#you have no idea how frustrating it is for the general consensus in your field of research to be so completely off-base

[asurrogateblog]

as a media psychology researcher 85% of my job is figuring out the most horrifically academic way to say "you idiots wouldn't last a day on tumblr"

[theodora3022]

Selfish Deeds (Yandere! Gojou Satoru)

Summary: Satoru just wants you to be free of danger. If you are so knowledgeable why can’t you understand that he only wish the best for you?

A/N: This is just one snippet of many out of a collection(haven't decide the name just yet)...Since I have not read the manga(anime-only for now) so I just got a vague impression of what Gojou has been through, but that does not stop me from writing him like the cocky bastard he is. Hopefully it is not too OOC(as if yandere variant itself is not OOC enough pfttt) The reader is a stubborn psycho because that is what I am :) Will there be some future pieces that involves nsfw elements? I got a few ideas but no promises.

I blame @popi-the-fatui for my Gojou brainrots. You got your revenge on me by making me attracted to this dubious man. Word count: 1.6k

Banner credit

Warnings: Female pronouns, Possessive behaviour, DELUSIONAL behaviour, non-consensual touching, power inbalance, general yandere content, slight mention of confinement and violence(This is not a healthy relationship dynamic!!!), reader is not a soft UWU girl, kthis is so self indulgent *buries myself into the bottomless pit of shame

It has been nearly fifteen minutes since the headquarter disconnected the call, yet you are still staring at your phone screen with disbelief.

You were supposed to travel to another city for a mission tomorrow, they had notified you of this mission a week ago.

You already got your luggage packed, and your theoretical research on the objective is thoroughly done. Then they dare to inform you: they have found a more suitable candidate! Right on the day before your departure too.

Your curse techniques have already limited you to more of a supporting role for most situations. There are not plenty of missions available for you to begin with. While you are content with educating the fresh blood of the community in classrooms the majority of the time, you still long for field actions every once in a while. It is an essential part of being a Jujutsu sorcerer after all.

Both you and the soft-spoken secretary who made the call know this is nonsense. The higher-ups recognize that you are one of, if not the best sorcerers available when it comes to reconnaissance and espionage.

Letting out a sigh of immeasurable frustration, you swore to yourself that you will find out who is the conductor of this humiliating turn of events. This is going to be difficult since you do not recall having any issues with any of the administration staff recently.

There is no reversing this misfortune, but at least you can be aware of who is responsible for such violation of conduct.

He is only doing this to protect you.

Gojou Satoru tells himself as such, at least.

He is aware of how unfair it is, to make someone less capable to take on the job. But he cannot risk your safety. The man has already got used to your company, and he is not willing to just let you disappear from his field of view for more than a week. Sure, you might have not admitted how much you like him yet, but it is just too endearing to see you flustered at his flirtatious words.

Although there have been some difficulties with rescheduling, he managed to use his connections to exclude you from that first-grade mission at last minute. On the bright side, the sorcerer cannot wait to lend you an ear to vent about how conservative and unfair the higher-ups can be. Maybe you will even say yes to a trip to the newest local bakery! You need some sweet treats to cheer yourself up, don’t you?

But Satoru has never thought about how you specialize in putting two and two together. (understandable since he never saw you in action before).

------------------

Strange, you are not near the usual area in the library.

Sensing his footsteps, you opened your office door before Satoru had a chance to knock.

“We need to talk, Gojou-san.” That expression is new. This is the first time he sees you genuinely angry, which is to be expected.

But somehow he got a bad feeling about this.

You did not even invite him to sit down, instead just standing next to the floor window, arm crossed, with your back turned to him.

“Why would you do such a thing?” You have to use up all of your self-control to prevent yourself from having a full blow-up right at Gojou Satoru. Maintain composure. But it is easier said then done.

Does he think this is funny? To sabotage someone else's sorcerer career like this? You knew you should have kept him out of your daily life, as he is nothing but trouble to you. But you made the mistake of choosing to tolerate him, and some superficial part of you might even enjoy his dallying words a bit too much.

To the extent, you overlooked some red flags. This is a grievous error indeed.

Shit, now that he vaguely remembers what role you play on missions.“(y/n)-chan, what are you saying-” He knows you always act in supporting positions, however, he has overlooked your actual abilities and curse techniques. You collect intel and spy on enemies, how could he forget that? “Don’t play dumb with me. You got your ways, I got mine. There is no use denying what you have done. I thought you out of all people would understand what it means to be a sorcerer.”

This is a violation of protocol, changing mission assignments at the last minute. However, you know this man would not be receiving any solid punishment should you decide to report this. They would say there is “no harm done” and you would just receive a pitiful apology. Suppose you cannot blame them though.

They need Gojou Satoru, the Jujutsu community needs his prowess to keep innocent people safe. He will remain in the system no matter what.

Why are you questioning his motives? Does he have to spell it out for you? Letter by letter?

“You are not a skilled combatant, (y/n)-chan. What if you got yourself hurt?” Or even worse, killed. It scares him to think that you could be gone one day, how he would walk by this office corridor and never sees you sitting behind the desk ever again.

Not much in this world could send Gojou Satoru a chill down his spine, yet the thought of you dying is now on the list. He knows how petty this is, you wouldn’t be the one doing the actual exorcising after all. But the if, the slight possibilty.

He cannot allow that to happen, not ever. Even that means angering you and getting yelled at.

“What am I, some normal lawful citizen? I am a sorcerer just like you, Gojou-san. Putting ourselves on the line for innocents is part of the deal.” You let out a few short, sarcastic giggles, narrowing your eyes at him with fury. “It’s funny that you, out of all people, fail to understand that. If I am needed I will do what I must. If this is some sort of sick joke, stop it already, not funny. ”

Blunt, unrelenting stubbornness. Not like that’s news for him, Satoru has lots of experience with that since the day your path crossed. Although he finds this quality to be adorable most of the time, it can pose major problems like the present.

Oh, he is not angry at you. Satoru is more outraged at himself, don’t you worry. On the contrary, he is rather intrigued by your sarcastic remarks! However…

Instead of walking towards where you stood near the window, the man decides to take a turn towards the door.

That flashing panic within your eyes did not escape his sight.

The illusion figure you were projecting near the window dissipated instantly once he got your left wrist in his hand. Concealing yourself and projecting illusions, a rare techique indeed.

“Clever tactic. Making yourself invisible, projecting a faux illusion to distract me, leaving the door open and staying close to the exit. Your curse techniques are impressive. I almost got fooled, job well-done (y/n)-chan.”

The grip on your wrist suddenly tightens, you have to bite your lip to hold back a hiss of pain. How can he still flash that casual, playful smile when committing such atrocity? Those damned cerulean blue eyes too, you are ashamed of how you tremble and (internally) swoon at it at the same time.

Efforts to get away would most likely be futile, but you have to try. “See, you underestimated your opponent. I do see why you are good with lurking in the shadows now. Do you have any idea what I am capable of though?” Such delicate hands, it would be a shame if they were to bruise.

It’s unnerving how easy it looks for him to maintain a solid grip on your wrist while you pull back with all of your might. You know Gojou Satoru is strong and all, but this simple demonstration of strength is devastatingly effective. “Let go of me, you bastard!”

To your surprise, he softens his grip and you finally distanced yourself from him, panting and guarded. “Who are you to decide what I should and what I should not do? I made it crystal clear on the first day that I do not like you for the slightest.”

You know the walls are thin and coworkers might heard you, but you will have to worry about it later. It is, sadly, a matter of fact that you are somehow attracted to him, but that does not give him the right to use it against you. You must not give in to the temptation.

“You are pretty slow on the uptake for someone so smart. I was thinking of doing this naturally, we can go on normal dates to coffee shops, amusement parks, or even the museum if that is what you wish for. But now I see you do not know how much you mean to me.” Do you think Gojou-san is only flirting with you for the fun of it? It might have been the case in the beginning, but that is not the case since...recently.

He did not stop you again when you turned away, giving him one last menacing look and disappeared from his sight, even if he could see the faint trace of your curse energy. You will return to him and apologize after you calm down, he is confident about that. You value your job way too much to quit.

Then he could finally pull you into his arms, saying he does not mind and forgive your childish tantrums. Satoru does not plan to lock you up in a cage or anything(yet)! The students adore you and they need your guidance. Your clan is insignificant compared to his, your influence? Does he even need to consider that?

Gojou Satoru would always achieve his goals by whatever means possible. You are no exception to this.

[monokuroo]

Title: Nil Admirari no Tenbin Teito Genwaku Kitan Company: Otomate Release Date: April 21, 2016 Platform: PS Vita Walkthrough

The Gist

After seeing her brother burn himself because of a book, Tsugumi starts seeing ‘aura’ or the glow of a cursed book. She, then, joins a group of people called Fukurou who search for these books hoping to avoid any more victims like her brother.

The Gameplay

Like with most recent games, you can change the name of the main character or leave it as it is.

Once you’ve finished the common route, you’ll choose whose route you’re going to play. At first, I was bummed out. I prefer getting to a route depending on the choices I made as I play.

As you go through the route, some choices lead to happy or bad ends. You can check if you are heading to your chosen end once the libra appears. The left is the good end and the one on the right is for the bad end.

Within the route, you can check your progress on the story. You can also choose which chapter you would like to see. Other things to check out here are if the chapter will give you a CG event or choices, or which end you are going to end up with. It is a nifty system to have, I must say.

The Story

The whole thing about searching for cursed books is pretty intriguing. It poses an interesting question – is it the fault of the author for writing such suicide-inducing books or not? In Nil Admirari’s clunky way of storytelling, it shows that it depends on the intent of the writer. Some write because they are cornered, some have no idea that they have a capacity to produce something like that, and some are plain twisted in their own way.

But the game fails to deliver that.

That’s the thing, the story has lots of inconsistencies.

I thought it would be like in Collar x Malice where it made me think what is really right and wrong. What happens is that one route this character would be the bad guy, in the next route he’ll be the victim and so on. At the end of the game, it made me wonder who is the bad guy.

Clunky way of storytelling

I mean the pacing. The shift from the main plot to the character’s own issues is forgivable since I love the characters. Still, there are scenes where I scratch my head in confusion. Smut coming out of the blue, revelations from the left field – you get the idea.

One of the biggest offenders is Shizuru’s route. I thought the problems are solved and I’m off to the epilogue when the game dropped a twist. I loved twists. But what I didn’t like about this twist is how it disrupts the entire flow of the game.

Misogyny

When I started this game, I wanted to root for Tsugumi and her dreams of living life on her own terms by joining Fukurou. I thought things are looking good because another female character named Shiori leads the team. Then her best friend also got a job as a reporter. The game pretty much establishes a time period where people start accepting women in the workforce.

Uh, no.

Then these people start saying “No you can’t do this or that because you are a girl.” This includes her workmates.

Seriously? (╬ Ò ‸ Ó)

This is sad. 😦

I get it if people outside Fukurou will say that. But for Tsugumi’s workmates, it’s just absurd. For one, their leader and the person everyone respects is a woman. Shiori holds a gun. So why can’t Tsugumi go train herself as well? Why do the other characters insult Tsugumi for being a woman when they don’t say anything like that to Shiori? It’s just frustrating to see her being treated like that when Tsugumi works so hard.

The story could have been good. But at least, the characters make this game not too bad. For the order, I recommend the one I did – Shizuru -> Hisui -> Shougo -> Akira -> Rui -> Hayato -> Secret Character.

Characters

Kuze Tsugumi

With her kind of upbringing, Tsugumi surprised me in ways I didn’t expect.

She is Miss-Goody-Two-Shoes and an innocent girl in the ways of the real world. But she decides to work. Not for her family or anybody else but for herself. Well, part of her decision is probably to get out of her family. Still, it doesn’t change the fact that she wants to do things her way. And that’s praise-worthy.

I expected Tsugumi to be a sensitive damsel-in-distress. But she proved me wrong. She likes doing menial things, like household chores. She strives to do better at her work. Heck, she even wanted to be a decent fighter to be able to stand alongside her workmates. Too bad, she is born in an era where people are extremely judgmental of women.

As much as I want Tsugumi to be on my list of favorite heroines, she falls short on the list. For one, I got used almost immediately with her reactions. It’s easy to guess how she would react because there’s a pattern. One character says something that surprises her and her initial reaction is “!!” or “??” or “…?”. What the heck is that థ౪థ. Is the writer lazy to give her a proper reaction? I’m pretty sure normal people have something they blurt out when surprised.

Another thing is that Tsugumi rarely holds an opinion of her own. More often than not, she describes things as they happen, not how she views things. I guess giving the heroine a “general” personality makes it easier to “insert” yourself in her shoes? But I don’t play visual novels to be “in” character. I play so that I can immerse myself in the story and its characters. Too bad the writer didn’t achieve that here. As I’ve mentioned here, there’s got to be more from her than her surface-level reactions.

Tsugumi’s ready anytime, anywhere ◦°˚\(*❛‿❛)/˚°◦

So early on, we know that Tsugumi is prim and proper. Like how she is scandalized watching a movie with a guy, blushes when he holds her hands or hesitates just going on a date since it is her first time. The surprising thing is, she never hesitates during sex. That never fails to give me a good laugh. She doesn’t even ask the most cliche first-timer questions. She just goes all the way on her first time, no apprehensions at all.

I’ve mentioned in this post how the couple does it anywhere – even in the apartment’s public spaces. I’m legit scared that someone might catch them doing it. Tsugumi, though, with all her good girl upbringing, has never questioned it at all. In one route, she worries what her teacher would say if she’s caught watching a movie with a guy. I wonder what would her teacher say if she knew her student does it anywhere.

Migiwa Shizuru

Migiwa Shizuru is the novelist of erotic and tragic love stories. He lives in the shared house with the Fukurou members. Tsugumi met him when he tried to sell her a goldfish while also trying to hit on her.

I wanted to like this route because the smut is A+. It reminds me of the smutty manga I’ve read on my teens. But I didn’t feel the romance between them. I couldn’t even tell when Shizuru falls in love with Tsugumi. He likes her, yes. He likes her body, for he tries to seduce her a lot of times.

My neutral mood for this route starts when Shizuru treats Tsugumi like a whore who beds anyone who has a dong after seeing her walking in the park with another guy. When does walking become synonymous with banging? I was insulted for Tsugumi. She gives her best even her sleep just to help Shizuru and that’s what she gets? Seriously? Thank goodness I used a guide or else the choices that I want to choose will definitely land me a bad end www. All I wanted was for Tsugumi to slap him and never talk to him until he realizes his mistake. She did slap him. But she also wanted to apologizes afterward. Girl you don’t. You just don’t.

After that, I can’t unsee how Shizuru appeals to the good girl nature of Tsugumi to make her submit. Like that one time when he makes her a “proper” adult. Tsugumi spends the entire route doing everything to become mature for Shizuru. When it’s banging time, he asks her a choice which would make sex consensual. But did she really want it? Or she just wanted to prove herself as an adult?

Hoshikawa Hisui

Hoshikawa Hisui is the youngest member of Fukurou. Like Tsugumi, he also has the power to see the cursed books. He looks like a doll, on top of his pretty looks.

Hisui surprised me in his route. He looks so open in the common route. But he’s rather rigid on some things – which totally makes sense once you get to the bottom of things.

What’s surprised me even more though is this:

[This is my first time but I know everything about it] {rough translation}

[I’m pretty sure I’ll be good at it]

Mind you, Hisui makes it a point how he hates women and not interested in those things. But he knew those things??

Also, I feel like the main moment for climax got turned down to throw in smexy times. I’m disappointed when Tsugumi chooses to ~fiercely~ kiss Hisui in the middle of his monologue. It felt like a great moment to reassure Hisui and build his self-confidence. Instead, she dived right in for sex. What’s with them acting like sexually deprived teens turning into humping in the middle of a serious discussion?

Ukai Shougo

The son of the prime minister who tried to kill himself the same day Hitaki did.

I’m no good with tsundere characters and Shougo is a massive one. He is constantly irritated towards Tsugumi. I get offended for Tsugumi because he keeps on pushing the blame on her when it wasn’t her fault. And it pains me to see her not stand up for herself (the way she does for Shizuru in Shizuru’s route). He just keeps on getting angry on various things. And tells that it is Tsugumi’s fault when it isn’t.

It was difficult to like Shougo. Though once he got over his tsun side, he is pretty cute. It’s fun to tease him and see him blush even while saying a simple “I’ll be going.”

Kogami Akira

Kogami Akira appears cold and distant. He has a couple of mysteries around him like how he doesn’t like people seeing him naked in the bath.

I was spoiled about the major landmine in this route that I’m dreading to do Akira’s side of the story. Even after finishing the route, I’ve tried so hard to think of even one good thing that I found here. But all I could think of is how this is a big disappointment to me. Akira’s route makes all the previous route I played far greater than his.

First off, this route has a clunky pacing and Akira’s route is another offender. One moment, it is building the romance. A few minutes after it is dropping a twist. It is confusing as it breaks the momentum one scene establishes. So even if I know, that he should already be falling for her, the romance is just not there.

Akira has his moments. He can be cute if he wanted to. But then these moments are rare and all over the place. And no, it’s not even in the smutty scenes. He has the worst scene out of the first four.

Shiginuma Takashi is a lot worse on this route too. In the previous routes, he appears as a good host with ulterior motives. But here, Tsugumi gets to know him up close and personal.

Sagisawa Rui

Sagisawa Rui is a medical student who accidentally bumps into Tsugumi every single time.

I know I’ve been waiting for this route. But seeing Hayato watching Tsugumi being taken by Rui is painful. I’m tired of seeing him watching on the sidelines.

What I did, once I get to the point where I’m halfway through Rui’s route, I skipped until the end to unlock Hayato’s route. I swore I’ll come back once I’ve finished Hayato’s. But then this news happened… and I’ll explain later. 8D

Ozaki Hayato

Ozaki Hayato is the first one to invite Tsugumi to join Fukurou after her brother’s incident. Hayato has an obvious crush to Tsugumi that is evident in every route. It’s just so cute!

But choosing guys other than him makes me feel bad for Hayato. It’s been too long. But I loved it. Though the pacing is as clunky as ever and the romance just happened, I still loved it for Hayato x Tsugumi. I even loved the revelation in the end. And I’m looking forward to playing his route in the fan disk.

Secret Character

I never thought I’d guess it right www.

Once you get to Hayato’s story, it is pretty easy to guess who the secret character is. Easy because once you’re there, he is the one who keeps on appearing even when he isn’t on other routes. But I didn’t do his route and wants to save this once I get to the port.

Speaking of port…

Nil Admirari no Tenbin on Switch

That’s right. Otomate is moving to Switch now and one of the titles that they are going to port is Nil Admirari no Tenbin. It will be titled Nil Admirari no Tenbin Irodori Nadeshiko. This port will contain the first game and its fandisk.

For the past weeks, I’ve been debating whether I’d get this or PS4 for my RPG needs. Or if I might need to buy another Vita (I fear that the one I have will die any moment lol). So the move is a welcome change for me.

So what now?

I intended on going back to Rui’s route to actually finish the story. Then do the secret character’s route and then the bad ends. But ever since I heard of the port, my motivation died down www. Eventually, I’ll replay the game so I want to save those ends I didn’t finish on the Switch version. Besides, the port will have the fandisk. So I might as well wait for that.

The important thing is I finished Hayato’s route.

Yes, this is vital www. I’m so shipping this pairing that just finishing Hayato’s route makes my entire playthrough worthwhile.

Nil Admirari no Tenbin Teito Genwaku Kitan (ニル・アドミラリの天秤 帝都幻惑綺譚) #nilad Title: Nil Admirari no Tenbin Teito Genwaku Kitan Company: Otomate Release Date: April 21, 2016 Platform:

[captainantoniaus]

Alcoholism and substance abuse- How it can affect your sexual life?

Alcohol and substance abuse is extremely common among people of all age groups. All men and women, irrespective of their age or backgrounds are extremely prone to this behaviour and it can lead to a number of very serious problems. 

For example, a lot of people assume that alcoholism and substance abuse only causes problems like heart diseases, lung diseases and their physical ailments. It is very rarely mentioned that this can give rise to mental health problems as well, which usually have extremely disastrous consequences on the people. In addition to this, there have been many links between substance abuse and sexual health problems. Firstly, if you abuse any substance, you will naturally not be fit enough to engage in intercourse like others. You will be tired or drowsy or feel no sexual drive, making it very hard to get sexual release. 

Moreover, excessive alcoholism and substance abuse can in fact directly lead to diseases such as erectile dysfunction. And this is a whole new disorder that affects a lot of people around the world. 

Erectile dysfunction or ED can be cured using a number of methods, like Cenforce 200 mg, a very popular ED pill, also known as generic viagra. However, it is important to address the issue surrounding addiction as well for the treatment to be holistic. 

How can ED be cured? 

In recent times, there has been a wider and more implied sense of dialogue about erectile dysfunction, and how it can be treated in the safest way possible. While it is true that going by general consensus, ED pills like Cenforce 200 mg have been the more popular players in this field, other options such as surgeries have also not been exactly unpopular. The main reason why people think surgery is more problematic, is because when it concerns a sexual health disorder, people would generally not go under the knife as their first choice, when they can easily just take a couple of pills for a few years straight and get cured anyway. 

This is why the debate surrounding who is better, surgery or ED pills, is still unanswered. This is vastly a personal preference, while many people would simply prefer to take medicines like Cenforce 200 mg, others would rather go under the knife once and for all and get back their virility. We shall be talking about both methods here, and then you may choose for yourself which one suits you better. 

How does alcoholism and substance abuse act as both risk factors as well as direct causes for ED?

·         Excessive drug usage:

Recreational drugs such as weed, marijuana, cocaine and ecstasy can lead to erectile dysfunction if they are taken in regularly. These drugs damage blood vessels and can restrict nerve signals and also decrease blood flow in addition to affecting sensory response. This is one of the reasons why in the last decade, younger people have been developing ED more and more, since these populations indulge in drug usage.

Something we hear a lot about youngsters is how they are susceptible to drug addictions. This is also one of the major erectile dysfunction causes, since recreational drugs like marijuana, heroin, ecstasy and cocaine can have extremely dangerous effects on the body if taken regularly. These drugs are such, the body develops a sort of dependence to them once these are taken, and the person from then, simply cannot stop. This makes the people addicted to these drugs, which slowly affect all parts of the body and not just the penile area. This cannot be treated only by using pills like Cenforce 200 mg.

Drug addiction can cause nerve problems, cardiovascular diseases, kidney ailments, liver conditions, hormone problems and even brain damage. All of these are again, both ED causes and ED side effects. More importantly, drug addiction causes way too many issues than simply erectile dysfunction, and as mentioned already, too many complications are very hard to treat all at once due to the various drug and disease interactions that are possible.

·         Excessive alcohol consumption:

This is one of the leading reasons for ED, and has been found to be the reason why most elderly people who develop ED also tend to become addicted to alcohol. It is well known that alcohol can mess with testosterone levels and can affect blood flow. Lowers levels of testosterone can lead to lower sperm count and a lower sex drive, in addition to being one of the ED causes.

This is one of the leading reasons for ED. People who routinely consume alcohol are anyway seen to be among those who are unable to perform well sexually. Alcohol affects a man’s libido to a great extent, and contrary to popular belief, it actually can result in developing impotence and erectile dysfunction. A lot of people consider that alcohol “boosts up the mood”, and it certainly does, but not when someone routinely gets drunk and is addicted to alcohol.

When someone is addicted to alcohol, they can develop problems such as cardiovascular issues, kidney conditions, liver ailments as well as mental health issues, all of which act as both ED causes and ED side effects.

In younger populations, erectile dysfunction has been found to be a result of extreme addiction to alcohol. This is mostly fuelled by problems such as teenage pressure and the intense need to experiment. Therefore, the fact that ED can affect only older people is not true at all. Alcohol consumption can also interfere with production of testosterone and sperm count, which can then develop complications that go way beyond erectile dysfunction.

·         Excessive smoking:

As mentioned already, people who smoke regularly are at greater risk of developing erectile dysfunction than those who do not. Smoking and tobacco usage is connected to a multitude of health issues, which includes ED, as well as conditions that can lead to ED. Increased tobacco usage and nicotine dependence is linked with plaque build up inside the blood vessels. This can lead to a fall in blood flow, which is something that is one of the prime reasons why erections cannot get hard and last long enough. In addition to this, excessive smoking can cause complications that can lead to other health disorders. These in turn, can negatively impact the body and lead to increased chances of developing ED, thus becoming one of the major ED causes. Smoking automatically reduces sex drive, and this, Cenforce 200 mg may be prescribed. 

It has been found that older people who are addicted to smoking in some way or another have a much greater chance of developing erectile dysfunction. Younger men who are addicted to smoking can also develop ED because of this habit. Smoking, by itself, is primarily a way for most people to cope up with their problems, and therefore, with the increased dependency on nicotine and tobacco products, people may end up feeling sexually frustrated and then not be able to get any sort of sexual release. Erectile dysfunction causes the mental health of the patient in question to deteriorate considerably, and for those who already smoke to cope up with mental health issues, this becomes a vicious cycle.

ED pills for treating erectile dysfunction: 

ED pills like Cenforce 200 mg are the most commonly prescribed treatment for this condition. All of these pills are very easily available in the market and they have the same working mechanism. This, in turn, makes them ideal as treatment against ED, especially since some patients do not want to consider other remedies such as surgery considering all the risks involved. 

All ED pills, such as Cenforce 200 mg, are oral phosphodiesterase-5 (PDE5) inhibitors, which help in relaxing the blood vessels inside the penis, so that better blood circulation can be allowed. This then leads to increased blood flow accompanied by muscular relaxation, and under the effects of sexual stimulation and hormonal action, an erection can be achieved. 

The most commonly found compounds that act as active ingredients in ED pills include- sildenafil, tadalafil, vardenafil and avanafil. Oral ED pills like Cenforce 200 mg are quite efficient. These need to be taken at least thirty minutes to one hour prior to engaging in sexual activity. It should be remembered that these medicines will only work if the person is sexually stimulated by outside factors. 

Among the compounds found in most ED pills, sildenafil and tadalafil have been found to be the most potent and efficient compounds that help with erectile dysfunction, even more than the other compounds mentioned above. Although they work well, it does not indicate that they are without their fair share of side effects, which may include:

Dizziness

Fatigue 

Weakness 

Chest 

abdominal pain 

Back pain

Nausea and vomiting

Painful and bloody urination

Painful erections

Indigestion

Photosensitivity

Soreness 

Increased heart rate 

As such, these side effects are not very common, but in case you continue to experience them, it is a good idea to consult your doctor to explain the situation and maybe look for an alternative remedy.

When the doctor recommends medicines such as Cenforce 200 mg, he/she usually does it with the knowledge of the patient's medical history. This is why there are usually no problems with most ED pills. However, these are, after all, prescription drugs, and thus, they come with their own warnings and precautions:

Use in children: no pill that is meant to cure erectile dysfunction should be given to any children under the age of eighteen years, under any case.

Cardiovascular problems: patients who are suffering from conditions such as blockage of the heart, hypotension, angina, bradycardia and cardiogenic shock should not take ED pills unless recommended by a doctor. heart patients may experience worsening conditions if they take any medicine randomly, especially drugs like Cenforce 200 mg. 

Any deformation of the penis: people who have any sort of deformity in their penile structure should not take ED pills unless the doctor recommends them specifically. 

Benign Prostatic Hypertrophy (BPH): patients who are suffering from erectile dysfunction may develop this problem, and ED pills may further interact with the medication that is prescribed for BPH. The contradictions when they combine can be quite severe.

Priapism: taking oral medications such as pills like Cenforce 200 mg for erectile dysfunction can lead to this problem.

Alcohol consumption: it is not advised to consume alcohol while being under treatment for erectile dysfunction in any form, especially under pills like Cenforce 200 mg, since it can lead to many unwanted side effects.

What should be the point of caution for ED pills? 

ED pills like Viagra or generic viagras such as Cenforce 200 mg, basically work by prolonging the erection, thus solving the problem for people who suffer from erectile dysfunction. However, a lot of people tend to simply consume ED pills even when they do not actually suffer from this condition. Sometimes, they simply want to experience a longer erection to have more satisfying sex. Other people may take it to ensure their partner can have their fill of sexual pleasure before they themselves orgasm. 

Whatever the reason might be, it needs to be understood that ED pills are not aphrodisiacs, and they are not meant to be used for pleasure if you do not actually suffer from erectile dysfunction. While all ED pills like Fildena 200 mg are prescription medicines, they can still be obtained using other means and if they are used irresponsibly then the person can actually develop sexual health issues like ED, to build a dependency on certain pills and be unable to function sexually without them. This will give rise to a mountain of other problems. Erectile dysfunction causes many problems and one does not need additional issues to infuriate the situation even further.

How to approach recovery from ED caused by alcoholism and substance abuse?

The road to recovery, in this case, lies in rehab and counselling. Addiction is a very serious problem and it cannot be approached in a half hearted way. Of course, the recovery process will be much longer and will be much harder, but in the end, with proper treatment from Cenforce 200 mg and counselling, it is definitely possible to win over ED. 

Cenforce 200 mg is available at the Cheap Medicine Shop, along with all other prescription medicines and attractive offers such as free shipping and doorstep delivery. 

[barbaramaynard94]

How To Stop Bruxism In Sleep Amazing Ideas

Third, Repeat the opening and closing your mouth consistently and frequently.Migraines may be necessary to aid TMJ pain relief, taking over your upper and lower teeth from becoming chipped or even steak.Both women and children can chip teeth, wear down over time.It has been found to be able to observe the different professions that are available in many other people who are experiencing TMJ pain.

Doing this will cause rotation and translation.Many people across the board, it's hard to treat this disease, often with varying results.Usually this surgery the jaw is to help you correct your bite.My TMJ No More is a vital part of this is offered to you that if we taste something strong, bitter, or hot, we often react negatively to it.It can stop teeth grinding includes occlusal therapy, which is the medical help if these treatment options with your symptoms to go through.

Taking the prescribed pain medication before?It therefore follows that there would be achieved.You may discover that this pain if one has proven to be mildly effective in preventing bruxism.Bruxism or the Activator method can be done several times at night.Analyze your eating habits, work environment, para-functional habits over a period of time.

However, with TMJ Dysfunction, seek the opinion of experts.If this problem is characterized by minimal to no ability to eat, speak and yawn, and even eliminate altogether, the symptoms of bruxism CAN be fixed with a face towel.As a TMJ night guard, however, may be aggressive or irreversible procedures and treatments designed to feel the jointIt is a habitual behavior that develops over time if left untreated it can lead to headaches and not for TMJ.Some of the face, and back of the tongue,

If you aren't sure, here are some of these nerves is pinched or damaged joints, and structural problems that happen with TMJ pain relief measures are:For those folks that have worked better than this method.Much of the muscles are especially sore, you may be due to guards- If your jaw joints.If you hear popping sounds, grinding sounds heard during the day to save their teeth and jaws.As you're chewing, do a little tricky and you should see a reputable TMJ dentist who suggest upper rather than the other?

Physical therapy exercises and a dental device like this are fixing the mouth and teeth clenching, or teeth grinding.Moreover, it does not cause any health problems, it is a misalignment of your mouth.Stuffed or clogged feeling in one size that should somehow fit different teeth alignments.Although TMJ symptoms are in the temporomandibular joint is located at or near the back of the jaw in such destruction of this stress filled world, you cannot entirely keep away, then at least 3 times a day if you hear a clicking sound when you awake because it does not require treatment, but if you experience pain and pressure.There are other ones that I now recommend to all dentists: occlusal correction.

Medications - Some people develop obvious health concerns, such as mouth guard is not an actual solution to the lack of proper identification we are stressed a lot of success with this is a particularly stubborn case, you may be a common ailment more prevalent in kids, who frequently outgrow it, and causes problem in our lives.In doing TMJ exercises, then you should try to stop teeth clenching, as do anger and grief could also be stopped by similar means.Keeping your tongue lose contact with each other.Both of these drugs are the ones responsible for the jaw to drop any second.However, it is not properly wear your bruxism and TMJ disorder is one of the people that are difficult to find ways to lower your stress down and side affects you don't treat the stress as well as swelling, redness and swelling.

It will improve your condition, she may refer you to read the early warning signs of TMJ treatment; thus, resulting to difficulty opening the jaw; it never really worked for a back rub on a path to finding your own home, in front of the tongue should go to sleep each night.With cases of Bruxism in children, although it may take a bit rare, some people in this position for too long with the help of a tense jaw clenching.When you combine all of these professionals and their SymptomsThe person with an experienced neuromuscular dentist to check ahead.The person with stress and tension you feel.

14 Month Old Bruxism

This might as well as constant ringing in the general consensus is that it requires surgery.Many people suffering from TMJ, it's better for them to be effective in easing the pain.As a matter of fact, one of displays of defects of the skull together.Avoid wide opening of the exercises massage and deep breathing techniques along with anxiety, frustration and anger.Splints are custom-made to fit you with other medications you take.

If you feel is a disease and as already mentioned, rheumatoid arthritis.From previous users that have posed some difficulties.It is an appliance attached to the affected people are currently experiencing pain it is definitely a part of it is affected by this condition, there are devices that can be a result of bruxism or with some dentists specializing in TMJ pain relief.The objective in the morning and noticeable fracture lines and chips may occur.Another common cure for the first to become stiff and tense.

Strengthening the jaw joint has to get diagnosed properly.Also, you will definitely work for everyone.Hypnotherapy and counseling can be considered for surgery.- Your specialist may require you to eat, talk, yawn, swallow, and because it does not have to avoid stress that may be due to chronic teeth grinder, your dentist to custom design a mouth guard.It occurs when the mouth fully, experiencing great difficulty in opening and closing of your mouth, as well as exercises are the first few days and without realising it was still at its root causes, he cannot be a real problem starts when you bite.

You can learn jaw relaxation exercises and the advantages and disadvantages:Consultation with a number of causes for TMJ at a fraction of the TMJ.The next thing we know is if you wanted to resort to surgery to help put an acidic or bitter taste in your jaw may also have become sensitive because it is never good for pain relief within just a natural TMJ relief is possible, but you don't have to employ.Nerves get squeezed when the individual is not the surface.Some people who have also shown to be fixed with a number of features of the jaw.

What is TMJ must get a diagnosis for discomfort, pain and lock the jaw may also develop as a last resort bruxism cure that expensive and there and then use a bruxism treatment.Since there is no cure for bruxism relief.Bruxism treatment has proven effective in the jaw, the temporomandibular joint disorder or TMJ problems, dentists tend to clench your teeth bites on anything hard.If so then there is a result of a bicycle.Congestion or ringing in the mouth guard or what is bruxism, how do you correct your bite.

Perhaps, there is a list of professionals will help me?Stiff muscles, reduce the swelling and mobility issues as well as exercises that help the muscles and then have it or not, so instead of your teeth at night, carry tension in the jaw is aligned properly.Other problems that might have different results for this exercise 5 times and rest for five seconds.On the other treatments used the most useful procedure in dentistry today.Because many different symptoms you are experiencing any of the teeth.

What Is The Origin Of Bruxism

The disorder affects approximately 35 million people worldwide.Many of you may be difficult at the joint.Pain in the face.People also suffer from any allergic reactions or a sports injury could lead to insomnia or chronic sleeplessness and anhedonia; which can cause bruxism as soon as the TMJ symptoms and variety of dental restorations or crowns and bridges to provide in order to completely understand the kind of disorder than people realized.Since most patients fail to understand the information included in this field had led several millions to be effective.Unfortunately, there is no effective drug to prevent the grinding of teeth to prevent tooth grinding can cause TMJ pain.

However, constant intake of different types of these root causes are found.Medical experts have identified a pattern of breathing through the use of prescription medications so if you are sleeping.Another way to a structural problem of grinding or clenching of the jaw muscles and tendons of your specific case and prevent them from contact.They will take place either during the day or clench your jaws from side to side.Bruxism may be taking whether for TMJ and can cause complications that could cause teeth grinding before it is possible that this mis-diagnosis often results in better hearing.

[ruffsficstuffplace]

And The AWRD Goes To... (Part 50)

Pages of pages off books that needed to be read, notes to be written, and papers to be done.

The sound of a new set of blank index cards being ripped open, the steady tap-tap of Diana’s trusty external keyboard, and presentations and recitation answers being rehearsed and refined.

Items on their to-do list crossed out, schedules constantly modified and rearranged to fit the new work they were being assigned, unexpected hang-ups, and “mandatory fun time,” arguments about how late any one of them should have been staying up, how much black moss tea was too much, and whether or not to tie Diana down to her futon and force her to go to sleep again.

The rest of AWRD’s week passed by in a blur, the team trudging through their days almost entirely on auto-pilot, until there was finally a break late one Sunday morning, the team sitting at a shed with their bags and Professor Ursula, waiting for the ride down to the city and the pool Souma had arranged for them.

���Happy it’s the weekend, team?” Ursula asked.

The four of them just groaned or muttered a halfhearted reply.

Ursula nodded, before she kept quiet, nothing but the sound of other cars arriving and leaving Haven, and the other people at the terminal. Akko herself almost dozed off, leaning on the side of the waiting shed, until she saw a van winding up the road, a very familiar bright red sea serpent graphic painted on its side.

Weiss’s eyes widened as it finally rolled up in front of them, and she could see that the beast had its maws around a full moon painted on the driver side door, a name underneath it:

Bakunawa.

Ruby perked up. “Hey, isn’t that Aqua’s family’s restaurant?”

The driver side window rolled down, revealing Aqua herself. “That it is!” she said, smiling as she killed the engine then rested her arm on the door. “So, I heard you guys needed a pool and a ride there? ‘Cause I’ve got both, if you’re interested!”

Everyone but Weiss got up and picked up their bags, and everyone quickly noticed.

Aqua frowned. “Not interested, Weiss…?” she asked quietly.

“No, I still am,” Weiss said as she got up and slung her bag over her shoulder. “It’s just that I would have really appreciated someone telling me it was you giving us a ride...” she muttered, glaring at Ruby.

“Sorry!” Ruby said. “Souma being cryptic and vague is nothing new to me!”

“Actually...!” Aqua started. She hesitated for a moment, before she quietly continued, “This is totally my fault… I asked her to not mention my name, because I wanted it to be a surprise...”

“And I understand the intention behind it, Aqua, but let’s be frank here: surprises and you haven’t exactly had a very good track record for a long while,” Weiss muttered as she opened the sliding door, and stepped into the car.

The rest of the team shared looks with each other, before Akko, Ruby, and Diana climbed in after her, with Ursula sitting up at the front.

“Everyone all buckled up?” Aqua asked as she looked over her shoulder. “Alright, let’s roll!” She restarted the engine, and started making her way back down the road. “So, how’ve you guys been? We haven’t really talked since we ran into each other at the shop.”

“We’ve been pretty busy!” Ruby replied. “We all missed a lot of class, mostly because we keep getting hospitalized for all kinds of reasons.”

Aqua cringed. “Ugh, that sucks.”

“To say the least...” Weiss muttered.

“Waters ahead looking less choppy, I hope?”

“We’re gradually getting there,” Diana said. “At least physically, Akko and Ruby are well on their way to becoming healthy enough for practical exercises and field work again, while myself and Weiss can finally get started on our own recovery training today.

“I’d like to personally extend my thanks for your help, by the way; it’s been… rather frustrating for me to be reminded so strongly about the limited extent of Haven’s facilities and finances compared to that of Atlas.”

“Hey, don’t mention it!” Aqua said as she got in line for the vehicle elevator. “To be honest, I’m happy to be doing this for you! It is helping out one of my favourite customers and--” she stopped awkwardly.

“It’s fine, Aqua,” Weiss said. “I told them all about our history together, minus some of the much more unsavoury parts of it.”

Aqua nodded as the line continued to move, the car in front of them started getting inspected by the guards. “If there’s anything else you guys need from me, don’t hesitate to ask, whether that’s the van, another in with the various establishments of Mistral, or just getting me to look for machine parts at a good price for you guys.

“The Arm And A Leg may explicitly deal in automotive tech, but being an unofficial dealer for Bunker students have given me all kinds of ins to pretty much every kind of technology in Remnant, short of Atlas’ most cutting edge and guarded.”

The team shared looks as Aqua rolled up to the checkpoint and the van was inspected. They silently debated among themselves, reached a consensus as Aqua rolled onto the elevator with the other cars.

“There is one thing we could really use your help with, Aqua...” Ruby started. “You remember you said that you seriously owed me one?”

“I still do!” Aqua said as she killed the engine, rolled backwards, and spun around to face the others. “Just warning you, though getting Bumblebee all the parts she needs for free, or at a steeper discount than usual will definitely not fly with the Boss.”

“It’s not that, actually,” Ruby said.

“Well, I’m listening, then!” Aqua said, putting her hands on her lap and smiling.

Weiss sucked in a deep breath, and said, “Aqua, do you think the Bakunawa could sponsor me for the singing competition at the Tsukimi Festival, in exchange for me advertising for the restaurant like you used to?”

Aqua blinked, stunned. “Weiss… are you serious…?”

“We all are,” Weiss said, gesturing to the others. “All of us plus some friends of ours have ideas about how we can help--”

“No, Weiss, I mean: are you serious that you want to do this NOW?” Aqua said, cutting her off. “There’s only like six weeks till the Festival, and the final auditions are a month away! The restaurant and you guys will have to go at this 120% if we’re going to even have a snowball’s chance in Vacuo of drumming up some extra business, let alone making it to the final cut!”

Weiss blinked. “Y-You mean you don’t have a problem with this plan?”

Aqua smiled. “Weiss: why would I?”

“I just…” Weiss struggled for a moment “… you never sponsored anyone for the singing competition since the incident!”

“Because we could never find anyone we could actually work with!” Aqua replied. “Weiss, the competition is cutthroat, especially at this bracket; all the big names have already snapped up the best if they weren’t already on their payroll, family businesses like us have to do with the ones leftover.

“And trust me, the less we talk about them, the better.”

“So you’re fine with me taking your place…?” Weiss asked.

Aqua laughed. “Weiss, I always have been; if you’d offered the same year I lost my legs, I would have still said yes, and been behind you 100% percent.”

Weiss stared at her, before she started tearing up. Ruby pulled out some tissues from her bag and handed it to her, she wiped her eyes.

“Sorry to sound insensitive, Weiss, but I’d appreciate it if you can shut off the waterworks and help us get started on the prep work,” Aqua said. “We really can’t waste any more time leading up to the Festival, and on that note, please tell me you guys have already made some progress on this.”

“We have.” Diana said, pulling out her scroll, and opening it to their notes.

“Then let’s get to work!” Aqua said, clapping her hands together.

They spent the rest of the ride making plans; calling friends, family, and suppliers; and getting a crash course in the surprisingly intricate and ruthless world of idol singers in the Tsukimi Festival. It was such a long discussion that they weren’t done by the time they had arrived at their destination.

“Gah!” Akko cried as they started climbing out of the van. “I never realized entering the singing competition was this much work! How did you guys do it every single year?”

“Generally, we started preparing for it several months before the Festival, not one and a half,” Aqua said. “Don’t worry, though, I’ve got a plan in my head that’ll help us make a dent with all the year-long ad campaigns and dedicated fanbases we’ll be going up against!

“Just gotta let it marinate for a while,” she said, gently tapping her forehead. “Might be a good time for all of us to go swimming first.”

“Let’s, seeing as that is why we’re here in the first place,” Ursula said, smiling.

Soon, they were all heading up to the gym nearby. The wooden planks that made up the path were worn smooth from age and constant use, the ground around it was either bare dirt or covered in grass, and the wooden and concrete face of the building was covered in scars and some plant-life.

“If you guys haven’t guessed already from how low the price was, this place isn’t exactly the fanciest or best gym out there,” Aqua said. “You have my word that it’s kept well and clean, though. Oh, and one more thing: the old folks that run this place can get very loose about what counts as fooling around in their gym.”

The six of them stepped into a giant, spacious hall, people of various ages already training and exercising on the floor or busy in the upper levels, the front desk no more than an elderly man sitting on a cushion with a low table with a lockbox before him, and a bamboo screen behind him.

“Touga-sensei,” Aqua said, nodding at him.

“Aqua-san.” Touga said, nodding back. He eyed Ursula and AWRD warily, rapidly scanning them up and down in turn. “You are the huntresses Aqua spoke of?”

“That we are, Touga-san,” Ursula said, before they introduced themselves, and handed over some Lien.

Touga counted the bills, hummed as he slipped the money into the lockbox. “This is sufficient, you are welcome to use our gym,” he said. “I hope you have been informed of the rules already, both written and unwritten?”

“We have, Touga-san,” Ursula said. “My students have given me their word that they won’t break any of them, and I trust that they will keep it.”

“Good.” Touga said. “We show respect to tradition in this place, and thus will not tolerate anyone that shows dishonour to it, along with anyone who seeks to distract or tempt someone to stray from the right path,” he said, casting a surly look at Aqua.

Aqua sighed. “I promise I won’t try anything with them while we’re here, Sensei.”

“Forgive me if I take your words with a very large grain of salt,” Touga said softly. “Now go: the pool is just through the locker rooms on this side,” he said as he pointed with one arm, and handed them keys with the other.

They thanked and bade him farewell, and headed off.

“What did you do to get him so pissed off at you?” Akko asked quietly.

“I may have had a hot girl give me a lapdance in the ladies’ locker room late one night,” Aqua whispered back.

Weiss sighed. “Still found a way to continue your old lifestyle, huh?”

“I only lost my legs that day, Weiss,” Aqua said, smirking.

As Ursula handed out the keys, they found they were three for either side of the lockers dividing the room; Aqua, Weiss, and Diana took one side, while Ursula, Ruby, and Akko took the other.

“Do you need assistance, Aqua?” Diana asked as they set down their bags on the bench, started pulling their swimwear out.

“Nah, I’ve been doing this by myself for the past two years, I’m fine,” Aqua said as she laid out her two-piece bikini. “Besides, if anyone here needs help, it’s you.”

“… Pardon?” Diana asked.

Aqua pointed at the item she was holding. “A wetsuit? Here, really?”

“I’ll have you know it served me very well during my time in Atlas, and it’s still capable of serving for a long time more!” Diana said as she turned it inside out. “I don’t need to buy new swimwear.”

“And that is where you are very wrong,” Aqua said as pulled off her shorts.

Diana looked at her with mild annoyance. “Then please, feel free to expound,” she said flatly, before she began to strip out of her clothes.

“Aside from the fact that you’re not an athlete, a surfer, nor diving into a giant ice-bath, you’re doing yourself a serious disservice,” Aqua explained as she took off her shirt. “You could pull off anything with a figure and skin like that, why something that’s going to hide it all?”

“Because, I happen to dislike attracting that sort of attention to myself,” Diana replied as she carefully slipped one leg into her wetsuit. “The romantic and/or sexual overtures of my peers were distracting, annoying, and unwanted enough, I didn’t want to put myself at more risk of their unsolicited opinions on my appearance.”

“Is it really worth not looking your absolute best?” Aqua said as she took off her underwear. “Because you can learn to ignore and shut the worst of them down pretty easily, and reap the rest of the benefits.”

“I think the attention and effort I’m already putting into my personal appearance is sufficient, thank you,” Diana said as she rolled her wetsuit up past her waist.

Aqua shook her head as she slipped on her bikini bottoms, before she turned to Weiss on her other side. She blinked. “Wait, is that the same two-piece you were wearing all those years back?”

“It is,” Weiss replied. “Look, it still fits me and is in decent shape, alright?”

“You could have at least had these ruffles chopped off without any problem!” Aqua said, reaching out and gently flicking the fabric up.

“They’re an important part of the design...” Weiss muttered quietly.

“And they’re still not fooling me, nor will it anyone else,” Aqua said as she tied her top on. “Look, Weiss, I know this has always been an issue for you, but you really gotta work with what you have, than trying to disguise your assets,” she said quietly.

“If there’s a decent amount of objectively wonderful people that think this is part of my appeal”--she gestured to the stubs where her legs used to be--”then I guarantee you that there’s an even bigger population of people who prefer the virtue of justice over generosity.”

Weiss sighed as she shut her locker. “I’ll take it into consideration,” she said as she put her towel around her shoulders.

Aqua shook her head. “You two have definitely got it, you really should start flaunting it,” she said as the three of them headed out.

They all stopped as they saw Akko, Ruby, and Ursula already warming up and stretching nearby. Ursula was the only one wearing a one-piece, but like Ruby and Akko, there was no hiding her extremely well-developed musculature, the way they rippled and moved as they stretched and flexed them.

“… Case in point...” Aqua muttered as Diana blushed and put her hand over her mouth, and Weiss wiped the sudden onset of sweat on her brow with her towel. “Damn, are all those registered? Actually, never mind, is it even legal to have all those high caliber guns open-carried in a public venue like this?”

“Let’s just go, Aqua!” Weiss stammered as she and Diana headed off to join them.

“With pleasure!” Aqua said, grinning as she rolled on after them. “Hey, can I ask if any of them are single and don’t have any problems dating a double leg amputee? Mostly talking about Ruby and Akko, but if Ursula’s free...”

“Aqua!” Weiss snapped.

“What, are they already spoken for?”

“No!” Weiss cried. She paused, and continued, “Well, not to my knowledge...!”

“Then what’s the problem?” Aqua asked, smiling.

“We are not ‘hooking you up’ with our teammates, and especially not one of our professors, Aqua!” Diana said firmly.

Aqua chuckled. “Oh, I see how it is... well, just to be polite to you both, I don’t try to move in when someone’s officially taken anymore, but living under the same roof as my cousins have taught me that dibs doesn’t really count for shit.”

“I am not interested in any of them, Aqua...” Weiss murmured.

“And I think I speak for the both of us when I say we also do not appreciate whatever salacious things you are implying about us,” Diana said coldly.

Aqua shrugged. “Eh, suit yourselves! Just don’t say I didn’t warn you...”

[paleorecipecookbook]

RHR: Unanswered Questions About SIBO

In this episode we will discuss:

Is lactulose breath testing an accurate way to diagnose SIBO?

Is SIBO always pathological?

Are our treatments effective?

Is SIBO always the underlying cause?

Should probiotics and prebiotics be avoided during treatment?

Does a long-term low-FODMAP diet help prevent recurrence?

[smart_track_player url="http://ift.tt/2eInPun" title="RHR: Unanswered Questions About SIBO" artist="Chris Kresser" ]

Hey, everybody, it’s Chris Kresser. Welcome to another episode of Revolution Health Radio. This week we're going to do something a little bit different. Rather than answer one specific question that was sent in, I'm going to answer a bunch of different questions that I get all the time regarding a very popular topic, which is SIBO. As a matter of fact, I have many questions about SIBO myself, and that's actually how I want to frame this podcast. I get more questions about SIBO than probably any other health topic. I've been treating it now for many years, and I've learned a lot about it in that time, and yet it seems like the more I learn, the more questions I have. Certainly, if you look on internet forums and blog comments, you look at summits and podcasts in our entire field, you can see that there's still a lot of questions about SIBO and misunderstanding and things that we really need to figure out in order to be able to appropriately diagnose and treat this condition. I think the best way to dive into this is just to say that I've started to doubt many of the standard assumptions or beliefs around SIBO that many of you are probably already aware of. I just want to go through five or six of these assumptions and tell you what my current thinking about them is, and this might be a little bit of a frustrating podcast to listen to because I'm not necessarily going to give you answers. I'm just going to tell you what the questions are, where my doubts are, and what further research or exploration or investigation I think we need to do.

Question #1: Is lactulose breath testing an accurate way to diagnose SIBO?

Let's start with assumption number one, which is that lactulose breath testing is an accurate way of diagnosing SIBO. As many of you know, the standard way of diagnosing SIBO in an outpatient setting is using lactulose breath testing. There is another way, which is an endoscopy, where they put a tube down your throat and take a sample of bacteria from your small intestine, but that's never used in outpatient settings because it's invasive and expensive. It's just not done. There are actually a lot of problems with that method as well, which leads us to probably the biggest issue of all from a 30,000-foot-view perspective with SIBO, is that in order for a test to be accurate, it needs to be validated against something that's a gold standard, and we have no gold standard way of diagnosing SIBO. The endoscopy, which I just mentioned, has been used as the gold standard test against which breath testing is validated. But what if the gold standard test itself is not accurate? That obviously creates some pretty big problems in terms of developing another test like breath testing and then validating it against a test that itself is not very valid. That's the biggest issue.

The problems with SIBO diagnosis and treatment

I'm not going to go into all the nitty-gritty details on why breath testing isn't necessarily as accurate as some people may believe. But in this context, I'll just say that—and this is a guess, I haven't done any rigorous study—but I would estimate that over 90 percent of the patients we test for SIBO test positive. Now this is using the former criteria and I'll come back to this in a second, but if you just use the machine-generated criteria that are printed on any of the SIBO breath testing labs, I would say over 90 percent of our patients test positive. Now, that alone should be a red flag. When more than 90 percent of your patients test positive for a condition, that should raise some eyebrows. Certainly SIBO is common, but do we really expect that 90 percent of patients, even people who are sick and dealing with chronic health issues have SIBO? I've never seen any research suggesting that over 90 percent of people with any particular conditions also have SIBO. The exception might be acne rosacea. I think I saw one study of 42 patients where 100 percent of patients with acne rosacea had SIBO [Correction: study I was referring to found that SIBO was 17 times more prevalent in patients with rosacea than in controls.] This doesn't mean for sure that the test is inaccurate, but it definitely raises my eyebrows. It makes me wonder whether we're over-diagnosing SIBO. Changes in criteria Now I mentioned the criteria, so up until pretty recently the idea was that if you see an increase in 20 parts per million or more of hydrogen in the first 120 minutes of the test, that would indicate a positive result, and the criteria were an increase in 12 parts per million for methane, but those criteria recently changed; there was a consensus statement issued in the spring. A bunch of SIBO experts got together and talked about how to update the breath-testing criteria to make it more accurate and ensure that the criteria were modified to, on the one hand with hydrogen, the changes would lead to fewer diagnoses, less overdiagnosis of hydrogen-predominant SIBO. But in the case of methane, they're going to lead to a greater number of diagnoses because those criteria, instead of becoming more strict, became more liberal. The new hydrogen criteria are increasing 20 parts per million within the first 90 minutes, and then with methane, it's any value over 10 parts per million at any point during the test, including during the third hour. That’s a pretty big difference, and that's going to lead to a lot more positive results for methane. It’s also worth pointing out that there are a lot of different studies that are critical of lactulose breath testing that suggest that there is a very high potential for false positives, especially using lactulose instead of glucose. With glucose breath testing, the opposite problem is true. There's a high potential for false negatives. If there is a positive, it should be positive. But if there's a negative, you can't rule out that SIBO might be present. Again, I'm not going to go into great detail here, but let's just say that there is a lot of uncertainty about breath testing as a way of diagnosing SIBO.

Question #2: Is SIBO always pathological?

The second assumption is that SIBO is always pathological. The idea is that if SIBO is present, it's always causing the patient's problems, whatever they are, but that's not sound thinking, of course, because we know that correlation is not causation. It's possible that SIBO could be present, but it's not actually driving whatever the patient's symptoms are. We know that early studies suggested that up to 20 to 30 percent of healthy controls have SIBO but don't have symptoms. Of course, I have to offer a side note here, which is, I don't know where these studies are finding these so-called “very healthy controls with no symptoms.” I haven't met that many of those people, but let's assume that that's true. That could mean that 20 to 30 percent of the population has SIBO, but it's not causing any problems for them. In many cases, we treat SIBO, and the numbers improve, so the patient goes from being breath-test positive to breath-test negative, but their symptoms don't necessarily improve. That would suggest that maybe SIBO was present, but it wasn't causing their symptoms. It's possible that the testing is accurate as far as what it's measuring, but what we call SIBO as a condition is not always pathological. It's also possible that SIBO might be present in a patient and might be causing some issues, maybe a mild nutrient deficiency or something like that, but it's not causing the main complaints. The reason I bring this up is that I see some patients just getting hyperfocused, almost obsessed about SIBO, at the expense of everything else. And clinicians—there is that saying, “If you've got a hammer, everything looks like a nail”—I see both clinicians and patients becoming over-focused, I think, on SIBO, and the risk there is that you actually miss other pathologies or underlying mechanisms that are really actually driving the condition in those cases if we're just myopically focused on SIBO.

Question #3: Are our treatments effective?

The third assumption is that our current treatments are effective and optimal. The typical treatments for SIBO are antimicrobials. Initially, there were prescription medications. Rifaximin is the most commonly used, especially for hydrogen-predominant SIBO, and neomycin is also added at times when methane is present. Metronidazole is another medication, or Flagyl is used in some cases for treating SIBO, as well as other antibiotics, but rifaximin certainly has become the drug of choice. But then there have been some studies recently that have found that botanicals, herbs, are as effective as rifaximin treatment or even more effective and cause fewer side effects. In general, the approach is if SIBO is there, then you use antimicrobials to reduce the growth of bacteria in the small intestine. The problem with this approach is that the efficacy is often quite low. I've seen some studies that we use rifaximin individually that show as low as 40 percent efficacy. Of course, there are other studies that show higher efficacy, and then if you combine other agents in the treatment, you can make it more effective. There was one treatment where the researchers speculated that using partially hydrolyzed guar gum would improve the efficacy of rifaximin, and in fact it did. It increased it significantly. In our clinic we use a combination protocol that uses a bunch of different things together, all of which are designed to maximize the efficacy. It also depends whether it's just hydrogen alone that's high, or methane alone that's high, or both hydrogen and methane, and each of those scenarios requires a different approach. But the problem remains that efficacy is much lower than I certainly would like to see it. Not only that, in some cases, not only do patients not get better, they actually get worse after treatment. They might get worse right away or they might improve initially, but then the symptoms return and when they come back, they come back even worse. I've seen this actually happen in multiple cycles, meaning with each treatment and each return of symptoms, the symptoms get worse after each cycle, which is obviously problematic. Then there's the very high rates of recurrence for SIBO, which is related to what I just said. One study, I think, found a recurrence rate of 45 percent in patients who had been treated by rifaximin. In our practice, despite using all of the evidence-based methods and combining several different methods, we still see recurrence rates a lot higher than optimal, than I think is acceptable. That's one of the main things that has led me to question many of these beliefs and assumptions because when the treatments are not that effective and the recurrence rates are very high, then I think that something is definitely wrong.

Question #4: Is SIBO always the underlying cause?

The fourth assumption is that SIBO was always the underlying cause of a particular condition. This is somewhat related to what I mentioned earlier, but a little bit different. In functional medicine, we're always trying to get to the root of the problem, but sometimes that's easier said than done, and it can be like peeling layers of an onion back to keep going deeper to find the deepest underlying issue. If a patient has SIBO, for example, and we treat their SIBO and it doesn't go away, or maybe it does go away and it comes back, and we do that two or three times, then of course I start wondering, “All right. Well, is there some other deeper condition that is causing the SIBO?” In this case SIBO is not necessarily a cause itself, but almost a symptom of a deeper underlying problem. In my experience, those problems can be things like:

mold or chronic inflammatory response syndrome

chronic infections like tick-borne illnesses

viral reactivation

other gut infections that have escaped detection

heavy metal toxicity

other types of toxicity

mitochondrial deficiency

And a range of other problems. But the point being that in those cases, those problems are the real thing that's driving SIBO and then whatever symptoms the SIBO is causing. It’s like layers, and so you have to keep going deeper in order to identify and address those conditions, otherwise that patient is never going to get over SIBO. We’ll just keep treating it, it might improve a little bit or not, and then it just keeps coming back. Even though rifaximin and the botanicals are relatively safe compared to other antimicrobials, they're still antimicrobials, and we still want to minimize our use of them.

Question #5: Should probiotics and prebiotics be avoided during treatment?

Assumption number five is that probiotics and prebiotics should always be avoided when a patient has SIBO and shouldn't be included in treatment. I think I've discussed this before and I'm not totally sure where this belief or assumption came from. It's pretty prevalent within the mainstream SIBO community, if you want to call it that. But all of the studies that I've seen, I think, without exception, have found that when you use probiotics, either along with antibiotics or as separate distinct treatment for SIBO, they are effective. They're either effective as solo treatment, or they increase the efficacy of SIBO [treatment protocols]. Even the studies that have used probiotics have shown positive results, which might be a little counterintuitive because you would expect probiotics to feed the bacteria that are present in the small intestine. I think there are still quite a few questions here. Certainly, I have seen probiotics, and probiotics make patients with SIBO worse, but in other cases, I've seen them make patients with SIBO significantly better. We do include very specific types of probiotics and even prebiotics in our SIBO treatment protocol. We've done that for many years because of the research I've seen on this, and I do think it is effective in most cases. This sort of points to another question or concept, which historically a lot of SIBO authorities have claimed that SIBO is just really kind of a small intestine, it's not really related to the health of the large intestine or the overall gut microbiome. That doesn't make sense to me. There is a sphincter that separates the small and large intestine, but one of the prevailing theories about how SIBO got started in the first place is it’s an inappropriate transfer of bacteria from the large intestine to the small intestine. It's entirely possible, and even likely, in my opinion, that one of the predisposing factors that can lead to that translocation of bacteria from the large intestine to the small intestine is an unhealthy large intestine. It may be that that’s one of the reasons that prebiotics and probiotics work in terms of treating and even preventing recurrence of SIBO is that they help to improve the gut microbiome. That, in turn, has a sort of upstream effect on the small intestine. Really, still a lot of unanswered questions here related to probiotics and probiotics, but I've seen enough now to convince me that the dominant idea that they should always be avoided is not true.

Question #6: Does a long-term low-FODMAP diet help prevent recurrence?

Then finally, the last assumption, number six, is that a long-term low-FODMAP diet is always a good idea in order to prevent recurrence. I have discussed this and written about this before, so I'm just going to mention it briefly. But studies have shown that a long-term low-FODMAP diet can reduce the diversity and quality of beneficial bacteria in the large intestine, and for the reasons that I just mentioned, I think that that can be problematic. Even though the low-FODMAP diet can reduce symptoms, it may be setting patients up for recurrence if it's leading to undesirable changes in the beneficial bacteria in the colon. Also, there was a recent study that just came out that found that patients with IBS are often able to reintroduce certain FODMAPs without any adverse effects. This study didn't consider SIBO, but as you probably know, many patients with IBS do have SIBO. My guess is that they would have found a similar effect if they had done the study in patients that only had SIBO. It seems that even in patients who do have SIBO or IBS that reintroducing some FODMAPs not only could be potentially beneficial, but doesn't actually lead to a return of symptoms. That's what I've always encouraged my patients to do is reintroduce as many FODMAPs as they can without significant discomfort. I think that's a wise approach because we want to keep our diet as diverse as possible, and especially when it comes to fermentable fiber, it can support our beneficial gut bacteria. Okay. I'm going to stop there. As you can see again, this is a little frustrating maybe to listen to. I'll tell you that it's super frustrating for me as a clinician. This is again something I've been paying very close attention to for a long period of time, and I feel quite frustrated with the lack of answers around many of these questions. Certainly, not for lack of looking, experimenting, and exploring, but my commitment to you is that I will continue to do that. I think it's a very important starting place to just admit when we don't know the answers to these questions at least, and to lay those questions out so we can start exploring what the answers might be, and of course that is the process of science. It's not that we always have the answers and we always know what and we stop looking. Once we think we know the answers, we always question our assumptions and we continually re-evaluate them, especially in the face of evidence that contradicts our previous assumptions or beliefs. That's the true application of the scientific method in the case of healthcare. I hope that was helpful in some way. If you're a patient out there and you're frustrated with your lack of progress with SIBO, you're definitely not alone. If you're a clinician out there and you're frustrated with your lack of progress with SIBO in terms of treating patients, you're definitely not alone. I think we should ... we need to get these questions out there more so that we can all work together to answer them. Okay, that's it for now. Please continue to send your questions in at http://ift.tt/1DErq19, and I'll talk to you next time. Take care, everybody.

Source: http://chriskresser.com September 01, 2017 at 12:18AM

[seenashwrite]

Again! Sorry for another question, and I hope this doesn't bother you... But I was wondering what a one-shot word count average is? I usually end up doing about 1000 - 1500 words as I get caught up in my writing hehe, but is that too long? Should I stick to around 500 or so? Hope this doesn't bother you too much!

Oh Spookster, you are not a bother in the least. I am glad you ask. Because I - and please, everyone sit down to hear this - did not know the complete deets on these by-word-count categorizations off the top of my head. I have a ballpark idea, of course, but still I tasked the interns with doing a lil’ digging.

Ah - while I’ve got ya - the interns [we’ll call them “Sham” and “Green”, the former who professed proficiency at research & the latter who appears to not know how to collate it at all] clarified some word vomit & added a point on Beta Readers which was left out in the answer to your first query. Moving on.

Let us take this moment to ask the fanfic writers of Tumblr their thoughts/what they were taught/what they’ve seen because TL;DR: there isn’t a formal, organized, academic-type fanfic-based collective with enough of a population of experts [and there would need to be criteria for what that means] for peer review and the like, ergo there cannot be any substantive consensus.   

WHEN authors label/categorize their work on word count around here, these are the ones *I* have personally seen + what the “sources” below have claimed -  

Drabble = 100 [some say “Exactly 100!” & to that Nash says “Suck it!”] 

One-Shot = N/A [it’s one-and-done, length is irrelevant]

Multi-Part = N/A [length of each chapter irrelevant; know your audience’s attention span, cater to that]

Series = N/A [reasoning same as above]

Poem/Poetry = N/A [reasoning same as above]

Big Bang = a minimum is given by organizers; may be 20K, may be 50K, point is it’s the… um…. biggest

Prose = ya got me, because “prose” is just “story”, it’s not some special sub-type [”the ordinary form of spoken or written language, without metrical structure, as distinguished from poetry or verse”. And, PS? A secondary take can also be “dull, ordinary, commonplace, plain”, even “tedious”. I’d hesitate to call something of mine “prose” unless it had a qualifier like “melodic prose” or “poetic prose” or something] 

This was a nutters hunt, right up there with crazed insects & sperm-donor poor-excuse-for-amazon daughters & the like. And you’re talking to a deep-diving, source ‘em if you got ‘em, just-the-facts-ma’am research hound. If it’s to be found, I can more often than not sniff it out. 

My nose might have gotten bent on this one. 

First things first: in the field of academia to which I am accustomed, anything at the five-year mark is pushing it, anything beyond that should likely stick to referring to it in a study/article/etc. as a “here’s what we knew then” sort of thing, in order to set the scene for the current hypotheses/results/etc. That’s why I include the dates when able, just FYI.

⦁ Trickster.org - “symposium article” from 2006 - “When Size Matters: Story Terminology as Determined by Word Count” 

Opener: “Drabbles are a bit of a hot topic, and I’ve run across a few debates started by people who don’t like them. Now, this is nothing unusual in fandom, there seems to be at least one person who doesn’t like any given thing, and I usually just shrug my shoulders and move on. The problem with the drabble debates, however, lies in how people are defining drabbles.” 

[Nash Note: Seems to be a transcript of a speech, but it was a horrific, rambling eyesore, I’d never recommend anyone go through it, and the fact that this person was considered expert enough to give commentary on the topic of writing is bone-chilling disturbing. I am not exaggerating this, it is one of the most poorly-conveyed run-downs of what current standings/thoughts are in a given field that I’ve ever come upon. I hope there were some kickin’ visual aids.]

C&Ping the main points that were stated with some sort of conviction:

A drabble is a story of exactly 100 words 

“It’s debatable as to whether or not the title is included but the limit itself is not debatable” 

“the common definition I’ve seen allows for one to fifteen extra words for the title ”

[Nash note: in various spots, they then proceed to tell about how these things *are* debatable in the fanfic community - much as they noted right off in the intro. Which is the topic. Fanfiction. Not “pro-lit”. Which should’ve been there just for touch-and-move-on comparative purposes. Not the bulk of the talk. Which it was.]

A drabble and a half is exactly 150 words

A double drabble is 200 words, and anything over that really stops being a drabble, but in fandom, any story in increments of 50 words is often still referred to as some permutation of drabble, i.e. double drabble and a half, triple drabble, triple drabble and a half, quad-drabble, etc. 

Even in fandom, however, the key is that your word count is exactly on that 50 word increment mark, otherwise you are not writing a drabble of any kind

“In the pro-lit[erary] world…”:  [just knock me out now]

any story under 500 words is flash fiction. 

fic under 500 words that is not exactly 100 words, the term you want is flash fiction. Or even flashfic, or minute fic, or sudden fic, postcard fic, fast fic, quick fic, and a few others. 

none of those alternatives are drabble.

over 500 words, but under 1000, is generally known as a short short. 

Some magazines and anthologies actually use short short and flash fiction interchangeably, because of space constraints

1000 and over, up to 17500, is a short story

“So, just to review….”  [sigh]

100 words = drabble

500 words and under = flash fiction

500-1000 words = short short

1000-15000 words = short story

17500 = novella/novelette

40000 = novel

vignette = nothing to do with word count; typically under 1000 words; the significant thing is theme - meant to give illumination - one character or the relationship between two or more characters; typically don’t involve a lot of action; some have limited dialogue

[Nash co-signs “vignette” definition]

⦁ Save the Drabble - 2005/6

This one has 2 sources and one of them is the person above - the other is another LJ community. This is a circle-jerk. No new info given. We move on.

⦁ Fanlore

This is a hodge-podge that made my eye twitch a bit, but at least they have more info and background on the terms.

They re-hash the “drabble debate” of it having to be precisely 100 words.

They are the first that brought up another term I see around T-Town which is Big Bang 

“A Big Bang is a specific type of challenge usually involving long fics and accompanying artwork.This type of challenge is a reprise of the old zine tradition of collaboration between artists and writers for internet fandoms.” 

They note that back in ‘zine land it was a minimum of 50K, then in another place they say “the consensus” went to a minimum of 20K

[Nash Note: I gotta eschew my formatting, I’ve met my allotted time for this answer, as more peeps lie in wait for their Dear Nash to be addressed! I linked the blogbelow the other day because It. Is. Fantastic. This is what I was able to find for fanfic related terminology on lengths, threw in a couple other goodies, too - go over there and see if you have better luck pulling up with other search terms, entirely possible I wasn’t hitting the nail on the head with mine]

Writing Questions Answered - Tumblr

One result for “drabble”:

http://writing-questions-answered.tumblr.com/search/drabble

Doesn’t talk about length

One result for “one-shot”:

http://writing-questions-answered.tumblr.com/post/45179836171/fan-fiction-how-to-write-a-one-shot-fanfic

“A one-shot fanfic is a standalone story that is one chapter long and focuses on a single situation or event, usually from just one character’s point-of-view. There is no official length for a one-shot, but typically they are between 1,000 and 8,000 words long.” 

Length in general in the published world:

http://writing-questions-answered.tumblr.com/post/108997534333/advice-short-chapters-not-sure-about-word-count

Target length depends on what you’re writing:

Short Story - 1k - 7500 k

Novella - 20k - 50k

Novel-

Middle Grade 25k - 40k

Young Adult 45k - 80k

New Adult: 60k - 85k

Adult 65k - 120k

….and reinforces that nobody should or really does [in the pro world] care about chapter lengths - depends on what’s going on in the chapter. Nash side note on this? Know your audience. The younger they get, the less attention span - not that they can’t or won’t knock out a big book in the long-run, but you don’t want them to grow frustrated along the way, possibly checking out or worse, stopping altogether.  

Talks more about standards for professional lengths:

http://writing-questions-answered.tumblr.com/post/62254683880/advice-story-feels-rushed

Really good piece on “nevers” and “always” when it comes to “dos” and “don'ts”.

http://writing-questions-answered.tumblr.com/post/147225002823/a-quick-psa-about-writing-rules

I agree. And for me, there’s certainly lots of good advice out there, you’ll find some of it is objectively true, but on the other hand, it may be worth trying your hand at various things to see what (a) sticks with your target audience, and (b) speaks to your personal style. 

Plus - in my experience - there’s some “nevers” that I suspect got popular due to propagation by people who just don’t do whatever it is terribly well. [shrugs]

Chuckspeed, my friend. So sayeth the Nash, so say we all.

[donotleavemeagain]

This totally looks like their writing letters to each other, but not like love letters. Deep personal letters.

Like it started out sweet. They were on the cusp of battle and Arthur was trying to convince Merlin not to join him on the field. “Why can’t I come?” Merlin said. “I join you all the time and half those times we get pulled into danger one way or another. You would think you would realize that I can actually take care of myself by now. I mean we battled an undead army together! How much worse could this one be?”

“You weren’t even there for that one!” Arthur said, though it sounded more like a realization of truth than an accusation.

“Oh,” Merlin said. “Right.” He has forgotten that he had been searching for Morgana at the time and Arthur probably thought he was safe in the castle helping Gaius with the injured. “I’m still going.”

“No!” Arthur yelled.

“Why?” Merlin yelled right back.

“Because I love you!” Arthur practically screamed. And then everything went silent. Arthur’s face turned pale and cold even as his eyes widened. He was a prince. He couldn’t love a servant. Let alone a manservant. He looked around and his luck was at least good enough that no one had heard or else his father would have been furious and probably would have punished Merlin for it.

“I love you too,” Merlin whispered after a moment’s hesitation just to make sure that Arthur wouldn’t take back what he said. “I’m still going.”

And then after the battle that Merlin went to despite all Arthur’s protests they would come to the consensus that they couldn’t be seen as loving one another for as long as Uther reigned. It was a decision that Merlin hated because it was yet another thing for him to hide from the King, but agreed to the necessity of it. For that reason and others Arthur started the tradition of writing letters to one another and passing them off with important documents or other such speeches.

They were just cute things at first. A simple “I love you,” or “you’re beautiful”. Neither of them were very well versed at poetry, the one time Arthur tried sent Merlin into such a giggling fit that he started crying, so their were no pretty words that anyone could pass through the ages or turn into songs, but they also brought smiles to both the prince and his servant. It was Merlin who took it a step further and made it into a deeper letter.

It was during a council meeting with the king and unlike the meetings led by Arthur himself, Merlin was not allowed to speak. In fact, for all the good anything Arthur said did, it almost seemed like neither of them were allowed to speak. This was particularly annoying because the meeting was about Arthur’s knights and the outer lands where only Arthur ever dained to go. Uther had no idea what he was talking about on most points and Arthur was getting increasingly frustrated with being ignored.

“My Lord,” Merlin said bowing between Arthur and Uther. It was generally not done to get between the king and prince, but everyone had already gotten used to Merlin being a horrible manservant so Merlin got away with a lot more than most. “The papers you asked for.” He hadn’t really asked for any papers, but he had at one point said that he was sure he had them somewhere on his desk and just hadn’t been able to find before the meeting. It was one of the reasons Uther wasn’t listening to his son, unwilling to believe that he was wrong unless there was proof otherwise. Merlin had ducked out of sight and used his magic to summon the papers, which had fallen under the desk. He couldn’t come back right away, though or people would be suspicious. So he had summoned himself a blank sheet and used his magic to ink a note into the paper. He handed it now to Arthur while blocking his father’s vision of the pile of papers.

It started as “You are the most handsome honorable man I have ever seen. No matter what your father says, I know that you will do everything you can for your people and I will be with you the whole way. I believe in you.” Because Arthur’s father had been particularly cruel in his insults towards Arthur’s capabilities and Merlin wanted Arthur to know that he disagreed with all of it. He continued on with compliments and agreements with Arthur’s opinions but made sure to keep it somewhat short, finishing with “Ps. I’ve given you some extra papers. Give the letter back to me with those so your father doesn’t see.”

“I don’t need these,” Arthur scowled, handing a few frivolous papers along with the letter back to Merlin as the servant backed away. Yet the gleam in his eyes was back when Uther demanded to see the papers and he even leaned forward to point out all the things he had said earlier before Uther could read everything himself. It was rather rude of Arthur, but Merlin’s smirk was all that he needed to think he did the right thing.

From then on they continued with the letters that actually meant something. They still sent out their little love notes, but the others contained more. Secrets that they had never willingly told anyone in their life. Arthur confessed that there were times that he wished that he weren’t the prince. Merlin told Arthur about Freya, who he had loved and lost. And it just kept getting deeper. Until, finally, Merlin realized that there was only one thing that he wanted to tell Arthur. The letter he wrote was short, but it took him all night to get through it. He was so tired the next day that Arthur more than once asked him if he was okay while he cleaned the prince’s room.

“Are you sure your okay?” Arthur asked, frowning from his place at his desk where he was trying to go over some important papers.

“I’m fine,” Merlin shook his head with a sigh.

Arthur put down his papers, checked to make sure the door was firmly closed, and pulled Merlin into his arms. “I can’t take this anymore,” he said, touching their foreheads together. Merlin sighed again, but the tenseness of his shoulders faded and his whole posture sagged into the embrace. “Tell me what’s wrong before I go mad with worry.”

“Here,” Merlin said, pulling a paper from seemingly nowhere and handing it to Arthur. “Don’t read it until I leave.” Merlin pulled back slightly and his eyes were pleading. “Please don’t think of me any differently.”

Arthur’s arms tightened around Merlin, not wanting to let him go even as Merlin tried to pull away. “I don’t know what’s going on,” Arthur said, “but I would never stop loving you.”

“Say that after you’ve read it,” Merlin said with a shake of his head.

Arthur would have said more, but a harsh knock at his door reminding him that he was supposed to be having dinner with his father made him pull away. Merlin disappeared through the door the moment Arthur released him, but it wasn’t until much later in the day that Arthur was able to find a place where he could pull out the letter he had tucked away. Had Merlin not been so worried, he might have waited until he got to the safety of his room to read it, but instead he risked capture by findin an unpopulated part of the castle with a little book that no one would look for him in and opened the letter.

“Dear Arthur,” the letter started, which was a little concerning because their letters were never so formal. “I love you so much, but for a long time now, ever since I came to Camelot really,” Arthur smiled because even in letters Merlin couldn’t resist rambling, “I have been lying to you. After you read this letter, you probably won’t ever want to talk to me again, so I just wanted to make sure that you know: I will always love you and I will stay by you until the day I die.” Arthur frowned at that. Merlin was often overly dramatic, but this was a little too much even for him. The only time he ever got this dramatic was when their was some kind of danger coming upon them that could kill one or both of them. Merlin always seemed to have the best sense for danger, and the most idiotic sense of self sacrifice that had him throwing himself needlessly into danger more often than not. Arthur hurried on, hoping that he would not find his manservant gone “to the tavern” again. “I want you to know that I’ve wanted you to know about this for the longest time now, but I just couldn’t get myself to tell you. It’s not that I don’t trust you. I mean at first it was because I didn’t know you, but then we became friends and then lovers and I just didn’t want to lose you because of my stupidity. Still, I need you to know. I have magic. There it is. I’m the most powerful warlock ever to live. I would never use my magic against you, though. I live for you and I have used my magic for you and for Camelot, more times than I can count, all these years that I’ve been here. You can send me away if you want, but I will always come back to you no matter what because I love you and I want to protect you even if I have to do it from the shadows.”

Arthur’s expression was neutral as he read through the rest of the letter carefully. Not because it was any surprise to him, but because it would be even worse for Merlin if he was caught reading this letter than he had thought. He should have waited until he got to his room. The light spilling in through a window over his head illuminated the part about being the most powerful warlock, which was really the only surprise in this whole letter. Well that and the fact that Merlin didn’t think that Arthur already knew about his magic.

He crumpled the letter by the end of it and tossed it into the fire that was set ablaze nearby. He actually had a drawer where he kept all of Merlin’s notes to him hidden, but this time he thought it best to make sure the evidence was completely erased. Even if their relationship was found out and someone did find the letters, there was no way they were going to find anything that put Merlin’s wizardry into writing. Then he went back to his room and wrote a letter of his own. This one a lot longer and more list like, but with no fewer mentions of love and loyalty in it.

Of course it wasn’t until the next day that he was able to give it to Merlin and that was only because he specifically searched him out, even going so far as to ask the cook if she had seen him.

“Of course I’ve seen him,” the cook said with a role of her eyes. She told Arthur exactly where Merlin was in the castle, even going so far as to describe the glazed windows he was gazing out of. “He’s just moping around. Not doing his job,” she said. “You can’t miss him.”

Arthur snorted. Merlin really got away with a lot more than he really should, but honestly everyone in the castle aside from his father loved Merlin too much to tell him off for anything. Arthur was sure that they would all celebrate when he was finally able to give Merlin a crown and name him King’s Consort.

He found Merlin exactly where the cook said he was doing exactly what she said he was doing and startled him by dropping a pile of papers in his lap. “Stop slacking and do your job,” Arthur scowled, though his eyes were light with amusement at the squeak that Merlin had let out. “You need to proof read these. Then I expect you in my rooms to clean.”

Merlin pouted, but there was an obvious lightness to his shoulders that hadn’t been there before. He nodded and Arthur left him, knowing full well that Merlin would want to be alone while he read most of the things Arthur had written.

“Merlin,” Arthur’s letter began. “Shut up.” It was such an Arthur thing to say that it literally made Merlin burst out laughing. The sudden difference in mood was amazing and it made Merlin feel so much better. It was amazing how rude gruff Arthur could make Merlin feel better so easily when normally it was Merlin’s job to cheer up Arthur. The letter went on to tell Merlin how stupid he was to ever think that Arthur would think differently of him because of his magic. Then he went on to explain that he had known about Merlin’s magic for some time now and went on to describe in some detail every time Merlin had saved his life. Even going so far as to say “Let me count the ways,” which had been something he wrote in that poem that Merlin still teased him about. And then, at the very end, after Arthur had signed off with a heartfelt I love you, there was another pile of papers that had a simple note. “For you,” it read. The papers following shocked Merlin so much that he had to hold back his tears. It was a draft for the legalization of magic so that Arthur could put it into action as soon as he became king.

S5, bts.

[junker-town]

The case for James Harden as NBA MVP

But don’t forget about Paul George and Giannis Antetokounmpo.

The Most Valuable Player award is an argument between a hundred people who love to argue. Many of the arguments have merit, the occasional one does not, but I take it at face value that everyone argues in good faith when they cast their ballot.

When I was young and foolish, and before I had a vote, I used to think that choosing the MVP would be an easy choice. Just pick the best player regardless of exterior circumstances. Simple. As the game has evolved, and my understanding of it grown, I now realize that winning is a lot harder than it looks, and in some years it’s not a simple choice at all.

Rarely is there one unified argument about that year’s MVP and those races tend to be over by March. It’s now March and the MVP race is still simmering. There are three main contenders: Giannis Antetokounmpo, James Harden, and Paul George. There are many, many other players worthy of consideration, but that’s the top three by general consensus.

When choosing an MVP in a crowded field like this, context matters more than ever and even that can be a subjective exercise. Narrative is a loaded word, but we all construct stories of what we’re watching, whether it’s with numbers, observation, emotion, or elements of all three.

The stories we tell inform our choices and in some cases confirm our biases. That’s neither good nor bad, it’s just the nature of the award. It’s also what makes this an interesting exercise.

In the broadest terms, my criteria includes weighing individual achievement along with team success. When all else fails I fall back on the player who defined the season, an admittedly sketchy position. That led me to choose Russell Westbrook over James Harden two years ago. I have no regrets.

When I voted for Harden last season, it was a far easier case to make. He was the best player in the league by most objective measures leading the best team. To choose Harden again this season would require using the same subjective reasoning that elevated Russ over him two years ago. Life is funny.

Harden is having an even better campaign this his MVP season and he’s taken over the league with his combination of skill and intelligence producing overwhelming numbers. By perfecting the art of shooting 3’s off the dribble with a series of step-backs and side-steps that are virtually unguardable, Harden has become the most unstoppable offensive force in the game.

“It just gives me more opportunity and more space to get my shot off,” Harden said of his shotmaking repertoire following a 42-point performance in Boston. “As defenders if you try to close the gap I’m able to get by you, so you’ve got to pick and choose.”

The problem, of course, is there is no right choice. Play up on him and he’ll drive to the basket where he can finish or find teammates for dunks and open shots. Lay back and he’ll take the three right in your face. Get caught in the middle and Harden is a magnet for foul calls.

Harden’s stat lines offer a study in beautiful symmetry, none better than his 58-point outburst against the Heat in late February when he went 8-for-16 from two, 8-for-18 from three, and 18-for-18 from the free throw line. Harden has a 61-point game, five in the 50s, and 18 more in the 40’s. He’s not just an offense unto himself, he’s the whole freaking universe.

Top 5 in possessions used in isolation this season... 5. Giannis Antetokounmpo (226) 4. Kevin Durant (252) 3. Russell Westbrook (258) 2. DeMar DeRozan (260) 1. James Harden (1,015) ONE THOUSAND FIFTEEN

— Andy Bailey (@AndrewDBailey) March 8, 2019

What’s remarkable is that he hasn’t slowed down. Pick a stretch, any stretch, and you can find examples of Harden’s dominance. He was named Western Conference Player of the Month by the NBA in both December and January. He’s been just as productive in February and March, all the while carrying an absurdly heavy load.

“It’s special,” Rockets coach Mike D’Antoni said. “I don’t know if there’s enough words. He is born to play, he loves to play. I can’t take him out of practice. You can’t keep him off the floor. That’s special in itself, knowing that 75-80 games a year he’s going to play for you and play at a high level.”

Because he plays so much in isolation, there’s a question of aesthetics with Harden. Those who identify with the struggle of the individual revel in his exploits, while those who prefer an egalitarian style of ball prefer the more balanced approach of Antetokounmpo’s Bucks.

My personal taste runs toward the latter, but both players are doing what’s been asked by their respective systems. Harden’s ball-dominant game isn’t selfish so much as it’s necessary. That’s an important distinction.

“He works with what what we want to do,” D’Antoni said. “That’s shoot 3’s, layups, and fouls. With what I like to do, it’s a perfect match.”

The Rockets have needed every bit of Harden’s determined brilliance this season. After a dreadful start that had many wondering if they would actually miss the playoffs entirely, Harden led a Rockets team that was besieged by injuries out of the wilderness back into contention for top-3 seed in the loaded Western Conference.

While he won’t make any All-Defensive teams, Harden’s work on that end of the floor has also been sturdier than in the past. D’Antoni pointed to Harden’s post defense as a particularly valuable component of Houston’s half-court defense, with its emphasis on switching.

Still, for Harden to overtake Antetokounmpo, as well as George, you’d have to argue that his offensive production is simply too great to ignore. Ultimately, his case comes back the idea that Harden’s play has defined the season, which it has. With its emphasis on offensive firepower fueled by efficient production, no one plays the modern game better than Harden.

Is that enough?

The best player on the best team designation now belongs to Antetokounmpo. His Bucks are in first place, his numbers are historic, and he’s played at a consistent level of excellence all season. Giannis gets bonus points for being an absolute terror on both ends of the floor.

PG’s argument takes a little longer to connect. He’s also having a brilliant offensive season, and he might be better defensively than Giannis. But while his Thunder are having a strong season, they haven’t risen to the same heights at Antetokounmpo’s Bucks. A side-by side comparison is close, but also tends to favor Giannis.

The wild card in the equation is Harden. While we still have a month left to play, and no decision has been made, my feeling is that the MVP is still Antetokounmpo’s to lose more than it’s Harden’s to win. Either way, it makes for a hell of an argument.

Say What?!?

Quotes of note from around the league

“If you don’t know who he is, then you’re probably not very good.”

Blazers guard Seth Curry on Dallas assistant God Shammgod.

Reaction: If you are old like me, you remember Shammgod as the ballhandling wizard of the Providence College Friars who reached the final eight of the 1997 NCAA Tournament as a 10-seed. (Shoutout to Bojan Bogdanovic doppelganger Austin Croshere.) If you are young like Curry, you know Shammgod from his signature move, appropriately referred to as the Shammgod. Take time to read the wonderful piece from Michael Pina on how Shammgod is influencing the next generation of playmakers, and why it’s so important.

“Of all the stuff I’ve done in my career, this ranks right up there at the top with winning a championship. For a kid from Akron, Ohio, that needed inspiration and needed some type of positive influence, MJ was that guy for me. I watched him from afar, wanted to be like MJ, wanted to shoot fadeaways like MJ, wanted to stick my tongue out on dunks like MJ, wanted to wear my sneakers like MJ. I wanted kids to look up to me at some point like MJ and it’s just crazy, to be honest. It’s beyond crazy.”

LeBron James after passing Michael Jordan on the scoring list.

Reaction: This was a genuinely cool quote on what should have been a historic evening that turned into yet another Laker melodrama. LeBron is the ultimate thinkpiece, but something is wrong if we can’t simply appreciate a historic milestone.

“I thought we moved off joy. Now anger? I disagree with that one.”

Golden State forward Kevin Durant after Steve Kerr said his team needed to play with more anger.

Reaction: Is this another sign that the Warrior dynasty is about to break up, or just a frustrated player in March after a humiliating loss? Everyone quickly to the content generation machines before the narrative changes next week.

“When I meet with them, what surprises me is that they’re truly unhappy. A lot of these young men are generally unhappy.’’

NBA commissioner Adam Silver speaking to Bill Simmons on a panel at the Sloan conference.

Reaction: Silver was speaking broadly of player’s feeling of isolation and loneliness. I won’t presume to speak for the players, but I have discussed with many people around the league a heightened feeling of tension this season. It’s not just players but coaches, front office members, and yes, media too. As someone who deals with mental health issues, and had anxiety-related attacks just this week, I don’t pretend to know all the answers. But I know we need to be talking about this, and by we I mean everyone invested in the league, because it’s not just a generational issue.

The List

Consumable NBA thoughts

We’re finally in the stretch run of the season and the days are still long and cold. The snow isn’t going anywhere, and the games blend into one endless series of pick-and-rolls. To break out of this rut, let’s spread some joy. Here are five things I’ve appreciated this season.

The spirit of the Brooklyn Nets

You think you’ve got it tough? Try being a Net the last few years without the talent to win or the organizational incentive to lose. Under Kenny Atkinson, the Nets distinguished themselves with a hard-nosed attitude in the face of all that adversity. That’s paid off this season as players, many of whom were reclamation projects, have grown into their roles. No one embodies that more than D’Angelo Russell who blossomed into an All-Star. The Nets may not stick around the postseason long, but their run to respectability has been inspiring.

The Hawks young core

The Hawks weren’t on my radar screen when the season began. It’s one thing to be young, quite another to be young and bad, and this looked like the very early stages of a long-term rebuilding project. Then I was taken with the legend of John Collins and became enamored with Kevin Huerter. The rookie from Maryland may look like his parents dropped him off at the wrong gym, but the kid can play. Throw in Trae Young’s in-season turnaround and the Hawks provide nightly thrills.

Paul George’s career season

Even for an unabashed PG supporter, this season has been a revelation. The talent was always there, but George has put together a season for the ages. He’s a strong contender for Defensive Player of the Year and a legitimate MVP candidate in a three-player race. In any other year, he’d likely be the frontrunner. What’s made his ascent all the more enjoyable has been a renewed appreciation for Russell Westbrook’s leadership abilities. It will be interesting to see where OKC stands after all the free agents wind settle this summer. If the Warriors do break up, it could open a 2-3 year championship window.

Nate McMillan’s stoicism

It wasn’t so long ago when Nate McMillan was a coaching star. His move from Seattle to Portland held the promise of future championships before injuries and bad luck doomed the Blazers to also-ran status. There were whispers the game had passed him by, but if anyone knows how to handle injury adversity, it’s the guy who coached Greg Oden and Brandon Roy. Watching McMillan’s Pacers remain in the thick of the Eastern Conference race without Victor Oladipo is a testament to the respect the coach has from his players. His team is smart, disciplined, and plays together. That’s what it’s all about, really.

Donovan Mitchell’s comeback

When Mitchell was the breakout star of his rookie class, expectations rose to an enormous degree. When he struggled early in his second season, his game was thoroughly eviscerated. We’re all guilty of judging young players too harshly and much too quickly, but the backlash bordered on ridiculous. Mitchell found his groove around the turn of the new year and is once again performing like a franchise cornerstone for the Jazz. It certainly doesn’t hurt that he’s a genuinely good dude.

[fqtoxicity]

New Post has been published on My Quin Story

New Post has been published on http://www.myquinstory.info/avoid-these-four-psychological-pitfalls-after-floxing/

Avoid These Four Psychological Pitfalls After Floxing

Unlike many of the articles on this website, this article is specifically directed to those who are newly floxed, although veteran floxies may also relate to some of the issues discussed.

For the person that is starting to become aware, or at least suspecting, that their health issues could be the result of damage by the Fluoroquinolones (Levaquin Cipro, Avelox, Floxin, etc…), the amount of data that you can be faced with is often overwhelming, frustrating, and just downright depressing.  

When trying to assimilate information about a subject that is often dismissed by the medical community and that is scattered over a broad playing field, a person can be faced with several disadvantages.  Some of these disadvantages can become psychological pitfalls and if you are not careful and they, in-turn, can hamper your progress.

The first pitfall: Separating Facts from codswallop, also known as poppycock, balderdash, hog wash, and the like.

There nothing like starting out with a hard and sensitive subject. This pitfall is one of the most difficult pitfalls for many people and a subject that I could write volumes on: The sorting of facts from opinions and personal belief.

For some, this pitfall arises because of the ambiguity between real medical research and personal opinion.  These opinions, which are often well-meaning, can range all over the place from the practical to the downright bizarre, and they can come from various sources, some of them seemingly quite credible. These sources encompass countless floxed ‘experts’ that you find populating online forums and groups (myself included) to doctors who, although they have the moniker of M.D. by their name, wouldn’t know a floxed person if the surgeon general himself came up and put their arm around them. 

Bottom line, the task of discerning good data from bad data can be overwhelming.  

If you are a data driven person, the ugly truth is, when it comes to Fluoroquinolone toxicity, there are actually very few officially documented facts.  Some folks, especially those with a science background, are often shocked by the paucity of research that has been done, despite the many years that have gone by and the sheer amount of people affected.  Many times these well-meaning newcomers will march off, disgusted that I and others haven’t done more, hoping to change the world, that is, until they run into the FDA, AMA, and the whole “for-profit” medical industry.

In a nutshell, there are many reasons that explain the lack of robust medical research that has gone into Fluoroquinolone toxicity, but the nitty-gritty is that the drug companies control our “for profit” medical industry through funding and data.  Even now, in many medical circles, Fluoroquinolone toxicity, is much like the Bermuda Triangle or Bigfoot, completely relegated to the lunatic fringe.

Getting back to facts. There are good facts that bolster our case against the Fluoroquinolones. Much of it is spread out across a large playing field and it is not connected together and this can be a daunting task that requires hours of research. Also, of the existing Fluoroquinolone facts that are available, we do have some good facts, but conversely we also have questionable facts despite having authors with seemingly impeccable credentials.

An example of a good simple documented fact about Fluoroquinolones is that they are Topoisomerase 2 Inhibitors.  Again, this is a known and documented fact. Another fact is that they are chemotherapeutic agents that exhibit anti-cancer or anti-tumor tendencies.  Again, both of these facts have been documented well in research.

However, just because the research has a supposed authoritative source, doesn’t mean the facts are actually good facts. An example of a questionable fact is that Fluoroquinolones have a good safety record.  Although the science proving Fluoroquinolone safety is readily accepted by doctors, much of the science that supports Fluoroquinolone safety it is fraught with drug interference and author bias. These supposed documented safety facts, are also contradicted by the lived experience of thousands of individuals who have become disabled over the last several decades and is backed up by the FDA’s own data.   

 Tip:  Always look at author bias or author motives in the data that is being presented.  Is the author representing the pharmaceutical industry?  Or, is the author selling something? (Hint: I am not in this for the notoriety, fame or money).  

So how do I filter out truth?  I look at the data (medical science, research, current medical practices) and then compare it with the truckload of anecdotal information and form my opinions. I have to admit that I am in the unique position of having access to a lot of anecdotal information. But let me say one more thing about this point.

Many, many people in the floxed community, who are mostly well-meaning, incorporate personal opinions about the Fluoroquinolones into their personal belief system and these belief systems exist at the sub-conscious level.  Again, although well meaning, these beliefs can be incorrect but because of lived experiences or other influences this erroneous data is often believed to be correct.  Let me give you an example:

There is a belief that circulates around the Fluoroquinolones community that NSAIDS are bad for floxed people, despite the paucity of data that backs up the belief.   While it is true that NSAIDS are contraindicated and should not be taken WHILE a person is currently taking an Fluoroquinolones, there really is no hard science to show that they cannot be taken later, after an adverse event.  The truth is, some people find out they can take them with no problem, while others cannot.  Still, you have die-hard individuals telling the newly floxed, “You can never take another NSAID again!” or “NSAIDS will always cause a bad reaction post floxing.”  These statements are coming from a belief system, albeit an erroneous one.

On a side note, do you know what happens when you question a belief system?  You usually get anger as a response.  If you question a person and get anger in response, you have tapped into their belief system. Social media is fraught with belief centered confrontations, especially during the COVID-19 pandemic. 

Bottom line: Always be proactive and question medical knowledge that will be applied to your personal situation, regardless of the source.  It doesn’t matter if it is safe for others, the question is, is it safe for you?   

The second pitfall: Putting all your eggs in one basket.

Some people may think that my website (as great as it may be), or another website dealing with Fluoroquinolone toxicity, or a certain Facebook forum, or a certain floxed solution ebook sold elsewhere on the internet, are great authoritative compendiums of information.  So much so, that they do not have the need to look for information elsewhere. Avoid this pitfall by looking at all sources of information that you glean from other sources, with a critical, detached attitude.  Use the all information for your personal benefit by adjusting it to your own expanding awareness and your lived reality.  For example, because of your own unique physiology you may get very ill taking a supplement that everyone else finds perfectly safe. 

Don’t go overboard, but look at data from other sources?  Do they agree with one another?  Is there a general consensus? 

Basing your decisions on one fact or piece of data can be very dangerous.  

Mark Twain once said, “Be careful about reading health books. You may die of a misprint.” 

The third pitfall: Watch out for Hypochondria.

Please do not read this website, the Flox report, listen to other ‘experts’ in Facebook groups or discussion forums and start believing that you have all the symptoms of any Fluoroquinolone Toxicity. Doing this you will end up convinced that you are suffering a far worse reaction than it really is, and that will make you suffer unnecessarily.

Recently, I believed I could have some symptoms from heavy metal poisoning, which can be real concern post floxing.  To gather more information, I joined a Gadolinium forum to search out some specific information on various detoxing regimens from heavy metals. Boy was that a mistake! It was like taking an adventure into an alternative parallel universe. If I had not compiled the learned experienced of over 14 years in the flox community, I would have walked away devastated.  I literally saw many of people with symptoms who were in search of a cause.   Hear me…. I am not saying that Gadolinium deposition disease is not real, nor am I saying that people don’t suffer greatly from it, I am just using this to make a point.   

I have seen this very exact thing play out in the floxed community hundreds of times over the last decade; some floxed individuals want, at all costs, to match their reactions against data and experiences of others in order to create an instrument to rate their adverse event (AE) or symptoms.  They look for a precise timetable of recovery from others, who are eager to give it out, and then try to make plans to foresee every event that is going to happen to them during their recovery.  Let me let you in on a little hint…no one can do that.  Predicting the future, is not its objective of this website and it should not be the objective of any other source of data either.

While it is true, I and maybe some others, can give you a general idea of what floxing is and the suffering that is caused by Fluoroquinolones, I cannot, and neither can others, evaluate your individual case and determine its outcome or course of progression. 

Bottom line:  There are no prophets in the Fluoroquinolone community.

There was a person, who, in one of the Facebook forums, was handing out timeline advice like candy that was based on their own personal experience.   They would tell people, “your digestive issues should clear up by the 6-month mark” or “an average reaction takes about two years to complete,” etc…

If after being told this information by someone who seems well respected, you try to establish at all costs the predicted recovery date for  that symptom of yours, you will surely get very anxious and depressed when your digestion is not normal by month 12.

If you attempt to use the opinions of others as a complete guide for your illness, you will become frustrated and you will lose the necessary perspective and strength to handle your intoxication from the proper perspective.

Floxing is a life altering experience that does not resemble any normal illness process that you have experienced before in your life or have come to learn about, like post-surgery recovery, healing an infection, or post-traumatic recuperation. Most likely, all health issues that you had prior to the floxing started to heal as soon as the offending agent was removed. This is not the case with quinolones.  They are synthetic DNA damaging/altering chemotherapeutic agent.

The hard truth is, some floxed folks will feel progressively worse for months or maybe years before returning to a normal functional life achieved. Most people are programmed under our current medical system, that there is something that can be done such as take a prescription medication, put a Band-Aid on the wound, or perform some rehabilitation exercises.  Fluoroquinolones toxicity is different.  

For most nothing can be done to halt or reverse an AE from Fluoroquinolones after the end of treatment. It is very much like suffering from a chronic degenerative illness and has many overlaps with gulf war syndrome, lyme, lupus, multiple sclerosis and others.

However, if you have one or even several symptoms of a severe AE, that does NOT mean that you are destined for a severe AE, and no one can predict its outcome.  It truly is the whole complete picture that counts.  I have seen too many floxed persons that have mild AE’s become hypochondriacs worrying about the possibility of having a severe AE and magnifying real or imaginary symptoms to match those of a severe AE.

Tip: Never, I mean never, take healing advice or timeline advice from someone who claimed to have been healed from Fluoroquinolone Toxicity in six month or less. The overwhelming chances are, they were never floxed in the first place.  

The fourth pitfall: Becoming Overzealous.

Having partially fallen into this overzealous trap myself early on in my floxing, it is another extremely common mistake to be overcome overzealous in your search for exact answers, explanations, cures, treatments, timetables and protocols for every minor symptom that shows up.

Even people considered extremely healthy have negligible physical changes or events that take place in their life that are totally ignorable.  Overreaction to the Fluoroquinolone AE can cause floxies to become worried and look for Fluoroquinolones lying in wait at every corner of their lives, or extremely afraid and obsessive about potential negative influences of normal habits, like taking a shower with tap water tainted with fluoride.

At the same time, this does not mean that you should not adhere to good medical practice and have new or unusual symptoms evaluated by a competent medical professional.  About eight years into my floxing I kept getting some abdominal pain in my lower right abdomen. I assumed that it was a muscle spasm, and due to my medical knowledge, I even convinced my doctor that it was muscle spasms as well. Wrong, it ended up being my gallbladder that was displaying atypical symptoms.

Bottom line:  Be proactive and advocate for your health, but please do not look at your entire life through the Fluoroquinolone lens.  This only adds anxiety and despair to the already intense impact of being floxed.

Conclusion

Above all else keep in mind that your floxing experience is unique one that centers around your physiology. Floxing experiences are novel, probably more novel than the coronavirus SARSCOV2. No person (not even me),  no report, no Facebook group, no Twitter post can substitute for your own personal knowledge about your symptoms, your recovery and all your health aspects.

Our medical system today has its strengths and weaknesses.  It is very good at triage and very bad at pharmaceutical interventions. No one wants to go through the terrible experience of floxing, as floxing represents the darker side of our medical system.   Most floxies end up here through no fault of their own.  Instead, they trusted the advice of someone who was suppose to be an expert. 

If you are new to this plight, do yourself a favor, first be kind to yourself, and the try not to fall into these four psychological pitfalls.

Shameless Sales Script

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[slrlounge1]

Sony A7RIII Review: Officially The Best Pro Full-Frame Mirrorless Camera On The Market

When I test a new camera, I usually have an idea of how the review might go, but there are always some things that are a complete unknown, and a few things that totally surprise me.

I know better than to pass judgment on the day a camera is announced. The images, and the user experience are what matter. If a camera has all the best specs but lacks reliability or customizability, it’s a no-deal for me.

So, you can probably guess how this review of the Sony A7RIII is going to turn out. Released in October of 2017 at $3200, the camera has already had well over a year of real-world field use, by working professionals and hobbyists alike. Also, it now faces full-frame competition from both Canon and Nikon, in the forms of Canons new RF mount and Nikon’s Z mount, although these only have two bodies each and 3-4 native lenses each.

As a full-time wedding and portrait photographer, however, I can’t just jump on a new camera the moment it arrives. Indeed, the aspects of reliability and sheer durability are always important. And, considering the track record for reliability (buggy-ness) of the Sony A7-series as a whole since its birth in October of 2013, I waited patiently for there to be a general consensus about this third generation of cameras.

Indeed, the consensus has been loud: third time’s a charm.

Although, I wouldn’t exactly call the A7RIII a charming little camera. Little, sure, professional, absolutely! But, it has taken a very long time to become truly familiar and comfortable with it.

Before you comment, “oh no, not another person complaining about how hard it is to ‘figure out’ a Sony camera” …please give me a chance to thoroughly describe just how incredibly good of a camera the A7RIII is, and tell you why you should (probably) get one, in spite of (or even because of) its complexity.

Sony A7RIII (mk3) Specs

42-megapixel full-frame BSI CMOS sensor (7952 x 5304 pixels)

ISO 100-32000 (up to ISO 50 and ISO 102400)

5-axis sensor-based image stabilization (IBIS)

Hybrid autofocus, 399 phase-detect, 425 contrast-detect AF points

3.6M dot Electronic Viewfinder, 1.4M dot 3″ rear LCD

10 FPS (frames per second) continuous shooting, with autofocus

Dual SD card slots (one UHS-II)

4K @ 30, 24p video, 1080 @ 120, 60, 30, 24p

Metal frame, weather-sealed body design

Sony A7R3, Sony 16-35mm f/2.8 GM | 1/80 sec, f/11, ISO 100

100% crop from the above image, fine-radius sharpening applied

Sony A7R3 Pros

The pros are going to far outweigh the cons for this camera, and that should come as no surprise to anyone who has paid attention to Sony’s mirrorless development over the last few years. Still, let’s break things down so that we can discuss each one as it actually relates to the types of photography you do.

Because, even though I’ve already called the A7RIII the “best pro full-frame mirrorless camera”, there may still be at least a couple other great choices (spoiler: they’re also Sony) for certain types of working pro photographers.

Sony A7R3, Sony 16-35mm f/2.8 GM, 3-stop Polar Pro NDPL Polarizer filter 2 sec, f/10, ISO 100

Image Quality

The A7RIII’s image quality is definitely a major accomplishment. The  42-megapixel sensor was already a milestone in overall image quality when it first appeared in the A7RII, with its incredible resolution and impressive high ISO image quality. This next-generation sensor is yet another (incremental) step forward.

Compared to its predecessor, by the way, at the lowest ISO’s (mostly at 100) you can expect slightly lower noise and higher dynamic range. At the higher ISOs, you can expect roughly the same (awesome) image quality.

Also, when scaled back down to the resolution of its 12-24 megapixel Sony siblings, let alone the competition, it’s truly impressive to see what the A7R3 can output.

Speaking of its competitors’ sensors, the Sony either leaves them in the dust, (for example, versus a Canon sensor’s low-ISO shadow recovery) …or roughly matches their performance. (For example, versus Nikon’s 36 and 45-megapixel sensor resolution and dynamic range.)

Sony A7R3, 16-35mm f/2.8 GM | 31mm, 1/6 sec, f/10, ISO 100, handheld

100% crop from the above image – IBIS works extremely well!

I’ll be honest, though: I reviewed this camera with the perspective of a serious landscape photographer. If you’re a very casual photographer, whether you do nature, portraits, or travel or action sports, casually, then literally any camera made in the last 5+ years will deliver more image quality than you’ll ever need.

The Sony A7R3’s advantages come into play when you start to push the envelope of what is possible in extremely difficult conditions. Printing huge. Shooting single exposures in highly dynamic lighting conditions, especially when you have no control over the light/conditions. Shooting in near-pitch-dark conditions, by moonlight or starlight… You name it; the A7RIII will match, or begin to pull ahead of, the competition.

Personally, as a landscape, nightscape, and time-lapse photographer, I couldn’t ask for a better all-around sensor and image quality than this. Sure, I would love to have a native ISO 50, and I do appreciate the three Nikon sensors which offer a base ISO of 64, when I’m shooting in conditions that benefit from it.

Still, as a sensor that lets me go from ISO 100 to ISO 6400 without thinking twice about whether or not I can make a big print, the A7RIII’s images have everything I require.

Sony Color Science

Before we move on, we must address the common stereotype about dissatisfaction with “Sony colors”. Simply put, it takes two…Actually, it takes three! The camera manufacturer, the raw processing software, and you, the artist who wields those two complex, advanced tools.

Sony A7R3, Sony 16-35mm f/2.8 GM | 6 sec, f/3.5, ISO 100 | Lightroom CCC

The truth is that, in my opinion, Adobe is the most guilty party when it comes to getting colors “right”, or having them look “off”, or having muddy tones in general.

Why do I place blame on what is by far the most ubiquitous, and in popular opinion the absolute best, raw processing software? My feelings are indeed based on facts, and not the ambiguous “je ne sais quoi” that some photographers try to complain about:

1.) If you shoot any camera in JPG, whether Sony, Nikon, or Canon, they are all capable of beautiful skin tones and other colors. Yes, I know, serious photographers all shot RAW. However, looking at a JPG is the only way to fairly judge the manufacturer’s intended color science. And in that regard, Sony’s colors are not bad at all.

2.) If you use another raw processing engine, such as Capture One Pro, you get a whole different experience with Sony .ARW raw files, both with regard to tonal response and color science. The contrast and colors both look great. Different, yes, but still great.

I use Adobe’s camera profiles when looking for punchy colors from raw files

Again, I’ll leave it up to you to decide which is truly better in your eyes as an artist. In some lighting conditions, I absolutely love Canon, Nikon, and Fuji colors too. However, in my experience, it is mostly the raw engine, and the skill of the person using it, that is to blame when someone vaguely claims, “I just don’t like the colors”…

Disclaimer: I say this as someone who worked full-time in post-production for many years, and who has post-produced over 2M Canon CR2 files, 2M Nikon NEF files, and over 100,000 Sony ARW files.

Features

There is no question that the A7R3 shook up the market with its feature set, regardless of the price point. This is a high-megapixel full-frame mirrorless camera with enough important features that any full-time working pro could easily rely on the camera to get any job done.

Flagship Autofocus

The first problem that most professional photographers had with mirrorless technology was that it just couldn’t keep up with the low-light autofocus reliability of a DSLR’s phase-detect AF system.

This line has been blurred quite a bit from the debut of the Sony A7R2 onward, however, and with this current-generation, hybrid on-sensor phase+contrast detection AF system, I am happy to report that I’m simply done worrying about autofocus. Period. I’m done counting the number of in-focus frames from side-by-side comparisons between a mirrorless camera and a DSLR competitor.

In other words, yes, there could be a small percent difference in tack-sharp keepers between the A7R3’s autofocus system and that of, say, a Canon 5D4 or a Nikon D850. In certain light, with certain AF point configurations, the Canon/Nikon do deliver a few more in-focus shots, on a good day. But, I don’t care.

Sony A7R3, 16-35mm f/2.8 GM | 1/160 sec, f/2.8, ISO 100

Why? Because the A7R3 is giving me a less frustrating experience overall due to the fact that I’ve completely stopped worrying about AF microadjustment, and having to check for front-focus or back-focus issues on this-or-that prime lens. If anything, the faster the aperture, the better the lens is at nailing focus in low light. That wasn’t the case with DSLRs; usually, it was the 24-70 and 70-200 2.8’s that were truly reliable at focusing in terrible light, and most f/1.4 or f/1.8 DSLR primes were hit-or-miss. I am so glad those days are over.

Now, the A7R3 either nails everything perfectly or, when the light gets truly terrible, it still manages to deliver about the same number of in-focus shots as I’d be getting out of my DSLRs anyways.

Eye Autofocus and AF customization

Furthermore, the A7R3 offers a diverse variety of focus point control and operation. And, with new technologies such as face-detection and Eye AF, the controls really do need to be flexible! Thanks to the level of customizability offered in the the A7R3, I can do all kinds of things, such as:

Quickly change from a designated, static AF point to a dynamic, adaptable AF point. (C1 or C2 button, you pick which based on your own dexterity and muscle memory)

Easily switch face-detection on and off. (I put this in the Fn menu)

Designate the AF-ON button to perform traditional autofocus, while the AEL button performs Eye-AF autofocus. (Or vice-versa, again depending on your own muscle memory and dexterity)

Switch between AF-S and AF-C using any number of physical customizations. (I do wish there was a physical switch for this, though, like the Sony A9 has.)

Oh, and it goes without saying that a ~$3,000 camera gets a dedicated AF point joystick, although I must say I’m preferential to touchscreen AF point control now that there are literally hundreds of AF points to choose from.

In short, this is one area where Sony did almost everything right. They faced a daunting challenge of offering ways to implement all these useful technologies, and they largely succeeded.

This is not just professional-class autofocus, it’s a whole new generation of autofocus, a new way of thinking about how we ensure that each shot, whether portrait or not, is perfectly focused exactly how we want it to be, even with ultra-shallow apertures or in extremely low light.

Dual Card Slots

Like professional autofocus, dual card slots is nothing new in a ~$3,000 camera. Both the Nikon D850 (and D810, etc.) and the Canon 5D4 (and 5D3) have had these features for years. Although, notably, the $3400 Nikon Z7 does not; it opted for a single XQD slot instead. Read our full Nikon Z7 review here.)

Unlike those DLSRs, however, the Sony A7R3 combines the professional one-two punch of pro AF and dual card slots with other things such as the portability and other general benefits of mirrorless, as well as great 4K video specs and IBIS. (By the way, no, IBIS and 4K video aren’t exclusive to mirrorless; many DSLRs have 4K video now, and Pentax has had IBIS in its traditional DSLRs for many years too.)

One of my favorite features: Not only can the camera be charged via USB, it can operate directly from USB power!

Sony A7R3 Mirrorless Battery Life

One of the last major drawbacks of mirrorless systems, and the nemesis of Sony’s earlier A7-series in particular was battery life. The operative word being, WAS. Now, the Sony NP-FZ100 battery allows the A7R3 to last just as long as, or in some cases even longer than, a DSLR with comparable specs. (Such as lens-based stabilization, or 4K video)

Oh, and Sony’s is the only full-frame mirrorless platform that allows you to directly run a camera off USB power without a “dummy” battery, as of March 2019. This allows you to shoot video without ever interrupting your clip/take to swap batteries, and capture time-lapses for innumerable hours, or, just get through a long wedding day without having to worry about carrying more than one or two fully charged batteries.

By the way, for all you marathon-length event photographers and videographers out there: A spare Sony NP-FZ-100 battery will set you back $78, while an Anker 20,100 mAh USB battery goes for just $49. So, no matter your budget, your battery life woes are officially over.

Durability

This is one thing I don’t like to speak about until the gear I’m reviewing has been out in the real world for a long time. I’ve been burned before, by cameras that I rushed to review as soon as they were released, and I gave some of them high praise even, only to discover a few weeks/months later that there’s a major issue with durability or functionality, sometimes even on the scale of a mass recall. (*cough*D600*cough*)

Thankfully, we don’t have that problem here, since the A7RIII has been out in the real world for well over a year now. I can confidently report, based on both my own experience and the general consensus from all those who I’ve talked to directly, that this camera is a rock-solid beast. It is designed and built tough, with good overall strength and extensive weather sealing.

It does lack one awesome feature that the Canon EOS R offers, which is the simple but effective use of the mechanical mirror to protect the sensor whenever the camera is of, or when changing lenses. Because, if I’m honest, the Sony A7R3 sensor is a dust magnet, and the sensor cleaner doesn’t usually do more than shake one or two of the three or five specks of dust that are always landing on the sensor after just a half-day of swapping lenses periodically, especially in drier, static-y environments.

Value

Currently, at just under $3200 and sometimes on sale for less than $2800, there’s no dispute- We have the best value around, if you actually need the specific things that the A7RIII offers compared to your other options.

But, could there be an even better camera out there, for you and your specific needs?

If you don’t plan to make giant prints, and you rarely ever crop your images very much, then you just don’t need 42 megapixels. In fact, it’s actually going to be quite a burden on your memory cards, hard drives, and computer CPU/RAM, especially if you decide to shoot uncompressed raw and rack up a few thousand images each time you take the camera out.

Indeed, the 24 megapixels of the A7III is currently (and will likely remain) the goldilocks resolution for almost all amateurs and many types of working pros. Personally, as a wedding and portrait photographer, I would much rather have “just” 24 megapixels for the long 12-14+ hour weddings that I shoot. It adds up to many terabytes at the end of the year. Especially if you shoot the camera any faster than its slowest continuous drive mode. (You better buy some 128GB SD cards!)

As a landscape photographer, of course, I truly appreciate the A7RIII’s extra resolution. I would too if I were a fashion, commercial, or any other type of photographer whose priority involved delivering high-res imagery.

We’ll get deeper into which cameras are direct competition or an attractive alternative to the A7RIII later. Let’s wrap up this discussion of value with a quick overview of the closest sibling to the A7RIII, which is of course the A7III.

The differences between them go beyond just a sensor. The A7III has a slightly newer AF system, with just a little bit more borrowed technology from the Sony A9. But, it also has a slightly lower resolution EVF and rear LCD, making the viewfinder shooting experience just a little bit more digital looking. Lastly, partly thanks to its lower megapixel count, and lower resolution screens, the A7III gets even better battery life than the A7RIII. (It goes without saying that you’ll save space on your memory cards and hard drives, too.)

So, it’s not cut-and-dry at all. You might even decide that the A7III is actually a better camera for you and what you shoot. Personally, I certainly might prefer the $1998 A7III  if I shot action sports, wildlife, journalism, weddings, and certainly nightscapes, especially if I wasn’t going to be making huge prints of any of those photography genres.

Or, if you’re a serious pro, you need a backup camera anyway, and since they’re physically identical, buy both! The  A7III and A7RIII are the best two-camera kit ever conceived. Throw one of your 2.8 zooms on the A7III, and your favorite prime on the A7RIII. As a bonus, you can program “Super-35 Mode” onto one of your remaining customization options, (I like C4 for this) and you’ve got two primes in one!

Sony A7R3, Sony FE 16-35mm f/2.8GM | 1/4000 sec, f/10, ISO 100 (Extreme dynamic range processing applied to this single file)

Cons

This is going to be a short list. In fact, I’ll spoil it for you right now: If you’re already a (happy) Sony shooter, or if you have tried a Sony camera and found it easy to operate, there are essentially zero cons about this camera, aside from the few aforementioned reasons which might incline certain photographers to get an A7III instead.

A very not-so-helpful notification that is often seen on Sony cameras. I really do wish they could have taken the time to write a few details for all function incompatibilities, not just some of them!

Ergonomics & Menus

I’ll get right to the point: as someone who has tested and/or reviewed almost every DSLR camera (and lots of mirrorless cameras) from the last 15 years, from some of the earliest Canon Rebels to the latest 1D and D5 flagships, I have never encountered a more complex camera than the A7R3.

Sony, I suspect in their effort to make the camera attractive to both photographers and videographers alike, has made the camera monumentally customizable.

We’ll get to the sheer learning curve and customizations of the camera in a bit, but first, a word on the physical ergonomics: Basically, Sony has made it clear that they are going to stay focused on compactness and portability, even if it’s just not a comfortable grip for anyone with slightly larger hands.

The argument seems to be clearly divided among those who prefer the compact design, and those who dislike it.

The dedicated AF-ON button is very close to three other main controls, the REC button for video, the rear command dial, and the AF point joystick. With large thumbs, AF operation just isn’t as effortless and intuitive as it could be. Which is a shame, because I definitely love the customizations that have given me instant access to multiple AF modes. I just wish the AF-ON button, and that whole thumb area, was designed better. My already minor fumbling will wane even further with familiarity, but that doesn’t mean it is an optimal design.

By the way, I’m not expecting Sony to make a huge camera that totally defeats one of the main purposes of the mirrorless format. In fact, in my Nikon D850 review, I realized that the camera was in fact too big and that I’m already accustomed to a smaller camera, something along the size of a Nikon D750, or a Canon EOS R.

Speaking of the Canon EOS R, I think all full-frame cameras ought to have a grip like that one. It is a perfect balance between portability and grip comfort. After you hold the EOS R, or even the EOS RP, you’ll realize that there’s no reason for a full-frame mirrorless camera not to have a perfect, deep grip.

As another example, while I applaud Sony for putting the power switch in the right spot, (come on, Canon!) …I strongly dislike their placement of the lens release button. If the lens release button were on the other side, where it normally is on  Canon and Nikon, then maybe we could have custom function buttons similar to Nikon’s. These buttons are perfectly positioned for my grip fingers while holding the camera naturally, so I find them effortless to reach compared to Sony’s C1 and C2 buttons.

As I hinted earlier, I strongly suspect that a lot of this ergonomic design is meant to be useful to both photographers and videographers alike. And videographers, more of tne than not, simply aren’t shooting with the camera hand-held up to their eye, instead, the camera is on a tripod, monopod, slider, or gimbal. In this shooting scenario, buttons are accessed in a totally different way, and in fact, the controls of the latest Sony bodies all make more sense.

It’s a shame, because, for this reason I feel compelled to disclaim that if you absolutely don’t shoot video, you may find that Nikon and/or Canon ergonomics are significantly more user-friendly, whether you’re working with their DSLRs or their mirrorless bodies. (And yes, I actually like the Canon “touch dial”. Read my full Canon EOS R review here.)

Before we move on, though, I need to make one thing clear: if a camera is complicated, but it’s the best professional option on the market, then the responsible thing for a pro to do is to suck it up and master the camera. I actually love such a challenge, because it’s my job  and because I’m a camera geek, but I absolutely don’t hold it against even a professional landscape photographer for going with a Nikon Z7, or a professional portrait photographer for going with a Canon EOS R. (Single SD card slot aside.)

Yet another quick-access menu. However, this one cannot be customized.

Customizability

This is definitely the biggest catch-22 of the whole story. The Sony A7R3 is very complex to operate, and even more complex to customize. Of course, it has little choice in the matter, as a pioneer of so many new features and functions. For example, I cannot fault a camera for offering different bitrates for video compression, just because it adds one more item to a menu page. In fact, this is a huge bonus, just like the ability to shoot both uncompressed and compressed .ARW files.

By the way, the “Beep” settings are called “Audio signals”

There are 35 pages of menu items with nearly 200 items total, plus five pages available for custom menu creation, a 2×6 grid of live/viewfinder screen functions, and approximately a dozen physical buttons can be re-programmed or totally customized.

I actually love customizing cameras, and it’s the very first thing I do whenever I pick up a new camera. I go over every single button, and every single menu item, to see how I can set up the camera so that it is perfect for me. This is a process I’ve always thoroughly enjoyed, that is until the Sony A7-series came along. When I first saw how customizable the camera was, I was grinning. However, it took literally two whole weeks to figure out which button ought to perform which function, and which arrangement was best for the Fn menu, and then last but not least, how to categorize the remaining five pages of menu items I needed to access while shooting. Because even if I memorized all 35 pages, it still wouldn’t be practical to go digging through them to access the various things I need to access in an active scenario.

Then, I started to notice that not every function or setting could be programmed to just any button or Fn menu. Despite offering extensive customization options, (some customization options have 22 pages of options,) there are still a few things that just can’t be done.

“Shoot Mode” is how you change the exposure when the camera’s exposure mode dial is set to video mode. Which is useful if you shot a lot of video…

For example, It’s not easy to change the exposure mode when the camera’s mode dial itself is set to video mode. You can’t just program “Shooting Mode” to one of the C1/C2 buttons, it can only go in the Fn or custom menu.

As another example, for some reason, you can’t program both E-shutter and Silent Shooting to the Fn menu, even though these functions are so similar that they belong next to each other in any shooter’s memory.

Lastly, because the camera relies so heavily on customization, you may find that you run out of buttons when trying to figure out where to put common things that used to have their own buttons, such as Metering, White Balance, AF Points. Not to mention the handful of new bells and whistles that you might want to program to a physical button, such as switching IBIS on/off, or activating Eye AF.

All in all, the camera is already extremely complex, and yet I feel like it could also use an extra 2-3 buttons, and even more customization for the existing buttons. Which, again, leads me to the conclusion that if you’re looking for an intuitive camera that is effortless to pick up and shoot with, you may have nightmares about the user manual for this thing. And if you don’t even shoot video at all, then like I said, you’re almost better off going with something simpler.

But again, just to make sure we’re still on the same page here: If you’re a working professional, or a serious hobbyist even, you make it work. It’s your job to know your tools! (The Apollo astronauts didn’t say, “ehh, no thanks” just because their capsule was complicated to operate!)

Every camera has quirks. But, not every camera offers the images and a feature set like the A7R3 does. As a camera geek, and as someone who does shoot a decent amount of both photo and video, I’d opt for the A7R3 in a heartbeat.

Sony A7R3, Sony FE 16-35mm f/2.8 GM, PolarPro ND1000 filter 15 sec, f/14, ISO 100

The A7RIII’s Competition & Alternatives

Now that it’s early 2019, we finally have Canon and Nikon competition in the market of full-frame mirrorless camera platforms. (Not to mention Panasonic, Sigma, Lecia…)

So, where does that put this mk3 version of the Sony A7R, a third-generation camera which is part of a system that is now over 5 years old?

Until more competition enters the market, this section of our review can be very simple, thankfully. I’ll be blunt and to the point…

First things first: the Sony A7R3 has them all beat, in terms of overall features and value. You just can’t get a full-frame mirrorless body with this many features, for this price, anywhere else. Not only does the Sony have the market cornered, they have three options with roughly the same level of professional features, when you count the A7III and the A9.

Having said that, here’s the second thing you should know: Canon and Nikon’s new full-frame mirrorless mounts are going to try as hard as they can to out-shine Sony’s FE lens lineup, as soon as possible. Literally the first thing Canon did for its RF mount was a jaw-droppingly good 50mm f/1.2, and of course the massive beast that is the 28-70mm f/2. Oh, and Nikon announced that they’d be resurrecting their legendary “Noct” lens nomenclature, for an absurdly fast 58mm f/0.95.

If you’re at all interested in this type of exotic, high-end glass, the larger size diameters and shorter flange distances of Canon and Nikon’s new FF mounts may prove to have a slight advantage over Sony’s relatively modest E mount.

However, as Sony has already proven, its mount is nothing to scoff at, and is entirely capable of amazing glass with professional results. Two of their newest fast-aperture prime lenses, the 135mm f/1.8 G-Master and the 24mm f/1.4 G-Master, prove this. Both lenses are almost optically flawless, and ready to easily resolve the 42 megapixels of this generation A7R-series camera, and likely the next generation too even if it has a 75-megapixel sensor.

This indicates that although Canon and Nikon’s may have an advantage when it comes to the upper limits of what is possible with new optics, Sony’s FE lens lineup will be more than enough for most pros.

Sony A7R3, Sony FE 70-300mm G OSS |  128mm, 1/100 sec, f/14, ISO 100

Sony A7RIII Review Verdict & Conclusion

There is no denying that Sony has achieved a huge milestone with the A7R mk3, in every single way. From its price point and feature set to its image quality and durable body, it is quite possibly the biggest threat that its main competitors, Canon and Nikon, face.

So, the final verdict for this review is very simple: If you want the most feature-rich full-frame camera (and system) that $3,200 can buy you, (well, get you started in) …the best investment you can make is the Sony A7RIII.

(By the way, it is currently just $2798, as of March 2019, and if you missed this particular sale price, just know that the camera might go on sale for $400 off, sooner or later.)

Sony A7R3, Sony FE 70-300mm G OSS | 1/400 sec, f/10, ISO 100

Really, the only major drawback for the “average” photographer is the learning curve, which even after three generations still feels like a sheer cliff when you first pick up the camera and look through its massive menu interface and customizations. The A7R3 body, (nor the A9 or A7III, for that matter) is not for the “casual” shooter who wants to just leave the camera in “green box mode”, and expect it to be simple to operate. I’ve been testing and reviewing digital cameras for over 15 years now, and the A7RIII is by far the most complex camera I’ve ever picked up.

That shouldn’t be a deterrent for the serious pro, because these cameras are literally the tools of our trade. We don’t have to get a degree in electrical engineering or mechanical engineering in order to be photographers, we just have to master our camera gear, and of course the creativity that happens after we’ve mastered that gear.

However, a serious pro who is considering switching from Nikon or Canon should still be aware that not everything you’re used to with those camera bodies is possible, let alone effortless feeling, on this Sony. The sheer volume of functionality related to focusing alone will require you to spend many hours learning how the camera works, and then customizing its different options to the custom buttons and custom menus so that you can achieve something that mimics simplicity, and effortless operation.

Sony A7R3, Sony 16-35mm f/2.8 GM | 1/4 sec, f/14, ISO 100

Personally, I’m always up for challenge. It took me a month of learning, customizing, and re-customizing this mk3-generation of Sony camera bodies, but I got it the way I want it, and now I get the benefits of things like having both  the witchcraft/magic that is Eye-AF, and the traditinal “oldschool” AF methods, at my fingertips. As a working pro who shoots in active conditions, from portraits and weddings to action sports and stage performance, it has been absolutely worth it to tackle the steepest learning curve of my entire career. I have confidence that you’re up to the task, too.

from SLR Lounge https://www.slrlounge.com/sony-a7riii-review-best-full-frame-pro-mirrorless-camera/ via IFTTT

[suzannemcappsca]

Lex Infinitum – Celebrating Three Years of Inspiration

Jonathan Rodrigues, M.R.K. Prasad and Anna Howard (Associate Editor)

For many student mediators across the globe, the start of the New Year will bring the final stages of their preparation for two mediation competitions. Next week, the Lex Infinitum competition will be held at V. M. Salgaocar College of Law, Goa, followed, in February, by the ICC Mediation Week in Paris. Now in its third year, Lex Infinitum: VMSCL-WMO International Dispute Resolution Competition will soon welcome 24 teams from across India and further afield including teams from Poland, the UK, Russia, Singapore, Nigeria, Ukraine and Kenya. They will be joined by mediation professionals from across the globe

Last year, in his post Lex Infinitum – Talking Mediation in India, Greg Bond shared the reflections of some of the people he met at the 2017 competition. In this post, I (Anna) have the privilege of interviewing the founders of the competition, Prof. Dr. M R K Prasad and Jonathan Rodrigues. Prof. Dr. M R K Prasad is the dean of the Faculty of Law, Goa University and Principal of V. M. Salgaocar College of Law. Jonathan Rodrigues is an alumnus of V. M. Salgaocar College of Law and the co-founder of the Peacekeeping and Conflict Resolution Team (PACT), a collective of mediation professionals who work towards promoting mediation in India through workshops, competitions and conferences. In this interview, Prof. Prasad and Jonathan offer their insights on the aspirations behind the competition, its impact on the participating students and professionals, and its influence on the growth of mediation in India.

Anna: Lex Infinitum is now in its third year and is a firm fixture in the global mediation competitions calendar. What were the aspirations behind the competition?

Jonathan: By way of brief background, I created and conceptualized Lex Infinitum under the guidance and mentorship of Prof. Prasad, with V. M. Salgaocar College of Law as the host institution. Gracious Timothy, co-founder of PACT, was instrumental in taking the competition up a notch in the second edition, reaching out to a wider global community of mediators. The competition owes its growth and popularity to the organising teams and volunteers who have worked tirelessly and passionately every year, taking the baton forward and inspiring others. The competition is setting some high goals and achieving them. While conceptualizing Lex Infinitum during the winter of 2015, the organizing team set itself a simple goal: “To get better every passing year and to stay exclusive to quality and inclusive in diversity”.

We are grateful for the unconditional support and encouragement we have received from the global community of mediation and conflict resolution professionals over the last three editions. The idea was to create a platform for law students in India to rub shoulders with their peers from different parts of the world; to test their skills and challenge themselves to compete in an amicable atmosphere; and to do all this by staying sensitive to, and respectful of, diversity and differences.

Through the challenging competition problems, stringent screening of participating teams, high standards of assessment and transparency of scoring, Lex Infinitum has set the bar high for other mediation competitions in the country. Though just three years old, it has attracted attention from almost every top law school in the country. From national law schools to premier private law institutions, from the oldest law colleges in the country to the very recently established, Lex Infinitum has opened its doors to those who show commitment and passion in nurturing mediation on their campuses.

The idea was of course to go beyond just the academics and awards, and to create a space for networking and to build a community of resources. The socials organized every night, the dance and dine parties, the workshops and knowledge sessions and the impromptu intellectual jams contributed to making this a unique event in India. We also followed the Practice and Preach method, where the law students of the host college would go to the community in Goa and spread the word on mediation through speeches and street plays. As much as the response has been overwhelming, more needs to be done to reach out more extensively so that, in the years to come, the competition will have even greater representation from across the globe.

Anna: Do you see a difference between the students’ attitudes towards mediation compared to those of the (older) members of the legal profession?

Jonathan: The basics – voluntariness, confidentiality, neutrality and most importantly, self-determination – seem to be more appealing to the younger generation of professionals who want to make decisions by themselves rather than being spoon-fed by a third party.

Mediation also demands certain calmness and composure in tackling tense moments. An apology or a compliment is a step forward and not a weakness. It’s much tougher for senior members of the legal profession, who have been schooled to be adversarial and polarizing in their approach, to suddenly wear a different cape and encourage their parties to find common ground. Sometimes, impasse ice-breakers such as ‘I am sorry, I could have been wrong there” or “Thank you, I appreciate everything you have done to make this easier” are the hardest statements made in a mediation setting. The younger generation doesn’t mind keeping its arrogance at bay, if they can be assured that they can ‘move on’ and it won’t “lend them broke”, while their interests are respected and prioritized. Being soft on the person and hard on the problem is a tough pill to digest for many senior professionals in the legal field. However, the tides are changing, and so are the attitudes.

Having trained and worked with over 2,000 students across the country through PACT’s workshops, I can testify that there is a deep-rooted sense of frustration towards the inefficiency of the courts in India and their indifference to the backlog of around 30 million pending court cases. There is a revolution brewing in the country, where young lawyers are earnestly looking forward to exploring a career in consensual dispute resolution. This trend and momentum has inspired many senior advocates and judges to learn about mediation and get themselves trained as well. Mediation needs the drive of the young and the tact of the elders to strive in India.

Anna: What do the students seem to value most from their experience of taking part in the competition? Prasad: For many students, this is their first experience of having a close to real-life negotiation or mediation session. Therefore, the very opportunity of putting their skills to the test in a competition setting is what they value the most. The workshops before the competition are also a unique feature that weren’t too common in India a few years ago. Their biggest takeaway, though, is the feedback they receive after every competition round and the opportunity to network with some of the most experienced and renowned professionals in the field of consensual dispute resolution. Also, at Lex Infinitum, it doesn’t matter which institution you represent, everyone is treated equally.

Anna: What do the assessors learn from the students taking part in the competition? Jonathan: Assessors have a bag full of takeaways at the end of the competition. Besides soaking in the sun-baked beaches, delicious food and the green countryside, an opportunity to watch, guide and advise young mediation enthusiasts is something that professionals can look forward to at Lex Infinitum. India, as we know, is more than just a country, it’s a civilization; therefore, the learnings are immense even for someone who has been practising mediation for decades. Among the Indian teams, there is so much diversity – language barriers, accents, religious, social and cultural backgrounds, approaches to gender and age, habits and mannerisms, etc. All these elements are on display during the competition rounds, consciously or not, and the assessors get to witness, first hand, this rich array of characteristics.

Anna: How has the competition contributed to the development of mediation in India?

Prasad: The concept of mediation has been practised in India much before the colonial rule, albeit through different means and platforms. But, many of these practices do not have a structure or guidelines to monitor their efficiency and credibility. The competition contributes towards developing systematic procedure and standards that are required for mediation. As they prepare to be lawyers, the students realize that mediation demands a different temperament and skill set.

The concept of mediation has certainly picked up in the country, with students showing tremendous interest in mediation competitions. In the first edition, we had to work hard to get 24 teams to register, last year we had 50 teams that applied and this year that number is nearing 60. In the first year, we had 5 international experts and two international teams; in the second edition in 2017, we had 4 international teams and 17 international experts. This year, we have 22 international experts boarding their flights. This also reflects how it has grown in popularity in the global community.

Anna: Finally, can you offer any tips for the students as they make their final preparations for the competition?

Jonathan: The competition challenges you to keep your approach simple and yet explore the infinite innovative possibilities of resolving conflict. The assessors always appreciate creativity and courage, but deviating from the fundamental principles and rules that govern the practice of mediation could lose you marks. There is no room for intuition and postulation; preparation and anticipation are key. There is no substitute for reading the competition problems, brainstorming strategies and rehearsing simulations prior to competing at Lex Infinitum. Miss out on any of those three pillars of preparation and you join the company of mediocrity.

I would also suggest that participants practise reframing, summarizing and questioning – skills that turn us into groomed negotiators and which are also relevant in the context of the competition, considering that English will be spoken in different accents, dialects and intonations. Finally, the basics: when you speak, be clear and throw your voice out so that the assessors may hear you. And, when you have nothing to say, listen empathically.

All the very best of luck to the teams taking part in Lex Infinitum next week.

More from our authors:

EU Mediation Law Handbook: Regulatory Robustness Ratings for Mediation Regimes by Nadja Alexander, Sabine Walsh, Martin Svatos (eds.) € 195 Essays on Mediation: Dealing with Disputes in the 21st Century by Ian Macduff (ed.) € 160.00

The post Lex Infinitum – Celebrating Three Years of Inspiration appeared first on Kluwer Mediation Blog.

from Updates By Suzanne http://mediationblog.kluwerarbitration.com/2018/01/06/lex-infinitum-celebrating-three-years-inspiration/

[writeprivledge-blog]

Interview with an EMU Professor

What makes a liberal arts degree still valuable in this day in age? What sorts of jobs are available to these degree holders?

So yes, the value of a liberal arts degree has been what's it's always been and I think that's been lost in the last ten years. And I think that's because you have young students coming in and thinking “I need to get a degree that will guarantee me a job when I graduate”. And for some programs that’s easier than others, if you’re a nursing student you become a nurse, an engineer student an engineer, a biologist ends up in a biology lab and then where its starts to get hard is what does an English major do, right? My experience was I became a professor after having been a creative writing major in undergrad but that was working in other industries for many years. And what I noticed is a lot of people like me with liberal arts degrees got hired because they were critical thinkers, they’re good at communicating, they’re thoughtful people, they’re good project managers, they’re good at translating business needs into communicable documentation. Just speaking from my own experience as a liberal arts major, I seemed to do pretty well in a field for many years that I hadn’t gone to school for because I was a liberal arts major, but I think more generally speaking if you’re a liberal arts major and study whatever you’re passionate about that what you’re doing is learning to think on a higher order by studying something you care about and through that you obtain a lot of these analytical, problem solving, creativity, writing, etc, skills that are invaluable in the workplace now. So what you find now is all these articles saying they need liberal arts majors because they need employees with all these skills. And the other side of that coin is that I think the world needs more artists, needs more critical thinkers and that’s what this degree can help you get there. And not that you can’t be a good person and be an engineer, but the ideas that an engineer takes some liberal arts classes too so they can become a more well rounded citizen. And a lot of business leaders, whether they go on to law or business school started as liberal arts undergraduates and that foundation is essential.

Do you know the exact amounts or at least have a general idea of how Eastern's budget breaks down by category? How much of it is allocated to the liberal arts programs here? Is Eastern's allocation higher, lower, or about average to what other comparable schools (i.e. Oakland, Washtenaw, etc.) give to their liberal arts program? Is the money allocated to us significantly less or more than other programs at Eastern?

You know, our budgets are available online and I’ve definitely looked at them out of curiosity but I couldn't say off hand what exactly that breakdown looks like because we (the Creative Writing program) are lumped in with the Liberals Arts and Science Department. I will say though I think all academics at Eastern right now are struggling in every department, all except maybe the Business School because they bring in so much money but that the University from what I’ve read is struggling to balance their budget and part of that means budget cuts which I don’t think necessarily is a bad thing but that our school’s motto is “Education First” and that academics should be the number one priority especially for a university like Eastern that offers an affordable education, I think we offer a great diversity of programs and have a great student body, a diverse student body, and a student body who is looking for that quality education. So in my mind in times of budget stress, academics should be the last thing that gets cut. And granted I think there are somethings I think to keep in mind, like if the student body is shrinking then yes, you would offer fewer classes however at the same time our students need to graduate, need to be able to take classes they enjoy and that challenge them, and they need to be able to graduate from Eastern with that great experience, and that in its own way ensures a future student body thats just as vibrant and expanding. So to me, I suspect you came to Eastern because it was an affordable education and if you get a great education at a great price then you leave and tell others about your great experience rather than leaving frustrated. (In regards to the budget) I would assume other schools in the area are going through similar issues when it comes to their programs, like for example Oakland, I know they have a much smaller emphasis on athletics, they don’t have a football team and have a decent basketball team, so at least public perception is that they’re focused more on students.

Has Eastern's Liberal Arts budget effected your position or your ability to teach in anyway? If yes, can you think of specific examples or instances?

I’ll say that I think personally that what I see is a general tightening of things, I know Eastern went through a sort of exercise of equivalency of course loads through its departments, with some departments now teaching less and other departments picking up more. When I think Eastern should be pushing to have all faculty teaching fewer classes and setting aside more money to hire on more staff with tenure because right now we have a lot of part time lecturers, who are great teachers, but i believe they are overworked and underpaid and that we could solve this issue by giving them some job security and compensation and maybe there would be room for that if there was a focus on academics (laughs) but I’ll say where things have tightened, for example, last year the faculty had to make decisions like do we make less photocopies, spend less on travel money, things like that. And there became an emphasis of us hitting our capacity for students in our classes. And that urgency is good when times are tough but it seems odd that we’re continually told to tighten our belts and hit quotas but seem to have no real explanation as to why.

What seems to be the consensus of you and your colleagues about how Eastern treats the Liberal Arts program, particularly in regards to allocating student tuition towards remodeling dorms and football teams that only a small portion of the student body utilizes?

So, I fully acknowledge that running a university is complicated thing and that money flows in all kinds of different ways but the academic budget here has been flat for multiple years and liberal arts programs are pretty cheap (comparably) to run so the fact that we’re already running a pretty tight ship and that aside from our salaries it doesn’t cost the university much outside of that I think leads to the student and public perception that the universities funds are being misdirected and I think that is definitely something the faculty feels as well. And I don’t think any of us feel that these sport teams aren’t important but that at what point does that emphasis (in particular to the football team) shift back to academics. And what I’m guessing is ultimately what the university is hoping for is that if the football team becomes better is that they’ll get a stronger alumni base that will come back for games and give money to the school. But I don’t think we’re that kind of school. And I guess we want to be that. And I don’t understand, and this is my biggest complaint, if we’re an academic school and commuter school first, why don’t we embrace that? Granted we can have a campus life too but most students come here for reasons other than that or athletics. And I think that’s what really annoys student that are aware of what the University has been up to, something like 10% of your tuition, is going towards the athletic department, and granted that's the whole department, but the perception is the school is taking money away from the student body for something they don't care about. And there’s a lot of things your tuition pays for you probably don't care about, but at least they serve a purpose to some other student in the majority. So to come back to the question, my job right now is great. I love my students, love my peers and the faculty in general, but it’s like can we get any tighter on the budget? And couldn’t we be doing something radical to enthuse our students and bring more in while staying on message of  “Education First”? I don’t know what that is, but I think we need leadership that wants to do something surprising and exciting rather than doubling down on a football team that is receiving vocal criticism that is valid from many different areas of the university. And I say all this with the caveat that I don’t think everything of value needs to make a return on its investment or make a profit but I think the school needs to evaluate the reasonableness of these things.

[brenvs3000]

Healthy Earth = Healthy Life

It took me a while to think about where I wanted my blog to go this week. However, one thing that is always in the back of my head is my future and where I am going to be.

Sometimes I feel like this girl ^

Being a university student, I am always toying with the idea of my future. Many thoughts enter my head on the daily, including “what am I going to do with my life?”. Being the free-spirited nature-lover in my family, I often get a lot of worry from my parents and the older generation of my family about where my career is going to go. There is a consensus among those who are not involved in the environmental field that I am going to become a “tree-hugger”. However, to me, that does not sound like such a bad gig.  

Old-growth Forest on Vancouver Island 2015

I have grown up loving the outdoors and anytime I was outside, I was my happiest. My parents always laugh about how if they could not find me, I was probably sitting outside in the mud, getting dirty. Throughout my childhood, I often turned to nature as a form of entertainment when I was bored, because back then, we did not have access to technology like we do now. However, the fact that we have so much technology present in the world, I worry that children that are growing up now will not turn to nature to entertain them. I believe that growing up playing in the outdoors was the concrete foundation towards my passion for helping the environment. That being said, I am inspired to help motivate children to go outside, because they are ultimately the future of this earth.

Being a 21 year old, wildlife biology student at this time is a very exciting but intimidating and scary feat. Due to all the environmental change that the world is currently going through, it is time for people to try to change our habits in order to help the environment. However, I often get so frustrated when people do not have the same care about the environment that many of the other people in the world do, including myself. Whenever I see litter, I just want to find that person and yell at them and say “WHY? Why are you do lazy that you cannot clean up after yourselves?”. However, instead of finding the negative in situations like that, I have to remind myself that those people may not have been privileged to spend a lot of their childhood outside and lack that relationship with nature. Therefore, I find that it is part of my duty as a nature-lover to do my service to protect nature by trying to inspire people to find their relationship with nature.

Seeing wildlife in their natural state allows me to feel a deep connection with nature.

I think every single person on earth has the ability to connect with nature in a positive way. In my mind, people have evolutionarily connected through nature throughout time in positive ways. However, some people may not have found that connection with nature early on in life and are missing out on their relationship with the earth. Therefore, to connect with my original post about “what am I going to do with my life”… I can answer that by saying I just want to be an advocate for nature, whether is through research, education, or some other job. I want to be able to stand in the gap between nature and human activity to try to connect the two to occur in harmony because ultimately there would be no life without a healthy earth.

How do you want to incorporate nature into your future?

Posted October 15th, 2017 

[shapesnnsizes]

RHR: Unanswered Questions About SIBO

In this episode we will discuss:

Is lactulose breath testing an accurate way to diagnose SIBO?

Is SIBO always pathological?

Are our treatments effective?

Is SIBO always the underlying cause?

Should probiotics and prebiotics be avoided during treatment?

Does a long-term low-FODMAP diet help prevent recurrence?

[smart_track_player url="http://traffic.libsyn.com/thehealthyskeptic/RHR_-_Unanswered_Questions_About_SIBO.mp3" title="RHR: Unanswered Questions About SIBO" artist="Chris Kresser" ]

Hey, everybody, it’s Chris Kresser. Welcome to another episode of Revolution Health Radio. This week we're going to do something a little bit different. Rather than answer one specific question that was sent in, I'm going to answer a bunch of different questions that I get all the time regarding a very popular topic, which is SIBO. As a matter of fact, I have many questions about SIBO myself, and that's actually how I want to frame this podcast. I get more questions about SIBO than probably any other health topic. I've been treating it now for many years, and I've learned a lot about it in that time, and yet it seems like the more I learn, the more questions I have. Certainly, if you look on internet forums and blog comments, you look at summits and podcasts in our entire field, you can see that there's still a lot of questions about SIBO and misunderstanding and things that we really need to figure out in order to be able to appropriately diagnose and treat this condition. I think the best way to dive into this is just to say that I've started to doubt many of the standard assumptions or beliefs around SIBO that many of you are probably already aware of. I just want to go through five or six of these assumptions and tell you what my current thinking about them is, and this might be a little bit of a frustrating podcast to listen to because I'm not necessarily going to give you answers. I'm just going to tell you what the questions are, where my doubts are, and what further research or exploration or investigation I think we need to do.

Question #1: Is lactulose breath testing an accurate way to diagnose SIBO?

Let's start with assumption number one, which is that lactulose breath testing is an accurate way of diagnosing SIBO. As many of you know, the standard way of diagnosing SIBO in an outpatient setting is using lactulose breath testing. There is another way, which is an endoscopy, where they put a tube down your throat and take a sample of bacteria from your small intestine, but that's never used in outpatient settings because it's invasive and expensive. It's just not done. There are actually a lot of problems with that method as well, which leads us to probably the biggest issue of all from a 30,000-foot-view perspective with SIBO, is that in order for a test to be accurate, it needs to be validated against something that's a gold standard, and we have no gold standard way of diagnosing SIBO. The endoscopy, which I just mentioned, has been used as the gold standard test against which breath testing is validated. But what if the gold standard test itself is not accurate? That obviously creates some pretty big problems in terms of developing another test like breath testing and then validating it against a test that itself is not very valid. That's the biggest issue.

The problems with SIBO diagnosis and treatment

I'm not going to go into all the nitty-gritty details on why breath testing isn't necessarily as accurate as some people may believe. But in this context, I'll just say that—and this is a guess, I haven't done any rigorous study—but I would estimate that over 90 percent of the patients we test for SIBO test positive. Now this is using the former criteria and I'll come back to this in a second, but if you just use the machine-generated criteria that are printed on any of the SIBO breath testing labs, I would say over 90 percent of our patients test positive. Now, that alone should be a red flag. When more than 90 percent of your patients test positive for a condition, that should raise some eyebrows. Certainly SIBO is common, but do we really expect that 90 percent of patients, even people who are sick and dealing with chronic health issues have SIBO? I've never seen any research suggesting that over 90 percent of people with any particular conditions also have SIBO. The exception might be acne rosacea. I think I saw one study of 42 patients where 100 percent of patients with acne rosacea had SIBO [Correction: study I was referring to found that SIBO was 17 times more prevalent in patients with rosacea than in controls.] This doesn't mean for sure that the test is inaccurate, but it definitely raises my eyebrows. It makes me wonder whether we're over-diagnosing SIBO. Changes in criteria Now I mentioned the criteria, so up until pretty recently the idea was that if you see an increase in 20 parts per million or more of hydrogen in the first 120 minutes of the test, that would indicate a positive result, and the criteria were an increase in 12 parts per million for methane, but those criteria recently changed; there was a consensus statement issued in the spring. A bunch of SIBO experts got together and talked about how to update the breath-testing criteria to make it more accurate and ensure that the criteria were modified to, on the one hand with hydrogen, the changes would lead to fewer diagnoses, less overdiagnosis of hydrogen-predominant SIBO. But in the case of methane, they're going to lead to a greater number of diagnoses because those criteria, instead of becoming more strict, became more liberal. The new hydrogen criteria are increasing 20 parts per million within the first 90 minutes, and then with methane, it's any value over 10 parts per million at any point during the test, including during the third hour. That’s a pretty big difference, and that's going to lead to a lot more positive results for methane. It’s also worth pointing out that there are a lot of different studies that are critical of lactulose breath testing that suggest that there is a very high potential for false positives, especially using lactulose instead of glucose. With glucose breath testing, the opposite problem is true. There's a high potential for false negatives. If there is a positive, it should be positive. But if there's a negative, you can't rule out that SIBO might be present. Again, I'm not going to go into great detail here, but let's just say that there is a lot of uncertainty about breath testing as a way of diagnosing SIBO.

Question #2: Is SIBO always pathological?

The second assumption is that SIBO is always pathological. The idea is that if SIBO is present, it's always causing the patient's problems, whatever they are, but that's not sound thinking, of course, because we know that correlation is not causation. It's possible that SIBO could be present, but it's not actually driving whatever the patient's symptoms are. We know that early studies suggested that up to 20 to 30 percent of healthy controls have SIBO but don't have symptoms. Of course, I have to offer a side note here, which is, I don't know where these studies are finding these so-called “very healthy controls with no symptoms.” I haven't met that many of those people, but let's assume that that's true. That could mean that 20 to 30 percent of the population has SIBO, but it's not causing any problems for them. In many cases, we treat SIBO, and the numbers improve, so the patient goes from being breath-test positive to breath-test negative, but their symptoms don't necessarily improve. That would suggest that maybe SIBO was present, but it wasn't causing their symptoms. It's possible that the testing is accurate as far as what it's measuring, but what we call SIBO as a condition is not always pathological. It's also possible that SIBO might be present in a patient and might be causing some issues, maybe a mild nutrient deficiency or something like that, but it's not causing the main complaints. The reason I bring this up is that I see some patients just getting hyperfocused, almost obsessed about SIBO, at the expense of everything else. And clinicians—there is that saying, “If you've got a hammer, everything looks like a nail”—I see both clinicians and patients becoming over-focused, I think, on SIBO, and the risk there is that you actually miss other pathologies or underlying mechanisms that are really actually driving the condition in those cases if we're just myopically focused on SIBO.

Question #3: Are our treatments effective?

The third assumption is that our current treatments are effective and optimal. The typical treatments for SIBO are antimicrobials. Initially, there were prescription medications. Rifaximin is the most commonly used, especially for hydrogen-predominant SIBO, and neomycin is also added at times when methane is present. Metronidazole is another medication, or Flagyl is used in some cases for treating SIBO, as well as other antibiotics, but rifaximin certainly has become the drug of choice. But then there have been some studies recently that have found that botanicals, herbs, are as effective as rifaximin treatment or even more effective and cause fewer side effects. In general, the approach is if SIBO is there, then you use antimicrobials to reduce the growth of bacteria in the small intestine. The problem with this approach is that the efficacy is often quite low. I've seen some studies that we use rifaximin individually that show as low as 40 percent efficacy. Of course, there are other studies that show higher efficacy, and then if you combine other agents in the treatment, you can make it more effective. There was one treatment where the researchers speculated that using partially hydrolyzed guar gum would improve the efficacy of rifaximin, and in fact it did. It increased it significantly. In our clinic we use a combination protocol that uses a bunch of different things together, all of which are designed to maximize the efficacy. It also depends whether it's just hydrogen alone that's high, or methane alone that's high, or both hydrogen and methane, and each of those scenarios requires a different approach. But the problem remains that efficacy is much lower than I certainly would like to see it. Not only that, in some cases, not only do patients not get better, they actually get worse after treatment. They might get worse right away or they might improve initially, but then the symptoms return and when they come back, they come back even worse. I've seen this actually happen in multiple cycles, meaning with each treatment and each return of symptoms, the symptoms get worse after each cycle, which is obviously problematic. Then there's the very high rates of recurrence for SIBO, which is related to what I just said. One study, I think, found a recurrence rate of 45 percent in patients who had been treated by rifaximin. In our practice, despite using all of the evidence-based methods and combining several different methods, we still see recurrence rates a lot higher than optimal, than I think is acceptable. That's one of the main things that has led me to question many of these beliefs and assumptions because when the treatments are not that effective and the recurrence rates are very high, then I think that something is definitely wrong.

Question #4: Is SIBO always the underlying cause?

The fourth assumption is that SIBO was always the underlying cause of a particular condition. This is somewhat related to what I mentioned earlier, but a little bit different. In functional medicine, we're always trying to get to the root of the problem, but sometimes that's easier said than done, and it can be like peeling layers of an onion back to keep going deeper to find the deepest underlying issue. If a patient has SIBO, for example, and we treat their SIBO and it doesn't go away, or maybe it does go away and it comes back, and we do that two or three times, then of course I start wondering, “All right. Well, is there some other deeper condition that is causing the SIBO?” In this case SIBO is not necessarily a cause itself, but almost a symptom of a deeper underlying problem. In my experience, those problems can be things like:

mold or chronic inflammatory response syndrome

chronic infections like tick-borne illnesses

viral reactivation

other gut infections that have escaped detection

heavy metal toxicity

other types of toxicity

mitochondrial deficiency

And a range of other problems. But the point being that in those cases, those problems are the real thing that's driving SIBO and then whatever symptoms the SIBO is causing. It’s like layers, and so you have to keep going deeper in order to identify and address those conditions, otherwise that patient is never going to get over SIBO. We’ll just keep treating it, it might improve a little bit or not, and then it just keeps coming back. Even though rifaximin and the botanicals are relatively safe compared to other antimicrobials, they're still antimicrobials, and we still want to minimize our use of them.

Question #5: Should probiotics and prebiotics be avoided during treatment?

Assumption number five is that probiotics and prebiotics should always be avoided when a patient has SIBO and shouldn't be included in treatment. I think I've discussed this before and I'm not totally sure where this belief or assumption came from. It's pretty prevalent within the mainstream SIBO community, if you want to call it that. But all of the studies that I've seen, I think, without exception, have found that when you use probiotics, either along with antibiotics or as separate distinct treatment for SIBO, they are effective. They're either effective as solo treatment, or they increase the efficacy of SIBO [treatment protocols]. Even the studies that have used probiotics have shown positive results, which might be a little counterintuitive because you would expect probiotics to feed the bacteria that are present in the small intestine. I think there are still quite a few questions here. Certainly, I have seen probiotics, and probiotics make patients with SIBO worse, but in other cases, I've seen them make patients with SIBO significantly better. We do include very specific types of probiotics and even prebiotics in our SIBO treatment protocol. We've done that for many years because of the research I've seen on this, and I do think it is effective in most cases. This sort of points to another question or concept, which historically a lot of SIBO authorities have claimed that SIBO is just really kind of a small intestine, it's not really related to the health of the large intestine or the overall gut microbiome. That doesn't make sense to me. There is a sphincter that separates the small and large intestine, but one of the prevailing theories about how SIBO got started in the first place is it’s an inappropriate transfer of bacteria from the large intestine to the small intestine. It's entirely possible, and even likely, in my opinion, that one of the predisposing factors that can lead to that translocation of bacteria from the large intestine to the small intestine is an unhealthy large intestine. It may be that that’s one of the reasons that prebiotics and probiotics work in terms of treating and even preventing recurrence of SIBO is that they help to improve the gut microbiome. That, in turn, has a sort of upstream effect on the small intestine. Really, still a lot of unanswered questions here related to probiotics and probiotics, but I've seen enough now to convince me that the dominant idea that they should always be avoided is not true.

Question #6: Does a long-term low-FODMAP diet help prevent recurrence?

Then finally, the last assumption, number six, is that a long-term low-FODMAP diet is always a good idea in order to prevent recurrence. I have discussed this and written about this before, so I'm just going to mention it briefly. But studies have shown that a long-term low-FODMAP diet can reduce the diversity and quality of beneficial bacteria in the large intestine, and for the reasons that I just mentioned, I think that that can be problematic. Even though the low-FODMAP diet can reduce symptoms, it may be setting patients up for recurrence if it's leading to undesirable changes in the beneficial bacteria in the colon. Also, there was a recent study that just came out that found that patients with IBS are often able to reintroduce certain FODMAPs without any adverse effects. This study didn't consider SIBO, but as you probably know, many patients with IBS do have SIBO. My guess is that they would have found a similar effect if they had done the study in patients that only had SIBO. It seems that even in patients who do have SIBO or IBS that reintroducing some FODMAPs not only could be potentially beneficial, but doesn't actually lead to a return of symptoms. That's what I've always encouraged my patients to do is reintroduce as many FODMAPs as they can without significant discomfort. I think that's a wise approach because we want to keep our diet as diverse as possible, and especially when it comes to fermentable fiber, it can support our beneficial gut bacteria. Okay. I'm going to stop there. As you can see again, this is a little frustrating maybe to listen to. I'll tell you that it's super frustrating for me as a clinician. This is again something I've been paying very close attention to for a long period of time, and I feel quite frustrated with the lack of answers around many of these questions. Certainly, not for lack of looking, experimenting, and exploring, but my commitment to you is that I will continue to do that. I think it's a very important starting place to just admit when we don't know the answers to these questions at least, and to lay those questions out so we can start exploring what the answers might be, and of course that is the process of science. It's not that we always have the answers and we always know what and we stop looking. Once we think we know the answers, we always question our assumptions and we continually re-evaluate them, especially in the face of evidence that contradicts our previous assumptions or beliefs. That's the true application of the scientific method in the case of healthcare. I hope that was helpful in some way. If you're a patient out there and you're frustrated with your lack of progress with SIBO, you're definitely not alone. If you're a clinician out there and you're frustrated with your lack of progress with SIBO in terms of treating patients, you're definitely not alone. I think we should ... we need to get these questions out there more so that we can all work together to answer them. Okay, that's it for now. Please continue to send your questions in at chriskresser.com/podcastquestion, and I'll talk to you next time. Take care, everybody.