50 lb bag of flour costco
Reddit Rescue Rangers (RRR) - Ranger CO 1st PLT
2012.07.04 06:17 mr1337 Reddit Rescue Rangers (RRR) - Ranger CO 1st PLT
Rangers Lead The Way
2023.05.28 18:49 smolmanbigworld Memorial Day sales
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2023.05.28 18:30 devsk8 if i download this "included with gold" will i always have it or only a limited time
2023.05.28 18:25 qedgbmk [Actives] Can someone more experienced go over my plan and make sure I’m not missing any steps?
After a successful UB tek grow, I’ve decided to go all in. Here’s my current plan and supplies-
8 spore syringes, 2 of 4 different strains (been sitting in my fridge for about a month, how long can I store them this way?)
8 grow bags .2 micron for inoculation
8 grow bags .5 micron for s2b
Lots of coco coir, verm, gypsum for s2b
23qt pressure canner
40 lbs of dry brown rice courtesy of costco
Cook the rice (how long? Do I boil or simmer?)
Put in .2 micron bags (how much per bag?)
Pressure cook bags (how long, what temp, general tips please!)
Squirt in the shroom juice, cover hole with paper tape (how many CCs per bag? Do I do a full syringe per bag or just .5 cc like UB tek or somewhere in the middle?)
Break and shake (should I even do this? Seen mixed opinions in shroom communities, some people have tested it and seen minimal to no benefit)
Put coir in 5 gal bucket, pour a pot of boiling water on it. Stir with knife, cover and let sit overnight (my last grow got contam after the first flush, so I think I may have messed up this step. Should I do it differently? Any advice?)
Put fully colonized rice in .5 micron bags for s2b with coco coir, verm, gypsum (how much of each ingredient? Do I use all the colonized rice from a .2 bag in a .5 s2b bag?)
Harvest as veils begin breaking
Rehydrate bag after flush (any advice on how to go about this?)
Repeat previous 2 steps until the bag is done
(Should I even s2b inside a bag? Should I buy a bunch more big monotubs and s2b there?)
Sorry for the long post, thanks for reading! If there’s any posts or other resources you’d recommend I check out before I go for it, please link them in the comments!
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to MushroomGrowers [link] [comments]
2023.05.28 18:22 chadowan A Comprehensive Guide to Pro Football Video Game Covers
Another Madden $70 re-skin is upon us, so let's take a moment to explore the history of all the people who have been featured on the cover of an pro football video game.
While the selection of the Madden cover athlete is now an event, there was a wild wild west period of football games from the 80s to the mid-2000s where anybody with a computer could and would build football games, with the selection of the cover being all over the place. Roger Craig was the first cover athlete in 1985 on NFL Challenge for MS-DOS. Madden's first game was in 1988, then by the mid-90s getting a cover athlete or spokesman for your football game was pretty standard.
I wanted to compile those games and covers based on this Wiki article
(and a few that it was missing from that list) and see who was on the main cover of all of those games (some games were almost completely irrelevant, so I left them off this list). Some of these may have more alternates with other people, but I'll stick with the main cover.
Covers by Position https://preview.redd.it/1dzua4o2hl2b1.png?width=600&format=png&auto=webp&s=79174425f34c9090dacddd78d3679923182d5f3a
*These are heavily boosted by John Madden being on 10 Madden covers
Obviously QBs dominate here, but I didn't realize how little defensive players have been on football game covers (9%), with none being on a cover since Richard Sherman in 2014. I'd love to see more defensive players on the Madden cover. Who would be the most likely defensive guy in the near future? Aaron Donald, TJ Watt, Nick Bosa, Myles Garrett, or Sauce Gardner?
Covers by Team https://preview.redd.it/8f29df4ygl2b1.png?width=600&format=png&auto=webp&s=cfa6fba341321f2fb7be68a4be1d0e89404f9e40
If a team's player was not a lead on the cover or was not any identifiable player, I gave them a *
The Re-skins/Commanders?, Jags, Panthers, and Bills have appeared on a cover but never with an athlete as the lead or with a real person. Only the Texans have never appeared at all on the cover of any football video game. I'd say the Bills are most likely to get one next (Josh Allen), then the Jags (Trevor Lawrence), then the Panthers/Texans if either hits a home run with Young or Stroud. The Commanders have a long road ahead to getting a feature cover athlete, unless you ask Sam Howell who thinks he should be this year's Madden cover athlete.
Most Prolific Cover People https://preview.redd.it/5axoymcakl2b1.png?width=2871&format=png&auto=webp&s=1ead25140a20a056d3e02e6cf5fdc14918a9ca51
Kordell Stewart, Daunte Culpepper, and Donovan McNabb (and possibly Lamar Jackson, still too early for him) are the only players with multiple appearances that are either not or are unlikely to make the Hall of Fame. McNabb is the only guy to appear in multiple covers in the same year. Also of note, 7 athletes were on a cover without ever making a pro bowl in their careers: Brad Muster, Pat Terrell, Gordon Laro, Chris Zorich, Albert Fontenot, William Floyd, and Peyton Hillis (Hillis was the only one to be the primary cover athlete).
I'll list all the games and their respective covers by their era below. I'll also attach some of my favorite covers from each era. If the cover person was a Hall of Famer, I'll mark them with a \
). If they're very likely to make the HoF but they're not yet eligible, I'll mark them with a +
Covers by Era
|Decade ||# of Games ||# of Games w/Cover Athletes ||# of Cover Athletes |
|60s ||1 ||0 ||0 |
|70s ||4 ||0 ||0 |
|80s ||11 ||2 (18%) ||2 |
|90s ||36 ||32 (89%) ||21 |
|00s ||40 ||38 (95%) ||36 |
|10s ||14 ||10 (71%) ||12 |
|20s ||8 ||4 (50%) ||5 |
|Total ||114 ||86 (75%) ||76 |
We didn't see the first cover athlete until 1985 with Roger Craig. They didn't really become standard until the early to mid-90s after Madden became a big selling point for the early Madden games. The dip in the last 2 decades is because there's just less games, so any generic football games will have a large effect.
The Early Days: 1965-1982 1978: Football! for the Magnavox Odyssey 2 was the first football video game with a cover, but obviously the cover athletes are generic.
The 2D Era: 1983-1996 1985: NFL Challenge was the first football game with a real cover athlete (Roger Craig). This was the original bar for realism in football simulation, to where it was used in a 1988 ESPN Program \"NFL Dream Season\" where they simulated the greatest teams of all time against each other. 1988: John Madden Football released on the Apple II, MS-DOS, and Commodore 64/128 (partly being developed by Bethesda), which was the beginning of the most dominant franchise in football video games. They featured no NFL teams due to a lack of an NFL license. 1991: Tecmo Super Bowl is probably still my personal favorite football video game. It's totally timeless, and if you pick the Raiders then you're a cheater.
|Year ||Game ||Cover Athlete ||Team ||Position |
|1983 ||10-Yard Fight ||Generic Jersey ||NA ||NA |
|1984 ||Super Action Football ||Generic player ||NA ||NA |
|1985 ||NFL Challenge ||Roger Craig ||49ers ||RB |
|1987 ||4th & Inches ||Generic players ||NA ||NA |
|1987 ||Tecmo Bowl ||Generic players ||NA ||NA |
|1988 ||TV Sports: Football ||Generic player ||NA ||NA |
|1988 ||John Madden Football ('88) ||John Madden* ||None ||John Madden |
|1989 ||ABC Monday Night Football ||Generic player ||NA ||NA |
|1989 ||NFL ||Generic players ||49ers, Raiders, Oilers, Broncos, Re-skins ||NA |
|1989 ||PlayMaker Football ||Equipment ||NA ||NA |
|1990 ||Joe Montana Football ||Joe Montana* ||None ||QB |
|1990 ||John Madden Football ('90) ||John Madden* ||None ||John Madden |
|1991 ||John Madden Football II (or '92) ||John Madden* ||None ||John Madden |
|1991 ||Tecmo Super Bowl ||Generic player ||NA ||NA |
|1992 ||NFL Sports Talk Football '93 ||Joe Montana* ||49ers ||QB |
|1992 ||Front Page Sports Football ||Generic players ||NA ||NA |
|1993 ||Capcom's MVP Football ||Brad Muster ||Bears ||FB |
|1993 ||Madden NFL '94 ||John Madden* ||NA ||HC/Announcer |
|1993 ||NFL Football '94 Starring Joe Montana ||Joe Montana* ||Chiefs ||QB |
|1993 ||Mutant League Football ||Mutant ||NA ||NA |
|1994 ||ESPN Sunday Night NFL ||Chris Berman ||NA ||Announcer |
|1994 ||Madden NFL '95 ||John Madden* ||NA ||John Madden |
|1994 ||Tecmo Super Bowl II: Special Edition ||Generic player ||Cowboys ||NA |
|1994 ||Troy Aikman NFL Football ||Troy Aikman* ||Cowboys ||QB |
|1995 ||Emmitt Smith Football ||Emmitt Smith* ||None ||RB |
|1995 ||Madden NFL '96 ||John Madden*, Pat Terrell, Gordon Laro ||NA, Panthers, Jags ||John Madden, DB, TE |
|1995 ||NFL Quarterback Club 96 ||Steve Young*, Chris Zorich, Albert Fontenot ||49ers, Bears ||QB, DL |
|1995 ||Sterling Sharpe: End 2 End ||Sterling Sharpe ||None ||WR |
|1995 ||Tecmo Super Bowl III: Final Edition ||Generic players ||Raiders, Bills ||NA |
|1995 ||NFL GameDay ||William Floyd ||49ers ||FB |
|1996 ||Madden NFL 97 ||John Madden* ||NA ||John Madden |
|1996 ||NFL '97 ||Kordell Stewart ||Steelers ||QB |
|1996 ||NFL Quarterback Club 97 ||Dan Marino* ||Dolphins ||QB |
|1996 ||NFL GameDay '97 ||Daryl "Moose" Johnston ||Cowboys ||FB |
The Parity Era: 1997-2004 1997: NFL Blitz came from Midway studios and was a breath of fresh air for football games. They had mostly been stagnant trying to hone in on realistic simulation in 2D form, whereas Blitz came out in 3D and threw realism out the window. I definitely spent too much money on the arcade version of this game. 2000: Madden 2001 started the tradition of having their games feature a cover athlete in this format, which consolidated into nearly everyone following this trend. 2001: Backyard Football 2002 was a more kid-friendly version of a football video game, and they also had other games for other professional sports. I definitely played this a lot on my old Windows Me computer, and Pablo Sanchez is a god. 2002: NFL Fever was Microsoft's foray into football video games on the original Xbox. All 3 of their games featured Peyton Manning as the cover athlete. 2002: NFL GameDay 2003 was 989 Sports' exclusive for Sony on the PlayStation platform. 2004: ESPN NFL 2K5 was the last great football game before the NFL exclusively gave their license to the EA. It was this game that definitely led to NFL's decision though, as they slashed their release price to an unheard of $20, which forced Madden 2004 to release at $30 instead of the typical $50. This pissed off the NFL, who decided to have less competition instead.
The Madden Era: 2005-Present 2005: NFL Street 2 was the second in the NFL Street series as a kind of spiritual successor to NFL Blitz. EA tried to have some diversity in their football video games outside of the Madden franchise, so they had the short-lived Street franchise under \"EA BIG\" 2006: NFL Head Coach was a new perspective on NFL Games where you play as the coach instead of the players. I enjoyed these although they could get a little boring. 2007: All Pro Football 2K8 was 2K's attempt at keeping the 2K football franchise alive without the coveted NFL license. They got three HoF players on the cover in Elway, Barry, and Rice, but not the actual license to any NFL team. This game received praise for its mechanics, but poor sales showed that a non-NFL licensed game would always struggle to make it. 2011: Madden 12 was maybe the last good Madden game. Also, Peyton Hillis. The only guy on a NFL football game cover to never make a Pro Bowl. This guy is an actual hero though, so good for him. 2019: Doug Flutie's Maximum Football was a mix of american and CFL football as another attempt at making a football game without the NFL license to poor results. They have announced a new game as a free to play title on new platforms, but no games in this franchise have released since 2020. 2020: Retro Bowl is a mobile game more in the style of Tecmo Super Bowl than Madden. It's probably the most successful non-Madden game since ESPN NFL 2K5, and it's pretty fun. People should definitely give this one a try since it's free to play on any mobile platform. 2022: Madden 23 gave the cover back to Madden for the first time since 1999 to honor the passing of the legend John Madden. Unfortunately the game inside the cover was crap, has been the style of Madden games for over a decade.
|Year ||Game ||Cover Athlete ||Team ||Position |
|2005 ||Madden NFL 06 ||Donovan McNabb ||Eagles ||QB |
|2005 ||NFL Street 2 ||Jeremy Shockey, Xzibit ||Giants, Pimp My Ride ||TE, Rapper |
|2005 ||Blitz: The League ||Generic players ||NA ||NA |
|2005 ||Backyard Football 2006 ||Daunte Culpepper ||Vikings ||QB |
|2006 ||Madden NFL 07 ||Shaun Alexander ||Seahawks ||RB |
|2006 ||NFL Head Coach ||Bill Cowher* ||Steelers ||HC |
|2006 ||NFL Street 3 ||Chad Johnson ||Bengals ||WR |
|2007 ||Backyard Football '07 ||Ben Roethlisberger+ ||Steelers ||QB |
|2007 ||Madden NFL 08 ||Vince Young ||Titans ||QB |
|2007 ||All-Pro Football 2K8 ||John Elway*, Barry Sanders*, Jerry Rice* ||Generic ||QB, RB, WR |
|2007 ||Backyard Football '08 ||Tom Brady+ ||Pats ||QB |
|2008 ||NFL Tour ||Shawne Merriman ||Chargers ||LB |
|2008 ||NFL Head Coach 09 ||Tony Dungy* ||Colts ||HC |
|2008 ||Backyard Football '09 ||Tom Brady+ ||Pats ||QB |
|2009 ||Madden NFL 10 ||Troy Polamalu*, Larry Fitzgerald+ ||Steelers, Cards ||DB, WR |
|2009 ||Backyard Football '10 ||Frank Gore+, Eli Manning+, Kurt Warner*, Peyton Manning*, Adrian Peterson+, Jason Witten+ ||49ers, Giants, Cards, Colts, Vikings, Cowboys ||RB, QB, TE |
|2010 ||Quick Hit Football ||Logo ||NA ||NA |
|2010 ||Madden NFL 11 ||Drew Brees+ ||Saints ||QB |
|2010 ||Backbreaker ||Generic player ||NA ||NA |
|2011 ||Madden NFL 12 ||Peyton Hillis ||Browns ||RB |
|2012 ||Madden NFL 13 ||Calvin Johnson* ||Lions ||WR |
|2013 ||Madden NFL 25 ||Barry Sanders* or Adrian Peterson+ ||Lions or Vikings ||RB |
|2014 ||Madden NFL 15 ||Richard Sherman+ ||Seahawks ||DB |
|2015 ||Madden NFL 16 ||Odell Beckham Jr. ||Giants ||WR |
|2016 ||Madden NFL 17 ||Rob Gronkowski+ ||Pats ||TE |
|2016 ||Axis Football 2016 ||Generic player ||NA ||NA |
|2017 ||Madden NFL 18 ||Tom Brady+ ||Pats ||QB |
|2017 ||Axis Football 17 ||Generic player ||NA ||NA |
|2018 ||Madden NFL 19 ||Antonio Brown+ ||Steelers ||WR |
|2019 ||Doug Flutie's Maximum Football 2019 ||Doug Flutie ||Generic (Stampeders) ||QB |
|2020 ||Sunday Rivals ||Helmet ||NA ||NA |
|2020 ||Retro Bowl ||Generic player ||NA ||NA |
|2020 ||Legend Bowl ||Silhouette ||NA ||NA |
|2019 ||Madden NFL 20 ||Patrick Mahomes+ ||Chiefs ||QB |
|2020 ||Madden NFL 21 ||Lamar Jackson ||Ravens ||QB |
|2021 ||Madden NFL 22 ||Tom Brady+, Patrick Mahomes+ ||Bucs, Chiefs ||QB |
|2022 ||Madden NFL 23 ||John Madden* ||NA ||John Madden |
|2023 ||NFL Pro Era ||Lamar Jackson ||Ravens ||QB |
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2023.05.28 18:14 thegatlife [WTS] Moving sale- OCP top/bottom, holsters, mag, bags and more
1)OCP medium regular top/bottom with tags $40
2)Viktos ranger green sling bag $40
3)Blackhawk fde dump pouch $15
4)Schmeisser 60rd mag (no ban states) $20
5)PIG alpha+ size small,brand new $25
6)Mossberg ghost ring sight kit, new $60 7)Haley strategic thorntail pic mount w/ 1” lint ring $30 8)LEFT HAND T1C sidecar for G19/17 with x300 $50 9) LEFT HAND no name sidecar for G19 $25
Long list of items, if you want to bundle anything shoot me a price.
First purchase gets a free ITS pouch
. PayPal for funds.
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2023.05.28 18:12 kilbane27 Where to find 00 Caputo flour
Does anyone know a place locally that is open to the public that sells the 55lb bag of 00 Caputo pizza flour? It's just way more cost effective to buy it that way but I don't know who has it locally for pickup.
submitted by kilbane27
to Minneapolis [link] [comments]
2023.05.28 17:48 Timathius [H] IA/Armada, Imp G, LOTR, AOS, [W] Astra Militarum, Terrain, Mats, octarius $$$ [Loc] MD USA
Thank you for looking at my extra plastic/metal/resin crack! shipping is not included. I will try and use flat rate boxes wherever possible. Multiple purchases I will combine shipping and offer discounts
I will also entertain trades for Astra Militarum (DKoK, vehicles, kasrkin/tempestus), 40k terrain, gaming mats(44x60/6x4) and octarius box sets
Armada and imperial assault lots I would like to not split but feel free to make an offer.
Imperial Assault https://imgur.com/a/BhxvUJ6
The imperial assault lot to be honest I don’t know everything that it contains. I have taken a substantial amount of pictures for you get a general idea of what is in there, but I can’t guarantee any of it is complete or that things won’t be missing. that is why I will be listing it as a pretty cheap Option for what it is. Also not pictured is a NiB leia expansion
The armada lot is similar. However, I do believe most everything is complete with the cards as I have not used it or split it up previously it has really only ever been used for display. It also comes with some promos such as the MC, 80, dice bag and other card and a NiB MC30
Imperial guard astra militarum
Lot of painted 3x HW teams, command, and two infantry squads of Cadians $50
Mixed bag of broken bits that has an entire squad of Cadian’s painted. $10
Cadian Eye of Terror campaign limited-edition at attention models $15 each
Catachan, female trooper $15
3x Catachan, snipers metal $20
Metal Lieutenant, with bionic arm, Cadian $10
Metal master vox cadian $15
Metal bits, including parts of Azriel and standardbearer wysiwyg $20
Original second edition medal, necron warriors- sold
Lord of the rings https://imgur.com/a/9bnwQQ7
Moria goblins- Sold
Eomer - sold
Gil galad $20
Kings of men $20
Hobbits with swords $30
Mary and pippin sitting $20 ($25 with Grishnakh)
Warhammer, fantasy age of sigmar https://imgur.com/a/i5HFk15
Grave guard with great weapons and some upgrade drakenhoff stuff sold
Terror Geist $30
Screaming skull catapult not sure if this is the whole thing $20
Nib Flamers of tzeentch finecast $30
Graveyard (I think this is 1.5 of them but regardless whats in the pictures is what you get)- sold
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2023.05.28 17:47 RickG_70 Last long run (50k) before 50 miler.
Had my last long run, which was 50k, before my 1st 50 miler in 4 weeks. I signed up for a race to practice race day strategy and have some company.
Overall, it went well. I had my hydration pack ready the night before, skipping the bladder since there were plenty of aid stations, and going with just soft flask. Gels, 1 granola and 1 Larar bar, and Gatorade Endurance powder in small bags to refill the flasks, plus a bag to leave at start/finish since it passed it 1/2 through. I prepared some rice balls and mashed potatoes and had them in zip lock bags since I like alternating gels with starchy carbs every 30 mins. Well first issue was about 30 minutes after leaving home I realized I left my rice/Potatoe in the refrigerator. I was annoyed at first but then just said it was a minor issue and part of ultras are dealing with the unexpected.
The course was nice since it had slight higher evaluation gain per mile than my 50 miler. I think my pace at the start could have been just a tad slower and walked hills a little sooner, it was difficult to gage since there were just tons of small hills that added up instead of some bigger climbs.
It got pretty warm, mid 80s and one of the hotter runs so far this spring (live in NH, raced in ME). I believe I got behind in my hydration a bit and should have drank more sooner. I did have about 4 liters of gatorade/tailwind and 1 liter of H2O but I think I waited too long since I did pee twice but the 2nd time was darker than typical. I think I did fine with calories between what I got from the Gatorade, gels, bars and aid station snacks, which I grabbed the chips, crackers and other non-sweets.
I finished in 6:40ish which I'm good with, the intent was a training. I feel pretty good today, did a real ez 1 hour recovery.
Lessons learned are pack early the day before to chill at night, start slower than I think I need to, hydrate more sooner and just make a simple check list to make sure I bring everything I need - drop bag, shoes, hydration pack and food from fridge!
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to Ultramarathon [link] [comments]
2023.05.28 17:44 pylori pylori's Physiology Bites - Kidney function, acute kidney injury, and acid-base disorders
This is a series I am going to be working on where I endeavour to cover various topics in physiology intermixed with clinical pearls to impart some knowledge that doctors of most specialties and grades will hopefully find useful when looking after acutely unwell patients. Join me as we dredge through the depths of anaesthetic exam revision to answer important questions like "why do CT ask for a pink cannula", "why frusemide is okay to give in AKI", "why is hypoxic drive a bunch of horse manure" and many more. Pick up some of this material and you'll be well on your way to becoming a pernickety anaesthetist, whether you like it or not!
Questions, comments, feedback, and suggestions are both encouraged and welcome.
Kidney function, acute kidney injury, and acid-base disorders Next stop along our systems review are the mighty kidneys. I won't talk to you about Lupus nephritis or renal tubular acidosis, however I will try my best to cover some more typical things you might encounter like acute kidney injury (AKI) and drug dosing in renal impairment while trying to avoid embarrassing myself as a non-renal doctor.
What do the kidneys do? An obvious question, they allow us to get rid of waste substances in urine. They are so much more than that however, they:
We will focus on only a few of these in this post, but the kidney's multiple roles and complex biochemical signalling deserves as mention as it can make diagnosing and understanding disease states difficult. It can also make us forget what other consequences there might be for patients in these disease states.
- Regulate electrolyte concentrations, water balance and plasma volume, plasma osmolality
- Regulate red blood cell production
- Regulate blood pressure via RAA system influencing vascular resistance
- Maintain acid-base homeostasis
- Control Vitamin D production
- Produce glucose from proteins and triglycerides (gluconeogenesis)
How do we measure kidney function? In some respects knowing the heart or the brain aren't working is easy. Low blood pressure and infection? Septic shock. Low blood pressure + STEMI? Cardiogenic shock. Unconsciounsess or coma? Well whatever it is, it ain't working. So what about the kidneys, well we have creatinine, right? WRONG.
Although the kidney has many functions as we noted before, the easiest methods to quantify function look at the obvious: waste production. Its function is the sum of filtration through all the glomeruli in the kidneys, the glomerular filtration rate (GFR). When a substance is freely filtered through the kidneys and is neither secreted nor reabsorbed (which occur in the tubules rather than the glomeruli), the rate at which that substance is removed or cleared from the plasma can be used to measure GFR (in mL/min).
This substance is inulin and not creatinine. Because inulin isn't naturally present in our bodies, it has to be infused and then its concentration and the rate of decay measured. This is impractical clinically, so creatinine was selected as a practical alternative. The correlation between serum creatinine and measured GFR was researched and various formulas like MDRD and CKD-EPI were developed to estimate GFR (eGFR). This is why labs report eGFR as opposed to GFR. (There are also other methods to determine GFR like radionuclide scintigraphy...)
What's the problem? The estimation of the GFR relies on assumptions that are not without problems. This review covers the topic at length, however the main points are:
The takeaway is that creatinine and eGFR are tools developed from the assessment and monitoring of long term renal function. It is not designed for use in patients with acute fluctuations or those with zero kidney function (eg, anuric dialysis dependent).
- Creatinine is secreted, unlike inulin. As mentioned this occurs in the tubules, so changes in secretion will affect serum creatinine level despite a static filtration rate. As renal diseases progress, more and more creatinine is secreted, making serum concentrations less reflective of actual filtration.
- To truly reflect instrinsic renal function creatinine has to be in a steady state with stable generation and serum concentration. Creatinine is produced as a waste product of protein breakdown mainly from muscles. Therefore anything affecting catabolism, muscle activity, dietary protein intake, can alter this steady state. Frail sarcopenic patients will have artificially low creatinines and may not get as significant of a rise as a young muscular person in AKI.
- There has to be adequate delivery of creatinine to the glomeruli. The kidneys receive ~20% of the cardiac output, so the heart has to be pumping out effectively with healthy blood vessels, good volume and blood flow. A hypovolaemic patient with an MI may have a high creatinine despite working kidneys, they're just not being adequately perfused. Chronic diseases like hypertension, diabetes, heart failure, lead to upset of autoregulation of normal afferent (entering) arterioles, whereas ACE inhibitors and ARBs block AT-II from causing vasoconstriction of efferent (outgoing) arterioles, an imbalance can lead to renal impairment if perfusion isn't maintained, or improved blood flow and urine output if it is.
- The studies from which eGFR formulas are derived were conducted in mostly European and North American populations with elderly, black and CKD patients being significantly underrepresented. They only measured GFR a few times a year. With increasingly older, frailer, sicker patients, leading more sedentary industrialized diets and lifestyles, will the accuracy of these formulas hold up with time?
- eGFR correlates loosely with important indicators like proteinuria, fluid status, blood pressure, acidosis, anaemia, bone disease, iron deficiency, tubular function, etc. In the absence of those indicators, the elderly often have decreased GFR without increases in morbidity and mortality.
What else we can monitor? The example of the heart earlier was misleading. Blood pressure is influenced by many factors. Septic shock is actually a high cardiac output state with low systemic vascular resistance (SVR). Patients with heart failure can have normal blood pressures despite severe systolic dysfunction and poor exercise tolerance. Blood pressure is an easy surrogate marker because determining cardiac output and SVR is invasive and complex (of course we have focused echocardiography to help us these days).
A surrogate marker we can use for the kidneys is urine output (UO). After all the end product of glomerular filtration is the ultrafiltrate which will become the urine. If there is adequate urine output despite raised or increasing creatinine levels, we can be reasonably satisfied the kidneys are actually receiving enough blood flow to get rid of waste and perform its other functions.
Acute Kidney Injury This leads us into one of the most commonly encountered entities in hospitalised patients: AKI. Let's look at the KDIGO criteria seen in the table below.
Note: UO <0.5mL/kg/hr is the definition of oliguria.
|AKI Stage ||Serum creatinine criteria ||Urine output criteria |
|1 ||SeCr increase ≥26 umol/L <48hrs or SeCr increase ≥1.5 - 2x from baseline ||<0.5mL/kg/hr for ≥6hrs |
|2 ||SeCr increase ≥2-3x from baseline ||<0.5mL/kg/hr for ≥12hrs |
|3 ||SeCr increase ≥354 umol/L <48hrs or SeCr increase ≥3x from baseline or started on renal replacement therapy (any stage) ||<0.3mL/kg/hr for ≥24hrs or anuria for ≥12hrs |
Definining by creatinine is a more practical screening test in most situations, allowing earlier diagnosis and intervention. UO can be monitored during the course of the day to identify patients who are borderline or not responding to treatment, may need re-evaluation of the cause, or escalation of care. This way a combination of the two can help offset the limitations of each method.
NICE guidance already exists on the diagnosis and management of AKI, most hospitals will have care bundles or even 'AKI nurses', so I'll run over a few important points.
- Pre-renal - This only means the cause lies outside the kidneys, and in at least in the early stages there is no histological change in the kidneys. In many cases like sepsis, diarrhoea, haemorrhage, there can be a relative or absolute fluid deficit and IV fluids are generally indicated. However excessive fluids can result in interstitial oedema in the kidneys, reducing the glomerular pressure gradient and so also reducing filtration. Similarly in poor cardiac output states where there is venous congestion there is a problem with the outflow of blood from the kidneys, so this is not a cause to reflexively withhold diuretics.
- Intrinsic - Here there are structural histological changes in the kidney, caused by many intrinsic renal diseases or nephrotoxic agents like aminoglycosides, vancomycin, NSAIDs, etc. If this is suspected, stopping the offending agent generally resolves AKI without needing a biopsy. Furosemide is not mentioned here as it is not inherently nephrotoxic. Acute tubular necrosis is often mentioned as a specific clinical entity, either due to nephrotoxic agents or sustained hypoperfusion from pre-renal causes. It is not a very helpful term since histological tubular damage has rarely been proven in studies, nor does it help with treatment.
- Post-renal - Obstruction may be incomplete, acute on chronic, with a normal ultrasound, no oligo/anuria, and may be associated with other pathologies like a kidney stone with pyelonephritis or sepsis. Catheters can get blocked too so don't forget a bladder scan if anuric, and obstruction can rarely be external such as by tumours or abdominal compartment syndrome.
When do I refer to renal or ICU? Local protocols aside, advice should be sought when the patient does not appear to be responding to medical management and there may be a need for renal replacement therapy (RRT). This is often in the form of intermittent haemodialysis (iHD) on renal wards, and continuous venovenous haemodiafiltration (CVVHDF) in ICU. There are small differences in mechanism, efficacy, and indications of the many forms of RRT, the details of which aren't important for most non specialists. Generally accepted indications for RRT include:
Absent from above include oligo/anuria or specific values of urea and creatinine. This doesn't exclude them as considerations, however the whole picture should be taken together to make decisions on an individualised basis. It might be that the patient improves despite a creatinine of 700, it might be they become acidotic and hyperkalaemic with a creatinine of 400. Even on the ICU we still don't know when the right time is to start RRT.
- Symptomatic uraemia - Encephalopathy, neuropathy, pericarditis. Elevated urea on its own is not generally an indication.
- Hyperkalaemia - Persistent hyperkalaemia (>6.5) despite insulin/dextrose. Severe hyperkalaemia (>8 ) with arrhythmias, requiring pacing or isoprenaline. This can occur even without anuria and should be escalated as it obviously can be life threatening.
- Severe metabolic acidosis, pH <7.1 - This will depend upon the cause and patient's condition. Patients with DKA and pH <7 can almost always quickly be turned around with insulin and fluids. Severely septic patients may not be able to tolerate medical management long enough to improve without RRT.
- Toxins or overdose - Some medications and toxins may be removed by RRT (eg, lithium, vancomycin), with specific type of RRT better for some drugs than others. This is uncommon and decisions will depend on the input from renal, clinical state of the patient, and advice from toxbase or national poisons service. A drug may not be removed by RRT but if it leads to another entity such as acidosis it may still warrant RRT.
- Fluid overload or pulmonary oedema refractory to diuretics - If patient is anuric despite diuretics then it's more likely they'll end up requiring RRT. In contrast pulmonary oedema in decompensated heart failure with worsening renal function is not helped more by RRT than by adequate diuresis.
This is a reason why renal and ICU often advise the generic "monitor I/O" rather than taking over care. We do appreciate accurate monitoring is unrealistic on the wards, but we also don't have the ability to admit everyone when few will need a specific intervention like RRT. An adequate UO to aim for is above 0.5mL/kg/hr. As AKI resolves some patients enter a polyuric phase, this will resolve but watch that they don't become hypovolaemic in the process, it may require further fluids matching what is lost.
Renal vs ICU referral This will depend on local arrangements and acuity. Refer to renal if:
Refer to ICU if:
- Single organ kidney failure - Normotensive haemodynamically stable patients, not septic or comorbid with poor cardiac function. The principal reason haemodialysis is intermittent because fluid is more rapidly removed therefore borderline hypotensive patients may not tolerate large volumes of blood and fluid being rapidly withdrawn from their intravascular space. I have seen patients arrest from starting dialysis!
- Unclear cause of AKI - ICU can offer RRT as a bridge, but the underlying cause has to be treated, if the cause is unclear or there is persistent renal dysfunction, this will require renal input. We refer for this from the ICU too.
- Diagnosis requiring specialist treatment - Immunosuppressive therapy for vasculitis.
- Renal transplant patients - Even with a clear cause and response to treatment, the precarious nature of immunosuppression, renal impairment and graft function mean these usually merit a call to transplant renal physicians.
- Multiorgan failure - Borderline blood pressure, high oxygen requirements, fluctuating consciousness level, coagulopathy, these patients are unlikely to tolerate iHD, but more importantly it suggests they are critically ill and may need rapid escalation of care (if appropriate) beyond what renal can provide (intubation, vasopressors, etc).
- No on-site dialysis service - In hours there may be arrangements to transfer to partnetertiary hospital particularly for complex patients. However hospitalised dialysis patients known to the renal team may require more urgent RRT than this allows. Some ICUs have the plumbing to offer dialysis (this will need a dialysis nurse however).
- Patient in extremis - ICU may be able to offer more timely input in patients needing urgent intervention especially if prior to surgery. A patient with bowel perforation and severe AKI will usually be septic and in multiorgan failure anyway, but a 70 year old with obstructive pathology may benefit from being close to theatre to offer RRT while awaiting a nephrostomy (or exchange). If it's reversible and there is somebody willing to operate, I would even dialyse a patient with a DNACPR we wouldn't otherwise admit.
- AKI in heart failure
- The heart-kidney interaction is complex and works both ways (see this review). Volume status and cardiac function needs to be carefully evaluated. Seeing CCF documented in the notes is meaningless. What does their most recent echo show? What did they present with? Stable HF with reasonable ventricular function and sepsis with no signs of overload can receive fluids. Acute cardiogenic pulmonary oedema with severe ventricular dysfunction probably has AKI rooted in the decompensation of heart failure (type 1 cardio-renal syndrome) and would benefit from diuresis.
- Acute decompensated HF is usually a hypervolaemic state. Elevated right atrial pressures reduce the arteriovenous pressure gradient in the kidney leading to venous congestion, poor outflow. Inflow is also limited adding to the poor cardiac output so glomerular filtration is reduced, leading to a vicious cycle. Aggressive diuresis with furosemide reduces this congestion, improves glomerular pressure gradient and increasing filtration (as long as the patient does not become hypovolaemic). Furosemide's initial beneficial effects in venous congestion is preceded by its diuretic action and is thought to be due to it causing venodilation, reducing preload. The addition of acetazolamide may improve decongestion further.
- Creatinine rising is not an indication to stop diuresis, it may in fact signify adequate decongestion with improved patient outcomes.
- AKI in liver disease
- Like in heart failure this is a complicated topic (see this recent review). AKI is very common, occuring in up to 50% of hospitalised patients with cirrhosis. While we hear things like hepatorenal syndrome thrown around, common things being common we have to look at all the usual causes we've discussed first (so don't just throw terlipressin at everyone!)
- Pre-renal causes are most common: Discontinue nephrotoxic drugs. Look for and cover for infections and spontaneous bacterial peritonitis. Hypovolaemia from diuretics or GI bleeds, resuscitate with crystalloids and blood as needed until euvolaemic (careful to avoid overload). Albumin has been found to improve survival in patients with SBP and can be considered if worsening renal function despite resuscitation (or following paracetensis for large volume >5L ascites). Hypervolaemia from congestion (cirrhotic cardiomyopathy leading to right heart failure can benefit from diuretics, abdominal compartment syndrome from tense ascites should be drained).
- Intrinsic leaves us with tubulointerstitial causes and hepatorenal syndrome (HRS). Low fractional excretion of sodium and urine microscopy can help confirm HRS which offers a grim prognosis. Terlipressin may improve renal function at the cost of significant pulmonary oedema so regular volume assessment and avoidance of overload is paramount. RRT would only expected to be offered if waiting, or under consideration, for liver transplantation. If not, palliation will be the most likely alternative course.
- Drug dosing
- I would avoid using the BNF in renal impairment. Many of its recommendations are different than common guidelines and frankly weird. Do talk to your pharmacist (also microbiologist where appropriate), they'll often refer to The Renal Drug Handbook which is a good resource and covers scenarios like RRT. Most drugs will be dosed based on creatinine clearance not eGFR so arm yourself with an app or calculator.
- Sodium bicarbonate
- Bicarbonate infusions offer temporary extra buffering capacity, mopping up excess hydrogen ions resulting in a higher pH. This is beneficial in hyperkalaemia as a higher pH favours potassium moving intracellularly (for this reason saline is more harmful and Hartmann's more beneficial in hyperkalaemia). It also has accepted roles in tricyclic antidepressant overdose with adverse ECG findings (QRS, QT prolongation), urinary alkalinization (in salicylate poisonining, poor evidence in rhabdomyolysis), and normal anion gap metabolic acidosis (there is high cloride to replace loss of bicarbonate, see later).
- Its use outside these indications is contentious. There is no evidence of benefit in DKA over conventional fluids even if normal saline's tendancy for acidosis may slow resolution of the acidaemia in DKA. It may be actively harmful in lactic acidosis and respiratory failure as the increased pH shifts the O2Hb dissociation curve to the left, causing reduced oxygen offloading. It also results in net CO₂ production (HCO₃⁻ + H⁺ → H₂CO₃ → H₂O + CO₂) which will have to be blown off with excess minute ventilation.
- So why do ICU and renal advise it or use it themselves even with a lack of solid indications? Well, essentially it's a temporising measure. Severe acidaemia contributes to myocardial dysfunction, arrhythmias, and catecholamine resistance. In the critically ill it can be useful as a delay while you insert lines or in the hope it will avoid the need for RRT. The BICAR-ICU trial did find it delays the need for RRT and may even possibly reduce the need. I'm not entirely sold on the latter, but it can be reasonable to try if there are positive indicators like good UO.
- How? Usually available in concentrated (8.4% with 1000mmol/L of each ion) or dilute (1.26% with 150mmol/L) forms. Due to the high tonicity of the former, 1.26% is generally preferrable especially if you can or want to give larger volumes. 8.4% should be reserved for fluid restricted states and should be given slowly via a central line except in an emergency. Slow infusions help combat significant CO₂ rises and hypernatraemia (especially with 8.4%). Dosing is 1 mmol/kg which is 1mL/kg of 8.4% or 6-7mL/kg of 1.26%. For real simplicity most patients can take a 50mL vial of 8.4% or 500mL bag of 1.26%.
- Iodinated contrast
- The entity contrast induced nephropathy, better termed contrast associated acute kidney injury, is a contentious topic. There are many good reviews already on this topic.
- The evidence is from old studies using high osmolality agents during PCI. Fluctuations in creatinine may not be indicative of actual renal function and may simply reflect the underlying illness requiring a scan rather than the contrast itself. Patients are not more likely to need long term RRT.
- IV contrast with modern low osmolality agents isn't associated with AKI in patients who aren't and even those who are critically ill. There was no association in patients even with pre-existing AKI. Prophylaxis with intravenous saline nor sodium bicarbonate have been found to make a difference even in CKD patients with eGFR >30.
- The tl;dr is unless you're in cath lab or IR suite bolusing large quantities of dye arterially it is probably irrelevant. The benefit of a quality contrast enhanced scan in diagnosing and treating the patient are likely to outweigh any miniscule risk. RCR guidelines mention appropriate consent and identification of patients at risk (eGFR <40) they do not exclude the use of contrast or require hydration, at any renal function. You are the doctor, it's up to you to discuss and determine need and benefit. (It's the radiographer's job to ask, don't @ them, but they shouldn't refuse either).
Acid-base disturbances Now it would seem we are forced to consider the fundamental concept of what acid-base physiology even is. You might have heard about strong ion difference and become lost in confusion. You're not alone. Put simply, there are two competing theories that try to explain how pH changes occur in the body: the traditional model that uses the Henderson-Hasselbalch equation to mathematically explain pH with bicarbonate, and the Stewart model that uses the concept of strong ion difference to explain why changes in bicarbonate occur. The bottom line is that these are detailed explorations of physiology more useful for bed time reading than the bedside. For the interested details can be read elsewhere.
More practically, we can work through a blood gas in a systematic fashion to help decipher the type of acid-base disturbance. Start with pH → PO₂ (always check oxygenation) → PCO₂ (respiratory component) → HCO₃⁻ (metabolic component). I've reproduced this in a simple but limited table below for reference, but this is a more intuitive flowchart to work through.
Numbers indicate primary abnormalities, arrows indicate compensatory changes. Respiratory compensation by altering ventilation occurs quickly, while renal compensation by altering bicarbonate excretion is a much slower process.
|pH ||PCO₂ ||HCO₃⁻ ||Disturbance |
|<7.35 ||>6 ||↔ ||Acute respiratory acidosis |
| || ||↑ ||Chronic respiratory acidosis |
| ||↔ /↓ ||<22 ||Metabolic acidosis |
|>7.45 ||<4.5 ||↔ ||Acute respiratory alkalosis |
| || ||↓ ||Chronic respiratory alkalosis |
| ||↔ /↑ ||>26 ||Metabolic alkalosis |
Respiratory With the topic being the kidney, I won't discuss respiratory acidosis here (see this earlier physiology bite). Acute respiratory alkalosis is due to hyperventilation blowing off CO₂. This can be due to obvious things like pain or anxiety, a compensation for hypoxaemia (eg, high altitude climbing), pregnancy (increased minute ventilation stimulated by progesterone), or salicylate poisoning (direct stimulation of respiratory centre).
Metabolic Dipping back into some physiology, we can consider two concepts that can give us more information: base excess and anion gap. The purpose of these concepts is help narrow our differential diagnosis, rather than serve as pathophysiological explanations of illness.
There are far too many causes and detailed physiology to discuss here exhaustively. If you want to read about the Cori cycle, Type A and B lactic acidosis, helpful mnemonics and more, head to this review or this section on Deranged Physiology.
- Base excess (BE) - This idea comes from Danish physicians during the polio epidemic where patients often experienced chronic CO₂ retention. For a standardised numerical way of gauging the degree of disturbance Siggaard-Andersen proposed BE to represent the quantity of acid in a lab that needed to be added to a solution of blood to normalise it to a pH to 7.40 and PCO₂ of 5.3. Not because the plan was to literally add acid, but this way you could easily quantify the degree of disturbance. Rather than use this concept Americans appear obsessed with the more complicated Winter's formula instead. Most blood gas analysers will calculate BE for us, often reported as standardised base excess (SBE), with a normal range of +/- 3. A negative base excess is sometimes described as a base deficit, they're the same thing.
- SBE <-3 - There is a metabolic acidosis, alone or as compensation for a respiratory alkalosis.
- SBE >3 - There is a metabolic alkalosis, alone or as compensation for a respiratory acidosis.
- Mild -4 to -9, moderate -10 to -14, and severe <-15 (same but positive values for alkalosis)
- It is especially helpful with mixed disorders or causes. A lactate of 4 doesn't explain a BE of -12 alone, are there other contributors to the acidosis? A bicarb of 30 doesn't explain a BE of +10, what else can be causing alkalosis?
- Anion gap (AG) - I have a more detailed reply here explaining anion gap. It is a theoretical number that exploits the body's need to maintain electroneutrality: we have a bunch of positively charged ions (cations) that are evenly matched with negatively charged ions (anions), and we measure some of these. When we have an excess of some anions that we don't measure like lactate this calculated number rises because one of the measured anions (bicarbonate) drops to compensate to maintain electroneutrality. Like BE, most blood gas analysers will calculate AG for you.
Metabolic acidosis Symptoms are non-specific, with the most obvious being hyperventilation for compensation. In severely acidotic states (pH <7) seek early ICU help. Awake patients will hyperventilate sometimes down to PCO₂ <2 which can dramatically increase work of breathing. Initiating invasive ventilation in this stage or patient fatigue can be very dangerous if hyperventilation isn't maintained, the acidosis can worsen and precipitate cardiac arrest. Hypotension from vasodilation and reduced cardiac contractility can occur, as well as arrhythmias, confusion, delirium, coma.
Treatment is aimed at eliminating the underlying cause with specific therapies as required like insulin in DKA, fomepizole for ethylene glycol poisoning, folinic acid in methanol poisoning, etc.
- High anion gap metabolic acidosis - The presence of unmeasured anions including: lactate, ketones (diabetes, starvation, alcoholic), salicylates, formate (metabolite of methanol), oxalate and glycolate (metabolites of ethylene glycol), other toxins.
- Normal anion gap metabolic acidosis - Losses of base (bicarbonate loss in GI tract via high ouput ileostomy or diarrhoea, renal loss via acetazolamide) or excess of acid (renal tubular acidosis, hyperchloraemia, adrenal insufficiency).
- Pitfalls: Albumin is an unmeasured anion, so low albumin can mask a high anion gap. Albumin corrected formulas have been developed. Similarly excessively high unmeasured cations like magnesium, calcium, and even lithium, can also lower the gap.
Metabolic alkalosis Despite metabolic acidosis being the usual focus, metabolic alkalosis is actually the more common abnormality of the two in hospitalised patients and is frequently seen as a mixed disorder (like as a response to prolonged CO2 retention as seen in mechanically ventilated patients). In severe states it can lead to delirium, seizures, obtundation, arrhythmias.
The 'opposite' of acidosis, here we see a gain of alkali or loss of acid, with impaired bicarbonate excretion required to maintain this (via chloride or potassium depletion, impaired renal function, or volume depletion).
Treating the underlying cause is important as always. Where there is low chloride and hypovolaemia, this usually responds well to fluid replacement with saline and potassium as required. Acetazolamide can be given if there is hypervolaemia although in practice this is rarely required unless continued diuresis with other diuretics is required. Alkalosis results in low ionised calcium that can cause paraesthesias, but as calcium is buffered by albumin this rarely requires treatment and resolves with correction of the alkalosis.
- Gain of alkali - Iatrogenic from bicarbonate infusions, citrate in transfused blood.
- Loss of acid - From the kidneys via diuretic therapy, or mineralocorticoid excess, hypokalaemia. From the GI tract by vomiting especially with pyloric stenosis or obstruction as there is gastric acid loss (with chloride) only, laxative abuse diarrhoea.
Conclusion This is another large topic where there was plenty to talk about. I had to cut down the scope significantly as it rapidly spun out of control, however I thought the nuances deserved a detailed writeup. Nothing is ever absolute so don't take any of this as incontrovertible evidence of the incompetence of a hated colleague (or their brilliance)! It will hopefully have given you some ideas to think about and research further when you see patients with AKI yourself.
Until next time!
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2023.05.28 17:33 ElYewii Semper imperialis - [Ch. 3]
•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~• March 19, 2019
I sat at the pool, haven't slept in days.
"What am I gonna do?" I asked myself,
"I have two kids to take care of, and... Oh Robert, why did you have to leave?"
"MOM?" I heard Miranda say through the echo of the room.
"He- here sweetie." I answered while waving her to come over.
"Mom?, are you alright?" she asked.
"Yes, I'm fine sweetie." I said as tears were still running down my face.
She just hugged me.
"I- I." snort
"I miss dad." She said while starting to sob.
"Oh baby me too." snort
I sat in my room that was across from mom's, I had moved to the other room we had booked, leaving mom and Miranda in the other one.
I stared out the window, not even three days were enough to process what was happening, 'Did I really have a conversation with one of them?'
I guessed my brain still hadn't processed the fact that they were alien invaders that overthrew us as the dominant species, feels like a dream, waiting to wake up any minute now, maybe wake up to dad dragging me out of bed for school.
"Yeah." I said softly to myself.
"I need fresh air."
I stepped out of my room and headed to the lobby, while making my way to the door it felt like I was walking through a ghost town, even though you could see humans and aliens they still felt like they weren't there. 'Yeah a certainly need fresh air.'
As I made my way to the main entrance, a marine that I hadn't noticed before stepped into my path, so I stopped.
"You can't leave yet, need to wait five more days." she said
"Ah come on I won't go far, I'll just stay at up there." I said while signaling at the bench right outside the door.
"Orders are orders." She said, all the while holding a rifle.
I was not about to get on their bad side and get marked as a trouble maker.
"Alright, alright, jeez." I said as I walked away back to the lobby, 'I'll try the courtyard then.'
It was a sunny day, too sunny for my liking, so I sat in the pool chairs covered by the trees above, it was nice having that perfect mix of sun rays and shade, while also getting a refreshing breeze, not to cold for me to shiver, but enough to feel comfortable.
If anything the ships above made an interesting view.
A nap felt like the best idea ever, or it would have been have it not been for Delara "Patrolling" the courtyard.
"Hey Jeeryl." She said somehow butchering my name even more, I was used to it but this was a whole 'nother level.
"Hey Delara" I answered.
"What you doing." she asked as if she didn't wake me up from my nap.
"Trying to nap." I answered while covering my eyes with my arm.
"What is nap?" 'Seriously?'
"Short sleep." I answered, hoping that would satiate her curiosity.
"Can I sit?" she asked.
After evaluating my options I chose the best one available.
"Sure, but don't you need to be working?" I asked her,
"Don't think they would notice."
"Delara can I ask you something."
"Y- Y- yes." she answered, probably trying to come up with the word.
"How is Shil?" I asked, was really curious what the planet where a purple big tiddied orc came from looked like
"Oh its really pretty, with lots of oceans and beaches, though now there is a lot more buildings, but its really pretty."
"Here have picture." She said as she pulled out her 'phone?'
It was a selfie of her with other 5 older looking women and what looked like her siblings and her dad, on a beach, it was truly beautiful, with almost impossible blue water, though in a alien planet nothing is out of limits I thought.
"Is that your family?" I asked her while pointing at the other people in the picture.
"Yes" She answered as she started to name them.
"This is my mother Arnac, this is my father Urkal."
"And the rest?" I asked, maybe they were her aunties and cousins.
"Oh this are my other mothers and siblings, this is mother Tehrisa, mother Clavnia, mother Vespra, and mother Safra, and this are all my siblings." then she proceeded to tell me their names though I was still stuck in the fact that she had apparently 4 step mothers while also having a biological mom?
"Delara, can you explain something?"
"Ah- Yeah sure."
"Why do you have so many moms and a single dad?" I asked while pointing at them in the picture.
"Oh yeah, well, we Shil'Vati have male to female birth rate of 1 to 8, so it's really normal for a single male to have several wives."
"So you all live together?"
"Yes!" she said with a lot of enthusiasm.
"What about you?" she asked back
"Well- more recently it's me, mom, my sister."
"What about your dad?"
"H- He was- He was in the city that got attacked." 'Oh'
Delara thought, 'Why why why why why, why can't you keep your mouth shut, you have this cute guy TALKING to you and you come and ask about his death father, WHY brain why are you like this? Of course that's why they were all crying that morning after that news broadcast, I assumed it was just because they lived there'
was what when through Delara's mind, but then she saw him start to tear up. 'Oh no, oh no, oh no, oh nonononononono don't cry, please, Hope no one sees us, quick Delara think, YES."
"Jeryl, do you want hug?"
"Huh? oh no its not nece-" I couldn't finish as Delara hugged me, and by hugging I mean suffocating me with hear great assets, I mean it was nice, they were really soft.
"Don't you worry I'm here for you." Delara said.
"hmmmfh, fmmgh." Was all Jeriel could get out.
This was nice don't get me wrong, in any other circumstances this would be an ideal way to die, but now, he really missed oxygen.
With all the forces I could muster I was able to lift my face enough to say "Delara!" 'You dumbass you are suffocating him'
I screamed in the back of my head.
"Sorry, sorry, sorry." Delara repeated hysterically. \
cough* *cough** "It's okay, just don't give me a heads up next time."
"Are you okay?" she asked while moving my face left and right.
"Yeah I'm fine, don't have to worry" I answered
"Oh shit." Delara said in Shil, as that's what I learned their language was called, they are not really original with names it seems.
"Have to go, it was good talking to you." she said as she rushed into the building
"Well... Great second interaction."
•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~•~• March 21, 2019
Today was march 21st, and this guy was turning 18, this for sure was about to be a different birthday at least.
I got out of my room for the first time today to get breakfast, I had spent all of the previous day between my and mom's room, we talked, We did our best to make her laugh and to alleviate the situation, y'know what they say, laughter is the best medicine,
On my way to the elevator I met up with Miranda to get breakfast and then get sum up for mom, I was worried she didn't get out in all of yesterday, Miranda said she cried whenever she wasn't there with her, the only thing that seemed to calm her down was TV.
We got down to the lounge where we walked past a group of marines having breakfast, they all followed me with their gaze, some even turning around.
“That’s creepy as shit” said Miranda
"What is?" I asked
"That!" she said while pointing at a group of marines having breakfast.
"Don't you see how they look at you? Isn't it a least a little bit weird?"
“Maybe, but I honestly don’t mind it, it’s not like girls paid much attention to me before”
“Ugh.” Miranda rolled her eyes
“I mean it could be worse”
“Worse? How?” she asked
“Well I don’t know, they could be ugly.
“And hey if they want a piece of me, I’m not completely opposed to it, they are basically Sheeva from mortal kombat”
“First eww, second you don’t even know how old they are or let alone how their years are different to ours.”
“Or even their biology who knows if she’s a hundred.”
“You are just jealous there isn’t any guys.”
“Yeah why is that by the way?”
“From what I understand their birth rate is disproportionate so there a very little males compared to the number of females.”
“Well that explains why they are the way they are.”
“That plus the fact that they are soldiers, if they are anything like our marines then they might be the horniest beings on the galaxy." Miranda said a little hyperventilated.
"Just- watch out, as much as I hate you I don’t want anything bad happening to you.”
“Alright mom." I said rolling my eyes
“Oh yeah by the way how is she doing? I couldn't see her yesterday.”
“A little better.”
“Stayed up late watching that cartoon that you used to watch when you were a kid.”
We stayed in silence thinking, both of us staring at the floor.
"What are we gonna do?" I asked.
"About this?" I said while signaling around us, "We are homeless, mom is jobless.
"Dad... y'know." I said trying to look elsewhere, Miranda did the same.
"You are out of school, and me well it's not like I can apply to UH anymore."
"We only have the things in our luggage, and who knows where they would send us, best case scenario the hotel allows us to stay, little worse scenario the aliens relocate us to a camp somewhere else, and worse case scenario we just get thrown into the street." I said while looking around us.
"Don't know, haven't really thought about it, talk about high school experience getting ruined."
"Huh, better get this up to her before it gets cold" she said.
"Right behind you."
We got into the room as the door unlocked, mom was in the bathroom, so we opened the curtains and set the breakfast on the little table that was in the room.
"Good morning kids
" mom said.
She had really bad bags under her eyes and looked tired as a whole.
"Above all to the birthday boy
" she said while hugging me and giving me a kiss on the forehead which I had to lower myself for, I might not be tall but mom was 5'0 on the spot, if the aliens were intimidating for me you must imagine how it was for her.
"Thanks mom, we brought you breakfast."
We finished eating breakfast, when mom got up from the table and went to the bathroom, but she came with a muffin.
"Where'd you get that?"
"The lounge, woke up early today, though I asked for a candle but the hotel people told me they couldn't find any.
"Well that's ok, it's the thought that matters."
We split the Muffin into three pieces, to the protest of both Miranda and mom, then we just laid back watching the peak of Canadian animation, the tale of a kid fighting an evil alien purple sphinx cat, that wants to take over earth.
"I remember you would get up for school early just so you could watch it." mom said.
"Yeah I remember that."
I thought about mentioning that it was dad's favorite cartoon but thought better of it, thought I could see that it still came to her mind.
The rest of the day was uneventful, we just stayed up watching TV, talking about stuff trying to avoid talking about our situation as much as possible, or walking through the hotel floors and lobby, there weren't many people in the hotel so, many of the people you would find had purple skin or a lot of fur.
It was already getting late I said bye to the both of them and went into my room, but it being a relatively hot day, I decided for a change in plans, going for a swim, so I put my trunks on a lose shirt grabbed my book a towel and made a b line to the door and elevator.
Today's shift had been as uneventful as all the previous ones for Delara, just walking around checking the perimeter, questioning any suspicious locals, which there weren't many of at the hotel they were posted at, but today was warm which was nice, it reminded her of Shil and her family, which reminded her of how much she liked to swim and that there was an outdoor pool, maybe she'll find Jeryl there again, and if she didn't she would still take a swim, of course she first had to consult it with Sergeant Lyria which said that she'll allow it but to keep it civil, whatever that meant.
So she went to her quarters, grabbed her standard issue bathing suit which wasn't very different from her normal workout clothes aside from the material it was made of, she put it on and headed out.
Jeriel sat in the same chair where he sat before, thought now instead of sleeping he was reading, he wasn't a great reader but he tried to get better, either way he still couldn't understand how people read a four hundred something page book or books in a week, he felt you didn't enjoy the book that way.
It was also unreasonably hot, if there was anything that he still didn't get used to in the US is the bipolar weather, one day is freezing, the other is hot enough to make water boil.
So reasonably so he had his shirt off, he enjoyed the calm and quiet besides the little waterfall on the pool.
That until then again he heard from behind him.
"Hey there cutie."
What would happen in the next chapter? come back Wednesday to find out.
This was it for today, hope y'all enjoyed it and as always comments are welcomed.
submitted by ElYewii
to Sexyspacebabes [link] [comments]
2023.05.28 17:29 ValiMeyer Dh Initiates Clothes Purge. Happy Results!
Out of the blue my DH announced yesterday morning, “ I want to purge my shirts”. Like most men, he had like 50 “work” t-shirts. We spent an hour & ended up w a huge bag to go, another huge pile to donate. Donate went out that afternoon. He later said “I can do this so much easier than when you help”. Another highlight: “ J [son] isn’t going to want these right? Old people are always trying to give stuff to their kids”. 🤣 And, “My clothes will stay unwrinkled”. Excellent session!
submitted by ValiMeyer
to declutter [link] [comments]
2023.05.28 17:17 allmyamaryllis How many pepper pods fit into a 20 gallon bag?
I plant my seeds in pods and this year all of my pepper pods germinated and are growing strong. The only problem is I don’t have enough 20 pound bags. How many pods can I safely fit in each 20 LB bag?
submitted by allmyamaryllis
to vegetablegardening [link] [comments]
2023.05.28 17:00 _call-me-al_ [Sun, May 28 2023] TL;DR — This is what you missed in the last 24 hours on Reddit
If you want to receive this as a daily email in your inbox, you can now join at this link President of Belarus hospitalised after meeting with Putin Comments Link More than half of voters now want Britain to forge closer ties with the EU, poll reveals Comments Link Iran, Taliban exchange heavy gunfire in conflict over water rights on Afghan border Comments Link Texas House launches historic impeachment proceedings against Attorney General Ken Paxton
As cancer drug shortages grow, some doctors are forced to ration doses or delay care
State Farm to stop accepting homeowners insurance applications in California due to wildfires, construction costs
Regular walks strengthen connections in and between brain networks, according to new research, adding to growing evidence linking exercise with slowing the onset of Alzheimer's disease.
Research has recently shown that nearly any material can be turned into a device that continuously harvests electricity from humidity in the air by applying nanopores with less than 100 nanometers in diameter
Psychedelic substance 5-MeO-DMT induces long-lasting neural plasticity in mice
One of the most difficult shots I've ever attempted, this is the moment the ISS transited the waxing crescent moon in broad daylight. Uncropped photo and video of the event linked in the comments.
A supernova the size of 9.461e+15 manatees appeared this week in the M101 galaxy. I was lucky enough to photograph it from my backyard.
Barnard 68 (B68) is a dark globule within the Milky Way. These molecular clouds, known to be some of the coldest objects in the Universe (around 10 K or -263 °C), play a crucial role as the birthplaces of stars and planets. Credit: FORS Team, 8.2-meter VLT Antu, ESO.
New IEA data shows the oil industry knows its days are numbered. Instead of investing in future production, it's distributing record profits to shareholders. Renewables are now the world's largest energy source as measured by future investment - almost double the size of fossil fuels
Japan to try beaming solar power from space in mid-decade
Study: anti-soil coating developed for solar panels. It boosted electricity production by 3% over a 9 month period
What is the male equivalent of a woman wearing a sexy mini dress?
What do you think is the biggest mistake people make in relationships?
What is the worst pick up line you’ve ever heard?
TIL that at the company Hormel Foods, which makes canned SPAM, employees are supposed to refer to spam emails as unwanted emails.
TIL that Carlo Urbani, an Italian Microbiologist, was the first to identify SARS-COV-1 in Vietnam and report it to the WHO as a dangerous new pathogen. Urbani himself died of SARS himself shortly after, having triggered a rapid response to a potential pandemic, and saving many lives.
TIL Burritos are popular food for astronauts in space because it's easy to eat and doesn't produce crumbs that could float around and damage equipment
[OC] Maximal Entropy Random Walk (MERW) - often more optimal than naive RW, lots of applications, e.g. shown my conductance model in semiconductor
[OC] Visualizing Financial Market Returns Across Many Asset Classes via Heatmaps
Years of occupation needed to adversely possess land, by US state
Why is the older generation so fearful of MSG?
What do you make for your partner when they are sick?
What's a flavor combination you were skeptical about, but was surprisingly delicious?
[Homemade] Chicago Style & Chili Cheese beef hotdogs.
[Homemade] Beignets with homemade jams
[homemade] 3 layer meat lasagna.
Directors Lord & Miller On Spider-Man Noir and Project Hail Mary
Ford v Ferrari (2019) Is the Best Car Movie I've Ever Seen
2023 Cannes Film Festival: 'Anatomy of a Fall' wins the Palme d'Or; Jonathan Glazer's 'The Zone of Interest' wins the Grand Prix; Tran Anh Hung wins Best Director, Kōji Yakusho wins Best Actor; and Merve Dizdar wins Best Actress
Seagull Man, Pink Blanket (me), Digital, 2023
"Armored Vanity", Chalky Nan (me), Digital, 2023
LEGO Moon Palace, legotruman (me), lego bricks, 2023
"Shiny Happy People: Duggar Family Secrets" The four-part docuseries (premiering June 2nd) interrogates disturbing abuse within the family and their insidious organization the IBLP
Marvel's Runaways Removed From Disney+ And Hulu Without Warning
Will ‘Better Call Saul’ Finally Win an Emmy?
Amazing performance at Cannes by Alina Baikova from Ukraine.
Hand embroidered chameleon bag made by me.
Reddit, thank you for putting a huge smile on my tractor hauling Dad this week.
Golden Retrievers Playing In The Water
The World’s Largest Open Pit Iron Mine In Hibbing, Minnesota. A Manmade Grand Canyon
M101 Supernova - SN2023ixf
Geological evolution of North America in the last 550 millon years
This restaurant named "Thai food near me"
My local coffee shop offers a single gummy worm as a food option
my local nordstrom is closing down and is selling a jetplane ejector seat as a part of their liquidation .-.
Huge colony of bats emerging from a cave in Mexico
.50 BMG pistol
Breaking this huge granite
*Dog rings the bell, gets confused and barks coz "Someone is at the door" *
This pumpkin is concerned about his future
An elderly man feeds 25 super hungry raccoons.
*Taking my kitty for a scooter ride to his favorite spot. *
That is a seVEREly happy dog.
Get this as a daily email!
submitted by _call-me-al_
to RedditTLDR [link] [comments]
2023.05.28 16:50 K-othic After the hype: 7HZ Salnotes Zero Review
| || | submitted by K-othic to headphones [link] [comments]
The acclaimed 7HZ Salnotes Zero are IEMs with a single dynamic driver per side that shook the IEM market a few months ago, receiving support from top reviewers and being highly recommended by many users for their excellent performance at a more than acceptable price ($20 USD). Video Review here More reviews here
Ranking (* = star): * * * * *
|Pros ||Cons |
|Exceptional timbre ||Below-average imaging |
|Good accessories ||Slightly lacking midbass presence (subjective) |
|Non-fatiguing tuning for long listening sessions || |
|Versatility across various genres || |
|Wide and deep soundstage || |
Unboxing, Build and Comfort
The box is simple but expected in this price segment. Like in most cases, upon opening it, we find the pair of headphones, and underneath them, two small bags: one with the 2 pin 0.78mm cable and another with 5 extra pairs of silicone tips. https://preview.redd.it/v7fxqi4olm2b1.jpg?width=4000&format=pjpg&auto=webp&s=4ffd7440869898e0f2a15dc84944f5d59a0dbb37
The construction of the IEM itself feels cheap. The 10mm driver with a metal composite diaphragm is protected by a plastic molded housing and a metal faceplate with the brand and model inscriptions. A positive aspect of this type of construction is the variety of colors offered for this model, with a total of 6 options: white, black, light blue, red, pink, and orange. https://preview.redd.it/tabwmhlplm2b1.jpg?width=4000&format=pjpg&auto=webp&s=bf179ea21edcf9f37c09b532c0ba7b0b1cd20bc2
Moving on to the cable, it is quite good for the price. It has good flexibility, doesn't tangle easily, and has a straight 3.5mm connector, relieving the tension at the cable termination point compared to "L-shaped" connectors. As negative points for this cable, it is slightly microphonic when it rubs against clothing, and the plastic ear guides may be uncomfortable for some. https://preview.redd.it/bfqw28wqlm2b1.jpg?width=3579&format=pjpg&auto=webp&s=00f2c6fd746ebe600d856a29a0240cc29718aa1f
Regarding the silicone tips, I was surprised by the quantity included (6 pairs, counting the ones already on the IEMs). Some of these are "wide bore" tips like the orange ones (which retain better bass and treble frequencies), while others have a narrow bore like the light blue ones (which reduce treble frequencies without affecting the bass, resulting in increased bass emphasis).
Lastly, the comfort of these headphones was excellent from day one. I always used them with the small-sized (S) orange tips, and both the shape of the IEM and those tips contributed to an exceptional seal in my outer ear. They are so lightweight and comfortable that I can wear them for hours without needing to readjust them. They are a great option for anyone needing peace in noisy environments.
Frequency response description Credits: https://crinacle.com/
- Deep sub-bass extension and well-presented bass
- Smooth transition from bass to the mids
- Mid frequencies following almost strictly the Harman target
- Laid back but airy treble with good extension
Subjective sound description https://preview.redd.it/a9wcyyzxmm2b1.jpg?width=2686&format=pjpg&auto=webp&s=0d770f0c78b243da5cf55264fc84c9f597d29dd2 Bass
The sub-bass has a lot of authority, as demonstrated in songs like "Xanny" by Billie Eilish and "Hot In It" by Tiesto. The sensation of "rumble" in these and other songs is very good, and the sub-bass can be felt in the chest.
On the other hand, the bass frequencies (>50-60 Hz to 200 Hz) are slightly lacking for my taste, as evidenced in EDM songs like "Follow" by Martin Garrix. However, this prevents the bass frequencies from "bothering" the mid frequencies and allows for a smooth transition between them.
I listened to several different singers to have a good reference for this frequency range. Freddie Mercury, Billie Eilish, Adele, and Calamaro - all these artists sounded correct here.
Both male and female voices are reproduced naturally with more than adequate presence, although female voices have a slightly more authoritative presence, as I heard in "Vivere" where Bocceli sings together with Gerardina Trovato.
The articulation between the different instruments and voices occupying this range is very good, without any interference or "disturbance" between them at any moment.
In general, the high frequencies may leave something to be desired for those who prefer a brighter and more detailed tuning. However, this is a very positive aspect for long listening sessions, where this IEM will reproduce the entire music library with exceptional musicality. In "Black Magic" by Slayer (Live Undead), the drummer's cymbal in the first 30 seconds is never offensive to the ear and has good presence. In "Revelations" by Iron Maiden, the variety of cymbals played by the drummer during the guitar solos have a gentle presence without being aggressive or overly bright.
The timbre of these headphones is something that other companies should take note of. I understand that it's not a bold tuning as it follows the Harman curve, but the instruments are so well represented that despite not being the best IEM in terms of resolution/detail, they can be compared to others that are far above their price range thanks to the excellent execution of timbre. All the instruments in Vivaldi's "Winter: Allegro non Molto" - performed by Fabio Biondi - are excellently distinguished from each other, from the lead violinist to the cellos and double bass accompanying the rest of the violins.
Soundstage & Imaging
As mentioned earlier in the frequency response description, the soundstage or spatiality of the sound is above average. Songs like Iron Maiden's "The Great Unknown" and Queen's "Bicycle Race" reveal that these headphones have a wide soundstage that can be deep when needed. In the latter mentioned song, a well-crafted three-dimensional scene is created, placing all the backing vocals and drums behind Freddie, with one of the cymbals having a distinct presence located behind and to the right during the chorus.
Regarding imaging, this is one of the few weak points I see in the Zeros. In Calamaro's "Alta Suciedad," it's difficult for me to discern between the guitars playing on the right and left channels. The same occurs during the introduction of the Iron Maiden song mentioned in the previous paragraph.
7HZ Salnotes Zero vs KZ DQ6
I decided to make a brief comparison between these two models as they are both in the same price range internationally and in Argentina (Price: $20 USD for any of them) Credits: https://crinacle.com/
- The DQ6 has more punch and rumble due to a more pronounced elevation in the bass frequencies. They are comparable in the sub-bass range, with the Zero having slightly better extension in this range.
- The more "correct" transition between the bass and mids makes vocals and instruments sound a bit more natural on the 7HZ compared to the DQ6.
- The high frequencies are two opposite poles in my experience: the DQ6 has bright highs at times that help create a sense of detail but may have some small sibilance, while the Zero has more relaxed/dark highs that are not as detailed but contribute to its musicality.
- In terms of timbre, there is no competition; the 7HZ Zero has achieved a better tuning in this aspect.
It is quite obvious that this is a product easy to recommend: good comfort, impeccable tuning for the price, a good amount of accessories of respectable quality for $20 USD. The few negative points I mentioned during my analysis clearly are not enough to lower this product from the pedestal it deserves to be on.
2023.05.28 16:35 redditbrowser7 IsitBullshit: electronic water softeners
We have hard water and a conventional salt-based water softener. Salt keeps getting more expensive plus it's a hassle to buy a bunch of 40 lb bags every month.
We see these electronic scale remover devices for around $300 or so, which would be a bargain if they worked but I don't want to waste that money if they don't. Some have ridiculous names that I'd expect on late night TV ads, others are German made that look like laboratory-grade gear.
The thing that really makes me leery is that the online customer ratings are all over the place on all of them.
Are these electronic scale-remover devices bullshit?
submitted by redditbrowser7
to IsItBullshit [link] [comments]
2023.05.28 16:31 OtakuRize HIKING HELP
Real quick, a friend and I are going hiking soon in Scotland for 9 days, at West Highland Way. What is our recommended bag size? Budget is fine, but its more of a question of how many litres the bag should be. 50? 65? I'm assuming it's within that range. Any help would be appreciated soon. I'm literally in the Decathlon rn. Cheers.
submitted by OtakuRize
to UKhiking [link] [comments]
2023.05.28 16:29 Odd_Blacksmith_5454 My Vasectomy Experience and Guide
Throwaway account due to containing some personal info
Thought I would share my experience, since you’re likely scrolling through this subreddit and reading a bunch of horror stories mixed with people saying the procedure wasn’t bad at all. I’m in the latter group, but I thought I would go into some extra detail on why the procedure wasn’t so bad as well as putting together a rough guide on optimizing your experience. One disclaimer is that I just had this procedure performed a week ago so I can’t speak to PVPS but I’m currently experiencing no pain. Also, I’m not a doctor so if your doctor recommends anything that contradicts with what I said, go with their recommendation. Feel free to comment with additional advice.
Step 1: Finding a Doctor
You’ll want to find a board-certified urologic surgeon (urologist) in your area that is willing to do a vasectomy on someone your age and performs at least 50 vasectomies per year(1). Your primary care physician can help give you a recommendation. You should ask at least these three questions before/during consultation with the urologist:
- How many vasectomies do you perform a year?
- How long have you been performing vasectomies at this rate/year?
- What type of vasectomy do you perform?
It’s also worth checking if the doctor has any discipline actions against them. Below is a link to the NYS website that can help with this (2), you may need to do some digging to find the equivalent for your state.
If possible, bring a friend/SO to the consolation to take notes. The doctor will likely thoroughly explain the procedure which, while helpful, made me so nervous that I stopped fully listening and then had to make some calls afterword to have them go over what they said again (don’t be like me, bring a buddy).
When it comes to vasectomy types, you’ll hear about a lot of options on the internet (traditional vs. no scalpel, cauterization vs. clips vs. open ended, no needle vs. needle). The reddit consensus seems to be that no-scalpel open ended is the preference, but it’s important to hear the trained urologists arguments for their method. FWIW I received a traditional with cauterization and haven’t had any issues so far (knock on wood).
If the doctor’s answers to your questions are satisfactory, ask them how much they charge for the procedure (assuming insurance doesn’t cover it) and when they can perform the vasectomy. You should ideally pick a date that doesn’t have anything too mentally taxing the week before, and too physically taxing the next two weeks after. Fridays are great as you can schedule PTO on Friday and Monday to have four days dedicated to recovery.
A note on budgeting, my procedure was $945 in total but the cost can vary. My recommended budget is $2,000 - $3,000. In addition to the procedure itself, there are a few items I recommend purchasing (listed below) to make recovery easier, and the amount left over can help cover any additional work that hopefully won’t be necessary.
- Jockstraps or athletic underwear (something that provides a lot of support to the nuts) x 4 packs (12 pair)
- Big box of gauze pads (ideally 25-50 pads)
- Hand sanitizer
- Neosporin (or similar antibiotic ointment)
- Tylenol (just in case)
- Something fun for after surgery (ex. subscribe to a new streaming service, buy a new video game, get a book from the library)
- Frozen peas (2 packs) or ice packs specifically designed for vasectomy recovery
- Ziplock bags (large enough to place frozen peas within)
- Fiber bars / bananas, eggs, spinach, minced garlic, tortilla wraps, cheese, bell peppers
- Laptop Bed Desk Table Tray Stand
- Wireless head phones
Step 2: The Week Before
This was the hardest part of the procedure in my experience. The thought of sharp objects near your sack isn’t a savory one, and it’s natural to be nervous. The toughest part I found was that I was having trouble sleeping. If you’re in a similar situation, my recommendation is to use this time to do some prep work. Since you can’t lift anything heavy after surgery, get your chores out of the way ahead of time so you can recover as long as possible. This is also a good opportunity to move some things around to minimize the amount of movement you need to do after surgery (ex. cleaning your nightstand and moving your Tylenol / gauze pads to an easy to reach location). Finally, feel free to do some meal prep so you spend minimal time standing by a stove after surgery.
Your doctor will likely tell you this, but I’ll reiterate, don’t take any blood thinners the week before. If you do, reschedule the appointment. Also, it may be worth asking your doctor if they can give you a valium (ask this ahead of the appointment date as they will likely need some time to get approval). I couldn’t get any valium during my surgery, but that also could be because I didn’t ask in advance.
Something I do recommend taking a few days before are those bananas / fiber bars. The thought of pooping right after surgery isn’t a great one, so a high fiber diet can help clean you out beforehand.
One final tip I have is to masturbate a few times the day before. You shouldn’t masturbate for 1-2 weeks after surgery so it's good to get it out of your system now.
Step 3: The Day Of
I would recommend taking a half-day today if your surgery is in the afternoon. While taking a full day can be tempting, you may want some work to keep your mind preoccupied.
When leaving the house to go to surgery, bring the following with you:
- Paperwork + insurance card
- Check (or credit card if they accept it)
- Wireless headphones
- Your phone
- Frozen peas (optional)
- Someone to drive home you after surgery
Now it’s time for the gory details and, honestly, it’s not all that gory. My urologist did inject lidocaine into my ballsack and he mentioned that there would be a burning sensation, but I felt very little. I’ve had lidocaine in my foot before and it was way worse that time. The actual insertion of the needle also didn’t hurt as much as I was expecting (less painful than getting blood drawn). My theory is that the ballsack doesn’t have much nerves tied to it (instead it’s the balls within the sack that feel pain and an experienced doctor won’t be bumping into those).
Once the lidocaine is in, you don’t really feel much after. It sorta feels like your doctor is thumbing at your scrotum but that’s about it. The worst part are the thoughts going through your head and I have a tip for that. Remember those wireless headphones I mentioned? Ask your doctor if you can wear them during surgery and play a meditation video during the procedure. Here’s a link to the one I used (3). Focusing on the meditation should help get you through. Overall, I would rate the physical pain of the procedure to be less than a dental cleaning / blood donation.
Step 4: What to Expect After
You’ll start to feel an aching feeling about 1-2 hours after the procedure as the lidocaine wears off. The good news is that, as far as I can tell, this is the worst the pain will be, assuming you don’t lift anything heavier than a phonebook during recovery. Now’s the time to elevate your feet and begin icing your balls. Put the frozen peas into the ziplock bag and then apply to the top surface of your underwear (which should still have a gauze pad under it as well). Set a timer for 20 minutes and begin the icing. Once the timer goes off, set another one for 15 minutes, put the frozen peas in the freezer and wait. You should also use a paper towel to wipe off any moisture from the ziplock bag. Ideally, you have someone else making runs to/from the freezer but an alternative could be to get a small icebox to store the peas near your couch/bed. Once this timer goes off, begin applying the peas again. Keep doing this for ~4 hours, then you can do it for less the next day if you don’t feel the ache. After the next day is over, the peas can be applied if you notice bruising. Bruising isn’t uncommon and can last 2-3 weeks after application. My bruising went away after 2-3 days and the aching mostly went away after the second day.
Speaking of the ache, let’s talk about it. Much like the surgery, it’s not as bad as I was expecting. I would describe it as that feeling you get when you sit in a weird position too long in tight pants, a mild pressing sensation over the scrotum and iliac furrows area. The peas and lack of movement will help reduce the pain/swelling (though it likely won’t go away as the peas are on you). Something that also surprised me is how small the cuts on the scrotum actually are (look less like major surgery and more like I nicked myself shaving).
Our new goal will be to minimize risk of infection. After about 4 hours after the surgery, feel free to swap out your gauze pad with a new one, with a very light amount of Neosporin on it. Be sure to clean your hand prior to these swaps (wash thoroughly and apply sanitizer). Right before bed, switch out both underwear and gauze. Keep legs in elevated position while you sleep (put a pillow under your legs). The next day, my recommended gauze swap out is as follows:
- Morning: Replace current gauze with a new one that has a light layer of neosporin on it
- 1-2 hours later: Swap out gauze with a fresh one that has no neosporine on it
- Before bed: Swap out gauze again for a new one with very light neosporine
Prior to applying that gauze pad before bed, it would be a good time to take a light shower. When applying soap to your scrotum, my recommendation is to lather the soap on your hands and then lightly flick the suds to your sack. This way, you have soap on your sack without actually touching it (minimizing risk of your hands infecting it or prematurely opening the stitches). If you are struggling with a cold sore, I would recommend washing your haiface separately from the body washing (ideally after washing your body and while bent over the bath spicket).
Some other tips I’m following is to treat it like any other wound recovery:
- Eating foods rich in vitamin c and protein.
- Avoiding sugar
- Keeping feet elevated with a pillow
- Keeping hands washed and sanitized
- Using the bed desk to discourage a cat/dog/child from hopping into your lap.
Follow doctors instructions regarding showering and abstinence. The current guideline is to avoid working out 1 week after surgery, but I’m going to wait 2 weeks as an added precaution.
One final suggestion for you. Throughout this process you may have been concerned about PVPS (post-vasectomy pain syndrome). The most concerning aspect of this illness is that it may arrive 5-7 years after surgery and can be tricky for urologists to identify as it seems to be the result of multiple different causes, including the following:
- Nerve compression
- Damage to the vas deferens tube
- Back pressure
- Scar tissue
While there’s no guarantee that this won’t occur, the steps above should at least help minimize risk of infection/scarring. Some further precautions you may want to consider are as follows:
- Avoid working out until at least 1 month after surgery and then begin by focusing on light cardio (avoid heavy weights for now)
- Consider investing in a hot tub in the distant future (this is pure speculation on my part but, if a potential cause is back pressure of sperm, then regular soaks in a heated environment may kill off said sperm and relieve pressure)
Hope all of instruction above provide you with some guidance and peace of mind regarding this process and, if you have any other tips for vasectomies, I would love to hear about them.
submitted by Odd_Blacksmith_5454
to Vasectomy [link] [comments]
2023.05.28 16:27 wushwick Lemongrass in the bag?
Picked up a bunch of lemongrass and want to throw it in the bag with a small 2 lb pork shoulder, but not sure this will actually taste good! Has anyone tried it?
submitted by wushwick
to sousvide [link] [comments]
2023.05.28 16:07 BPatt34 16-Team Contract IDP League startup on Fleaflicker ($50 annually through Teamstake)
Tired of 10-12 team leagues where managers quit halfway through the season or tank in dynasty? Looking for a challenge? These leagues have a hard $600 salary cap, used to bid on player through the salary cap draft and Blind Bid Auction/FAAB. The salary cap draft wipes out tanking for the first pick. You must manage your team’s budget and stay under the salary cap while building your team’s roster.
The winning bids determine the player’s salary. Managers may retain players for four years before they go back into the free agent pool. There are bonuses for rushing/passing/receiving yards. IDP is in use to increase the player pool. I adjusted IDP scoring so IDP players are nearly on par with offensive players.
Each team will have a maximum of 22 players on the roster, with the 14 starting positions below:
1 QB, 2 RB, 2 WR, 1 TE, 1 RB/WTE, 1 DL, 2 DB, 1 LB, 2 DL/DB/LB, 1 K
These leagues have a regular season of 14 games and an 8-team playoff, with the division champions as the top seeds. Please pay the $50 buy in to draft as soon as possible. Below are the annual prizes:
o 1st place - $410.00
o 2nd place - $50.00
o Division Champions - $50.00 each
o Highest scoring IDP defense (weekly) - $5.00
o Largest margin of victory (weekly) - $5.00
The Fleaflicker league will draft on Sleeper 8/12/2023 at 2pm EST if the league is paid and full. After the initial draft, the following annual drafts will be 3 rounds for rookies and free agents, then any empty roster spots can be filled through Blind Bid Auction/FAAB.
Have a look around the leagues in the links below. Check the league charter in the link in the commissioner’s note and other info. Also review the rules and scoring. Message me for more information or if interested in joining, your email address and which platform:
submitted by BPatt34
to findaleague [link] [comments]
2023.05.28 15:56 Cohacq Why does Auctioneer do this all the time?
2023.05.28 15:48 eyal8r Salvage or Trash? Subaru EX21 7.0
Got a freebie pressure washer with a Subaru EX21 7.0 (Homelite hp3127s). I'm trying to decide if it's worth salvaging or just toss it. I think CostCo sells decent pressure washers that are comparable for $300. The gas tank is trashed- leaks bad and totally rusted out. The carb bowl is filled with rust/debris- I think they stored this outside in rough weather for years without weatherizing it. It needs a complete tune up (air filter, carb, spark plug, etc). If those things are in bad shape, I'm SURE it would also need a new pump too (not sure if you can rebuild those or not).
So, I'm looking at about $200 to repair it ($50 for fuel tank, $30 tune-up kit, $100 pump). That's just to get it to try to run- who knows how bad of shape the actual engine is, and what other repairs it would need. I'm not a mechanic guy (Handy, but total idiot when it comes to engines). I'm having a hard time just throwing this out- is this worth trying to restore? Or should I just junk it, save the heartache and just buy a new one with a warranty?
submitted by eyal8r
to smallenginerepair [link] [comments]
2023.05.28 15:03 drewbsterz [WTS/WTT] Send-It-Sunday - Messenger bags, Tanodized A2 upper bundle, Vortex Strike Eagle bundle - and more!
Happy Send-It-Sunday all!
More items added including a Vortex Strike Eagle optic and some messenger bags I no longer have use for. See below for details!
- Clear anodized "Tanodized" bundle - Selling as a bundle, this includes:
- Clear anodized A2 stripped upper w/ M4 feed ramps - THERE IS A BLEMISH ON THE LEFT SIDE ON THIS RECIEVER, PLEASE SEE PHOTO GALLERY ABOVE FOR DETAILS. the blem appears to be an issue in the anodize, as the black marks and flecks cannot be removed by any amount of scrubbing or solvent. Looks worse in phots than it is. Brand new, never used.
- Clear anodized charging handle.
- Matching color dust cover complete assembly.
- Matching color round forward assist complete assembly.
- Black A2 grip, no grip screw included.
- $290 for all
- Vortex Strike Eagle bundle which will include:
- Coach Men's Burgundy/Black Leather Ultimate brief- A great messenger bag that I used for a few years at work to carry my laptop to and from the office. Used, but not abused. Purchased from a Coach Outlet store. The pebbled leather is in excellent condition and clean, no blemishes that I can see. Dimensions are approximately 16" x 5" x 12". Will comfortably fit a 15" laptop + various accoutrements. Strap is in excellent shape and metal hardware is not visibly worn. - TV $70, SV $60
- J. Crew Men's Abingdon waxed canvas bag - Purchased from J. Crew around the same time as the coach bag, been sitting in my closet ever since. Brand new, never used, tags still on it. Dimensions are approximately 15" x 5" x 11". It should also house a 15" laptop without issue. - TV $50, SV $40
- Shaffer Machine Streamlight Pressure Switch MLok mount - new, never used. See their website for details - $25
- UTG .4" RMR picatinny riser - mounted and used, will have blue Loctite reside. No appreciable salt, Loctite residue can be cleaned up with acetone or Hoppes, but you won't see it when you mount your optic anyway. See the Product Page for more info. - $15
- Unbranded 1" picatinny light mount- catch and release, seems to either be a clone of the GG&G one or something else. Good shape, no appreciable salt. Will fit any light with a 1" diameter body. - $15
- x3 Magpul (MAG410) XTM Rail Cover FDE - Each pack includes 4 total covers, so total of 12. Catch and release. - $20
- Luth-AR A1 style rear sight complete assembly - Brownell's cancelled my C7 upper order, so no longer need this. Brand new in the packaging. - $20
Add-ons - add on with another item, or pay shipping
- A2 style flash hiders- your choice, one is timed other is not. untimed is Ruger, timed is maybe YHM?- $5 each
- All prices include shipping (except for the add-ons unless purchased with another item) and are open to negotiation. The worst I can say is No.
- PP FF preferred (if you want to use G&S you cover the 3%) but I also have Venmo.
- Comment first, then DM me
- Calling Dibs is a full price commitment to buy
- bundles beat dibs, dibs beat DMs
- I'll wait 30 minutes for payment, then move onto the next in line
- No notes in any payments (emoji for Venmo). Here's why
- No chats, if you send one it it will be ignored. PLEASE DM ME.
submitted by drewbsterz
to GunAccessoriesForSale [link] [comments]