BC CULTURE
Saved by @jay_millerjay

1/I'm excited that Dr. @AjayManhapra is presenting on concerns about mandatory opioid taper for VA's MAT-VA journal club, based on our shared paper... he notes Human costs of mandatory and widespread opioid taper

 2/He cites @BethDarnall as the best available study, noting that even when one offers the best support system, a significant % of patients do not have a reduction in pain or pain worsens.
3/In a way that will seem controversial, he proposes that opioid therapy is not exactly an analgesic. This is daily use of an addictive substance that offers relief, where only a minority develop addiction.
4/I should caution that @AjayManhapra is far from a "fan" of opioids for pain. Many people on them do not get benefit, he says. My reading of same data is more favorably disposed, even though we collaborate
5/There is an "opponent effect" so that relief from opioids is also opposed - not in all people and to the same degree - but this is part of the dependence dilemma for some persons at high dose
6/Trigger warning: Dr. Manhapra describes a distinct category of Opioid Use Disorder (which most patients do not have at all) from what he and some others call Complex Persistent Opioid Dependence
6/Opioid tapering is intuitively appealing but the goals of a taper are rarely declared and when they are (see below) they are not regularly achieved
7/The available data on opioid taper suggests (with low confidence) improvement if patients are in "intensive multimodal pain interventions".

And "none of these (tapering) studies showed functional improvement" says @AjayManhapra
8/As Dr. Manhapra summarizes, regarding opioid taper

"There is no clear benefit but there are reports of harm"
9/Dose and risk of harm are correlated, but it's complicated. "It's not the opioids alone" - the risk is determined by what else is going on in their lives, personal characteristics. Dose is a MINOR factor in the modeled risk in Veterans Administration
10/Most overdose happens at low dose- so focus on dose is not solid. Veterans Affairs overdose data.
11/Even with heroin/fentanyl, the deaths are polypharmacy often with LOW dose of heroin!
12/Opioid cessation associated with increased risk of overdose/suicide in Veterans. It's highest in the first month afterward. Then begins to fall. But it never comes down to the level of the persons who were continued on opioids. https://t.co/HdjqNhujHN
13/Also all cause mortality was elevated after long term opioid therapy interruption in a VA HIV cohort (VACS). Note Dr. Manhapra (like me) is pointing out a fact pattern and NOT arguing every death is Cause and Effect. Humility is called for
14/In pursuing this discussion I want to highlight issues that we understand are subject to immense dispute because the underlying data are themselves either do not exist or are quite poor
15/If a patient is stable and ostensibly at a higher level of risk for adverse effects from opioids they receive, would reduction of dose make them safer, if they *consented for that personally*? We are aware of *no evidence* although I think it's totally reasonable to discuss
16/If a patient has shown higher-risk problems (like turning up drunk in the ER while also having taken the prescribed opioids, i.e. major overdose risk), do the clinicians make the patient *safer* by switching to buprenorphine as a "safer opioid". FYI: this comes up a lot
17/Please note that honest discussion here has a few limitations. First my friends and I (who discuss these matters with in good faith) often do NOT agree. I am still wrestling with what it would mean to adopt concepts put forward by my friend Ajay. He knows that!
18/Sadly, there are also bad-faith discussants who have slung arrows. Usually, from folks who:

*don't have frontline primary care experience
*don't propose, fund and deliver peer-reviewed research
*are paid by law firms
*discount experiences of people with lived experience
19/The story should be about the people and the families whose care has been upended in part because of poor science, immodesty, and policymakers addiction to "quick fixes"

#Listen (YES: after 19 tweets in a row, that applies to me too)

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Thread: *Post-Liberal reading list*
1/ Religion and the Rise of Capitalism - R.H. Tawney
Unto This Last - John Ruskin
Liberty, Equality, Fraternity - James Fitzjames Stephen
The Great Transformation - Karl Polanyi
The Quest for Community - Robert Nisbet

2/ Family and Civilisation - Carle C. Zimmerman
Science, Politics and Gnosticism - Eric Voegelin
Liberty Before Liberalism - Quentin Skinner
The Great Debate - Yuval Levin
Lincoln and the Politics of Christian Love - Grant Havers
Where We Are - Roger Scruton

3/ The Humane Vision of Wendell Berry - Various
The Unsettling of America - Wendell Berry
Moral Matters - Mark Dooley
Red Tory - Phillip Blond
Blue Labour - Eds. Ian Geary and Adrian Pabst
Together for the Common Good - Eds. Nicholas Sagovsky & Peter McGrail

4/ The Politics of Virtue - John Milbank & Adrian Pabst
Localism in a Mass Age - Eds. Mark T. Mitchell & Jason Peters
The Antimodern Condition - Peter King
The Principle of Duty - David Selbourne
Nostalgia - Anthony Esolen
A Common Human Ground - Claes G. Ryn

5/ The Politics of Gratitude - Mark T. Mitchell
A Time to Build - Yuval Levin
Remaking One Nation - Nick Timothy
Despised - Paul Embery
Defending Identity - Natan Sharansky
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Paras Chopra
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1/ Here are my notes from @robertwrighter's book - Nonzero: the logic of human destiny. I enjoyed the book very much.

The basic premise of the book is that history has a direction which favors co-operation and non-zero sum games, and that causes an increase in complexity.


2/ Starting from the first replicating molecule which co-operated with an outer layer to form first proto-cell, evolutionary and cultural history is full of examples where two entities come together to survive and progress a lot more than they would have done individually.

3/ This co-operative entity fares much better than two individual entities because of specialization. If two entities are in the same boat - that they win together or lose together - then trust is implicit.

4/ In a non-zero sum game, trust causes entities to focus on what they do best.

For example, eukaryotic cells - the ones animals and plants have - emerged when two proto-cells merged, and one took the role of energy generator (mitochondria), the other specialized in protection.

5/ Some scientists believe that even nucleus in a cell is a result of an early cell merging with another cell.

So M&A is not a recent phenomena, entities have been merging because of common interests ever since life started.
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All warfare is based on deception.

Everybody assuming Trump hasn't been working furiously behinds the scenes to affect certain outcomes were wrong.

They based their assumption Trump doing nothing & just hoping for the best on the surface of things.

As they were supposed to.
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Wealthy Brains
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Lessons I learned from "Rich Dad, Poor Dad"

~ Thread ~

1. Put your money to work

You cannot get rich with your money in savings account,

Invest it in appreciating assets.

2. Amount of money retained matters

It is not the amount of money you make,

It's the amount of money you keep that matters.

3. Acquire assets

Rich people acquire assets while poor accumulates liabilities,

Your choices will determine your fate.

4. You are not born to work for others for lifetime

Most people consider this slavery as their life,

Completely forgetting the life possible beyond that.
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chika unigwe
chika unigwe
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So last week I wrote about the disinheritance of daughters in parts of Igbo land & to my disbelief, there were Ndi Igbo claiming that this customary law of inheritance that privileges sons doesn't exist, that I had somehow fabricated this out of thin air

(even as I and others on my TL gave concrete, real life examples and some Igbo daughters have successfully brought cases contesting the law before civil court).

One ill-informed young man stated that I had to “malign Igbo culture” so that “white people” would give me money. LOL. I understand that we don’t like to see the worst of ourselves reflected back to us but how do we progress if we refuse to confront it?

We can’t pretend that we are perfect, our traditions are perfect, our lives are perfect; we can’t create false narratives in the face of overwhelming evidence disputing those narratives;

we can’t go through life with our head perpetually buried in the sand because that isn’t a sustainable posture to hold. Sand go enter your nose and choke you, abi?
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The Straddle is a delta neutral strategy and it is important to keep deltas in check during the course of the Trade and not let them run away from you. Of course Volatility is the elephant in the room- but not going there as that will require a separate discussion

The first and most common method is to go 'inverted.' That is to say to shift the untested side to generate additional Premium and increase the runway to Breakeven. So if you start with a Straddle at 700 and price goes to 740, you can move the PE up to say 720.

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10 Signs of Social Intelligence 🧠

1-Smile
2-Good posture
3-Strong eye contact
4-Fluid hand gestures
5-Let’s others talk more
6-Listens & relates
7-Comfortable Touching people
8-Walk with a swagger
9-Speaks at slower pace
10-Keeps calm under criticism

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1-Smile

How do you feel when you see someone that looks angry?

It’s a downer

No one will want to interact with you if you look pissed all of the time, it’s just negative energy

Plus, smiling is a sign of confidence and boosts others moods


2-Good posture

Don’t walk Into any social setting looking like the hunchback

It’s weak and makes you look low energy

Plus, you’re displaying low status with weak posture

Stand up straight with your chin up & chest out like a god

Walk like you’re proud of yourself


3- Strong eye contact

Ever shake someone’s hand & their eyes are either looking down or darting?

It’s weak & you probably won’t trust them

Or in conversation?

Eye contact while talking means you’re listening and paying *Attention*

Strong eye contact displays confidence


4-Fluid hand gestures

Use your hands to talk & express your points

Don’t stand there like a robot

Using the hands can make what you’re talking about exciting

It can also be used to emphasize

Exciting = positive emotion

Remember, making people FEEL is what’s important
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Kolaru Pathigam-Thevaram hymn composed by ThiruGnana Sambandar- #Thread

In Tamil Kol means planets,Aru means cut- set of songs in Kolaru Pathigam addresses all Navagrahas& last 2 lines of every song with end a plea to Bhagwan Shiva to reduce/erase the ill effects of Navagrahas


கோளறு பதிகம் - This pathigam was sung by Thirugnana Sambandar at Thirumaraikadu Kshetram -Vedaranyam,Tamilnadu

Thirugnana Sambandar & Appar(Thirunavukkarasar) travelled together to various Shiva Alayam to spread shivam & bhakti among people.They both reached Thirumaraikadu.


Thirumaraikadu(Vedaranyam) -
Appar & Sambandar were asked to enter the temple through side entrance.The main door was locked by Vedas many years ago.Appar&Sambandar sang devotional hymns praising Shiva, after which the gates opened & closed.After which main door opened for all.


After darshan of Bhagwan Shiva at Thirumaraikkadu,Sambandar received a message to travel to Madurai.
During that time, Samanam was on the rise in the Pandya Kingdom.The Pandya King converted to Samanam.The Queen Mangaiyarkkarasi was a staunch Shiva devotee and was upset.

Kularchirai Nayanar ,Chief Minister of Pandya kingdom was in agony by the turn of events.Queen requested Kulachirai Nayanar to escort Thiru gnana Sambandar to Madurai.Kularchirai Nayanar met Thiru gnana Sambandar at Thirumaraikkadu & requested him to visit Madurai.
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Benefits of writing SRI RAMA Jayam!!!

Writing Sri Rama Jayam is known as Likitha Japam- Writing Meditation. This gives one a complete sense of surrender to an inner conscience and peace while writing or chanting the mantras.

#Sri_Rama_Jayam #RamaNavami

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You can write this in any language of your choice. It is the connecting chords with the divine and your inner self.

Below are some points that we came across on the benefits :

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1. Vedas tell that as the sun dispels the darkness, the chanting of Rama Nama dispels all evil and obstacles of life. It is a way of liberation and salvation of human suffering.

2. When you think, that all roads are blocked to walk away from day to day problems..

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writing ‘Sri Ram Ram Ram’ gives you the most needed clarity of thoughts to find away out of odd situations.

3. It was told that a calmness engulfs as one indulges in writing the Sri Rama Jayam bringing in more clarity of mind, tolerance & strength to withstand obstacles in life.

4. Devotion of service of life and its varied forms is devotion to God. So there is no right or wrong way of writing this. The very thought and process to write is a connection with god and finds a inner meaning.

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1) My Stan Lee story happened when I was in 5th grade. I was visiting NYC with my Dad and had read the address for Marvel in the comics I read constantly. I begged my Dad to take me and to his credit he did. And guess what? It was just an office.

2) We were down in the lobby and I was kind of crushed. I don’t know what I expected, The Thing and the Yancy Street Gang to be sitting around smoking cigars? Anyway, my Dad was taking a beat to figure where we were going next and a guy came up to us.

3) He was wearing a white shirt and tie and said to Dad “Is he disappointed because. The Marvel offices were just offices?” My Dad said yes and then the guy who had gray around his temples and a mustache said “hold on a second” and opened one of those office mailboxes with a key.

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