Balkinization
an unanticipated consequence of
Jack M. Balkin
Jack Balkin:
jackbalkin at yahoo.com
Bruce Ackerman
bruce.ackerman at yale.edu
Ian Ayres
ian.ayres at yale.edu
Corey Brettschneider
corey_brettschneider at brown.edu
Mary Dudziak
mary.l.dudziak at emory.edu
Joey Fishkin
joey.fishkin at gmail.com
Heather Gerken heather.gerken at yale.edu
Abbe Gluck abbe.gluck at yale.edu
Mark Graber
mgraber at law.umaryland.edu
Stephen Griffin
sgriffin at tulane.edu
Jonathan Hafetz
jonathan.hafetz at shu.edu
Jeremy Kessler
jkessler at law.columbia.edu
Andrew Koppelman
akoppelman at law.northwestern.edu
Marty Lederman
msl46 at law.georgetown.edu
Sanford Levinson
slevinson at law.utexas.edu
David Luban
david.luban at gmail.com
Gerard Magliocca
gmaglioc at iupui.edu
Jason Mazzone
mazzonej at illinois.edu
Linda McClain
lmcclain at bu.edu
John Mikhail
mikhail at law.georgetown.edu
Frank Pasquale
pasquale.frank at gmail.com
Nate Persily
npersily at gmail.com
Michael Stokes Paulsen
michaelstokespaulsen at gmail.com
Deborah Pearlstein
dpearlst at yu.edu
Rick Pildes
rick.pildes at nyu.edu
David Pozen
dpozen at law.columbia.edu
Richard Primus
raprimus at umich.edu
K. Sabeel Rahmansabeel.rahman at brooklaw.edu
Alice Ristroph
alice.ristroph at shu.edu
Neil Siegel
siegel at law.duke.edu
David Super
david.super at law.georgetown.edu
Brian Tamanaha
btamanaha at wulaw.wustl.edu
Nelson Tebbe
nelson.tebbe at brooklaw.edu
Mark Tushnet
mtushnet at law.harvard.edu
Adam Winkler
winkler at ucla.edu
Compendium of posts on Hobby Lobby and related cases
The Anti-Torture Memos: Balkinization Posts on Torture, Interrogation, Detention, War Powers, and OLC
The Anti-Torture Memos (arranged by topic)
Recent Posts
The NY Same Sex Marriage Case
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Saturday, February 05, 2005
The NY Same Sex Marriage Case
JB
In Hernandez v. Robles a New York State trial court judge held that the New York State constitution prohibited restricting marriage to opposite sex couples.
The court held that prohibition on same sex couples violated the Due Process Clause and Equal Protection Clauses of the New York State Constitution. The court did not remand to the legislature to fix the law, as the Vermont Supreme Court did in Baker v. State. Instead, the Court noted that the specific provision of the Domestic Relations Law which governs marriage licenses did not specifically exclude same sex couples by its language, but that other accompanying statutes did refer to husbands and wives, brides and grooms. Therefore, the appropriate remedy, the court argued, was to read the accompanying New York statutes so "that the words `husband', `wife', `groom', and `bride', as they appear in the relevant sections of the Domestic Relations law are and shall be construed to mean `spouse' and all personal pronouns, as they appear in the relevant sections of the Domestic Relations Law, are and shall be construed to apply equally to either men or women."
Hernandez is a puzzling case on two counts. First, the Due Process argument is that the right of privacy under the New York State Constitution includes a right to marry, which the Court says is the right to choose whom to marry. But the problem is that this would undermine state laws regarding incest and polygamy as well, and the court makes no attempt to distinguish those cases from the case of same-sex marriage. Indeed, at one point in the opinion (p. 45), the court uses the example of polygamy to show that marriage has meant different things at different times and in different places. Perhaps the court really means to say that as applied to same sex couples, the state has provided no compelling reasons for restricting who may marry, leaving to another day the question of whether there would be compelling reasons in cases of incest and polygamy. But if that is the holding of Hernandez-- and perhaps it is the best reading of the case-- the point is nowhere clearly expressed. And what is puzzling about the opinion is that the court does not even seem to spot the difficulty.
The court also says that prohibition on same sex marriages violates New York's Equal Protection Clause. The court does not hold that the prohibition violates sex equality because it restricts the choice of a person's marital partner on the basis of one's sex. Rather, the court holds that the restriction violates the prohibition against discrimination on the basis of sexual orientation. The New York Court of Appeals has not held that discrimination based on sexual orientation requires heightened judicial scrutiny. Nevertheless, the court in Hernandez argued that the state of New York did not offer even a rational basis for excluding same sex couples from marriage. This part of the opinion is quite short and, because it is so short, it is not very convincing. At least the Massachusetts court in Goodridge spent some time trying to explain why the state's reasons failed the test of rational basis. What the court says in Hernandez is mostly conclusory.
I have no idea whether this case will be affirmed by the New York Court of Appeals. But if it is affirmed, it will have to be for somewhat different reasons than the court gives here. The court has not given the New York Court of Appeals very much to work with. It will pretty much have to start from scratch.
I strongly support same sex marriage, but my decided preference is for legislatures to adopt reform of the marriage laws rather than have courts impose the reform. If courts are going to get involved, I greatly prefer the approach of the Vermont Supreme Court in Baker v. State-- hold that the current law is unconstitutional, explain the rough contours of the constitutional principles that a statute would have to satisfy, and send the issue to the legislature to come up with a solution. That is not the same thing as having the legislature take the issue up on its own, but it does have the advantage of giving the result some degree of democratic ratification. My view is that this is probably what the U.S. Supreme Court should have done in Roe v. Wade and Doe v. Bolton as well.
For this reason, I would argue that if the New York Court of Appeals decides to uphold this case (although it will have to be on different grounds), it should reverse the trial court's remedy and give the New York Legislature 90 days to come up with a statutory solution.
Posted
11:17 AM
by JB [link]
Comments:
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It would be nice if we could get some judges to put out some better reasoned opinions when they are tackling such epic legal questions. Earlier this year an Arkansas state judge struck down a ban on adoptions by gay couples based upon a legal technicality rather than any constitutional issue. While the case was a "victory" it was also a cop-out.
Further comments here: http://www.jurispundit.com
Further comments here: http://www.jurispundit.com
Having linked to Prof. Balkin's spot-on analysis, I find myself wondering why trial courts are handling constitutional challenges in the first place. I think trial judges are more prone to sweeping, conclusory rulings based on legal hunches, because that's how so much of the work of a trial judge does (and must) go. (See old joke at end of comment.)
Would there be any loss in rewriting the rules of the game so that pure constitutionality challenges go straight to an appellate court?
Old joke:
Three hunters go out duck hunting at a private game reserve: a law prof, an appellate judge, and a trial judge. The guide took them out to the blinds and stationed them there, and told them "Now there’s just one thing I need to tell you before I leave. You’re here to shoot ducks. And this reserve has very strong, strict rules here. If you shoot anything but a duck, you will be asked to leave."
The guide left, and the three, were out there, and pretty soon things started appearing on the horizon, flying toward them. So, they looked at each other, the judges said to the law professor, “I think you ought to take the first shot.” So, the law professor says, “OK!” He stood up, and a bird started flying towards him and looked at it and he said, “Well, I’ve spent many years studying the law and written many a learned treatise on it, and I would say by the speed and conformation of that fowl, that’s probably a duck.” By that time the bird was gone.
The next one started flying, and the trial judge turned to the appellate judge and said, “Well, I think you ought to take the shot.” The appellate judge says, “OK!” The appellate judge stood up and said, “Well, I see from the color and the markings of this bird and based upon my many years on the bench and studying briefs and writing learned opinions, I’d say that’s probably a duck.” By that time the bird was gone.
The trial judge stood up, next one came, he raised his shotgun and--bamm!--shot it, and said, “Damn, I hope that was a duck!”
Would there be any loss in rewriting the rules of the game so that pure constitutionality challenges go straight to an appellate court?
Old joke:
Three hunters go out duck hunting at a private game reserve: a law prof, an appellate judge, and a trial judge. The guide took them out to the blinds and stationed them there, and told them "Now there’s just one thing I need to tell you before I leave. You’re here to shoot ducks. And this reserve has very strong, strict rules here. If you shoot anything but a duck, you will be asked to leave."
The guide left, and the three, were out there, and pretty soon things started appearing on the horizon, flying toward them. So, they looked at each other, the judges said to the law professor, “I think you ought to take the first shot.” So, the law professor says, “OK!” He stood up, and a bird started flying towards him and looked at it and he said, “Well, I’ve spent many years studying the law and written many a learned treatise on it, and I would say by the speed and conformation of that fowl, that’s probably a duck.” By that time the bird was gone.
The next one started flying, and the trial judge turned to the appellate judge and said, “Well, I think you ought to take the shot.” The appellate judge says, “OK!” The appellate judge stood up and said, “Well, I see from the color and the markings of this bird and based upon my many years on the bench and studying briefs and writing learned opinions, I’d say that’s probably a duck.” By that time the bird was gone.
The trial judge stood up, next one came, he raised his shotgun and--bamm!--shot it, and said, “Damn, I hope that was a duck!”
It seems that Professor Balkin prefers a form of "dialogue" between the court and legislature on this point. I agree. It is certainly preferable in these circumstances for the legislature, rather than the courts, to write new laws that are consistent with the principles as articulated (though, this decision appears to lack analysis on this point). The Courts should articulate principles and the legislature should be writing the laws.
In Canada, various Supreme Court of Canada decisions have invoked the metaphor of a "Charter dialogue" (Charter being the Canadian Charter of Rights and Freedoms) between legislatures and courts, wherein elected representatives "reply" to constitutional rulings of the Court by enacting new legislation that supposedly reflects the representatives' view on what is required by the constitutional principles articulated by the Court.
In Canada, various Supreme Court of Canada decisions have invoked the metaphor of a "Charter dialogue" (Charter being the Canadian Charter of Rights and Freedoms) between legislatures and courts, wherein elected representatives "reply" to constitutional rulings of the Court by enacting new legislation that supposedly reflects the representatives' view on what is required by the constitutional principles articulated by the Court.
The courts should articulate principles and the legislature should be writing the laws? That's a strange way to separate powers. It reduces the legislature to the status of clerks for the judiciary.
Principles are revealed or determined by debate in the legislature (in theory, anyway). That is why legislatures have enough members to stage debates. The judiciary has, among other things, the responsibility for resolving conflicts between laws. In constitutional cases, the Constitution is one of the laws - the supreme law of the land - and the court determines whether or not there is a conflict, and if so, strikes down the conflicting law.
And as a practical matter, I would expect any legislature to be a bit huffy if presented with "guidance" from a mere judge.
Principles are revealed or determined by debate in the legislature (in theory, anyway). That is why legislatures have enough members to stage debates. The judiciary has, among other things, the responsibility for resolving conflicts between laws. In constitutional cases, the Constitution is one of the laws - the supreme law of the land - and the court determines whether or not there is a conflict, and if so, strikes down the conflicting law.
And as a practical matter, I would expect any legislature to be a bit huffy if presented with "guidance" from a mere judge.
Perhaps I should clarify my comments. Obviously, there are certain principles that underly a given legislative or constitutional provision that will help understand the purpose or object of that provision. Courts have always attempted to discern the purpose of a provision, often using both legal and constitutional principles.
The idea of "dialogue" means that not just the Courts but also the legislature play an active role in articulating principles, be it constitutional or otherwise; not leaving such tasks for only courts to embark upon.
So, when you say that principles are articulated during debates in the legislature, I certainly agree with you; I just think those principles are to be clearly delineated in a piece of legislation that responds to a given constitutional ruling of a court.
The idea of "dialogue" means that not just the Courts but also the legislature play an active role in articulating principles, be it constitutional or otherwise; not leaving such tasks for only courts to embark upon.
So, when you say that principles are articulated during debates in the legislature, I certainly agree with you; I just think those principles are to be clearly delineated in a piece of legislation that responds to a given constitutional ruling of a court.
The right to marry, including deciding who to marry (is this supposed to be a strange statement on the judge's part?), has long been held to bea fundamental right by the Supreme Court. "Fundamental" means there must be a compelling reason, especially if the law discriminates. Cases of incest provide said reason. Also, when the Supremes spell out why a law invades this right, it tends not to distinguish (surely not in much detail) incest etc. each time.
Just because a ruling is "short" does not make it necessraily unconvincing. In fact, Lawrence v. Texas, which Prof. Balkin (though one might not know it from the temper of his remarks here) throughly praised, was at times rather short in analytical detail. Did he find it "unconvincing?" Some might argue that finding the current regime "irrational" is not too hard at any rate.
Also, this is only a district court ruling. Prof. Balkin's bottom line is reasonable, but shouldn't it be left to the highest court to settle on such a remedy? In fact, the judge here did justify her particular remedy, backing up her reasoning with precedent (respecting a gender specific rape law). Anyway, who listens to district court rulings on subjects destined to be appealled anyway?
Also, as to his Roe remarks, was that generally done in 1973? It might be worth mentioning that the district court basically left the state to handle the details, not even supplying an injunction. The state continued to prosecute.
Trouble accessing the .pdf file leads me to be unable to read the whole ruling, but the Professor's remarks are a bit strange as well.
Just because a ruling is "short" does not make it necessraily unconvincing. In fact, Lawrence v. Texas, which Prof. Balkin (though one might not know it from the temper of his remarks here) throughly praised, was at times rather short in analytical detail. Did he find it "unconvincing?" Some might argue that finding the current regime "irrational" is not too hard at any rate.
Also, this is only a district court ruling. Prof. Balkin's bottom line is reasonable, but shouldn't it be left to the highest court to settle on such a remedy? In fact, the judge here did justify her particular remedy, backing up her reasoning with precedent (respecting a gender specific rape law). Anyway, who listens to district court rulings on subjects destined to be appealled anyway?
Also, as to his Roe remarks, was that generally done in 1973? It might be worth mentioning that the district court basically left the state to handle the details, not even supplying an injunction. The state continued to prosecute.
Trouble accessing the .pdf file leads me to be unable to read the whole ruling, but the Professor's remarks are a bit strange as well.
The punch line of the "duck hunting" joke may have been the basis for the torture memos on the treatment of the Gitmo prisoners not covered by the Geneva Convention.
I think the reason the court's explanation is poor is because they did not set out to actually make a sound decision, but rather to justify the decision they sought to make. The problem the courts are running into is that they are trying to ignore the entire concept of the institution of marriage. The argument that marriage was not defined as between a man and a woman is ridiculous; that is exactly what the term meant at the time the statutes were written. Nobody at the time was confused about that aspect, and probably couldn't conceive of future generations being uncertain. It is intelectually dishonest to pretend the statutes are somehow ambiguous. Let the legislatures introduce gay "marriage" as a new institution, becuase that is what it is. What is happening right now is that the courts are impatient and want gay marriage legalized now, so they are writing poor opinions with the goal of bypassing the legislature. The end results is that the body of law legalizing gay marriage will be weak and easily overturned by future courts who will recognize the failure of constitutional judgement. Judges need to be more technocratic and less philosophical about their judgements. As I recall, the original purpose of the judiciary was to prevent the legislature from creating new laws that violated the constitution. What we have now is a judiciary that is making up its own laws by dishonestly claiming that a word like "marriage" was not carefully defined. What about the precedent this sets for future reasoning? What other terms can we claim were not properly defined? We could change the definition of citizenship, the military, or even the judiciary itself.
The weakness of the entire argument on marriage (both sides) is that nobody really seems willing to stake out what are the compelling reasons to insert the state into the entire mess in the first place. You could go through every one of the 1049 laws mentioning marriage in the federal code and strike them out entire and not have a reasonable Constitutional challenge. You could do the same thing to the state code in every 50 states.
Once you have wiped out marriage law in its entirety, you could introduce a bill to give some privilege to some relationships over others in the law. Why would any of it pass muster? The hard truth is that there are state purposes to marriage in the continuance of society and in the stability of the social order that people aren't comfortable advocating in today's environment.
Let me take up the case for incest for a moment. Why is it banned? It can't be for genetic reasons. We don't ban marriage between any sort of couple that has the same or higher rates of genetic abnormality as an occasional 1st cousin pairing would provide. So why are 1st cousin marriages banned in so many states? You could extend the argument to any level of consanguinity and not encounter anything that would offend the judge in Hernandez v Robles. Tripartite lesbian relations are even at the edge of Hernandez as some of the plaintiffs are lesbian couples who have essentially rented a man's gonads to get a child. If the rest of the man comes along for the ride and wants to raise the child, what's the rationale stopping a more involved father from becoming part of a group marriage?
This is an awful decision.
Once you have wiped out marriage law in its entirety, you could introduce a bill to give some privilege to some relationships over others in the law. Why would any of it pass muster? The hard truth is that there are state purposes to marriage in the continuance of society and in the stability of the social order that people aren't comfortable advocating in today's environment.
Let me take up the case for incest for a moment. Why is it banned? It can't be for genetic reasons. We don't ban marriage between any sort of couple that has the same or higher rates of genetic abnormality as an occasional 1st cousin pairing would provide. So why are 1st cousin marriages banned in so many states? You could extend the argument to any level of consanguinity and not encounter anything that would offend the judge in Hernandez v Robles. Tripartite lesbian relations are even at the edge of Hernandez as some of the plaintiffs are lesbian couples who have essentially rented a man's gonads to get a child. If the rest of the man comes along for the ride and wants to raise the child, what's the rationale stopping a more involved father from becoming part of a group marriage?
This is an awful decision.
"Perhaps the court really means to say that as applied to same sex couples, the state has provided no compelling reasons for restricting who may marry, leaving to another day the question of whether there would be compelling reasons in cases of incest and polygamy. But if that is the holding of Hernandez-- and perhaps it is the best reading of the case-- the point is nowhere clearly expressed."
Actually the court says, "Defendant has articulated no legitimate State purpose that is rationally served by a bar to same-sex marriage, let alone a compelling State interest in such a bar."
Actually the court says, "Defendant has articulated no legitimate State purpose that is rationally served by a bar to same-sex marriage, let alone a compelling State interest in such a bar."
Excellent post, one which this gay person agrees fully. It's a shame the court's decision failed to distinguish same-sex marriage from polygamy and incest. It's an oversight that (as I argue on my blog) the religious right is already exploiting.
I'm not really sure how one does distinguish same-sex marriage from incest, assuming that the individuals involved are consenting adults. If you limit marriage to two people who love one another and need not procreate, then that includes a brother and sister or two sisters or a grandparent and grandchild, or what-have-you. If you limit marriage to erotic love between two persons, that eliminates polygamy, but not incest. But if marriage is about erotic love, then I'm not sure why six people can't have sex with each other and have their sex acts sanctioned by the state. And if marriage is not about erotic love, but is about distributing property rights between persons who love one another, I'm not sure why two brothers or five brothers can't spread their insurance costs amongst each other by getting married. Where to draw the line and how to draw the line is quite problematic and consequential, which is perhaps why only legislatures instead of courts should handle re-defining "family." But I don't think it is obvious that incest and polygamy do not follow from same-sex marriage at a high enough level of generality, which is perhaps why the omission of discussion of these issues was so remarkable in the NY opinion. It's like the judge who wrote it never went to law school.
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mesothelioma Mesotheliomais a form of cancer that is almost always caused by exposure to Asbestos In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the body's internal organs. Its most common site is the pleura (outer lining of the lungs and internal chest wall), but it may also occur in the peritoneum (the lining of the abdominal cavity), the heart the pericardium (a sac that surrounds the heart or tunica vaginalis.
Most people who develop
mesothelioma have worked on jobs where they inhaled asbestos particles, or they have been exposed to asbestos dust and fiber in other ways. Washing the clothes of a family member who worked with asbestos can also put a person at risk for developing Mesothelioma Unlike lung cancer, there is no association between mesothelioma and smoking but smoking greatly increases risk of other asbestos induced cancer.Compensation via
Asbestos funds or lawsuits is an important issue in
mesothelioma The symptoms of
mesothelioma include shortness of breath due to pleural effusion (fluid between the lung and the chest wall or chest wall pain, and general symptoms such as weight loss. The diagnosis may be suspected with chest X-ray and CT scan and is confirmed with a biopsy (tissue sample) and microscopic examination. A thoracoscopy inserting a tube with a camera into the chest) can be used to take biopsies. It allows the introduction of substances such as talc to obliterate the pleural space (called pleurodesis, which prevents more fluid from accumulating and pressing on the lung. Despite treatment with chemotherapy, radiation therapy or sometimes surgery, the disease carries a poor prognosis. Research about screening tests for the early detection of mesothelioma is ongoing.
Symptoms of mesothelioma may not appear until 20 to 50 years after exposure to asbestos. Shortness of breath, cough, and pain in the chest due to an accumulation of fluid in the pleural space are often symptoms of pleural
mesotheliomaSymptoms of peritoneal
mesothelioma include weight loss and cachexia, abdominal swelling and pain due to ascites (a buildup of fluid in the abdominal cavity). Other symptoms of peritoneal
mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions.
Mesothelioma that affects the pleura can cause these signs and symptoms:
chest wall pain
pleural effusion, or fluid surrounding the lung
shortness of breath
fatigue or anemia
wheezing, hoarseness, or cough
blood in the sputum (fluid) coughed up hemoptysis
In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung The disease may metastasize, or spread, to other parts of the body.
Tumors that affect the abdominal cavity often do not cause symptoms until they are at a late stage. Symptoms include:
abdominal pain
ascites, or an abnormal buildup of fluid in the abdomen
a mass in the abdomen
problems with bowel function
weight loss
In severe cases of the disease, the following signs and symptoms may be present:
blood clots in the veins, which may cause thrombophlebitis
disseminated intravascular coagulation a disorder causing severe bleeding in many body organs
jaundice, or yellowing of the eyes and skin
low blood sugar level
pleural effusion
pulmonary emboli, or blood clots in the arteries of the lungs
severe ascites
A
mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs
Diagnosing
mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history. A history of exposure to asbestos may increase clinical suspicion for
mesothelioma A physical examination is performed, followed by chest X-ray and often lung function tests. The X-ray may reveal pleural thickening commonly seen after asbestos exposure and increases suspicion of
mesothelioma A CT (or CAT) scan or an MRI is usually performed. If a large amount of fluid is present, abnormal cells may be detected by cytology if this fluid is aspirated with a syringe. For pleural fluid this is done by a pleural tap or chest drain, in ascites with an paracentesis or ascitic drain and in a pericardial effusion with pericardiocentesis. While absence of malignant cells on cytology does not completely exclude
mesothelioma it makes it much more unlikely, especially if an alternative diagnosis can be made (e.g. tuberculosis, heart failure
If cytology is positive or a plaque is regarded as suspicious, a biopsy is needed to confirm a diagnosis of
mesothelioma A doctor removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples.
If the cancer is in the abdomen, the doctor may perform a laparoscopy. To obtain tissue for examination, the doctor makes a small incision in the abdomen and inserts a special instrument into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
There is no universally agreed protocol for screening people who have been exposed to
asbestosScreening tests might diagnose mesothelioma earlier than conventional methods thus improving the survival prospects for patients. The serum osteopontin level might be useful in screening asbestos-exposed people for
mesotheliomaThe level of soluble mesothelin-related protein is elevated in the serum of about 75% of patients at diagnosis and it has been suggested that it may be useful for screening. Doctors have begun testing the Mesomark assay which measures levels of soluble mesothelin-related proteins (SMRPs) released by diseased mesothelioma cells
Incidence
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. The incidence rate is approximately one per 1,000,000. The highest incidence is found in Britain, Australia and Belgium: 30 per 1,000,000 per year. For comparison, populations with high levels of smoking can have a lung cancer incidence of over 1,000 per 1,000,000. Incidence of malignant mesothelioma currently ranges from about 7 to 40 per 1,000,000 in industrialized Western nations, depending on the amount of asbestos exposure of the populations during the past several decades. It has been estimated that incidence may have peaked at 15 per 1,000,000 in the United States in 2004. Incidence is expected to continue increasing in other parts of the world. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age. Approximately one fifth to one third of all mesotheliomas are peritoneal.
Between 1940 and 1979, approximately 27.5 million people were occupationally exposed to asbestos in the United States.[ Between 1973 and 1984, there has been a threefold increase in the diagnosis of pleural mesothelioma in Caucasian males. From 1980 to the late 1990s, the death rate from mesothelioma in the USA increased from 2,000 per year to 3,000, with men four times more likely to acquire it than women. These rates may not be accurate, since it is possible that many cases of mesothelioma are misdiagnosed as adenocarcinoma of the lung, which is difficult to differentiate from mesothelioma.
Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure exists in almost all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos. In rare cases, mesothelioma has also been associated with irradiation, intrapleural thorium dioxide (Thorotrast), and inhalation of other fibrous silicates, such as erionite.
asbestos
is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven.
asbestos
has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
The combination of smoking and
asbestos exposure significantly increases a person's risk of developing cancer of the airways (lung cancer bronchial carcinoma). The Kent brand of cigarettes used
mesothelioma in its filters for the first few years of production in the 1950s and some cases of
. have resulted. Smoking modern cigarettes does not appear to increase the risk of mesothelioma.
Some studies suggest that simian virus 40 may act as a cofactor in the development of mesothelioma.
Asbestos was known in antiquity, but it wasn't mined and widely used commercially until the late 1800s. Its use greatly increased during World War II Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with
. exposure were not publicly known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of
. exposure in the workplace, and created guidelines for engineering controls and respirators, protective clothing, exposure monitoring, hygiene facilities and practices, warning signs, labeling, recordkeeping, and medical exams. By contrast, the British Government's Health and Safety Executive (HSE) states formally that any threshold for
mesothelioma must be at a very low level and it is widely agreed that if any such threshold does exist at all, then it cannot currently be quantified. For practical purposes, therefore, HSE does not assume that any such threshold exists. People who work with
asbestos wear personal protective equipment to lower their risk of exposure. Recent findings have shown that a mineral called erionite has been known to cause genetically pre-dispositioned individuals to have malignant mesothelioma rates much higher than those not pre-dispositioned genetically. A study in Cappadocia, Turkey has shown that 3 villiages in Turkey have death rates of 51% attributed to erionite related
mesotheliomaExposure to
asbestos fibres has been recognised as an occupational health hazard since the early 1900s. Several epidemiological studies have associated exposure to asbestos with the development of lesions such as asbestos bodies in the sputum, pleural plaques, diffuse pleural thickening, asbestosis, carcinoma of the lung and larynx, gastrointestinal tumours, and diffuse mesothelioma of the pleura and peritoneum.
The documented presence of
asbestos fibres in water supplies and food products has fostered concerns about the possible impact of long-term and, as yet, unknown exposure of the general population to these fibres. Although many authorities consider brief or transient exposure to
asbestos fibres as inconsequential and an unlikely risk factor, some epidemiologists claim that there is no risk threshold. Cases of mesothelioma have been found in people whose only exposure was breathing the air through ventilation systems. Other cases had very minimal (3 months or less) direct exposure.
Commercial
asbestos mining at Wittenoom, Western Australia, occurred between 1945 and 1966. A cohort study of miners employed at the mine reported that while no deaths occurred within the first 10 years after crocidolite exposure, 85 deaths attributable to mesothelioma had occurred by 1985. By 1994, 539 reported deaths due to mesothelioma had been reported in Western Australia.
Family members and others living with
asbestos workers have an increased risk of developing
mesothelioma and possibly other asbestos related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to asbestosMany building materials used in both public and domestic premises prior to the banning of
asbestos may contain
asbestos Those performing renovation works or activities may expose themselves to asbestos dust. In the UK use of Chrysotile asbestos was banned at the end of 1999. Brown and blue
asbestos was banned in the UK around 1985. Buildings built or renovated prior to these dates may contain asbestos materials.
For patients with localized disease, and who can tolerate a radical surgery, radiation is often given post-operatively as a consolidative treatment. The entire hemi-thorax is treated with radiation therapy, often given simultaneously with chemotherapy. Delivering radiation and chemotherapy after a radical surgery has led to extended life expectancy in selected patient populations with some patients surviving more than 5 years. As part of a curative approach to
mesothelioma radiotherapy is also commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall.
Although
mesothelioma is generally resistant to curative treatment with radiotherapy alone, palliative treatment regimens are sometimes used to relieve symptoms arising from tumor growth, such as obstruction of a major blood vessel.
Radiation Therapy when given alone with curative intent has never been shown to improve survival from
mesothelioma The necessary radiation dose to treat mesothelioma that has not been surgically removed would be very toxic.
Chemotherapy is the only treatment for
mesothelioma that has been proven to improve survival in randomised and controlled trials. The landmark study published in 2003 by Vogelzang and colleagues compared cisplatin chemotherapy alone with a combination of cisplatin and pemetrexed (brand name Alimta) chemotherapy) in patients who had not received chemotherapy for malignant pleural mesothelioma previously and were not candidates for more aggressive "curative" surgery. This trial was the first to report a survival advantage from chemotherapy in malignant pleural
mesothelioma showing a statistically significant improvement in median survival from 10 months in the patients treated with cisplatin alone to 13.3 months in the combination pemetrexed group in patients who received supplementation with folate and vitamin B12. Vitamin supplementation was given to most patients in the trial and pemetrexed related side effects were significantly less in patients receiving pemetrexed when they also received daily oral folate 500mcg and intramuscular vitamin B12 1000mcg every 9 weeks compared with patients receiving pemetrexed without vitamin supplementation. The objective response rate increased from 20% in the cisplatin group to 46% in the combination pemetrexed group. Some side effects such as nausea and vomiting, stomatitis, and diarrhoea were more common in the combination pemetrexed group but only affected a minority of patients and overall the combination of pemetrexed and cisplatin was well tolerated when patients received vitamin supplementation; both quality of life and lung function tests improved in the combination pemetrexed group. In February 2004, the United States Food and Drug Administration approved pemetrexed for treatment of malignant pleural mesothelioma. However, there are still unanswered questions about the optimal use of chemotherapy, including when to start treatment, and the optimal number of cycles to give.
Cisplatin in combination with raltitrexed has shown an improvement in survival similar to that reported for pemetrexed in combination with cisplatin, but raltitrexed is no longer commercially available for this indication. For patients unable to tolerate pemetrexed, cisplatin in combination with gemcitabine or vinorelbine is an alternative, although a survival benefit has not been shown for these drugs. For patients in whom cisplatin cannot be used, carboplatin can be substituted but non-randomised data have shown lower response rates and high rates of haematological toxicity for carboplatin-based combinations, albeit with similar survival figures to patients receiving cisplatin.
In January 2009, the United States FDA approved using conventional therapies such as surgery in combination with radiation and or chemotherapy on stage I or II Mesothelioma after research conducted by a nationwide study by Duke University concluded an almost 50 point increase in remission rates.
Treatment regimens involving immunotherapy have yielded variable results. For example, intrapleural inoculation of Bacillus Calmette-Guérin (BCG) in an attempt to boost the immune response, was found to be of no benefit to the patient (while it may benefit patients with bladder cancer.
mesothelioma cells proved susceptible to in vitro lysis by LAK cells following activation by interleukin-2 (IL-2), but patients undergoing this particular therapy experienced major side effects. Indeed, this trial was suspended in view of the unacceptably high levels of IL-2 toxicity and the severity of side effects such as fever and cachexia. Nonetheless, other trials involving interferon alpha have proved more encouraging with 20% of patients experiencing a greater than 50% reduction in tumor mass combined with minimal side effects.
A procedure known as heated intraoperative intraperitoneal chemotherapy was developed by at the Washington Cancer Institute. The surgeon removes as much of the tumor as possible followed by the direct administration of a chemotherapy agent, heated to between 40 and 48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes and then drained.
This technique permits the administration of high concentrations of selected drugs into the abdominal and pelvic surfaces. Heating the chemotherapy treatment increases the penetration of the drugs into tissues. Also, heating itself damages the malignant cells more than the normal cells.
What is the mesothelium?
The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs to glide easily against adjacent structures.
The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The
mesothelioma tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.
What is mesothelioma?
mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs.
cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.
How common is mesothelioma?
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. About 2,000 new cases of mesothelioma are diagnosed in the United States each year. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age.
What are the risk factors for mesothelioma?
Working with asbestos is the major risk factor for mesothelioma. A history of . exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to
Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. . has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person's risk of developing cancer of the air passageways in the lung.
Who is at increased risk for developing mesothelioma?
asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.
The risk o f asbestosrelated disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.
There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to
asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.
What are the symptoms of mesothelioma?
Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to
asbestos Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma. Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis
How is
mesotheliomadiagnosed?
Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.
A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the
cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the
cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.
Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.
How is
.treated?
Treatment for mesothelioma depends on the location of the
cancerthe stage of the disease, and the patient's age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.
Surgery is a common treatment for
mesotheliomaThe doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural
mesotheliomaa lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.
Stereo Tactic Radiation Therapy also called radiotherapy, involves the use of high-energy rays to kill
cancercells and shrink tumors Radiation therapy affects the
cancercells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the
cancercells are found (internal radiation therapy).
Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat
mesotheliomaare given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).
To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation Therapy and surgery may also be helpful in relieving symptoms.
Most people who develop
mesothelioma have worked on jobs where they inhaled asbestos particles, or they have been exposed to asbestos dust and fiber in other ways. Washing the clothes of a family member who worked with asbestos can also put a person at risk for developing Mesothelioma Unlike lung cancer, there is no association between mesothelioma and smoking but smoking greatly increases risk of other asbestos induced cancer.Compensation via
Asbestos funds or lawsuits is an important issue in
mesothelioma The symptoms of
mesothelioma include shortness of breath due to pleural effusion (fluid between the lung and the chest wall or chest wall pain, and general symptoms such as weight loss. The diagnosis may be suspected with chest X-ray and CT scan and is confirmed with a biopsy (tissue sample) and microscopic examination. A thoracoscopy inserting a tube with a camera into the chest) can be used to take biopsies. It allows the introduction of substances such as talc to obliterate the pleural space (called pleurodesis, which prevents more fluid from accumulating and pressing on the lung. Despite treatment with chemotherapy, radiation therapy or sometimes surgery, the disease carries a poor prognosis. Research about screening tests for the early detection of mesothelioma is ongoing.
Symptoms of mesothelioma may not appear until 20 to 50 years after exposure to asbestos. Shortness of breath, cough, and pain in the chest due to an accumulation of fluid in the pleural space are often symptoms of pleural
mesotheliomaSymptoms of peritoneal
mesothelioma include weight loss and cachexia, abdominal swelling and pain due to ascites (a buildup of fluid in the abdominal cavity). Other symptoms of peritoneal
mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions.
Mesothelioma that affects the pleura can cause these signs and symptoms:
chest wall pain
pleural effusion, or fluid surrounding the lung
shortness of breath
fatigue or anemia
wheezing, hoarseness, or cough
blood in the sputum (fluid) coughed up hemoptysis
In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung The disease may metastasize, or spread, to other parts of the body.
Tumors that affect the abdominal cavity often do not cause symptoms until they are at a late stage. Symptoms include:
abdominal pain
ascites, or an abnormal buildup of fluid in the abdomen
a mass in the abdomen
problems with bowel function
weight loss
In severe cases of the disease, the following signs and symptoms may be present:
blood clots in the veins, which may cause thrombophlebitis
disseminated intravascular coagulation a disorder causing severe bleeding in many body organs
jaundice, or yellowing of the eyes and skin
low blood sugar level
pleural effusion
pulmonary emboli, or blood clots in the arteries of the lungs
severe ascites
A
mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs
Diagnosing
mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history. A history of exposure to asbestos may increase clinical suspicion for
mesothelioma A physical examination is performed, followed by chest X-ray and often lung function tests. The X-ray may reveal pleural thickening commonly seen after asbestos exposure and increases suspicion of
mesothelioma A CT (or CAT) scan or an MRI is usually performed. If a large amount of fluid is present, abnormal cells may be detected by cytology if this fluid is aspirated with a syringe. For pleural fluid this is done by a pleural tap or chest drain, in ascites with an paracentesis or ascitic drain and in a pericardial effusion with pericardiocentesis. While absence of malignant cells on cytology does not completely exclude
mesothelioma it makes it much more unlikely, especially if an alternative diagnosis can be made (e.g. tuberculosis, heart failure
If cytology is positive or a plaque is regarded as suspicious, a biopsy is needed to confirm a diagnosis of
mesothelioma A doctor removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples.
If the cancer is in the abdomen, the doctor may perform a laparoscopy. To obtain tissue for examination, the doctor makes a small incision in the abdomen and inserts a special instrument into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
There is no universally agreed protocol for screening people who have been exposed to
asbestosScreening tests might diagnose mesothelioma earlier than conventional methods thus improving the survival prospects for patients. The serum osteopontin level might be useful in screening asbestos-exposed people for
mesotheliomaThe level of soluble mesothelin-related protein is elevated in the serum of about 75% of patients at diagnosis and it has been suggested that it may be useful for screening. Doctors have begun testing the Mesomark assay which measures levels of soluble mesothelin-related proteins (SMRPs) released by diseased mesothelioma cells
Incidence
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. The incidence rate is approximately one per 1,000,000. The highest incidence is found in Britain, Australia and Belgium: 30 per 1,000,000 per year. For comparison, populations with high levels of smoking can have a lung cancer incidence of over 1,000 per 1,000,000. Incidence of malignant mesothelioma currently ranges from about 7 to 40 per 1,000,000 in industrialized Western nations, depending on the amount of asbestos exposure of the populations during the past several decades. It has been estimated that incidence may have peaked at 15 per 1,000,000 in the United States in 2004. Incidence is expected to continue increasing in other parts of the world. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age. Approximately one fifth to one third of all mesotheliomas are peritoneal.
Between 1940 and 1979, approximately 27.5 million people were occupationally exposed to asbestos in the United States.[ Between 1973 and 1984, there has been a threefold increase in the diagnosis of pleural mesothelioma in Caucasian males. From 1980 to the late 1990s, the death rate from mesothelioma in the USA increased from 2,000 per year to 3,000, with men four times more likely to acquire it than women. These rates may not be accurate, since it is possible that many cases of mesothelioma are misdiagnosed as adenocarcinoma of the lung, which is difficult to differentiate from mesothelioma.
Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure exists in almost all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos. In rare cases, mesothelioma has also been associated with irradiation, intrapleural thorium dioxide (Thorotrast), and inhalation of other fibrous silicates, such as erionite.
asbestos
is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven.
asbestos
has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
The combination of smoking and
asbestos exposure significantly increases a person's risk of developing cancer of the airways (lung cancer bronchial carcinoma). The Kent brand of cigarettes used
mesothelioma in its filters for the first few years of production in the 1950s and some cases of
. have resulted. Smoking modern cigarettes does not appear to increase the risk of mesothelioma.
Some studies suggest that simian virus 40 may act as a cofactor in the development of mesothelioma.
Asbestos was known in antiquity, but it wasn't mined and widely used commercially until the late 1800s. Its use greatly increased during World War II Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with
. exposure were not publicly known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of
. exposure in the workplace, and created guidelines for engineering controls and respirators, protective clothing, exposure monitoring, hygiene facilities and practices, warning signs, labeling, recordkeeping, and medical exams. By contrast, the British Government's Health and Safety Executive (HSE) states formally that any threshold for
mesothelioma must be at a very low level and it is widely agreed that if any such threshold does exist at all, then it cannot currently be quantified. For practical purposes, therefore, HSE does not assume that any such threshold exists. People who work with
asbestos wear personal protective equipment to lower their risk of exposure. Recent findings have shown that a mineral called erionite has been known to cause genetically pre-dispositioned individuals to have malignant mesothelioma rates much higher than those not pre-dispositioned genetically. A study in Cappadocia, Turkey has shown that 3 villiages in Turkey have death rates of 51% attributed to erionite related
mesotheliomaExposure to
asbestos fibres has been recognised as an occupational health hazard since the early 1900s. Several epidemiological studies have associated exposure to asbestos with the development of lesions such as asbestos bodies in the sputum, pleural plaques, diffuse pleural thickening, asbestosis, carcinoma of the lung and larynx, gastrointestinal tumours, and diffuse mesothelioma of the pleura and peritoneum.
The documented presence of
asbestos fibres in water supplies and food products has fostered concerns about the possible impact of long-term and, as yet, unknown exposure of the general population to these fibres. Although many authorities consider brief or transient exposure to
asbestos fibres as inconsequential and an unlikely risk factor, some epidemiologists claim that there is no risk threshold. Cases of mesothelioma have been found in people whose only exposure was breathing the air through ventilation systems. Other cases had very minimal (3 months or less) direct exposure.
Commercial
asbestos mining at Wittenoom, Western Australia, occurred between 1945 and 1966. A cohort study of miners employed at the mine reported that while no deaths occurred within the first 10 years after crocidolite exposure, 85 deaths attributable to mesothelioma had occurred by 1985. By 1994, 539 reported deaths due to mesothelioma had been reported in Western Australia.
Family members and others living with
asbestos workers have an increased risk of developing
mesothelioma and possibly other asbestos related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to asbestosMany building materials used in both public and domestic premises prior to the banning of
asbestos may contain
asbestos Those performing renovation works or activities may expose themselves to asbestos dust. In the UK use of Chrysotile asbestos was banned at the end of 1999. Brown and blue
asbestos was banned in the UK around 1985. Buildings built or renovated prior to these dates may contain asbestos materials.
For patients with localized disease, and who can tolerate a radical surgery, radiation is often given post-operatively as a consolidative treatment. The entire hemi-thorax is treated with radiation therapy, often given simultaneously with chemotherapy. Delivering radiation and chemotherapy after a radical surgery has led to extended life expectancy in selected patient populations with some patients surviving more than 5 years. As part of a curative approach to
mesothelioma radiotherapy is also commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall.
Although
mesothelioma is generally resistant to curative treatment with radiotherapy alone, palliative treatment regimens are sometimes used to relieve symptoms arising from tumor growth, such as obstruction of a major blood vessel.
Radiation Therapy when given alone with curative intent has never been shown to improve survival from
mesothelioma The necessary radiation dose to treat mesothelioma that has not been surgically removed would be very toxic.
Chemotherapy is the only treatment for
mesothelioma that has been proven to improve survival in randomised and controlled trials. The landmark study published in 2003 by Vogelzang and colleagues compared cisplatin chemotherapy alone with a combination of cisplatin and pemetrexed (brand name Alimta) chemotherapy) in patients who had not received chemotherapy for malignant pleural mesothelioma previously and were not candidates for more aggressive "curative" surgery. This trial was the first to report a survival advantage from chemotherapy in malignant pleural
mesothelioma showing a statistically significant improvement in median survival from 10 months in the patients treated with cisplatin alone to 13.3 months in the combination pemetrexed group in patients who received supplementation with folate and vitamin B12. Vitamin supplementation was given to most patients in the trial and pemetrexed related side effects were significantly less in patients receiving pemetrexed when they also received daily oral folate 500mcg and intramuscular vitamin B12 1000mcg every 9 weeks compared with patients receiving pemetrexed without vitamin supplementation. The objective response rate increased from 20% in the cisplatin group to 46% in the combination pemetrexed group. Some side effects such as nausea and vomiting, stomatitis, and diarrhoea were more common in the combination pemetrexed group but only affected a minority of patients and overall the combination of pemetrexed and cisplatin was well tolerated when patients received vitamin supplementation; both quality of life and lung function tests improved in the combination pemetrexed group. In February 2004, the United States Food and Drug Administration approved pemetrexed for treatment of malignant pleural mesothelioma. However, there are still unanswered questions about the optimal use of chemotherapy, including when to start treatment, and the optimal number of cycles to give.
Cisplatin in combination with raltitrexed has shown an improvement in survival similar to that reported for pemetrexed in combination with cisplatin, but raltitrexed is no longer commercially available for this indication. For patients unable to tolerate pemetrexed, cisplatin in combination with gemcitabine or vinorelbine is an alternative, although a survival benefit has not been shown for these drugs. For patients in whom cisplatin cannot be used, carboplatin can be substituted but non-randomised data have shown lower response rates and high rates of haematological toxicity for carboplatin-based combinations, albeit with similar survival figures to patients receiving cisplatin.
In January 2009, the United States FDA approved using conventional therapies such as surgery in combination with radiation and or chemotherapy on stage I or II Mesothelioma after research conducted by a nationwide study by Duke University concluded an almost 50 point increase in remission rates.
Treatment regimens involving immunotherapy have yielded variable results. For example, intrapleural inoculation of Bacillus Calmette-Guérin (BCG) in an attempt to boost the immune response, was found to be of no benefit to the patient (while it may benefit patients with bladder cancer.
mesothelioma cells proved susceptible to in vitro lysis by LAK cells following activation by interleukin-2 (IL-2), but patients undergoing this particular therapy experienced major side effects. Indeed, this trial was suspended in view of the unacceptably high levels of IL-2 toxicity and the severity of side effects such as fever and cachexia. Nonetheless, other trials involving interferon alpha have proved more encouraging with 20% of patients experiencing a greater than 50% reduction in tumor mass combined with minimal side effects.
A procedure known as heated intraoperative intraperitoneal chemotherapy was developed by at the Washington Cancer Institute. The surgeon removes as much of the tumor as possible followed by the direct administration of a chemotherapy agent, heated to between 40 and 48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes and then drained.
This technique permits the administration of high concentrations of selected drugs into the abdominal and pelvic surfaces. Heating the chemotherapy treatment increases the penetration of the drugs into tissues. Also, heating itself damages the malignant cells more than the normal cells.
What is the mesothelium?
The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs to glide easily against adjacent structures.
The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The
mesothelioma tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.
What is mesothelioma?
mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs.
cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.
How common is mesothelioma?
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. About 2,000 new cases of mesothelioma are diagnosed in the United States each year. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age.
What are the risk factors for mesothelioma?
Working with asbestos is the major risk factor for mesothelioma. A history of . exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to
Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. . has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person's risk of developing cancer of the air passageways in the lung.
Who is at increased risk for developing mesothelioma?
asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.
The risk o f asbestosrelated disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.
There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to
asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.
What are the symptoms of mesothelioma?
Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to
asbestos Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma. Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis
How is
mesotheliomadiagnosed?
Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.
A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the
cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the
cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.
Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.
How is
.treated?
Treatment for mesothelioma depends on the location of the
cancerthe stage of the disease, and the patient's age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.
Surgery is a common treatment for
mesotheliomaThe doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural
mesotheliomaa lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.
Stereo Tactic Radiation Therapy also called radiotherapy, involves the use of high-energy rays to kill
cancercells and shrink tumors Radiation therapy affects the
cancercells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the
cancercells are found (internal radiation therapy).
Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat
mesotheliomaare given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).
To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation Therapy and surgery may also be helpful in relieving symptoms.
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obat untuk herpes mulut
obat herpes di muka
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obat untuk menghilangkan herpes
cara menghilangkan herpes kelamin
obat nyeri herpes
obat nyeri herpes zoster
obat pereda nyeri herpes
nama obat herpes genitalis
nama obat herpes di apotik
obat penghilang nyeri herpes
obat untuk nyeri herpes
nama obat herpes
obat penghilang rasa nyeri herpes
nama obat herpes zoster
cara mengobati herpes kelamin
nama obat herpes simplex
obat pereda nyeri herpes zoster
obat herpes oles
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obat herpes untuk orang hamil
obat-obat herpes
obat herpes pada anak
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Obat herpes
obat herpes alami
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obat untuk menghilangkan herpes
cara menghilangkan herpes kelamin
obat nyeri herpes
obat nyeri herpes zoster
obat pereda nyeri herpes
nama obat herpes genitalis
nama obat herpes di apotik
obat penghilang nyeri herpes
obat untuk nyeri herpes
nama obat herpes
obat penghilang rasa nyeri herpes
nama obat herpes zoster
cara mengobati herpes kelamin
nama obat herpes simplex
obat pereda nyeri herpes zoster
obat herpes oles
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obat herpes untuk orang hamil
obat-obat herpes
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obat herpes pada bibir
Obat herpes
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Obat sipilis manjur atasi raja singa
obat sipilis di apotik
obat sipilis di apotik umum
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obat sipilis tradisional
obat sipilis paling ampuh
obat sipilis raja singa
obat sipilis pada wanita
obat sipilis resep dokter
obat tradisional kutil kelamin pada pria
propolis untuk obat kutil kelamin
obat alami untuk penyakit kutil kelamin
obat kutil kelamin resep dokter
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Obat wasir dan ambeyen
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obat sipilis di apotik
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propolis untuk obat kutil kelamin
obat alami untuk penyakit kutil kelamin
obat kutil kelamin resep dokter
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Obat wasir dan ambeyen
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Obat wasir dari dokter
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Obat wasir dragonrear
Obat wasir dimasukkan ke anus
Obat wasir di bandung
Obat wasir dr hembing
Obat wasir di pasaran
obat kutil kelamin resep dokter
resep obat kutil kelamin
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obat kutil di sekitar kelamin
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Obat kutil kelamin yang untuk wanita hamil
obat kutil kelamin terbaru
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cara menyembuhkan herpes kelamin
obat herpes pada alat kelamin pria
obat herpes paling mujarab
obat herpes paling ampuh
obat herpes paling manjur
obat herpes pada alat vital
obat herpes pada balita
obat herpes propolis
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Obat wasir untuk ibu hamil
Obat wasir untuk ibu hamil
Obat wasir apotik
Obat wasir paling ampuh
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Obat wasir di apotik
Obat wasir luar
Obat wasir ampuh di apotik
Obat wasir alami dari tumbuhan
Obat wasir untuk ibu menyusui
Obat wasir parah
Obat wasir venaron
Obat kutil kelamin
resep obat kutil kelamin
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obat kutil di sekitar kelamin
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Obat kutil kelamin yang untuk wanita hamil
obat kutil kelamin terbaru
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cara menyembuhkan herpes kelamin
obat herpes pada alat kelamin pria
obat herpes paling mujarab
obat herpes paling ampuh
obat herpes paling manjur
obat herpes pada alat vital
obat herpes pada balita
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obat herpes pada pria
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obat herpes penyakit kelamin
Obat wasir untuk ibu hamil
Obat wasir untuk ibu hamil
Obat wasir apotik
Obat wasir paling ampuh
Obat wasir ardium
Obat wasir di apotik
Obat wasir luar
Obat wasir ampuh di apotik
Obat wasir alami dari tumbuhan
Obat wasir untuk ibu menyusui
Obat wasir parah
Obat wasir venaron
Obat kutil kelamin
obat penyakit kutil kelamin
obat penghilang kutil kelamin
obat perontok kutil kelamin
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obat kutil kelamin resep dokter
resep obat kutil kelamin
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Obat kutil kelamin yang untuk wanita hamil
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obat herpes genital tradisional
obat herpes pada anak balita
obat herpes pdf
obat herpes pria
obat herpes pada payudara
obat herpes ringan
obat herpes rekuren
obat herpes resep dokter
obat untuk herpes ringan
resep obat herpes genital
resep obat herpes zoster
obat penghilang kutil kelamin
obat perontok kutil kelamin
obat tradisional kutil kelamin pada pria
obat kutil kelamin resep dokter
resep obat kutil kelamin
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obat kutil di sekitar kelamin
obat sakit kutil kelamin
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Obat kutil kelamin yang untuk wanita hamil
obat kutil kelamin terbaru
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obat tradisional untuk menyembuhkan kutil kelamin
obat herpes genital tradisional
obat herpes pada anak balita
obat herpes pdf
obat herpes pria
obat herpes pada payudara
obat herpes ringan
obat herpes rekuren
obat herpes resep dokter
obat untuk herpes ringan
resep obat herpes genital
resep obat herpes zoster
Obat herpes kelamin herbal de nature
Obat herpes
Obat herpes alami
Obat herpes zoster
Obat herpes kulit
Obat herpes simplex
Obat herpes genital
Obat herpes di apotik
Obat herpes kulit di apotik
Obat herpes genital di apotik
Obat herpes untuk bayi
resep obat kutil kelamin
obat kutil kelamin salep
obat kutil di sekitar kelamin
obat sakit kutil kelamin
obat kutil kelamin terbaik
Obat kutil kelamin yang untuk wanita hamil
obat kutil kelamin terbaru
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obat tradisional untuk kutil kelamin
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obat tradisional untuk menyembuhkan kutil kelamin
Obat jengger ayam ampuh
obat kutil kelamin salep
obat kutil di sekitar kelamin
obat sakit kutil kelamin
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obat tradisional untuk menyembuhkan kutil kelamin
Obat herpes simplex dan herpes zoster
Obat herpes alami
Obat herpes zoster
Obat herpes kulit
Obat herpes simplex
Obat herpes genital
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Obat herpes kulit di apotik
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Obat herpes untuk bayi
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Obat herpes alami
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Obat herpes kulit
Obat herpes simplex
Obat herpes genital
Obat herpes di apotik
Obat herpes kulit di apotik
Obat herpes genital di apotik
Obat herpes untuk bayi
resep obat kutil kelamin
obat kutil kelamin salep
obat kutil di sekitar kelamin
obat sakit kutil kelamin
obat kutil kelamin terbaik
Obat kutil kelamin yang untuk wanita hamil
obat kutil kelamin terbaru
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obat tradisional untuk kutil kelamin
obat herbal untuk kutil kelamin
obat tradisional untuk menyembuhkan kutil kelamin
Obat jengger ayam ampuh
obat kutil kelamin salep
obat kutil di sekitar kelamin
obat sakit kutil kelamin
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obat kutil kelamin terbaru
obat tradisional kutil kelamin
obat tradisional untuk kutil kelamin
obat herbal untuk kutil kelamin
obat tradisional untuk menyembuhkan kutil kelamin
Obat herpes simplex dan herpes zoster
Obat herpes alami
Obat herpes zoster
Obat herpes kulit
Obat herpes simplex
Obat herpes genital
Obat herpes di apotik
Obat herpes kulit di apotik
Obat herpes genital di apotik
Obat herpes untuk bayi
Obat herpes untuk ibu hamil
obat sipilis paling ampuh
obat sipilis yang ada di apotik
obat sipilis jogja
obat sipilis de nature
obat sipilis tradisional daun sirih
obat sipilis antibiotik
obat sipilis kimia farma
obat sipilis dokter
obat sipilis murah
obat sipilis thiamycin
obat sipilis apotik
Cara untuk menghilangkan jengger ayam
obat herbal untuk jengger ayam
obat penyakit kulit jengger ayam
obat untuk menghilangkan jengger ayam
obat penyakit jengger ayam alami
obat ampuh jengger ayam
obat antibiotik jengger ayam
obat alami untuk penyakit jengger ayam
obat ampuh penyakit jengger ayam
obat kutil atau jengger ayam
obat sipilis yang ada di apotik
obat sipilis jogja
obat sipilis de nature
obat sipilis tradisional daun sirih
obat sipilis antibiotik
obat sipilis kimia farma
obat sipilis dokter
obat sipilis murah
obat sipilis thiamycin
obat sipilis apotik
Cara untuk menghilangkan jengger ayam
obat herbal untuk jengger ayam
obat penyakit kulit jengger ayam
obat untuk menghilangkan jengger ayam
obat penyakit jengger ayam alami
obat ampuh jengger ayam
obat antibiotik jengger ayam
obat alami untuk penyakit jengger ayam
obat ampuh penyakit jengger ayam
obat kutil atau jengger ayam
Ramuan tradisional obat kencing nanah
Ramuan untuk obat kencing nanah
Resep obat tradisional kencing nanah
Resep obat untuk kencing nanah
Obat kencing nanah surabaya
Obat kencing nanah secara tradisional
Obat kencing nanah super tetra
Obat kencing nanah semarang
Obat sakit kencing nanah
Super tetra obat kencing nanah
Cara mengobati jengger ayam dan kutil kelamin
obat kutil kelamin
obat kutil kelamin di apotik
obat kutil kelamin tradisional
obat kutil kelamin wanita
obat kutil kelamin pada pria
obat kutil kelamin apotik
obat kutil kelamin murah
obat kutil kelamin de nature
obat kutil kelamin untuk ibu hamil
obat kutil kelamin dokter
Ramuan untuk obat kencing nanah
Resep obat tradisional kencing nanah
Resep obat untuk kencing nanah
Obat kencing nanah surabaya
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Obat kencing nanah semarang
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Super tetra obat kencing nanah
Cara mengobati jengger ayam dan kutil kelamin
obat kutil kelamin
obat kutil kelamin di apotik
obat kutil kelamin tradisional
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obat kutil kelamin pada pria
obat kutil kelamin apotik
obat kutil kelamin murah
obat kutil kelamin de nature
obat kutil kelamin untuk ibu hamil
obat kutil kelamin dokter
ramuan obat herpes tradisional
resep obat herpes
ramuan obat herpes
obat herpes kulit ringan
obat herpes selain acyclovir
obat herpes salep acyclovir
obat herpes secara alami
obat herpes sembuh total
obat herpes selangkangan
Obat kutil kelamin/jengger ayam
Obat kutil kelamin paling murah
Obat kutil kelamin dari dalam
Obat antibiotik kutil kelamin
Obat kutil kelamin yang dijual di apotik
Beli obat kutil kelamin di apotik
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Obat kutil kelamin yang ada di apotik
Obat kutil kelamin bandung
Beli obat kutil kelamin
Dimana beli obat kutil kelamin
resep obat herpes
ramuan obat herpes
obat herpes kulit ringan
obat herpes selain acyclovir
obat herpes salep acyclovir
obat herpes secara alami
obat herpes sembuh total
obat herpes selangkangan
Obat kutil kelamin/jengger ayam
Obat kutil kelamin paling murah
Obat kutil kelamin dari dalam
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Obat kutil kelamin yang dijual di apotik
Beli obat kutil kelamin di apotik
Nama obat kutil kelamin di apotek
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obat herpes secara tradisional
obat herpes soster
obat herpes selain asiklovir
obat herpes simplex untuk ibu hamil
obat herpes simplex pada anak
obat herpes simplex adalah
obat sakit herpes kulit
obat salep herpes zoster
obat salep herpes kelamin
obat herpes tradisional
Obat kutil kelamin yang untuk wanita hamil
obat kutil di sekitar kelamin
obat sakit kutil kelamin
obat kutil kelamin terbaik
obat kutil kelamin salep
obat kutil kelamin terbaru
obat tradisional kutil kelamin
obat tradisional untuk kutil kelamin
obat herbal untuk kutil kelamin
obat tradisional untuk menyembuhkan kutil kelamin
obat kutil kelamin yang tersedia di apotek
Obat salep buat kutil kelamin
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Obat cina kutil kelamin
Cuka obat kutil kelamin
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obat herpes secara tradisional
obat herpes soster
obat herpes selain asiklovir
obat herpes simplex untuk ibu hamil
obat herpes simplex pada anak
obat herpes simplex adalah
obat sakit herpes kulit
obat salep herpes zoster
obat salep herpes kelamin
obat herpes tradisional
Obat kutil kelamin yang untuk wanita hamil
obat kutil di sekitar kelamin
obat sakit kutil kelamin
obat kutil kelamin terbaik
obat kutil kelamin salep
obat kutil kelamin terbaru
obat tradisional kutil kelamin
obat tradisional untuk kutil kelamin
obat herbal untuk kutil kelamin
obat tradisional untuk menyembuhkan kutil kelamin
obat kutil kelamin yang tersedia di apotek
Obat wasir alami yang ampuh
Obat wasir anoral
Obat wasir ambeven
Obat wasir ardium hd
Obat wasir berdarah di apotik
Obat wasir bentuk peluru
Obat wasir bengkak
Obat wasir boraginol
Obat wasir bagus
Obat wasir paling ampuh
Obat wasir ardium
Obat wasir di apotik
Obat wasir luar
Obat wasir ampuh di apotik
Obat wasir alami dari tumbuhan
Obat wasir untuk ibu menyusui
Obat wasir parah
Obat wasir venaron
Obat wasir dalam
Obat wasir alami bagus
Obat wasir ampuh tanpa operasi
Obat wasir ambeien
Obat wasir ambeclear
Obat wasir akut
Obat wasir atau ambeien
Obat wasir aman untuk ibu hamil
Obat wasir ampuh bagus
Obat wasir alami untuk ibu hamil
Obat wasir anak
Cuka apel obat kutil kelamin
Obat ampuh menghilangkan kutil kelamin
Obat alami menyembuhkan kutil kelamin
Obat apotek untuk kutil kelamin
Apa obat untuk kutil kelamin
Obat wasir anoral
Obat wasir ambeven
Obat wasir ardium hd
Obat wasir berdarah di apotik
Obat wasir bentuk peluru
Obat wasir bengkak
Obat wasir boraginol
Obat wasir bagus
Obat wasir paling ampuh
Obat wasir ardium
Obat wasir di apotik
Obat wasir luar
Obat wasir ampuh di apotik
Obat wasir alami dari tumbuhan
Obat wasir untuk ibu menyusui
Obat wasir parah
Obat wasir venaron
Obat wasir dalam
Obat wasir alami bagus
Obat wasir ampuh tanpa operasi
Obat wasir ambeien
Obat wasir ambeclear
Obat wasir akut
Obat wasir atau ambeien
Obat wasir aman untuk ibu hamil
Obat wasir ampuh bagus
Obat wasir alami untuk ibu hamil
Obat wasir anak
Cuka apel obat kutil kelamin
Obat ampuh menghilangkan kutil kelamin
Obat alami menyembuhkan kutil kelamin
Obat apotek untuk kutil kelamin
Apa obat untuk kutil kelamin
Obat alami untuk mengobati kutil kelamin
Obat kutil kelamin yang ada di apotik
Dimana beli obat kutil kelamin
Obat tradisional buat kutil kelamin
Beli obat kutil kelamin
Obat salep buat kutil kelamin
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Obat cina kutil kelamin
Cuka obat kutil kelamin
Obat cina untuk kutil kelamin
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Obat china untuk kutil kelamin
Obat kutil di kelamin pria
Obat tradisional kutil di kelamin
Obat kutil di daerah kelamin
Obat untuk menghilangkan kutil di kelamin
Obat dokter untuk kutil kelamin
Obat kutil di sekitar kelamin
Obat farmasi untuk kutil kelamin
Obat generik untuk kutil kelamin
Obat kutil kelamin imiquimod
Jual obat kutil kelamin
Jual obat kutil kelamin murah
Obat kutil kelamin yg di jual di apotik
Jual obat penghilang kutil kelamin
Obat kutil kelamin yang ada di apotik
Dimana beli obat kutil kelamin
Obat tradisional buat kutil kelamin
Beli obat kutil kelamin
Obat salep buat kutil kelamin
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Obat cina kutil kelamin
Cuka obat kutil kelamin
Obat cina untuk kutil kelamin
Obat cina penghilang kutil kelamin
Obat china untuk kutil kelamin
Obat kutil di kelamin pria
Obat tradisional kutil di kelamin
Obat kutil di daerah kelamin
Obat untuk menghilangkan kutil di kelamin
Obat dokter untuk kutil kelamin
Obat kutil di sekitar kelamin
Obat farmasi untuk kutil kelamin
Obat generik untuk kutil kelamin
Obat kutil kelamin imiquimod
Jual obat kutil kelamin
Jual obat kutil kelamin murah
Obat kutil kelamin yg di jual di apotik
Jual obat penghilang kutil kelamin
Obat sipilis Obat kutil kelamin obat wasir
Obat sipilis raja singa paling ampuh
obat sipilis amoxicillin
obat sipilis adalah
obat sipilis atau raja singa
obat sipilis apa
obat sipilis anjuran dokter
obat sipilis apa ya
obat sifilis akut
obat sipilis apa namanya
obat alami sipilis pada pria
obat antibiotik sipilis di apotik
obat sifilis ampuh
apa obat sipilis
obat sifilis apotek
obat sifilis adalah
obat sifilis atau raja singa
Cara paling ampuh mengobati kutil kelamin
pengobatan ampuh kutil kelamin pada wanita
obat kutil kelamin yang ada di apotik
obat kutil kelamin yg dijual di apotik
obat kutil di kemaluan wanita
pengobatan kutil kelamin pada pria
pengobatan penyakit kutil kelamin pada pria
obat penyakit kutil pada kelamin pria
Pengobatan kutil kelamin aman dan tanpa operasi
obat kutil pada alat kelamin pria
pengobatan kutil kelamin
Obat herpes zoster tradisional
Obat herpes untuk ibu hamil
Obat herpes ampuh
Obat herpes untuk anak
Obat herpes mulut
Obat herpes tradisional yang ampuh
Obat sipilis raja singa paling ampuh
obat sipilis amoxicillin
obat sipilis adalah
obat sipilis atau raja singa
obat sipilis apa
obat sipilis anjuran dokter
obat sipilis apa ya
obat sifilis akut
obat sipilis apa namanya
obat alami sipilis pada pria
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obat sifilis ampuh
apa obat sipilis
obat sifilis apotek
obat sifilis adalah
obat sifilis atau raja singa
Cara paling ampuh mengobati kutil kelamin
pengobatan ampuh kutil kelamin pada wanita
obat kutil kelamin yang ada di apotik
obat kutil kelamin yg dijual di apotik
obat kutil di kemaluan wanita
pengobatan kutil kelamin pada pria
pengobatan penyakit kutil kelamin pada pria
obat penyakit kutil pada kelamin pria
Pengobatan kutil kelamin aman dan tanpa operasi
obat kutil pada alat kelamin pria
pengobatan kutil kelamin
Obat herpes zoster tradisional
Obat herpes untuk ibu hamil
Obat herpes ampuh
Obat herpes untuk anak
Obat herpes mulut
Obat herpes tradisional yang ampuh
Obat herpes untuk balita
Obat herpes selain acyclovir
Obat herpes di wajah
Obat herpes alami
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Books by Balkinization Bloggers
Gerard Magliocca, The Heart of the Constitution: How the Bill of Rights became the Bill of Rights (Oxford University Press, 2018)
Cynthia Levinson and Sanford Levinson, Fault Lines in the Constitution: The Framers, Their Fights, and the Flaws that Affect Us Today (Peachtree Publishers, 2017)
Brian Z. Tamanaha, A Realistic Theory of Law (Cambridge University Press 2017)
Sanford Levinson, Nullification and Secession in Modern Constitutional Thought (University Press of Kansas 2016)
Sanford Levinson, An Argument Open to All: Reading The Federalist in the 21st Century (Yale University Press 2015)
Stephen M. Griffin, Broken Trust: Dysfunctional Government and Constitutional Reform (University Press of Kansas, 2015)
Frank Pasquale, The Black Box Society: The Secret Algorithms That Control Money and Information (Harvard University Press, 2015)
Bruce Ackerman, We the People, Volume 3: The Civil Rights Revolution (Harvard University Press, 2014)
Balkinization Symposium on We the People, Volume 3: The Civil Rights Revolution
Joseph Fishkin, Bottlenecks: A New Theory of Equal Opportunity (Oxford University Press, 2014)
Mark A. Graber, A New Introduction to American Constitutionalism (Oxford University Press, 2013)
John Mikhail, Elements of Moral Cognition: Rawls' Linguistic Analogy and the Cognitive Science of Moral and Legal Judgment (Cambridge University Press, 2013)
Gerard N. Magliocca, American Founding Son: John Bingham and the Invention of the Fourteenth Amendment (New York University Press, 2013)
Stephen M. Griffin, Long Wars and the Constitution (Harvard University Press, 2013)
Andrew Koppelman, The Tough Luck Constitution and the Assault on Health Care Reform (Oxford University Press, 2013)
James E. Fleming and Linda C. McClain, Ordered Liberty: Rights, Responsibilities, and Virtues (Harvard University Press, 2013)
Balkinization Symposium on Ordered Liberty: Rights, Responsibilities, and Virtues
Andrew Koppelman, Defending American Religious Neutrality (Harvard University Press, 2013)
Brian Z. Tamanaha, Failing Law Schools (University of Chicago Press, 2012)
Sanford Levinson, Framed: America's 51 Constitutions and the Crisis of Governance (Oxford University Press, 2012)
Linda C. McClain and Joanna L. Grossman, Gender Equality: Dimensions of Women's Equal Citizenship (Cambridge University Press, 2012)
Mary Dudziak, War Time: An Idea, Its History, Its Consequences (Oxford University Press, 2012)
Jack M. Balkin, Living Originalism (Harvard University Press, 2011)
Jason Mazzone, Copyfraud and Other Abuses of Intellectual Property Law (Stanford University Press, 2011)
Richard W. Garnett and Andrew Koppelman, First Amendment Stories, (Foundation Press 2011)
Jack M. Balkin, Constitutional Redemption: Political Faith in an Unjust World (Harvard University Press, 2011)
Gerard Magliocca, The Tragedy of William Jennings Bryan: Constitutional Law and the Politics of Backlash (Yale University Press, 2011)
Bernard Harcourt, The Illusion of Free Markets: Punishment and the Myth of Natural Order (Harvard University Press, 2010)
Bruce Ackerman, The Decline and Fall of the American Republic (Harvard University Press, 2010)
Balkinization Symposium on The Decline and Fall of the American Republic
Ian Ayres. Carrots and Sticks: Unlock the Power of Incentives to Get Things Done (Bantam Books, 2010)
Mark Tushnet, Why the Constitution Matters (Yale University Press 2010)
Ian Ayres and Barry Nalebuff: Lifecycle Investing: A New, Safe, and Audacious Way to Improve the Performance of Your Retirement Portfolio (Basic Books, 2010)
Jack M. Balkin, The Laws of Change: I Ching and the Philosophy of Life (2d Edition, Sybil Creek Press 2009)
Brian Z. Tamanaha, Beyond the Formalist-Realist Divide: The Role of Politics in Judging (Princeton University Press 2009)
Andrew Koppelman and Tobias Barrington Wolff, A Right to Discriminate?: How the Case of Boy Scouts of America v. James Dale Warped the Law of Free Association (Yale University Press 2009)
Jack M. Balkin and Reva B. Siegel, The Constitution in 2020 (Oxford University Press 2009)
Heather K. Gerken, The Democracy Index: Why Our Election System Is Failing and How to Fix It (Princeton University Press 2009)
Mary Dudziak, Exporting American Dreams: Thurgood Marshall's African Journey (Oxford University Press 2008)
David Luban, Legal Ethics and Human Dignity (Cambridge Univ. Press 2007)
Ian Ayres, Super Crunchers: Why Thinking-By-Numbers is the New Way to be Smart (Bantam 2007)
Jack M. Balkin, James Grimmelmann, Eddan Katz, Nimrod Kozlovski, Shlomit Wagman and Tal Zarsky, eds., Cybercrime: Digital Cops in a Networked Environment (N.Y.U. Press 2007)
Jack M. Balkin and Beth Simone Noveck, The State of Play: Law, Games, and Virtual Worlds (N.Y.U. Press 2006)
Andrew Koppelman, Same Sex, Different States: When Same-Sex Marriages Cross State Lines (Yale University Press 2006)
Brian Tamanaha, Law as a Means to an End (Cambridge University Press 2006)
Sanford Levinson, Our Undemocratic Constitution (Oxford University Press 2006)
Mark Graber, Dred Scott and the Problem of Constitutional Evil (Cambridge University Press 2006)
Jack M. Balkin, ed., What Roe v. Wade Should Have Said (N.Y.U. Press 2005)
Sanford Levinson, ed., Torture: A Collection (Oxford University Press 2004)
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