median arcuate ligament syndrome/celiac artery compression

This is another great case of celiac artery compression syndrome or median arcuate ligament syndrome. This has the classic findings of a high-grade stenosis of the celiac origin with poststenotic dilation.

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There was a heated discussion about the significance of this with the emergency room physician Dr. Moshini who received an addendum regarding some reconstructed images. I will not go into the details but the diagnosis is clear and was clearly communicated.

The discussion reminds me that it is easy to lose sight of the patient and get caught up in the radiologic report. A radiologic study cannot be interpreted without sufficient knowledge of the patient and radiologic findings alone do not automatically require treatment.

 

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Scapholunate Tear

Patient with popping imaged several months after the initial injury.  I’ve been told by the one of the best doctors I’ve ever met that it’s the dorsal 4 mm that contribute almost all of the structural stability to the wrist. That doc is Bill Gramig, MD at Greensboro Orthopedics.

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Further, the malalignment that occurs with a tear of the scapholunate ligament is thought to be due to torsional rigidity of the wrist; that is to say that the wrist is “sprung” when the ligaments are intact and with a tear of the ligament, the stability of the proximal row becomes disrupted leading to an “unsprung” wrist and ligamentous DISI.

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The DISI was not as “slap you in the face” as I like to see it on MR so I waffled a tiny bit, even though I was sure it was present radiographically.  Even though these lateral images are oblique, this is an example of smack you in the face DISI.

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Intracranial Hypotension after instrumentation

This patient had several “unsuccessful” lumbar puncture attempts and persistent severe positional headache following procedures. It is unknown whether they actually achieved access to the thecal sac for harvesting of CSF but the thecal sac was clearly disrupted.

 

 

There is a subdural hygroma in the lumbar spine that extends cranially into the thoracic spine beyond the field-of-view. This is consistent with dural tear associated with the lumbar punctures. The exact layer where the fluid spreads is not at all clear from the images but it is certainly demonstrated that the arachnoid meninges are displaced around the nerve roots of the cauda equina. There is fluid surrounding the arachnoid meningeal layer.

 

 

An MRI of the brain was performed contemporaneously and this demonstrated a few finding suggestive of intracranial hypotension including distended dural venous sinuses with rounding of the superior sagittal sinus superior to the torcula and lack of distention of the optic nerve sheaths. Another sign which I had not been accustomed to look for is the bulbous contour of the pituitary which is glaring on the sagittal images.

HomeAssistant Configurator Setup with Autostart

This is a supercool and easy way to edit your files from Home Assistant.  I have been juggling windows which isn’t bad but for remote work, a web interface is really nice.

WARNING: I am running HASS as root and this is not the recommended setup

Here is a screenshot of the final product:

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The initial steps are pretty easy.

Get the configurator and put the configurator.py file in your homeassistant directory.  In my case, it’s .homeassistant

Edit the configurator file if you need to put in the basepath and password:

Code for configurator.py file:

# Set BASEPATH to something like "/home/hass/.homeassistant/" if you're not running the
# configurator from that path
BASEPATH = "/root/.homeassistant/"

# If a password is required to access the API, set it in the form of “password”
# if you have HA ignoring SSL locally this is not needed if on same machine.
HASS_API_PASSWORD = “PASSWORD”

When you do this, You’ll find that the file runs in the foreground and it should be present after you add an iframe to the config (I have a love hate relationship with the iframe module, this is the first time it’s been useful to me).

Code for configuration.yaml file:

panel_iframe:
  configurator:
    title: 'Config'
    icon: mdi:wrench
    url: 'http://10.xxx.xxx.xxx:3218' 


NB: On my dev server, I set this to loopback 127.0.0.1 and it worked fine.
If you’re storing secrets like a HASS API password, you probably want to ignore configurator.py from your GIT backups.

Making the configurator.py run as a service:
navigate to /etc/systemd/system

nano ha-configurator@root.service

That file should look like this

[Unit]
Description=HASS-PoC-Configurator
After=network.target

[Service]
Type=simple
#Set the path to your configurator.py location
ExecStart=/usr/bin/python3 "/root/.homeassistant/configurator.py"

[Install]
WantedBy=multi-user.target

exit nano, saving it.

Then do the magic to make it a system service with autostart.

sudo systemctl --system daemon-reload
sudo systemctl enable ha-configurator@root.service
sudo systemctl start ha-configurator@root.service
sudo systemctl status ha-configurator@root.service

TD Ameritrade backpedals on their “enhanced ETF list”…kinda

The original post is here.

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Harry Sit’s commentary is here.  

I pulled my entire Roth.  I encourage others to do the same. The best way to vote in a financial market is with your feet or dollars.

Although TD’s boneheaded move instigated it, I’ve been wanting to consolidate my accounts for a while but since there wasn’t really anything wrong with their platform, I didn’t bother.

Now their platform has something wrong with it.  I have to keep my other account with them which is invested in Vanguard funds.  I weighed exchanging their crappy new lineup for my low cost VG ETFs but decided against it.  I’d rather just pay the commission to liquidate if I have to keep my funds there.  There is no cost unless liquidating at this point.

It is true that it would be cleaner to exchange VG funds for their new lineup, in terms of future assets.  Using their new funds with VG funds doubles the holdings, but hey, I’m not planning on doing anything with my triple tax free account for a long time.  I’ll eat the commission when it comes due.

God only knows what new boneheaded plan they’ll have in place when I need to liquidate my HSA holdings.

Dear Valued Client,
Last week, you received an email about the upcoming launch of our new commission-free ETF Market Center. Since then, we’ve learned investors could use more time to evaluate the new fund line-up. So we’re extending the effective date to January 19, 2018, giving you 90 days to review the funds and make any changes.
The restructured commission-free platform triples the number of ETF choices to 296 – the most in the industry – including many that are among the lowest-cost core ETFs available in the market today. We’ve also increased exposure to 77 Morningstar categories, including such strategies as smart beta, actively managed, market sectors and commodities providing more options for you to tailor your portfolio. We appreciate that this is a big change and we want to make sure you have the time and information you need.
Key takeaways
  • We have extended the commission-free transition period for legacy ETFs until January 19, 2018.
  • All new funds are available to trade commission-free today.
  • After January 19, 2018, the 84 legacy funds will still be available at TD Ameritrade at the standard online commission rate. The remaining 16 funds will continue to be a part of the enhanced ETF Market Center.
  • All other previously communicated changes remain in place. Enrollment and short-term redemption fees will be eliminated effective November 20, 2017. Selling legacy ETFs prior to November 20,2017 may incur a short-term redemption fee.