Women say 'casual sex is immoral'
Nine out of 10 women think one night stands are immoral, psychologists will hear at a conference.
Women in nursing homes often have bladder problems
NEW YORK (Reuters Health) - While a very small proportion of female nursing home residents are diagnosed with urinary incontinence, more than half actually have prblems with bladder control, researchers report.
Infections May Trigger Dangerous Blood Clots
Respiratory, urinary tract problems linked to deep vein thrombosis, a new study suggests.
Common painkillers may impair rotator cuff healing
NEW YORK (Reuters Health) - Experiments in rats show that the painkillers celecoxib (brand name, Celebrex) and indomethacin, given after repair of a rotator cuff injury, impair the healing process, orthopedists report in The American Journal of Sports Medicine.
System Keeps Scan Results From Going Astray
Lost or misdirected MRI, CT scans can have devastating consequences for patients
Top Docs Debate Elective C-Sections
They got together to discuss the latest that's known about the pros and cons of C-sections, as more women than ever opt for the procedures. Pregnancy expert Dr. Catherine Spong was there and discussed the ongoing controversy with Rene Syler.
Boost for 'superbug' drug
Research into soil bacteria sparks hopes of urgently-needed new drugs to treat infections like MRSA.
Medicare patients confronting drug restrictions
Thousands of elderly patients are learning the hard way that it isn’t enough to check whether their medicines are covered under a new Medicare drug plan they have chosen.
New Pennsylvania Analysis On Cost Of Hospital-Acquired Infections Released; House Energy And Commerce Committee To Review Issue
The Unseen Impact - Could Adult Diseases Be Caused By Food And Chemicals Before Birth?
New Gene That Causes Spread Of Cancer Identified, University Of Liverpool
UK Government Guilty Of Betrayal Over Bowel Cancer Screening, Cancer Research UK
Classical Swine Fever: Movement Restrictions On Pigs In North-Rhine Westphalia, Germany
Antimicrobials In The Home Not Necessary, Canadian Paediatric Society
Friday, March 31, 2006
How Quackery Sells
With Thanks to Quackwatch
Stephen Barrett, M.D.William T. Jarvis, Ph.D.
Modern health quacks are supersalesmen. They play on fear. They cater to hope. And once they have you, they'll keep you coming back for more . . . and more . . . and more. Seldom do their victims realize how often or how skillfully they are cheated. Does the mother who feels good as she hands her child a vitamin think to ask herself whether he really needs it? Do subscribers to "health food" publications realize that articles are slanted to stimulate business for their advertisers? Not usually.
Most people think that quackery is easy to spot. Often it is not. Its promoters wear the cloak of science. They use scientific terms and quote (or misquote) scientific references. Talk show hosts may refer to them as experts or as "scientists ahead of their time." The very word "quack" helps their camouflage by making us think of an outlandish character selling snake oil from the back of a covered wagon—and, of course, no intelligent people would buy snake oil nowadays, would they?
Well, maybe snake oil isn't selling so well, lately. But acupuncture? "Organic" foods? Hair analysis? The latest diet book? Megavitamins? "Stress formulas"? Cholesterol-lowering teas? Homeopathic remedies? Magnets? Nutritional "cures" for AIDS? Products that "cleanse your system"? Or shots to pep you up? Business is booming for health quacks. Their annual take is in the billions! Spot reducers, "immune boosters," water purifiers, "ergogenic aids," systems to "balance body chemistry," special diets for arthritis. Their product list is endless.
What sells is not the quality of their products, but their ability to influence their audience. To those in pain, they promise relief. To the incurable, they offer hope. To the nutrition-conscious, they say, "Make sure you have enough." To a public worried about pollution, they say, "Buy natural." To one and all, they promise better health and a longer life. Modern quacks can reach people emotionally. This article shows how they do it.
Appeals To Vanity
An attractive young airline stewardess once told a physician that she was taking more than 20 vitamin pills a day. "I used to feel run-down all the time," she said, "but now I feel really great !"
"Yes," the doctor replied, "but there is no scientific evidence that extra vitamins can do that. Why not take the pills one month on, one month off, to see whether they really help you or whether it's just a coincidence. After all, $300 a year is a lot of money to be wasting."
"Look, doctor," she said. "I don't care what you say. I KNOW the pills are helping me."
How was this bright young lady converted into a true believer? First, an appeal to her curiosity persuaded her to try and see. Then an appeal to her vanity convinced her to disregard scientific evidence in favor of personal experience—to think for herself. Supplementation is encouraged by a distorted concept of biochemical individuality—that everyone is unique enough to disregard the Recommended Dietary Allowances (RDAs). Quacks won't tell you that scientists deliberately set the RDAs high enough to allow for individual differences. A more dangerous appeal of this type is the suggestion that although a remedy for a serious disease has not been shown to work for other people, it still might work for you. (You are extraordinary!)
A more subtle appeal to your vanity underlies the message of the TV ad quack: Do it yourself—be your own doctor. "Anyone out there have 'tired blood'?" he used to wonder. (Don't bother to find out what's wrong with you, however. Just try my tonic.) "Troubled with irregularity?" he asks. (Pay no attention to the doctors who say you don't need a daily movement. Just use my laxative.) "Want to kill germs on contact?" (Never mind that mouthwash doesn't prevent colds.) "Trouble sleeping?" (Don't bother to solve the underlying problem. Just try my sedative.)
Turning Customers into Salespeople
Most people who think they have been helped by an unorthodox method enjoy sharing their success stories with their friends. People who give such testimonials are usually motivated by a sincere wish to help their fellow humans. Rarely do they realize how difficult it is to evaluate a "health" product on the basis of personal experience. Like the airline stewardess, the average person who feels better after taking a product will not be able to rule out coincidence (spontaneous remission)—or the placebo effect (feeling better because he thinks he has taken a positive step). Since we tend to believe what others tell us of personal experiences, testimonials can be powerful persuaders. Despite their unreliability, they are the cornerstone of the quack's success.
Multilevel companies that sell nutritional products systematically turn their customers into salespeople. "When you share our products," says the sales manual of one such company, "you're not just selling. You're passing on news about products you believe in to people you care about. Make a list of people you know; you'll be surprised how long it will be. This list is your first source of potential customers." A sales leader from another company suggests, "Answer all objections with testimonials. That's the secret to motivating people!"
Don't be surprised if one of your friends or neighbors tries to sell you vitamins. Millions of Americans have signed up as multilevel distributors. Like many drug addicts, they become suppliers to support their habit. A typical sales pitch goes like this: "How would you like to look better, feel better and have more energy? Try my vitamins for a few weeks." People normally have ups and downs, and a friend's interest or suggestion, or the thought of taking a positive step, may actually make a person feel better. Many who try the vitamins will mistakenly think they have been helped—and continue to buy them, usually at inflated prices.
The Use of Fear
The sale of vitamins has become so profitable that some otherwise reputable manufacturers are promoting them with misleading claims. For example, for many years, Lederle Laboratories (makers of Stresstabs) and Hoffmann-La Roche advertised in major magazines that stress "robs" the body of vitamins and creates significant danger of vitamin deficiencies.
Another slick way for quackery to attract customers is the invented disease. Virtually everyone has symptoms of one sort or another—minor aches or pains, reactions to stress or hormone variations, effects of aging, etc. Labeling these ups and downs of life as symptoms of disease enables the quack to provide "treatment."
Some practitioners claim to detect "deficiencies" (or "imbalances" or "toxins," etc.) before any symptoms appear or before they can be detected by conventional means. Then they can sell you supplements (or balance you, or remove toxins, etc.). And when the terrible consequences they warn about don't develop, they can claim success.
Food safety and environmental protection are important issues in our society. But rather than approach them logically, the food quacks exaggerate and oversimplify. To promote "organic" foods, they lump all additives into one class and attack them as "poisonous." They never mention that natural toxicantsare prevented or destroyed by modern food technology. Nor do they let on that many additives are naturally occurring substances.
Sugar has been subject to particularly vicious attack, being (falsely) blamed for most of the world's ailments. But quacks do more than warn about imaginary ailments. They sell "antidotes" for real ones. Care for some vitamin C to reduce the danger of smoking? Or some vitamin E to combat air pollutants? See your local supersalesperson.
Quackery's most serious form of fear-mongering has been its attack on water fluoridation. Although fluoridation's safety is established beyond scientific doubt, well-planned scare campaigns have persuaded thousands of communities not to adjust the fluoride content of their water to prevent cavities. Millions of innocent children have suffered as a result.
Hope for Sale
Since ancient times, people have sought at least four different magic potions: the love potion, the fountain of youth, the cure-all, and the athletic superpill. Quackery has always been willing to cater to these desires. It used to offer unicorn horn, special elixirs, amulets, and magical brews. Today's products are vitamins, bee pollen, ginseng, Gerovital, pyramids, "glandular extracts," biorhythm charts, aromatherapy, and many more. Even reputable products are promoted as though they are potions. Toothpastes and colognes will improve our love life. Hair preparations and skin products will make us look "younger than our years." Olympic athletes tell us that breakfast cereals will make us champions. And youthful models reassure us that cigarette smokers are sexy and have fun.
False hope for the seriously ill is the cruelest form of quackery because it can lure victims away from effective treatment. Even when death is inevitable, however, false hope can do great damage. Experts who study the dying process tell us that while the initial reaction is shock and disbelief, most terminally ill patients will adjust very well as long as they do not feel abandoned. People who accept the reality of their fate not only die psychologically prepared, but also can put their affairs in order. On the other hand, those who buy false hope can get stuck in an attitude of denial. They waste not only financial resources but what little remaining time they have left.
Clinical Tricks
The most important characteristic to which the success of quacks can be attributed is probably their ability to exude confidence. Even when they admit that a method is unproven, they can attempt to minimize this by mentioning how difficult and expensive it is to get something proven to the satisfaction of the FDA these days. If they exude self-confidence and enthusiasm, it is likely to be contagious and spread to patients and their loved ones.
Because people like the idea of making choices, quacks often refer to their methods as "alternatives." Correctly employed, it can refer to aspirin and Tylenol as alternatives for the treatment of minor aches and pains. Both are proven safe and effective for the same purpose. Lumpectomy can be an alternative to radical mastectomy for breast cancer. Both have verifiable records of safety and effectiveness from which judgments can be drawn. Can a method that is unsafe, ineffective, or unproven be a genuine alternative to one that is proven? Obviously not.
Quacks don't always limit themselves to phony treatment. Sometimes they offer legitimate treatment as well—the quackery is promoted as something extra. One example is the "orthomolecular" treatment of mental disorders with high dosages of vitamins in addition to orthodox forms of treatment. Patients who receive the "extra" treatment often become convinced that they need to take vitamins for the rest of their life. Such an outcome is inconsistent with the goal of good medical care which should be to discourage unnecessary treatment. Another clever trick is to include their product or procedure in a list of otherwise commonly-accepted practices in order to promote it by association. They may say, for example that their method works best when combined with lifestyle changes (which, quite often, will produce tangible benefits).
The one-sided coin is a related ploy. When patients on combined (orthodox and quack) treatment improve, the quack remedy (e.g., laetrile) gets the credit. If things go badly, the patient is told that he arrived too late, and conventional treatment gets the blame. Some quacks who mix proven and unproven treatment call their approach complementary or integrative therapy.
Quacks also capitalize on the natural healing powers of the body by taking credit whenever possible for improvement in a patient's condition. One multilevel company—anxious to avoid legal difficulty in marketing its herbal concoction—makes no health claims whatsoever. "You take the product," a spokesperson suggests on the company's introductory videotape, "and tell me what it does for you." An opposite tack—shifting blame -- is used by many cancer quacks. If their treatment doesn't work, it's because radiation and/or chemotherapy have "knocked out the immune system."
Another selling trick is the use of weasel words. Quacks often use this technique in suggesting that one or more items on a list is reason to suspect that you may have a vitamin deficiency, a yeast infection, or whatever else they are offering to fix.
The disclaimer is a related tactic. Instead of promising to cure your specific disease, some quacks will offer to "cleanse" or "detoxify" your body, balance its chemistry, release its "nerve energy," bring it in harmony with nature, or do other things to "help the body to heal itself." This type of disclaimer serves two purposes. Since it is impossible to measure the processes the quack describes, it is difficult to prove him wrong. In addition, if the quack is not a physician, the use of nonmedical terminology may help to avoid prosecution for practicing medicine without a license.
Books espousing unscientific practices typically suggest that the reader consult a doctor before following their advice. This disclaimer is intended to protect the author and publisher from legal responsibility for any dangerous ideas contained in the book. Both author and publisher know full well, however, that most people won't ask their doctor. If they wanted their doctor's advice, they probably wouldn't be reading the book in the first place.
Sometimes the quack will say, "You may have come to me too late, but I will try my best to help you." That way, if the treatment fails, you have only yourself to blame. Patients who see the light and abandon quack treatment may also be blamed for stopping too soon.
The "money-back guarantee" is a favorite trick of mail-order quacks. Most have no intention of returning any money—but even those who are willing know that few people will bother to return the product.
Another powerful persuader—something for nothing—is standard in ads promising effortless weight loss. It is also the hook of the telemarketer who promises a "valuable free prize" as a bonus for buying a water purifier, a six-month supply of vitamins, or some other health or nutrition product. Those who bite receive either nothing or items worth far less than their cost. Credit card customers may also find unauthorized charges to their account.
Another potent technique is cultural association, in which promoters ally themselves with religious or other cultural beliefs by associating their product or service with an article of faith or prejudice of their target audience.
In a contest for patient satisfaction, art will beat science nearly every time. Quacks are masters at the art of delivering health care. The secret to this art is to make the patient believe that he is cared about as a person. To do this, quacks lather love lavishly. One way this is done is by having receptionists make notes on the patients' interests and concerns in order to recall them during future visits. This makes each patient feel special in a very personal sort of way. Some quacks even send birthday cards to every patient. Although seductive tactics may give patients a powerful psychological lift, they may also encourage over-reliance on an inappropriate therapy.
Psychologist Anthony R. Pratkanis, Ph.D., has identified nine strategies used to sell pseudoscientific beliefs and practices [Pratkanis AR. How to sell a pseudoscience, Skeptical Inquirer 19(4):19-25, 1995.]. They include setting phantom goals (such as better health, peace of mind, or improved sex life), making statements that tend to inspire trust ("supported by over 100 studies"), and fostering grandfalloons (proud and otherwise meaningless associations of people who share rituals, beliefs, jargon, goals, feelings, specialized information, and "enemies"). Multilevel sales groups, nutrition cultists, and crusaders for "alternative" treatments fit this description well.
Handling the Opposition
Quacks are involved in a constant struggle with legitimate health care providers, mainstream scientists, government regulatory agencies and consumer protection groups. Despite the strength of this science-based opposition, quackery manages to flourish. To maintain their credibility, quacks use a variety of clever propaganda ploys. Here are some favorites:
"They persecuted Galileo!" The history of science is laced with instances where great pioneers and their discoveries were met with resistance. Harvey (nature of blood circulation), Lister (antiseptic technique) and Pasteur (germ theory) are notable examples. Today's quack boldly asserts that he is another example of someone ahead of his time. Close examination, however, will show how unlikely this is. First of all, the early pioneers who were persecuted lived during times that were much less scientific. In some cases, opposition to their ideas stemmed from religious forces. Secondly, it is a basic principle of the scientific method that the burden of proof belongs to the proponent of a claim. The ideas of Galileo, Harvey, Lister and Pasteur overcame their opposition because their soundness can be demonstrated.
A related ploy, which is a favorite with cancer quacks, is the charge of "conspiracy." How can we be sure that the AMA, the FDA, the American Cancer Society, drug companies and others are not involved in some monstrous plot to withhold a cancer cure from the public? To begin with, history reveals no such practice in the past. The elimination of serious diseases is not a threat to the medical profession—doctors prosper by curing diseases, not by keeping people sick. It should also be apparent that modern medical technology has not altered the zeal of scientists to eliminate disease. When polio was conquered, iron lungs became virtually obsolete, but nobody resisted this advancement because it would force hospitals to change. Neither will medical scientists mourn the eventual defeat of cancer. Moreover, how could a conspiracy to withhold a cancer cure hope to be successful? Many physicians die of cancer each year. Do you believe that the vast majority of doctors would conspire to withhold a cure for a disease which affects them, their colleagues and their loved ones? To be effective, a conspiracy would have to be worldwide. If laetrile, for example, really worked, many other nations' scientists would soon realize it.
Claims of "suppression" are used to market publications as well as treatments. Many authors and publishers purport to offer information that your doctor, the AMA, and/or government agencies "don't want you to know about."
Organized quackery poses its opposition to medical science as a "philosophical conflict" or "paradigm shift," rather than a clash between proven versus unproven or fraudulent methods. This creates the illusion of a "holy war" rather than a conflict that could be resolved by examining the facts. Another diversionary tactic is to charge that quackery's critics are biased or have been bought off by drug companies.
Quacks like to charge that, "Science doesn't have all the answers." That's true, but it doesn't claim to have them. Rather, it is a rational and responsible process that can answer many questions—including whether procedures are safe and effective for their intended purpose. It is quackery that constantly claims to have answers for incurable diseases. The idea that people should turn to quack remedies when frustrated by science's inability to control a disease is irrational. Science may not have all the answers, but quackery has no answers at all! It will take your money and break your heart.
Many treatments advanced by the scientific community are later shown to be unsafe or worthless. Doctors also make mistakes. Such failures become grist for organized quackery's public relations mill in its ongoing attack on science. Actually, "failures" reflect a key element of science: its willingness to test its methods and beliefs and abandon those shown to be invalid. True medical scientists have no philosophical commitment to particular treatment approaches, only a commitment to develop and use methods that are safe and effective for an intended purpose. When a quack remedy flunks a scientific test, its proponents merely reject the test.
Each of these ploys represents a basic technique called misdirection -- analogous to what magicians do to shift the audience's attention away from what is important in order to deceive them. When faced with a criticism they cannot meet head on, quacks simply change the topic.
How to Avoid Being Tricked
The best way to avoid being tricked is to stay away from tricksters. Unfortunately, in health matters, this is no simple task. Quackery is not sold with a warning label. Moreover, the dividing line between what is quackery and what is not is by no means sharp. A product that is effective in one situation may be part of a quack scheme in another. (Quackery lies in the promise, not the product.) Practitioners who use effective methods may also use ineffective ones. For example, they may mix valuable advice to stop smoking with unsound advice to take vitamins. Even outright quacks may relieve some psychosomatic ailments with their reassuring manner.
This article illustrates how adept quacks are at selling themselves. Sad to say, in most contests between quacks and ordinary people, the quacks still are likely to win.
Related Topics
Spontaneous Remission and the Placebo Effect
Why Bogus Therapies Often Seem to Work
Common Questions about Science and "Alternative" Health Methods
Why Extraordinary Claims Demand Extraordinary Proof
Response to an Alt-Muddled Friend
This article was revised on January 20, 2005.
Stephen Barrett, M.D.William T. Jarvis, Ph.D.
Modern health quacks are supersalesmen. They play on fear. They cater to hope. And once they have you, they'll keep you coming back for more . . . and more . . . and more. Seldom do their victims realize how often or how skillfully they are cheated. Does the mother who feels good as she hands her child a vitamin think to ask herself whether he really needs it? Do subscribers to "health food" publications realize that articles are slanted to stimulate business for their advertisers? Not usually.
Most people think that quackery is easy to spot. Often it is not. Its promoters wear the cloak of science. They use scientific terms and quote (or misquote) scientific references. Talk show hosts may refer to them as experts or as "scientists ahead of their time." The very word "quack" helps their camouflage by making us think of an outlandish character selling snake oil from the back of a covered wagon—and, of course, no intelligent people would buy snake oil nowadays, would they?
Well, maybe snake oil isn't selling so well, lately. But acupuncture? "Organic" foods? Hair analysis? The latest diet book? Megavitamins? "Stress formulas"? Cholesterol-lowering teas? Homeopathic remedies? Magnets? Nutritional "cures" for AIDS? Products that "cleanse your system"? Or shots to pep you up? Business is booming for health quacks. Their annual take is in the billions! Spot reducers, "immune boosters," water purifiers, "ergogenic aids," systems to "balance body chemistry," special diets for arthritis. Their product list is endless.
What sells is not the quality of their products, but their ability to influence their audience. To those in pain, they promise relief. To the incurable, they offer hope. To the nutrition-conscious, they say, "Make sure you have enough." To a public worried about pollution, they say, "Buy natural." To one and all, they promise better health and a longer life. Modern quacks can reach people emotionally. This article shows how they do it.
Appeals To Vanity
An attractive young airline stewardess once told a physician that she was taking more than 20 vitamin pills a day. "I used to feel run-down all the time," she said, "but now I feel really great !"
"Yes," the doctor replied, "but there is no scientific evidence that extra vitamins can do that. Why not take the pills one month on, one month off, to see whether they really help you or whether it's just a coincidence. After all, $300 a year is a lot of money to be wasting."
"Look, doctor," she said. "I don't care what you say. I KNOW the pills are helping me."
How was this bright young lady converted into a true believer? First, an appeal to her curiosity persuaded her to try and see. Then an appeal to her vanity convinced her to disregard scientific evidence in favor of personal experience—to think for herself. Supplementation is encouraged by a distorted concept of biochemical individuality—that everyone is unique enough to disregard the Recommended Dietary Allowances (RDAs). Quacks won't tell you that scientists deliberately set the RDAs high enough to allow for individual differences. A more dangerous appeal of this type is the suggestion that although a remedy for a serious disease has not been shown to work for other people, it still might work for you. (You are extraordinary!)
A more subtle appeal to your vanity underlies the message of the TV ad quack: Do it yourself—be your own doctor. "Anyone out there have 'tired blood'?" he used to wonder. (Don't bother to find out what's wrong with you, however. Just try my tonic.) "Troubled with irregularity?" he asks. (Pay no attention to the doctors who say you don't need a daily movement. Just use my laxative.) "Want to kill germs on contact?" (Never mind that mouthwash doesn't prevent colds.) "Trouble sleeping?" (Don't bother to solve the underlying problem. Just try my sedative.)
Turning Customers into Salespeople
Most people who think they have been helped by an unorthodox method enjoy sharing their success stories with their friends. People who give such testimonials are usually motivated by a sincere wish to help their fellow humans. Rarely do they realize how difficult it is to evaluate a "health" product on the basis of personal experience. Like the airline stewardess, the average person who feels better after taking a product will not be able to rule out coincidence (spontaneous remission)—or the placebo effect (feeling better because he thinks he has taken a positive step). Since we tend to believe what others tell us of personal experiences, testimonials can be powerful persuaders. Despite their unreliability, they are the cornerstone of the quack's success.
Multilevel companies that sell nutritional products systematically turn their customers into salespeople. "When you share our products," says the sales manual of one such company, "you're not just selling. You're passing on news about products you believe in to people you care about. Make a list of people you know; you'll be surprised how long it will be. This list is your first source of potential customers." A sales leader from another company suggests, "Answer all objections with testimonials. That's the secret to motivating people!"
Don't be surprised if one of your friends or neighbors tries to sell you vitamins. Millions of Americans have signed up as multilevel distributors. Like many drug addicts, they become suppliers to support their habit. A typical sales pitch goes like this: "How would you like to look better, feel better and have more energy? Try my vitamins for a few weeks." People normally have ups and downs, and a friend's interest or suggestion, or the thought of taking a positive step, may actually make a person feel better. Many who try the vitamins will mistakenly think they have been helped—and continue to buy them, usually at inflated prices.
The Use of Fear
The sale of vitamins has become so profitable that some otherwise reputable manufacturers are promoting them with misleading claims. For example, for many years, Lederle Laboratories (makers of Stresstabs) and Hoffmann-La Roche advertised in major magazines that stress "robs" the body of vitamins and creates significant danger of vitamin deficiencies.
Another slick way for quackery to attract customers is the invented disease. Virtually everyone has symptoms of one sort or another—minor aches or pains, reactions to stress or hormone variations, effects of aging, etc. Labeling these ups and downs of life as symptoms of disease enables the quack to provide "treatment."
Some practitioners claim to detect "deficiencies" (or "imbalances" or "toxins," etc.) before any symptoms appear or before they can be detected by conventional means. Then they can sell you supplements (or balance you, or remove toxins, etc.). And when the terrible consequences they warn about don't develop, they can claim success.
Food safety and environmental protection are important issues in our society. But rather than approach them logically, the food quacks exaggerate and oversimplify. To promote "organic" foods, they lump all additives into one class and attack them as "poisonous." They never mention that natural toxicantsare prevented or destroyed by modern food technology. Nor do they let on that many additives are naturally occurring substances.
Sugar has been subject to particularly vicious attack, being (falsely) blamed for most of the world's ailments. But quacks do more than warn about imaginary ailments. They sell "antidotes" for real ones. Care for some vitamin C to reduce the danger of smoking? Or some vitamin E to combat air pollutants? See your local supersalesperson.
Quackery's most serious form of fear-mongering has been its attack on water fluoridation. Although fluoridation's safety is established beyond scientific doubt, well-planned scare campaigns have persuaded thousands of communities not to adjust the fluoride content of their water to prevent cavities. Millions of innocent children have suffered as a result.
Hope for Sale
Since ancient times, people have sought at least four different magic potions: the love potion, the fountain of youth, the cure-all, and the athletic superpill. Quackery has always been willing to cater to these desires. It used to offer unicorn horn, special elixirs, amulets, and magical brews. Today's products are vitamins, bee pollen, ginseng, Gerovital, pyramids, "glandular extracts," biorhythm charts, aromatherapy, and many more. Even reputable products are promoted as though they are potions. Toothpastes and colognes will improve our love life. Hair preparations and skin products will make us look "younger than our years." Olympic athletes tell us that breakfast cereals will make us champions. And youthful models reassure us that cigarette smokers are sexy and have fun.
False hope for the seriously ill is the cruelest form of quackery because it can lure victims away from effective treatment. Even when death is inevitable, however, false hope can do great damage. Experts who study the dying process tell us that while the initial reaction is shock and disbelief, most terminally ill patients will adjust very well as long as they do not feel abandoned. People who accept the reality of their fate not only die psychologically prepared, but also can put their affairs in order. On the other hand, those who buy false hope can get stuck in an attitude of denial. They waste not only financial resources but what little remaining time they have left.
Clinical Tricks
The most important characteristic to which the success of quacks can be attributed is probably their ability to exude confidence. Even when they admit that a method is unproven, they can attempt to minimize this by mentioning how difficult and expensive it is to get something proven to the satisfaction of the FDA these days. If they exude self-confidence and enthusiasm, it is likely to be contagious and spread to patients and their loved ones.
Because people like the idea of making choices, quacks often refer to their methods as "alternatives." Correctly employed, it can refer to aspirin and Tylenol as alternatives for the treatment of minor aches and pains. Both are proven safe and effective for the same purpose. Lumpectomy can be an alternative to radical mastectomy for breast cancer. Both have verifiable records of safety and effectiveness from which judgments can be drawn. Can a method that is unsafe, ineffective, or unproven be a genuine alternative to one that is proven? Obviously not.
Quacks don't always limit themselves to phony treatment. Sometimes they offer legitimate treatment as well—the quackery is promoted as something extra. One example is the "orthomolecular" treatment of mental disorders with high dosages of vitamins in addition to orthodox forms of treatment. Patients who receive the "extra" treatment often become convinced that they need to take vitamins for the rest of their life. Such an outcome is inconsistent with the goal of good medical care which should be to discourage unnecessary treatment. Another clever trick is to include their product or procedure in a list of otherwise commonly-accepted practices in order to promote it by association. They may say, for example that their method works best when combined with lifestyle changes (which, quite often, will produce tangible benefits).
The one-sided coin is a related ploy. When patients on combined (orthodox and quack) treatment improve, the quack remedy (e.g., laetrile) gets the credit. If things go badly, the patient is told that he arrived too late, and conventional treatment gets the blame. Some quacks who mix proven and unproven treatment call their approach complementary or integrative therapy.
Quacks also capitalize on the natural healing powers of the body by taking credit whenever possible for improvement in a patient's condition. One multilevel company—anxious to avoid legal difficulty in marketing its herbal concoction—makes no health claims whatsoever. "You take the product," a spokesperson suggests on the company's introductory videotape, "and tell me what it does for you." An opposite tack—shifting blame -- is used by many cancer quacks. If their treatment doesn't work, it's because radiation and/or chemotherapy have "knocked out the immune system."
Another selling trick is the use of weasel words. Quacks often use this technique in suggesting that one or more items on a list is reason to suspect that you may have a vitamin deficiency, a yeast infection, or whatever else they are offering to fix.
The disclaimer is a related tactic. Instead of promising to cure your specific disease, some quacks will offer to "cleanse" or "detoxify" your body, balance its chemistry, release its "nerve energy," bring it in harmony with nature, or do other things to "help the body to heal itself." This type of disclaimer serves two purposes. Since it is impossible to measure the processes the quack describes, it is difficult to prove him wrong. In addition, if the quack is not a physician, the use of nonmedical terminology may help to avoid prosecution for practicing medicine without a license.
Books espousing unscientific practices typically suggest that the reader consult a doctor before following their advice. This disclaimer is intended to protect the author and publisher from legal responsibility for any dangerous ideas contained in the book. Both author and publisher know full well, however, that most people won't ask their doctor. If they wanted their doctor's advice, they probably wouldn't be reading the book in the first place.
Sometimes the quack will say, "You may have come to me too late, but I will try my best to help you." That way, if the treatment fails, you have only yourself to blame. Patients who see the light and abandon quack treatment may also be blamed for stopping too soon.
The "money-back guarantee" is a favorite trick of mail-order quacks. Most have no intention of returning any money—but even those who are willing know that few people will bother to return the product.
Another powerful persuader—something for nothing—is standard in ads promising effortless weight loss. It is also the hook of the telemarketer who promises a "valuable free prize" as a bonus for buying a water purifier, a six-month supply of vitamins, or some other health or nutrition product. Those who bite receive either nothing or items worth far less than their cost. Credit card customers may also find unauthorized charges to their account.
Another potent technique is cultural association, in which promoters ally themselves with religious or other cultural beliefs by associating their product or service with an article of faith or prejudice of their target audience.
In a contest for patient satisfaction, art will beat science nearly every time. Quacks are masters at the art of delivering health care. The secret to this art is to make the patient believe that he is cared about as a person. To do this, quacks lather love lavishly. One way this is done is by having receptionists make notes on the patients' interests and concerns in order to recall them during future visits. This makes each patient feel special in a very personal sort of way. Some quacks even send birthday cards to every patient. Although seductive tactics may give patients a powerful psychological lift, they may also encourage over-reliance on an inappropriate therapy.
Psychologist Anthony R. Pratkanis, Ph.D., has identified nine strategies used to sell pseudoscientific beliefs and practices [Pratkanis AR. How to sell a pseudoscience, Skeptical Inquirer 19(4):19-25, 1995.]. They include setting phantom goals (such as better health, peace of mind, or improved sex life), making statements that tend to inspire trust ("supported by over 100 studies"), and fostering grandfalloons (proud and otherwise meaningless associations of people who share rituals, beliefs, jargon, goals, feelings, specialized information, and "enemies"). Multilevel sales groups, nutrition cultists, and crusaders for "alternative" treatments fit this description well.
Handling the Opposition
Quacks are involved in a constant struggle with legitimate health care providers, mainstream scientists, government regulatory agencies and consumer protection groups. Despite the strength of this science-based opposition, quackery manages to flourish. To maintain their credibility, quacks use a variety of clever propaganda ploys. Here are some favorites:
"They persecuted Galileo!" The history of science is laced with instances where great pioneers and their discoveries were met with resistance. Harvey (nature of blood circulation), Lister (antiseptic technique) and Pasteur (germ theory) are notable examples. Today's quack boldly asserts that he is another example of someone ahead of his time. Close examination, however, will show how unlikely this is. First of all, the early pioneers who were persecuted lived during times that were much less scientific. In some cases, opposition to their ideas stemmed from religious forces. Secondly, it is a basic principle of the scientific method that the burden of proof belongs to the proponent of a claim. The ideas of Galileo, Harvey, Lister and Pasteur overcame their opposition because their soundness can be demonstrated.
A related ploy, which is a favorite with cancer quacks, is the charge of "conspiracy." How can we be sure that the AMA, the FDA, the American Cancer Society, drug companies and others are not involved in some monstrous plot to withhold a cancer cure from the public? To begin with, history reveals no such practice in the past. The elimination of serious diseases is not a threat to the medical profession—doctors prosper by curing diseases, not by keeping people sick. It should also be apparent that modern medical technology has not altered the zeal of scientists to eliminate disease. When polio was conquered, iron lungs became virtually obsolete, but nobody resisted this advancement because it would force hospitals to change. Neither will medical scientists mourn the eventual defeat of cancer. Moreover, how could a conspiracy to withhold a cancer cure hope to be successful? Many physicians die of cancer each year. Do you believe that the vast majority of doctors would conspire to withhold a cure for a disease which affects them, their colleagues and their loved ones? To be effective, a conspiracy would have to be worldwide. If laetrile, for example, really worked, many other nations' scientists would soon realize it.
Claims of "suppression" are used to market publications as well as treatments. Many authors and publishers purport to offer information that your doctor, the AMA, and/or government agencies "don't want you to know about."
Organized quackery poses its opposition to medical science as a "philosophical conflict" or "paradigm shift," rather than a clash between proven versus unproven or fraudulent methods. This creates the illusion of a "holy war" rather than a conflict that could be resolved by examining the facts. Another diversionary tactic is to charge that quackery's critics are biased or have been bought off by drug companies.
Quacks like to charge that, "Science doesn't have all the answers." That's true, but it doesn't claim to have them. Rather, it is a rational and responsible process that can answer many questions—including whether procedures are safe and effective for their intended purpose. It is quackery that constantly claims to have answers for incurable diseases. The idea that people should turn to quack remedies when frustrated by science's inability to control a disease is irrational. Science may not have all the answers, but quackery has no answers at all! It will take your money and break your heart.
Many treatments advanced by the scientific community are later shown to be unsafe or worthless. Doctors also make mistakes. Such failures become grist for organized quackery's public relations mill in its ongoing attack on science. Actually, "failures" reflect a key element of science: its willingness to test its methods and beliefs and abandon those shown to be invalid. True medical scientists have no philosophical commitment to particular treatment approaches, only a commitment to develop and use methods that are safe and effective for an intended purpose. When a quack remedy flunks a scientific test, its proponents merely reject the test.
Each of these ploys represents a basic technique called misdirection -- analogous to what magicians do to shift the audience's attention away from what is important in order to deceive them. When faced with a criticism they cannot meet head on, quacks simply change the topic.
How to Avoid Being Tricked
The best way to avoid being tricked is to stay away from tricksters. Unfortunately, in health matters, this is no simple task. Quackery is not sold with a warning label. Moreover, the dividing line between what is quackery and what is not is by no means sharp. A product that is effective in one situation may be part of a quack scheme in another. (Quackery lies in the promise, not the product.) Practitioners who use effective methods may also use ineffective ones. For example, they may mix valuable advice to stop smoking with unsound advice to take vitamins. Even outright quacks may relieve some psychosomatic ailments with their reassuring manner.
This article illustrates how adept quacks are at selling themselves. Sad to say, in most contests between quacks and ordinary people, the quacks still are likely to win.
Related Topics
Spontaneous Remission and the Placebo Effect
Why Bogus Therapies Often Seem to Work
Common Questions about Science and "Alternative" Health Methods
Why Extraordinary Claims Demand Extraordinary Proof
Response to an Alt-Muddled Friend
This article was revised on January 20, 2005.
Gastrointestinal Complications
Introduction
This patient summary on gastrointestinal complications is adapted from a summary written for health professionals by cancer experts. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials, is available from the National Cancer Institute. Gastrointestinal complications such as constipation, impaction, bowel obstruction, and diarrhea are common problems for cancer patients, with causes that include the cancer itself or treatment of the cancer. This brief summary describes the differences between constipation, impaction, bowel obstruction, and diarrhea; their causes, and treatment. Treatment of children is different from adults. The doctor will prescribe treatments according to the child's age and diagnosis.
Overview
Constipation is the slow movement of feces (stool or body wastes) through the large intestine resulting in infrequent bowel movements and the passage of dry, hard stools. The longer it takes for the stool to move through the large intestine, the more fluid is absorbed and the drier and harder the stool becomes.
Inactivity, immobility, or physical and social barriers (for example, bathrooms being unavailable or inconveniently located) can make constipation worse. Depression and anxiety caused by cancer treatment or cancer pain can also lead to constipation. The most common causes of constipation are not drinking enough fluids and taking pain medications.
Constipation is annoying and uncomfortable, but fecal impaction (a collection of dry, hard stool in the colon or rectum) can be life-threatening. Patients with a fecal impaction may not have gastrointestinal symptoms. Instead they may have circulation, heart, or breathing problems. If fecal impaction is not recognized, the signs and symptoms will get worse and the patient could die.
A bowel obstruction is a partial or complete blockage of the small or large intestine by a process other than fecal impaction. Bowel obstructions are classified by the type of obstruction, how the obstruction occurred, and where it is. Tumors growing inside or outside the bowel, and scar tissue that develops after surgery, can affect bowel function and cause a partial or complete obstruction. Patients who have colostomies are especially at risk of developing constipation, which can lead to bowel obstruction.
Diarrhea can occur at any time during cancer treatment. Although diarrhea occurs less often than constipation, it can be physically and emotionally devastating for patients who have cancer.
Diarrhea can cause:
Changes in eating patterns.
A loss of body fluids.
Chemical imbalances in the blood.
Impairments in physical function.
Excessive tiredness.
Skin problems.
A decrease in physical activity.
Problems that can be life-threatening in some patients.
Diarrhea is an abnormal increase in the amount of fluid in the stool that lasts more than 4 days but less than 2 weeks. It may also be described as an abnormal increase in the amount of fluid in the stool and the passage of more than 3 unformed stools during a 24-hour period. Diarrhea is considered a long-term problem when it lasts longer than 2 months.
Constipation
Description and Causes
Common factors that may cause constipation in healthy people are eating a low-fiber diet, postponing visits to the toilet, using laxatives and enemas excessively, not drinking enough fluids, and exercising too little. In persons with cancer, constipation may be a symptom of cancer, a result of a growing tumor, or a result of cancer treatment. Constipation may also be a side effect of medications for cancer or cancer pain and may be a result of other changes in the body (organ failure, decreased ability to move, and depression). Other causes of constipation include dehydration and not eating enough. Cancer, cancer treatment, aging, and declining health can contribute to causing constipation.
More specific causes of constipation that can result in bowel impaction include:
Diet
Not including enough high-fiber foods in the diet.
Not drinking enough water or other fluids.
Changed Bowel Habits
Repeatedly ignoring the urge to pass stool.
Using too many laxatives and enemas.
Immobility and Lack of Exercise
Spinal cord injury, spinal cord compression, bone fractures, fatigue, weakness, long periods of bedrest.
Inability to tolerate movement and exercise due to respiratory or cardiac problems.
Medications
Chemotherapy treatments.
Pain medications.
Medications for anxiety and depression.
Stomach antacids.
Diuretics.
Vitamin supplements such as iron and calcium.
Sleep medications.
General anesthesia.
Bowel Disorders
Irritable colon.
Diverticulitis.
Tumor.
Muscle and Nerve Disorders (nerve damage can lead to loss of muscle tone in the bowel)
Brain tumors.
Spinal cord compression from a tumor or other spinal cord injury.
Stroke or other disorders that cause muscle weakness or movement.
Weakness of the diaphragm or abdominal muscles making it difficult to take a deep breath and push to have a bowel movement.
Body Metabolism Disorders
Under-secretion of the thyroid gland.
Increased level of calcium in the blood.
Low levels of potassium or sodium in the blood.
Diabetes with nerve dysfunction.
Environmental Factors
Needing assistance to go to the bathroom.
Being in unfamiliar surroundings or a hurried atmosphere.
Living in extreme heat leading to dehydration.
Needing to use a bedpan or bedside commode.
Lack of privacy.
Assessment of Constipation
A medical history and physical examination can identify the causes of constipation. The examination may include a digital rectal exam (the doctor inserts a gloved, lubricated finger into the rectum to check for stool impaction) or a test for blood in the stool. If cancer is suspected, a thorough examination of the rectum and colon may be done with a lighted tube inserted through the anus and into the colon. The following questions may be asked:
What is your normal bowel pattern? How often do you have a bowel movement? When and how much?
When was your last bowel movement? What was it like (how much, hard or soft, color)? Was there any blood?
Has your stomach hurt or have you had any cramping, nausea, vomiting, pain, gas, or feeling of fullness near the rectum?
Do you use laxatives or enemas regularly? What do you normally do to relieve constipation? Does this usually work?
What kind of food do you eat? How much and what type of fluids do you drink daily?
What medicine are you taking? How much and how often?
Is this constipation a recent change in your normal habits?
How many times a day do you pass gas?
Treatment
Treatment of constipation includes prevention (if possible), elimination of possible causes, and limited-use of laxatives. Suggestions for the patient's treatment plan may include the following:
Keep a record of all bowel movements.
Increase the fluid intake by drinking eight ounce glasses of fluid each day (if not contraindicated by kidney or heart disease).
Exercise regularly, including abdominal exercises in bed or moving from the bed to chair if the patient cannot walk.
Increase the amount of dietary fiber by eating more fruits (raisins, prunes, peaches, and apples), vegetables (squash, broccoli, carrots, and celery), and whole grain cereals, breads, and bran. Patients must drink more fluids when increasing dietary fiber or they may become constipated. Patients who have had a bowel obstruction or have undergone bowel surgery (for example, a colostomy) should not eat a high-fiber diet.
Drink a warm or hot drink about one half-hour before the patient's usual time for a bowel movement.
Provide privacy and quiet time when the patient needs to have a bowel movement.
Help the patient to the toilet or provide a bedside commode instead of a bedpan.
Take only medications prescribed by the doctor.
Do not use suppositories or enemas unless ordered by the doctor. In some cancer patients these treatments may lead to bleeding, infection, or other harmful side effects. Impaction
Description and Causes
Five major factors can cause impaction:
Opioid pain medications.
Inactivity over a long period.
Changes in diet.
Mental illness.
Long-term use of laxatives.
Regular use of laxatives for constipation contributes most to the development of constipation and impaction. Repeated use of laxatives in higher and higher doses make the colon less able to signal the need to have a bowel movement. (Refer to the Constipation section for causes of constipation that can result in impaction.)
Patients with impaction may have symptoms similar to patients with constipation, or they may have back pain (the impaction presses on sacral nerves) or bladder problems (the impaction presses on the ureters, bladder, or urethra). The patient's abdomen may become enlarged causing difficulty breathing, rapid heartbeat, dizziness, and low blood pressure. Other symptoms can include explosive diarrhea (as stool moves around the impaction), leaking stool when coughing, nausea, vomiting, abdominal pain, and dehydration. Patients who have an impaction may become very confused and disoriented with rapid heartbeat, sweating, fever, and high or low blood pressure.
Assessment of Impaction
The doctor will ask questions similar to those in the Assessment of Constipation section and do a physical examination to find out if the patient has an impaction. The examination may also include x-rays of the abdomen and/or chest, blood tests, and an electrocardiogram (a test that shows the activity of the heart).
Treatment of Impaction
Impactions are usually treated by moistening and softening the stool with an enema. Enemas must be given very carefully as prescribed by the doctor since too many enemas can damage the bowel. Some patients may need to have stool manually removed from the rectum after it is softened. Glycerin suppositories may also be prescribed. Laxatives that stimulate the bowel and cause cramping must be avoided since they can damage the bowel even more. Bowel Obstruction
Description and Causes
A bowel obstruction may be caused by a narrowing of the intestine from inflammation or damage to the bowel, tumors, scar tissue, hernias, twisting of the bowel, or pressure on the bowel from outside the intestinal tract. It can also be caused by factors that interfere with the function of muscles, nerves, and blood flow to the bowel. Most bowel obstructions occur in the small intestine and are usually caused by scar tissue or hernias. The rest occur in the colon (large intestine) and are usually caused by tumors, twisting of the bowel, or diverticulitis. Symptoms will vary depending on whether the small or large intestine is involved.
The most common cancers that cause bowel obstructions are cancers of the colon, stomach, and ovary. Other cancers, such as lung and breast cancers and melanoma, can spread to the abdomen and cause bowel obstruction. Patients who have had abdominal surgery or radiation are at a higher risk of developing a bowel obstruction. Bowel obstructions are most common during the advanced stages of cancer.
Assessment of Bowel Obstruction
The doctor will do a physical examination to find out whether the patient has abdominal pain, vomiting, or any movement of gas or stool in the bowel. Blood and urine tests may be done to detect any fluid and blood chemistry imbalance or infection. Abdominal x-rays and a barium enema may also be done to find the location of the bowel obstruction.
Treatment of Acute Bowel Obstruction
Patients who have abdominal symptoms that continue to become worse must be monitored frequently to prevent or detect early signs and symptoms of shock and constricting obstruction of the bowel. Medical treatment is necessary to prevent fluid and blood chemistry imbalances and shock.
A nasogastric tube may be inserted through the nose and esophagus into the stomach or a colorectal tube may be inserted through the rectum into the colon to relieve pressure from a partial bowel obstruction. The nasogastric tube or colorectal tube may decrease swelling, remove fluid and gas build-up, or decrease the need for multiple surgical procedures; however, surgery may be necessary if the obstruction completely obstructs the bowel.
Treatment of Chronic, Malignant Bowel Obstruction
Patients who have advanced cancer may have chronic, worsening bowel obstruction that cannot be removed with surgery. Sometimes, the doctor may be able to insert an expandable metal tube called a stent into the bowel to open the area that is blocked.
When neither surgery nor a stent is possible, the doctor may insert a gastrostomy tube through the wall of the abdomen directly into the stomach by a very simple procedure. The gastrostomy tube can relieve fluid and air build-up in the stomach and allow medications and liquids to be given directly into the stomach by pouring them down the tube. A drainage bag with a valve may also be attached to the gastrostomy tube. When the valve is open, the patient may be able to eat or drink by mouth without any discomfort because the food drains directly into the bag. This gives the patient the experience of tasting the food and keeping the mouth moist. Solid food should be avoided because it may block the tubing to the drainage bag.
If the patient's comfort is not improved with a stent or gastrostomy tube, and the patient cannot take anything by mouth, the doctor may prescribe injections or infusions of medications for pain and/or nausea and vomiting.
Diarrhea
Causes of Diarrhea
In cancer patients, the most common cause of diarrhea is cancer treatment (chemotherapy, radiation therapy, bone marrow transplantation, or surgery). Other causes of diarrhea include antibiotic therapy, stress and anxiety related to being diagnosed with cancer and undergoing cancer treatment; and infection. Infection may be caused by viruses, bacteria, fungi, or other harmful microorganisms. Antibiotic therapy can cause inflammation of the lining of the bowel, resulting in diarrhea that often does not respond to treatment. Other causes of diarrhea in cancer patients include:
The cancer itself.
Physical reactions to diet.
Medical problems and diseases other than cancer.
The laxative regimen.
Bowel impaction with leakage of stool around the blockage.
Undergoing surgery to the stomach and/or intestines can affect normal bowel function and cause diarrhea. Some chemotherapy drugs cause diarrhea by affecting how nutrients are broken down and absorbed in the small bowel. Radiation therapy to the abdomen and pelvis can cause inflammation of the bowel. Patients may have problems digesting food, and experience gas, bloating, cramping, and diarrhea. These symptoms may last up to 8 to 12 weeks after therapy or may not develop for months or years. Treatment may include diet changes, medications, or surgery. Patients who are undergoing radiation therapy while receiving chemotherapy often experience severe diarrhea. Hospitalization may not be required, since an outpatient clinic or special home care nursing may give the care and support needed. Each patient's symptoms should be evaluated to determine if intravenous fluids or special medication should be prescribed. (Refer to the PDQ summary on Radiation Enteritis.)
Patients who undergo donor bone marrow transplantation may develop graft-versus-host disease (GVHD). Stomach and intestinal symptoms of GVHD include nausea and vomiting, severe abdominal pain and cramping, and watery, green diarrhea. Symptoms may occur 1 week to 3 months after transplantation. Some patients may require long-term treatment and diet management.
Assessment
Because diarrhea can be life-threatening, it is important to identify the cause so treatment can begin as soon as possible. The doctor may ask the following questions:
How often have you had bowel movements in the past 24 hours?
When was your last bowel movement? What was it like (how much, how hard or soft, what color)? Was there any blood?
Have you been dizzy, extremely drowsy, or had any cramping, abdominal pain, nausea, vomiting, fever, or rectal bleeding?
What have you eaten? What and how much have you had to drink in the past 24 hours?
Have you lost weight recently? How much?
How often have you urinated in the past 24 hours?
What medicine are you taking? How much and how often?
Have you traveled recently?
The doctor will also do a physical examination that should include checking blood pressure, pulse, and respirations; evaluation of the skin and tissue lining the inside of the mouth to check for blood circulation and amount of fluid in the tissue; examination of the abdomen for pain, tenderness, and bowel sounds; and a rectal exam to check for stool impaction and collect stool to test for blood.
Stool may be tested in the laboratory to check for bacterial, fungal, or viral infections. Blood and urine tests may be done to detect fluid and blood chemistry imbalances or infection.
In some cases abdominal x-rays may also be done to identify bowel obstruction or other abnormalities. In rare cases, a thorough examination of the rectum and colon may be done with a lighted tube inserted through the anus and into the colon.
Treatment
Diarrhea is treated by identifying and treating the problems causing diarrhea. For example, diarrhea may be caused by stool impaction and medications to prevent constipation. The doctor may make changes in medications, diet, and fluids. Diet changes that may help decrease diarrhea include eating small frequent meals and avoiding some of the following foods:
Milk and dairy products.
Spicy foods.
Alcohol.
Caffeine-containing foods and drinks.
Some fruit juices.
Gas-forming foods and drinks.
High-fiber foods.
High-fat foods.
For mild diarrhea, a diet of bananas, rice, apples, and toast (the BRAT diet) may decrease the frequency of stools. Patients should be encouraged to drink up to 3 quarts of clear fluids per day including water, sports drinks, broth, weak decaffeinated tea, caffeine-free soft drinks, clear juices, and gelatin. For severe diarrhea, the patient may need intravenous fluids or other forms of intravenous nutrition. (Refer to the PDQ summary on Nutrition in Cancer Care.)
To manage diarrhea caused by graft-versus-host disease (GVHD), the doctor may recommend a special 5-phase diet. During phase 1 the patient receives intravenous fluids and nothing by mouth to rest the bowel until the diarrhea slows down. In phase 2, the patient may begin drinking fluids. If the patient is able to drink fluids and the diarrhea improves, he or she may begin phase 3, eating solid foods that are low-fiber, low-fat, low-acid, and do not irritate the stomach. In phase 4, the patient is gradually allowed to eat regular foods. If the patient is able to eat regular foods without any episodes of diarrhea, he or she may begin phase 5, eating their regular diet. Many patients may continue to have problems digesting milk and dairy products.
Depending on the cause of the diarrhea, the doctor may change the laxative therapy regimen or may prescribe medications that slow down bowel activity, decrease bowel fluid secretions, and allow nutrients to be absorbed by the bowel.Changes to This Summary (06/17/2005)
http://www.acor.org/cnet/62834.html
This patient summary on gastrointestinal complications is adapted from a summary written for health professionals by cancer experts. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials, is available from the National Cancer Institute. Gastrointestinal complications such as constipation, impaction, bowel obstruction, and diarrhea are common problems for cancer patients, with causes that include the cancer itself or treatment of the cancer. This brief summary describes the differences between constipation, impaction, bowel obstruction, and diarrhea; their causes, and treatment. Treatment of children is different from adults. The doctor will prescribe treatments according to the child's age and diagnosis.
Overview
Constipation is the slow movement of feces (stool or body wastes) through the large intestine resulting in infrequent bowel movements and the passage of dry, hard stools. The longer it takes for the stool to move through the large intestine, the more fluid is absorbed and the drier and harder the stool becomes.
Inactivity, immobility, or physical and social barriers (for example, bathrooms being unavailable or inconveniently located) can make constipation worse. Depression and anxiety caused by cancer treatment or cancer pain can also lead to constipation. The most common causes of constipation are not drinking enough fluids and taking pain medications.
Constipation is annoying and uncomfortable, but fecal impaction (a collection of dry, hard stool in the colon or rectum) can be life-threatening. Patients with a fecal impaction may not have gastrointestinal symptoms. Instead they may have circulation, heart, or breathing problems. If fecal impaction is not recognized, the signs and symptoms will get worse and the patient could die.
A bowel obstruction is a partial or complete blockage of the small or large intestine by a process other than fecal impaction. Bowel obstructions are classified by the type of obstruction, how the obstruction occurred, and where it is. Tumors growing inside or outside the bowel, and scar tissue that develops after surgery, can affect bowel function and cause a partial or complete obstruction. Patients who have colostomies are especially at risk of developing constipation, which can lead to bowel obstruction.
Diarrhea can occur at any time during cancer treatment. Although diarrhea occurs less often than constipation, it can be physically and emotionally devastating for patients who have cancer.
Diarrhea can cause:
Changes in eating patterns.
A loss of body fluids.
Chemical imbalances in the blood.
Impairments in physical function.
Excessive tiredness.
Skin problems.
A decrease in physical activity.
Problems that can be life-threatening in some patients.
Diarrhea is an abnormal increase in the amount of fluid in the stool that lasts more than 4 days but less than 2 weeks. It may also be described as an abnormal increase in the amount of fluid in the stool and the passage of more than 3 unformed stools during a 24-hour period. Diarrhea is considered a long-term problem when it lasts longer than 2 months.
Constipation
Description and Causes
Common factors that may cause constipation in healthy people are eating a low-fiber diet, postponing visits to the toilet, using laxatives and enemas excessively, not drinking enough fluids, and exercising too little. In persons with cancer, constipation may be a symptom of cancer, a result of a growing tumor, or a result of cancer treatment. Constipation may also be a side effect of medications for cancer or cancer pain and may be a result of other changes in the body (organ failure, decreased ability to move, and depression). Other causes of constipation include dehydration and not eating enough. Cancer, cancer treatment, aging, and declining health can contribute to causing constipation.
More specific causes of constipation that can result in bowel impaction include:
Diet
Not including enough high-fiber foods in the diet.
Not drinking enough water or other fluids.
Changed Bowel Habits
Repeatedly ignoring the urge to pass stool.
Using too many laxatives and enemas.
Immobility and Lack of Exercise
Spinal cord injury, spinal cord compression, bone fractures, fatigue, weakness, long periods of bedrest.
Inability to tolerate movement and exercise due to respiratory or cardiac problems.
Medications
Chemotherapy treatments.
Pain medications.
Medications for anxiety and depression.
Stomach antacids.
Diuretics.
Vitamin supplements such as iron and calcium.
Sleep medications.
General anesthesia.
Bowel Disorders
Irritable colon.
Diverticulitis.
Tumor.
Muscle and Nerve Disorders (nerve damage can lead to loss of muscle tone in the bowel)
Brain tumors.
Spinal cord compression from a tumor or other spinal cord injury.
Stroke or other disorders that cause muscle weakness or movement.
Weakness of the diaphragm or abdominal muscles making it difficult to take a deep breath and push to have a bowel movement.
Body Metabolism Disorders
Under-secretion of the thyroid gland.
Increased level of calcium in the blood.
Low levels of potassium or sodium in the blood.
Diabetes with nerve dysfunction.
Environmental Factors
Needing assistance to go to the bathroom.
Being in unfamiliar surroundings or a hurried atmosphere.
Living in extreme heat leading to dehydration.
Needing to use a bedpan or bedside commode.
Lack of privacy.
Assessment of Constipation
A medical history and physical examination can identify the causes of constipation. The examination may include a digital rectal exam (the doctor inserts a gloved, lubricated finger into the rectum to check for stool impaction) or a test for blood in the stool. If cancer is suspected, a thorough examination of the rectum and colon may be done with a lighted tube inserted through the anus and into the colon. The following questions may be asked:
What is your normal bowel pattern? How often do you have a bowel movement? When and how much?
When was your last bowel movement? What was it like (how much, hard or soft, color)? Was there any blood?
Has your stomach hurt or have you had any cramping, nausea, vomiting, pain, gas, or feeling of fullness near the rectum?
Do you use laxatives or enemas regularly? What do you normally do to relieve constipation? Does this usually work?
What kind of food do you eat? How much and what type of fluids do you drink daily?
What medicine are you taking? How much and how often?
Is this constipation a recent change in your normal habits?
How many times a day do you pass gas?
Treatment
Treatment of constipation includes prevention (if possible), elimination of possible causes, and limited-use of laxatives. Suggestions for the patient's treatment plan may include the following:
Keep a record of all bowel movements.
Increase the fluid intake by drinking eight ounce glasses of fluid each day (if not contraindicated by kidney or heart disease).
Exercise regularly, including abdominal exercises in bed or moving from the bed to chair if the patient cannot walk.
Increase the amount of dietary fiber by eating more fruits (raisins, prunes, peaches, and apples), vegetables (squash, broccoli, carrots, and celery), and whole grain cereals, breads, and bran. Patients must drink more fluids when increasing dietary fiber or they may become constipated. Patients who have had a bowel obstruction or have undergone bowel surgery (for example, a colostomy) should not eat a high-fiber diet.
Drink a warm or hot drink about one half-hour before the patient's usual time for a bowel movement.
Provide privacy and quiet time when the patient needs to have a bowel movement.
Help the patient to the toilet or provide a bedside commode instead of a bedpan.
Take only medications prescribed by the doctor.
Do not use suppositories or enemas unless ordered by the doctor. In some cancer patients these treatments may lead to bleeding, infection, or other harmful side effects. Impaction
Description and Causes
Five major factors can cause impaction:
Opioid pain medications.
Inactivity over a long period.
Changes in diet.
Mental illness.
Long-term use of laxatives.
Regular use of laxatives for constipation contributes most to the development of constipation and impaction. Repeated use of laxatives in higher and higher doses make the colon less able to signal the need to have a bowel movement. (Refer to the Constipation section for causes of constipation that can result in impaction.)
Patients with impaction may have symptoms similar to patients with constipation, or they may have back pain (the impaction presses on sacral nerves) or bladder problems (the impaction presses on the ureters, bladder, or urethra). The patient's abdomen may become enlarged causing difficulty breathing, rapid heartbeat, dizziness, and low blood pressure. Other symptoms can include explosive diarrhea (as stool moves around the impaction), leaking stool when coughing, nausea, vomiting, abdominal pain, and dehydration. Patients who have an impaction may become very confused and disoriented with rapid heartbeat, sweating, fever, and high or low blood pressure.
Assessment of Impaction
The doctor will ask questions similar to those in the Assessment of Constipation section and do a physical examination to find out if the patient has an impaction. The examination may also include x-rays of the abdomen and/or chest, blood tests, and an electrocardiogram (a test that shows the activity of the heart).
Treatment of Impaction
Impactions are usually treated by moistening and softening the stool with an enema. Enemas must be given very carefully as prescribed by the doctor since too many enemas can damage the bowel. Some patients may need to have stool manually removed from the rectum after it is softened. Glycerin suppositories may also be prescribed. Laxatives that stimulate the bowel and cause cramping must be avoided since they can damage the bowel even more. Bowel Obstruction
Description and Causes
A bowel obstruction may be caused by a narrowing of the intestine from inflammation or damage to the bowel, tumors, scar tissue, hernias, twisting of the bowel, or pressure on the bowel from outside the intestinal tract. It can also be caused by factors that interfere with the function of muscles, nerves, and blood flow to the bowel. Most bowel obstructions occur in the small intestine and are usually caused by scar tissue or hernias. The rest occur in the colon (large intestine) and are usually caused by tumors, twisting of the bowel, or diverticulitis. Symptoms will vary depending on whether the small or large intestine is involved.
The most common cancers that cause bowel obstructions are cancers of the colon, stomach, and ovary. Other cancers, such as lung and breast cancers and melanoma, can spread to the abdomen and cause bowel obstruction. Patients who have had abdominal surgery or radiation are at a higher risk of developing a bowel obstruction. Bowel obstructions are most common during the advanced stages of cancer.
Assessment of Bowel Obstruction
The doctor will do a physical examination to find out whether the patient has abdominal pain, vomiting, or any movement of gas or stool in the bowel. Blood and urine tests may be done to detect any fluid and blood chemistry imbalance or infection. Abdominal x-rays and a barium enema may also be done to find the location of the bowel obstruction.
Treatment of Acute Bowel Obstruction
Patients who have abdominal symptoms that continue to become worse must be monitored frequently to prevent or detect early signs and symptoms of shock and constricting obstruction of the bowel. Medical treatment is necessary to prevent fluid and blood chemistry imbalances and shock.
A nasogastric tube may be inserted through the nose and esophagus into the stomach or a colorectal tube may be inserted through the rectum into the colon to relieve pressure from a partial bowel obstruction. The nasogastric tube or colorectal tube may decrease swelling, remove fluid and gas build-up, or decrease the need for multiple surgical procedures; however, surgery may be necessary if the obstruction completely obstructs the bowel.
Treatment of Chronic, Malignant Bowel Obstruction
Patients who have advanced cancer may have chronic, worsening bowel obstruction that cannot be removed with surgery. Sometimes, the doctor may be able to insert an expandable metal tube called a stent into the bowel to open the area that is blocked.
When neither surgery nor a stent is possible, the doctor may insert a gastrostomy tube through the wall of the abdomen directly into the stomach by a very simple procedure. The gastrostomy tube can relieve fluid and air build-up in the stomach and allow medications and liquids to be given directly into the stomach by pouring them down the tube. A drainage bag with a valve may also be attached to the gastrostomy tube. When the valve is open, the patient may be able to eat or drink by mouth without any discomfort because the food drains directly into the bag. This gives the patient the experience of tasting the food and keeping the mouth moist. Solid food should be avoided because it may block the tubing to the drainage bag.
If the patient's comfort is not improved with a stent or gastrostomy tube, and the patient cannot take anything by mouth, the doctor may prescribe injections or infusions of medications for pain and/or nausea and vomiting.
Diarrhea
Causes of Diarrhea
In cancer patients, the most common cause of diarrhea is cancer treatment (chemotherapy, radiation therapy, bone marrow transplantation, or surgery). Other causes of diarrhea include antibiotic therapy, stress and anxiety related to being diagnosed with cancer and undergoing cancer treatment; and infection. Infection may be caused by viruses, bacteria, fungi, or other harmful microorganisms. Antibiotic therapy can cause inflammation of the lining of the bowel, resulting in diarrhea that often does not respond to treatment. Other causes of diarrhea in cancer patients include:
The cancer itself.
Physical reactions to diet.
Medical problems and diseases other than cancer.
The laxative regimen.
Bowel impaction with leakage of stool around the blockage.
Undergoing surgery to the stomach and/or intestines can affect normal bowel function and cause diarrhea. Some chemotherapy drugs cause diarrhea by affecting how nutrients are broken down and absorbed in the small bowel. Radiation therapy to the abdomen and pelvis can cause inflammation of the bowel. Patients may have problems digesting food, and experience gas, bloating, cramping, and diarrhea. These symptoms may last up to 8 to 12 weeks after therapy or may not develop for months or years. Treatment may include diet changes, medications, or surgery. Patients who are undergoing radiation therapy while receiving chemotherapy often experience severe diarrhea. Hospitalization may not be required, since an outpatient clinic or special home care nursing may give the care and support needed. Each patient's symptoms should be evaluated to determine if intravenous fluids or special medication should be prescribed. (Refer to the PDQ summary on Radiation Enteritis.)
Patients who undergo donor bone marrow transplantation may develop graft-versus-host disease (GVHD). Stomach and intestinal symptoms of GVHD include nausea and vomiting, severe abdominal pain and cramping, and watery, green diarrhea. Symptoms may occur 1 week to 3 months after transplantation. Some patients may require long-term treatment and diet management.
Assessment
Because diarrhea can be life-threatening, it is important to identify the cause so treatment can begin as soon as possible. The doctor may ask the following questions:
How often have you had bowel movements in the past 24 hours?
When was your last bowel movement? What was it like (how much, how hard or soft, what color)? Was there any blood?
Have you been dizzy, extremely drowsy, or had any cramping, abdominal pain, nausea, vomiting, fever, or rectal bleeding?
What have you eaten? What and how much have you had to drink in the past 24 hours?
Have you lost weight recently? How much?
How often have you urinated in the past 24 hours?
What medicine are you taking? How much and how often?
Have you traveled recently?
The doctor will also do a physical examination that should include checking blood pressure, pulse, and respirations; evaluation of the skin and tissue lining the inside of the mouth to check for blood circulation and amount of fluid in the tissue; examination of the abdomen for pain, tenderness, and bowel sounds; and a rectal exam to check for stool impaction and collect stool to test for blood.
Stool may be tested in the laboratory to check for bacterial, fungal, or viral infections. Blood and urine tests may be done to detect fluid and blood chemistry imbalances or infection.
In some cases abdominal x-rays may also be done to identify bowel obstruction or other abnormalities. In rare cases, a thorough examination of the rectum and colon may be done with a lighted tube inserted through the anus and into the colon.
Treatment
Diarrhea is treated by identifying and treating the problems causing diarrhea. For example, diarrhea may be caused by stool impaction and medications to prevent constipation. The doctor may make changes in medications, diet, and fluids. Diet changes that may help decrease diarrhea include eating small frequent meals and avoiding some of the following foods:
Milk and dairy products.
Spicy foods.
Alcohol.
Caffeine-containing foods and drinks.
Some fruit juices.
Gas-forming foods and drinks.
High-fiber foods.
High-fat foods.
For mild diarrhea, a diet of bananas, rice, apples, and toast (the BRAT diet) may decrease the frequency of stools. Patients should be encouraged to drink up to 3 quarts of clear fluids per day including water, sports drinks, broth, weak decaffeinated tea, caffeine-free soft drinks, clear juices, and gelatin. For severe diarrhea, the patient may need intravenous fluids or other forms of intravenous nutrition. (Refer to the PDQ summary on Nutrition in Cancer Care.)
To manage diarrhea caused by graft-versus-host disease (GVHD), the doctor may recommend a special 5-phase diet. During phase 1 the patient receives intravenous fluids and nothing by mouth to rest the bowel until the diarrhea slows down. In phase 2, the patient may begin drinking fluids. If the patient is able to drink fluids and the diarrhea improves, he or she may begin phase 3, eating solid foods that are low-fiber, low-fat, low-acid, and do not irritate the stomach. In phase 4, the patient is gradually allowed to eat regular foods. If the patient is able to eat regular foods without any episodes of diarrhea, he or she may begin phase 5, eating their regular diet. Many patients may continue to have problems digesting milk and dairy products.
Depending on the cause of the diarrhea, the doctor may change the laxative therapy regimen or may prescribe medications that slow down bowel activity, decrease bowel fluid secretions, and allow nutrients to be absorbed by the bowel.Changes to This Summary (06/17/2005)
http://www.acor.org/cnet/62834.html
Scar tissue and pain after back surgery
Effects scar tissue on back pain and leg pain
The formation of scar tissue near the nerve root (also called epidural fibrosis) is a common occurrence after back surgery—so common, in fact, that it often occurs for patients with successful surgical outcomes as well as for patients with continued or recurrent leg pain and back pain. For this reason, the importance of scar tissue (epidural fibrosis) as a potential cause of postoperative pain—commonly called failed back surgery syndrome—is controversial.
Scar tissue formation is part of the normal healing process after a spine surgery. While scar tissue can be a cause of back pain or leg pain, in and of itself the scar tissue is rarely painful since the tissue contains no nerve endings. Rather, the principal mechanism of back pain or leg pain is thought to be the binding of the lumbar nerve root by fibrous adhesions.
Examining other causes of pain after back surgeryIf a patient suffers from continued back pain and/or leg pain after discectomy or laminectomy surgery, a comprehensive physical examination and appropriate diagnostic imaging techniques can often pinpoint the cause of pain.
In addition, there are a few things that can be done before and/or after spine surgery that have the potential to limit the formation of scar tissue over the operative disc.
About 200,000 lumbar laminectomy and discectomy (microdiscectomy) surgeries are performed every year in the United States. Approximately 90% of these surgeries will result in a good outcome. For the remaining 10% of patients who do not do well after spine surgery, the search for a solution to their continued pain begins with an assessment of the likely cause of that back pain or leg pain.
Clinical profile of epidural fibrosis. Typically, symptoms associated with epidural fibrosis appear at 6 to 12 weeks after back surgery. This is often preceded by an initial period of pain relief, after which the patient slowly develops recurrent leg pain. Sometimes, the improvement occurs immediately after back surgery, but occasionally the nerve damage from the original pathology makes the nerve heal more slowly.In general, if the patient experiences continued leg pain directly after spine surgery, but starts to improve over the next three months, he or she should continue to improve. If, however, there is no improvement by three months postoperatively, the spine surgery is unlikely to have been successful, and the patient will continue to have back pain or leg pain.
Spine-Health.com topics > Surgery> Scar tissue and postoperative pain
The formation of scar tissue near the nerve root (also called epidural fibrosis) is a common occurrence after back surgery—so common, in fact, that it often occurs for patients with successful surgical outcomes as well as for patients with continued or recurrent leg pain and back pain. For this reason, the importance of scar tissue (epidural fibrosis) as a potential cause of postoperative pain—commonly called failed back surgery syndrome—is controversial.
Scar tissue formation is part of the normal healing process after a spine surgery. While scar tissue can be a cause of back pain or leg pain, in and of itself the scar tissue is rarely painful since the tissue contains no nerve endings. Rather, the principal mechanism of back pain or leg pain is thought to be the binding of the lumbar nerve root by fibrous adhesions.
Examining other causes of pain after back surgeryIf a patient suffers from continued back pain and/or leg pain after discectomy or laminectomy surgery, a comprehensive physical examination and appropriate diagnostic imaging techniques can often pinpoint the cause of pain.
In addition, there are a few things that can be done before and/or after spine surgery that have the potential to limit the formation of scar tissue over the operative disc.
About 200,000 lumbar laminectomy and discectomy (microdiscectomy) surgeries are performed every year in the United States. Approximately 90% of these surgeries will result in a good outcome. For the remaining 10% of patients who do not do well after spine surgery, the search for a solution to their continued pain begins with an assessment of the likely cause of that back pain or leg pain.
Clinical profile of epidural fibrosis. Typically, symptoms associated with epidural fibrosis appear at 6 to 12 weeks after back surgery. This is often preceded by an initial period of pain relief, after which the patient slowly develops recurrent leg pain. Sometimes, the improvement occurs immediately after back surgery, but occasionally the nerve damage from the original pathology makes the nerve heal more slowly.In general, if the patient experiences continued leg pain directly after spine surgery, but starts to improve over the next three months, he or she should continue to improve. If, however, there is no improvement by three months postoperatively, the spine surgery is unlikely to have been successful, and the patient will continue to have back pain or leg pain.
Spine-Health.com topics > Surgery> Scar tissue and postoperative pain
THE HIPPOCRATIC OATH
I swear by Apollo the physician, by Sculapius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath.
"To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction. I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."
Blogger~ Remember all this oath as you participate in healing us. We are your brothers and sisters, mothers and fathers, family and friends.
Tell us the truth is all we ask. Let us know what we face and accept the magnitude of the Problem of ARD. Don't be perpetuating the suffering by denial, become part of the solution and work with us to bring light to the darkness. Tell us the truth and keep no secrets. The whole world is waiting for you to do the right thing. Tell us you are aware. Tell us you know what is wrong. Silence is as bad as lying and this silence causes great suffering to all humanity.
Let it start here in America, let the truth and financial ramifications of adhesion realted disorder be spoken of loud and clear. It will change the face of healthcare forever once it is known thoughtout the world....just a simple phrase on the imformed consent prior to surgery. A brief explanation about adhesions and voila. You have told the truth.
The truth and fear of change...well in the long run the truth always comes to pass. Please excellerate the process by simply telling you presurgical patient about their risk of adhesions and the needed changed will come to pass and the world will go round as it always has but with less suffering. Trickle down crisis relief from one ard sufferer and you save a whole family and a cirlce of friends.
Do the Right Thing! Become an American Hero! Speak to your patient about Adhesion Related Disorder
"To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction. I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."
Blogger~ Remember all this oath as you participate in healing us. We are your brothers and sisters, mothers and fathers, family and friends.
Tell us the truth is all we ask. Let us know what we face and accept the magnitude of the Problem of ARD. Don't be perpetuating the suffering by denial, become part of the solution and work with us to bring light to the darkness. Tell us the truth and keep no secrets. The whole world is waiting for you to do the right thing. Tell us you are aware. Tell us you know what is wrong. Silence is as bad as lying and this silence causes great suffering to all humanity.
Let it start here in America, let the truth and financial ramifications of adhesion realted disorder be spoken of loud and clear. It will change the face of healthcare forever once it is known thoughtout the world....just a simple phrase on the imformed consent prior to surgery. A brief explanation about adhesions and voila. You have told the truth.
The truth and fear of change...well in the long run the truth always comes to pass. Please excellerate the process by simply telling you presurgical patient about their risk of adhesions and the needed changed will come to pass and the world will go round as it always has but with less suffering. Trickle down crisis relief from one ard sufferer and you save a whole family and a cirlce of friends.
Do the Right Thing! Become an American Hero! Speak to your patient about Adhesion Related Disorder
Don?t Tell Me!
I have shared this poem elsewhere, but feel that it needs to be posted here as well. Each and every day we hear from our friends, neighbors, bosses and just people on the street that we "look good". Well, I get so sick of hearing it so I wrote this.
Don?t Tell Me!
I walk down the street slowly, pausing to recognize my friends as I see them. We stop to talk and I see those most-hated words forming in their mouths. You look good!? They are well-intentioned statements, but words that I don?t want to hear. Just as when you ask me ?How are you?? You really don?t want to hear how I am really feeling. Did you know that when you made that statement I had just been released from the hospital, or, that I was in unbearable pain? Did you know that I am dying? No, I?m not losing my hair as with cancer, nor am I extremely thin. But.you see, I have an invisible disease, one that you only see by searching my soul. I hide my disease well. Please don?t tell me ?You look good? When inside I waste away. Please just give me a hug or wish me a good day, because I don?t want to hear those words.
It?s really easier that way!
Damn Tired
Don?t Tell Me!
I walk down the street slowly, pausing to recognize my friends as I see them. We stop to talk and I see those most-hated words forming in their mouths. You look good!? They are well-intentioned statements, but words that I don?t want to hear. Just as when you ask me ?How are you?? You really don?t want to hear how I am really feeling. Did you know that when you made that statement I had just been released from the hospital, or, that I was in unbearable pain? Did you know that I am dying? No, I?m not losing my hair as with cancer, nor am I extremely thin. But.you see, I have an invisible disease, one that you only see by searching my soul. I hide my disease well. Please don?t tell me ?You look good? When inside I waste away. Please just give me a hug or wish me a good day, because I don?t want to hear those words.
It?s really easier that way!
Damn Tired
Thursday, March 30, 2006
The latest from IHRT: Crisis in Germany Endogyn Dr Kruschinski Emma Klinik
...and for goodness sake will you get some sleep
Helen Dynda,You should be ashamed of yourself...
The Poor UK
UKAS is infiltrated !
Dr. Kruschinski Emma Clinic Perpare to be Booted
Daniel the Hooker and “The Endogate Papers”
Hell Hath No Fury Like A Woman Scarred
IHRT Chapter FOUR of: The ever changing world of Endogyn!!" Kruschinski
"Russian Roulette"
News flash! this just out of Endogyn
Helen Dynda,You should be ashamed of yourself...
The Poor UK
UKAS is infiltrated !
Dr. Kruschinski Emma Clinic Perpare to be Booted
Daniel the Hooker and “The Endogate Papers”
Hell Hath No Fury Like A Woman Scarred
IHRT Chapter FOUR of: The ever changing world of Endogyn!!" Kruschinski
"Russian Roulette"
News flash! this just out of Endogyn
Medical Headlines ARDvark Blog
McGinty forced to guarantee patient's surgery
The West Australian Government is under pressure over revelations a 77-year-old Bibra Lake man has been forced to wait nine months for a simple bladder operation that should have been performed within 90 days.
Vitamins 'may up pregnancy risk'
High doses of vitamin supplements may raise the risk of pre-eclampsia in pregnant women rather than protecting against it, research suggests.
Basic social care 'must be free'
Ministers are urged to scrap means-testing and give all elderly people a minimum level of state-funded social care.
Medical Board pursues Patel accusations
The Queensland Medical Board is hoping for a directions hearing, in its case against disgraced surgeon Jayant Patel, in the Health Practitioners Tribunal next month.
Sleeping pill competition may spur ad war
NEW YORK (AP) - The maker of Ambien has begun a new ad campaign it hopes will reverse a sales slide triggered by reports that some patients couldn't recall driving or eating while sleepwalking when using the prescription sleep aid. The campaign Sanofi-Aventis SA launched Wednesday is likely the first salvo in what analysts predict will be a fierce advertising war in the market which has seen sales drop in the aftermath of the negative news. Sanofi's Ambien is expected to have a new competitor by this summer when Pfizer Inc. and partner Neurocrine Sciences Inc. are slated to debut a new pill
Carrying multiple babies risky for mom: study
NEW YORK (Reuters Health) - Women with multifetal pregnancies have a higher risk of pregnancy-related death than those with singleton pregnancies, according to a report in the journal Obstetrics and Gynecology.
No clear advice on elective C-sections
WASHINGTON (AP) - Women who want several children should avoid the new trend of purely elective Caesarean sections - planned surgical births when there's no clear medical need - government advisers said Wednesday. But for mothers-to-be who plan only one or two children, there's too little research to say definitively whether it's a good or bad idea.
U.S. Military Has New Online Mental Health Resource
Anonymous self-assessment program helps spot problems
Patient sues for possible disease exposure
ATLANTA (AP) - A woman has filed a lawsuit against Emory Healthcare after she underwent surgery there with instruments that had been exposed to a fatal disease similar to the human version of mad cow disease. Wayne Grant, an attorney for Tracy Price, said the lawsuit was filed Tuesday in DeKalb County. It accuses the university's healthcare system of medical malpractice, breach of fiduciary duty, reckless infliction of emotional distress and breach of informed consent. It seeks unspecified damages.
Pneumonia Vaccine Saving Lives
Study finds big drop in infection-linked death in hospitalized patients
Meeting To Determine Risks, Benefits Of Pre-Planned C-Sections Begins
FDA Approves Extended Dosing Of Aranesp
New Family Of Biodegradable Polymers Shows Promise For Intracellular Drug Delivery
Doctors Not Expected To Act Like ‘Saints' But Should Always Put Patients First, General Medical Council, UK
Health Protection Agency's Partner Launches Decontamination Product For Surgical Instruments, UK
Guidance On Internet Pharmacy Services By The Royal Pharmaceutical Society Of Great Britain
How Many Americans Have Multiple Sclerosis? No One Knows With Absolute Certainty
New York Times Letter To The Editor Responds To Opinion Piece On Physician-Patient Relationship
Growing Body Of Research Links Lead To Osteoporosis
The West Australian Government is under pressure over revelations a 77-year-old Bibra Lake man has been forced to wait nine months for a simple bladder operation that should have been performed within 90 days.
Vitamins 'may up pregnancy risk'
High doses of vitamin supplements may raise the risk of pre-eclampsia in pregnant women rather than protecting against it, research suggests.
Basic social care 'must be free'
Ministers are urged to scrap means-testing and give all elderly people a minimum level of state-funded social care.
Medical Board pursues Patel accusations
The Queensland Medical Board is hoping for a directions hearing, in its case against disgraced surgeon Jayant Patel, in the Health Practitioners Tribunal next month.
Sleeping pill competition may spur ad war
NEW YORK (AP) - The maker of Ambien has begun a new ad campaign it hopes will reverse a sales slide triggered by reports that some patients couldn't recall driving or eating while sleepwalking when using the prescription sleep aid. The campaign Sanofi-Aventis SA launched Wednesday is likely the first salvo in what analysts predict will be a fierce advertising war in the market which has seen sales drop in the aftermath of the negative news. Sanofi's Ambien is expected to have a new competitor by this summer when Pfizer Inc. and partner Neurocrine Sciences Inc. are slated to debut a new pill
Carrying multiple babies risky for mom: study
NEW YORK (Reuters Health) - Women with multifetal pregnancies have a higher risk of pregnancy-related death than those with singleton pregnancies, according to a report in the journal Obstetrics and Gynecology.
No clear advice on elective C-sections
WASHINGTON (AP) - Women who want several children should avoid the new trend of purely elective Caesarean sections - planned surgical births when there's no clear medical need - government advisers said Wednesday. But for mothers-to-be who plan only one or two children, there's too little research to say definitively whether it's a good or bad idea.
U.S. Military Has New Online Mental Health Resource
Anonymous self-assessment program helps spot problems
Patient sues for possible disease exposure
ATLANTA (AP) - A woman has filed a lawsuit against Emory Healthcare after she underwent surgery there with instruments that had been exposed to a fatal disease similar to the human version of mad cow disease. Wayne Grant, an attorney for Tracy Price, said the lawsuit was filed Tuesday in DeKalb County. It accuses the university's healthcare system of medical malpractice, breach of fiduciary duty, reckless infliction of emotional distress and breach of informed consent. It seeks unspecified damages.
Pneumonia Vaccine Saving Lives
Study finds big drop in infection-linked death in hospitalized patients
Meeting To Determine Risks, Benefits Of Pre-Planned C-Sections Begins
FDA Approves Extended Dosing Of Aranesp
New Family Of Biodegradable Polymers Shows Promise For Intracellular Drug Delivery
Doctors Not Expected To Act Like ‘Saints' But Should Always Put Patients First, General Medical Council, UK
Health Protection Agency's Partner Launches Decontamination Product For Surgical Instruments, UK
Guidance On Internet Pharmacy Services By The Royal Pharmaceutical Society Of Great Britain
How Many Americans Have Multiple Sclerosis? No One Knows With Absolute Certainty
New York Times Letter To The Editor Responds To Opinion Piece On Physician-Patient Relationship
Growing Body Of Research Links Lead To Osteoporosis
The New Medicine ...must see TV
Researchers, physicians, insurance companies and medical schools change the practice of medicine; a memorial to host Dana Reeve.
The New Medicine will premiere nationwide on PBS stations on Wednesday, March 29, 2006, from 9-11:00 EST. Please check your local listings for more broadcast information..
Watch a Video Preview
Program Description
Returning Human Touch to High-Tech Care
When Bill Moyers’ series, Healing and the Mind, premiered on PBS over 10 years ago, integrative medicine still lay on the fringes of the U.S. health care system. Today, it is booming. Even the most conservative health institutions are beginning to practice therapies once considered “new age”— acupuncture, visualization, self-hypnosis and mindfulness— alongside the more traditional drugs and surgery. Equally important is a new attitude that treats the patient as a whole person rather than a cog in an assembly line. The New Medicine, a two-hour documentary, hosted by Dana Reeve, takes viewers inside medical schools, healthcare clinics, research institutions and private practices to examine the rapidly expanding world of integrative medicine.
The producers of The New Medicine also created a related
The New Medicine Web site.
The New Medicine will premiere nationwide on PBS stations on Wednesday, March 29, 2006, from 9-11:00 EST. Please check your local listings for more broadcast information..
Watch a Video Preview
Program Description
Returning Human Touch to High-Tech Care
When Bill Moyers’ series, Healing and the Mind, premiered on PBS over 10 years ago, integrative medicine still lay on the fringes of the U.S. health care system. Today, it is booming. Even the most conservative health institutions are beginning to practice therapies once considered “new age”— acupuncture, visualization, self-hypnosis and mindfulness— alongside the more traditional drugs and surgery. Equally important is a new attitude that treats the patient as a whole person rather than a cog in an assembly line. The New Medicine, a two-hour documentary, hosted by Dana Reeve, takes viewers inside medical schools, healthcare clinics, research institutions and private practices to examine the rapidly expanding world of integrative medicine.
The producers of The New Medicine also created a related
The New Medicine Web site.
State Infertility Insurance Laws
If a state is not listed here, or if you have questions about insurance laws in your state, please call your state's Insurance Commissioner's office.
To learn about pending legislation in your state, please contact your State Representatives.
Click here to see ASRM publications and materials on Insurance Issues
Arkansas California Connecticut Hawaii Illinois MarylandMassachusetts Montana New Jersey New York OhioRhode Island Texas West Virginia
To learn about pending legislation in your state, please contact your State Representatives.
Click here to see ASRM publications and materials on Insurance Issues
Arkansas California Connecticut Hawaii Illinois MarylandMassachusetts Montana New Jersey New York OhioRhode Island Texas West Virginia
Gynecologic surgery and subsequent bowel obstruction
Diaa M. El-Mowafi Associate Professor, Obstetrics and GynaecologyDepartment of Obstetrics and Gynecology, Benha Faculty of MedicineLecturer and Researcher, Wayne State University, Detroit, Michigan, USAFellow, Geneva University, Switzerland
Michael P. DiamondProfessor and DirectorDivision of Reproductive Endocrinology and Infertility, Department of Obstetrics and GynecologyWayne State University, Detroit, Michigan, USA
Intestinal obstruction is a broad term, which entails cessation of the normal progression of the intestinal contents. Intestinal obstruction can be segregated into complete and incomplete blockage, and be due to mechanical or functional etiologies.
Mechanical obstruction is a term usually applied when there is an actual physical barrier blocking the intestinal lumen, such as bands of adhesion, strangulated hernias, and pressure from pelvic tumors. In contrast, adynamic ileus is used to describe disorders of propulsive motility of the bowel.
Mechanical Intestinal Obstruction
Intestinal obstruction is one of the more common and potentially fatal complications following gynecologic surgery. Forty years ago, mortality rate of 40% to 60% was not uncommon. Currently, the mortality rate has decreased but is still between 10% to 20% for all patients with obstruction of the small intestine.1
Adhesions, usually secondary to previous surgical procedures, are the most common cause of intestinal obstructions in the United States, and are responsible for 49% to 74% of small bowel obstruction in industrial countries.2 Menzies and Ellis3 reported that 93% of 210 patients who had previously undergone abdominal operations had substantial peritoneal adhesions at the time of reoperation. Gynecologic procedures, appendectomies, and other intestinal operations are the three most common type of surgical procedures performed before these occurrences.4,5 Lo et al,6 in 1966, reported a series in which 21% of patients with small bowel obstruction secondary to adhesions have had some form of gynecologic surgery. Melody,7 in 1957, reported that abdominal hysterectomy is the most common operation, which was associated with postoperative intestinal obstruction among 487 gynecological surgeries. In 1983, Ratcliff et al.,15 reviewed 59 cases of admitted women who underwent exploratory laparotomy for relief of small bowel obstruction. They found that 49 patients (83%) had previous abdominal surgery. Of these 49 patients, 38 (78%) had some type of obstetric or gynecologic abdominal procedure, of which 33 of the 49 (67%) had previously undergone a total abdominal hysterectomy.
In 1994, Monk et al.,8 reported that postoperative adhesions occur in 60% to 90% of patients undergoing major gynecologic surgery. The incidence of adhesion-related intestinal obstruction after gynecologic surgery for benign conditions without hysterectomy was approximately 0.3%, increased to 2% to 3% among patients who underwent hysterectomy, and was as high as 5% if a radical hysterectomy was performed.
ADYNAMIC ILEUS
Some degree of adynamic ileus occurs after any intra-abdominal operation as well as in association with nearly all cases of intra-abdominal inflammation. The recovery of motor function of the intestines depends on many factors, including the length of the operation, the extent of handling of the bowel, the degree of chemical and bacterial peritonitis, and the underlying disease. After abdominal operations the patient usually feels hungry and passes flatus within the first three postoperative days. If the patient is not interested in eating, denies flatus and the abdomen is distended and has inaudible intestinal sounds, further diagnostic procedure may be called for. Radiography of adynamic ileus shows distention of both the small and large bowel, with scattered air-fluid levels.
The treatment consists of correction of any electrolyte imbalance, if present, as low serum potassium or sodium as well as hypomagnesemia and severe protein depletion can cause bowel atony. Ambulation, systemic and localized intestinal stimulation by rectal suppositories may be helpful. Otherwise, nasogastric intubation for decompression may be needed.1
PATHOPHYSIOLOGY OF INTESTINAL OBSTRUCTION
Obstruction of the small intestine causes collection of intestinal contents proximal to the obstruction leading to intestinal distention. Swallowed air, that represents over 70% of the air in the gastrointestinal tract, increases this distention. Because the veins and arteries enter the intestinal wall tangentially, the tension on them increases rapidly with distention. The veins, having the lower pressure, show the effect of the increase in tension first. As they are stretched, resistance in them increases, and flow slows down. Fluid rich in protein and salt begins to exude from the capillaries resulting in edema. Intraluminal fluid accumulation increases from both active secretion and decreased absorption. Subsequently, blood cells begin to escape from the capillaries, venous flow finally stops, and as arterial flow continues, blood accumulates in the wall and in the lumen of the bowel. If this process continues unabated gangrene occurs, intestinal integrity is lost and peritonitis quickly follows.1 Importantly, even in the absence of food and liquid ingestion, the volume within the gastrointestinal tract may continue to expand. The total volume of daily secretions into the normal gastrointestinal tract is estimated to be about 10 liters. As much as 7-8 liters of fluid can easily be sequestered in the bowel with intestinal obstruction.
Stagnant bowel contents in a distended loop of ileum show an increase in the number of bacteria. As long as the mucosa is intact and viable, the bacteria are harmless; however, increased intraluminal pressure for a sustained period will produce patchy areas of necrosis that allow some of the intestinal contents to escape into the peritoneal cavity. The main avenue of sepsis from intestinal obstruction is absorption from the peritoneal cavity and not the venous and lymphatic system.9
PATHOPHYSIOLOGY OF ADHESION FORMATION
Following peritoneal injury, the microvasculature beneath the mesothelium becomes disrupted. This is followed by extravasation of serum and cellular elements. Within 3 hours, this proteinaceous fluid coagulates, producing fibrinous bands between abutting surfaces.10 Twelve hours later; polymorphonuclear cells are entangled in fibrin strands, which are subsequently replaced with a macrophage infiltrate. By 48 hours after peritoneal injury, the wound surface is covered with a layer of macrophages.8 In normal peritoneal healing, the fibrinolytic system is triggered to lyse these fibrinous strands within 72 hours of the insult. Within the initial 5 days, re-epithelization of the peritoneal injury occurs. Interestingly, it appears that centripetal growth from the margin of peritoneal wounds contributes little to the healing p; the new mesothelium is derived from the metaplasia of subperitoneal perivascular connective tissue cells that resemble primitive mesenchymal cells.11 Disruption of the existing equilibrium between fibrin deposition and fibrinolysis leads to persistence of the fibrinous strands, which then becomes infiltrated by proliferating fibrobiasts. Subsequently, vascularization and cellular ingrowth occur, and an adhesion is created.10
During mesothelial repair, macrophages and lymphocytes produce growth factors that modulate fibroblast proliferation and collagen synthesis, including platelet-derived growth factor, transforming growth factor-b , fibroblast growth factor, epidermal growth factor, interleukin-l, and tumor necrosis factor-a .12,13 Prostaglandins, particularly prostaglandin E2, are also involved in normal and abnormal mesothelial repair,14,15 most likely through a separate mechanism not related to fibroblast proliferation.16
Adequate blood supply is critical for normal fibrinolysis to occur. Peritoneal injurischemia interferes with fibrinolysis and leads to organization rather than resolution of the fibrin-cellular matrix.8 Ischemia may also induce adhesion formation by stimulating the growth of blood vessels form a non-ischemic to an ischemic site.17 Ischemia may result from excessive handling, crushing, ligating, suturing, cauterizing, or stripping of the peritoneum.
Foreign body reaction causes excessive formation of the fibrin coagulum that stimulates the development of adhesions. Common foreign bodies include sutures as well as cornstarch powder and lint from drapes, caps, gown, masks, and laparotomy pads. It is interesting that foreign bodies in the absence of peritoneal injury are an infrequent cause of adhesion formation.17
The presence of intraperitoneal blood has also been proposed to play a role in adhesion formation, although its actual contribution is not clear. However, free blood in the peritoneal cavity generally does not lead to adhesions, except in the presence of tissue ischemia.19
Infection may result in the development of adhesions by causing the release of proteolytic enzymes, which lead to ischemia and tissue damage, resulting in the formation of adhesions.5
In summary, ischemia seems to play the central role in adhesions formation and factors that compromise blood flow within the area of tissue injury lead to the development of adhesions. Thermal injury,20,21 infection,22 foreign body reaction,22,23 radiation induced endarteritis,24 and impairment of the fibrinolytic activity, all probably act via inducing ischemia to enhance adhesion formation. The thermal effect on adhesion formation called the question about optimal method to achieve hemostasis; is it cautery or sutures as both are incriminated in the etiology of development of adhesions.
DIAGNOSIS OF INTESTINAL OBSTRUCTION
The initial symptom of intestinal obstruction is sudden onset of crampy abdominal pain. This pain is intermittent, with intervals devoid of it which are longer than the periods of pain. The pain is classically periumbilical for a midgut obstruction. Vomiting may accompany the onset of pain with the possibility of recurrence if obstruction persists.
Inspection of the abdomen usually shows distention in persistent obstruction. Loops of intestine with visible peristalsis may be seen beneath the abdominal wall in the very thin patient. High-pitched, tinkling, or metallic intestinal sounds are characteristic of obstruction and occasionally can be heard without a stethoscope. These sounds represent the existence of the air-fluid interface. Motility with violent bursts of peristalsis occurs proximal to the obstruction. The duration of quiet intervals between bursts of peristalsis may suggest the level of obstruction; in high obstruction the time may be 3 to 5 minutes, whereas in low obstruction it may be 10 to 15 minutes.1 Palpation in the early stage of the disease may disclose no tenderness. As distention progresses, it is usual to find tenderness over the point of obstruction.
X-ray study demonstrating distended loop(s) of intestine with air-fluid levels, is suggestive of a mechanical obstruction, whereas grossly dilated loops of small bowel with gas in the colon is typically found is adynamic ileus.7 Computed tomography (CT) was used recently to diagnose postoperative intestinal obstruction due to adhesions.25 The CT findings that suggest strangulated obstruction are serrated beaks, mesenteric edema or vascular engorgement, and moderate to severe bowel wall thickening. In contrast, simple obstruction could be assumed when the beak is smooth, there are no mesenteric changes, and the bowel wall is normal or mildly thickened.
PERITONEAL CLOSURE AND ADHESIVE INTESTINAL OBSTRUCTION
Suturing the parietal peritoneum of the anterior abdominal wall at completion of gynecologic and obstetric surgery was always a tradition. Intuitive logic suggests that it will be of benefit to re-establish normal anatomical relationships and to prevent adhesion formation between the intestines and/or uterus and fascia. However, data supporting this hypothesis is lacking, and in fact it may be incorrect. Importantly, reperitonalization also places pelvic and abdominal contents within the abdominal cavity, and possibly makes fascial closure easier.
The microscopic cellular studies in animals have demonstrated that the broad peritoneal repairative process is different from that of the edge-to-edge skin cicatrization.26 When left undisturbed, peritoneal defects demonstrate mesothelial integrity (reperitonization) by 48 hours and complete indistinguishable healing i.e. without scaring can be achieved by 5 days.27, 28
Adhesions are caused by ischemia, inflammation, and infection rather than by open surfaces. Re-approximation of peritoneal edges or repair of defects via grafts, even with suture material considered to be minimally reactive, results in increased tissue ischemia and foreign-body tissue reaction, and may lead to increased adhesion formation at the site of reperitonization.29
Pietrantini and co-workers30 compared 127 patient in whom the peritoneum was left unsutured after cesarean section with another 121 patients in whom it had been closed with a continuous 000 polyglactin suture. There were no postoperative differences between the two groups regarding the incidence of wound infection, dehiscence, endometritis, ileus, and length of hospital stay. They concluded that peritoneal closure at cesarean delivery provides no postoperative benefits, while unnecessarily lengthening surgical time, anesthesia exposure, and increasing patient costs. Finally, they advocated the elimination of closure of the parietal peritoneum from cesarean technique. However, they did actually evaluate the issue of the frequency of adhesion development as a function of peritoneal closure.
Hull and Yarner31 extended this modality to non-closure of the visceral and parietal peritoneum during lower segment cesarean section. In their randomized study on 113 patients, 59 patient were assigned to closure of both the visceral and parietal peritoneum with absorbable suture. The other 51 patients were left with no peritoneal closure. The incidence of postoperative fever, endometritis, or wound infection was not different between the two groups. The numbers of oral analgesic doses was significantly greater with closure of the peritoneum than without. The frequency with which postoperative lieus was diagnosed in each group was similar. Bowel stimulants were administered more frequently to the closure than to the non-closure patients. The average operating time was shorter for the open group than for the closure one.
Stricker et al32 reviewed 100 cases of female intestinal obstruction where they found that postoperative adhesions was the most common cause being present (59%). Fifty-six percent of those patients had a prior gynecologic surgery, most commonly abdominal hysterectomy. From 11 patients who had records from their previous operation, 9 patients had peritoneal closure; among these patients adhesions were found always to the site of reperitonization. In the 2 patients iwhom the peritoneum was left open, the adhesions causing the obstruction were found away form the site of reperitonization. In their study, Tulandi and others33 confirmed that non-closure of the parietal peritoneum after gynecologic surgery, as compared to closure using chromic cut gut suture did not increase adhesion formation found at second-look laparoscopy
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Michael P. DiamondProfessor and DirectorDivision of Reproductive Endocrinology and Infertility, Department of Obstetrics and GynecologyWayne State University, Detroit, Michigan, USA
Intestinal obstruction is a broad term, which entails cessation of the normal progression of the intestinal contents. Intestinal obstruction can be segregated into complete and incomplete blockage, and be due to mechanical or functional etiologies.
Mechanical obstruction is a term usually applied when there is an actual physical barrier blocking the intestinal lumen, such as bands of adhesion, strangulated hernias, and pressure from pelvic tumors. In contrast, adynamic ileus is used to describe disorders of propulsive motility of the bowel.
Mechanical Intestinal Obstruction
Intestinal obstruction is one of the more common and potentially fatal complications following gynecologic surgery. Forty years ago, mortality rate of 40% to 60% was not uncommon. Currently, the mortality rate has decreased but is still between 10% to 20% for all patients with obstruction of the small intestine.1
Adhesions, usually secondary to previous surgical procedures, are the most common cause of intestinal obstructions in the United States, and are responsible for 49% to 74% of small bowel obstruction in industrial countries.2 Menzies and Ellis3 reported that 93% of 210 patients who had previously undergone abdominal operations had substantial peritoneal adhesions at the time of reoperation. Gynecologic procedures, appendectomies, and other intestinal operations are the three most common type of surgical procedures performed before these occurrences.4,5 Lo et al,6 in 1966, reported a series in which 21% of patients with small bowel obstruction secondary to adhesions have had some form of gynecologic surgery. Melody,7 in 1957, reported that abdominal hysterectomy is the most common operation, which was associated with postoperative intestinal obstruction among 487 gynecological surgeries. In 1983, Ratcliff et al.,15 reviewed 59 cases of admitted women who underwent exploratory laparotomy for relief of small bowel obstruction. They found that 49 patients (83%) had previous abdominal surgery. Of these 49 patients, 38 (78%) had some type of obstetric or gynecologic abdominal procedure, of which 33 of the 49 (67%) had previously undergone a total abdominal hysterectomy.
In 1994, Monk et al.,8 reported that postoperative adhesions occur in 60% to 90% of patients undergoing major gynecologic surgery. The incidence of adhesion-related intestinal obstruction after gynecologic surgery for benign conditions without hysterectomy was approximately 0.3%, increased to 2% to 3% among patients who underwent hysterectomy, and was as high as 5% if a radical hysterectomy was performed.
ADYNAMIC ILEUS
Some degree of adynamic ileus occurs after any intra-abdominal operation as well as in association with nearly all cases of intra-abdominal inflammation. The recovery of motor function of the intestines depends on many factors, including the length of the operation, the extent of handling of the bowel, the degree of chemical and bacterial peritonitis, and the underlying disease. After abdominal operations the patient usually feels hungry and passes flatus within the first three postoperative days. If the patient is not interested in eating, denies flatus and the abdomen is distended and has inaudible intestinal sounds, further diagnostic procedure may be called for. Radiography of adynamic ileus shows distention of both the small and large bowel, with scattered air-fluid levels.
The treatment consists of correction of any electrolyte imbalance, if present, as low serum potassium or sodium as well as hypomagnesemia and severe protein depletion can cause bowel atony. Ambulation, systemic and localized intestinal stimulation by rectal suppositories may be helpful. Otherwise, nasogastric intubation for decompression may be needed.1
PATHOPHYSIOLOGY OF INTESTINAL OBSTRUCTION
Obstruction of the small intestine causes collection of intestinal contents proximal to the obstruction leading to intestinal distention. Swallowed air, that represents over 70% of the air in the gastrointestinal tract, increases this distention. Because the veins and arteries enter the intestinal wall tangentially, the tension on them increases rapidly with distention. The veins, having the lower pressure, show the effect of the increase in tension first. As they are stretched, resistance in them increases, and flow slows down. Fluid rich in protein and salt begins to exude from the capillaries resulting in edema. Intraluminal fluid accumulation increases from both active secretion and decreased absorption. Subsequently, blood cells begin to escape from the capillaries, venous flow finally stops, and as arterial flow continues, blood accumulates in the wall and in the lumen of the bowel. If this process continues unabated gangrene occurs, intestinal integrity is lost and peritonitis quickly follows.1 Importantly, even in the absence of food and liquid ingestion, the volume within the gastrointestinal tract may continue to expand. The total volume of daily secretions into the normal gastrointestinal tract is estimated to be about 10 liters. As much as 7-8 liters of fluid can easily be sequestered in the bowel with intestinal obstruction.
Stagnant bowel contents in a distended loop of ileum show an increase in the number of bacteria. As long as the mucosa is intact and viable, the bacteria are harmless; however, increased intraluminal pressure for a sustained period will produce patchy areas of necrosis that allow some of the intestinal contents to escape into the peritoneal cavity. The main avenue of sepsis from intestinal obstruction is absorption from the peritoneal cavity and not the venous and lymphatic system.9
PATHOPHYSIOLOGY OF ADHESION FORMATION
Following peritoneal injury, the microvasculature beneath the mesothelium becomes disrupted. This is followed by extravasation of serum and cellular elements. Within 3 hours, this proteinaceous fluid coagulates, producing fibrinous bands between abutting surfaces.10 Twelve hours later; polymorphonuclear cells are entangled in fibrin strands, which are subsequently replaced with a macrophage infiltrate. By 48 hours after peritoneal injury, the wound surface is covered with a layer of macrophages.8 In normal peritoneal healing, the fibrinolytic system is triggered to lyse these fibrinous strands within 72 hours of the insult. Within the initial 5 days, re-epithelization of the peritoneal injury occurs. Interestingly, it appears that centripetal growth from the margin of peritoneal wounds contributes little to the healing p; the new mesothelium is derived from the metaplasia of subperitoneal perivascular connective tissue cells that resemble primitive mesenchymal cells.11 Disruption of the existing equilibrium between fibrin deposition and fibrinolysis leads to persistence of the fibrinous strands, which then becomes infiltrated by proliferating fibrobiasts. Subsequently, vascularization and cellular ingrowth occur, and an adhesion is created.10
During mesothelial repair, macrophages and lymphocytes produce growth factors that modulate fibroblast proliferation and collagen synthesis, including platelet-derived growth factor, transforming growth factor-b , fibroblast growth factor, epidermal growth factor, interleukin-l, and tumor necrosis factor-a .12,13 Prostaglandins, particularly prostaglandin E2, are also involved in normal and abnormal mesothelial repair,14,15 most likely through a separate mechanism not related to fibroblast proliferation.16
Adequate blood supply is critical for normal fibrinolysis to occur. Peritoneal injurischemia interferes with fibrinolysis and leads to organization rather than resolution of the fibrin-cellular matrix.8 Ischemia may also induce adhesion formation by stimulating the growth of blood vessels form a non-ischemic to an ischemic site.17 Ischemia may result from excessive handling, crushing, ligating, suturing, cauterizing, or stripping of the peritoneum.
Foreign body reaction causes excessive formation of the fibrin coagulum that stimulates the development of adhesions. Common foreign bodies include sutures as well as cornstarch powder and lint from drapes, caps, gown, masks, and laparotomy pads. It is interesting that foreign bodies in the absence of peritoneal injury are an infrequent cause of adhesion formation.17
The presence of intraperitoneal blood has also been proposed to play a role in adhesion formation, although its actual contribution is not clear. However, free blood in the peritoneal cavity generally does not lead to adhesions, except in the presence of tissue ischemia.19
Infection may result in the development of adhesions by causing the release of proteolytic enzymes, which lead to ischemia and tissue damage, resulting in the formation of adhesions.5
In summary, ischemia seems to play the central role in adhesions formation and factors that compromise blood flow within the area of tissue injury lead to the development of adhesions. Thermal injury,20,21 infection,22 foreign body reaction,22,23 radiation induced endarteritis,24 and impairment of the fibrinolytic activity, all probably act via inducing ischemia to enhance adhesion formation. The thermal effect on adhesion formation called the question about optimal method to achieve hemostasis; is it cautery or sutures as both are incriminated in the etiology of development of adhesions.
DIAGNOSIS OF INTESTINAL OBSTRUCTION
The initial symptom of intestinal obstruction is sudden onset of crampy abdominal pain. This pain is intermittent, with intervals devoid of it which are longer than the periods of pain. The pain is classically periumbilical for a midgut obstruction. Vomiting may accompany the onset of pain with the possibility of recurrence if obstruction persists.
Inspection of the abdomen usually shows distention in persistent obstruction. Loops of intestine with visible peristalsis may be seen beneath the abdominal wall in the very thin patient. High-pitched, tinkling, or metallic intestinal sounds are characteristic of obstruction and occasionally can be heard without a stethoscope. These sounds represent the existence of the air-fluid interface. Motility with violent bursts of peristalsis occurs proximal to the obstruction. The duration of quiet intervals between bursts of peristalsis may suggest the level of obstruction; in high obstruction the time may be 3 to 5 minutes, whereas in low obstruction it may be 10 to 15 minutes.1 Palpation in the early stage of the disease may disclose no tenderness. As distention progresses, it is usual to find tenderness over the point of obstruction.
X-ray study demonstrating distended loop(s) of intestine with air-fluid levels, is suggestive of a mechanical obstruction, whereas grossly dilated loops of small bowel with gas in the colon is typically found is adynamic ileus.7 Computed tomography (CT) was used recently to diagnose postoperative intestinal obstruction due to adhesions.25 The CT findings that suggest strangulated obstruction are serrated beaks, mesenteric edema or vascular engorgement, and moderate to severe bowel wall thickening. In contrast, simple obstruction could be assumed when the beak is smooth, there are no mesenteric changes, and the bowel wall is normal or mildly thickened.
PERITONEAL CLOSURE AND ADHESIVE INTESTINAL OBSTRUCTION
Suturing the parietal peritoneum of the anterior abdominal wall at completion of gynecologic and obstetric surgery was always a tradition. Intuitive logic suggests that it will be of benefit to re-establish normal anatomical relationships and to prevent adhesion formation between the intestines and/or uterus and fascia. However, data supporting this hypothesis is lacking, and in fact it may be incorrect. Importantly, reperitonalization also places pelvic and abdominal contents within the abdominal cavity, and possibly makes fascial closure easier.
The microscopic cellular studies in animals have demonstrated that the broad peritoneal repairative process is different from that of the edge-to-edge skin cicatrization.26 When left undisturbed, peritoneal defects demonstrate mesothelial integrity (reperitonization) by 48 hours and complete indistinguishable healing i.e. without scaring can be achieved by 5 days.27, 28
Adhesions are caused by ischemia, inflammation, and infection rather than by open surfaces. Re-approximation of peritoneal edges or repair of defects via grafts, even with suture material considered to be minimally reactive, results in increased tissue ischemia and foreign-body tissue reaction, and may lead to increased adhesion formation at the site of reperitonization.29
Pietrantini and co-workers30 compared 127 patient in whom the peritoneum was left unsutured after cesarean section with another 121 patients in whom it had been closed with a continuous 000 polyglactin suture. There were no postoperative differences between the two groups regarding the incidence of wound infection, dehiscence, endometritis, ileus, and length of hospital stay. They concluded that peritoneal closure at cesarean delivery provides no postoperative benefits, while unnecessarily lengthening surgical time, anesthesia exposure, and increasing patient costs. Finally, they advocated the elimination of closure of the parietal peritoneum from cesarean technique. However, they did actually evaluate the issue of the frequency of adhesion development as a function of peritoneal closure.
Hull and Yarner31 extended this modality to non-closure of the visceral and parietal peritoneum during lower segment cesarean section. In their randomized study on 113 patients, 59 patient were assigned to closure of both the visceral and parietal peritoneum with absorbable suture. The other 51 patients were left with no peritoneal closure. The incidence of postoperative fever, endometritis, or wound infection was not different between the two groups. The numbers of oral analgesic doses was significantly greater with closure of the peritoneum than without. The frequency with which postoperative lieus was diagnosed in each group was similar. Bowel stimulants were administered more frequently to the closure than to the non-closure patients. The average operating time was shorter for the open group than for the closure one.
Stricker et al32 reviewed 100 cases of female intestinal obstruction where they found that postoperative adhesions was the most common cause being present (59%). Fifty-six percent of those patients had a prior gynecologic surgery, most commonly abdominal hysterectomy. From 11 patients who had records from their previous operation, 9 patients had peritoneal closure; among these patients adhesions were found always to the site of reperitonization. In the 2 patients iwhom the peritoneum was left open, the adhesions causing the obstruction were found away form the site of reperitonization. In their study, Tulandi and others33 confirmed that non-closure of the parietal peritoneum after gynecologic surgery, as compared to closure using chromic cut gut suture did not increase adhesion formation found at second-look laparoscopy
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DISCRIMINATION ACROSS THE NATION..
FOR CENTURIES WE HAVE READ AND HEARD FIRST HAND OF PEOPLE BEING DISCRIMINATED AGAINST.
THE AREAS OF DISCRIMINATION ARE SO BROAD , I THINK PEOPLE TEND TO NOT TAKE NOTICE TO CERTAIN GROUPS SO AFFECTED , THEY WOULD RATHER CRAWL IN A HOLE , SO TO SPEAK THAN DO SOMETHING ABOUT IT.
TAKE ARD FOR EXAMPLE, DO YOU FEEL THERE IS DISCRIMINATION TOWARDS THIS DISEASE?
SURE THERE IS.
WHEN DRS. IN EVERY FIELD CAN LOOK AT AN ARD SUFFERER AND REFER TO THEM AS EITHER BEING MENTALLY ILL, BECAUSE SURELY THIS DISEASE CANNOT CAUSE THESE ENORMOUS TYPES OF PAIN, SPASMS, NAUSEA, VOMITING, OBSTRUCTIONS,WEIGHT LOSS, WEIGHT GAIN, THIS IS DISCRIMINATION!
I CANNOT UNDERSTAND UNLESS THEY WALK A DAY IN OUR BODIES WHY THEY HAVE THE RIGHT TO JUDGE THIS PARTICULAR ILLNESS SO SEVERELY.
THEY DO NOT HAVE THAT RIGHT!! IT IS THE ARD SUFFERER THAT HAS TO TAKE A STAND TO THIS INJUSTICE.. IMMEDIATELY..
I REMEMBER WALKING MY HANDICAPPED CHILD THROUGH THE MALL, PEOPLE WOULD STARE, I WOULD BECOME ANGRY, I WOULD APPROACH THE PERSON AND DECLARE.. "IF YOU WISH TO STARE, PLEASE ASK ME WHAT YOUR QUESTION IS INSTEAD OF MAKING HIM AND I FEEL BAD .
SEE IT IS THROWN BACK TO THE PERSON WHO IS BEING DISCRIMINATED TOWARDS. THE FEELINGS OF DESPAIR, ISOLATION, SADNESS SET IN.
PEOPLE NEED TO BE ASKED WHY DO YOU LOOK? MAKE THEM BE ACCOUNTABLE FOR THE LACK OF INTELLIGENCE THEY ARE SHOWING ATT HIS PARTICULAR MOMENT!!!
I ONCE TRIED TO HIRE AN ATTORNEY TO PURSUE A LAW SUIT IN MY SON'S BEHALF AS HE HAD BEEN IN A NURSING HOME FOR CHILDREN FOR A SHORT PERIOD, AND IN THIS STAY SOMEONE WHILE HE WAS PLAYING ON THE FLOOR ROLLED OVER HIS HAND WITH A WHEEL CHAIR.
NOT ONLY WAS THIS HUSH , HUSH, WHEN I CAME DOWN TO RING HIM HOME FOR HIS WEEKEND VISIT HERE WAS A BRUISED MIDDLE FINGER THAT WAS NOT TENDED TO , BUT WHEN ASKED NOONE KNEW WHAT HAPPENED.
OF COURSE BEING THE GOOD PARENT I WAS , I TOOK HIM TO OUR FAMILY DR IMMEDIATELY.
EXRAYS WERE DONE, THE FINGER WAS SMASHED.
HERE IS WHAT THE LAWYERS SAID: "WHAT QUALITY OF LIFE DOES HE HAVE ANYWAY?" IF HE WERE AN ARTIST MAYBE WE COULD SUE.. BUT HE DOESN'T USE THE HAND THEREFORE WE HAVE NO CASE.
THEY GOT AWAY WITH THIS CRIME BECAUSE JOSHUA ONCE AGAIN WAS DISCRIMINATED AGAINST.
I REMEMBER THE HELPLESSNESS I FELT INSIDE, THE DEEP SADNESS I FELT FOR THIS CHILD, IF IT WEREN'T FOR ME HE WOULD HAVE BEEN CARTED OFF AND HID FROM SOCIETY.
WHEN HE WAS AN INFANT .. THEY SAID "TAKE HIM HOME AND LET HIM DIE". Do YOU FEEL THIS WAS DISCRIMINATION? I DO..
THEY MINIMIZED MY SON'S QUALITY OF LIFE IMMEDIATELY!!
TO THE YEAR HE PASSED, THE DRS WERE SAYING THERES NOTHING TO DO. SEE THEY HAD GIVEN UP, THE DRS , SO EASILY, BECAUSE IN THEIR MINDS HERES A CHILD WHO WOULD ALWAYS BE A CHILD, COST THE GOVERNMENT MASS QUANTITIES OF MONEY ETC... THEY WOULD FURTHER NO MORE TOHELP HIM STAY OUT OF PAIN, HAVE A MORE COMFORTABLE LIFE... ALL BECAUSE THEY DISCRIMINATED HIS QUALITY OF LIFE YOU SEE.
ARD IS DISCRIMINATED IN THIS MANNER.
IT IS IRONIC THE VARY SURGEONS THAT SEE THE ARD SUFFERER OPENED, THEY SEE AND FIX THE ULTIMATE DAMAGE THAT HAS ENSUED IN OUR BODIES, YET THEY ARE THE BIGGEST PART OF WHY WE ARE BEING DISCRIMINATED AGAINST!!!!
THEY ARE THE FIRST ONES TO SAY.... THIS COULD NOT BE THAT PAINFUL..
DISCRIMINATION ACROSS THE NATION I SAY!!!!!!!!!!!!
WHAT WILL IT TAKE FOR US TO BE HEARD????
WRITE YOUR LETTERS IF YOU ARE TOO SICK TO PROTEST ON GOVERNMENT STEPS... BE HEARD!!!!!!!! WE ARE THE ONLY ONES TO CHANGE THIS MIND SET OF OTHERS....
SOMETHING HAS BEEN LOST IN THIS DAY AND AGE, AS IN THE PAST GROUPS WOULD BE YELLING TO THE RAFTERS ABOUT THE DISCRIMINATION GOING ON ABOUT ARD!!!!
FOOD FOR THOUGHT...........SOT
THE AREAS OF DISCRIMINATION ARE SO BROAD , I THINK PEOPLE TEND TO NOT TAKE NOTICE TO CERTAIN GROUPS SO AFFECTED , THEY WOULD RATHER CRAWL IN A HOLE , SO TO SPEAK THAN DO SOMETHING ABOUT IT.
TAKE ARD FOR EXAMPLE, DO YOU FEEL THERE IS DISCRIMINATION TOWARDS THIS DISEASE?
SURE THERE IS.
WHEN DRS. IN EVERY FIELD CAN LOOK AT AN ARD SUFFERER AND REFER TO THEM AS EITHER BEING MENTALLY ILL, BECAUSE SURELY THIS DISEASE CANNOT CAUSE THESE ENORMOUS TYPES OF PAIN, SPASMS, NAUSEA, VOMITING, OBSTRUCTIONS,WEIGHT LOSS, WEIGHT GAIN, THIS IS DISCRIMINATION!
I CANNOT UNDERSTAND UNLESS THEY WALK A DAY IN OUR BODIES WHY THEY HAVE THE RIGHT TO JUDGE THIS PARTICULAR ILLNESS SO SEVERELY.
THEY DO NOT HAVE THAT RIGHT!! IT IS THE ARD SUFFERER THAT HAS TO TAKE A STAND TO THIS INJUSTICE.. IMMEDIATELY..
I REMEMBER WALKING MY HANDICAPPED CHILD THROUGH THE MALL, PEOPLE WOULD STARE, I WOULD BECOME ANGRY, I WOULD APPROACH THE PERSON AND DECLARE.. "IF YOU WISH TO STARE, PLEASE ASK ME WHAT YOUR QUESTION IS INSTEAD OF MAKING HIM AND I FEEL BAD .
SEE IT IS THROWN BACK TO THE PERSON WHO IS BEING DISCRIMINATED TOWARDS. THE FEELINGS OF DESPAIR, ISOLATION, SADNESS SET IN.
PEOPLE NEED TO BE ASKED WHY DO YOU LOOK? MAKE THEM BE ACCOUNTABLE FOR THE LACK OF INTELLIGENCE THEY ARE SHOWING ATT HIS PARTICULAR MOMENT!!!
I ONCE TRIED TO HIRE AN ATTORNEY TO PURSUE A LAW SUIT IN MY SON'S BEHALF AS HE HAD BEEN IN A NURSING HOME FOR CHILDREN FOR A SHORT PERIOD, AND IN THIS STAY SOMEONE WHILE HE WAS PLAYING ON THE FLOOR ROLLED OVER HIS HAND WITH A WHEEL CHAIR.
NOT ONLY WAS THIS HUSH , HUSH, WHEN I CAME DOWN TO RING HIM HOME FOR HIS WEEKEND VISIT HERE WAS A BRUISED MIDDLE FINGER THAT WAS NOT TENDED TO , BUT WHEN ASKED NOONE KNEW WHAT HAPPENED.
OF COURSE BEING THE GOOD PARENT I WAS , I TOOK HIM TO OUR FAMILY DR IMMEDIATELY.
EXRAYS WERE DONE, THE FINGER WAS SMASHED.
HERE IS WHAT THE LAWYERS SAID: "WHAT QUALITY OF LIFE DOES HE HAVE ANYWAY?" IF HE WERE AN ARTIST MAYBE WE COULD SUE.. BUT HE DOESN'T USE THE HAND THEREFORE WE HAVE NO CASE.
THEY GOT AWAY WITH THIS CRIME BECAUSE JOSHUA ONCE AGAIN WAS DISCRIMINATED AGAINST.
I REMEMBER THE HELPLESSNESS I FELT INSIDE, THE DEEP SADNESS I FELT FOR THIS CHILD, IF IT WEREN'T FOR ME HE WOULD HAVE BEEN CARTED OFF AND HID FROM SOCIETY.
WHEN HE WAS AN INFANT .. THEY SAID "TAKE HIM HOME AND LET HIM DIE". Do YOU FEEL THIS WAS DISCRIMINATION? I DO..
THEY MINIMIZED MY SON'S QUALITY OF LIFE IMMEDIATELY!!
TO THE YEAR HE PASSED, THE DRS WERE SAYING THERES NOTHING TO DO. SEE THEY HAD GIVEN UP, THE DRS , SO EASILY, BECAUSE IN THEIR MINDS HERES A CHILD WHO WOULD ALWAYS BE A CHILD, COST THE GOVERNMENT MASS QUANTITIES OF MONEY ETC... THEY WOULD FURTHER NO MORE TOHELP HIM STAY OUT OF PAIN, HAVE A MORE COMFORTABLE LIFE... ALL BECAUSE THEY DISCRIMINATED HIS QUALITY OF LIFE YOU SEE.
ARD IS DISCRIMINATED IN THIS MANNER.
IT IS IRONIC THE VARY SURGEONS THAT SEE THE ARD SUFFERER OPENED, THEY SEE AND FIX THE ULTIMATE DAMAGE THAT HAS ENSUED IN OUR BODIES, YET THEY ARE THE BIGGEST PART OF WHY WE ARE BEING DISCRIMINATED AGAINST!!!!
THEY ARE THE FIRST ONES TO SAY.... THIS COULD NOT BE THAT PAINFUL..
DISCRIMINATION ACROSS THE NATION I SAY!!!!!!!!!!!!
WHAT WILL IT TAKE FOR US TO BE HEARD????
WRITE YOUR LETTERS IF YOU ARE TOO SICK TO PROTEST ON GOVERNMENT STEPS... BE HEARD!!!!!!!! WE ARE THE ONLY ONES TO CHANGE THIS MIND SET OF OTHERS....
SOMETHING HAS BEEN LOST IN THIS DAY AND AGE, AS IN THE PAST GROUPS WOULD BE YELLING TO THE RAFTERS ABOUT THE DISCRIMINATION GOING ON ABOUT ARD!!!!
FOOD FOR THOUGHT...........SOT
Wednesday, March 29, 2006
The Dr. Kruschinski Dance : Now Playing ~ Emma Klinik
My friend the witchdoctor, he taught me what to sayMy friend the witchdoctor, he taught me what to doI know that you'll be mine when I say this to youooh eeh ooh ahah, ting tang wallawallabingbangooh eeh ooh ahah, ting tang wallawallabangbangooh eeh ooh ahah, ting tang wallawallabingbangooh eeh ooh ahah, ting tang wallawallabangbang
David Seville and the Chipmunks
Medical headlines ARDvark Blog
Mononucleosis increases risk of multiple sclerosis
NEW YORK (Reuters Health) - Infection with Epstein-Barr virus (EBV), resulting in infectious mononucleosis, which primarily effects adolescents and young adults, more than doubles the risk of developing multiple sclerosis (MS) later in life, results of a large review of studies suggest.
Couples must demand better deal for IVF
Infertile patients who spend thousands of pounds trying for a baby are risking exploitation, an expert has claimed
Chocolate may deepen depression
Chocoholics can happily eat chocolate for pleasure but for those who are stressed and clinically depressed, the high is short-lived and chocolate may even deepen the downer, a review shows.
Everyday Foods May Yield Medicinal Benefits
Chives, grape seeds and pine nut oil all show early promise, researchers say.
Most New Moms Exhausted: Study
C-sections, breast-feeding especially linked to postpartum woes.
Expert: Fertility industry needs regulation
Fertility treatment is a multi-billion dollar global industry that needs regulation to protect infertile couples and assure equal access to treatment, a leading American economist said.
New York Times Magazine Examines Issues Surrounding Induced Labor
Delay In Surgery Of Three Months Decreases Survival For Bladder Cancer Patients
Guidelines For Medication Withdrawal: When Or How To Stop
Physicians, Other Care Providers Rally To Protest Closing Of New Orleans' Charity Hospital
Disclosure Of Physicians' Financial Incentives May Increase Trust, Loyalty Among Their Patients
New Handbook Addresses Lesbian, Gay, Bisexual And Transgender Health Issues
High-dose Vitamin C As A Cancer Therapy
Should The US And New Zealand Ban Consumer Drug Ads?
Medical Device Related Adverse Incident Reports, UK
One In Seven Adults Uses The ER For Medical Care, USA
New Study Establishes Criteria To Detect Ovarian Cancer In Asymptomatic Postmenopausal Women
NEW YORK (Reuters Health) - Infection with Epstein-Barr virus (EBV), resulting in infectious mononucleosis, which primarily effects adolescents and young adults, more than doubles the risk of developing multiple sclerosis (MS) later in life, results of a large review of studies suggest.
Couples must demand better deal for IVF
Infertile patients who spend thousands of pounds trying for a baby are risking exploitation, an expert has claimed
Chocolate may deepen depression
Chocoholics can happily eat chocolate for pleasure but for those who are stressed and clinically depressed, the high is short-lived and chocolate may even deepen the downer, a review shows.
Everyday Foods May Yield Medicinal Benefits
Chives, grape seeds and pine nut oil all show early promise, researchers say.
Most New Moms Exhausted: Study
C-sections, breast-feeding especially linked to postpartum woes.
Expert: Fertility industry needs regulation
Fertility treatment is a multi-billion dollar global industry that needs regulation to protect infertile couples and assure equal access to treatment, a leading American economist said.
New York Times Magazine Examines Issues Surrounding Induced Labor
Delay In Surgery Of Three Months Decreases Survival For Bladder Cancer Patients
Guidelines For Medication Withdrawal: When Or How To Stop
Physicians, Other Care Providers Rally To Protest Closing Of New Orleans' Charity Hospital
Disclosure Of Physicians' Financial Incentives May Increase Trust, Loyalty Among Their Patients
New Handbook Addresses Lesbian, Gay, Bisexual And Transgender Health Issues
High-dose Vitamin C As A Cancer Therapy
Should The US And New Zealand Ban Consumer Drug Ads?
Medical Device Related Adverse Incident Reports, UK
One In Seven Adults Uses The ER For Medical Care, USA
New Study Establishes Criteria To Detect Ovarian Cancer In Asymptomatic Postmenopausal Women
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