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Re: [linux-dell-laptops] Digest Number 347 - Part 4

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  • linux-dell-laptops@yahoogroups.com
    Note that this will not force lilo to boot into that default option, Q: PharmInfo.com: Rheumatoid Arthritis Discussion Group Q: PharmInfo.com: Thrombolytic
    Message 1 of 1 , Apr 2, 2001
      Note that this will not force lilo to boot into that default
      >option,
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      >option, "> Si su pregunta no ha sido contesta, por favor pulse aqu� para enviar la pregunta a un experto

      >> but will remind you that you suspended.
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      Si su pregunta no ha sido contesta, por favor pulse aqu� para enviar la pregunta a un experto

      >>
      >> I don't really see what those lines you added to the lilo.conf
      >file
      >> have to do with the whole hibernation problem...
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      >> I don't really see what those lines you added to the lilo.conf >file >> have to do with the whole hibernation problem... "> Si su pregunta no ha sido contesta, por favor pulse aqu� para enviar la pregunta a un experto

      >
      >maybe I should make it more clear...
      A: CARDIO-CONSULT Case Presentation 42 y/owhite male - TIA I would like an opinion on how to proceed with this case. JB is a 42 y/oWM who, approximately 15 minutes after getting out of bed had a transient total loss of vision in the right eye. This resolved after approximately 20 minutes. Later that morning he experienced some right handed clumsiness and weakness tha, again resolved after 20 minutes. Non-smoker, non-drinker, mild HTN controlled with diet/exercise. No medications or allergies. No family Hx of MI, CAD, PVD, stroke. Physical exam: WDWN 42 y/oWM in NAD. BP: 110/70, P 88/regular, R 18. HEENT: Essentially Nl, Neuro Nl. Fundi Nl (limited exam) Tandem gait nl. DTRs all intact and nl. Neck w/out carotid bruit. COR NSR w/out gallop/rub. Soft grade 2/6 systolic murmur over LSB. Abd slightly obese, soft, active BS. Ext w/all pulses intact, no peripheral edema. Labs: Hct 42; Plt cnt 234,ooo; PT 12/12.5 APTT 28/28.2 LFT: All Nl EKG:! NSR MRI: Negative Carotid dublex scan negative Echo: Negative TEE: Small Patent Foramin Ovale w/positive bubble test. Started on ASA and experienced an allergic reaction characterized by skin rash, shortness of breath and wheezing. One cardiologist recommends do nothing. Another recommends coumadization for 1 year then re-assess. CT surgeon does not feel PFO is source of TIA and it is too small to warrant surgery at this time. So, this is a young man in general good health who experienced TIA ? cardiac source. What does the group feel the best approach fot this man is? Coumadin? Periodic follow-up? Wait for the next neurologic event? If coumadin for a year, what then? Thanks in advance! Edward J. Mathes, RPA-C Internal Medicine Responses Have you consider more of an occular event? I would think in a differential dx you would want to r/o a lesion. Maybe an opth referal? Probably CV in nature, but I would want to make sure. Roger Thanks Roger.Neuro-opthalmology evaluation was n! egative. I forgot to include that! Because of the second event, pure opthalmologic event is unlikely. Edward J. Mathes, RPA-C Have you considered trying ticlid? 250mg bid with food. Ticlid is indicated in the prevention of stroke in patients who have had a completed thrombolytic stroke, or precursors to stroke who are unable to tolerate aspirin. The only thing is to watch out for thrombocytopenia, so a weekly CBC would be needed at first, as well as checking for abnormally increased bleeding times. Cut back to q2 weeks for the next few months. Drew Halasz, RN BSN I would complete by phlebography to exclude asymptomatic deep venous thrombosis (not so unfrequent). If positive , this is an important point to consider surgery of the PFO and to treat with AC. On the other hand, could you precise if you have done Valsalva manoeuver during contrast injection. Was the bubble passage early (within the 4 cardiac cycles after filling of the right atrium), how many bubbles? Was the intera! uricular septum normal? There is no proof in the literature that coumadin will protect your patient, only aspirin has been demonstrated to decrease incidence of TIA. B. Cosyns Cardiology Department/ St-Pierre University Hospital Bernard Cosyns wrote: I would complete by phlebography to exclude asymptomatic deep venous thrombosis (not so unfrequent). Duplex scan of the deep veous system in both legs was negative. On the other hand, could you precise if you have done Valsalva manoeuver during contrast injection. Was the bubble passage early (within the 4 cardiac cycles after filling of the right atrium), how many bubbles? Was the interauricular septum normal? Valsalva was performed. Bubble passage was early.I don't know how many bubbles per the report I received. Intraauricular septum was normal. There is no proof in the literature that coumadin will protect your patient, only aspirin has been demonstrated to decrease incidence of TIA. Thank you. Patient is ASA Allergic. Ticlid?! Edward J. Mathes, RPA-C tony bevill wrote: I'd lean to the safe side with this guy. Since you can't use ASA you're choices are pretty limited. However, my review of the literature is unclear if coumadin has any effect on prevention of the next neurologic event. I seem to recall people with PFO who have stroked have an overall risk of restroke in the range of 10% within the first year. Is this correct? He could have thrown an embolis from the PFO That is the current thought. Right. But coumadin has no platelet effect. Ticlid? Edward J. Mathes, RPA-C Blaine P. Carmichael wrote: I would consider migraine equivalents or variants in the Ddx. Was the transient loss of vision a Fujax or was it sudden, total and transient? Might need to consider a distal internal carotid artery lesion or ophthalmic artery lesion. You may want to consider an arteriogram (or did you already get one?) Sudden, total and transient. MRI/MRA done that day were negative, as was the neuro-opthalmology evaluat! ion. The anti-coag profile was also negative. The source of his embolus is most likely his PFO. The question is to anticoagulate or not given his allergy to ASA. Ticlid is another choice, I think. Edward J. Mathes, RPA-C Assuming a thrombotic origin is either established or seems likely, this type of case may respond to oral anti-GP IIb/IIIa therapy. Unfortunately, none are on the market yet. I believe Searle is the farthest along in developing an oral agent. Meanwhile, Ticlid or clopidogrel seems to be a good choice. I would be concerned about doing 'nothing'. Todd Lorenz Thank you. I agree.to do nothing is not a good thing. The consulting cardiologist recommends anticoagulation because, according to him, 8-10% of patients with this type of PFO experience a second neurologic event w/in a year. Patient is resistant to coumadin for various reasons. Edward J. Mathes, RPA-C Do you agree or disagree with his reasons? Your job is to advise, his is to decide. Have you considered **g! asp** fish oils/omega 3 fatty acids? I don't have time to show how smart I am and expound by cutting & pasting from websites, but documentation is abundant re: effects on platelet function. Probably the biggest downside is that because they can't be patented, no "suit" with tasseled shoes is going to show up @ your office to spoonfeed you glossy 4 color literature about how great it is, while proffering trinkets to you. You might have to actually look it up yourself. How about a free medline search at NLM?? John B. O'Brien, PA-C Physician Assistant You should get the chip off of your shoulder - it appears to be affecting your judgement. Omega 3 fatty acids do have anti-platelet action, but are rather weak in this regard. They may be useful for chronic, preventive treatment but are grossly inappropriate in patients with life-threatening thrombotic disease. The anti-gpIIb/IIIa agents are potent anti-platelet agents that block aggregation at the final common pathway - the fibrino! gen receptor. If you are recommending weak therapeutic agents for acute pathology, you are doing your patients a gross disservice. Todd J. Lorenz Are you reasonably sure that the patient is 'allergic' to *ASA* or could there be there some procedure that was done done at the time that may be in fact the cause of the allergic reactions you observed (did you in fact observed them or did the patient or a third party report them to you?). Had the patient used ASA before with or without signs or symptoms of of hypersensitivities? As suggested elsewhere, clopidogrel would be preferable to coumadin (a lot of things are) and a recent clinical trial *seems* to have indicated that it would be more effective (??) than ASA. Be that as it may, I would hate to do nothing as was also suggested to you. Considering the cost of Ticlid relatively to ASA, if that is important to your patient, and its novelty (we still don't know half the nasty things it can do but will sureley emerge when it will ! used in general practice, as with all new medecines) would you consider, under close monitoring, to give ASA another try? Correction: Sorry, I meant clopidogrel (not Ticlid) a new antiplatelet agent. Another correction to my post concerns the source of info which I finally retraced. The results of the trial CAPRIE (Clodo. versus Aspirin .) were not published but reported at the last American Heart Association meeting in New Orleans (Nov. 97). Guy Beaulieu, Ph.D. (Cardiovascular pharmacologist) He was taking an ASA (ECOTRIN) one per day. After about two weeks of therapy he developed tightness in his chest and wheezing necessating transport to the emergency department. SaO2 was in the mid-80's on room-air. He was relieved with albuterol via nebulizer and sub-q epinephrine. Trsting done by the allergist shows him to be "highly sensative" to aspitin. Edward J. Mathes, RPA-C Your patient may be a good candidate for less-invasive PFO closure with a clam-shell device done via heart c! atheterization. Andrew Chung, MD/PhD Emory Cardiology Fellow Thanks. This was not suggested or discussed by the cardiologist/CT surgeon. I'll be seeing the cardiologist this week and ask about this. Edward J. Mathes, RPA-C The neurological signs emanate from diverse locations, and as an initial presentation this rules out the only other possibilities, which would have been some wierd type of partial epilepsy or (very possibly) migraine. Again, the diverse locations suggests that the source of the emboli are proximal to the Circle of Willis. Overwhelmingly most likely diagnosis is indeed TIAs x 2. Sounds like the PFO is the only lesion that could explain them. A young man at risk of stroke demands that something be offered. The allergy to aspirin is unfortunate. Although there is usually quite a bit of overlap amongst NSAIDs for allergy, ticlopidine can sometimes be tolerated by such patients. How about a catheter closure of the PFO ? A.W.Fox In all our discussions.patient, mys! elf, my supervising physician, the cardiologists and CT surgeon.none mentioned catheter closure of the PFO. I have a call in to the invasive cardiologist at the University for more information. Meanwhile, we have started Ticlid. I had a case earlier this summer of a 42 y/o woman who presentex with a 6-week history of cough. Chest x-ray significant only for borderline heart and increased vascular markings. Echo demonstrated pulmonary hypertension with an estimated PAD of 30mmHg. TEE showed a large, 1cm VSD. She underwent successful operative repair last month. In discussing her case, no mention was made of possible catheter closure. So, I have some reading to do. Thanks all for your help. Edward J. Mathes, RPA-C There have been reports of ASA-desensitization (similar to what is done with penicillin - starting with VERY low doses and working up) for patients in whom ASA is the drug-of-choice but who are allergic. I do not have the exact protocol, but I am sure that it would be e! asy to find. Mark West, Pharm.D. CT surgeon does not feel PFO is source of TIA and it is too small to warrant surgery at this time. I'm going to go out on a limb a little bit here. With a negative carotid study, and a negative echo other than the PFO, I think the PFO probably is the source of the problem (as do you, I think), allowing a small, otherwise unimportant little clot from the lower venous system to pass over into this poor man's brain. A neurologist might back this up for you, if need be. Luckily, the patient cleared it, and is left with no sequelae. Next time, who knows? A stroke at age 42 is no way to live the rest of your life. Therefore, as I see it, the options are: ensure that he builds no more leg clots, ie lifelong coumadin. That's probably going to be 40 years or so, at expense, and risk of, say, 1% year of significant bleed, or 40% risk of bleed over the course. fix the PFO, either with surgery or an umbrella, if the umbrella technique works in your area. R! isk of morbidity and mortality, about 1%. Personally, I'd take the 1% risk and go with option 2. I don't know if ASA would even be an option for this in my opinion. It doesn't do much to help leg clots at all. I realize that ASA is usually the first line for TIA's, but this is a unique situation. This man's TIA's are not coming from the usual platelet clumps on plaques in the arterial system. Likewise, I'm not sure what Ticlid would do to help here either. No effect on leg clots that I know of. What does your patient want to do? I'd be inclined to put it to him, outlining the options. Kenneth F. Cunningham, MD, FRCPC Lion's Gate Hospital, North Vancouver British Columbia, Canada In addition to the clear thinking [expressed by Kenneth F. Cunningham, MD], is it possible that abnormal hemodynamics around the PFO might have been sufficient to scrape up the endothelium and get some localised platelet aggregation going (the ECHO being too insensitive for what could be a very small l! esion, or invisible when no aggregates attached) ? Fixing the PFO would be best. But the lower limb clot possibility might also justify an inferior vena caval umbrella or filter, if fixing the PFO is really not possible. Just an idea. A.W.Fox
         
      >maybe I should make it more clear... "> Si su pregunta no ha sido contesta, por favor pulse aqu� para enviar la pregunta a un experto

      >I now have 3 choices in lilo.:
      >1. boot Windows ME. Here, Windows itself regocnizes when hibernated
      >because it uses a file on its own partition. No chance to mess up.
      Q: Medical Informatics: Digital Images
      >1. boot Windows ME. Here, Windows itself regocnizes when hibernated >because it uses a file on its own partition. No chance to mess up. "> Si su pregunta no ha sido contesta, por favor pulse aqu� para enviar la pregunta a un experto

      >2. boot Linux
      >3. boot from the hibernation partition, where a system (I only do that
      >under linux) was safed pressing Fn-A.
      >
      >The problem is to mess up 2. and 3.
      >I would like to have a mechanism that tells lilo to use option 3
      >regardless if 2. or 3. are pressed IF the hibernation partition was
      >used.
      >
      >This leads to another problem....
      >How do I "unactivate" the hibernation partition when linux was shut
      >down and should be started from scratch.
      >
      >Maybe too many risks to mess up the system.
      >But using lilo and a daemon might be a solution - for experts...
      >
      >Thanks,
      > Arne
      >
      >
      >>
      >> >===== Original Message From abiastoch@u... =====
      >> >Hi,
      >> >
      >> >using mks2d from Dell I created a Suspend-to-disk (Hibernation)
      >> >partition and am now able to safe the current system using Fn-A.
      >> >I created an extra entry in the lilo configuration:
      >> >
      >> >other = /dev/hda3
      >> > table = /dev/hda
      >> > label = os2
      >> > loader = /boot/os2_d.b
      >> >
      >> >and can now the Hibernation partition to restore the system.
      >> >
      >> >Now, since there is the potential danger to boot linux "from
      >scratch"
      >> >though it was suspended to disk before. This would certainly mess
      >up
      >> >at least the filesystem and the open applications.
      >> >
      >> >Is there a way to avoid that, e.g. tell lilo that the Hibernation
      >> >partition HAS to be taken when it exists?
      Are there any kind of
      >flags
      >> >for linux or lilo?
      >> >
      >> >I am using SuSE 7.1 on a Dell 4000.
      >> >
      >> >Thanks for any suggestions.
      >> >-Arne
      >> >
      >> >
      >> >
      >> >--------------------------------------------------------------
      >> >Please post your X config files in the group links or database
      >> >
      >> >Your use of Yahoo! Groups is subject to
      >http://docs.yahoo.com/info/terms/
      >>
      >>
      >----------------------------------------------------------------------
      >> David Rodr�guez Ibeas Undergraduate Living
      >Form
      >>
      >----------------------------------------------------------------------
      >> University of Iowa Universidad Polit�cnica de
      >Madrid
      >> Electrical & Computer Engineering E.T.S.I.
      >Telecomunicaci�n
      >> Iowa City, IA Madrid,
      >Spain
      >>
      >----------------------------------------------------------------------
      >
      >
      >
      >--------------------------------------------------------------
      >Please post your X config files in the group links or database
      >
      >Your use of Yahoo! Groups is subject to http://docs.yahoo.com/info/terms/

      ----------------------------------------------------------------------
      David Rodr�guez Ibeas Undergraduate Living Form
      ----------------------------------------------------------------------
      University of Iowa Universidad Polit�cnica de Madrid
      Electrical & Computer Engineering E.T.S.I. Telecomunicaci�n
      Iowa City, IA Madrid, Spain
      ----------------------------------------------------------------------

      ________________________________________________________________________
      ________________________________________________________________________

      Message: 12
      Date: Fri, 30 Mar 2001 01:02:13 +0200
      From: "Luis M. Cruz"
      Subject: Re: safe Hibernation

      El d�a Fri, Mar 30, 2001 at 08:25:27AM +1200, Ryurick M. Hristev escribi�:

      > IIRC from my experiments:
      > the BIOS will let you restore from s2d as many times as you wish
      > but won't let you save to s2d if there is an already unused s2d.
      > (silly, it should be exactly the other way around) so the BIOS marks
      > and knows if the s2d was used at least once or not.
      >
      > The most elegant solution would be if we can detect the state of s2d
      > partition, then we could stop the boot somewhere in rc.single before
      > / is remounted rw. It certainly should be possible, question is how ?

      S2D routines use the bootable flag of the S2D partition to remember if
      there's an unrecovered session on it - besides to autoresume at restart time
      (when we have an standard MBR; if we put LILO on MBR we can then have
      control over it and make another OS to boot instead, for example, and resume
      later ;) ).

      Cheers!

      --
      ______________________________________________________________________________
      Luis Mar�a Cruz http://moon.inf.uji.es/~failure
      PGP keyIDs: 0x6848D470 (DSS) / 0x255E9505 (RSA) failure en IRC-Hispano
      Asociaci�n de usuarios de LiNUX de M�laga http://www.linux-malaga.org

      [This message contained attachments]

      ________________________________________________________________________
      ________________________________________________________________________

      Message: 13
      Date: Thu, 29 Mar 2001 23:19:17 -0000
      From: abiastoch@...
      Subject: Re: safe Hibernation

      --- In linux-dell-laptops@y..., "Ryurick M. Hristev"
      wrote:
      > On Thu, 29 Mar 2001 abiastoch@u... wrote:
      >
      >
      > > Now, since there is the potential danger to boot linux "from
      scratch"
      > > though it was suspended to disk before. This would certainly mess
      up
      > > at least the filesystem and the open applications.
      >
      > Yes, I've seen that. I've got my first notebook (I8k) just one week
      ago
      > and so I don't have much experience and had no time to
      > dig in depth; but an quick, dirty and incomplete hack:
      >
      > First create a lilo.conf without the save-to-disk (s2d) boot option.
      Then...
      >
      > At boot time (e.g. in rc.local) automatically add the s2d option and
      rerun
      > lilo.
      >
      > At shutdown time remove the s2d partition (fdisk can handle this)
      and
      > remove the s2d option from lilo.
      >
      > The problem is what do you do if the system crashes in between ?
      > (yes it happens even to the best of us :-)

      I think, that's the point. I would not like to run lilo one or two
      times automatically. If anything goes wrong (which is likely) you
      might end up with a messed up boot header and would not be able to
      boot any OS.

      Isn't there any lilo configuration trick or flag that might choose the
      right option?
      Maybe one could choose the hibernation partition in
      every case, so that
      - if a linux state exists it restores
      - if no linux state exists linux is booted from the linux partition.

      One would only have to avoid suspend windows to that partition. But
      windows itself can suspend to its file on its own filesystem

      _

      ________________________________________________________________________
      ________________________________________________________________________

      Message: 14
      Date: Thu, 29 Mar 2001 18:09:53 -0600
      From: David Rodriguez
      Subject: RE: Re:
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