巴菲特：我们还有一个庞大的投资组合，在某些情况下，其市值可能会急剧下降（如1987年10月19日发生的那样）。然而，无论发生什么，伯克希尔都将拥有稳定的净资产、现金流和流动性，能够轻松应对任何不利局面。任何其他方法都是危险的。多年来，很多聪明人已经通过艰难的方式了解到，一连串令人印象深刻的数字乘以零，终究是等于零。我不想亲身体验这个方程式的效果，我更不想承担将这种惩罚强加于他人的责任。（巴菲特 2005年）
原文：We also own a large investment portfolio whose market value could fall dramatically and quickly under certain conditions (as happened on October 19, 1987). Whatever occurs, though, Berkshire will have the net worth, the earnings streams and the liquidity to handle the problem with ease. Any other approach is dangerous. Over the years, a number of very smart people have learned the hard way that a long string of impressive numbers multiplied by a single zero always equals zero. That is not an equation whose effects I would like to experience personally, and I would like even less to be responsible for imposing its penalties upon others.（2005）
释义：1.“dramatically”意为“显著地”；
2.“string”意为“一串”。
原文：We also own a large investment portfolio whose market value could fall dramatically and quickly under certain conditions (as happened on October 19, 1987). Whatever occurs, though, Berkshire will have the net worth, the earnings streams and the liquidity to handle the problem with ease. Any other approach is dangerous. Over the years, a number of very smart people have learned the hard way that a long string of impressive numbers multiplied by a single zero always equals zero. That is not an equation whose effects I would like to experience personally, and I would like even less to be responsible for imposing its penalties upon others.（2005）
释义：1.“dramatically”意为“显著地”；
2.“string”意为“一串”。
#健康要有文化素養 & 健康要有哲學頭腦#
Episodic Hives and Abdominal Pain in a Hiker
Neil Khoury, MD; John W. Birk, MD
DISCLOSURES April 18, 2024
This patient smokes marijuana (one joint per week); however, it is unlikely that his recurrent episodes of nausea, vomiting, and abdominal pain are due to cannabinoid hyperemesis syndrome (CHS). The majority of patients with CHS use marijuana daily or more than once daily (47.9% and 23.7%, respectively).[5] This patient's symptoms are not relieved by hot showers, which makes CHS less likely. Although relief with hot showers is a common feature of CHS and should raise great suspicion for this diagnosis, it should not be considered a unique finding, because 48% of patients with cyclic vomiting syndrome who do not use cannabis and 72% of those who do use cannabis have reported symptom relief with hot baths.[6]
Moreover, a diagnosis of CHS would not explain the patient's diarrhea; this symptom is not routinely reported in patients with CHS. Additionally, this patient has no symptoms in between his episodes, which further tends to exclude CHS. Patients with CHS go through prodromal, hyperemetic, and recovery phases. This patient has not described any features consistent with passing through the prodromal phase, such as early-morning nausea in between episodes.
Question 1 of 2
A serum alpha-gal IgE antibody level is ordered for the patient in this case, and the result is 2.4 IU/mL (reference range, < 2.0 IU/mL), which confirms the suspected diagnosis of alpha-gal syndrome. What is the preferred initial treatment for him?
Dietary elimination of pork, beef, lamb, and mammalian-derived products
Omalizumab (monoclonal anti-IgE antibody)
Diphenhydramine as needed
Epinephrine pen as needed
Question 2 of 2
The patient returns to the gastroenterology clinic for routine follow-up. He has been doing well on an alpha-gal avoidance diet and has been cautious to avoid additional tick bites. It has been 6 months since the initial diagnosis, and he has not experienced further GI symptoms, hives, shortness of breath, or wheezing. What is the best next step for this patient?
Referral to an allergist
Auto-injectable epinephrine education
Empirical diphenhydramine 25 mg before red meat consumption
Repeated alpha-gal IgE antibody measurement
SAVE AND PROCEED
Question 1 of 2
A serum alpha-gal IgE antibody level is ordered for the patient in this case, and the result is 2.4 IU/mL (reference range, < 2.0 IU/mL), which confirms the suspected diagnosis of alpha-gal syndrome. What is the preferred initial treatment for him?
Your Peers Chose:
Dietary elimination of pork, beef, lamb, and mammalian-derived products
95%
Omalizumab (monoclonal anti-IgE antibody)
4%
Diphenhydramine as needed
1%
Epinephrine pen as needed
0%
Initial treatment includes an alpha-gal avoidance diet (elimination of pork, beef, lamb, and mammalian-derived products) and prevention of further tick bites. Patients with hives, breathing difficulty, voice changes, or swelling of the face and/or throat should be referred to an allergist and will need formal instruction on using an epinephrine auto-injector.
Omalizumab is a monoclonal anti-IgE antibody; however, it is not an appropriate choice for initial treatment. The US Food and Drug Administration approved omalizumab for patients with chronic idiopathic or spontaneous urticaria.[8] Although small studies and case reports have used omalizumab to treat chronic urticaria related to alpha-gal syndrome, it is typically used after an appropriate trial of dietary elimination.[9]
Diphenhydramine as needed is a reasonable choice; however, it is not the best option. Initial treatment for this patient should focus on addressing the underlying etiology of his condition rather than on treating symptoms. Additionally, this patient did not report urticaria; he presented with a GI-predominant phenotype.
The use of an epinephrine pen as needed is not the preferred initial step for this patient. Although the possibility of future anaphylactic events should be considered for all patients with alpha-gal syndrome, those who have a GI phenotype without any episodes of throat closing or shortness of breath are unlikely to require an allergist referral for education about auto-injectable epinephrine.
Question 2 of 2
The patient returns to the gastroenterology clinic for routine follow-up. He has been doing well on an alpha-gal avoidance diet and has been cautious to avoid additional tick bites. It has been 6 months since the initial diagnosis, and he has not experienced further GI symptoms, hives, shortness of breath, or wheezing. What is the best next step for this patient?
Your Peers Chose:
Referral to an allergist
12%
Auto-injectable epinephrine education
7%
Empirical diphenhydramine 25 mg before red meat consumption
13%
Repeated alpha-gal IgE antibody measurement
68%
It may be beneficial to repeat measurement of alpha-gal IgE antibodies in 6-12 months to re-evaluate levels. Those with low levels may tolerate reintroduction of small amounts of mammalian products, starting with dairy alone.[4] The possibility of future anaphylactic events is a consideration for all patients with alpha-gal syndrome; however, those with a GI phenotype who have not experienced hives, throat closing, or dyspnea are unlikely to need an allergist referral for auto-injectable epinephrine education. Finally, red meat should not be reintroduced into this patient's diet at this time.
Episodic Hives and Abdominal Pain in a Hiker
Neil Khoury, MD; John W. Birk, MD
DISCLOSURES April 18, 2024
This patient smokes marijuana (one joint per week); however, it is unlikely that his recurrent episodes of nausea, vomiting, and abdominal pain are due to cannabinoid hyperemesis syndrome (CHS). The majority of patients with CHS use marijuana daily or more than once daily (47.9% and 23.7%, respectively).[5] This patient's symptoms are not relieved by hot showers, which makes CHS less likely. Although relief with hot showers is a common feature of CHS and should raise great suspicion for this diagnosis, it should not be considered a unique finding, because 48% of patients with cyclic vomiting syndrome who do not use cannabis and 72% of those who do use cannabis have reported symptom relief with hot baths.[6]
Moreover, a diagnosis of CHS would not explain the patient's diarrhea; this symptom is not routinely reported in patients with CHS. Additionally, this patient has no symptoms in between his episodes, which further tends to exclude CHS. Patients with CHS go through prodromal, hyperemetic, and recovery phases. This patient has not described any features consistent with passing through the prodromal phase, such as early-morning nausea in between episodes.
Question 1 of 2
A serum alpha-gal IgE antibody level is ordered for the patient in this case, and the result is 2.4 IU/mL (reference range, < 2.0 IU/mL), which confirms the suspected diagnosis of alpha-gal syndrome. What is the preferred initial treatment for him?
Dietary elimination of pork, beef, lamb, and mammalian-derived products
Omalizumab (monoclonal anti-IgE antibody)
Diphenhydramine as needed
Epinephrine pen as needed
Question 2 of 2
The patient returns to the gastroenterology clinic for routine follow-up. He has been doing well on an alpha-gal avoidance diet and has been cautious to avoid additional tick bites. It has been 6 months since the initial diagnosis, and he has not experienced further GI symptoms, hives, shortness of breath, or wheezing. What is the best next step for this patient?
Referral to an allergist
Auto-injectable epinephrine education
Empirical diphenhydramine 25 mg before red meat consumption
Repeated alpha-gal IgE antibody measurement
SAVE AND PROCEED
Question 1 of 2
A serum alpha-gal IgE antibody level is ordered for the patient in this case, and the result is 2.4 IU/mL (reference range, < 2.0 IU/mL), which confirms the suspected diagnosis of alpha-gal syndrome. What is the preferred initial treatment for him?
Your Peers Chose:
Dietary elimination of pork, beef, lamb, and mammalian-derived products
95%
Omalizumab (monoclonal anti-IgE antibody)
4%
Diphenhydramine as needed
1%
Epinephrine pen as needed
0%
Initial treatment includes an alpha-gal avoidance diet (elimination of pork, beef, lamb, and mammalian-derived products) and prevention of further tick bites. Patients with hives, breathing difficulty, voice changes, or swelling of the face and/or throat should be referred to an allergist and will need formal instruction on using an epinephrine auto-injector.
Omalizumab is a monoclonal anti-IgE antibody; however, it is not an appropriate choice for initial treatment. The US Food and Drug Administration approved omalizumab for patients with chronic idiopathic or spontaneous urticaria.[8] Although small studies and case reports have used omalizumab to treat chronic urticaria related to alpha-gal syndrome, it is typically used after an appropriate trial of dietary elimination.[9]
Diphenhydramine as needed is a reasonable choice; however, it is not the best option. Initial treatment for this patient should focus on addressing the underlying etiology of his condition rather than on treating symptoms. Additionally, this patient did not report urticaria; he presented with a GI-predominant phenotype.
The use of an epinephrine pen as needed is not the preferred initial step for this patient. Although the possibility of future anaphylactic events should be considered for all patients with alpha-gal syndrome, those who have a GI phenotype without any episodes of throat closing or shortness of breath are unlikely to require an allergist referral for education about auto-injectable epinephrine.
Question 2 of 2
The patient returns to the gastroenterology clinic for routine follow-up. He has been doing well on an alpha-gal avoidance diet and has been cautious to avoid additional tick bites. It has been 6 months since the initial diagnosis, and he has not experienced further GI symptoms, hives, shortness of breath, or wheezing. What is the best next step for this patient?
Your Peers Chose:
Referral to an allergist
12%
Auto-injectable epinephrine education
7%
Empirical diphenhydramine 25 mg before red meat consumption
13%
Repeated alpha-gal IgE antibody measurement
68%
It may be beneficial to repeat measurement of alpha-gal IgE antibodies in 6-12 months to re-evaluate levels. Those with low levels may tolerate reintroduction of small amounts of mammalian products, starting with dairy alone.[4] The possibility of future anaphylactic events is a consideration for all patients with alpha-gal syndrome; however, those with a GI phenotype who have not experienced hives, throat closing, or dyspnea are unlikely to need an allergist referral for auto-injectable epinephrine education. Finally, red meat should not be reintroduced into this patient's diet at this time.
軸心島 | Axis Isand-VioletRiesing
這是我們的巴士底獄 不准怯場
https://t.cn/A6T1edgd
*關於我
1.sexual orientation方面是allo-ace,identity是fluxdemi-girl,any pronouns,反LGBTQ+的不要關注我。
2.typology方面是INTJ-A 3w4 sp/so 351 ILI，討厭MBTI二分法討厭刻板印象。
3.政治光谱在左下，品客和激女也不要關注我。
4.Peace & Love不會參與任何吵架，不站任何一隊，不屬於任何一方的自由靈魂。
5.自由至上，不要指控我或是對我發的內容指手畫腳，不喜歡我的任何行為和話可以直接離開，我不會受任何人的無端指控。
這是我們的巴士底獄 不准怯場
https://t.cn/A6T1edgd
*關於我
1.sexual orientation方面是allo-ace,identity是fluxdemi-girl,any pronouns,反LGBTQ+的不要關注我。
2.typology方面是INTJ-A 3w4 sp/so 351 ILI，討厭MBTI二分法討厭刻板印象。
3.政治光谱在左下，品客和激女也不要關注我。
4.Peace & Love不會參與任何吵架，不站任何一隊，不屬於任何一方的自由靈魂。
5.自由至上，不要指控我或是對我發的內容指手畫腳，不喜歡我的任何行為和話可以直接離開，我不會受任何人的無端指控。
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