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Prostate Screening


All types of screening give rise to false positives - and, tragically, false negatives as well. Prostate specific antigen (PSA) testing for prostate cancer is by no means fully reliable (4 August, p 12). It remains, however, the only non-invasive test that detects four out of five prostate cancers. The condition is incurable once the cancer escapes the capsule that surrounds the organ, and as with all cancers, early action is best.

The problem with prostate cancer is not how best to detect it, but how to treat it. Because the gland is deeply embedded among other organs, it is virtually impossible to destroy the cancer without affecting surrounding tissues. However, the alternatives are even less attractive, and treatment is usually the wisest option.

Measuring PSA levels regularly enables the rate of increase or "PSA velocity" to be established - which is valuable for diagnosis.

Paracetamol


I read Tiffany O'Callaghan's article about the shifting understanding of the risks around paracetamol (acetaminophen) and the mounting concerns regarding its efficacy and side effects with great interest (31 May, p 34).

I was very surprised, however, by how much of the discussion into the dangers of paracetamol toxicity was about doses far above the maximum recommended dosage of 4 grams per day. A vast number of drugs routinely prescribed by physicians would be extremely dangerous if taken above the maximum doses for prolonged periods of time. These include basic heart medications such as diuretics, beta blockers, ACE inhibitors and digoxin.

O'Callaghan goes on to note that 6 per cent of US adults are routinely prescribed doses above 4 grams. If this were any other drug, the focus would be on dangerous prescribing by physicians rather than a lack of safety in the drug itself.

Instead of suggesting that paracetamol use should be discontinued, the article should serve as a wake-up call to doctors not to become complacent about routinely prescribed medications.

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It doesn't surprise me that paracetamol is linked to increased internal bleeding. While the drug itself doesn't interfere with vitamin K metabolism - vital to blood coagulation - one of its metabolites does interfere with the activities of enzymes dependent on vitamin K. So, in a sense, paracetamol has warfarin-like properties, and if we take too much warfarin, we bleed.

Fresh Air and Sunshine


Frank Swain's look at the sidelined antibiotic role of fresh air and sunlight in controlling infection (14 December 2013, p 34) raises questions about hospital design.

I was a medical student in the 1980s, in hospitals built in the Victorian era - huge airy spaces flooded with natural light. They almost seemed to be half outside. Now many hospitals have low ceilings, slit-like windows that barely open and fluorescent lights. With a lack of fresh air and 24-hour artificial lighting, it is not surprising that patients succumb to infections or get depressed.

Our new hospitals are designed to reduce infection risk and to be cleaner and more efficient. But if such designs add to morbidity, perhaps we need a rethink.

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Swain's article accurately describes good hospital practice of 50 years ago. However, there were downsides.

After a successful operation, I was one of the bedridden patients wheeled outside to benefit from the autumn air. Unfortunately, we were left unattended under horse chestnut trees, which shed their hard conkers onto our heads. We were powerless to take evasive action.

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When will hospitals and schools revert to using brass instead of stainless steel for door furniture? I understand that some germs like iron, but most hate copper. In an epidemic, even a small reduction in transmission is worthwhile.

Another overlooked traditional weapon against infection is salt. Used on wounds it kills bacteria and dries the wound. The pain resulting from the salt might cue a stronger immune response.

Ebola


There is one group of people who can do a lot to help stop Ebola (18 October, p 10). They are the survivors. About 50 per cent of those who get the disease survive, and they are then, as far as is known, immune. They should be recruited to take care of those who have the disease and to clean up after them. Since the disease has a short duration compared with the rate at which the number of cases doubles, there should be more survivors than sick people. They can also give blood, which can then be used to give antibodies to those who are sick.

Young Blood


Helen Thomson writes that transfusions of young blood may help treat age-related conditions such as Alzheimer's and heart disease (23 August, p 8).

Given that there are about 2 million blood transfusions in the UK every year, and that the blood services and hospitals keep detailed records, could the research benefit by analysis of this existing data?

There are a large number of variables, but even if only the transfusions that were required for a physical loss of blood were considered, there should still be a huge number to work with.

The editor replies: • There is a lot of blood swapping going on, but the benefits of young blood are likely to be transient, making any effect difficult to measure retrospectively. In addition, uncovering the age of existing donors may be difficult.

Head Transplants?


My grandfather's favourite saying was "you can't put an old head on young shoulders". Soon you might be able to, literally (28 February, p 10). Would it not be better for surgeon Sergio Canavero to use this developing technology to help people with paraplegia? In this case, the nerves to be joined would be from the same body, avoiding the problems of rejection. Now that would really bring hope to thousands.

Before we get carried away with the idea of head transplants, recall the article in the same issue about people who received bionic replacements for their hands. Since we can make human-like robots, perhaps we should use the technique to transplant the head of someone with quadriplegia onto a robot body.

It may be easier to source robot bodies than human body donors with no serious damage anywhere other than the head. Learning to drive a robot body with preset functions might be easier than attempting to relearn the precise movements for a biological one.

Apart from the technical difficulties of head transplants yet to be resolved, one of the ethical concerns would be whether or not the donor body was the same sex as the original. The implications are intriguing.

Genetic Repairs


In his passionate case for genetic engineering, Michael Le Page suggests that the limiting factor in germ-line genetic engineering is mainly technological (14 February, p 26).

If only. The real obstacle is appropriate knowledge of the effects that even the simplest genetic manipulations have. So far, we are only good at restoring deleterious mutations. The proper term for this is patching up, not engineering, and adopting it would provide us with a good analogy to convince opponents that it is right to do so. Rather than engineering a race car, we are simply taking our modest sedan to the repair shop.

Faecal Transplants


Once again, New Scientist shows that it is greater than the sum of its parts by the juxtaposition of two otherwise unrelated articles.

Writing about microbes in the human environment (7 February, p 38), Andy Ridgway reports that the bacteria found on the seat of a chair are associated with the gut and vagina. Researcher James Meadow concludes that "we're incredibly leaky animals and our clothes are definitely not the impermeable barrier we like to think they are". The following week, Jessica Hamzelou discusses faecal transplants (14 February, p 8), writing that "the number of people thought to be conducting their own faecal transplants at home is rising".

Maybe buses, trains and theatres were humankind's first foray into facilitating this medical procedure.

Fitbits and Health Monitors


(Original story) Would you lead a more active lifestyle if it meant lower life insurance premiums? Insurer John Hancock and Vitality, a global wellness firm, are hoping the answer is yes. But there is a condition: They get to track your activity.The practice is already employed in Australia, Europe, Singapore and South Africa, where Vitality is based.

(Fark responses)A life insurance company wants to give you a FitBit and will discount your policy depending on activity levels. I plan on strapping mine to a paint shaker.

Strap it to a toddler. Then give him coffee.

I'll strap mine to my right forearm.

So, strap it to the dog, take the dog for a run in the park. Easy.

How long until you can buy a hacked fitbit. Looks like you got eight hours restful sleep, 62 minutes of vigorous activity in the morning and then a moderately active lifestyle. We just can't figure out why you have a BMI of 72.

I see a business opportunity. All these people can put their trackers on me, and for $10/day each, I'll walk around on a jogging trail all day. Plenty of exercise for me, and I get paid. Who wants to sign up?

Ah humans, we'll put more effort into trying to get away with something than just actually doing the thing that would be better for everyone.

Britain's National Health Service


In response to a LT article:"The NHS is bust because the model is fundamentally flawed. This does not mean there aren't fine and committed healthcare staff doing wonderful things for patients. But the NHS simply cannot do what it says on the tin: provide equal care for all, free at the point of use.

Britain tells itself that the NHS is a national treasure because no other system in the world matches it for decency and compassion. This is simply untrue.

In the Mid Staffordshire Trust, more than 1,200 patients died through the incompetence, negligence and callousness of the staff, a story repeated elsewhere.

My own previously firm commitment to the NHS was irrevocably shaken by the way my own elderly parents were treated with indifference, neglect and even cruelty. From those experiences and many worse horrors recounted to me, I concluded three things: that there was a moral problem at the heart of the NHS; that if you were old and feeble you were particularly vulnerable; and that the most important thing patients lacked for their own protection was leverage."


The NHS is superb. I benefit from it's service regularly. It is a brilliant system... and simply not fit for purpose in the modern world. It cannot deal with an ever increasing, ever more elderly population by providing cradle to grave, comprehensive care, free at the point of delivery. It cannot be done.

Most people in the UK would rather take the risk of receiving below standard treatment from the NHS as long as it free at the point of need.

A few accounts of good or bad experiences out of the millions that take place each year in the NHS is not a meaningful basis for forming an opinion. The only statistics that matter are those based on outcomes and how they compare with those of the health services of other modern industrial countries. A rational approach would be to learn from and adopt the health models that yield the best outcomes for patients.

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The continued success of the NHS in proving the level of service that it actually does is completely inexplicable to anyone who regards free market processes as the only way that delivery of any goods or services can be achieved. How can the system possibly work at all if no money changes hands? Where is the motivation for the surgeon if he it not paid by results? Yet even if we do not have the best health service in the world, we do have a health service which does work, and which delivers the level of service that it actually does on entirely socialist principles.

I have no doubt that if we tried to run the distribution of fruit and vegetables in the country on entirely socialist principles, it would be a complete disaster. What delivers fresh and varied produce to you day by day at remarkably low cost, is the regular exchange of goods which pass through the same hands as does the cash. When you try to apply the same model to the supply of electricity there is not the same unqualified success. All that the competing suppliers compete in, is the process of billing, and the hands that handle the cables, do not handle the cash.

Moving to an insurance based system of health care would add a whole raft of expensively remunerated people to the system who would never handle or deliver anything but would be money men and contract men and profit men, and would work miles from the nearest hospital. Perhaps nevertheless they could apply such wisdom and such efficiency to the operation of hospitals that they would be worth the rewards that they would expect.

But I return to my original point. If you think that the free market model is the only possible system, why do you think the NHS works at all? You really cannot deny that it does. It has been doing so for decades.

I think it works because the case of illness is a rare example of a situation when you can get a better result by relying upon human altruism than human self interest. Another is the life boat service.

I am inclined to think that it will be a peerlessly well managed private enterprise system that does better than the NHS. However we do not do peerlessly managed private enterprise systems in this country. They do peerlessly well managed private enterprise rented property in Europe. Here, we do Rachmanism, and aspirational home ownership. We do not have a culture of well managed delivery of services for profit by the private sector here, but we do have a system of social medicine which is generally admired.

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I would like to see co-payments and 'top-up' payments allowed. They're taboo at the moment - how is that helping anything. People 'upgrade' all the time when they take a hotel room, ...why not give them a choice, and just see if it works, without getting too ideological about it? Many people have special needs, and a single/private room with extra nurse would be appropriate - why not let them pay for it, within the system? I'd rather pay for a non-stressful time in hospital with reliable, proper care, than have a holiday, and I'm sure I'm not the only one. I think the answer is in empowering people and encouraging responsibility for their own health. We need to look to the best way for this. Centralised, anonymous, generalised policy - with not even the same consultant over one issue - has poor outcomes, far too often.

Only the state has access to the funds needed to provide comprehensive healthcare, and in reality we should pay for it out of our taxes because, as long as it is run reasonably efficiently, every penny should go back into system. Run privately, how much is going into shareholders pockets or chief execs. Of course, that means the NHS would have to be run more efficiently and people at the top would have to accept they should be paid less. Which is a fundamental problem with capitalism and the free market - people see others with more and want it.

"Health has to be tax part-funded"? No it doesn't, for all sorts of reasons. Self-evidently so in fact, given that no other country does this, or certainly not like we do. Are we uniquely right and everyone else out of step?

Why do you separate health care from every other service we use - food, clothing, cars, holidays, restaurants - there is no logic to your argument about profit in healthcare. The NHS could not operate without private suppliers all making profit.

What the Greeks did first, and most importantly, in "The Cuts' was to rigorously define the term 'Front Line Worker' (In Britain it means anything the managers want it to mean!). It was defined as those staff dealing directly and personally with patients / pupils / clients / victims /customers for at least 50% of their working time. From that perspective very few British ward sisters, matrons or consultants would qualify as protected front-line staff. Certainly almost no British police officers would (and I used to be one). It was apparently rather funny how many Greek desk jockeys suddenly appeared in the wards etc. - It didn't work - 50% were still sacked. As in the British 'Flea-bites', un-defined cuts administered by management and administrators are inevitably executed, by them, on front line workers!

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Your special report on the future of healthcare raises some good points, but it doesn't address the fundamental problem of the UK's National Health Service (21 March, p 22). Nye Bevan introduced the NHS in 1948 for everything "from the cradle to the grave", free of charge at the point of need. It was excellent by the standards of the day, but in the day "everything" was not very much.

There was midwifery, some neonatal care, general practice, plenty of lung cancer (always fatal), and so on. Life expectancy was 65 years. There was a culture of self-reliance, and little appetite for prolonging life for the sake of it. So the costs of the early NHS were easily met by a tax increase.

More diagnostic tests and expensive scans are now used and more treatments are possible, some of them absurdly expensive. There is an obesity epidemic, diabetes incidence has more than trebled, and a rising incidence of mental health problems is poorly addressed. Above all, a huge increase in life expectancy and consequent morbidity has exploded the demographic time bomb that we health workers discussed in the 1960s.

"Everything from the cradle to the grave" must be replaced by defining what the NHS will and will not do. The required alteration in public expectations will be as radical as the introduction of the NHS itself was in its time. But there are no votes in that.

Migraines


I enjoyed Helen Phillips's recent article on the neurological changes in the brains of people who experience migraine (7 March, p 38).

About 35 years ago, when much less was known about the disorder, I attended a lecture in which an eminent US physician described the typical patient at his migraine clinic as a well-dressed woman, but did not mention any possible hormonal link with migraine attacks.

At the time, it was easy to infer a swipe at "uptight bored housewives", but perhaps his observation unwittingly supports the more recent work? My friend who has migraines dresses neatly, and cannot tolerate untidiness or background noise from radio or conversation – all could be signs of the mental distress caused by progressive structural changes to the brain. Being a bit uptight may be the result rather than the cause of a tendency to have repeated migraines.

With a family history of migraineurs going back at least three generations, I was prone to motion sickness which was exacerbated by flickering lights, such as that caused by driving past tall trees. I suffered no headaches until I started using a contraceptive pill in the 1970s.

Frequent migraines occurred thereafter, even without the pill, until a ruptured ovarian cyst resulted in a hysterectomy in my mid-thirties. I haven't had a migraine in the 30 years since. Drastic, but totally effective.

There is indeed a cure for migraine that works for some, especially those warned of onset by the aura (7 March, p 38).

After a few years of migraine agony in my teens, I found a Reader's Digest article which advised that as soon as you experience the aura, you should lie down and relax every muscle from toe to head. It worked for me. No more migraines for five years – until I mistook an aura for sun glare and ended up in hospital. I have since remained migraine-free for 55 years.

Many migraine sufferers I have spoken to have dismissed the method without trying it. Others are cured for life. What is the science here?

Placebos

Shannon Fischer's description of the power of placebos is fascinating (NS 12 March, p 32). It chimes with my having heard the marketing manager for a big-brand painkiller saying that the more you advertise the stronger the drug becomes - and that its effects kick in within 5 minutes, which is pharmacologically impossible.

Treat Sugar Like Tobacco?

original LT article

Threats work. I was told by my consultant that my cartilage problem in my knee can be fixed but if I do not lose weight I would need a knee replacement in 5 years time. The thought of having to hobble around on bad knees for the rest of my life hit home. After the op, with the help of my Fitbit, I am now just 2 stone from my healthy weight having shed 4 stone since April 2016. I feel better to the point of near righteousness soaking up the compliments, and it could get worse!! Threats really do work, you just need a threat that's right for you.

In the case of sugar it cannot be treated in the same way as tobacco because the relationship between smoking and ill-health is a much more linear one than with sugar. We are at the mercy of the dreaded experts again. The very ones that had us worrying about fat all this time and forgot to tell us about the whole sugar/ diabetes thing.

But if you want to legislate against food producers bear in mind that this will lead you into other kinds of censorship. TV for example. Surely Mary Berry can't be allowed to carry on corrupting us anymore with her Pavlovas and sponges. Contemplate having to illegally download episodes of Bake-off and I can only presume that images of Nigella licking chocolate fondant mix of her fingers would be available only in some forbidden corner of the dark web.

However if you really want be draconian the answer is simple. Make people pay for their own healthcare. For example, I doubt very much whether the massed ranks in our town centres would continue to get comatose and pick fights on a Saturday night if they had to pay the police and hospital bills every time they had to be peeled off the pavement. If paying for extra large seats on planes would act as an incentive then why not got the whole hog.

The truly shocking thing is how many children are very overweight. I craved sugar as a child, but lived under a strict regime! Sweets on Friday only. I think the great Theodore Dalrymple - the prison doctor - said that the British no longer eat off a dining table. Children graze and forage at all times of the day. And there is the teaching of food technology in schools, which I think used to be called cookery.

The idea that a specific food is inherently unhealthy is nonsense. It is a diet that is unhealthy. There is nothing wrong for most people in a burger and chips, a packet of crisps or a pizza every now and then. The problems come when people eat nothing else and in quantities greater than their bodies need.

One frightening fact is clear though, being overweight is now being seen as normal.

Calorie consumption has fallen for 40 years, and our diet has never been better. So there is no justification for taxing consumption. That leaves punishment as the main motive for new taxes. This is correct. The data are sourced to official statistics. The Fat Lie . Summary below:



I think the author has missed one rather obvious contributor to obesity - alcohol, particularly wine. Home consumption of alcohol has increased exponentially over the past twenty years and these "dead" calories are headed straight for the waistline. The fact that many people, particularly middle aged women, don't actually consider wine drinking as a form of alcohol consumption shows the power of social acceptability. If their friends were "necking" a half bottle of vodka the tongues would wag, but a couple of bottles of wine, that's just socialising. Of course once the wine bottle has been opened you can kiss goodbye to any form of exercise - ever see anyone get up mid bottle to go for a quick stint in the gym?

I gave up all alcohol for 10 days recently while on antibiotics. It made no difference at all. I've tried everything - I walk everyday, am constantly on the go and sometimes do some other exercise such as rebounding. I've eaten protein only for 5 days. Nothing budges the weight I have. I am fit though so does it really matter? My blood pressure is good, I have no health problems. I am 69 so possibly it's hormonal. The only problem for me is that my husband is constantly telling me I'm fat! He's encouraged I think by the constant references to how we should all be stick thin! Please press and media, give it up!

I think a massive issue is lack of information/knowledge that these "ready meals" and "ready snacks" are so bad for you. This is the same as smoking was back in the 50s and 60s when people just didn't realise the harm it was doing, and sometimes the only way for people to realise is to 'push' through taxation and law.

I try not to be weightest but fat people make it so difficult. I try to soften it up by coming up with new phrases like "morbidly jolly." There is a difference. Whatever you say, passive smoking did have an effect on people's health, while watching other people eat has no such effect. Mr Creosote may be disgusting and expensive for society, but he has no direct effect on your health except when he explodes all over you.

If self-discipline were it, I would be thin... Don't ever think an obese person wants to be fat. I am trying to work out how to lose weight and remain thin. I have yo yo'd dieted for years, and having thought I have resolved a problem, another one appears. I would dearly like one day, where I don't have to think what I am eating, and why because it might do something to me. So far the Low Carb and High Fat systems seems to be maintaining my weight, but I am not losing it. I am exercising, which is great for keeping me alert, but not doing anything for my weight. You can hit your head against a brick wall so many times, but you feel that you and your body don't make sense anymore. Anyone who has had to face that, knows what it is to be obese, and if you are have never been in that situation, then you will never understand it. There is not a one size fits all solution, and if it were, we would all be thin.

I really do empathise with you, as I have had similar problems. The inescapable truth, however, is that people who are fat are eating too much for their own metabolism.

BMI correlates with mortality from diabetes, heart attacks, strokes and cancer. It is pretty good and lasted 200 years since Quetelet devised it!

Quetelet devised it to study populations, not individuals. Even he admitted it took no account of body shape. All it does is compare weight to height, it takes no account of composition, shape, medical condition, etc. People like it because it's simple but that doesn't mean it's accurate. Quetelet wasn't even a doctor but a mathematician who developed the measurement in the 1830s to discover who represented the 'average man' and was not interested in health issues. I think this misapplication needs revision in the 21st century.

What about detention after work, or perhaps an enforced gym session nightly? Perhaps a few nasty electric shocks on Saturday morning at the GP's surgery if, after weighing, no poundage has been lost. If all else fails deportation is readily available.

My doctor calls smokers National Health Heroes and would award them a VC. They contribute enormously to the public purse through tax. They then die young, and although the treatment is expensive it is short-lived, and costs much less than terminal care for the average aged person, moribund for years. He says that although the reduction in smoking has many good effects it is helping to cripple the Health Service; more ancient sufferers are surviving longer and making more (and more costly) demands. If all seen and unseen cost are accounted for, I wonder whether those who abuse drugs and alcohol are, on balance, more or less expensive?

Chronic Fatigue

Emma Young treats fatigue as if it were only a medical problem (15 October, p 28). In many cases it can be an engineering issue. As a designer of heating, ventilation and air-conditioning systems with over 30 years’ experience, I believe that I have stumbled over some of the traps. Willis Carrier was the first person to design a modern air-conditioning system. His designs called for about 20 per cent of the air passing through the system to come from outside the building. This ventilation component uses about 50 per cent of the system’s energy, on average, so there is a temptation to reduce the outside ventilation. Chemicals from carpet, furniture, building materials and even people can then pollute the air and make us feel tired.

In Carrier’s designs conditioned air came into contact only with zinc on galvanised steel or with the copper of cooling coils. Zinc and copper have recognised antimicrobial properties. But in the 1970s came new designs using materials such as aluminium, with few or no such properties.

I was surprised that your very interesting in-depth article on tiredness made no mention of caffeine. Like virtually everyone I know, I regularly consume tea, coffee or cola to boost alertness on a temporary basis. I wonder whether the tiredness many complain of is not in fact simply a withdrawal symptom?

I suggest one more factor that could result in tiredness – noise. My kitchen has a washing machine, tumble drier, fan oven, electric kettle and microwave, and even the new taps are noisier than the old ones. One or other of the family usually has radio, TV or CD player on. Outside, traffic is heavy and noisy; shops and restaurants often have music playing...

Thank you for providing sensible explanations for the feeling of being tired all the time. There is a further simple possibility: carbon monoxide (CO) poisoning stemming from faulty heating or cooking appliances powered by any carbon-based fuel, including gas, coal, oil, petrol or wood. At very low concentrations, symptoms of CO poisoning include headache, tiredness and confusion. It cannot be detected directly by any human sense. A concentration of less than 2 per cent CO in the air can kill in between 1 and 3 minutes. The independent charity CO-Gas Safety has lobbied government and industry since 1995 for primetime TV warnings about this. We have been ignored – or told that such warnings are “so last century”.

Putting a Price on Life


Difficult decisions are necessary in a health service with limited resources (22 October, p 5). But patients have a right to robust and transparent decision-making about which treatments are funded. NHS England is reviewing funding for second stem cell transplants for people with blood cancer and blood disorders – which lead to at least five extra years of life in a third of cases.

While a transplant carries an upfront cost, the alternative treatments are also costly and unlikely to save the patient. The price of a treatment must be considered, but it is equally important to assess the cost of not providing it.

One of your 22 October Leader articles refers to the valuation of life and the need to secure value for money from the public healthcare budget. The other highlights amazing advances in treating infertility, which many couples will desire. Prosthetic joints are no less remarkable a breakthrough, and yet I know of people refused hips and other treatments for reasons of limited public health finances.

As the gap between health technology capability and patient demand grows we need real public involvement in how healthcare provision is prioritised.

As researchers in the field of estimating what is legitimate to spend on safety measures, we understand the need to value human life in financial terms. But we cannot fully accept your statement that the world should embrace the formulae of the UK’s National Institute for Health and Care Excellence (NICE). These are based on the Quality-Adjusted Life Year: but the value of this is linked to the Value of a Prevented Fatality used by the UK’s Department for Transport.

We have shown that this value is devoid of any evidential basis (Process Safety and Environmental Protection, doi.org/bs3h). It was based on a 1997 survey of the stated preferences of 167 people. The authors have acknowledged that the research had limitations.

NICE’s basic approach, valuing the increase in life expectancy brought about by a medical treatment, is nevertheless good.

I enjoyed Shannon Fischer’s article about the price of a life (22 October, p 28). But I’m not sure in what form you buy carbon and sodium. I get carbon for A$100 a tonne in the form of coal, and sodium for A$500 a tonne when bought as salt for my pool. (The editor writes: These prices – supplied by the UK’s Royal Society of Chemistry – were for elements in their purest available form. Some refining might be required.)













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