Coca-Cola has special privileges to import raw coca leaves. They extract the cocaine (which is then sold for pharmaceutical use). The mostly-cocaine free extract is then used to flavor their cola. AFAIK Coca-Cola is the only entity in the US allowed to do this, so it is unsurprising that other cola brands taste significantly different.

Phenylephrine is useless as an oral decongestant. It is still quite useful for other indications, including as a vasopressor (given IV to increase blood pressure such as in hypotensive shock). I believe it is actually the only commonly available vasopressor in the US that is a pure alpha-1 agonist which in certain scenarios is desirable.

It is also indicated for treatment of priapism.

The real kicker is that phenylephrine actually does work as a nasal decongestant when it is used as an intranasal spray, which has the added benefit of fewer systemic side effects compared with oral decongestants.

humm, so, crush and and snort it?

https://en.wikipedia.org/wiki/Pentadactyl

To give a tangible example I'll start with the unnecessary ankle x-ray. There is a set of guidelines called the Ottowa Ankle Rules[1] which we use to justify ordering plain films for a suspected fracture, but there are plenty of reasons why a doctor would still get them if the criteria weren't met.

One reason is clinical judgment and experience. Guidelines are just guidelines. Ultimately the doctor is the one making the call, as well as suffering the blame for that call if things go sideways. If everything were as simple as following algorithms and checklists, medical training wouldn't take 7+ years of post-undergraduate work.

But probably the most important reason has to do with the "patient satisfaction" (customer service) aspect. Ideally medicine wouldn't be a business, but it is and there's not much we can do about that.

Patients who present to an urgent care center or ED generally carry an implicit "something is seriously wrong with me or I would have just made an appointment with my PCP" vibe. These patients often don't like it when you explain that based on your history and exam, they most likely have a sprain/strain injury and an xray is not appropriate since we want to avoid unnecessary costs/radiation exposure-- as opposed to being relieved that they only suffered a minor injury. Even when spoken in a compassionate, straightforward manner, this explanation can come across to the patient as "nothing is wrong with you / you are malingering / your concerns aren't valid / I don't care about your symptoms", etc.

Sometimes patients outright demand tests, or worse, they'll say nothing but then complain to your employers that you medically neglected them, or you are incompetent, or what have you. Now if they had the audacity to file a malpractice suit, you'd (ideally) have no problem justifying your actions in a courtroom or deposition. But say they complain to the MBA (or some other person with no medical training) who runs the clinic or care center employing you. Your argument will likely fall on deaf ears, and be countered with some diatribe about how you're causing them to lose money. In that case it's a lot easier to just order the unnecessary xray.

Basically, the squeaky wheel gets the grease. There are plenty of other examples like this, and they all come down to choosing your battles wisely. I think it's kind of hard to blame the over-worked and behind-schedule doctor who orders something like an xray or lab test rather than taking an extra 10-15 minutes discussing the pros and cons with the patient, after which the patient might still not be convinced.

Having said that, there is a problem with superfluous testing in EDs, especially ones that rely on "standing orders" where e.g. virtually any patient presenting with abdominal pain might get a CT scan before the physician even sees them (something I strongly disagree with and can't think of a legitimate excuse for).

[1] http://www.theottawarules.ca/ankle_rules

For instance, there was a with E.U. doctor referral for ultrasound and blood work. The reply was if it bothers me to consider painkillers or wait for it to get worse and come back. (Why should I take painkillers if we are not certain of the cause to begin with?) On the other hand, walking a friend into urgent care for their leg leads to a full checkup.

With the above I want to complement your view, that there is some extreme behavioral gap in how doctors' react that is not related with the patient's ailment.

And there is a lack of a middle ground between urgent care and making a personal doctor appointment. I find it surprising that if I break my leg I need to go to urgent care. There is no contagious disease, and I am not going to die if left untreated, but it is an event that requires time sensitive treatment. Yet, there is no concept of walking into a doctor's office, or at least it is not that easy.

Example case 2. Eye pain etc. After failing to get an appointment with any doctor, K is instructed to go to urgent care. K called ahead and asked if they could handle their case, yet there was no actual ophthalmologist there. K got a full "checkup" and got a "it's probably an infection"; they were prescribed antibiotics. Next day K's eye pain worsens with new symptoms. K gets an appointment with an optometrist so as to be referred to an ophthalmologist. It is the protocol to have an optometrist check you first apparently. Another half a day later, an ophthalmologist actually checks K and comments "thank god you came in this fast." That was after my wife begging several times on the phone with several doctors, that we need an appointment today and not in 2 months. Yes, patient K is I. (I could not make any phone call or walk at this point, I was for all intents and purposes blind and in pain.)

Thus, the system in place from my experience assumes that the patient i) is stupid ii) if not dying does not need a checkup within the next 2 months, or else has to go to urgent care.

Thus is it really the patients' fault when they are used to walk into urgent care to get any sort of timely treatment? Why would a person with a broken leg take the invaluable resources from someone actually in need of urgent care? I argue the system somewhat enforces this over-treatment. You have to go through the urgent care for any timely treatment, it is rightfully instilled in you that perhaps there is something serious going on. You would not pay urgent care prices for a strain right? Thus, it must not be a strain.

My E.U. experience: As a patient,you walk in to a doctor you consider appropriate (You can also make an appointment ahead of time and ask if uncertain). One might wait for a few hours. If it is deemed urgent, the doctor will make sure to see you first, or send you to urgent care/emergency room or hospital. If the doctor is not of the appropriate specialty, they will refer one appropriately. Paying everything out of pocket, costs extremely less compared to my copay for urgent care -- this is a simple doctor appointment, no urgent care.

Pre-implantation genetic diagnosis (or PGD, what you described as 'selective IVF') is not cheap. It costs upwards of US$100,000 and no commercial or government insurance will cover it.

Genetic screening is also not cheap. An exome (essentially looks at all ~22,000 known exons, or the genes that directly contribute to protein formation) costs US$6,000 - $8,000 and most insurances will fight tooth and nail not to have to cover it even when it is ordered by a geneticist. You might think "but there are much cheaper genetic tests besides an exome" which is true, but remember we are talking about rare diseases. Exome testing is still imperfect but it is essentially the only realistic option if your goal is to rule out as many known genetic diseases as possible, or if you know there is a high pretest probability of a genetic disease but less exhaustive testing was negative or inconclusive.

Actually, current PGD doesn't use exome testing but much more selective testing often based on the parents. One technique is FISH which can essentially only tell you if there are any "large" genetic abnormalities, like (micro-) duplications or deletions, which are large relative to, say, a point mutation. As an example, FISH testing would not reveal cystic fibrosis. The other is PCR, which is currently the technological limit for PGD testing because of the small number of cells and minimal amount of genetic material available for testing. There are several PCR assays available for specific conditions in the setting of PGD, which is where the parents fit in. We will probably see more and more assays becoming available, but it is unlikely that anything resembling an exome will be feasible for PGD in the foreseeable future.

Disclaimer: I am not a geneticist or reproductive specialist. If you can find sources by physicians in these fields, I would defer to them.

https://www.cdc.gov/lyme/stats/graphs.html

https://www.cdc.gov/lyme/stats/maps.html

https://www.cdc.gov/lyme/stats/tables.html

As an aside, it's tricky interpreting certain stats regarding epidemiology. The incidence is the number of new cases in the population in a given time frame, and prevalence is the total number of people known to have the disease in the population. Sometime a disease can appear to be "on the rise" because there is increased surveillance and screening for the disease, or because diagnostic methods have improved, which naturally lead to an increased incidence and prevalence.

Disclaimer: I'm not arguing that Lyme Disease isn't real, isn't serious, or anything along those lines. But from a medical perspective, we deal with fear of Lyme way more often than the actual disease. Some parents will bring their child into the clinic every time they think they may have seen a tick within arm's reach of them. And when someone presents with an attached tick, it's more often than not an adult wood tick (which can transmit RMSF and tularemia but are not B. Burgdorfi vectors).

When you are bitten by a tick, or any insect, some inflammatory response is expected, i.e. your skin will probably turn red. It doesn't automatically mean it's erythema migrans (bull's eye rash). But to muddy the waters even further, as little as 50-80% of confirmed LD cases had the EM sign, and many don't recall a tick bite whatsoever.

But if you are in an endemic area, clinical suspicion for LD is high, we should be able to prove you have the disease with lab tests, right? Well, unfortunately Borrelia are notoriously difficult to culture, so that's out. The CDC recommends a two-step testing process.

Step 1 is the Enzyme Immunoassay (EIA). If your EIA is negative, LD is ruled out. If it is positive or "indeterminate" (2nd most common outcome after negative in my experience), you move on to the Western blot which looks for antigenic proteins associated with the disease. It is considered positive if 2 specific bands are visualized or if at least 5 of a list of 10 other bands are seen. The problem is that these bands can take up to 6 weeks after exposure to become detectable. If you have no idea when/if you were actually exposed, this test is a shot in the dark. To top it all off, it can also come back "mildly" to "moderately" positive for LD.

So if your EIA is negative, or if your WB is 2/2 or 5+/10 positive, we can give you a definitive answer. Otherwise, it comes down to clinical judgment and weighing the risks and benefits of treatment. If you were bitten by a tick, got a rash, had no drug allergies, the safer play is to assume LD, give antibiotics, and forgo the serologic testing that may or may not give an answer.

TLDR - Lyme Disease is complicated.

As for the really obvious, though fairly rare, dangers such as C. Diff., other resistant pathogens, SJS, and things like drug induced liver injury, I don't think anyone working in the medical field would question the reality of those.

https://atom.io/packages/browser-plus

http://manpages.ubuntu.com/manpages/xenial/man1/netpbm.1.htm...

https://github.com/l-tamas/Fiasco

I'll bet the farm it was lisinopril, or another ACE inhibitor. The ACEI cough is notorious enough that any 1st year medical student probably should have been able to piece this together.

The problem is not that those doctors were ignorant. It's more likely that they did not ask the right questions to get a proper history. You should ask every patient to list their medical problems and medications unless it is a routine follow-up when nothing has changed.

Something else that can happen is patient ignorance (and I am not insinuating your dad was guilty of this, or making a value judgment on people who are).

Often times you can't get a proper past medical history or medication list unless the patient brings all of their prescription bottles to the office. E.g.:

>"What medications are you on?"

>"Well, I'm on a sugar pill, a water pill, a cholesterol pill, a stomach pill, and some allergy medicines."

>"Ok, do you know the name of that sugar pill?"

>"It's a little white pill. I think it starts with an 'F'. No wait, I'm thinking of my water pill."

or

>"Do you have any medical problems?"

>"No."

>[glances at meds list] "Ok, so why do you take metformin, hydrochlorothiazide, atorvastatin, omeprazole, cetirizine..."

I'm not trying to undermine your point entirely, but there is a flip side.

I can't tell you how many times I have seen a patient start a medication, then come back to the office within 48 hours because they coincidentally have every side effect that is listed in the pharmacy's information sheet or that they looked up online. The vast majority of these side effects are benign, present with next to no pertinent physical exam findings, and can't be definitively tied to the new med (like upset stomach, fatigue, headache, etc.).

Then they will start listing that medication as one of their "allergies", and if the nurse/doctor documenting doesn't dutifully probe what type of "allergic reaction" they had, they may end up not being prescribed that med in the future when it really is the drug of choice. A little nausea is a small price to pay if it kills a potentially life-threatening infection.

Also, I'm skeptical about the seizure risk. The thing about side effects is that they are supposed to be stratified according to risk. Doctors are typically aware of these risks, but patients aren't. So if your drug is listed as causing "headache, nausea, and seizures", there may have only been one patient out of millions who had a seizure while 50% experienced headache, yet the handout probably won't tell you that.

But even if it is a notable risk, I would be surprised if the propylene glycol you inhale from an e-cig could accumulate to a high enough level in the bloodstream to cause drug interactions, although I admit adequate research on the subject is lacking.

My advice would be trust your doctor first. If you don't trust your doctor, start seeing a doctor that you do trust. Then if you have a significant adverse reaction to a medication, talk to your doctor about it. Quite often they know something that you are not going to find by spending a few minutes on the internet.

As a side note, a good history includes asking about many habits. A lot of healthcare providers are guilty of simply asking "Do you smoke, drink, or use drugs?", but ideally the smoking aspect should be phrased as "Do you use any tobacco or nicotine products?". Patients usually won't read your mind and volunteer that kind of information. They will tend to give yes/no answers, so direct and specific questions are important.

Odd, here in Norway that's exactly the kind of information I expect to see on a leaflet inside the packet, not only on prescription drugs but also over the counter pain killers like paracetamol. Roughly translated from the Norwegian it says:

Rare side effects (more than one in ten thousand but fewer than one in one thousand patients) include: over sensitivity, allergic skin reaction/rash, reduced white blood count, anaemia, disturbed liver function. Very rare side effects include serious skin reactions. Liver function can be affected by paracetamol and alcohol abuse.

That seems like a major problem. Is there any reason that more detailed information can't be included? Mathematical literacy may be a problem, but that doesn't mean that there aren't millions upon millions of mathematically and scientifically literate consumers who could use this information effectively.

I'm not trying to justify any of this, but that's how it is.

Not sure if it will be helpful in the future, but I can tell you that descriptors used with side effects follow a standard convention:

    very common: > 10% 
    common: 1%-10%
    uncommon: 0.1% - 1% 
    rare: 0.01% - 0.1% 
    very rare: < 0.01%