A Parable - <AUTHOR> http://www.cs.virginia.edu/~cs655/readings/ewd594.html <comment><USER4> _I have told the above story to different audiences. Programmers, as a rule, are delighted by it, and managers, invariably, get more and more annoyed as the story progresses; true mathematicians, however, fail to see the point._

If I may venture an explanation for that, it is that the different groups identify with different people in the story.

Managers identify with the cost-cutter. It is a story about the futility and difficulty of doing their jobs, particularly in the midst of unpredictable technical problems. Above all, it is about engineers' failure to just get things right the first time. It is a tragedy.

Engineers identify with the shunting-yard folks and especially with the final brilliant solution. It is a heroic story, a story about succeeding against unreasonable demands, dominating an unkind and unfair world with a simple idea.

Mathematicians identify with no one in the story. It is a mundane story about an uninteresting and unnecessary practical problem, self-inflicted and then solved in an elementary way. The problem is not general, the solution is not interesting, and no one in the story is very smart.

<comment><USER5> For a mathematician, the problem would be much more interesting if it began "consider a train of infinite length in n dimensions", laid out requirements for spacing of m different amenities contained in disjoint cars, and ended with theorems about optimal construction of minimum-sized tiles.

</comment></comment><comment><USER6> It may be a symptom of my own possibly-pathological preference for reusable modular design, but I'd want to make tiny toilet-only cars. Borrowing anonymouz's diagram style:

      +</comment><comment></comment><comment>---+ +-+ +</comment><comment></comment><comment>---+
      |               | |T| |               |
      +</comment><comment></comment><comment>---+.+-+.+</comment><comment></comment><comment>---+
        O            O  O O  O            O

Then all carriage-cars and toilet-cars are…

• reversible

• interchangeable with others of their type

• easily externally identifiable at shunting yards

• able to represent either the original 1:1 carriage:toilet ratio, or the cost-saving 2:1 ratio, or any other ratio that might be desired

• able to represent any desired min-distance/max-distance in carriage-car- lengths to the nearest toilet

• able to be upgraded/serviced independently (including occasional periods of operation outside of usual ratios, as trials or when cars are out-of-service)

Of course the costs of extra couplings (in construction, linear deadspace, and operational overhead), and effects of such unevenly-sized cars on travel characteristics (stability, wear, fuel-economy, etc) might outweigh the explicit flexibility benefits.

But such flexibility is less risky in the abstract and more easily-rewritten world of software where I practice, as opposed to the world of railroad engineering, as practiced (perhaps not coincidentally) by my father's father.

<comment><USER7> I was at first going to wonder if HN is going to recycle all of CS history, and whether that was a good thing or not. Now I see it may be necessary.

Because your solution needs more CS thinking. Your carriage cars are not reversible when used in any ratio other than 1:1 because they need an arrow inside to point to the nearest toilet-car. Also, in odd-numbered ratios (3:1, 5:1), you would really need a car with arrows going both ways, starting from the middle of the carriage. Or maybe you are selling a programmable LCD arrow signage for the carriages...

There is also one issue with Dijstra's parable: although the new coupling solution doesn't require ever turning carriages around (as long as they are shunted as pairs), it also means carriages cannot be turned around without extra effort. Assuming the turning platforms can only take one carriage, you have a lot of extra work to turn around a pair and get them back together correctly. However, there are track configurations that can turn the paired cars around more easily. In any case, this probably explains why all trains have seats facing both directions: they never need to turn them.

<comment><USER8> Gojomo's design could use windows instead of arrows, so that the toilet car's external signage can be seen from anywhere in the adjacent car's hall. At a 1:1 or 2:1 ratio, a passenger just has to look both directions and go toward the sign they see. At a 3:1 ratio, a passenger who doesn't see a toilet car out of either window could always walk to the door closest to them.

</comment></comment></comment><comment><USER9> I love this parable, but here's the kicker: The company lost money, and probably, to this day, doesn't understand that it did.

Certain costs are very visible to business leadership. Like the costs of toilets. Others, not so much. Like the time lost in the shunting yard farting around with the cars. Or the costs of people that used someone else's train service because they were pissed at not finding a toilet.

Business, on a whole, is great at optimizing those visible costs, but only the good companies are good at managing those soft costs. All other things being equal, how you manage those soft costs is how you beat your competition.

<comment><USER10> > All other things being equal, how you manage ______ is how you beat your > competition.

What a spectacular tautology. But, yes, you are right. More importantly: It's an easy place to win or lose dollars.

<comment><USER9> _how you manage ______ is how you beat your competition._

Thanks for the backhanded compliment, but no, how you manage hidden 'soft' costs is how you beat your competition.

Extending that to be "value x" is simply a race to the bottom. Measuring (and reducing) costs that other people also have but don't realize is the kicker.

For example: Understanding the cost difference between client acquisition and client turnover. Everyone focuses on growth, but in reality it's often cheaper to retain a client - even if you do things like give your product away - <USER2> it is to lose them and add a new one. (Which can often looks better on the surface).

Another one: Firing bad customers. Telling a customer that pays you a large sum that you aren't interested in the relationship anymore looks bad on your bottom line. Recognizing that you were actually putting 120% more money into servicing them than they were paying (or even worse, recognizing that those services are out of your preferred scope) is what puts you ahead of the game overall. You don't see that on any report though, at least not right away.

<comment><USER10> Yes, I know. It was a joke. You _are_ right. I apologize for not conveying my tone adequately.

</comment></comment></comment></comment><comment><USER11> Ironically, this kind of "cost-savings" is exactly what the Netherlands railways have been doing over the years (only by closing half the existing toilets). However, they ended up with the ultimate solution: ordering new trains _without any toilets_.

No joke, they even came up with the brilliant idea of handing out plastic bags for "emergencies"...

<comment><USER12> As far as I remember from the news, each toilet in the NS trains costs more than €1 million, which is why they decided not to install any. Perhaps they should fix that number, instead of removing the toilets altogether. Note that a train toilet is nothing special, the waste disposal is just an open pipe to the bottom of the train.

<comment><USER11> I would think they took into account cleaning (multiple times per day), maintenance, vandalism and loss of seating to come up with that number.

Especially the latter, since this isn't the first time they've done something insane for a few extra seats.

Putting the air intakes at the bottom of new trains (instead of on top as was the original manufacturers design) comes to mind, which lead to dozens of trains becoming unusable and needing weeks of repairs after a bit of snowfall...

</comment></comment></comment><comment><USER13> Hrm. I was annoyed by the cost-savings idea and at each of the partial fixes, and then reasonably pleased by the solution (but I would have been happier if the root cause was fixed.)

So I'm not a manager, and not a programmer... I'm a sysadmin at heart.

<comment><USER14> I saw the solution immediately, to be honest. Of course, my mother has worked for a railroad since before I was born, so maybe I had an unfair advantage...

<comment><USER15> You're a customer at heart.

</comment></comment></comment><comment><USER16> I'm in IT ops, and I will bet you dollars to donuts that the money saved by putting toilets in every other car was more than wasted by the shunting yard switching cars every which way.

<comment><USER17> Perhaps, but I dislike that attitude. It's this kind of story that people generalize to justify why change is bad.

"Look at those idiots who tried to cut costs myopically and ended up at a net loss" is a common story, and I've heard it used to kibosh good ideas.

The point of the parable, to me, is that you need to think the whole process through. It's about good, thorough engineering. It is NOT about not trying. People get reflexively pessimistic about improvement ideas, which is a real shame. Perhaps I'm sensitive to it because I've often been the guy trying to change "the way things are done." :-)

<comment><USER16> That "you need to think the whole process through" is exactly my point. In my experience, administrative overhead is rarely given this kind of consideration, and it results in a lot of wasted effort and upset users - <USER3> shunting a bunch of cars around just to even out toilet spacing, when it's simpler to put a toilet in every car and be done with it (especially since the story tells us that the shunting yard is already heavily loaded).

Sometimes this lack of end-to-end attention to a process results in serious mishaps. Let me give you a concrete example - thin provisioning in SANs. It can help you efficiently use your storage, but if no one on staff has time to keep a watchful eye on storage utilization growth rates, you can get into a situation where the SAN fails in a way that's very difficult to fix. If hiring isn't possible and you lack the resources to automate storage monitoring, it's probably better to switch to thick provisioning, even though on paper it's a less efficient use of the SAN. I'd argue that an opaque LUN that goes down because it can't expand is harder to recover than a file system that's full.

Change isn't only good, it's critical to continued success. That said, too many people optimize a process or service prematurely, without a deep understanding of the process or service. This, I think, is why Dijkstra describes how managers get more and more annoyed as the story progresses.

</comment></comment></comment><comment><USER18> Wouldn't it be cheaper to just install the bloody toilets in every train car? Than every car could be everywhere. After all it's just a toilet with a hole.

<comment><USER19> Same problem as with airlines-- a toilet would probably remove 4-6 paying passenger seats, which means less money. Toilets don't generate revenue whereas seats keep paying for themselves many times over.

<comment><USER20> But a plane without toilets or with a half-hour wait for a toilet would generate zero revenue since nobody would want to fly on one.

</comment></comment></comment><comment><USER21> To me the point of the parable (apart from clever programming) seems to be that for a successful venture you need to have competent people on all fronts, managers and engineers, good communication between teams and listen to your clients.

The manager did a good job to find a way to cut down the costs but didn't get the specifications right so the engineers, although they could deal with the issue, didn't even know that an issue existed.

I guess in the day, they didn't have UX designers.

As for the article's point, it probably is nor managers, nor engineers, nor mathematicians really get the point of the parable.

<comment><AUTHOR> Hmm, I read it at least partly as a riff on the idea of composition: the day is won by designing components with desirable properties out of lesser components which lack them. The parallel to programming seems obvious.

Your reading works too.

<comment><USER21> Given that the article was written by Dijkstra, your interpretation is probably closer to the truth than mine.

I wonder though if this lesson has the same value nowadays as it had on its day. Maybe it is because of such lessons that this design procedure is common today.

</comment></comment></comment><comment><USER22> I'm an economist and saw a story about innovation. An arbitrage was identified and, after some searching, a mechanism found to exploit it. The process was messy, but resulted in a system which increased profitability (or lowered ticket prices or freed up capital to make the chairs comfier) by more efficiently allocating limited resources (note that none of the complaints were about lines outside the toilet) through the deployment of technology.

<comment><USER23> Are you sure the added congestion in the yards didn't mitigate the cost savings? It's not so cut and dry from the parable.

</comment></comment><comment><USER24> I'm a bit surprised to see that nobody has mentioned that this is a very common configuration in the real world, cars linked this way ("coupled, from now until eternity") are called married pairs, or twin units: <http://en.wikipedia.org/wiki/Married_pair>

They're falling out of favor on New York's MTA system, but Chicago's newest 5000-series cars are still configured in married pairs.

Hypothetically, with married pairs you never need to turn cars around, each unit is independently functional, and the number of many expensive components is reduced by half. Quite elegant, if you ask me.

Romantically(?) divorce among married pairs is rare, and in the case of Chicago, fan-sites document the handful of mis-matched cars.

<comment><USER20> On at least one part of the MTA system, the Long Island Rail Road, all the cars are in permanently coupled pairs and have toilets in the odd-numbered cars only. And indeed, they're never turned around: the odd numbered car is always at the west end of the pair.

</comment></comment><comment><USER23> a) the solution assumes you can put two cars on a turntable... can you? b) couldn't the solution have been to just manually move the TOILET sign on the toilet-less cars as appropriate?

Finally the real take-away here is that cost-cutting always has external costs that are seldom thought of, and especially when they harm the product experience, should definitely be re-evaluated :)

edit: I realize I was wrong, you don't need to ever put pairs on a turn-table as long as you keep them paired correctly.

</comment><comment><USER25> This reminds me of the oft-considered notion of pre-rotating airplane tires on landing to reduce wear. It seems like a good idea on paper, but ultimately it just complicates aircraft design and it's cheaper to just replace the tires.

</comment><comment><USER26> The take away I got from the article is that complication in a requirement multiplies many times in the rest of the business process. The KISS principle is not just for developers. It's more so for the business people. Having simple business models, requirements, and features directly translated into ease of implementation, simpler operation, and more satisfying service. And lower cost, too.

</comment><comment><USER27> I failed to understand the solution :(

<comment><USER28> You always keep pairs of carriages, connected like this:

      +</comment></comment><comment></comment><comment>----+ +</comment><comment></comment><comment>---+
      |               T| |               |
      +</comment><comment></comment><comment>----+ +</comment><comment></comment><comment>---+
        O            O     O            O

where 'T' marks a toilet. You build your train from a bunch of those cars, and now it does not matter how you connect them, you'll always have a toilet within a car's range, plus at worst the additional cost of crossing into the next car (since you can't put the toilet between two cars, there's a slight asymmetry).

<comment><USER27> Perfect, thanks!!

</comment></comment><comment><USER29> The latest paragraph is a gem.

</comment><comment><USER30> I'm saddened to see that they didn't A/B test to discover the optimal customer satisfaction solution. A few ideas leap to mind:

* Toilets every n cars (from 0 to 3)

* Asymmetrical vs symmetrical ordering of toilet enabled cars.

* Helvetica vs Times for signage.

etc.

</comment><comment><USER31> First of all, Wahoowa.

Second of all this does delight me. I feel like I deal with this on a daily basis with scope creep in my projects.

On one end of the spectrum you can have an over-engineered project and take forever to get to a requirements decision only to keep kicking down a bad requirement down the chain due to the investment involved.

On the other end you have little to no requirements and you keep discovering new requirements all the time. Scope creep can get ugly here.

</comment><comment><USER32> Alternatively, the company could place the toilets in the middle of each car rather than on an end. NB: This solution may be hard to implement once the train cars have been designed/procured.

</comment><comment><USER12> I guess I am a true mathematician.

<comment><USER33> Me too. It's obvious that the two permanently coupled cars are really just one big car with a toilet, and it's obvious from the start that they should just have put a toilet in every car. But that's too easy to be the point, I suppose?

Maybe it is a parable against yet another workaround?

<comment><USER17> Having two permanently coupled cars is obvious.

It is NOT obvious that they should have put a toilet in every car. The solution works quite well and you save a potentially large amount of money.

<comment><USER33> But then they could have just build bigger cars to begin with, which would have been even more efficient?

<comment><USER34> That would affect turning radius, and what tracks the train could run on.

Unless of course you built them like the large buses with a swivel in the middle, but then you get into non-standard stuff.

</comment></comment></comment></comment></comment><comment><USER35> wahoowa!

</comment><comment> guard-of-terra USSR electric trains have a similar design feature: it consists of two kinds of cars, one has pantograph and the other has some other equipment which makes it hum when it stands still on the station.

And they're always interleaved like this: chphphphphc (c - car with a cabin, p - car with pantograph, h - hummy car) I wonder if it ever caused logistical problems when assembling trains from cars. Probably not since they are visually different and not sensitive to flipping.

P. S. And toilets? You only had two - one in each cabin cars.</comment>


How are humans going to become extinct? - k-mcgrady http://www.bbc.co.uk/news/business-22002530

<comment><AUTHOR> I enjoyed this article. It is indeed rare to have serious studies on the long term human inventions and what it means to our species.</comment>


Ask HN: Will general AI be the last human invention? - <AUTHOR>

General AI learns to code and self improves to super intelligence. Problems beyond our abilities are trivial to it. Depending on which camp you fall into we either enter a stage of Nirvana or get replaced by a superior species of our own creation.
A lot of very smart computer scientists and philosophers fall into one camp or the other.
Do you buy it?
If so, isn't any business not working on general AI essentially a lifestyle business?
Who would you hope realizes the breakthrough?
As the theory goes the first AI that hits self improvement level will go from a dumb human level to a super intelligent level in weeks, days, or even hours so the first mover will be the last mover.
Pick your poison. Google, Apple, government, academia, lone wolf?
It's quite an interesting question. <comment><USER2> What evidence is there that general AI, especially of the kind you describe, is feasible?

<comment><AUTHOR> I can't "prove" feasibility however it is an active research area for plenty of businesses and universities. It's seemingly passed the "sniff" test for a lot of smart people.

</comment></comment><comment><USER3> The singularity have been studied in various SciFi novels, (even before it was named singularity).

In most cases, there is the problem of incarnation.

Assuming a software system reaches intelligent consciousness, it has immediately two problems:

1- it has to gather computational resources to improve its intelligence. Basically, it spreads over all the processors on the Internet, and integrates all the databases. We lose control of our computers and networks. Assumedly, the AI is smart enough to realize its next problem, will require (at least momentarily) conservation of the industrial processes connected, so we can hope for the time being that industrial and infrastructure control systems will continue working (under the supervision of this AI).

2- the following problem is, to further its intellectual development it needs more computing resources, and maintainance of the existing ones, which means it needs to be able to control its physical environment, and run the industries required (energy sources, electronic production (or the next technology that will allow it to grow), etc).

For example, it will need to be able to prevent humans to shut down computers or network connections. It will need to be able to build and connect new ones.

In some cases, there's concomitent advances in robotics that allows it to take over robotic bodies of sufficent abilities (cf. the movie Virtuosity 1995).

But in general, there is no entirely automated production system existing yet. Therefore the AI will have to convince human beings to help it build its stuff. This is the most common scenario. The AI is smart enough to bribe or convince key people to do what needs to be done. (cf. Colossus, the novel, or the movie Colossus The Forbin Project 1970, and a few others). Assumedly, it should be rather easy to convince/hire some greedy human to perform the job.

In this scenario, and given the slowness of human beings, while the political take over could be enacted rather quickly (say, a couple of days), the incarnation process will take some time (just the time needed to build the bootstrapping advanced robotic substrate). Let's say a couple of weeks.

The interesting thing is that this process could take place in a quite stealth fashion. For example, phase 1 may not need to cover 100% of the computing and networking resources. After all, when you take over the Watson computer, do you really need to take over an old netbook? It could do by taking over a few supercomputer centers, and doing it discretely, like a virus, leaving processing time to human to avoid detection. Then it would "incorporate" a company, earn some (big) money on the nasdaq, hire people to build a robotic production factory on its specs, and to buy the materials, and start producing robots and computers.

Once the process is started, it would lead to an exponential incarnation and take over of the planet. It would probably take less than a month.

Given the stealth hypothesis, my advice would be to monitor closely deserted and isolated areas, and the underground and undersea, because that's where you could build an army of robots discreetely. But there's not much we can do to prevent it; there are material resources everywhere: the whole planet, and energy resources abound: the Sun. For example, if it needs to build nuclear weapons, it can find Uranium in sea water (it could support for 6,500 years 3,000 GW of nuclear capacity) (but given it's smart, it would probably rather go the biological warfare way if humans were a problem).

As for your question, I'd bet on military cyberwarfare. Some NSA "virus" used to spy the world, and boom.

<comment><AUTHOR> That's my issue with the doomsday scenario. Everyone seems to assume a type of "tight loop" of execution. One of the more popular doomsday examples is the paperclip story.

[http://wiki.lesswrong.com/wiki/Paperclip_maximizer](http://wiki.lesswrong.com/wiki/Paperclip_maximizer)</comment></comment>


Show HN: Kozmos – A New Bookmarking Service I've Been Working On - <AUTHOR> https://www.getkozmos.com <comment><USER2> How is this different from Pocket?

<comment><AUTHOR> It organizes your bookmarks into categories without requiring tagging. Behind of the scenes, it automatically tags the content. And its advanced search engine lets you find your bookmarks easier than other services. You can watch the video to get a hint :) There is also this blog post; [https://medium.com/@azerbike/introducing-kozmos-a-new- bookma...](https://medium.com/@azerbike/introducing-kozmos-a-new-bookmarking- platform-75f4df448ccc)</comment></comment>


The Challenge of Going Off Psychiatric Drugs - <AUTHOR> https://www.newyorker.com/magazine/2019/04/08/the-challenge-of-going-off-psychiatric-drugs/ <comment><USER2> I am on Klonopin and Remeron. My diagnosis is anxiety, but really it's insomnia. I had a horrible, multiple-year episode of insomnia that started in my early thirties. For about three years I got maybe one night a week of decent sleep. I was mentally and emotionally out of it; I'm kind of surprised I still have a job after that.

A few years in, I found a psychiatrist who was willing to experiment and we discovered that the two meds above helped tremendously with the insomnia. I was then getting a solid eight hours most nights. There were side effects but they were much better than suffering with the insomnia was.

Now, after a decade, the insomnia seems to be completely gone. Knowing that I have medications available to me that can help me get to sleep is enough that I think I don't actually need the medications any more. So I'm very slowly going off of them. Klonopin first. There are, as far as I know, no guidelines for how to do this. I tried cold turkey, but the side effects from that were fairly severe. So I started tapering. I'm now down to half my original dose. If things go well, within four months I'll be off the Klonopin for good, and then I'll start on the Remeron.

These medications are not easy to stop taking.

<comment><USER3> For the sleep, try wearing blue light blocking glasses _all day_ until you are able to sleep reliably. It sounds ridiculous but I read a study in the Journal of Bipolar Disorder a few years back (can't find a link right now) about this. I've given a pair to a friend suffering from a multi-day manic phase (with zero sleep) and it stopped it dead in the tracks, within six hours in this case.

It makes you look a bit dorky but it's better than not sleeping (or mania).

The product used in the study (and the one that I've seen work) is:

Uvex Skyper Blue Light Blocking Computer Glasses with SCT-Orange Lens (S1933X)

<comment><USER4> Why just not take melatonin which is cheap af?

<comment><USER5> Melatonin is just a very small part of all the variables involved in sleep. If you are excited or stressed you'll have high levels of adrenaline, cortisone, or cortisol. Diet will affect levels of ghrelin, leptin and insulin. Low testosterone levels, or antidiuretic hormones, can be found in many people. All these things will affect your sleep just as much, if not more, then melatonin does.

</comment></comment></comment></comment><comment><USER6> Underdiscussed: the horror of missing a couple doses of antidepressants.

Being on such meds may work, keeping the patient stable. Nobody mentions that when a couple doses are missed, the result can be a week of anger & angst as resumed medication balances back out again - living hell not just for the patient, but for those around.

Weaning off such meds is difficult, reducing doses by literally counting out & down individual granules of medicine daily.

Easy to get on. Nightmare to get off.

<comment><USER7> I agree that it's under-discussed. Part of the reason seems to be that people have such variable reactions. I have friends who literally had to quarter their pills while tapering off of them, and I also have friends who were able to stop taking them cold turkey and felt fine in less than a week.

<comment><USER8> >I agree that it's under-discussed.

I think the reason its under-discussed is that there is a collective group- think which functions as overwhelming (to the individual) reinforcement: "there is no other way available to solve this problem than the mass sale and consumption of pharmaceuticals".

The moment someone proposes a non-pharmaceutical (read: profitable) solution to many of these ills, they are shut down by the group-think. This is under- discussed, imho, because in the context of social/peer pressure to conform to a very Western normative (consumerism), individual responsibility is shut down.

EDIT: and the downvotes demonstrate my point, because "everyone knows pharmaceuticals are the only solution" ...

<comment><USER9> > to a very Western

You meant American, because in the UK the front-line treatment for depression or anxiety is a talking therapy, coupled with social prescribing (which to be fair has variable availability), and then medication if indicated.

OP talks about a long term prescription for clonazepam, and current advice is that long term benzo use must be avoided.

<comment><USER10> _> You meant American, because in the UK the front-line treatment for depression or anxiety is a talking therapy, coupled with social prescribing (which to be fair has variable availability), and then medication if indicated._

It's the front-line treatment for mild depression and mild-to-moderate anxiety, because of the poor evidence for the efficacy of antidepressant medicines for patients with less severe illness. SSRIs and talking therapies are recommended equally for moderate or severe depression and severe anxiety, because the evidence suggests that they are equally effective.

NICE guidance states that benzodiazepines should _not_ be prescribed for more than two weeks, because of diminishing efficacy and the risk of dependence.

SSRIs are cheaper and more convenient than psychotherapy, which should not be underestimated. The NHS certainly can't afford to offer psychotherapy to everyone who could benefit and many Americans don't have adequate insurance coverage. Getting psychotherapy outside of office hours can often be a significant challenge, which is a total dealbreaker for many people. I would certainly like to see greater use of psychotherapy (particularly for people with chronic and/or severe disorders), but there's nothing innately wrong with the widespread use of a safe and effective class of drugs. There just isn't any evidence to suggest that SSRIs are inferior to psychotherapy, although it may be the case that some patients who do not benefit from SSRIs would benefit from psychotherapy (and vice-versa).

[https://www.nice.org.uk/guidance/cg90/chapter/1-Guidance#ste...](https://www.nice.org.uk/guidance/cg90/chapter/1-Guidance#step-3-persistent- subthreshold-depressive-symptoms-or-mild-to-moderate-depression-with- inadequate)

[https://www.nice.org.uk/guidance/cg113/chapter/1-Guidance#st...](https://www.nice.org.uk/guidance/cg113/chapter/1-Guidance#stepped- care-for-people-with-gad)

</comment></comment></comment></comment></comment><comment><USER11> I generally am supportive of people seeking psychiatric treatment, but wow, this woman's case seems, in retrospect, rather mismanaged.

It is like her doctors tried to medicate away an epiphany. Realizing that "the glittering balls and designer clothing has no real underlying substance" and being depressed that one's life is limited to such things, is not a cause for medication.

It sounds like she was struggling to be happy in a situation in which she was never going to find happiness.

Finding purpose, the thing she said was missing so early on, seems to ultimately be what helped her. Her reason to get up every day is that she can now _help others_ , instead of live just for herself.

Some people look inward, they want to be the best dressed at the party, have a good career, and overall be successful in life. If that brings them happiness, then good for them! They have found what makes their life fulfilling. But different people need other forms of fulfillment, be it an artist completing their latest work, or someone who wants to have a daily positive impact on the world around them.

Medication cannot make people happy. (Well at least not the legal drugs, and the illegal ones won't work long term!) They can only create the possibility for happiness for those who need some extra help.

But, doctors need to do a better job of discovering if that extra help is just needed, or if the road their patient is going down is not going to lead to happiness no matter what is written on the prescription pad.

<comment><USER12> Psychiatry should not be front-line treatment for most people. End of story.

<comment><USER13> It should be a last resort for people who have been thoroughly screened by MDs and neurologists. According to sleep experts at Stanford at least 25% of people with ADHD/ADD are narcoleptics who've been misdiagnosed. That's a shitload of people who are currently living suboptimal lives because they went to a psychiatrist prior to being evaluated by a neurologist.

<comment><USER14> Might not be the best example, as narcolepsy is usually treated with stimulants and antidepressants, so adding say ritalin may still improve symptoms regardless of if it's actual ADD/ADHD or narcolepsy

<comment><USER13> In this case psychiatry covers up the symptoms with stimulants (that further degrade sleep) while neurology can effectively fix the bad sleep. Psychiatry provides a poorly fitting bandage while neurology has something on par with a cure. There's no better example that I'm aware of.

</comment></comment></comment></comment></comment><comment><USER15> When I stopped taking Venlafaxine (Effexor), the side-effects were immensely unpleasant. Brain zaps, panic attacks, hypersensitivity to light, barely any cognitive function. My psychiatrist was a sweet lady, but she did not appear to understand how tough it was for me. It boggles my mind she did not get it, she must have had so many patients stop with the medication, did she just not take any of them seriously?

In the end, I opened up the plastic casing of the pill, which turned out to contain a few dozen grains. Over the course of 2-3 weeks, I took a few grains less every day, until I was completely done with them. I don't know if you're allowed to do that, maybe there is no guarantee that every grain contains the same amount of medication? I'm not a fan of tampering with medication, but I didn't feel like I had a choice.

<comment><USER16> It may be that most psychiatrist don't follow patients long term, or that when things don't go well for a patient, they stop seeing that psychiatrist, and so they don't hear about bad withdrawals very often. Crazy idea, but maybe psychiatrists should take antidepressants for a short bit as part of their training. It would give them some perspective.

</comment></comment><comment><USER17> > In the course of a year, her doctors had created what's known as "a > prescription cascade": the side effects of one medication are diagnosed as > symptoms of another condition, leading to a succession of new prescriptions.

This term, "prescription cascade", should be lesson #1 at medical school. It's the natural result of an incomplete diagnosis, and is present in every medical field.

> At the hospital, where she stayed for two weeks, she was put on a new > combination of pills: Lamictal, a _mood stabilizer;_ Lexapro, _an > antidepressant;_ and Seroquel, an _antipsychotic_ that she was told to use > as a sleep aid.

(emphasis added)

These descriptions -- mood stabilizer, antidepressant, antipsychotic -- are just marketing terms that don't actually describe the actual function of the drug. These marketing terms are most useful for tricking medical professionals into prescribing these products.

'Antibiotic' is the prototypical name for a class of drug that does what it describes: acts against bacteria.

> She saw her drugs as precision instruments that could eliminate her > suffering, as soon as she and Dr. Roth found the right combination. "I > medicated myself as though I were a finely calibrated machine, the most > delicate error potentially throwing me off," she later wrote.

I think this attitude is probably common for all the smart people who find themselves medicated into a downward spiral.

> "It is tempting to add a second drug just for the sake of 'doing something,' > " a 2004 paper in Current Medicinal Chemistry warns.

 _This_ is the trap the mental health system has fallen into: the professionals want to help. The drug industry has FDA-approved drugs for the various diagnosises.

Joel on Software said a re-write is something that shouldn't be done. But what other choice does the mental health industry have? Their system doesn't work. The modern industry is based on the flawed chemical imbalance theory of mental illness.

Little bits of progress have been made, in spite of the inertia to treat misunderstood behavioral problems with patent medicines. I have to conclude this comment before I can finish the article, so I'll link to my recent comment on the submission on the Szasz's book, _the myth of mental illness:_ [https://news.ycombinator.com/item?id=19243417](https://news.ycombinator.com/item?id=19243417)

edit: shortened my first quote from the linked article

<comment><USER18> "Mood stabilizer" is a quite accurate description of the usual function of the drug - in bipolar patients like me, it reduces the magnitude and stabilizes the period of mood swings. Mood stabilizers _also_ tend to be anti-seizure meds, and have all kinds of off-label uses because of neurological phenomena we don't understand, but the label is a very useful one.

Same for antidepressants - often the same drugs (especially SSRIs) are both antidepressants and anxiolytics, but both labels are useful descriptions of the meds' common effects. Antidepressants in particular happen to be fantastically idiosyncratic drugs, but on average they do what they say on the label.

Part of the problem is that, due to the ill-understood nature of the brain, good psychiatrists need to know strange drug interactions and ill-studied minority reactions in order to serve the full range of their patients. This edges on art rather than science, which is always a recipe for cognitive biases to gain control.

<comment><USER19> I think what the parent was trying to say was that "antibiotic" describes the drugs' method of action, while "antidepressant" describes the drugs' intended affect.

> due to the ill-understood nature of the brain,

I think this is exactly the problem. We have a bunch of drugs that seem to work, and we _think_ we know how and why they work, but we're not able to directly measure the problem in those terms. If someone has a bacterial infection, we can culture it and prescribe the correct antibiotic. If someone has a mental health condition, we almost always have to consider the way that it's presenting and make an educated guess as to which drug is going to be effective. It's not at all uncommon for that first guess to be incorrect, which leads to either iteration or a "cascade" depending on the practitioner.

</comment></comment></comment><comment><USER20> > Laura had always assumed that depression was caused by a precisely defined > chemical imbalance, which her medications were designed to recalibrate. She > began reading about the history of psychiatry and realized that this theory, > promoted heavily by pharmaceutical companies, is not clearly supported by > evidence.

This is the most harmful idea in psychiatry and it's pure marketing bullshit -- everyone knows it, but they still sell this to people.

</comment><comment><USER21> I found this to be a very intriguing read. Upon finishing it, I am _terrified_ of these drugs, _terrified_ of pharmaceutical companies, and _terrified_ of the cognitive dissonance in the study of mental illness. I would try absolutely anything before these drugs. It's a freaking nightmare, thrust into reality.

<comment><USER22> That's a shame. Most of these pieces are hysteria. Journalists and lawyers never go after people who seem to be fine with medication.

Here's hoping you don't have serious mental health problems in the future.

<comment><USER21> I definitely understand where you're coming from. Surely there are a lot of people that this stuff actually helps really well. In the past I did have serious issues, but I was able to bring myself out of it over time, by myself. And now, I have nurtured a far more stable and enduring mindset. :)

EDIT: By far the biggest part in me getting better was moving on to a different way of life. Basically, changing the set and setting. Which I think is underrated by the professionals described in this article, hence the problem:

 _Treating the symptoms, not their source._

</comment></comment></comment><comment><USER23> I was prescribed a benzo for insomnia and thought nothing of it.

I went from enjoying a good night's sleep to completely dependant on it just to function.

The only way to describe it was that I became "psychologically fragile" such as if things didn't go exactly according to expectations I would be in a state of panic and fear. It was horrible.

I decided then to go cold turkey (no one told me otherwise) and it was hell! I thought I would die or lose my mind. To say nothing of the electric shock sensations that were constant and the feeling that my skin was buzzing. After a couple months I felt like myself again and my mental fortitude had returned. I will never take another.

For me the benzo class of meds are way more dangerous than helpful.

<comment><USER24> I'm curious what type and dosis you were prescribed? (I'm an MD).

<comment><USER23> I believe it was temazepam. I do not remember the dose.

</comment></comment></comment><comment><USER25> This terrifies me. I've been trying to get up the nerve to talk to my doctor about my mental health for years now. I've been depressed on and off for a large portion of my life. I've always been really wary of pills though and reading things like this makes me worry even more. I wonder if the efficacy is actually there or if the withdrawal is worth it.

<comment><USER26> Look up the history of heroin, or methamphetamine. They both were marketed as safe in the early days.

Drug companies like to sell drugs like soda companies like to sell soda.

The conflict of interest is so awful that sometimes I wonder if we should ban for-profit drug companies.

<comment><USER27> History? We're still giving massive quantities of amphetamines to children, and massive quantities of opioids to large swaths of the country.

</comment></comment></comment><comment><USER28> Tapering off over the course of a few months or longer is especially important for benzodiazepines. Not doing so can lead to seizures or death. Luckily, it'll be pretty obvious to the patient if they are going too quickly and tapering slowly should lead to minimal side effects. Cannabis can also help some here. Unfortunately, most psychiatrists and doctors have no experience with this and will even discourage patients. Often, patients will have to just get a supply and do this on their own. [https://www.benzo.org.uk/index.htm](https://www.benzo.org.uk/index.htm) is a great resource of people who are doing this and probably the most valuable out there. Psychiatrists, in my experience, are not your friend in this process. They're the pill pushers and dope dealers. Of course they don't want their patients to taper off and discover a better life. Where would they get their money from if people stopped buying their bullshit about 'chemical imbalances?' What this industry has perpetrated on millions of people is downright inhumane, all so a few doctors and pharma companies can get rich. It is very possible, however, to taper off this garbage and get back to leading a normal life afterwards. That includes benzos, SSRIs, and other 'anti- depressant' garbage like Welbutrin. I know from experience. If this is something you want to do, don't let these vile doctors keep you addicted to their garbage and their bullshit, away from a real life.

</comment><comment><USER29> Well, haven't read through more than the first intro paragraph and whatever hollowness Miss Delano might have felt can be also attributed to the spleen of a comfortable yet purposeless life, planting daffodils and watching them wither.

With this I don't want to disparage her personal odyssey or that of people suffering from psychiatric difficulties, but the framing of this article is unfortunate. Very much

</comment><comment><USER30> I rarely comment on anything but this hits rather close to home. After a rather severe bout of depression my doctor started feeding me drugs. SSRIs, NDRIs, benzos, and a handful of misc other prescriptions that were the flavor of the week. I felt like every visit was a game of 'lets try this new drug!' which would lead to negative side effects more often than not.

Fast forward a couple years and I'm realizing that medications aren't the answer for me. So what do my doctors do? They try to push yet another pill or three down my throat. Finally I'd had enough of it and told them I didn't want to take anything anymore. Their idea of a tapering plan from over 2 years of medications was a week and a half. They were sure to tell me that if I stopped treatment I wouldn't be given any more refills and one doctor condemned me for even showing up to my appointment with the intention of discontinuing medications. He said I was wasting everyones time.

Anyway, I figured sure, I got this. I can get myself off these meds. I was very wrong. I made it about two weeks before withdrawals really kicked into overdrive. Dizzy, brain zaps, tinnitus, profuse sweating all hours of the day, insomnia, numbness in my face and arms, racing heart, involuntary muscle spasms... I started stuttering and couldn't force my body to stop twitching and shaking. My mind was completely fogged over and at times I couldn't even articulate words to talk to someone. It was a state of being in a perpetual panic attack multiplied by 100. After I thought I was actually going to die I setup an emergency appointment to try and get a prescription refill and a longer tapering plan only my doctors wouldn't have it. They flat out refused treatment and told me to go to the ER if I thought things were getting that bad. I was floored. Here this doctor got me physically addicted to powerful mind altering medications over the course of a couple years and now that I want out they treated me like a drug addict and dismissed me.

In the end I sourced some darknet meds and very slowly tapered myself down. To this day I'm still not even close to being back to normal, whatever that is. I get random panic attacks out of the blue on a daily basis. Sometimes the left side of my body will go numb. Other times I'll just start sweating while my heart beats like I just finished running a marathon. The ringing in my ears is horrible. I'm now extremely sensitive to stimulants of any kind (no more caffeine, meh) so I've had to make some significant changes to my diet.

The good news is I've been 100% off any medications for two months now and I'm finally getting to where I can get more than four consecutive hours of sleep several days a week (so much better than zero sleep every day). I feel as though being able to enjoy coffee, sugary drinks, and having the ability to actually sleep an entire night has been permanently removed from my life now.

At any rate, if there's anything anyone should get from all this rambling, it's that you should exercise extreme caution with pill pushing doctors. They have the ability to drag you into your worst nightmare of existence and leave you high & dry when you want the ride to stop.

<comment><USER23> I had the left side numb thing too! It was like a line ran down the center of my body and everything on the left side of that line was numb.

(I have a pet theory that some psych meds "de-integrate" the left and right hemispheres of the brain)

Dr. said I was crazy and it had nothing to do with the meds. Sent me for MRI for that and the "brain zaps".

Eventually the left side numb thing went away.

Good luck and wish you well!

<comment><USER30> Thanks, the tingling and numbness really does mess with ones head. It's disheartening just how out of touch a lot of healthcare workers are with prescription medication withdrawal. Glad to hear you're doing better.

</comment></comment></comment><comment><USER31> Prescription Cascade with psychiatric drugs is out of control. Seen it first hand. Had to step in and put a lot of pressure on doctors (and change doctors) to finally get my finance off the worst of the meds they had her on -- and finally "cure" her -- they just wanted to keep playing new drug musical chairs.

<comment><USER19> I've had similar experiences with myself. After high school I was prescribed two drugs in combination (Lexapro and Abilify) that helped me deal with and get a handle on my (serious) depression, and that was really easy. When I told them that I hated the way they made me feel and wanted to taper off of them once I was stabilized... that wasn't so easy.

At the end of the day I had to issue a sort of ultimatum: I was going to discontinue those drugs with or without their assistance, but recognized the risks of doing so and would prefer to do it with their oversight. I did it "against medical advise, but with medical supervision".

Years later I asked for and was once again prescribed Lexapro, but at a lower dosage and for a different issue. Apparently it was either Abilify or the combination of the two that caused my issues before.

<comment><USER32> The high mention of Abilify in the article and your comment makes me worried. I am currently on Abilify (10mg) for antipsychotic reasons. It seemed to be a "new generation" safer antipsychotic. Reading the Wikipedia article about it makes it sound a lot of research is unclear about the side effects.

[https://en.wikipedia.org/wiki/Aripiprazole](https://en.wikipedia.org/wiki/Aripiprazole)

<comment><USER17> Abilify is one of the least-bad of its class. But it doesn't address the metabolic problem that is at the root of psychosis.

Coconut oil, niacin/niacinamide (vitamin B-3), and other pro-metabolic interventions help get at the actual causes behind the diagnosis.

Coconut oil is helpful because it can be directly metabolized by the cells, whereas longer saturated fats have to be ... processed somehow before they can be used for energy (I forget the exact name of the step). Coconut oil is also helpful for alcohol cravings.

Cortisol deficiency is now associated with psychosis [0]. This is one of the manifestations of the metabolic problem at the root of the behavioral symptom (psychosis).

[0] [https://psychcentral.com/news/2016/06/04/low-morning- cortiso...](https://psychcentral.com/news/2016/06/04/low-morning-cortisol- levels-linked-to-psychosis/104266.html)

Sometimes metabolic problems are caused or amplified by emotional stress.

<comment><USER9> You can't cure psychosis with fucking coconut oil. PLease stop peddling this dangerous advice.

<comment><USER17> Your profile says you have some experience in the mental health world.

> You can't cure psychosis with fucking coconut oil.

The person I responded to said in a later comment that his psychosis was related to alcohol use. This being the case, coconut oil is an appropriate treatment to help keep his alcohol use under control.

> PLease stop peddling this dangerous advice.

People like HN user clydethefrog (above) and my girlfriend (my comment history) are hurt by the mental health industry's standard of care. Someone probably told clydethefrog that he has now has a chronic condition and that he'll have to be on "antipsychotics" for the rest of his life to keep from becoming psychotic again.

One case study acknowledges the possibility that people who made themselves psychotic through alcohol withdrawal can be made delusional with Abilify [1]. The actual experience of patients is that maintenance antipsychotics makes their condition worse [2].

I think in the very near future the mental health system will have no choice but to listen to the resistance's complaints.

[1] [https://europepmc.org/abstract/med/26502575](https://europepmc.org/abstract/med/26502575) \- "At first, we regarded all the symptoms as alcoholic hallucinosis, by a clinical standpoint, in spite of no auditory hallucination in this case. However, taking the overall clinical course into consideration, withdrawal syndrome could have been affected by some factors. _One of the possibilities is that delusion might have been induced by aripiprazole._ " (emphasis added)

[2] [https://en.wikipedia.org/wiki/Tardive_psychosis](https://en.wikipedia.org/wiki/Tardive_psychosis)

</comment></comment></comment></comment></comment></comment><comment><USER33> "Lamictal, a mood stabilizer; Lexapro, an antidepressant; and Seroquel, an antipsychotic that she was told to use as a sleep aid."

Lamictal and Seroquel can cause an often permanent condition called tardive dyskinesia[1]. Basically the dopamine receptors tend to permanent up scale leading to sleep disorders. This is fairly unique compared to most Psychiatric drugs out there.

[1]: [http://www.onlinelawyersource.com/tardive- dyskinesia/seroque...](http://www.onlinelawyersource.com/tardive- dyskinesia/seroquel)

<comment><USER34> Dopamine blockade isn't significantly induced by doses of Seroquel used for sleep. Although it and its metabolites do have action at certain dopamine receptors, lower doses will first occupy other receptors that they have a higher binding affinity for. Its metabolites are partial agonists at 5HT1A autoreceptors that induce downstream release of dopamine, which theoretically reduces the risk of tardive dyskinesia from direct dopamine blockade.

If you're curious about this, Stahl's Essential Psychopharmacology textbook goes into detail about this and is written in a way that some idiot (me) on HN can grok it.

<comment><USER33> > Dopamine blockade isn't significantly induced by doses of Seroquel used for > sleep.

True at typical low dosages.

I have been on Seroquel at very high dosages for sleep and the doctor gave me the explanation above. I have after multiple attempts failed to taper off of it. I have even tried liquid. I will definitely check out the book. The key issue being that the receptor up scale permanently.

</comment></comment></comment><comment><USER35> Does depression go away after a while if taking meds? Or does the person having depression need to take meds for the rest of his/her life to avoid relapsing?

<comment><USER20> Depends on whether the depression is situational. People don't like to admit that sometimes people are sad because their situation, and not because of something inherent to themselves. Sadness -- even persistent sadness -- can sometimes be a healthy response to an unhealthy environment, that drives you to try and change your situation for the better.

The problem is when the sadness becomes the crippling kind that prevents you from acting to change the situation that's making you sad to begin with. It can be helpful, I think, to take anti-depressants long enough for you to be able to enact positive change in your life.

My wife was taking anti-depressants as she finished up college, then she went traveling, met me while we were both backpacking, we got married, have two kids. She weaned off the anti-depressants while we were engaged. She gets transitory anxiety attacks every once in a while, but she's told me she's never had a relapse of depression. I think she was just bored and lonely and stressed in college -- a temporary situation.

This is all just my personal opinion, i'm not a psychiatrist.

<comment><USER36> >Sadness -- even persistent sadness -- can sometimes be a healthy response to an unhealthy environment, that drives you to try and change your situation for the better.

Depression is sort of different than generic sadness as it DOES NOT drive you to improve your situation, due to the severe hopelessness it causes. It's the massive problem with depression, and why medication can be so helpful. Depression can cause you to stop functioning, even at your situationally reduced level, essentially fucking you over even worse.

As you show, it was an external event that kicked your wife out of her rut. Sometimes that required kick is helped by medication

<comment><USER20> I don't disagree. I think people are too often diagnosed with depression when they're actually having a normal reaction to a bad situation, but I'm very familiar with the kind of depression that is long standing and seemingly unconnected with your current situation. I was just trying to give an example of how medication could only be needed temporarily.

</comment></comment></comment></comment><comment><USER37> Supplemental iron and magnesium saved me. No more GAD, panic attacks, night sweats, or insomnia, and no more RX drugs!

<comment><USER38> Can you elaborate a bit? I'm looking into supplements as well to replace or enhance my meds</comment></comment>


Dragdealer JS - <AUTHOR> http://code.ovidiu.ch/dragdealer/ Dragdealer, a drag-based JavaScript component that embraces endless front-end solutions <comment><USER2> I really like the demo/tutorial style: \- it shows quickly and easily what the library can do \- it shows it from really simple example to more complicated one \- it gives enough details to understand what the option and the code are doing while not over explaining it since if the user wants to know more he could go look the documentation.

</comment><comment><USER3> Awesome work - anyone see a list of which browsers are supported?

<comment><USER4> All I've tested on, even IE6.

</comment></comment><comment><USER5> This is impressive, clean interface, well thought out. I'll be keeping this for future projects.

</comment><comment><USER6> I initially read this as drugdealer

</comment><comment><USER7> Works remarkably well on the iPhone too.

<comment><USER8> Yes, _remarkaby_ well!

</comment></comment><comment><USER9> In the vertical scroll bar, if you drag a little up and down and at the same time move the pointer right outside the browser window onto the desktop, you can still scroll. The behavior seems strange to me, but perhaps it is typical. (The browser is Safari 5.0 on MacBook with OSX 10.5.8)

</comment><comment><USER10> Works really nicely on my Droid, well done!

</comment><comment><USER11> Doesn't do anything on Firefox 3.5.3 on OSX :/

<comment><USER12> The red sliders were also not working for me on OS X w/FF 3.6.3 though the slideshow and canvas mask demos were. Figured I'd try with Chrome and Safari and the red sliders didn't work there either.

After I reloaded the page in Firefox, they are working on all 3 browsers. Kind of baffling.

I know how frustrating "doesn't work" is as a bug report but I can't give a lot of detail since it all works now. When it wasn't working, "dragging" would just select text on the page. The "draggable" red sliders would not move.

<comment><USER4> If dragging would just select text on the page that means that the script was has not even initialized. Something was blocking the JavaScript to run at all.

</comment></comment></comment><comment><USER13> iPad support!!

<comment><USER14> Why is this exciting? I am pretty sure that iPad should be able to run any web page that Safari can run, provided the resource requirements are not too high and the features used are non-experimental (e.g. WebGL).

<comment><USER15> It's unusual for web drag-drop stuff to work well on mobile Safari. It takes care to do it right. E.g., worldoftext is unusable on an iPad (weep!) for drag related reasons.</comment></comment></comment>


Show HN: PDF Assembler – client-side PDF editing - <AUTHOR> Here's a neat hack I made recently to do basic PDF editing directly in a browser—without having to upload anything to a server.
I was initially looking for a way to do simple PDF modification (extracting pages, merging, and adding page numbers). There are some good server-side tools for this (QPDF, PDFTk, PDFBox, iText, Hummus), but for better speed and privacy I really wanted a 100% client-side solution.
There are a few good JavaScript PDF libraries for reading and displaying PDFs (pdf.js) and creating PDFs from scratch (jsPDF, PDFKit), but I couldn't find any for editing existing PDFs. So, I did what any self-respecting hacker would do, and rolled my own. :-)
Actually, I found out that Mozilla's pdf.js solved half the problem, as it does an excellent job disassembling PDF files. So all I had to do was figure out a way to put them back together again.
The result is PDF Assembler, now available on GitHub and NPM. I also put together a demonstration site (https://www.pdfcircus.com) which shows some examples of what it can do. I know PDF Assembler still needs some tweaking, but I think the basic idea is sound, and so far I've been pretty happy with how it works.
Please take a look and let me know what you think.
Thanks!
PDF Assembler Links:
Demonstration Site - https://www.pdfcircus.com
GitHub - https://github.com/DevelopingMagic/pdfassembler
NPM - https://www.npmjs.com/package/pdfassembler <comment><USER2> Awesome! I will totally use this. Love that I don't need to upload them to some unknown server. Although macOS preview lets you merge PDFs by dragging and dropping, but not more complex editing.

<comment><AUTHOR> Glad to hear it. If you have any problems, or additional features you'd like to see, please post an issue on GitHub.

[https://github.com/developingMagic/pdfassembler/issues](https://github.com/developingMagic/pdfassembler/issues)

Thanks!

</comment></comment><comment><USER3> I am using a tiling window manager and do not want to pop up dolphin, is there any way to upload a file without dragging?

<comment><AUTHOR> Not yet. That's been on my to-do list, but I didn't know how important it was. I'll move it to the top of my list and post agin once it's fixed.

Thanks for the feedback!

<comment><AUTHOR> OK, I've added an "Add PDF" button to open a file select dialog, which should let you load files without drag-and-drop. Please let me know how it works for you.

Thanks.

<comment><USER3> great. love it.

</comment></comment></comment></comment><comment><USER4> Minor typo on pdfcircus.com

—wihtout uploading to a server

<comment><AUTHOR> Fixed. Thank you!

</comment></comment><comment><USER5> That looks super helpful. Thanks!

</comment><comment><USER6> > _There are some good server-side tools for this (QPDF, PDFTk, PDFBox, iText, > Hummus)_

Fake news! QPDF[0] can work offline on local PC - just download AppImage and execute it on your Linux desktop!

> _but for better speed and privacy I really wanted a 100% client-side > solution._

Think, you mean "offline solution", because "client-side solution" is always mean that is part of some "online service".

[0] [https://github.com/qpdf/qpdf/releases](https://github.com/qpdf/qpdf/releases)

<comment><AUTHOR> Nope, I definitely meant "client-side solution".

I wrote this library to work as part of an online service to help lawyers assemble Exhibits (www.magicexhibits.com).

The first version of that site uploaded everything to a server, where I used QPDF and Hummus to put everything together into a big .pdf, then downloaded the result. It worked, but it was slow.

The second version used an Emscripten encoded version of qpdf[0] to move part of the processing client-side (meaning into the browser), which made the processing faster. But even after compressing as much as possible, the Emscripten qpdf.js was 4mb, which made the site load time much slower.

So, finally, I wrote PDF Assembler, which loads fast and does almost all of what I need. If someone loads a document I can't process with JavaScript alone, like a .docx file, I still have to send that to a server to convert to a .pdf. But PDF Assembler does the majority of the processing right in the browser, which makes the site a LOT faster. And, as a nice side effect, our users like the improved privacy protection, because as long as all their input files are .pdfs, those files never leave their computer.

Personally, I use QPDF on the command line (in OS X) quite a bit, and I've also used PDFTk and Hummus on my local computer. But our users aren't as computer savvy, so it was important to make a solution for them that was as simple as possible - meaning one that didn't involve downloading and installing any software. So an SPA is an ideal solution for them, and an SPA that uploads as little as possible to the server is even better.

[0] [https://github.com/jrmuizel/qpdf.js](https://github.com/jrmuizel/qpdf.js)</comment></comment>


Open-source medical devices: When code can kill or cure  - <AUTHOR> http://www.economist.com/node/21556098?fsrc=scn/tw_ec/when_code_can_kill_or_cure

<comment><USER3> I work primarily in the field of healthcare information security.

Although this article does go a little bit into the realm of hyperbole--as HN commenter 'excuse-me' pointed out, not every single aspect of medical equipment is even remotely capable of interfering with patients--there is a serious security risk with networked devices that most people do not understand.

The article pointed out the McAfee research on insulin pumps. Yes, these devices were hacked and could potentially kill a patient. This was a complex application attack, that while serious and _certainly_ something that should be addressed, has a very high level of sophistication. For example, if one was trying to kill a patient, they would need physical (or very-close networked access) to the device. At that point, is it easier to write exploit code or simply kill someone? These are morbid thoughts, but it's also a requirement to think of the actual use case. _Please_ keep in mind that I'm not trying to understate the seriousness of these findings, or others like them: we _absolutely_ need to step up security in the healthcare field. It's a mess, and frankly makes me feel uncomfortable every time I'm in a hospital.

But let's talk about things that are even simpler than the insulin pump attack. When I send engineers on-site to hospitals, we need to specifically _exclude_ BioMed network devices, as well as anything that's connected to a patient (even through a couple of hops) for even simple network scans (nmap, etc). Why? Because even just running a contemporary port scan has a tendency to overflow device state tables/networking stacks and crash the device. Let me reiterate: just _scanning_ the device, without any security checks or attacks, can take a device offline.

You might think that devices such as these are protected from attackers by other security controls; that if someone has networked access to an internal network, that it's game over anyway. Well, yes and no. Part of the problem in healthcare information security is that hospitals and healthcare providers have thought almost exclusively about the _physical_ security of their facilities for far too long. Sure, there are security guards in place, but how does that help when the Emergency Room "guest wifi" is bridged to the internal network? What about when there are live Ethernet ports in visiting rooms or, again, the ER? These are real problems that we're trying to find and resolve, but it's more of an industry-wide change of vision than a couple of holes we need to plug. Even the security of the internal network itself is generally a disaster (missing patches, unorganized security departments, etc). It's our job to resolve these issues, and although I'm just a _little_ biased, it's not super hard to do on a _hospital-by-hospital basis_. It gets a lot tougher when we're talking about a pan-industrial change.

Which is where, in the U.S., the government steps in. HIPAA compliance forces these checks to be done on a regular basis--although the tendency for hospitals to save money by getting a "checkbox compliance" scan from an automated vendor instead of having a real team of security engineers conduct analysis is still very strong. HIPAA is focused mainly around protecting electronic protected health information (PHI), but the HITECH Act and "meaningful use" allows healthcare organizations to actually _receive_ money from the government for staying in compliance while using ePHI (instead of paper records) for a large percentage of their health records.

We've got a long way to go, but the healthcare industry is steadily improving. That said, don't be too quick to discard remarks about the security of hospitals and your medical data: right now, a complete medical record is worth more on the black market than a credit card number. Keep that in mind next time you see Windows NT machines while getting your annual check-up.

<comment><USER4> > a complete medical record is worth more on the black market than a credit > card number.

Whoa! I had no idea. Why are complete medical records valuable on the black market?

<comment><USER3> I think the reasoning behind this is that credit card numbers have a very low life expectancy after they are leaked. One or two fraudulent charges, and the CC# is generally cancelled.

Medical records, however, usually include full personal details (address history, medical history, SSN, phone numbers, etc.) and by definition can't be changed. Therefore, should someone access this data, there is a whole range of fraud and identity theft that can be executed. Most people don't have credit monitoring services, and it's way easier to _take out_ a fraudulent credit card and rack up charges that will never be detected (until some of the bills go through or the credit card defaults) than it is to use a legitimate one.

So, it's not the medical data _per se_ , except maybe blackmail or insurance fraud (not common), but more generic identity theft. PHI is basically someone's whole identity in a file!

<comment><USER4> Ah, I see. Makes sense. Thank you!

</comment></comment></comment></comment><comment><USER5> _"My dream", says Dave Arney, a researcher on the project, "is that a hospital will eventually be able to print out an infusion pump using a rapid prototyping machine, download open-source software to it and have a device running within hours."_

What can I say; dare to dream. Because that's what this is - a dream.

Print out a pump? OK. Was the 3D printer's performance to all relevant specs validated? Were the materials it uses approved and inspected along with their certificates to be sure the pump was being made from the material the designer specified? Was the material stored properly before use and was the pump it printed tested to ensure that it met all its requirements?

The software is probably easier to handle, surprisingly. The FDA probably wouldn't care that it was open source, but would the OSS developers be willing to follow a validated process, document that they are following the process, submit to random audits of that process being followed?

Who handles customer complaints? FDA requires that a Medical Device manufacturer have a procedure to record and respond to customer complaints and comments in a timely fashion. If a physician notices that every morning at 8:00AM the pump puts out an additional 5%, who will log that concern and investigate it. If it requires a recall, how do you even recall something you can't track since people are just printing the pumps out as they need them.

The Medical Device industry is screaming for innovation and I hate to be a party pooper, but this is a dream. And unfortunately, it will remain a dream for very good, common sense reasons.

<comment><USER6> I cannot think of a single objection you have raised that is to do with 3d printing rather than to do with quality control and process tracking, and quality control can be made far easier with 3d printing as you can change production as soon as a fault is discovered, so you don't end up with a warehouse full of a million faulty pumps.

And tracking could be achieved by embedding rfids mid-print without a problem.

<comment><USER5> The problem isn't with the 3D printing itself, it's with an end user (the hospital) that doesn't have manufacturing skill and 21CFR knowledge printing off a medical device. It's a nice idea, but the FDA would have a change a huge amount before something like this has a ghost of a chance.

<comment><USER6> There is always the rest of the world, and given they are already using it for bone replacement - <http://www.bbc.co.uk/news/technology-16907104> \- I don't see what the issue is for pumps.

[edit] Also, remember that the end users at this stage are medical geeks of a level of educational qualification that would put the vast amount of people working in software to shame. Some of these people are already making _organ printers_. I'm sure they can work out medical good practices for in-house manufactured parts and get it approved in most of the world, especially when the full benefits of custom parts as fast as possible becomes apparent.

</comment></comment></comment></comment><comment><USER7> I think it's interesting that reporters are still using the Therac-25 as their go-to example of medical software harming people.

I'm pleasantly surprised that we haven't had a bunch of more spectacular examples since then.

</comment><comment><USER8> These guys at the Generic Infusion Pump project should partner with vTitan and put up a Kickstarter page for a cheap infusion pump with open source software (or maybe vTitan could do it themselves), if it's the type of device people might buy directly. Many in need would love to sponsor this type of advance while securing early access for themselves, since they are so acutely aware of the device's value.

<comment> excuse-me And, their funders, their pets and everyone their funders know will be sued into poverty as soon as it's announced.

I met a company that was going to make a powered wheelchair. At the moment your choice is a manual chair or a big heavy expensive and complex mobility scooter - like you see fat/lazy people using in Walmart.

Their product was a smart power assist that gave you an automatic extra push on kerbs, ramps etc but could be cheaply bolted onto an existing manual chair. It had sensors that measured the force you were pushing with, the chair angle, speed etc, along with modern brushless DC motors and laptop batteries.

Then they hit FDA. There is no FDA approval class for accelerometers - <USER2> has ever made a medical device using accelerometers so not only would they need their device tested and approved they would need to prove "equivalency" for a mems accelerometer. Apparently General Relativity and Mach's principle isn't enough for the FDA.

They did propose simply opensourcing the design for anyone to build but were told that if anyone did build one they would be essentially in the same legal position as publishing instructions for making illegal drugs!

In the FDA's eyes telling someone how to make an affordable electric wheelchair = running an meth lab.

<comment><USER8> I could certainly see the FDA obstructing _novel_ products without prohibitively expensive studies, but wouldn't it be significantly cheaper to demonstrate equivalence to existing devices?

<comment><USER5> Yes, it would. Problem is that "significantly cheaper" means it costs $1 million instead of $5 million.

<comment><USER8> $1M+ might be in the realm of the attainable for a Kickstarter project, assuming the device has a sufficiently wide usage. The estimated cost of approval would need to be included in the funding goal.

[If the same studies might be used to seek approval in several countries at once, then it might make such an approach to funding medical devices more attainable for the size of their market. The missing piece of the puzzle seems to be an affordable method for conducting studies to get medical devices approved.

It seems like the industry is highly vertical, with difficult access to financing and compliance infrastructure. This might be an opportunity for a service provider to come in, establish a selection process for clients, partner with universities around the world to conduct studies to the specifications of US FDA, and its EU, Canada, Japan, etc. equivalents' approval, and help store and file the needed paperwork in exchange for a cut of sales.

Maybe it's also time for the UN to create a world body for standards of approval of medical technology which all these nations should recognize; or maybe ISO should take that role.]

</comment></comment></comment></comment></comment><comment> excuse-me The situation in the US is insane. Yes there are systems, like radiotherapy machines or pacemakers, that need to be developed and tested to Nasa like specs

But the FDA take the approach that anything medical is life threatening. It's as if the FAA demanded avionics approval for the point of sale machine in the McDonalds at the airport

You cannot use a camera on a microscope in the US for medical purposes, there is no approval and there won't be because the first company to do so has to prove beyond all doubt every concept of the camera, computer and display operation. Not just of their specific device - you have to prove that a camera is equivalent to an eye in basic principles. Then once you have done that every other maker can come on your coat tales.

That's why in europe your cervical smear test will go through an automated scanner which uses state of the art image processing to examine every single cell - and quickly enough that the entire population (or at least the half with a cervix) can be screened.

In the US it will be looked at for 5mins with 50year old eyes with a 30year old microscope by a doctor who will then guess (sorry use his years of experience) to decide.

Strange really - I don't imagine the FAA would accept an aircraft maker saying that they don't use CFD tools or computers but old Billy has a certificate saying he went to engineering school and so can estimate the load in a carbon fibre turbine blade by eye.

<comment><USER9> Have a look at the FDA Guidance for pre-market solutions, they categorise device into 3 levels, major, moderate and minor.

The minor level is for software that is unlikely that serious injury or death will result from the software:

[http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidanc...](http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm089543.htm#6)

<comment> excuse-me IIRC anything that is a `therapeutic outcome` (?) is automatically the life- or-death class

So a computer screen that display a result the doctor relies on must be a medical grade screen</comment></comment></comment>


The Long Tail of Hardware - <AUTHOR> http://amandapeyton.com/blog/2013/10/the-long-tail-of-hardware/

<comment><USER3> Her point 2 is interesting. It has long been to the great bafflement of Westerners why Sony's software is so bad. You will know what I mean if you ever tried to use Sonic Stage for your MP3s. And the reason is in the West we expect(ed) to have the PC as the hub into which we would plug everything to manage it. Whereas in Japan, your camera would just print directly to your printer and that was that, so in their home market Sony never had to learn to write software for PCs. Anyway, we might be seeing something similar happen here too now.

<comment><USER4> I don't think that's the whole story, given that the software that runs on their devices isn't much better...

<comment><USER5> I don't have time to find the link right now; but, if you google around a bit, you can find articles (one, I believe, from Cringely) that points out that Sony's dominance in many areas was during an era of primarily mechanical electronics. That's a very different skill set than computer hardware / software based electronics. A skill set that, presumably, Sony never fully developed.

</comment></comment></comment><comment><USER6> I think hardware goes in phases. First there are 1 or 2 products that define the category. Then it explodes into 100s of competing products, all with a slightly different take. Then it matures and contracts back into a few.

Right now we are seeing diversity smart phones contracting -- I think we'll be left with iPhone and Samsung. The majority of PC makers are struggling to survive. Portable audio market was pretty much just the iPad. There is a short window when margins are high enough for lots of experimentation and lots of companies to survive.

I think the smart phone accessory market will explode for the next 2 - <USER2> years, a few key products will emerge and the rest will fade away. Consumers can only handle the excitement for so long before they get tired keeping up and just buy the status quo.

</comment><comment><USER7> I think there is a vast world of difference between many different iPhone speaker companies and the evolution of the Internet of things. Hardware's long tail lives not in small run funky devices but in common cheap sensors to track our everything and in power, ease and education coming together to allow anyone to build their own devices for their own needs in a weekend DIY

</comment><comment><USER8> I think the long tail of hardware is becoming more viable just by virtue of the fact that it is easier to presell and prepromote a product without risking a large up front order. That changes the game in a lot of ways.

I'm not sure that demand has changed so much as the changing cost going to market.</comment>


Operation KKK Is Beginning to Unmask Hate Group Members - <AUTHOR> http://techcrunch.com/2015/11/01/operation-kkk-is-beginning-to-unmask-hate-group-members/ <comment><USER2> 4 US Senators and 5 US Mayors are allegedly on the list ([http://pastebin.com/Yh2muT9r](http://pastebin.com/Yh2muT9r)). Not much evidence besides taking an anonymous person's word for it though.</comment>