What I need to know about Hirschsprung Disease

Source: http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/hirschsprung-disease/Pages/ez.aspx
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What is Hirschsprung disease (HD)?
Hirschsprung* disease (HD) is a disease of the large intestine that causes severe constipation or intestinal obstruction. Constipation means stool moves through the intestines slower than usual. Bowel movements occur less often than normal and stools are difficult to pass. Some children with HD can’t pass stool at all, which can result in the complete blockage of the intestines, a condition called intestinal obstruction. People with HD are born with it and are usually diagnosed when they are infants. Less severe cases are sometimes diagnosed when a child is older. An HD diagnosis in an adult is rare.

*See Pronunciation Guide for tips on how to say the words in bold type.


HD is a disease of the large intestine that causes severe constipation or intestinal obstruction.

What are the large intestine, colon, rectum, and anus?
The large intestine, which includes the colon and rectum, is the last part of the digestive tract. The large intestine’s main job is to absorb water and hold stool. The rectum connects the colon to the anus. Stool passes out of the body through the anus. At birth, the large intestine is about 2 feet long. An adult’s large intestine is about 5 feet long.

Why does HD cause constipation?
People with HD have constipation because they lack nerve cells in a part or all of the large intestine. The nerve cells signal muscles in the large intestine to push stool toward the anus. Without a signal to push stool along, stool will remain in the large intestine.

Healthy large intestine. Nerve cells are found throughout the large intestine.

Short-segment HD. Nerve cells are missing from the last segment of the large intestine.

Long-segment HD. Nerve cells are missing from most or all of the large intestine and sometimes the last part of the small intestine.

How severe HD is depends on how much of the large intestine is affected. Short-segment HD means only the last part of the large intestine lacks nerve cells. Long-segment HD means most or all of the large intestine, and sometimes the last part of the small intestine, lacks nerve cells.

In a person with HD, stool moves through the large intestine until it reaches the part lacking nerve cells. At that point, the stool moves slowly or stops, causing an intestinal obstruction.

What causes HD?
Before birth, a child’s nerve cells normally grow along the intestines in the direction of the anus. With HD, the nerve cells stop growing too soon. Why the nerve cells stop growing is unclear. Some HD is inherited, meaning it is passed from parent to child through genes. HD is not caused by anything a mother did while pregnant.

What are the symptoms of HD?
The main symptoms of HD are constipation or intestinal obstruction, usually appearing shortly after birth. Constipation in infants and children is common and usually comes and goes, but if your child has had ongoing constipation since birth, HD may be the problem.

Symptoms in Newborns
Newborns with HD almost always fail to have their first bowel movement within 48 hours after birth. Other symptoms include
•green or brown vomit
•explosive stools after a doctor inserts a finger into the rectum
•swelling of the belly, also known as the abdomen
•lots of gas
•bloody diarrhea

Symptoms in Toddlers and Older Children
Symptoms of HD in toddlers and older children include

•not being able to pass stools without laxatives or enemas. A laxative is medicine that loosens stool and increases bowel movements. An enema is performed by flushing water, or sometimes a mild soap solution, into the anus using a special wash bottle.
•swelling of the abdomen.
•lots of gas.
•bloody diarrhea.
•slow growth or development.
•lack of energy because of a shortage of red blood cells, called anemia.

People with anemia tire easily because of a shortage of red blood cells.

How is HD diagnosed?
HD is diagnosed based on symptoms and test results.

A doctor will perform a physical exam and ask questions about your child’s bowel movements. HD is much less likely if parents can identify a time when their child’s bowel habits were normal.

If HD is suspected, the doctor will do one or more tests.

X rays
An x ray is a black-and-white picture of the inside of the body. To make the large intestine show up better, the doctor may fill it with barium liquid. Barium liquid is inserted into the large intestine through the anus.

If HD is the problem, the last segment of the large intestine will look narrower than normal. Just before this narrow segment, the intestine will look bulged. The bulging is caused by blocked stool stretching the intestine.

Manometry
During manometry, the doctor inflates a small balloon inside the rectum. Normally, the rectal muscles will relax. If the muscles don’t relax, HD may be the problem. This test is most often done in older children and adults.

Biopsy
Biopsy is the most accurate test for HD. The doctor removes a tiny piece of the large intestine and looks at it with a microscope. If nerve cells are missing, HD is the problem.

How is HD treated?
Pull-through Procedure
HD is treated with surgery called a pull-through procedure. A surgeon removes the segment of the large intestine lacking nerve cells and connects the healthy segment to the anus. The pull-through procedure is usually done soon after diagnosis.

Pull-through Procedure

Before pull-through surgery: The diseased segment doesn’t push stool.

Step 1: The diseased segment is removed.

Step 2: The healthy segment is attached to the remaining rectum.

Ostomy surgery
An ostomy allows stool to leave the body through an opening in the abdomen. Although most children with HD do not need an ostomy, a child who has been very sick from HD may need an ostomy to get better before the pull-through procedure.

For ostomy surgery, the surgeon first takes out the diseased segment of the large intestine. The end of the healthy intestine is moved to an opening in the abdomen where a stoma is created. A stoma is created by rolling the intestine’s end back on itself, like a shirt cuff, and stitching it to the abdominal wall. An ostomy pouch is attached to the stoma and worn outside the body to collect stool. The pouch will need to be emptied several times each day.


If the surgeon removes the entire large intestine and connects the small intestine to the stoma, the surgery is called an ileostomy. If the surgeon leaves part of the large intestine and connects it to the stoma, the surgery is called a colostomy.
Later, during the pull-through procedure, the surgeon removes the stoma and closes the abdomen with stitches.

Ostomy Surgery

Step 1: The diseased segment is removed.

Step 2: The healthy intestine is moved to an opening in the abdomen where a stoma is created.

What will my child's life be like after surgery?
After Ostomy Surgery
Infants will feel better after ostomy surgery because they will be able to easily pass gas and stool.

Older children will feel better, too, but they must adjust to living with an ostomy. They will need to learn how to take care of the stoma and how to change the ostomy pouch. With a few changes, children with ostomies can lead normal lives. However, they may worry about being different from their friends. A special nurse called an ostomy nurse can answer questions and show how to care for an ostomy.
An ostomy nurse can answer questions and show how to care for an ostomy.

After the Pull-through Procedure
Most children pass stool normally after the pull-through procedure. Children may have diarrhea for awhile, and infants and toddlers may develop diaper rash, which is treatable with diaper creams. Over time, stool will become more solid and the child will go to the bathroom less often. Toilet training may take longer. Children often must learn how to use the muscles of the anus after surgery. Some children may leak stool for awhile, but most will learn to have better bowel control as they get older.

Diet and Nutrition
After the pull-through procedure, children with long-segment HD need to drink more fluids. Now that the large intestine is shorter, or entirely gone, it is less able to absorb fluids the body needs. Drinking more helps make up for the loss.

Some infants may need tube feedings for awhile. A feeding tube allows infant formula or milk to be pumped directly into the stomach or small intestine. The feeding tube is passed through the nose or through an incision in the abdomen.

Eating high-fiber foods can help reduce constipation and diarrhea. Fiber helps form stool, making bowel movements easier. High-fiber foods include whole-grain breads, vegetables, and fruits. Some children may need laxatives to treat ongoing constipation. Consult a doctor before giving a laxative to your child.

Infection
People with HD can suffer from an infection of the intestines, called enterocolitis, before or after surgery.
Symptoms include
•fever
•swollen abdomen
•vomiting
•diarrhea
•bleeding from the rectum
•lack of energy

Call the doctor right away if your child shows any of these signs.

Children with enterocolitis need to go to the hospital. An intravenous (IV) tube is inserted into a vein to give fluids and antibiotics. The large intestine is rinsed regularly with a mild saltwater solution until all stool has been removed. The solution may also contain antibiotics to kill bacteria. A temporary ostomy may be needed to help the intestine heal.

Sometimes infection is a sign of a problem with the pull-through procedure. More surgery may be needed to correct the problem and prevent future infections.

If I have more children, will they also have HD?
If you have a child with HD, your chance of having more children with HD is greater. Talk with your doctor about the risk.


Points to Remember
•Hirschsprung disease (HD) is a disease of the large intestine that causes severe constipation or intestinal obstruction. People with HD are born with it.

•The large intestine, which includes the colon and rectum, is the last part of the digestive tract.

•The cause of HD is unclear. HD is not caused by anything a mother did while pregnant.

•The main symptoms of HD are constipation or intestinal obstruction, usually appearing shortly after birth.

•Newborns with HD almost always fail to have their first bowel movement within 48 hours after birth.

•HD is diagnosed based on symptoms and test results.

•HD is treated with surgery called a pull-through procedure.

•A child who has been very sick from HD may need an ostomy to get better before the pull-through procedure.

•Most children pass stool normally after the pull-through procedure.

•People with HD can suffer from an infection of the intestines, called enterocolitis, before or after surgery.

•If you have a child with HD, your chance of having more children with HD is greater.

Hope through Research
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports basic and clinical research into many digestive disorders, including HD. Scientists are studying the genetics involved in HD to improve diagnosis, treatment, and genetic counseling. They are also looking at therapies for treating enterocolitis, a major complication of HD.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

Pronunciation Guide
abdomen (AB-doh-men)
anemia (uh-NEE-mee-uh)
anus (AY-nuhss)
barium (BA-ree-uhm)
biopsy (BY-op-see)
colostomy (koh-LOSS-toh-mee)
constipation (KON-stih-PAY-shuhn)
diarrhea (DY-uh-REE-uh)
enemas (EN-uh-muhz)
enterocolitis (EN-tur-oh-koh-LY-tiss)
Hirschsprung (HURSH-spruhng)
ileostomy (IL-ee-OSS-tuh-mee)
intestine (in-TESS-tin)
intravenous (IN-truh-VEE-nuhss)
laxatives (LAK-suh-tivz)
manometry (muh-NOM-uh-tree)
obstruction (ob-STRUHK-shuhn)
ostomy (OSS-tuh-mee)
rectum (REK-tuhm)
stoma (STOH-muh)

For More Information
International Foundation for Functional Gastrointestinal Disorders
P.O. Box 170864
Milwaukee, WI 53217–8076
Phone: 1–888–964–2001 or 414–964–1799
Fax: 414–964–7176
Email: iffgd@iffgd.org
Internet: www.iffgd.org

United Ostomy Associations of America, Inc.
P.O. Box 66
Fairview, TN 37062–0066
Phone: 1–800–826–0826 or 615–799–2990
Fax: 615–799–5915
Email: info@uoaa.org
Internet: www.uoaa.org
You may also find additional information about this topic by visiting MedlinePlus at www.medlineplus.gov .

This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.govExternal Link Disclaimer. Consult your doctor for more information.

Acknowledgments
Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. The National Digestive Diseases Information Clearinghouse would like to thank the following individuals for providing scientific and editorial review or facilitating field-testing of the original version of this publication:

Paul Hyman, M.D.
University of Kansas Medical Center
Kansas City, KS

Jacob C. Langer, M.D.
The Hospital for Sick Children
Toronto, Ontario, Canada

Andrea M. Anastas
International Foundation for Functional Gastrointestinal Disorders, Inc.
North Andover, MA

Kimberly Robinstein
Hirschsprungs & Motility Disorders Support Network, The Guardian Society
Land O' Lakes, FL

Thank you also to the parents of children with Hirschsprung disease and the nurse practitioners who helped shape this booklet.

--------------------------------------------------------------------------------
National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892–3570
Phone: 1–800–891–5389
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: nddic@info.niddk.nih.gov
Internet: www.digestive.niddk.nih.gov

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.
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NIH Publication No. 10–4384
February 2010

Hirschsprung Disease Treatment & Management
Author: Justin P Wagner, MD; Chief Editor: BS Anand, MD

Source: http://emedicine.medscape.com/article/178493-treatment#showall

Approach Considerations


If Hirschsprung disease is suspected, neonates and children should be assigned to a center where pediatric specialists are available to make the diagnosis and to provide definitive care.

Consult with pediatric surgeons and pediatric gastroenterologists. Genetic consultation may be indicated (if a heritable or chromosomal anomaly is suspected).

Hirschsprung disease cannot be prevented; however, perceptive clinical acumen may prevent delays in diagnosis.

Medical Care

The general goals of medical care are 3-fold: (1) to treat the manifestations and complications of untreated Hirschsprung disease, (2) to institute temporizing measures until definitive reconstructive surgery, and (3) to manage postoperative bowel function.

The goals of medical care are to maintain normal fluid and electrolyte balance, to minimize bowel distension and prevent perforation, and to manage complications. Intravenous fluid resuscitation and maintenance, nasogastric decompression, and administration of intravenous antibiotics (as indicated) remain the cornerstones of initial medical management.

Colonic lavage, consisting of mechanical irrigation with a large-bore rectal tube and large volumes of irrigant, may be required.

Intravenous administration of balanced salt solutions may help prevent electrolyte imbalances.

Postoperative medical management


Postoperatively, routine colonic irrigation and prophylactic antibiotic therapy may decrease the risk of developing enterocolitis.[35, 36] For patients who do develop enterocolitis, nasogastric decompression, intravenous fluids, antibiotics, and colonic lavage may be necessary. Sodium cromoglycate, a mast cell stabilizer, has also been reported to benefit these patients.[37]

Botulinum toxin injections within the contracted internal sphincter mechanism have been reported to induce more normal patterns of bowel movements in postoperative patients with enterocolitis.[38]

Diet and activity

The patient should have nothing by mouth for 6-8 hours prior to operation.

Postoperatively, the patient will receive intravenous fluids and antibiotics; however, nothing may be administered by mouth until passage of flatus or stool signifies return of bowel function. If a newborn undergoes creation of a diverting colostomy, the passage of flatus or stool from the stoma is necessary prior to institution of oral feeding.


Upon resumption of bowel function, tube feeding or formula/breast milk may resume. Clear liquids are delivered by mouth, and the diet may be advanced until feeding goals are met. Feedings are usually initiated 24-48 hours after the creation of a colostomy. The patient may be discharged from the hospital upon attaining full feedings.

Diets consisting of fresh fruits, vegetables, and high-fiber articles may improve postoperative bowel function.
With regard to activity, limit physical activity for about 6 weeks to allow incisions to heal properly (applies more to older children).

Also see Pediatric Hirschsprung Disease and Hirschsprung Disease Imaging.

Surgical Care


Surgical management of Hirschsprung disease begins with the initial diagnosis, which often requires a full-thickness rectal biopsy. Traditionally, a diverting colostomy was created at the time of diagnosis, and definitive repair was delayed until the child grew to a weight of 10 kilograms.

This standard of treatment was developed in the 1950s after Swenson reported relatively high leak and stricture rates with a single-stage operation. Advancements in anesthesia administration and hemodynamic monitoring have led many surgeons to advocate a single-stage pull-through procedure without initial diversion. Contraindications to a single-stage procedure include severely dilated proximal bowel, severe enterocolitis, perforation, malnutrition, and inability to accurately determine the zone of transition between healthy and aganglionic bowel, intraoperatively.

For neonates undergoing creation of a diverting colostomy, the transition zone is identified and the colostomy is placed proximal to this area. The presence of ganglion cells at the colostomy site must be unequivocally confirmed by histological evaluation of a frozen-section biopsy. Either a loop- or end-colostomy is created at the surgeon’s discretion.

A number of definitive procedures have demonstrated excellent results when performed by experienced surgeons. The most commonly performed repairs are the Swenson, Duhamel, and Soave procedures. In any elective operation for Hirschsprung disease, a robust preoperative colon cleanse must be performed.[39] Intraoperatively, histological examination of a frozen-section biopsy must confirm the presence of ganglion cells at the proximal margin of bowel intended for anastomosis. A meta-analysis performed by Friedmacher and Puri in 2011 reported that residual aganglionosis and transition-zone tissue account for persistent bowel symptoms in one third of patients undergoing a second, corrective pull-through procedure.[40]

Also see Pediatric Hirschsprung Disease and Hirschsprung Disease Imaging.

Swenson procedure

The Swenson procedure was the original pull-through procedure used to treat Hirschsprung disease. The aganglionic segment is resected down to the sigmoid colon and rectum, and an oblique anastomosis is performed between the normal colon and the low rectum.

Duhamel procedure

The Duhamel procedure was first described in 1956 as a modification to the Swenson procedure. A retrorectal approach is used, and a significant segment of aganglionic rectum is retained.

The aganglionic bowel is resected down to the rectum, and the rectum is oversewn. The proximal bowel is then brought through the retrorectal space (between rectum and sacrum), and an end-to-side anastomosis is performed with the remaining rectum.

Soave (endorectal) procedure

The Soave procedure was introduced in the 1960s. The mucosa and submucosa of the rectum are resected, and the ganglionic bowel is pulled through the aganglionic muscular cuff of the rectum.

The original operation did not include a formal anastomosis, relying on scar tissue formation between the pull-through segment and the surrounding aganglionic bowel. The procedure has since been modified by Boley to include a primary anastomosis at the anus.

Anorectal myomectomy

For patients with extremely short-segment Hirschsprung disease, anorectal myomectomy is an alternative surgical option.

The surgeon removes a 1-cm-wide strip of extramucosal rectal wall, beginning immediately proximal to the dentate line and extending to the normal ganglionic rectum. The mucosa and submucosa are preserved and closed.

Procedures for long-segment Hirschsprung disease

Patients with total colonic involvement require modified procedures to exclude the aganglionic colon while preserving maximal absorptive epithelium. The goal of these procedures is to bypass dysfunctional bowel while maximizing the chance of postoperative nutritional function and growth.

Most procedures include a side-to-side anastomosis of healthy small bowel with a short segment of the aganglionic/absorptive colon. Either a short right colonic patch or the small bowel is anastomosed to the rectal wall, similar to a Duhamel procedure. Importantly, a short patch (< 10 cm) is maintained.

Long-segment anastomoses, such as the Martin procedure, are no longer advocated.

Laparoscopic approach

A laparoscopic approach to the surgical treatment of Hirschsprung disease was first described in 1999 by Georgeson.[41] The transition zone is first identified laparoscopically, after which the rectum is mobilized below the peritoneal reflection. A transanal mucosal dissection is performed, and the rectum and aganglionic bowel is prolapsed through the anus. The healthy proximal bowel is anastomosed to the rectal cuff. Functional outcomes of this laparoscopic approach appear to be equivalent to open techniques based on short-term results.[41, 42, 43]

Transanal pull-through procedures

Transanal pull-through procedures have been described in which no intra-abdominal dissection is performed.[21, 44] The entire procedure is performed transanally in a manner similar to perineal rectosigmoidectomy.

The mucosa is incised circumferentially above the dentate line, and a submucosal dissection is directed proximally. The muscularis is incised circumferentially, and the remainder of the dissection is carried external to the rectal wall until the transition zone is identified. Upon confirmation of ganglion cells on frozen section, the aganglionic bowel is resected and an anastomosis is performed.

Outcomes of the transanal pull-through procedure have been similar to open single-stage approaches, and analgesia requirements and hospital stays are decreased.[21, 45, 46] Recent studies also report lower rates of postoperative incontinence and shorter operating times in transanal pull-through procedures.[47, 48]

Novel strategies

Several other creative approaches have been described, including a modification of the transanal approach with transabdominal open or laparoscopic assistance, single-incision laparoscopic endorectal pull-through (SILEP), and natural orifice transluminal endoscopic surgery (NOTES).[49, 50, 51, 52]

Regenerative strategies are under investigation to restore function in aganglionic intestine. Stem cell transplantation to regenerate the enteric nervous system is the subject of many recent experimental series.[53] Stem cells derived from the neural crest persist into adulthood, and several are capable of proliferation and differentiation within the intestine. Hotta and colleagues recently reported successful generation of functional enteric neurons from precursor cells transplanted into recipient colon.[54] Though auspicious, these discoveries warrant further study to translate cell-based therapies into clinical practice.

Outpatient Monitoring


After a definitive pull-through procedure is performed, the patient should achieve normal growth and development.

Patients should be monitored for their bowel habit. Patients with no other underlying disorders and no postoperative complications often develop improved bowel function; however, normal bowel habit may take years to develop.

After definitive surgical repair, patients may experience persistent abnormal gastrointestinal motility. Postoperative hypomotility is relatively common, and many patients require a prolonged course of laxative treatment. Patients who retain stool despite laxative therapy may require enemas.[55]


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MD Anderson Cancer Center at Cooper - Debby: Breast Cancer and Pregnant

Her breast cancer “Dream Team” gave Debby a chance to live out her own dreams of motherhood. Debby was seven months pregnant when she discovered a lump in her breast. Within just a few days, Debby had appointments with the breast cancer experts at MD Anderson Cooper. Debby started aggressive chemotherapy treatments soon after the birth of her daughter and went on to have radiation treatment and surgery. Today Debby is cancer-free and enjoying her life and motherhood thanks to the hope, support and advanced cancer treatments she received at MD Anderson Cooper.

Source: http://www.cooperhealth.org/view_video/78296

Tales of Triumph

South Jersey Magazine

Source: http://www.southjerseymagazine.com/articles/?articleid=1638

Debby Madiraca
One week before her baby shower, Westmont’s Debby Madiraca felt a lump on her breast. She didn’t immediately become concerned, chalking it up to her changing body, but mentioned it at her next weekly OB appointment. She went for an ultrasound to have it checked, and when the doctor was called in to review it, she knew something wasn’t right.

“They told me to call my doctor immediately,” says Madiraca. “I asked her, ‘Is it bad?’ and she said, ‘It isn’t good.’” Her OB set up appointments with physicians from the MD Anderson Cancer Center at Cooper, including Dr. Kristin Brill, director of its breast program, and Dr. Generosa Grana, head of hematology and oncology and director of the MD Anderson Cancer Center at Cooper.

After Madiraca’s biopsy results were in, Brill confirmed the cancer in her breast. “When she told me, I started crying, but the nurse, Helen Nichter stayed in the room with me and told me she was a survivor. Seeing her standing there—alive—that was a game changer for me,” Madiraca says. “From that moment on, I only wanted to hear and read stories of hope and inspiration. They helped keep me going.”

She met with Grana to discuss treatment, but there was the matter of the baby to consider. Dr. Elyce Cardonick, who specializes in treating cancer in pregnant women, helped decide which options would be safest for mother and baby. “They felt I was far enough along in the pregnancy for Amelia to be delivered safely so I could start chemo right away,” says Madiraca. Amelia was born July 30, 2013.

With the baby out, Madiraca was able to have a PET-CT (PET scan) to get a better idea of what was going on. This testing revealed the cancer had spread to Madiraca’s liver, which meant she was now diagnosed as Stage IV.

Because of the limits on scans during pregnancy, Grana says they could not have known until after the baby was born that it had spread. The abnormality in the liver meant considering a new treatment plan. “If the cancer is limited to the breast and underarm we’re able to cure many of those … but if it spreads elsewhere, the bones, lungs, the liver, however, is not so common, the cure rates are less. It changes the playing field.”

There was a bit of good news, though. Special genetic testing revealed that Madiraca’s cancer was estrogen receptor positive (HER2). “If there is a good type of cancer, this is it,” says Grana. They were able to target the cancer with new drugs that have proven effective in those with the HER2-positive cancer.

Madiraca spent her maternity leave going to chemotherapy treatments, the first round lasting six months. “Having Amelia made me fight harder because it wasn’t about me, it was about her growing up with a mom,” she says.

After the first round, Madiraca had a lumpectomy to remove tissue where the tumor was. Soon after, she received news that her pathology test was clear—there were no signs of cancer.

“With chemotherapy your goal is a complete response and eventual complete disappearance,” says Grana. “When the disease is in the liver, you may only achieve complete disappearance in 20 to 30 percent, and for those who do achieve it, it’s not always permanent, but each scan gives us hope.”

Madiraca’s scans have been clear for nearly two years. She still receives drug treatment every three weeks, but she says it’s not a drag to be there because the whole team at the MD Anderson Cancer Center has become part of her family. “I’m not cured, I know it’s not guaranteed, but I know cancer won’t kill me,” Madiraca says, “… it’ll probably be the day my daughter starts driving.”

S.J. doctors: Gains made in breast cancer battle

Source: http://www.courierpostonline.com/story/life/wellness/2014/10/05/sj-doctors-gains-made-breast-cancer-battle/16676741/?from=global&sessionKey=&autologin=

October 5, 2014


Debby Madiraca of Haddon Township was diagnosed with metastatic breast cancer when she was 8 months pregnant with her daughter Amelia. She was a candidate for new medications which target the estrogen receptors that fed her kind of cancer tumors. Though she will be on expensive medication for the rest of her life, she is cancer free and she's not looking back. Thursday, October 2, 2014.(Photo: JOHN ZIOMEK/Courier-Post)

Eight months into her pregnancy, Debby Madiraca of Westmont figured the new lump in her breast was normal.

She mentioned it anyway at her next obstetrics appointment. Within days, Madiraca learned she had late-stage breast cancer that had already spread to her liver.

Her baby would need to arrive early, so the first-time mother could begin treatment.

Genetic testing showed her particular kind of tumors made her a candidate for a new regimen of chemotherapy drugs that included Perjeta, Herceptin and docetaxel.

After just three rounds, a second scan showed the estrogen-fed cancer was completely gone.

"I didn't know it was such a miraculous thing to happen like that," said Madiraca, who recently celebrated her 36th birthday.

"I'm learning now that everyone's not that fortunate."

Breast cancer detection and treatment are improving rapidly, South Jersey doctors say, catching tumors earlier and offering hope to patients with later-stage cancer who once had little chance of survival.

"Although early-stage breast cancers are where your successes are, because it's often highly curable, there's a lot of excitement in (the treatment of) advanced breast cancer," said Dr. Generosa Grana, director of the MD Anderson Center at Cooper and Madiraca's specialist.

"It's not the doom and gloom that it used to be."

Except for skin cancer, breast cancer is the most common among American women. About one in eight will develop invasive breast cancer during her lifetime, according to the American Cancer Society, and 40,000 people are expected to die this year from the disease.

Even so, a woman's chances of dying from breast cancer are just 3 percent.

Survival rates have improved by 50 percent in the past decade, said Dr. Arnold Baskies, chief science officer for the American Cancer Society and a medical director at Virtua. Rates are expected to improve another 34 percent in the next five years.

"We know that already," Baskies said. "The genetic code has been broken. We're able to identify women at high risk, and we're able to give targeted therapies to people based on the genetics of their individual breast cancer.

"That's made a huge difference."

Debby Madiraca (top and above) of the Westmont section of Haddon Township was diagnosed with metastatic breast cancer when she was 8 months pregnant with her daughter, Amelia. Today she is cancer free, thanks to new medications that targeted the estrogen receptors which fed her tumors. (Photo: Photos by John Ziomek/Courier-Post )

Madiraca is among the patients benefiting from Perjeta, a new chemotherapy drug produced by the Swiss pharmaceutical company Roche. Patients with aggressive HER2-positive breast cancer survived a median five years when given the new medication in combination with two others, Roche reported.

Grana has seen several patients with metastatic disease beat even those improved odds, still living seven years after their initial diagnosis without signs of cancer.

"How long will that remission last?" she mused. "We don't know.

"For many of these women, it may be permanent."

Jacqueline Timmons hopes to be among them. A year ago, the Bridgeton native noticed her right breast felt suddenly heavy and swollen. Between biopsies and her diagnosis, a golf ball-size lump quickly grew under her arm.

"I was praying, 'Lord, if this is what it is, this is nothing you and I can't get through together,' " recalled Timmons, who lives at the Joint Base McGuire-Dix-Lakehurst Air Force with her husband and two children, 12 and 17.

Tests revealed she had stage 3 breast cancer, the kind fed by estrogen. She had just celebrated her 41st birthday.

In the past year, Timmons has endured a regimen that included Perjeta, 28 rounds of radiation and a double mastectomy with newly constructed breasts made from her own belly tissue.

Though her body is stiff and sore, her nails and hair are growing back.

"Today, I feel really good," Timmons insisted. "I feel like every day is getting better."

Debby Madiraca of Haddon Township was diagnosed with metastatic breast cancer when she was 8 months pregnant with her daughter, Amelia. She was a candidate for new medications that have helped keep her cancer-free. (Photo: JOHN ZIOMEK/Courier-Post )

Fourteen months since giving birth to her daughter, Madiraca doesn't dwell on the tumor that once lived in her liver. To keep it at bay, she'll be on a regimen of cancer drugs for the rest of her life.

She lugs her laptop to her infusion appointments every three weeks, working through the three hours it takes to receive her medicine.

Though she misses her long hair, Madiraca counts herself blessed to be in remission.

"I don't have time for cancer," she noted. "I have too much going on.

"I think it picked the wrong person to mess with."

Reach Kim Mulford at (856) 486-2448 or kmulford@courierpostonline.com. Follow her on Twitter @CP_KimMulford

Debby's Blog "Boot Camp & Buttercream" - started June 2016

How America Went Gay By Charles W. Socarides, M.D.

Source: http://www.theroadtoemmaus.org/RdLb/22SxSo/PnSx/HSx/SocrdsHowAmerGay.htm
America - November 18, 1995

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Charles W. Socarides, M.D., is clinical professor of psychiatry at Albert Einstein College of Medicine/Montefiore Medical Center in New York. He is president of the National Association for Research and Therapy of Homosexuality, and author of Homosexuality: A Freedom Too Far (Adam Margrave Books, Phoenix, Arizona).

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For more than 20 years, I and a few of my colleagues in the field of psychoanalysis have felt like an embattled minority, because we have continued to insist, against today's conventional wisdom, that gays aren't born that way. We know that obligatory homosexuals are caught up in unconscious adaptations to early childhood abuse and neglect and that, with insight into their earliest beginnings, they can change. This "adaptation" I speak of is a polite term for men going through the motions of mating not with the opposite sex but with one another.

For most of this century, most of us in the helping professions considered this behavior aberrant. Not only was it "off the track"; the people caught up in it were suffering, which is why we called it a pathology. We had patients, early in their therapy, who would seek out one sex partner after another-total strangers-on a single night, then come limping into our offices the next day to tell us how they were hurting themselves. Since we were in the business of helping people learn how not to keep hurting themselves, many of us thought we were quietly doing God's work.

Now, in the opinion of those who make up the so-called cultural elite, our view is "out of date." The elite say we hurt people more than we help them, and that we belong in one of the century's dustbins. They have managed to sell this idea to a great many Americans, thereby making homosexuality fashionable and raising formerly aberrant behavior to the status of an "alternate lifestyle."

You see this view expressed in some places you would least expect. The Pope says same-sex sex is wrong, but a good many of his own priests in this country (some of whom are gay themselves) say the Pope is wrong. Indeed, in much of academe and in many secondary school classrooms gays are said to lead a new vanguard, the wave of the future in a world that will be more demographically secure when it has fewer "breeders" (which is what some gay activists call heterosexuals these days).

How did this change come about? Well, the revolution did not just happen. It has been orchestrated by a small band of very bright men and women-most of them gays and lesbians-in a cultural campaign that has been going on since a few intellectuals laid down the ideological underpinnings for the entire tie-dyed, try-anything-sexual Woodstock generation. In various ways, Theodore Reich, Alfred Kinsey, Fritz Perls, Norman O. Brown, Herbert Marcuse and Paul Goodman preached a new countercultural gospel: "If it feels good, do it."

It was all part of a plan, as one gay publication put it, "to make the whole world gay." I am not making this up. You can read an account of the campaign in Dennis Altman's The Homosexualization of America. In 1982 Altman, himself gay, reported with an air of elation that more and more Americans were thinking like gays and acting like gays. There were engaged, that is, "in numbers of short-lived sexual adventures either in place of or alongside long-term relationships." Altman cited the heterosexual equivalents of gay saunas and the emergence of the swinging singles scene as proofs that "promiscuity and 'impersonal sex' are determined more by social possibilities than by inherent differences between homosexuals and heterosexuals, or even between men and women."

Heady stuff. Gays said they could "reinvent human nature, reinvent themselves." To do this, these reinventors had to clear away one major obstacle. No, they didn't go after the nation's clergy. They targeted the members of a worldly priesthood, the psychiatric community, and neutralized them with a radical redefinition of homosexuality itself. In 1972 and 1973 they co-opted the leadership of the American Psychiatric Association and, through a series of political maneuvers, lies and outright flim-flams, they "cured" homosexuality overnight-by fiat. They got the A.P.A. to say that same-sex sex was "not a disorder." It was merely "a condition"-as neutral as lefthandedness.

This amounted to a full approval of homosexuality. Those of us who did not go along with the political redefinition were soon silenced at our own professional meetings. Our lectures were canceled inside academe and our research papers turned down in the learned journals. Worse things followed in the culture at large. Television and movie producers began to do stories promoting homosexuality as a legitimate lifestyle. A gay review board told Hollywood how it should deal or not deal with homosexuality. Mainstream publishers turned down books that objected to the gay revolution. Gays and lesbians influenced sex education in our nation's schools, and gay and lesbian libbers seized wide control of faculty committees in our nations' colleges. State legislatures nullified laws against sodomy.

If the print media paid any attention at all, they tended to hail the gay revolution, possibly because many of the reporters on gay issues were themselves gay and open advocates for the movement. And those reporters who were not gay seemed too intimidated by groupthink to expose what was going on in their own newsrooms.

And now, what happens to those of us who stand up and object? Gay activists have already anticipated that. They have created a kind of conventional wisdom: that we suffer from homophobia, a disease that has actually been invented by gays projecting their own fear on society. And we are bigots besides, because, they say, we fail to deal with gays compassionately. Gays are now no different than people born black or Hispanic or physically challenged. Since gays are born that way and have no choice about their sexual orientation, anyone who calls same-sex sex an aberration is now a bigot. Un-American, too. Astoundingly now, college freshmen come home for their first Thanksgiving to announce, "Hey, Mom! Hey, Dad! We've taken the high moral ground. We've joined the gay revolution."

My wife, Clare, who has an unerring aptitude for getting to the heart of things, said one day recently in passing, "I think everybody's being brainwashed." That gave me a start. I know "brainwashing" is a term that has been used and overused. But my wife's casual observation only reminded me of a brilliant tract I had read several years ago and then forgotten. It was called After the Ball: How America Will Conquer its Fear and Hatred of Gays in the 1990's, by Marshall Kirk and Hunter Madsen.

That book turned out to be the blueprint gay activists would use in their campaign to normalize the abnormal through a variety of brainwashing techniques once catalogued by Robert Jay Lifton in his seminal work, Thought Reform and the Psychology of Totalism: A Study of Brainwashing in China.

In their book Kirk and Madsen urged that gay activists adopt the very strategies that helped change the political face of the largest nation on earth. The authors knew the techniques had worked in China. All they needed was enough media-and enough money-to put them to work in the United States. And they did. These activists got the media and the money to radicalize America-by processes known as desensitization, jamming and conversion.

They would desensitize the public by selling the notion that gays were "just like everyone else." This would make the engine of prejudice run out of steam, i.e., lull straights into an attitude of indifference.

They would jam the public by shaming them into a kind of guilt at their own "bigotry." Kirk and Madsen wrote:

All normal persons feel shame when they perceive that they are not thinking, feeling, or acting like one of the pack....The trick is to get the bigot into the position of feeling a conflicting twinge of shame...when his homohatred surfaces. Thus, propagandistic advertisement can depict homophobic and homohating bigots as crude loudmouths....It can show them being criticized, hated, shunned. It can depict gays experiencing horrific suffering as the direct result of homohatred-suffering of which even most bigots would be ashamed to be the cause.

The best thing about this technique, according to Kirk and Madsen: The bigot did not even have to believe he was a loathsome creature:

Rather, our effect is achieved without reference to facts, logic, or proof. Just as the bigot became such, without any say in the matter, through repeated infralogical emotional conditioning, his bigotry can be alloyed in exactly the same way, whether he is conscious of the attack or not. In short, jamming succeeds insofar as it inserts even a slight frisson of doubt and shame into the previously unalloyed, self-righteous pleasure. The approach can be quite useful and effective-if our message can get the massive exposure upon which all else depends.

Finally-this was the process they called conversion-Kirk and Madsen predicted a mass public change of heart would follow, even among bigots, "if we can actually make them like us." They wrote, "Conversion aims at just this...conversion of the average American's emotions, mind, and will, through a planned psychological attack, in the form of propaganda fed to the nation via the media."

In the movie "Philadelphia" we see the shaming technique and the conversion process working at the highest media level. We saw Tom Hank's character suffering (because he was gay and had AIDS) at the hands of bigots in his Philadelphia law firm. Not only were we ashamed of the homophobic behavior of the villainous straight lawyers in the firm; we felt nothing but sympathy for the suffering Hanks. (Members of the Motion Picture Academy felt so much sympathy they gave Hanks an Oscar.) Our feelings helped fulfill Kirk and Madsen's strategy: "to make Americans hold us in warm regard, whether they like it or not."

Few dared speak out against "Philadelphia" as an example of the kind of propaganda Kirk and Madsen had called for. By then, four years after the publication of the Kirk-Madsen blueprint, the American public had already been programmed. Homosexuality was now simply "an alternate lifestyle." Best of all, because of the persuaders embedded in thousands of media messages, society's acceptance of homosexuality seemed one of those spontaneous, historic turnings in time-yes, a kind of conversion. Nobody quite knew how it happened, but the nation had changed. We had become more sophisticated, more loving toward all, even toward those "afflicted" with the malady-excuse me, condition.

By 1992 the President of the United States said it was time that people who were openly gay and lesbian should not be ousted from the nation's armed forces. In 1993 the nation's media celebrated a huge outpouring of gay pride in Washington, D.C. Television viewers chanted along with half a million marchers, "Two, four, six, eight! Being gay is really great." We felt good about ourselves. We were patriotic Americans. We had abolished one more form of discrimination, wiped out one of society's most enduring afflictions: homophobia. Best of all, we knew now that gay was good, gay was free.

Excuse me. Gay is not good. Gay is not decidedly free. How do I know this? For more than 40 years, I have been in solidarity with hundreds of homosexuals, my patients, and I have spent most of my professional life engaged in exercising a kind of "pastoral care" on their behalf. But I do not help them by telling them they are O.K. when they are not O.K. Nor do I endorse their "new claim to self-definition and self-respect." Tell me: Have we dumped the idea that a man's self-esteem comes from something inside himself (sometimes called character) and from having a good education, a good job and a good family-and replaced that notion with this, that he has an affinity to love (and have sex with) other men?

In point of fact, many of my patients had character; they had an education; they were respected ad men and actuaries and actors. But they were still in pain-for one reason and one reason alone. They were caught up in this mysterious compulsion to have sex with other men. They were not free. They were not happy. And they wanted to see if they could change.

Over the years, I found that those of my patients who really wanted to change could do so, by attaining the insight that comes with a good psychoanalysis. Others found other therapies that helped them get to the bottom of their compulsions, all of which involved high motivation and hard work. Difficult as their therapeutic trips were, hundreds and thousands of homosexuals changed their ways. Many of my own formerly homosexual patients-about a third of them-are married today and happily so, with children. One-third may not sound like a very good average. But it is just about the same success rate you will find at the best treatment centers for alcoholics, like Hazelden in Minnesota and the Betty Ford Clinic in California.

Another third of my patients remain homosexual but not part of the gay scene. Now, after therapy, they still have same-sex sex, but they have more control over their impulses because now they understand the roots of their need for same-sex sex. Some of these are even beginning to turn on to the opposite sex. I add this third to my own success rate-so that I can tell people in all honesty that my batting average is .667 out of more than a thousand "at bats."

Of course, I could bat .997 if I told all my patients in pain that their homosexuality was "a special call" and "a liberation." That would endear me to everyone, but it would not help them. It would be a lie-despite recent pieces of pseudo-science bolstering the fantasy that gays are "born that way." The media put its immediate blessing on this "research," but we were oversold. Now we are getting reports, even in such gay publications as The Journal of Homosexuality, that the gay-gene studies and the gay-brain studies do not stand up to critical analysis. (The author of one so-called "gay-gene theory" is under investigation by the National Institutes of Health for scientific fraud.)

I was not surprised to hear this. My long clinical experience and a sizable body of psychoanalysis research dating all the way back to Freud tell me that most men caught up in same-sex sex are reacting, at an unconscious level, to something amiss with their earliest upbringing- overcontrolling mothers and abdicating fathers. Through long observation I have also learned that the supposedly liberated homosexual is never really free. In his multiple, same-sex adventures, even the most effeminate gay was looking to incorporate the manhood of others, because he was in a compulsive, never-ending search for the masculinity that was never allowed to build and grow in early childhood.

When I tried to explain these dynamics to the writer who helped me put together a kind of popular catechism on homosexuality, I found he had a hard time understanding what this "incorporation" meant. He said, "Your patient would be more manly if he took in the penis of another man? Sounds a little dumb. Would I run faster if I ate the flesh of a deer?"

I told him, "You have to understand that we are talking about feelings that come from deep in the unconscious mind. They are very primitive. In fact, if you have ever read any Indian lore, you may remember that Indians would, in fact, eat the flesh of a deer in order to become faster afoot. To us, that is a very primitive idea. But it had a mythic significance for a young Iroquois brave. And Madison Avenue still makes use of such mythic meanings. The ad people sell us things based on the notion that we will become what we eat or drink or possess." The point I was making was this: We do not understand same-sex sex until we realize that the dynamics involved are unconscious.

This is one reason why psychoanalysis is the tool that gets us to the heart of everything. Once my patients have achieved an insight into these dynamics-and realized there is no moral fault involved in their longtime and mysterious need-they have moved rather quickly on the road to recovery. Their consequent gratitude to me is overwhelming. And why shouldn't it be? They were formerly caught up in compulsions they could not understand, compulsions they could not control. Now they are in charge of their own lives.

Their former promiscuity may have looked a lot like "liberation." But it was not true freedom. It was a kind of slavery. And it was not a lifestyle. With the onset of AIDS, as the playwright and gay militant Larry Kramer said in a 1993 interview, it turned out to be a death style. I have had some patients tell me, "Doctor, if I weren't in therapy, I'd be dead."

Testimonials from my recovered patients make me feel my work is worthwhile-despite regular demands from the gay rights community for my silence. What would they have me do? Pack my bags, find a new profession, lock up a lifetime of research and analysis, hide my truth under a bushel? It is not my psychoanalytic duty to tell people they are marvelous when they are out of control, much less ask disingenuous rhetorical questions like, "What kind of God would afflict people with an 'objective disorder' in the disposition of their hearts?"

Giving God the credit for their gayness is a persistent refrain in much gay literature today, and I am saddened to see people of evident good will become unwitting parties to the blasphemy. Gays ascribe their condition to God, but he should not have to take that rap, any more than he should be blamed for the existence of other man-made maladies-like war, for instance, which has proven to be very unhealthy for humans and for all other living things. God does not make war. Men do.

And, when homosexuality takes on all the aspects of a political movement, it, too, becomes a war, the kind of war in which the first casualty is truth, and the spoils turn out to be our own children. An exaggeration? Well, what are we to think when militant homosexuals seek to lower the age of consensual sexual intercourse between homosexual men and young boys to the age of 14 (as they did in Hawaii in 1993) or 16 (as they tried to do in England in 1994)? In the Washington March for Gay Pride in 1993, they chanted, "We're here. We're queer. And we're coming after your children."

What more do we need to know?

[This article first appeared in America (November 18, 1995). Used by permission of the author.]

Transgender Surgery Isn't the Solution: A drastic physical change doesn't address underlying psycho-social troubles By Paul McHugh

Source: http://www.wsj.com/articles/paul-mchugh-transgender-surgery-isnt-the-solution-1402615120
June 12, 2015
Wall Street Journal

The government and media alliance advancing the transgender cause has gone into overdrive in recent weeks. On May 30, a U.S. Department of Health and Human Services review board ruled that Medicare can pay for the "reassignment" surgery sought by the transgendered—those who say that they don't identify with their biological sex. Earlier last month Defense Secretary Chuck Hagel said that he was "open" to lifting a ban on transgender individuals serving in the military. Time magazine, seeing the trend, ran a cover story for its June 9 issue called "The Transgender Tipping Point: America's next civil rights frontier."

Yet policy makers and the media are doing no favors either to the public or the transgendered by treating their confusions as a right in need of defending rather than as a mental disorder that deserves understanding, treatment and prevention. This intensely felt sense of being transgendered constitutes a mental disorder in two respects. The first is that the idea of sex misalignment is simply mistaken—it does not correspond with physical reality. The second is that it can lead to grim psychological outcomes.

The transgendered suffer a disorder of "assumption" like those in other disorders familiar to psychiatrists. With the transgendered, the disordered assumption is that the individual differs from what seems given in nature—namely one's maleness or femaleness. Other kinds of disordered assumptions are held by those who suffer from anorexia and bulimia nervosa, where the assumption that departs from physical reality is the belief by the dangerously thin that they are overweight.

With body dysmorphic disorder, an often socially crippling condition, the individual is consumed by the assumption "I'm ugly." These disorders occur in subjects who have come to believe that some of their psycho-social conflicts or problems will be resolved if they can change the way that they appear to others. Such ideas work like ruling passions in their subjects' minds and tend to be accompanied by a solipsistic argument.

For the transgendered, this argument holds that one's feeling of "gender" is a conscious, subjective sense that, being in one's mind, cannot be questioned by others. The individual often seeks not just society's tolerance of this "personal truth" but affirmation of it. Here rests the support for "transgender equality," the demands for government payment for medical and surgical treatments, and for access to all sex-based public roles and privileges.

With this argument, advocates for the transgendered have persuaded several states—including California, New Jersey and Massachusetts—to pass laws barring psychiatrists, even with parental permission, from striving to restore natural gender feelings to a transgender minor. That government can intrude into parents' rights to seek help in guiding their children indicates how powerful these advocates have become.

How to respond? Psychiatrists obviously must challenge the solipsistic concept that what is in the mind cannot be questioned. Disorders of consciousness, after all, represent psychiatry's domain; declaring them off-limits would eliminate the field. Many will recall how, in the 1990s, an accusation of parental sex abuse of children was deemed unquestionable by the solipsists of the "recovered memory" craze.

You won't hear it from those championing transgender equality, but controlled and follow-up studies reveal fundamental problems with this movement. When children who reported transgender feelings were tracked without medical or surgical treatment at both Vanderbilt University and London's Portman Clinic, 70%-80% of them spontaneously lost those feelings. Some 25% did have persisting feelings; what differentiates those individuals remains to be discerned.

We at Johns Hopkins University—which in the 1960s was the first American medical center to venture into "sex-reassignment surgery"—launched a study in the 1970s comparing the outcomes of transgendered people who had the surgery with the outcomes of those who did not. Most of the surgically treated patients described themselves as "satisfied" by the results, but their subsequent psycho-social adjustments were no better than those who didn't have the surgery. And so at Hopkins we stopped doing sex-reassignment surgery, since producing a "satisfied" but still troubled patient seemed an inadequate reason for surgically amputating normal organs.

It now appears that our long-ago decision was a wise one. A 2011 study at the Karolinska Institute in Sweden produced the most illuminating results yet regarding the transgendered, evidence that should give advocates pause. The long-term study—up to 30 years—followed 324 people who had sex-reassignment surgery. The study revealed that beginning about 10 years after having the surgery, the transgendered began to experience increasing mental difficulties. Most shockingly, their suicide mortality rose almost 20-fold above the comparable nontransgender population. This disturbing result has as yet no explanation but probably reflects the growing sense of isolation reported by the aging transgendered after surgery. The high suicide rate certainly challenges the surgery prescription.

There are subgroups of the transgendered, and for none does "reassignment" seem apt. One group includes male prisoners like Pvt. Bradley Manning, the convicted national-security leaker who now wishes to be called Chelsea. Facing long sentences and the rigors of a men's prison, they have an obvious motive for wanting to change their sex and hence their prison. Given that they committed their crimes as males, they should be punished as such; after serving their time, they will be free to reconsider their gender.

Another subgroup consists of young men and women susceptible to suggestion from "everything is normal" sex education, amplified by Internet chat groups. These are the transgender subjects most like anorexia nervosa patients: They become persuaded that seeking a drastic physical change will banish their psycho-social problems. "Diversity" counselors in their schools, rather like cult leaders, may encourage these young people to distance themselves from their families and offer advice on rebutting arguments against having transgender surgery. Treatments here must begin with removing the young person from the suggestive environment and offering a counter-message in family therapy.

Then there is the subgroup of very young, often prepubescent children who notice distinct sex roles in the culture and, exploring how they fit in, begin imitating the opposite sex. Misguided doctors at medical centers including Boston's Children's Hospital have begun trying to treat this behavior by administering puberty-delaying hormones to render later sex-change surgeries less onerous—even though the drugs stunt the children's growth and risk causing sterility. Given that close to 80% of such children would abandon their confusion and grow naturally into adult life if untreated, these medical interventions come close to child abuse. A better way to help these children: with devoted parenting.

At the heart of the problem is confusion over the nature of the transgendered. "Sex change" is biologically impossible. People who undergo sex-reassignment surgery do not change from men to women or vice versa. Rather, they become feminized men or masculinized women. Claiming that this is civil-rights matter and encouraging surgical intervention is in reality to collaborate with and promote a mental disorder.

Dr. McHugh, former psychiatrist in chief at Johns Hopkins Hospital, is the author of "Try to Remember: Psychiatry's Clash Over Meaning, Memory, and Mind" (Dana Press, 2008).

Obituary - Ellis

Tina Aileen Ellis

Profile Views: 363
Birthday: November 08, 1946
Death: May 16, 2014
Place of Rest: Shalom Memorial Cemetery in David

Life Story

Tina A. Ellis, 67, died Friday, May 16th, 2014 at her Home in Northeast Philadelphia. She was born November 8, 1946 in Philadelphia, the daughter of Mildred and Louis Fagan. Tina Aileen Ellis is survived by her husband, Zeke; a daughter, Lindsay of Fox Chase ; a step-daughter Dawn Cassidy of Florida; a son, Lewis of Pennsauken, NJ; a step-son Frank of Medford, NJ; one sister Nanette Berman of Texas; four step grandchildren; a great step-grandchild; and a few nieces and nephews and pre-deceased by her little daughter Jaime Rachel. A graveside funeral service was held Sunday May 18th 2014 at the Shalom Memorial Park in Hundingdon Valley. 

Source: http://www.valleyoflife.com/TinaEllis/

9/5/1993 Tina Ellis at Caesars in Atlantic City to see Barry Manilow.

What to Eat with IBS By Amber

Source: http://www.eatsandexercisebyamber.com/home/what-to-eat-with-ibs
April 26, 2015

Having Irritable Bowel Syndrome means that every single thing I eat has a direct effect on my intestines and whether or not I will have symptoms.  Since IBS is extremely individualized and symptoms and severity can vary from person to person, finding what works best for YOU and YOUR body is literally a lengthy process of trial and error.  I'm still learning what works for my body. 
There are medication options, as well as natural remedy options, but for some people, like myself, one or a combination of both of those treatments are not enough.

For me, and many others, altering what I eat, has made a huge difference in managing my IBS. For a while, I feared food because I felt that no matter what I ate, my intestines would become irate, and they did. My flareups lasted weeks, and I almost was always experiencing symptoms for a period of time. I couldn't pinpoint a cause to all my suffering, because there were too many variables (foods) causing it.  

The question of "What to Eat with IBS" has taken me over a year to find an answer for and is one I'm still working on. Beginning the process of finding what foods work for you requires effort and hard work, BUT, it is worth it. I always say, "Our Health is Our Greatest Wealth"

To get started with your "What to Eat with IBS" Journey, use a Symptom Diary
This will help you document what you eat and how much you eat, as well as symptoms and bowel habits.  It isn't only the food itself, but the amount of food that can cause symptoms in those with IBS.

Now, before we get started, I need to make one thing clear:
I HATE the word diet. It tends to have such a negative connotation associated with it, and is seen as something done for the "short term" so for the purpose of this post, I am going to call the options for "What to Eat with IBS" Eating Plans.  

Getting Started:
1. As ALWAYS - Talk to your doctor, before trying ANYTHING.  
In this case, he or she may be able to assist you (if trying something like Low Fodmap) or they may suggest you see a nutritionist
2. Download a Symptom Diary 
3. Seek support - this is NOT easy, having people who are going to be able to support you, whether it be family, friends, or an online community, will make the process easier

Tips for the Process:

• Do NOT go crazy measuring food amounts, rough estimates are fine. For example, no need to record 1/2 cup of quinoa, but make note of how much you filled that bowl and use that same bowl  through out your trial and error process.  Eat ten carrots and get cramps write it down. Then, next time, try only five carrots. 
• Do NOT eliminate/test out multiple foods at a time. Finding what triggers your symptoms is a literal science, if you suspect something is causing you symptoms, you must eliminate it or test these foods out, one at a time, take notes of your symptoms, and then re introduce them one a a time.
• Do NOT expect people to understand. This was my issue and became the root of a lot of heartache for me while trying to figuring out what foods worked best for my body. I got called "difficult", a "picky eater" and even worse, accused of being anorexic and having an eating disorder when I tried to explain why I would not eat certain foods anymore, even IF they were gluten free and lactose free.  
• Educate yourself and others AS MUCH as possible. In order to gain support from loved ones, I began sending them articles about food and its effect on those with IBS. In specific, the certain types of Eating Plans I chose to follow
• Even IF you find a food causes you to experience symptoms, it is still YOUR choice to eat it or not. Although I know eating french fries or something with milk in it can cause me to become sick, sometimes I think it is "worth" the suffering for the enjoyment.  It's YOUR body, YOUR rules!

IBS Eating Plans
Based on YOUR IBS and symptoms, one or a combination of Eating Plans may be necessary. When combining Eating Plans, certain foods may be "OK" on one plan, but not on another, so listen to your body and decide whether the food is is safe for you or not. I put an asterisk* next to the Eating Plans that I currently follow. 
I avoided listing foods, or providing too many specifics because I want YOU to do your own research and consult your doctor when attempting this process, this is all based on MY experience and research.

• Anti-Gas*

       Avoiding or limiting foods that produce gas - see photo below Read More for a list
       Some Low Gas Foods are High FODMAP - beware!

• Avoiding IBS Irritants*

       Not all "irritants" will irritate those with IBS - see what you can and cannot have
       - Alcohol (I don't drink for this reason, I am a very atypical 20something year old)
       - Caffeine (I can personally have caffeine once a day)
       - Chocolate (I can eat dark chocolate, no problem)
       - Coffee (I can have one cup a day, it actually stimulates my intestines in the morning)
       - Fatty Foods (I cannot eat high fat content food)

• High Fiber

       This can be beneficial for those with IBS D. Those with IBS C should ONLY attempt a high fiber 
       plan IF a doctor suggests it, I was on one for a period of time, and it made my symptoms worse.

• Lactose-Free*

       Whether you are diagnosed as Lactose Intolerant or not, milk products cause a variety of intestinal 
       distress for those with IBS because lactose is: gas producing and also a HIGH FODMAP!
       IF you can ingest lactose no problem - keep at it! No need to eliminate something that doesn't 
       cause you issues!
       Many, including myself, who cannot have lactose CAN have greek yogurt with no issues

• Low Fat*

       Through my own personal trial and error, I have found that eating foods high in fat content, 
       whether it be healthy or unhealthy, (avocado, anything fried, guacamole, nuts, nut butters, etc.)
       causes me to bloat and become constipated. This does NOT mean I never eat cookies, cupcakes, 
       or things that are fried.  I STILL eat fat, I just space it out through out the day, or take the  
       consequences of eating an entire basket of french fries, because sometimes eating for enjoyment 
       is worth it.

• Low Fiber*

       I avoid eating foods that are high in fiber. Instead, I space my fiber intake out through out the 
       day.  Bars, breads, and other grain products that have high fiber content for a single serving are 
       NOT my friend (I'm looking at you Quest Bars!).

• Low FODMAP*

       FODMAPS are carbohydrates (sugars) found in foods but not all carbohydrates are FODMAPS.
       There are five groups: Fructose, Lactose, Fructans, Galactans, and Polylols.
       FODMAPS are osmotic, meaning they draw water into the intestinal tract, and can easily ferment 
       with bacteria causing symptoms with those that have IBS.
       A Low FODMAP plan is VERY individualized since not ALL the foods listed in each group need to be 
       avoided, and some can be allowed in certain amounts, it just depends on YOUR body.
       For example, asparagus is a moderate FODMAP. I can have a few spears with no problem, if I eat 
       ten, I get extreme cramps for the evening. Therefore, I limit my intake, and it is not a food item 
       I eat every single day.

Simply put, WHAT I eat and HOW MUCH I eat of it will forever be a factor for me in managing my IBS, as well as the case for so many others.  Sometimes, it's a mathematical equation that can be exhausting, especially when it's a food that has nutritional benefits, such as watermelon.  Except, what's supposed to be "healthy for everyone" may not be healthy for you if it causes you symptoms!

Following an IBS Eating Plan is not easy, it requires advocacy for yourself, and often explaining to others why you are avoiding certain foods BUT it IS worth it.  While the list of foods I cannot eat may be longer than the ones that I actually can eat, I am happy and I am healthy, and I am no longer afraid of food.

Closing Tips

• IBS Eating Plans CAN change.  Once your IBS is manageable, try introducing a food item back into your plan in small amounts. You MAY be able to tolerate it again!
• Do NOT be afraid to try new foods and ingredients, just err on the side of caution with the amount you try and take notes if any symptoms occur
• MAKE A LIST/PLAN FOR YOURSELF. I created a Word Document with three categories: Safe, Limit, and Avoid and a list of foods for myself, organized by food groups. That way, when I want to try something new or when I'm suffering, I can check my list and see, did I eat too much of a limit food item, or did I have a new recipe that used an "avoid" ingredient I forgot about.

• It is YOUR body and YOUR rules. IF you experience negativity about your choices to try and live a healthier and happier lifestyle by managing your symptoms through an IBS Eating Plan, stand your ground and advocate for yourself.  Only YOU know what is best for your body, no one else!

• Do you follow an Eating Plan for IBS or another condition?
• Do you think food can be used as medicine?
• Have you ever experience negativity due to a choice you made for your health?

I am not a a medical doctor, and the information, advice, and tips provided are based on my own experiences with IBS and research I have done myself.  My information is by no means a replacement for seeing an actual doctor, and any medication or supplements should not be taken unless you consult with your doctor first.  IBS is a complex condition that is different for everyone, so what works for me, may not work for you.  Keep reading, researching, and experimenting until you find what works best for your body! 
Helpful Science Backed Resource: http://www.aboutibs.org/site/treatment/diet/  and http://www.healthline.com/health-slideshow/ibs-diet#6 

This list provides you with foods that are gas-producing.  These are NOT to be confused with FODMAPS, but rather are foods that cause gas to be produced when digested in the intestines.
  
PLEASE NOTE: 

• Just because a food is "high gas" and says to avoid, does not mean YOU HAVE TO avoid the specific food item.  For example, I can eat carrots, in small quantities, NO PROBLEM.  As I said, with EVERYTHING else, it is a process of trial and error.
  
• Some Low Gas foods, such as Grapes are actually Moderate FODMAPS, so be careful when looking at eating plan lists, because what is "safe" for one type of Eating Plan may not be on another.
• DO YOUR OWN RESEARCH :) It's YOUR body, just because a list says it is "allowed/limit/avoid" doesn't mean YOUR body will react that way!  We are all individuals, these lists are here as a guide to help, not to strictly adhere to!

---

Soprano is an expert on the grape By Barbara S. Rothschild

Source: http://www.burlingtoncountytimes.com/life-style/bct-food/soprano-is-an-expert-on-the-grape/article_3b12691c-a1ee-50cb-8f51-e0899442687e.html
April 29, 2015

To cantorial soloist Sandra Messinger, a fine wine can be a religious experience.

The soprano, who leads Mount Laurel’s Reform synagogue Adath Emanu-El in song both sacred and joyous, is also an expert on the grape — a happy pairing that is, in fact, a byproduct of Messinger’s vocation.

Call it bashert, the Yiddish term for “destiny”: This vocalist is as comfortable reading a wine list as she is following the musical patterns of a religious trope. In both disciplines, the notes are varied and complex — and a way for Messinger to challenge herself while doing what she loves.

Sandra Messinger, cantor at Adath Emanu-El, talks about wine pairings during a tasting at the synagogue. Tracie Van Auken/Freelance

“Wine is a part of many Jewish celebrations, from weddings to sanctifying the Sabbath. So if you are going to rejoice with wine, it should be something that tastes good,” Messinger said. “It’s very much a part of celebration and joyfulness — as long as it’s in moderation. If you are going to have a little bit of something, it should be wonderful.”

Messinger, 44, is a Willingboro native whose family joined Adath Emanu-El when the future chanteuse was 5. The synagogue, then known as Temple Emanu-El, was a fixture in Willingboro until it moved to Mount Laurel in 1997. Messinger’s family remained in Willingboro, but continued to attend the renamed temple.

Messinger opens a sparkling white zinfandel for sampling. Tracie Van Auken

The John F. Kennedy High School graduate majored in music performance at Rowan University, followed by a study in opera performance at the International Academy in Rome. There, she performed such classic roles as Tosca, Contessa Almaviva from “The Marriage of Figaro,” Suor (Sister) Angelica, and Magda from “The Consul.” At the same time, she began cultivating an appreciation of fine wines as she also became more attuned to her faith.

Messinger said she started developing an interest in wine while touring Europe in her 20s. “It was partly because of the culture of it, and partly because I’m a foodie — and food and wine go together,” she said.

Faith had something to do with it, too. “One of the times I really started connecting with wine was when I was singing in Italy,” Messinger said. “Wine was a part of the culture, and even the table wines were spectacular.”

Sandra Messinger, cantor at Adath Emanu-El, talks about wine pairings during a tasting. Tracie Van Auken

At the same time, she was feeling like a fish out of water in Rome, a city without many Jews. She found the Jewish quarter and reconnected with her religion while embracing the city’s wine offerings.

“The two really overlapped in Rome, as I gained a new appreciation of Judaism and of wine. That is where they connected in my mind,” Messinger said.

At that event, about a dozen participants indulged in everything from cheese, nuts and chocolate to carrot cake, cheesecake, brownies and fruit pies while pairing them with six wines selected by Messinger, with an emphasis on products from local vineyards. Tracie Van Auken/Freelance

After returning from Europe, Messinger got a job singing and waiting tables at La Boheme, a now-defunct Northern Italian restaurant — despite the French name — in the Chambersburg section of Trenton.

“It was a small restaurant and other than the chef, I was the one who knew about wine,” she recalled. “They didn’t have a sommelier, and they wanted someone to suggest wine pairings.”

Sandra Messinger pours a sparkling white zinfandel during the tasting. Tracie Van Auken/Freelance

From there, Messinger got a job at what was then The Pantheon, an Italian restaurant at the Ritz-Carlton on Broad Street in Philadelphia. “I was waitressing at the beginning, and buddied up to its sommelier. I learned everything I could from him, and I became the go-to person about wines when he was not available,” she explained. “The chef there let me taste things, and the manager was very supportive of my education in terms of wines and pairings.”

After that, Messinger further developed her wine palate by frequenting wine tastings and festivals. In 2001, she became cantorial soloist at Adath Emanu-El.

“I kept studying wine for my own enjoyment while learning how to better serve my congregation through music and developing professionally in the Jewish community,” said Messinger, who has performed in England, Spain and Israel as well as in Italy and various U.S. locales.

An ice wine from Tomasello Winery was among the sweet wines sampled during the tasting. Tracie Van Auken

In addition to her cantorial role, Messinger acts as conductor for the temple’s youth, teen and adult choirs, and is also a bar/bat mitzvah tutor and Hebrew teacher. Soon, she hopes to complete her bachelor’s degree — coursework having been interrupted by her performing abroad — and earn certification as a full-fledged cantor.

Messinger has held several wine pairing events at Adath Emanu-El, aiming to help others develop their own palates. Topics have included general pairings, kosher wines and, most recently, dessert wines.

Messinger has held several wine pairing events at Adath Emanu-El, aiming to help others develop their own palates. Topics have included general pairings, kosher wines and, most recently, dessert wines. Tracie Van Auken/Freelance

At that event, about a dozen participants indulged in everything from cheese, nuts and chocolate to carrot cake, cheesecake, brownies and fruit pies while pairing them with six wines selected by Messinger, with an emphasis on products from local vineyards.

“This is the one I’m most excited about,” said Messinger as she indicated a bottle of Valenzano’s Jersey Devil No. 1 — a honey wine, or mead, from the Shamong winery, with hints of Madagascar vanilla beans and orange zest. She remarked that the mead, aged in bourbon barrels that add depth of flavor, went really well with the brownies.

Also from Valenzano, Messinger chose a sweet-yet-tart plum wine and a full-bodied blackberry syrah. “The syrah is good with the nuts, too. They work with the spiciness in the syrah,” she said. “And dark chocolate and blackberry — that’s a gimme.”

Her other offerings included a sauvignon blanc from New Zealand, a California white zinfandel, and a vidal blanc ice wine, made from partially frozen grapes, from Tomasello Winery in Hammonton.

“It’s all about what brings out the flavors you like and hides the favors you don’t,” she said, advising the group to rinse with water — and then spit it out — between wines. “It’s not a matter of right and wrong. Is anyone finding that some things taste better with the wine and some things taste awful?”

Participants at the dessert wine pairing were pleased to let their palates be their guide. “I liked the sauvignon blanc with the cheesecake, but not with the fruit,” said Sunny Butchin, of Willingboro.

Added Willingboro resident Josselyne Jackson, “I liked it better with the strawberries.”

Messinger said there remain certain chemical truths about wines and food — that a harsh-tasting red wine will cut through the fat in meats and cheeses, while the fat in the food will cut the harshness in the wine, for instance.

But, she added, the old way of looking at wine pairings — white with fish, red with beef — is not how people should approach the discipline today. “Pairings have to be user-friendly now,” Messinger said.

Maria Kelly of Edgewater Park said she was a fan of the plum wine. “It’s very good with the gouda,” Kelly said, prompting Messinger to say, “The plum wine balances it.”

Moorestown resident Judy Richter said she knows very little about wine. “I wanted to get an idea of what goes best with fruit, cake and nuts,” she said.

Eileen Chmielinski, of Evesham, said she took one of Messinger’s classes before. “It was fun then, too. I think wine is a good thing to enjoy and add to your meals.”

Messinger said white port is one of her favorite new finds. She always gets excited about amarone, a red wine from the Tuscany region of Italy that she describes as “big, rich, complex and fabulous.”

In all her travels, Messinger has continued to gravitate to wine, noting that it has given her an appreciation of cultural differences while making her more grounded in self-knowledge. Sharing her hobby of wine appreciation with those she mentors professionally as a Jewish spiritual guide is truly the best pairing for her.

“It’s a way of finding what home is, in terms of both a congregation and favorite wines,” Messinger said. “For me, home is where I started. Not everyone gets to do that.”

Tracie Van Auken

Cantor Teaches Wine Pairing

A sauvignon blanc from Peter Yealands was among the wines sampled at a tasting event held at Adath Emanu-El in Mount Laurel.

Tracie Van Auken/Freelance

Cantor Teaches Wine Pairing

Valenzano’s Jersey Devil No. 1 — a honey wine, or mead, from the Shamong winery, with hints of Madagascar vanilla beans and orange zest, goes really well with brownies, said Messigner.