Sunday, July 29, 2012

"Patients may initiate communications with a provider using e-mail. If this situation occurs, the..."

“Patients may initiate communications with a provider using e-mail. If this situation occurs, the health care provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual. If the provider feels the patient may not be aware of the possible risks of using unencrypted e-mail, or has concerns about potential liability, the provider can alert the patient of those risks, and let the patient decide whether to continue e-mail communications.”

- Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients?

Posted on infosnack.

Friday, July 27, 2012

thedailywhat: This photo was taken in New York, which, along...



thedailywhat:

This photo was taken in New York, which, along with most of the East Coast, is experiencing a bit of a storm problem.

Weather.com is liveblogging the extreme event, describing it as a derecho. What’s aderecho? They explain:

Derechoes are large clusters of thunderstorms that produce widespread wind damage, usually as a result of one or more curved lines of thunderstorms known as bow echoes.

Stay safe, everyone!

[weather.com]



Posted on infosnack.

Dark Skies app.



Dark Skies app.



Posted on infosnack.

Thursday, July 26, 2012

Nice piece by CBS News on Jay Parkinson’s Sherpaa. (If you...



Nice piece by CBS News on Jay Parkinson’s Sherpaa. (If you watch closely, you can spot my photo.)

(via Doctor’s company reimagines health care delivery - CBS News)



Posted on infosnack.

Tuesday, July 24, 2012

"Much respect to the medical intern writing her hospital patient notes in Markdown."

“Much respect to the medical intern writing her hospital patient notes in Markdown.”

- @joshuaschwimmer

Posted on infosnack.

Sunday, July 22, 2012

Alan Adler's AeroPress Calculations

Alan Adler's AeroPress Calculations:

> Hi All, Someone asked, “How Many AeroPress Scoops to the pound?” The answer is about 38. Here is some coffee math that I posted on the coffeegeek forum about a month ago: A level AeroPress scoop of beans or grind weighs approximately 12 grams (sometimes a bit less). Over the past four decades, several coffee researchers, including Ted Lingle of the SCAA (Specialty Coffee Association) have found that the best flavor results when coffee is extracted at a rate of 20% and diluted to a strength of 1.25% coffee in water. When you use the AeroPress as directed with fine drip grind and 175F water filled to the top of the 2 oval, you get 20% extraction. Following these recommended guidelines for two scoops (24 grams of coffee) we get: 20% extraction = 0.2*24 = 4.8 grams of coffee extracted from the grind. 1.25% brew strength: 1/.0125 = 80 grams of diluted brew per gram of extracted coffee. 80*4.8 = 384 total grams of brew, or 13.5 ounces. However, you don’t get to drink all of that because with all brewing methods some of your brew is trapped in the damp grounds. That reduces the drinkable brew to about the volume of an average 10-ounce coffee mug. The lower bitterness and acidity of the Aero lead many users to prefer a richer brew than the SCAA standard of 1.25%. So if your two scoops of coffee are diluted to an 8 ounce Americano, you’ll probably like it even more. Best regards, Alan.

Nerdy coffee stuff for future reference.



Posted on infosnack.

lovagemetender: Dag Hammarskjold Greenmarket, Wednesday July...


cranberry beans


fresh shallots


japanese eggplant


corn


fairytale eggplanbt


purple and white eggplant


pasilla and hungarian hot wax peppers

lovagemetender:

Dag Hammarskjold Greenmarket, Wednesday July 18.  In one day we went from near 100 degree temperatures to total downpour.  Standing under the tent we were soaked by rain that seemed to be coming at us sideways.  We couldn’t even see to the end of the block.  Despite the drought (somewhat eased by today’s rain) I’m totally thrilled to be in the thick of our summer season.  The peppers are particularly spicy because of the heat - pasillas and hungarian hot wax, frying peppers, jalapenos and serranos.  We seem to be overflowing with eggplant - purple, white and rosa bianca, fairytale and japanese.  The tomatoes are just beginning to come in, so I’m sticking to sun golds for now.  And the first of the shelling beans - I think tomorrow I’ll make some cranberry beans with bacon and sage.  With a little more rain and a touch of luck we’ll have watermelons before too long.



Posted on infosnack.

iPhone Home Screen



iPhone Home Screen



Posted on infosnack.

How to fix Chrome in ten seconds

How to fix Chrome in ten seconds:

thisistheverge:

David Pierce throws down some pro tip heat in the forums:

Go to the wrench menu > Settings > Show Advanced Settings > Content Settings (under Privacy) and then scroll down to Plug-ins and select Click to Play.



Posted on infosnack.

Saturday, July 21, 2012

DNA Art.



DNA Art.



Posted on infosnack.

by zeldman http://instagr.am/p/NWnsD3Of56/



by zeldman http://instagr.am/p/NWnsD3Of56/



Posted on infosnack.

Indigo tomatoes at Maxwell’s Farm. (Taken with...

Indigo tomatoes at Maxwell’s Farm. (Taken with...:

tumblr.com



Posted on infosnack.

inothernews: CLOUD CITY   From a jet plane 10,000 feet above,...



inothernews:

CLOUD CITY   From a jet plane 10,000 feet above, former NFL player Dhani Jones snapped this photo of a thunderstorm wracking New York City.  Though it may look familiar, the National Weather Service says no tornadoes struck the area — “just earth-shaking thunder, a downpour that dumped 1.7 inches on Central Park within an hour, more than 500 lightning flashes every 15 minutes, and one-inch hailstones,” according to the New York Daily News.  (Photo: Dhani Jones / Twitter via the Daily News)



Posted on infosnack.

100 Tips for Doctors on Call (Part 2)

The following post initially appeared in The Efficient MD. It demonstrates the unexpected power of blogs and Twitter for soliciting advice from large groups of people with specialized knowledge.]

Addendum: For the most recent version of this page to which you can add your own advice, visit The Efficient MD Wiki.

Have a printout of every patient you are covering in your pocket. “Keep to do list with check boxes next to each items. Write down tasks to be done at a particular time. For example, check labs on Mr. X, Mrs. Y, and Z at 2200. Keep commonly used numbers on the sheet or handy in your pocket (other residents, cardiology fellow, common hospital floor numbers.)” (Mark Johnson)

When “cross-covering” a patient, write down everything you do. (Mark Johnson)

Reevaluate your templates. Being on call is a stress test of the system.

Bring your favorite foods from home. “I bring 2 bottles of water and 2 sodas each weekend call. I like to bring ~6 sandwich bags of sliced cheese, crackers, nuts, carrots, dry cereal to snack on throughout the night, also a few chocolates makes the night.” (Mark Johnson)

If you’re staying overnight, stuff a call bag. One resident’s call bag includes a medical book, non-medical book, travel-sized deoderant, toothbrush, toilet paper, fresh pair of scrubs, undershirt, and underwear for the AM. (Mark Johnson)

Carefully choose your pocket resources. For residents, consider Massachussets General Hospital’s “Blue book,” Tarascon’s Internal Medicine/Critical Care, and Tarascon’s Pharmacopia. (MarkJohnson) I also liked On Call: Principles and Protocols.

Treat your call day just just like a regular work day. “I go through my same routine. I don’t come in later, but rather at my usual time. I avoid nurse signout time (7am at our hospital) and I start with the most critically ill.” (Nephron129)

Write as you talk on the phone. You may often be put on hold or on a phone call which doesn’t require your full attention. Make productive use of this time. Write notes, check labs, or do other activities. The general principle is that there should be no downtime unless you want it.

Knock on the door (or the wall) before entering patients’ rooms. Even when you’re at your most harried, be polite. Patients will appreciate it, and when you do have time, being polite will be second nature.

Write standing. If you find that your energy is flagging, or that you your notes are overly lengthy, experiment with writing standing up.

Always keep a stack of business cards handy. Good advice generally, but especially while on call. You never know when a new patient or physician will ask for your card.

Find that zone of maximum benefit. Avoid defensive medicine, too much writing, and too much testing. The curves for you and for your patient are different.

Be kind. Say kind words to people who can’t understand or hear you because they are unconscious. (Sometimes, they can hear you.)

Watch your body language. Face patients. Smile. Don’t rush. Don’t hunch your shoulders.

Have your fellow pre-round on everyone. Then come in at 8. (Huck)

Change up your routine. Start at a difference place in the hospital. Write with a different pen. Consciously alter large or small parts of your usual routine.

Some institutions film you. Be aware of how you appear. (Anonymous)

nephron129 said…

The best piece of advice for weekends on call came from one of my mentors. The people who are the most bitter are those who think that just because it’s a weekend that somehow they can still make plans to attend some event in the early afternoon.
I try to avoid socializing but I also try to recognize when I’ve hit the wall and I need a break. I try to take 10-15 minutes to recharge in the late morning and then again in the early afternoon. It sounds silly but getting nourishment is important too. If you remember back to your intern days, you usually had a snack in your pocket or at least knew where the food was on the nursing units.
Just some thoughts.
Anonymous said…
MAKE SURE YOU KNOW WHERE THE PATIENTS ARE IN THE HOSPITAL:
WE HAVE A RATHER LARGE HOSPITAL. IT’S IRRITATING, AND TIME-WASTING, TO GO TO THE ICU TO SEE MRS X, ONLY TO FIND THAT SHE’S JUST BEEN TRANSFERRED TO THE REGULAR NURSING UNIT — USUALLY THE ONE YOU WERE JUST AT — WHICH IS THE EQUIVALENT OF 2 BLOCKS AWAY. SOMETIMES, EVEN THE PHYSICIAN SIGNING OUT TO ME MAY NOT KNOW THAT HIS/HER PT HAS BEEN OR WILL BE TRANSFERRED.
WE ALSO HAVE A TERRIBLE HOSPITAL EMR WHICH ITSELF MAKES IT HARD TO FIND PATIENTS, SO WE HAVE TO BE SURE THAT SIGN-OUTS AND CONSULTS GIVE US PATIENT’S EXACT FULL NAME. EG IF I WERE TOLD (ON THE PHONE) TO SEE A HARRISON BROWN, BUT HE’S REALLY HARRISON BROWNE, THIS EMR SYSTEM WOULD SIMPLY TELL US NO HARRISON BROWN IN SYSTEM — OR WOULD GIVE US INFO ON WRONG PT.

FINALLY, MAKE SURE THE PT STAYS IN THE ROOM WHEN YOU’RE ON YOUR WAY. TELL NURSES TO VERIFY HE’S IN HIS ROOM AND KEEP HIM THERE. I’VE SOMETIMES GONE TO SEE A CONSULT (IN THE A.M.) FOUND, UPON ARRIVAL, THAT PT WAS DOWN AT MRI AND WOULDN’T BE BACK FOR AN HOUR, AND HAVE THEN HAD TO COME BACK LATER IN DAY (OR EVENING) TO DO WHAT I INTENDED TO DO AT 8 A.M. KEEP PT IN ROOM; THEY CAN DO THE MRI OR WHATEVER AFTER YOUR EVAL, UNLESS IT’S REALLY URGENT.
Huck said…
“Check in with your significant other EVERY call-night, set aside a time to talk, or at least text saying when you will call. They are lonely, and you get so busy that you can easily forgot.

Things I would like to implement
- “Jott” notes to myself to keep todo list on iphone
- Carry the hospital’s cell phone (I found it took bulky, and phones are about everywhere)
- however if you do a lot of “page & run” its great to be able to page to cell phone, the uber-busy neurosurgeon residents are great @ this”
Theresa Chan (Rural Doctoring) said…
Physical survival on call

* Before call, determine food strategy. Some hospitals have horrendous food, residents almost always know where to call for delivery, etc. but bring food if you want alternatives/healthier stuff to eat.
* Sleep when you can:
o Even if you only have 5 minutes, it might turn into 20 minutes or an hour
o Don’t be picky about where you nap—call room might be far away from where the action is. Nothing wrong with napping on a loveseat, 2 rolling chairs, the floor…
o Don’t sleep on top of your pager if it is on vibrate mode, you probably won’t feel it.
* Caffeine is helpful up to a point but drinking plenty of water or Gatorade is better for the long haul. You won’t feel as seedy/sick after you get off call.
* Choose good shoes. Your feet will ache after being up for 24+ hours. Running shoes are good for some, clogs for others. Make sure they have good support and shock absorption. Some people wear TED hose.
* Bring a toothbrush. You will feel more human after freshening up.
* Bring Artifical Tears. Eyes feel weary and dry in the hospital at 0300.
* Apply deodorant before call. Please.

Call Team Strategies

* Before calling the attending/cardiologist/nephrologist, etc., page the rest of your team to see if they have to speak to the same person. Saves redundant beeps and attendings will be less grumpy as a result.

Cross-cover

* Have signouts on you, whether electronically or on paper. Make sure signouts are complete when you receive them.
* If there are labs to check on signout, make sure you check them. Also make sure the resident signing out tells you what to do with abnormals.
* If you’re cruising around the wards/units, you might as well check in with the charge nurse to see if there are any questions/PRNs needed so you don’t get beeped as soon as you leave. Similarly, if you get called to one ward, ask “Does anybody else need to speak to me?” before you get off the phone.
* Expect the most floor calls as soon as a new admission gets to the ward.
* Have strategies for the most common calls: fever, low/high bp, agitation
* Be nice to RNs when they call, but be clear about the info you need for specific questions, so they will learn to have that info ready when they call in the future. For example: if they are calling about hypertension, ask: has it been this high before? what meds is the patient on? HR?

Admissions

* In ER, write down vitals, labs, meds, allergies and look at ECGs/XR before you see the patient if possible
* Get the old chart. (Hopefully you have EMR and this won’t be a big deal.)
* Don’t automatically accept the ER attending’s diagnosis
* History-taking: Get the big picture, then zoom in on details
* At first you may feel you need to write your H&P before you write orders, but take time to develop a running idea of the orders you need as you interview the patient. It will actually save you time in the future.
* Don’t forget PRNs. Think about the poor schmo you’re going to sign out to after call is over.

When you don’t know the answer/what to do

* Talk to your senior resident
* Look stuff up in your favorite resource. Find one broad resource and stick to it. (I use UpToDate).
* Go look at the patient again
* If the issue is whether to do the LP/paracentesis/thoracentesis in the middle of the night, you’re better off doing the procedure and getting the data then trying to justify not doing it the next day. When it come to paracentesis/thoracentesis, you can do a small-volume diagnostic tap at least [I can write up some instructions one day, or maybe your program already teaches residents how to do these.]

Prioritizing

* When on call, you’re going to have multiple nurses, attendings, patients pulling your attention in 1,000,000 different directions. Get used to it. It doesn’t get better after residency.
* Process requests/questions by urgency:
o Patient status deteriorating?
o Order or study needs to be done now or else you’ll lose the opportunity to get essential data?
o Cranky attending on the phone and you need to speak to him/her?
* If none of the above are true, and if the situation will not create an irreversible calamity, it is far better for you to finish what you’re doing right now, assuming it can be finished in 15-30 minutes or less, than it is for you to be pulled away and leave a task unfinished. What you want to avoid is having a dozen loose ends all around the hospital.
* Group tasks: if you’re checking labs on the computer, take a second to run your list and check all the outstanding labs at once. Ditto radiology. Ditto dictations—once you’re on the phone, get ‘em all done.
* I cannot emphasize this enough: Dictate the same day you see the patient. It is painful at first but your life will get much better if you can get in the habit early.
Want to contribute your own advice? Please leave a comment.

Image Credit: Fractal Hospital, Flickr

Posted on infosnack.

jasonpermenter: Sometimes I can’t believe how much my wife...



jasonpermenter:

Sometimes I can’t believe how much my wife knows about stuff. Now, the folks over here at Mule Design (disclosure: that includes me) have found the perfect way to use her huge, globally-connected brain. 

Introducing Evening • Edition: it’s a one-page, commute-home way to catch up on the day’s news after a long day at work. Here’s what my buddy Jim says about it:

It’s a summary of the day’s news, written by an actual journalist, with links to the best reporting in the world, published once a day. It’s optimized for your phone or iPad so you can read it on the train home or on the couch. It can be the starting point for a deep-dive or just enough so you sound erudite at your next cocktail party. What it’s not, and what it will never be, is another chirp of noise constantly guilting you into checking it.

One page per day. A handful of stories. Five minutes of your brain. It’s really good, you guys.



Posted on infosnack.

Friday, July 20, 2012

photojojo: Did you know that the caffeine in your soda is...



photojojo:

Did you know that the caffeine in your soda is actually a natural pesticide used by plants? That’s right, the world’s favorite stimulant is rather toxic to our six legged friends.

The photo above is caffeine when false colored and viewed through an electron microscope! 

Caffeine Crystals Under the Lens: Annie Cavanagh and David McCarthy

via Fresh Photons



Posted on infosnack.

"KidneyNotes started as an email list among friends and colleagues a few years ago. Several times..."

“KidneyNotes started as an email list among friends and colleagues a few years ago. Several times weekly, I’d email links to articles I found interesting. To give you a sense, one of the first articles was about thyroid patients treated with radioactive iodine setting off newly installed radiation detectors in the subways of New York City. I sent out so many of these emails that someone suggested I start a blog, so I did. It’s a journal, filing system, forum, and educational tool. Simultaneously.”

- Medscape Interview (2006)

Posted on infosnack.

BPHnejm.org Lower uri­nary tract symp­toms affect more than half...



BPH
nejm.org

Lower uri­nary tract symp­toms affect more than half of older men. Options for both­er­some symp­toms include α- adrenergic-receptor block­ers, 5α-reduc­tase inhibitors, phosphodiesterase-5 inhibitor ther­a­py, and antimus­carinic ther­a­py. Read …



Posted on infosnack.

Amazon same-day delivery: How the e-commerce giant will destroy local retail.

Amazon same-day delivery: How the e-commerce giant will destroy local retail.:

Now that it has agreed to collect sales taxes, the company can legally set up warehouses right inside some of the largest metropolitan areas in the nation. Why would it want to do that? Because Amazon’s new goal is to get stuff to you immediately—as soon as a few hours after you hit Buy.



Posted on infosnack.

emergentfutures: Truth in advertising: Barclay campaign says...



emergentfutures:

Truth in advertising: Barclay campaign says “For the best fixed rates”


Via Twitter



Posted on infosnack.

Thursday, July 19, 2012

How Doctors Can Use Evernote as a Professional Memory (Part 2)

Evernote is a new searchable, friendly, available-anywhere, online personal database — and for many health care providers, it’s rapidly becoming indispensable. Part 1 provided an introduction to Evernote and described how to use it to file away journal articles. In this part, I’ll discuss how health care providers can use Evernote as a hybrid electronic health record (EHR).

Let me be clear: I’m not suggesting that Evernote is a substitute for any of the excellent commercial EHRs currently available. The following is presented as a proof of concept only for how a simple, inexpensive, customizable EHR built on Evernote might work. Please see the disclaimer. As always, HIPAA is a major issue: Evernote provides encrypted communication and many security safeguards, but it’s uncertain whether Evernote fulfills all HIPAA requirements. (Update: Evernote has confirmed by email that, “At this time we do not plan to pursue HIPAA certification for our (consumer) Evernote service.” So, there you are.) Thanks to those who directed me to the “Federal Security Standards for the Protection of Electronic Protected Health Information.” Of course, if you’re concerned about transmitting information to the Evernote servers, you can always instruct Evernote to keep all data on your local computer. This bypasses the HIPAA issue and you’d still be able to use Evernote, but this means that you won’t be able to access patient data from the web unless you use a program like GoToMyPc.com.

First, some background. EHRs have many advantages over paper medical records. With an EHR, when a patient calls with a question — or if a lab calls with a dangerously abnormal result — it’s simple to pull up the medical history, medications, and details of the patient’s last visit. In contrast, if you’ve used a paper medical record, you’ve occasionally waited in frustration until someone found the chart you needed. Very likely, you’ve also experienced an important chart being misfiled or lost.

If spending time looking for paper medical records is so inefficient, why do over 80% of physicians in the U.S. still use them? The barriers to switching from paper records to EHRs are many: expense, hours of training required, uncertain benefits, interfaces that are user-hostile (many EHRs inexplicably seem to model themselves after Windows 98), inertia, lack of flexibility, and concerns about being locked into a relationship with a single vendor.

I’m convinced another reason why more physicians haven’t switched to EHRs is that there’s previously been no middle ground. That is to say, until now there’s been no easy way to realize some of the major benefits of EHRs — searchability, accessibility, cut-and-pasteability, and templates — without investing in a full-blown system.

That’s where Evernote comes in. In addition to its other uses, Evernote can provide a secure, searchable, available-anywhere database of all patient notes and data. And even if you already use an EHR, you might still find Evernote useful to record information — phone messages or snapshots of lab reports, for example — when your usual EHR is not available.

Regarding the issue of security: the premium version of Evernote ($5 a month) offers encrypted communication with the Evernote servers. Here’s what the website says:

Security and privacy are extremely important topics for Evernote users, and for good reason. Evernote would like to provide a single service to manage your memories for many years. To achieve this, we must provide a very high level of system and data security while offering users a variety of choices to manage their own privacy requirements. Here is a high-level overview of some of the ways in which your data is protected by Evernote.

When you add a note to the service, it is secured like your email would be at a high-end email provider. This means that your notes are stored in a private, locked cage at a guarded data center that can only be accessed by a small number of Evernote operations personnel. Administrative maintenance on these servers can only be performed through secure, encrypted communications by the same set of people. All network access to these servers is similarly protected by a set of firewalls and hardened servers. Your login information is only transmitted to the servers in encrypted form over SSL, and your passwords are not directly stored on any of our systems.
Evernote also confirmed through email that communication with the iPhone app — if you have a premium account — is also encrypted.

In Part 3, I’ll provide step-by-step instructions for using Evernote as an EHR.

(Also posted on The Efficient MD.)

This was originally written for the Tech Medicine Blog in 2008.

Posted on infosnack.

Collapsing glomerulopathy.

Collapsing glomerulopathy.:
Collapsing glomerulopathy is a morphologic variant of focal segmental glomerulosclerosis (FSGS) characterized by segmental and global collapse of the glomerular capillaries, marked hypertrophy and hyperplasia of podocytes, and severe tubulointerstitial disease. The cause of this disorder is unknown, but nearly identical pathologic findings are present in idiopathic collapsing glomerulopathy and human immunodeficiency virus (HIV)-associated nephropathy, and collapsing glomerulopathy has been associated with parvovirus B19 infection and treatment with pamidronate. The pathogenesis of collapsing glomerulopathy involves visceral epithelial cell injury leading to cell cycle dysregulation and a proliferative phenotype. Clinically, collapsing glomerulopathy is characterized by black racial predominance, a high incidence of nephrotic syndrome, and rapidly progressive renal failure. Collapsing glomerulopathy also may recur after renal transplantation or present de novo, often leading to loss of the allograft. The optimal treatment for collapsing glomerulopathy is unknown. Treatments may include steroids or cyclosporine in addition to aggressive blood pressure control, angiotensin converting enzyme inhibitors and/or angiotensin II receptor blockers, and lipid lowering agents. The role of other immunosuppressive agents such as mycophenolate mofetil in the treatment of collapsing FSGS remains to be defined. Prospective clinical trials are needed to define optimal therapy of this aggressive form of FSGS.


Posted on infosnack.

Tumblr...



Tumblr likes:



Posted on infosnack.

Dag Hammarskjold Greenmarket, Wednesday July 18....

Dag Hammarskjold Greenmarket, Wednesday July 18....:

tumblr.com



Posted on infosnack.

How to Cite Blogs in Formal Academic Medical Papers

Unexpectedly, the National Library of Medicine / National Institutes of Health, in the second edition of their Style Guide for Authors, Editors, and Publishers, included a section on citing blogs and other material on the internet. Also unexpectedly, as one of the examples, they included Kidney Notes, a personal blog which I’ve written for over 2 years.

KidneyNotes.com [blog on the Internet]. New York: KidneyNotes. c2006 - [cited 2007 May 16]. Available from: http://www.kidneynotes.com/.
Cory Doctorow posted a link to the style guide on BoingBoing, the most popular blog on the Internet, and it generated some interesting (and heated) discussion. I’ve also discussed issues related to citing blogs with some friends who are more scientific than I. Some of the arguments are summarized below:
  • Blogs (and wikis) are not credible sources of information and should not be cited in medical papers.
  • “Blog on the Internet” is a redundant phrase. Where else would a blog be?
  • There is useful information to be found in blogs, it should be cited and is going to be cited, and therefore there should be a style guide for citing it.
  • Citing blogs on your CV is just another way to pad it if you don’t have more substantive publications.
  • The “permalink” should be cited, not the blog itself.
  • People have been citing “personal communication” for years. Why not blogs (or emails), which are forms of personal communication?
For more discussion on this topic, see these links:
(First posted in 2007.)

Posted on infosnack.