague on Dec 13 who had fallen ill while there but come to the session anyway. She coughed and sneezed through the two hours she was there and then left halfway through, so sick she immediately caught a plane home.
My relative fell ill when he returned to NM. He became so ill with respiratory symptoms that, he said, at times he thought he “wasn’t going to make it.” At Urgent Care they tested him for flu, which came back negative.
This week, his colleague from that session sent him an email: Her Post-Doc, who also attended the meeting, grew up in Wuhan. He spent his evenings socializing with friends from Wuhan who had come from China for the meeting. He also fell ill, as did one other of her students. None were tested for Covid19 as this was December 2019.
We suspect these may have been some of the first cases of the virus in the USA. Reliable antibody tests will be needed to determine when the disease really arrived in the USA.
From this article:

https://www.nytimes.com/2020/04/22/us/coronavirus-first-united-states-death.html?action=click&module=Well&pgtype=Homepage&section=US+News&fbclid=IwAR0Gqffjr5hhUi-7KYU2yguwC4Fa_oFes6cSDh1O_JqC-_Yknvo-HjV2Dsc

This just in from the Royal Free hospital London.

From the Head of ICU at the Royal Free. Please feel free to disseminate further. If you feel it's relevant, please copy this message to your time line. That will be really helpful for many.

“Dear All,

I have just finished a very useful ICU / NHS Nightingale teleconference, the aim of which was to consolidate experiences about CV19 and how best to manage the disease. I have provided a summary below. Please understand that the information is experience, not evidence. I think it highlights a number of areas that we need to discuss URGENTLY as a group. The take home message is that advice given at the beginning of this journey needs to be adapted as we learn more about CV19. The other important thing to begin to understand is that this disease has distinct phases and treatment will differ as patients move through these phases.

The call had about 80 people on it, most listening. There were about ten “experts” invited to speak, from high volume centres. I represented our site. Others included Georges, GSST & Brompton.

Ventilation

- Early high PEEP is probably not the right strategy and may be harmful. This is not ARDS in the early phase of the illness. 

- Avoid spontaneous ventilation early in ICU admission as also may be harmful.

- There is clear microvascular thrombosis happening in the pulmonary circulation, which leads to an increased dead space.

- Also some evidence of early pulmonary fibrosis reported from Italy, possibly oxygen related, possibly inflammation related. 

- Not many patients have reached extubation yet in London, re-intubation seems to be common. I highlighted our experiences of airway swelling / stridor / reintubation. 

- Brompton are seeing wedge infarcts in the lungs on imaging, along with pulmonary thrombosis without DVT. 

- Proning is essential and should be done early. Don’t just do it once. Threshold for many centres is a PF ratio of 13, but all agreed, do it even earlier. 

- Early on in the disease, the benefit of proning lasts < 4 hours when turned back to supine, as the disease progresses into a more ARDS type picture, the effect is more long lasting. 

- Many centres using inhaled nitric oxide and prostacyclin with good effect. Tachyphylaxis with NO after 4-5 days. 

- Generally people are using humidified circuits with HMEs. 

- A very interesting thing they are doing at Georges is cohorting by phase of disease i.e. early, late, extubation / trachy. It involves more moving of patients but helps each team to focus on things more easily. 

- Leak test before extubation is crucial, others are also seeing airway swelling. 

- Wait longer than usual before extubating, high reintubation rates reported. Do not extubatne if inflam markers still high.

My conclusions from this are:

- Less aggressive PEEP strategy at the beginning of the disease and go straight for proning. 

- Thromboembolic disease is prevalent, look for it. No one is sure about whether we should anti-coagulate everyone, this is probably too risky. 

- An extubation protocol is needed immediately. 

- We should consider using inhaled prostacyclin again (like we previously did) as it seems to be working early in the disease.

Fluid balance

- All centres agreed that we are getting this wrong. 

- Most patients come to ICU after a few days of illness where their temp was 38-40 and they were hyperventilating i.e. severely dehydrated. 

- High rates of AKI being caused by over zealous driving with frusemide, leading to unnecessary CVVHF. 

- Hypovolaemia leads to poor pulmonary perfusion and increased dead space. 

- Centres echo’ing their patients are seeing a lot of RV dysfunction without raised PA pressure. 

- Many have improved oliguria by dropping the PEEP i.e. these patients are really hypovolaemic. 

[On nights I have observed many of our patients with a zero fluid balance and temperature of 39 i.e. they will be 2-3 litres negative in reality.]

- Most centres are therefore now backing off of strict zero balance, particularly in hyperpyrexia. They are moving more towards avoidance of large positive fluid balance. 

- Lung ‘leak’ not as prominent in this disease as classic ARDS

My conclusions from this are:

- Avoid hypovolaemia as it will impede gas exchange and cause AKI. Progression to CVVHF increases mortality. 

- Avoid hypervolaemia

- How we achieve this is difficult, but the frusemide and noradrenaline cocktail needs to be carefully tailored, especially in pyrexial patients. 

- Echo patients to understand their volume status.

Renal

- Higher than predicted need for CVVHF - ? Due to excess hypovolaemia. 

- Microthrombi in kidneys probably also contributing to AKI.

- CVVHF circuits clot frequently. Georges and Kings now fully anticoagulant the patient (rather than the circuit) as it is the only way they can prevent this. One centre using full dose LMWH as they have run out of pumps. 

- Kings now beginning acute peritoneal dialysis as running out of CVVHF machines.

My conclusions from this are:

- Aggressive anticoagulant strategy required for CVVHF, potentially systemic. 

- If we run out of machines, PD may / may not help (our previous experiences with it are not great, but I have no alternative other than using CVVHF like intermittent dialysis and sharing machines)

Workforce

- A ’tactical commander’ is essential on every shift, who is not directly responsible the care of ICU patients. 

- Most centres now getting towards 1:6 nursing ratio with high level of support workers on ICU. 

- Training has largely fallen by the wayside as it is too large a task. People are being trained on the job.

My conclusions from this are:

- On call consultant to coordinate but not be responsible for patients (as is the model we have now adopted).

- We need one support worker per patient. Other centres are using everyone they have. From med students to dental hygienists. We are behind the curve ++ with this. Last time I was on a night shift, theatres were full of non-medical staff refusing to help ICU - this is unacceptable.

There were some brief discussion about CPAP:

- Proning patients on CPAP on the ward is very effective, I tried it the other day - worked wonders.

- Prolonged use of CPAP may (I stress the word may) lead to patients being more systemically unwell when they get to ICU. 

- Considerable oxygen supply issues with old school CPAP systems.

My conclusions from this are:

- As per local guidelines, assess the effectiveness of CPAP after an hour, if it isn’t effective then bail out and consider intubation. 

- If effective, regular review is required. If at any point it is failing, bail out and consider ventilation. 

- Whilst we may have a shortage of ventilators, holding people indefinitely on CPAP may be short-sighted as it may be converting single organ failure into multiple organ failure.

OK, that’s all I have.

I will stress again that this is simply a summary of discussions, none of which are backed up by large, robust multi-centre RCTs.

My conclusions after each section are nothing more than suggestions to be discussed.

We need to adapt fast to what we learn about this disease and learn from our colleagues at other centre. We are all in this together and joined up thinking is required.

Lastly, we desperately need to look at our own data to understand whether we are getting this right or not.

Good luck, stay stay safe and be kind to one another.

Dan

Daniel Martin OBE

Macintosh Professor of Anaesthesia

Intensive Care Lead for High Consequence Infectious Diseases

Royal Free Hospital

London

Advice for a Volatile Stock Market

1.  Invest, don’t “Trade”. Trading is gambling.  Investing is buying for the future.

2. Be patient. Look at the long term.  You’ve chosen a good company, give them some rope.

3.  Don’t watch the Ticker Tape!  Your portfolio should be a “Set it and Forget it”

4.  Expect a normal ROI. Stocks ROI has been ~10%.  A 3% Return on Investment (ROI) has been the historic return on all other investments. 

5.  You a buying a part of a company. Buy what you know. Good companies that make good products. 

6. Have a plan. Mine is The Housewife’s Method of Investing*.  Yours can be different
7. Keep a Wish List.  Opportunity/Luck favors the prepared.
8. Never believe a “Customer’s Man” AKA Broker. They depend on your Buying & Selling. They will profit, you will lose.  I have many stories! Don’t pay your gains to someone else.
9.  This is not a Lottery. The Stock Market is not a place to “Play”. You’ll only hear stories about Player’s wins, not their losses. Players are amateurs. Professionals do deep research, visit companies, have PHDs in the companies they invest in.  We are not them.  I know some Professionals!
10.  Don’t “Time” the market.  Don’t anticipate it.  It’ll make you Crazy! That’s Playing.
11. The Market is not Liquid.  Only put into it the money you won’t need for a while (5 years?)
12. Buy into a good company when you see they’re having a temporary hard time.  I bought Apple when the PR was against them.  I bought Toyota when they had those brake/acceleration problems.  I won’t buy GE because my experiences with their products has been abysmal!
13.  Luck favors those who prepared before the opportunity arises.
14. Research!!!
15. Buy Low; Sell High.  Never sell Low... Duh.
16. It’s a Market!  Buyers have to have sellers.  I’ve seen days between trade executions because no one is selling.
17. The Market is a very emotional entity. It reflects the mood of the people.  You need to be unemotional.

*Buy small lots of good companies. Buy to hold for your lifetime. My stocks are competitors in the same arena, i.e. Coke/Pepsi, Toyota/Honda, Target/Walmart. Idea is that if one goes down, the other goes up. Only leaders in their areas, though. Buy companies that make products you know to be good. Buy for a lifetime and only sell when you must. It is NOT Luck. Never sell into a down market. My Gma was a Stockbroker from the 40s to the 60s. Never believe a ‘Customer’s Man”; Buy Low, Sell High. You know it’s the bottom when it bounces up and down. Be patient.

Homemade Yogurt

There are so many ways to make yogurt. The basics are: Warm milk to 110F (hand warm), stir in some thinned yogurt from the store or a previous batch, keep at about 100F until it gels.
Sounds simple. But. There's the right way, the wrong way and My Way:
I add dry milk to whole milk (to thicken the end product), then heat it to 180F for 30 minutes (to denature the proteins, and double pasteurize it) in a pot inside another pot filled with water (water jacket), then take it out of the water jacket and cool it in a sink of cold water to 110F, add a small amount of yogurt (thin this with some of your heated milk so that it's not lumpy), stirring thoroughly. At this point you can pour it into jars and put it back into the water jacket (110F). Put it in a warm place. I put mine on a heating pad set on low, but used to use a cooler with another jug of hot water, and also have used the oven with the light on. After a period of time, 4-12 hours, it will have gelled enogh tht a knife will cut it. Cool it again in a sink of cold water and refrigerate. You will find your own way; it is a very forgiving food. The favorite so far is a yogurt that looks almost slimy and even snotty. However the taste is so good that the children ask for it without any additions. Weird, hunh?
You don't have to add dry milk, but doing so makes an almost greek yogurt. The heating to 180F also makes it thicker, but if you buy pasturized milk you can skip that too. Pouring into containers makes it easier to handle. If you have a sous vide setup you can put it in ziplock freezer bags and keep it at 110F until it gels.I have made it without the pot-in-pot water jacket, so you can skip that, too. Go back to basics, or rather start with the basics: 110F, add yogurt and keep warm until it gels. Folks used to make it from any old milk, poured into a leather sack and taken to bed. In the morning it was yogurt! Enjoy the process. Anything that comes out will be edible, so consume your mistakes. The fun is in the journey! Then think about making Brie, which is almost as easy!

Hog Butchering: Offal List

Well, I couldn't find this listed anywhere on the Web, so I compiled my own list. 

These are my requests to the butcher who is processing a pig for us.  I included diagrams (unattached), so he could see where the parts are.  We'll see whether I get what I want. He's only used to cutting meat, so this is a lesson for him and I expect him to charge us for his education. Large animal dissection is not an easy thing when you are up to your ears in guts and have little ideas what you're looking for. In addition to his finding the parts, he'll have to process, cut, vacuum pack and label them.

Pork parts, each item vacuum packed, labeled, as noted:

·      Head:    Split in half, packed separately

Ears, cut off, packed together

Tongue, deeply cut

Brain, halves packed separately

·      Feet, packed in pairs

·      Hocks, with scraped skin

·      Tail, skinned

·      Skirts/diaphragm, both thin and thick, and pads, in medium portions

·      Trimmings not used for sausage

·      Bones, all, un-scraped, in medium sized bundles, large bones split and/or cut into pot sizes

·      Fat, all, whatever is not needed for sausage, in medium sized portions

·      Caul fat, in small, ±1 foot, portions (also called lace fat, wrapped around organs)

·      Skin, scraped of hair and packed in medium sized amounts

·      Organ meats, packed separately by type, labeled:

o  Thyroid: at neck, below voice box, one on either side of, and bridging, bronchia, dark colored, see diagrams

o  Pancreas, if large, pack in lobes: long, dark, crossways of the body, under liver at the stomach toward the spine and kidneys, see diagrams,

o  Spleen, cut in medium sizes, packed separately: a long, dark, organ, wrapped around and under stomach, see diagrams

o  Thymus, not usually found in adults: two smallish, dark organs, beside the bronchia or in the front of the chest just under the ribs, see diagrams

o  Liver, unsliced, packed in lobes

o  Kidneys, one per pack, two if small

o  Heart, whole

o  Lungs, without bronchia, cut in lobes, packed separately

o  Stomach, packed in medium portions

o  Testicles or uterus and ovarian structures

o  Penis

o  Blood, coagulated, in quarts/half gal portions, in blocks or large cups

o  Tripe, cleaned, packed in medium portions

Best Gluten Free Rice Bread

Dry Ingredients (Mix thoroughly):
(You can pre-mix this to have on hand)

2 cups/320g        white rice flour
; prefer Goya Enriched
(can sub another flour: up to 1/2 by Weight)

1 cup/122g         tapioca starch or 1/2&1/2 with Expandex*


½ cup/62.5g       cornstarch 


2/3 cup/45g        powdered dry milk


½ cup/112.5g     sugar
1/2 T                  salt (=1.5 tsp)

Add just before making and mix in thoroughly:
1/2 T                xanthan gum


1/2 T                guar gum*

1 tsp                 psyllium powder*(or Metamucil)

1.5 Tbs            dry yeast 


Liquid (Mix separately and thoroughly):

4/200-230g        eggs, large, beaten well (weigh eggs)


1.5 cups/354g    warm water

3-4 T                  corn oil (It’s still good without)


1 tsp                   vinegar

• Use a good stand mixer, oven thermometer and instant-read thermometer.
• Weigh dry ingredients (and eggs) instead of using volume measures!   
• All ingredients at room temperature.
• Mix liquids thoroughly and add to thoroughly mixed dry ingredients.
• Whip until stiff peaks form: 10 minutes (can’t overmix)
• If it’s too thin to whip properly add a bit more starch.
• Put into greased regular bread pans.  It will fill the pan.
• Level with a wet spatula; spray with oil to keep top moist.
• Let rise until just domed; it will rise a lot in the oven.  If it over-rises it will overflow! Re-mix and replace in the pan to re-rise.
• Bake 50+ min. at 350 degrees. When making multiple loaves gently rearrange for even baking.
• Bake until the middle is 205F. If it gets too brown, cover with foil.
• Close to the end of baking turn it on its side to set the middle. 
• Remove from the pan and leave in the oven on its other side so it will cool slowly.
• If thermometer or probe shows a wet interior, leave in oven on 250-300F for a while; retest until drier.
• Makes good rolls! Cook on parchment or greased pan.

April 2013 Notes:

• You can substitute almost any other GF Flour for the rice flour up to 1/2 by Weight.  Teff flour makes it 'wheatier'.
• I haven't yet tried substituting other starches, but you could try the same thing: 1/2 by weight.
• Expandex may not be necessary. Experiment!
• Goya brand is the only Enriched Rice flour I have found. Iron deficiency often goes with Celiac.
• Beating into whipped cream texture is KEY!  See the pictures.
• Pans with just crisco work well, rarely stick.
• Don't let it over rise!  It doesn't help the texture.
• I have had to extend the baking time
• I've been making 'mixes' of the dry ingredients so I can throw together a couple loaves quickly.
• Add the gums and yeast just before you make your loaf, not to any 'mixes' you'll store.  They don't like air exposure and won't work as well.
• I mix my wet ingredients separately and thoroughly.  When I make multiple loaves I mix separate containers for each loaf.
• Doubling the recipe is not recommended.
• Timing is everything: in mixing and in baking.  Experiment for yourself.  I'm happier with a darker loaf and a firmer, drier middle than a paler loaf and moist middle. Over 200F in the middle is optimal. Under will be soggier.
• Slice it after cooling and put in the freezer.  Take out just what you'll use in a couple days.  I've never had it mold, even in a week. When I make multiple loaves I freeze them whole.
• Failures make good breadcrumbs!

*My changes to the original recipe. Expandex is modified tapioca starch bought on the internet, supposed to help GF breads rise.  Psyllium powder can be bought @ Whole Foods type stores in the digestive area; use Metamucil as a substitute. Combination of Expandex, gums and psyllium mimics gluten.

http://www.celiac.com/articles/457/1/White-Bread-2-Gluten-Free/Page1.html

Mushroom Season!

Pholiota has fruited up on a recently downed river birch. I checked out their edibility and got mixed results.  Some say they're edible and good, others say they're edible but insipid and then some say they'll make you sick if you eat them with a meal with alcohol.  Several call them poisonous.  Hmmm.  I think I'll forgo them since I'm heading to DC to celebrate my brother's birthday.

Gluten Free Tomato Soup

Extra Thick, 

2 cans (or equivalent)       Tomatoes, peeled, & diced or crushed,
                                         drain & save juice

1 T                                    Salt

1 t                                     Pepper

2T                                     Italian dressing or any vinaigrette
                                          dressing or dry mix. 

2 cans                               Tomato juice or V8

1/4 C                                Corn starch (or any thickening starch)

1 C                                   Milk or cream to taste

*      Simmer tomato pulp and 1/2 of the juice

*     Add spices to taste.

*     Mix starch and 1/4 of the cold juice to a slurry.

*     Add cold starch slurry to simmering tomatoes.  Stir a lot to ensure even distribution.

*     Assess whether you need more thickening.  

*     If you're going to add milk before serving make it extra thick.  Use the rest of the juice and more starch, a tablespoon at a time. Or use the rest of the juice to thin out the soup.  It will thicken more as it cools, and even more if you reheat it.

Best Gluten Free Bread (so far)

This recipe from Celiac.com is 2/3 rice flour an 1/3 tapioca starch. (http://www.celiac.com/articles/457/1/White-Bread-2-Gluten-Free/Page1.html).
I used half xanthan gum and half guar gum rather than all xanthan gum and added a teaspoon of psyllium powder. I also used half Expandex and half regular tapioca starch.  I think that the whipping the batter into a 'whipped cream' state was the main reason it has such a tight texture, though the psyllium and split gums may have helped keep the loaves from collapsing.  The recipe almost fills a regular loaf pan, and the rise only adds a little more volume, but the oven spring really jumps it up!  They didn't shrink after cooling, though I did put them on their side for the initial cooling, removed them from the pans and left them in the oven to slow-cool.

This is the best I've done so far. It toasts well and tastes very good.  I'm going to tweak the buckwheat recipe next. (Did 2 more loaves... same great results!)