Throwaway05
1d ago
I'm not particularly interested in litigating how to analyze research quality which is an extremely complicated topic.
The thrust of my post is that several (referenced) practice guidelines all reports that medications are not a good option and suggest lifestyle modification be done first, which is the recommendation I relayed in my post.
If you want to discuss what appropriate exclusion criteria are I'm not your guy in this setting.
Throwaway05
1d ago
I think one of the kernels was that women are surprising consumers of lesbian and solo female porn for similar reasons that men are surprising consumers of big dick porn. Focus on aspirational anatomy and the pleasure of the specific genitals the viewer has.
Gay porn is often also produced with an aim towards the (gay) male gaze - women like gay male romance novels and such (at least Japanese ones do) but it is quite different to actually viewing the railing as it where.
Throwaway05
1d ago
Do they? Last time I saw data on this I thought it said straight women didn't really consume gay porn.
Throwaway05
2d ago
What do you imagine happens with this information?
Research for instance requires patient direct informed consent or your data to be totally anonymized. Your privacy is protected, although someone else may benefit from having cared for you.
Some information needs to be given to your insurance for instance so they can pay, that's the primary point of boilerplate like this.
To give an example of how restricted and scary HIPAA is - you do not require patient consent to reach out to a patient's primary care doctor to gather information on the patient. This is important because most patient's struggle to remember all of their health history, their medications, the results of recent lab tests you wouldn't necessarily want to duplicate, imaging results and so on.
Despite this most systems will require patient consent to be faxed to them anyway, even in situations where the patient is say, not able to consent due to illness severity.
If health systems are willing to let quality of care be damaged how free with your information do you think they are?
Throwaway05
3d ago
Yes there are a lot of considerations, that was my point.
I'm really not sure where you are going for this.
Throwaway05
3d ago
It's not actually FDA approved for neuropathic pain (or most of what it actually ends up using for) because there isn't enough evidence that the benefits outweigh the risks. Except you just pointed to a study? Shit is messy. One study does not equal consensus.
CBT-I is cheap and found to be effective in a variety of studies and has an extremely small harm profile. Medications for insomnia have been found to be ineffective more often than not and have side effects that include up to things like dementia and death.
CBT-I first.
Throwaway05
3d ago
If I told you Gabapentin wasn't actually indicated for neuropathic pain would that alter your thoughts at all?
Throwaway05
3d ago
I wrote a long comment here but I ended up deleting because their were too many edge cases and complexity but the short version is:
-
If a healthcare facility or employee abuses your personal information in ANY.WAY. the government will absolutely anally violate anyone involved with several rusty implements. They are extremely aggressive about this to the point where it has become counterproductive and directly harms patient care (ex: nobody wants to send care-critical records to anyone for fear of being beaten with the HIPAA spoon). Exceptions exist but are for the most part extremely well validated.
-
The above poster is not giving good advice. Having suicidal thoughts is not grounds for commitment. While some health systems are overly aggressive with commitment (so it is a real problem) tons of people are sent home from the hospital or leave their doctor's office after expressing suicidal thoughts. Something like a plan for how you would kill yourself is not the same thing.
Having suicidal thoughts and not telling your doctor or people in your life is for the obvious reasons much more dangerous to you.
Throwaway05
5d ago
Ancient Greeks had a different ethical system, what seems immoral to us may not to them etc.
Throwaway05
6d ago
If you are expecting a wide body of clear and convincing evidence you just aren't going to find it often in medicine, especially when something drifts more into psychiatry, nutrition, and the other more complicated domains.
CBT-I seems to have a good number of sources saying it does something helpful. That's enormously more efficacious than most of the medications which research often suggests do nothing or are counter productive.
Mechanistically this makes sense in the same sense that exercise is better for weight loss than medication. Yes implementation is hard, but working out actually works and medications of various kinds are significantly more variable.
Additionally some of the other sources (like the AAFP) are more positive.
Ultimately medical research is hard and is hampered by ethics and expense. The evidence base for ANYTHING is pretty poor but if it seems to work and makes biological sense, we run with it.
Most medications do not or run into clear issues which just doesn't apply to CBT-I.
Throwaway05
6d ago
The way you write suggests to me that what I'm about to say may already be known to you, so mostly throwing out additional context for others-
Patient reported sleep issues are more about subjective experience in most cases (as opposed to objective). This is a big piece of why benzos can be popular while melatonin often isn't, since benzos effectively make you pass out more than they make you sleep but to patients that seems like a good deal.
Paradoxical agitation due to benzo administration in a hospital setting is a known quantity and dare I say it, the norm. However what to do about this becomes a complicated and long running fight. Yes, in some settings getting any sleep at all is the way to go (most classically: helping to abort a manic episode or substance induced insomnia) but more commonly we see nursing staff demanding benzo administration until the medical team or a consulting team gives up and recommends it to make nursing shut up.
Nursing isn't entirely wrong since an agitated patient takes away from others and can be dangerous in a variety of ways, but the literature suggests this is typically a bad idea.
For Quetiapine, Mirtazapine, and TCAs- for these managing the side effects is the primary problem. In the US we don't really use Quetiapine anymore because of concerns of weight gain, even in the setting of psychiatric comorbidity. Mirtazapine still has weight gain concerns but ultimately is better on that front so you see it more often. TCAs are a bit more complicated but probably the most commonly used option in settings where cost is a big factor.
Throwaway05
6d ago
The only complaint I've had thus far is that the enemies can sometimes be overly damaging if you don't pull off the dodge/parry
Later you can make builds that rely less on this, but I found it helpful to know that one of the main developers is a Sekiro speed runner - the game is 100% designed around the realtime inputs. Once you give up and embrace that (and get gud) it becomes more enjoyable.
At least, that's the process I went through.
Throwaway05
6d ago
Scott promotes CBT-i apps as a good way of doing CBT-i. One for the medico-commies - the best CBT-i apps (apart from ludicrously expensive prescription-only ones) were developed by the VA, and are free to users as a result.
Endorse this!
The biggest problem with CBT-I is that it can be hard to find someone who does it and even harder to find someone in your price range. An app will never be as good, but access is access and free is free.
Throwaway05
7d ago
The U.S. medical education consists of 4 years of undergrad (which is a mash of yes you absolutely need to take this in advance (basic sciences), eh it is going to be hard without it (learning biochem for the first time in med school is gonna suck) to totally pointless (yes working in a soup kitchen twice a week for three years is totally helping me be a better doctor. Then you do medical school which is four years*. Then you do residency which is ~3-7 years, and sometimes fellowship which is 0-X years.
Finally you are an independent practicing physician.
Here's the thing. The process is confusing. An intern outranks a med student. A fourth year medical student and a first year resident are super different - one is in school, one is an employee....but depending on the program and student they can be doing the exact same thing and have similar knowledge levels.
Coverage in the U.S. of medical scandals almost always mixes up multiple parts of this and misses things like - a first and second year medical student is mostly in lecture and a third and fourth year student is mostly in the hospital seeing and to some extent treating patients. Sure looks like a full on doctor to most patients!
It seems pretty likely that various interests in this story are intentionally or unintentionally mixing some of this up.
*Some path exist for changing these time lines but they are rare.
Throwaway05
7d ago
Saying most effective in medicine is probably overstating my case, although if asked to justify that I could easily point to adherence issues being the primary point of failure for CBT-I and say something like "if only the patients actually followed the treatment it would work!" which is absolutely true but is a bit dickish.
If you look at your link in the key points section it says things like "CBT-I across several delivery modes improves global and sleep outcomes compared with passive control in the general adult population (moderate strength evidence). Evidence was insufficient to assess adverse effects of CBT-I."
Keep in mind that that the quotes you pulled out are looking at individual sleep metrics as opposed to global sleep outcomes. It is not unreasonable for a treatment method to have more impact on say sleep onset than sleep maintenance.
The AAFP guidelines note:
"Psychological interventions included stimulus control, sleep restriction, relaxation techniques, sleep hygiene education, and CBT for insomnia. CBT for insomnia is a combination of cognitive therapy, behavioral interventions (i.e., sleep restriction and stimulus control), and education (i.e., sleep hygiene). There were insufficient data to draw conclusions on the effectiveness of specific interventions alone (e.g., stimulus control, sleep restriction, relaxation techniques), but based on a meta-analysis of 20 trials, CBT for insomnia improved global and sleep outcomes in the general adult population."
Which is fair and measured.
That said if you change my quoted statement to "CBT-I is the most effective treatment modality for sleep" it becomes significantly more relevant and strictly speaking more accurate. All of the guidelines recommend CBT-I over medication in most circumstances because of severe safety/benefit issues with medication management.
Throwaway05
8d ago
Looking at our mundane problems and existential threats (ex: climate change) the biggest problem is people not thinking long term.
Inheritance helps force people to think longer term than their own lives.
That has value!
Throwaway05
9d ago
Agree with this.
I know some people who point to the OJ chase or trial as one of their first concrete memories.
Nothing since comes anywhere close, not even any of the BLM adjacent trials.
Throwaway05
9d ago
Rather, the league and the Browns and Watson came to an agreement to let Watson fake an injury, collect his checks, and the Browns are able to recoup some cap room through an insurance policy.
I feel like this requires a level of planning and intellect which is essentially never observed in the league.
Throwaway05
12d ago
With the exception of Scrubs it's probably the best medical TV show period (in terms of vibe capturing and medical accuracy).
And yes it captures the reality. So much fighting about if kidney labs are racist.
Throwaway05
12d ago
Absolutely true to life though! Some mostly not burnt out and energetic trainee yelling at a more junior trainee who is just trying to not die and then herself getting yelled at by a much more burnt out supervisor. This is life!
The resolution of the arc you are thinking about is done very well, don't worry.
And yes practical experience of medicine can be very black pilling - homeless, drug users, illegal immigrants...but then also fat people, people who refuse to take their meds or listen to other advice...it gets murky very quickly.
Throwaway05
12d ago
Arcane is very clearly about class struggle and has a lot of woke casting and other type things, but it is also simply good, and is able to do the class struggle through enough of a historical lens that it doesn't run into modern woke issues.
The Pitt recently finished its first season and is an excellent medical drama. Some of the doctors get mega preachy and at times their is some serious "very special episode" energy but it's overall very good and anyone who has worked in those settings know that's how a lot of people talk.
Throwaway05
17d ago
Here you sometimes hear of people suddenly committing murder---but in a bizarre way, like randomly stabbing a girl, or randomly stabbing a woman, or a bunch of people, or doing the truck ramming thing then leaping out of said murder truck and, again, stabbing. The stabbing isn't that surprising (as a technique I mean) since knives, unlike guns, are readily available. What's surprising is the sudden randomness.
You'd be surprised how common this is in the U.S. actually.
Background: I spent some time working clinically in corrections.
A number of things need to go wrong for someone to engage in egregiously violent behavior (this is most studied when it comes to serial killers but applies all the way down). Society is filled with people who have things like intellectual reserve, good impulse control, social resources, appropriate time preference, and so on but have the underlying psychiatric and psychological temperament to do really bad shit. These people usaully end up run of the mill shitty people or things like your classic corporate raider sociopath.
In the U.S. (and many other countries with a significant amount of the criminal element) you see people who are missing one or more of the protective factors sliding into the criminal class, getting into trouble early, and so on. This knocks off a lot of people who would be doing what you describe and puts them in another bucket early.
The number of people who have had thoughts about killing others for little reason is shocking, but most are somewhat repressed by social pressure, fear of consequence, and adequate impulse control... but they still have those thoughts. Again the U.S. has mechanisms like the criminal underclass which lets people with interest get it out and get in trouble etc, but fundamentally a lot of people are walking around with "what if I stabbed people" and absent opportunity to misbehave they don't unless something else goes wrong.
In the U.S. usually this is things like said criminal stuff, substance problems, medical/psychiatric issues or sufficient life stressors. I imagine Japan is similar.
Salarymen wonders his whole life what killing people would be like, but likes the "deal" society gives him enough to maintain his other psychological needs so he doesn't do it. Then he gets fired....and well why not?
Now Japanese police have their issues so it is certainly possible that is what is going on here, but my suspicion is that modern Japanese society keeps these people buttoned up more adequately than the U.S. and sometimes you run into the rare thing that causes them to snap and check out what they've always thought about.
About 3% of the male population has antisocial personality disorder (ASPD). Most of these people would kill if the right situation came up, but it doesn't...most of the time.
Plenty of people don't really care about others adequately. Some of this is clearly pathology (think stereotype of a gangbanger - that's gotta be ASPD). Some of it is in-group outgroup bias type stuff. Some of it is things like woke advocates whose virtual signaling overtakes actual virtue. This is a spectrum that applies to a lotttttt of people in some way or another. Get far enough down the spectrum and have anything that makes you ask certain questions, and you have random killer in the making waiting for the "right" change in their life or stressor.
Throwaway05
20d ago
In other countries prison is bad because the guards are bad and don't care about the prisoners.
In the U.S. the prisons are bad because they are filled with American prisoners. Somehow this is often worse. Additionally in the U.S. guards are frequently prevented from "managing" the prison which can cause unnecessary problems.
Throwaway05
21d ago
Despite online feminist complaints the biggest users of "females" to describe women (well outside of scientific literature anyway) is the American Black community.
Keep this in mind when people complain about use of "female" and accuse nerdy white males of doing it.
I can tell you it's not a show, if I'm in an elevator talking about "John Doe" or even like Dingle McCringleberry the nursing administration gestapo are going to crawl straight up my rectum.
I suspect the rest of your stuff would be resolved if you actually talked to someone who knew what they were talking about and wasn't worried about covering their ass (for instance an HIE in this context probably refers to routine health record sharing that you want in case you are in a car accident in another city).
Granted something like 23 and Me is a different story.
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