Wagthesam

Reading a recent post here, I felt like I could add more detail on the strategies and tactics for how to ship at large companies.

After I wrote the article, a lot of it boils down to basic project management. But each of these points I’ve made mistakes on and I don’t personally find any of this that intuitive so I hope this helps others

that used to be desirable. But the canadian health care system has degraded, and cost of living is now super high with the housing boom

I say this as a canadian based in sf

I have wondered recently about head of line blocking's impact to latency at AZ level within AWS. How reliable are TCP connections within the same datacenter and do these issues noticeably impact performance at the tail end?

One thing I'm wondering about is that http3 seems to be from end user to search, which is a general serving problem and not really about search. Do dropbox clients call the search service directly?

Funny how school lessons are not applied in the real world. I worked at a Waterloo unicorn, and we had a single refund function that either authorized or denied a refund, with dozens of parameters in the function header

What, it was? I went to an anon anti Scientology protest once. Was I just being used?

do you work at google? most engineering roles ive been in engineers absolutely own their systems and take on call rotations.

I agree though, hasty response is the mark of a junior eng

I have one of these https://www.amazon.com/EMAY-SleepO2-Bluetooth-Overnight-Cont...

I have a similar issue where maybe once or twice a night now my sp02 drops below 90, followed by a spike in my heart rate. From the word of my sleep doctor, that is not normal for a younger person. She used this to try to justify the cost of a psg to my insurance company.

Find a different doctor. Young and fat is not the qualifying criterea. From this entire thread you can get a sense that there are a lot of people suffering out there that have sleep apnea but not fat. Also, a take home sleep study is cheap and easy and covered by insurance.

that seems like inflated pricing. there are solutions from the internet for hsat (lofta and night owl) that used standardized devices. If you want a psg, there's a place in sacramento (axg sleep diagnostics) that will mail you the psg device for a night, for around 600.

My hsat was covered by insurance, but I had to self fund psg and my insurance wouldn't pay for it. My sleep specialist quoted 3k, I went with axg sleep diagnostics.

I defer to his expertise for a lot as he's considered one of the top experts in sleep apnea surgery in the world. He's had more cases for example on MMA than aggregate studies in the literature

He considers DISE to show collapse that would not normally occur. Because under dise you are heavily sedated. Like after drinking alcohol, the airway is not the same as a normal state.

I was quoted 3k for a psg by my sleep specialist. I went and got one from axg sleep diagnostics out in Sacramento, for around 600

Dr choy in Palo Alto is amazing. But for shots you want someone near you as it’s a huge multi year commitment. Dr opal gupta is great as well

Dr choy is great and spent more time with me than expected. But I could not commute to Palo Alto every week for shots, so I used someone local. Both docs are top notch but Dr choy sent the extra mile

I know about SLIT, but from my research most allergists don't mix in enough to make it comparable to shots. From studies I read you need 30-100x the dose of shots taken in monthly aggregate for it to be comparable. For example Odactra which is fda approved for dust mites is 30x the concentration of a monthly maintenance dose. I am allergic to almost everything, so I imagine it will be too costly to treat properly

Also it is much less regulated as its not fda approved, so the quality you are getting is less certain than shots. I would not be surprised if the majority of SLIT use cases in the US are placebo due to cost constraints outside of the fda approved tablets covered by insurance. Yes studies is one thing and its shown clearly that its comparable, but you need the right concentrations

TBH I am skeptical of startups that operate in this type of environment as theres not enough oversight. For me to be comfortable it would need to be very transparent what is going into the mix

source: https://fairfieldcountyallergy.com/whats-the-story-on-allerg... "Sublingual immunotherapy is not currently covered by health insurance companies in the United States because it is ineffective as it is done here"

One detail to add that I think was missing. My message is you need to own your diagnosis and treatment. But much of the work has to be done by doctors in partnership. These doctors do not have time to direct your treatment outside their specialities, so you need to own the entire process.

I had a team of specialists:

- Sleep: Dr Sinha (primary), AXG Sleep Diagnostics (for psg), Lofta, and Night Owl

- ENT: Dr. Gerald Kangelaris (nasal surgery), Dr Andrew H. Murr (consult)

- Allergist: Dr Opal Gupta (primary) and Dr Carmen Choy (amazing doctor! consult)

- Gastroenterologist: (upper gi endoscopy), unnamed as I dont recommend

- Sleep apnea surgical expert: Dr Kasey Li (triple board certified, best in the world)

- Primary care (One Medical)

Yeah. Kanye is a roscharch test. Mental illness is not pleasant or even easy to pity. It will offend you. It can be disturbing, violent, and insane. I have no ideas, this is just the way things are

Yes one thing that I didn't emphasize enough was that I had a team of specialists treating me:

- An ENT and a consulting ENT for a second opinion

- A oral surgeon specializing in sleep apnea

- Two sleep medicine doctors

- Two allergists ( one for shots, one for consult )

- Multiple GP's from one medical

- A gastroenterologist that did an upper gi endoscopy

My message I tried to convey is that you need to own the entire process though. none of the people above will do it for you or do their job beyond their specialty

We exist in constant competition with one another for status and worth. But thankfully in this part of my career I have more choice as to what I want to do / the level I need to sacrifice.

congrats on your recovery!

No because the diganostic criterea is nasal restriction + sp02 decrease. Or microarousals scored manually by a specialist from an ecg. You need a physical device measuring these signals

Possibly. But you need continuous sp02 monitoring, whereas fitbits only do it a few times per hour.

A take home sleep test is easy and is covered by insurance.

if you suspect central sleep apnea, you need to work with a specialist that has done research in central sleep apnea. Its a poorly understood condition. But from my understanding treatment is different

I don't have central apnea thankfully. One thing to note

Yes opening windows brings in dirt and car fumes and pollen. AC and air purifiers much better for environmental health

They are all about the same. What you want is flow rate. Meaning 99.9% efficiency high end filter is not that much more than 99%. But if air gets filtered 2x vs 5x every hour then the 5x worse filter will probably be better

So just make sure to not place the air purifier in a corner, but more central. And turn it up to a higher power. Or run your AC fan continuously

A sleep test diagnoses sleep apnea. DISE can give clues, but Dr Kasey Li is against it saying it gives a lot of false positives from his experience. Home test + polysomnography is his standard, along with using his experience to review your CBCT scans

I did not put strict detail in the medical interventions as this is not meant to replace medical advise and its not as engaging in story form to list things rigorously

But I did followup home tests after treating it, and have done polysomnography which is the gold standard of diagnostic test. I also wear continuous spo2 monitoring on a monthly basis to see where I am from my own device bought on amazon

To treat, I needed a team of specialists (sleep doctor, allergist, ent, maxillofacial surgeon, GPs, and a gastroenterologist) to tackle the various causes and measure the effect. I also consulted Dr Kasey Li, probably the world's leading expert on sleep apnea surgery. He recommended his own surgery expanding the maxilla, but I don't think I need to go that far as its very expensive and I am much better today. I've seen several sleep doctors, will list Dr Sinha at peninsula as someone I would recommend, along with AXG Sleep Diagnostics for an affordable polysomngraphy if you need to pay out of pocket. For ENT, I will also recommend Dr Gerald Kangelaris (skilled surgeon) in SF and Dr Andrew Murr (head of ucsf ENT) if you need a second opinion

Also a lot of my interventions are done daily. So if I miss things or get lazy I can recognize if there is a difference. I also motion record myself automatically every night. In the morning I review how much I toss and turn. Its been about a year of experimentation

if its allergic, then treat the allergies. non allergic I have less experience with, but my understanding is flonase / antihistamines could still help

many other causes though (nasal infection, diet, etc)

You have congestion. Could be allergic, or non allergic. See an allergist and an ENT and get it checked out

My ENT gave me afrin and used it as a diagnostic tool