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Jeffrey A. Claridge MD, FACS

• Assistant Professor of Surgery, MetroHealth Medical Center, Case Western Reserve
• School of Medicine, Cleveland, Ohio

Chronic rectal pain from coccygodynia occurs because of a weakness in the sacrococcygeal joint or a weakness between one of the coccygeal segments erectile dysfunction by age statistics generic 100mg kamagra gold otc. Prolotherapy to strengthen the ligamentous support of the weakened area cures chronic rectal pain from coccygodynia erectile dysfunction icd 9 code proven kamagra gold 100mg. Some telltale signs that you have spinal instability include chronic muscle spasms impotence yoga postures discount kamagra gold 100mg overnight delivery, pain that shoots down the legs intermittently impotence from priapism surgery order 100mg kamagra gold free shipping, your spine cracks and pops strongest erectile dysfunction pills order kamagra gold 100mg fast delivery, and you feel the need to manipulate your spine or receive frequent adjustments and massages impotence 24 purchase generic kamagra gold from india. The causes can be many, such as traumatic or over time due to poor posture or overuse. Prolotherapy strengthens ligaments and eliminates chronic back pain in conditions such as degenerated discs, herniated discs, spondylolisthesis, post-surgery pain syndromes, arachnoiditis, and scoliosis. Prolotherapy should be tried before any surgical procedure is performed for chronic back pain. Because Prolotherapy is an extremely effective treatment for chronic low back pain, and it permanently strengthens the structures that are causing the pain, many people are choosing to Prolo their chronic back pain away! As with pain in all other body parts, neck, headache, Radiculopathy Stenosis Neck pain and facial pain are almost Vertebrobasilar Degenerative always caused by weakness insufciency disc disease in a soft tissue structure. Cervical Ligament weakness in Whiplash Instability Post the neck accounts for associated concussion disorder syndrome the majority of chronic headaches, neck, ear, Cervicocranial and mouth pain. Because Headaches syndrome Spondylosis Prolotherapy stimulates the growth of the weakened Conditions related to cervical instability that are helped ligament causing the with Prolotherapy. What this chapter will explain is not just how Prolotherapy helps with common headache and neck pain, but also how it helps bizarre symptoms that are due to cervical instability, such as dizziness, visual disturbances, eye pressure, mouth pain, sinus congestion, tinnitus, and more. Such1 pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions such as disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and cervicocranial syndrome. When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae. In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/ or paresthesia in Figure 5-1: Cervical spinal continuum and role of Prolotherapy. In either tingling down the arm that comes and goes, the treatment of choice is case, the presence Prolotherapy. Severe spinal instability such as what occurs with fracture of excessive motion necessitates spinal fusion for stabilization. If fusion surgery has been recommended, an opinion from a Prolotherapist who specializes in complicated neck cases should be sought. Prolotherapy can prevent the need for cervical spine fusion, and alleviate the symptoms by restoring ligament strength and normal motion. Such excessive ligament elongation induces laxity to the facet joints, which puts the cervical spine more at risk for further degenerative changes and instability. Therefore, capsular ligament injury appears to cause upper cervical 5 instability because of laxity in the stabilizing structure of the facet joints. Anyone who has experienced a migraine headache or has seen a loved one suffer through a migraine attack knows it is a most unpleasant experience. Typical medical management of migraine headaches involves the avoidance of 6 various foods like chocolate, tyramine-containing cheese, and alcoholic beverages. Various medications are used in an attempt to abort the migraine once it has started. Prophylactic medications, such as Propranolol, are used in an attempt to prevent the dreaded migraine. Neither is it an aspirin, ibuprofen, acetaminophen, imitrex, or Elavil deficiency. Migraine headaches have a cause and that cause can be determined by a careful examination. The cause of migraine headaches can nearly always be found by a good listening ear and a strong thumb. In these instances, Prolotherapy must be combined with Natural Medicine techniques, such as elimination of allergic foods from the diet, natural hormone supplementation, or yeast infection treatment, to obtain completely curative results. The hormonal abnormality is usually due to a low progesterone level during the second half of the menstrual cycle. Giving natural progesterone during this part of the menstrual cycle will often relieve the problem. If the migraine headaches occur when eating particular foods, during particular times of the year, or when exposed to certain scents, an allergic component to the migraines should be investigated. Eliminating the suspect food from the diet will likely solve the migraine problem. The patient dependent on these drugs for headache relief lives in fear of the next migraine attack. Patients describe their migraine headaches as similar to having one half of their head hit repeatedly with a baseball bat. From an anatomical perspective, cervical instability is the culprit in the majority of non-hormone or diet-related headaches and migraines. Upon palpation along the base of the head, and through the neck, tenderness or pain indicates weakness at the ligament attachments, the pain sensors of the body. While stress can certainly be a contributing factor to healing, the structures are tight for a reason. The muscles in the neck are trying to keep a 10 pound head balanced on the small, upper cervical vertebra. Normally, the ligaments provide the stability needed to turn the head, side to side, up or down, and safely return back to a neutral position. With cervical ligament damage, the muscles have to kick into high gear, without rest, in order to stabilize the head. The muscles and ligaments are screaming for relief in the form of a crushing headache. Thus, Prolotherapy to the cervical ligament attachments makes the most sense for long-term success against headaches and migraines. Patients were seen quarterly, and the only treatment that many of them had available was the Prolotherapy we offered, or possibly some pain medication. Due to limited funds, many were not able to do testing for food allergies or hormone levels. Therefore, we had a very clear picture of just how powerful Prolotherapy could be, even when given months apart, instead of the more ideal 4-8 weeks. Fifteen total patients were included in the study for either tension headaches (8) or migraine headaches (7). After Prolotherapy, 47% had no headaches and 100% experienced at least some relief 7 in regard to headache intensity and frequency. In another study based in the same charity clinic, we reported on 98 patients seen at the quarterly clinic who were treated for neck pain. In a subgroup of 43 patients, they had been previously told by another doctor that there were no other treatment options available. The assessments were conducted between one and 39 months post-treatment (mean = 24 months). Ninety-five percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported. A mean of 86% of patients reported overall sustained improvement, while 33% reported complete functional recovery. The good news is a dysfunction in the posterior that Prolotherapy to the cervical spine resolves the cervical sympathetic nervous underlying cause of these syndromes, mainly cervical instability and many of the symptoms above, over time. The posterior cervical sympathetic syndrome became known as Barre-Lieou syndrome and cervicocranial syndrome. The posterior cervical sympathetic nervous system is a group of nerves 11,12 located near the vertebrae in the neck. Other symptoms may include dysesthesias of the hands and forearms (painful pins-and-needles sensation), corneal sensitivity, dental pain, lacrimation (tearing of the eyes), blurred vision, facial numbness, shoulder pain, swelling of one side of the face, nausea, vomiting, and localized cyanosis of the face (bluish color). A reasonable question to ask is: How can one disorder cause all of these problems The answer lies in understanding the function of the sympathetic nervous system, which is part of the autonomic nervous system. It keeps your heart pumping, your blood flowing through your blood vessels, your lungs breathing, and a myriad of other activities that occur in your body all the time, every day of your life. The blood vessels shift blood away from the intestines into the muscles, enabling you to run or fight the offender. The posterior-cervical sympathetic nervous system signals the sympathetic part of the autonomic nervous system that controls the head, neck, and face area. In cervicocranial syndrome, the posterior cervical sympathetic system is underactive because the vertebrae in the neck are pinching the sympathetic nerves. Vertebrae the primary symptom pushing on cervical is a headache, since sympathetic ganglion headaches are caused by dilation of blood vessels, as in cervicocranial Figure 5-5: Anterior cervical instability. Symptoms can include dysphagia, tongue numbness, blurred vision, tinnitus, vertigo, dizziness, neck pain, and cervicocranial syndrome migraine headaches. A decrease in sympathetic output to the inner ear will cause an accumulation of fluid in the inner ear. When fluid accumulates in the inner ear, as is often the case with an upper respiratory infection, the ear feels full and the body feels off balance. When Prolotherapy is performed on the head and neck, the posterior sympathetic nervous system begins to function correctly. Often, immediately after Prolotherapy injections to the posterior head and neck areas, patients with cervicocranial syndrome who have had sinus trouble for years experience clear breathing, which they have not had in years. The other symptoms, such as blurred vision, severe fatigue, dysesthesias (pins-and needles sensation down the arm), low blood pressure, and low heart rate, are easily understood by a decrease in the output of the sympathetic system of the head, neck, and face areas. Weakness of the neck ligaments commonly occurs because most people spend a good portion of their days looking down at phones and hunched over while working. Their work may consist of typing on a computer or being constantly tethered to their mobile devices for many hours per day, as well as the huge surge in computer gaming. The ligament laxity causes an even more head-forward position, as the ligaments can no longer keep Figure 5-6: Forward head posture from hours of the cervical vertebrae in their computer work and texting resulting in cervical proper posterior alignment. Creep, which is a term signifying the slow stretching of ligaments, most commonly paracervical muscles (the neck occurs by a forward head posture from computer muscles) tighten to stabilize the work or looking at a smart phone. Once the ligaments weaken, the muscles contract to give support but this joints and head. Eventually, the muscles can no longer stabilize the vertebrae and the ligaments are stretched even more. Massage therapy, physical therapy, chiropractic/osteopathic manipulation, and pain medicines all help to temporarily relieve the pain. Prolotherapy addresses the root cause of neck pain, ligament laxity, and is consequently effective at eliminating the problem. Prolotherapy to the vertebrae in the neck is the treatment of choice to permanently eliminate cervicocranial syndrome. This occurs because Prolotherapy causes the vertebrae in the neck to move posteriorly (back) and no longer pinch the sympathetic nerves. Fifty-two percent had associated sympathetic nervous system symptoms (as seen in cervicocranial syndrome), 55% of the people had symptoms longer than three months, 81% had symptoms and injuries in other parts of the body, in addition to the neck, and 49% had some kind of legal action because of an auto accident (79% were involved in auto accidents). By all practical purposes these were not simple cases of neck strain, yet Prolotherapy totally eliminated the pain in 60% of the patients, and 86% of the patients considered the end result to be satisfactory (in other words, they had pain relief with the Prolotherapy). Claussen noted that in Germany in 1992 they had 197,731 cases of whiplash injuries due to traffic accidents. In our own case series published in the European Journal of Preventative Medicine, neck pain, migraines, and other cervicocranial syndrome (Barre-Lieou syndrome) symptoms were resolved following a prescribed series of Prolotherapy injections administered in a pain clinic setting. These patients experienced complete or nearly complete amelioration of pain with relief that lasted months to years after Prolotherapy treatment. Migraine sufferers know that pain on one side in the base Figure 5-7: Prolotherapy to the cervical facet joints. This is an By stabilizing the vertebral motion, Prolotherapy resolves the important clue that the impingement of the cervical sympathetic ganglion and the resultant symptoms.

Kathy tried physical therapy erectile dysfunction treatment herbal remedy order kamagra gold on line, but it was too painful for her to make it through a whole session erectile dysfunction treatment injection cost order kamagra gold in united states online. Kathy had known about Prolotherapy for years impotence grounds for divorce buy kamagra gold 100 mg without a prescription, and decided to fly to our Chicagoland office hcpcs code for erectile dysfunction pump discount kamagra gold on line. Hauser emphasized that healing her shoulder would be part Prolotherapy and part her dedication to perform the rehabilitation exercises smoking causes erectile dysfunction through vascular disease purchase cheap kamagra gold online. After only one treatment erectile dysfunction vegan discount kamagra gold 100 mg online, she soon started feeling pain relief, enough that she could finally do the recommended exercises that took her the rest of the way to a full recovery. Nearly a year later, Kathy ran smack into a door, with her left shoulder taking the brunt this time. She was aware of the pain all the time and getting through work was becoming more difficult. Her shoulder was becoming more painful and less mobile until she could barely lift her arm. Again, she decided it was overdue for her to just get Prolotherapy and stop living that way. With one treatment to her left shoulder, she was able to return to work without pain and her motion was fully restored. She did just that a few years later when she came in for hip pain, which resolved with only one visit. While the average number of treatments is three to six, some people only need one or two to achieve pain relief! This joint is called the acromioclavicular joint and is noted on the surface of the skin at the apex (top) of the shoulder. When this occurs, the weight of the body is transmitted to the acromioclavicular joint. When these ligaments are injured and become lax, the joint grinds and grates and causes pain. Acromioclavicular ligament laxity causes pain upon lifting or activity involving the hands in front of or across the body. Prolotherapy is extremely effective at strengthening the acromioclavicular ligaments, eliminating the shoulder grinding and chronic shoulder pain from this area. From this little nub of bone, stem some very important structures, Figure 6-8: Prolotherapy of the top of the shoulder. Common including the pectoralis sites of tenderness are marked along the scapular spine, clavicle, minor muscle, and deltoid insertion. This area of the shoulder is palpated during a routine Prolotherapy shoulder examination. Prolotherapy injections are given to strengthen the fibro-osseous junctions of all the above structures at the coracoid process. Frequent sites of treated to relieve chronic injection are demonstrated, including the coracoid process, shoulder pain. People often develop a bone spur on the clavicle that decreases the space through which the supraspinatus 8 tendon must travel. Occasionally, surgery is needed to give the supraspinatus tendon more room to move. For the few patients who have needed surgery for impingement syndrome after Prolotherapy, the response rate of the combined approach has been excellent. The Prolotherapy has strengthened the rotator cuff tendons and surgery has eliminated the impingement of those tendons, leading to complete relief of the chronic shoulder pain. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement, the structures within the glenohumeral joint themselves are impinged. We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy. An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation), after Prolotherapy. This also included 39% of patients in a sub-group who were told by their medical doctors that there were no other treatment options for their pain and 21% who were told that surgery was their only option. Over 82% of all patients experienced improvements Prolotherapy Shoulder Study Results in sleep, exercise ability, All No Other Surgery anxiety, depression, and Demographics Shoulder Treatment Only overall disability with Patients Option Option Prolotherapy. Remember, these studies were conducted on people who did not have any symptoms of shoulder pain. It is imperative that an evaluation be done by a Prolotherapist because diagnostic tests can often lead a clinician astray. If left untreated, this supraspinatus tendon laxity leads to adhesive capsulitis, or frozen shoulder. Prolotherapy is the treatment of choice for chronic shoulder pain because it corrects the underlying weakness causing the pain. Remember, removing any tissue that God has put in the body will have a consequence. That consequence is often joint instability, the primary cause of chronic pain and degenerative arthritis of the knee. The tissues most commonly removed during arthroscopic surgery in the knee are parts of the meniscus and the articular cartilage. Both of these structures are needed by the body to help the femur bone glide smoothly over the tibia. Eventually, whatever meniscus or articular cartilage is left after the arthroscopic surgery is worn away. Once this occurs, bone begins rubbing against bone and proliferative arthritis begins. After a course of cortisone shots, nonsteroidal anti-inflammatory drugs, and several trials of physical therapy, the patient is again under the knife, this time for a knee replacement. Once an arthroscope touches the knee, the chance of developing arthritis in the knee tremendously increases. This is because surgery, especially when any tissue is removed, increases joint instability. Before letting an arthroscope touch you, it is imperative to have an evaluation by a physician familiar with Prolotherapy. Prolotherapy will begin collagen formation both outside and inside the knee joint depending on the structure(s) that are 1 injected. Surgery in the knee is appropriate when a ligament is Lateral & medial Articular femoral condyles cartilage completely torn, such Posterior as would occur from cruciate a high-velocity injury. Synovial fuid ligament Prolotherapy is only Anterior cruciate Medial ligament meniscus helpful to regrow ligaments if both ends Lateral Medial aspect aspect of the ligament remain attached to bone. Lateral Medial Remember, 98% of meniscus collateral ligament ligament injuries are Lateral collateral partial tears for which Tibia ligament Prolotherapy would be helpful. Numerous studies have shown Inferior aspect Prolotherapy is an effective treatment Figure 7-1: Anterior aspect of the right knee. It is no longer acceptable for a physician who treats chronic pain to say that he or she has not heard of Prolotherapy or that there is not evidence for its effectiveness! More than 82% of patients also showed improvement in walking ability, medication usage, athletic ability, depression, and overall disability due to Prolotherapy treatment. The average patient reported pain for an average of 5 years prior to Prolotherapy. Additionally, 2 out of 5 patients were taking at least one pharmaceutical pain medication. The population represented chronic, and often hopeless, cases who had exhausted the traditional medicine system. This reinforced what we see everyday in our clinic: quality of life can be drastically improved with Prolotherapy! This can be due to a number of ligaments and tendons attachments becoming torn or degenerated, as well as damaged or removed cartilage and meniscal tissue. It is also important to understand the Pain Levels Before and After Prolotherapy referral patterns of knee ligaments that can trigger pain sensations further down the leg and into the foot. The medial collateral ligament refers pain down the leg to the big toe and the lateral collateral ligament refers pain to the lateral foot. Figure 7-2: Starting and ending pain levels before and after receiving Hackett-Hemwall dextrose Prolotherapy in 80 the ligaments patients (119 knees) with unresolved knee pain. These ligaments help stabilize the knee, preventing excessive forward and backward movement. If these ligaments are loose, even in a young person, degenerative arthritis begins to form. The feeling of a loose knee is reason enough to suspect a cruciate ligament injury. Even in cases of significant arthritis, crippling knee pain is often due to pes anserinus tendonitis or bursitis. This condition is easily treated with Prolotherapy, eliminating the chronic knee pain. The pes anserinus tendons are also known as Figure 7-3: Muscles and the inside hamstring muscles. Running, hiking, pregnancy, and aging may predispose a patient to develop a fallen arch. This outward rotation of the tibia places additional stress on the pes anserinus tendons. Eventually, these tendons become lax and are no longer able to control the tibial movement, adding to the chronic knee pain. Addressing the fallen arches of the foot may also be required to fully alleviate the knee pain. Prolotherapy injections strengthen the tendon attachments of the pes anserinus, resolving the chronic knee pain. This condition is also called patellofemoral dysfunction or patellar-tracking dysfunction, and is common among runners and also athletes where the sport involves a lot of running (soccer, tennis, etc. Typical conventional treatments for this condition include taping the knee, exercising to strengthen the thigh muscles, and stretching exercises. Prolotherapy, 17 on the other hand, can help patellar tracking and relieve chondromalacia pain. Many factors work against it, as it has the high pressure job of handling hundred of pounds of weight with each step the body takes, all the while receiving very little nourishment from the synovial fluid. The menisci (plural of meniscus) are a pair of C-shaped fibrocartilages which lie between the femur and tibia in each knee, extending peripherally along each medial and lateral aspect of the knee. Each meniscus has a flat underside to match the smooth top of the tibial surface, and a concave superior shape to provide congruency with the convex femoral condyle. Anterior and posterior horns from each meniscus then attach to the tibia to hold them in place. This organic matter is primarily a fibrous collagen matrix consisting of type I collagen, fibrochondrocytes, proteoglycans, and a small amount of dry noncollagenous matter. Most studies indicate that the menisci transmit about 50% of the load at the knee, while the remaining 50% is borne directly by the articular cartilage and surfaces. Tears are the most common form of meniscal injury, and are generally classified by appearance into four categories: longitudinal tears (also referred to as bucket handle tears), radial tears, horizontal tears, and oblique tears. Longitudinal (bucket handle) tears vertical tear around the long axis of the meniscus often with displacement of the inner margin (bucket handle). Horizontal tears tears that are in the same horizontal axis as the meniscus tissue. Oblique tears full thickness tears running obliquely from the inner edge of the meniscus out into the body of the meniscus. Each can be further described as partial thickness tears or complete thickness tears, depending on the vertical depth of the tear. Essentially every study shows that articular cartilage pressures escalate when the menisci are removed. Ahmed and Burke showed Figure 7-6: Increase in joint contact stress versus percent of meniscus removed.

Research also suggests that the fnal quarter of 2014 erectile dysfunction causes generic kamagra gold 100 mg on-line, representing approximately half users may eventually graduate to more complex systems; of the total e-cigarette sales in the tracked retail channels erectile dysfunction effects order kamagra gold 100 mg with amex. Unfortunately erectile dysfunction young living cheap kamagra gold 100mg with amex, in the tracked retail and online channels erectile dysfunction reddit purchase kamagra gold 100mg line, including cer sales data by demographics are very limited impotence quotes the sun also rises cheap kamagra gold online mastercard, and studies tain convenience stores and food erectile dysfunction pump hcpc discount kamagra gold line, drug, and big-box stores have not yet examined how sales of e-cigarette products (Wells Fargo Securities 2015a; see Table 4. In the United States, one of the biggest players in Giovenco and colleagues (2015) found that sales of men the premixed e-liquid market for refllable e-cigarettes is thol-favored e-cigarettes in traditional U. This graph reveals an association between real price and the this section summarizes the limited evidence on sales volume for disposable e-cigarettes from 2010 to the the impact of e-cigarette prices on the sales and consump second quarter of 2013: As real price declined over time, tion of these products. Looking back, the rapid decline in ining the effects of taxes and prices on the sale and use the price of disposable e-cigarettes between 2007 and 2011 of conventional cigarettes (Chaloupka and Tauras 2011; (Huang and Chaloupka in press) may have occurred because International Agency for Research on Cancer 2011) leads of improvements in product technology and industry pro to the conclusion that price increases resulting from motion, which signifcantly cut the costs of producing such higher excise taxes are effective tools for reducing ciga products (Bhatnagar et al. The rather modest declines in prices since 2011 may refect the fact that further technological improve Trends in E-Cigarette Prices overTime ments became less feasible (Wells Fargo Securities 2015c). A study by Huang and Chaloupka (in press) docu In terms of volume, the substantial decrease in 2014 mented and analyzed the relationship between real price may be partly attributable to consumers shifting away and sales volume for both disposable and rechargeable from cigalikes to tanks, mods, and other more powerful e-cigarettes by using Nielsen data, which refected the devices, for which sales were not tracked well. Between 2010 and 2014, the average unit price for able e-cigarettes between 2010 and 2014 based on data from rechargeables decreased markedly, dropping from $37 Huang and Chaloupka (in press). The price In terms of volume, the estimate for disposables increased fuctuations for rechargeables were likely because of the Figure 4. Activities of the E-Cigarette Companies 155 A Report of the Surgeon General change in product mix and the infux of various new types were approximately 1. Sales volume appeared to be emerging as substitutes for recharge increased dramatically between 2010 and 2014, rising ables (a 10% increase in rechargeable e-cigarette prices from a minimal amount at the beginning of 2010 to about increased sales of disposable e-cigarettes by about 5%). Own-price changing the price of e-cigarettes affects the number elasticity is a measure showing how much demand for a sold, the potential effects of the price of conventional product will change given a change in its price, while cross cigarettes on the purchase of e-cigarettes are less clear. In store scanning service, this study employed fxed-effects contrast, Grace and colleagues (2015), who measured the models to estimate elasticity of demand and associa cross-price elasticity of e-cigarettes and conventional cig tions between e-cigarette sales and either the prices of arettes using simulated demand for the latter in a sample conventional cigarettes or smokefree policies from 2009 of New Zealand smokers, found that the cross-price elas to 2012. Results demonstrated (a) that e-cigarette sales ticity of e-cigarettes was signifcantly positive, suggesting were quite responsive to own-price changes (estimated that e-cigarettes may be partially substitutable for con own-price elasticities for disposable e-cigarettes centered ventional cigarettes. These chan in infuencing consumer preferences, and the potential nels have included extensive marketing on the Internet for marketing to infuence smoking behaviors has been and advertising in mainstream media, including popular a source of public health concern for many years (DiFranza magazines, retailer point-of-sale ads, product placement et al. Research has demonstrated a causal relation an advertising option unavailable to cigarette manufac ship between tobacco marketing and smoking, with the turers because of regulatory policies (Legacy for Health majority of research focusing on the impact of tobacco 2014; Ganz et al. However, the available data about Magazine and Print Advertising e-cigarette marketing also underestimate total mar Print has been the dominant channel for tracked keting expenditures. The three most common media the Rutgers University School of Public Health and the were print, television, and e-mail, and spending was Stanford Research into the Impact of Tobacco Advertising highest for print ads (Richardson et al. From 2012 to 2013, the number Rolling Stone publication as compared with the female of e-cigarette advertisements in magazines with high dominated Us Weekly. A content analysis by Banerjee and colleagues (2015) television in 2013 and early 2014 (Farrelly et al. The Truth found in 24 magazines, 11 of which had been identifed in Initiative (formerly the American Legacy Foundation) prior studies as having youth and young adult readerships found that in 2014, television advertising reached sim greater than 2 million per year or for which the teen por ilar proportions of youth (62% of 12 to 17-year-olds) and tion of the audience was more than 10%. By number, ads for young adults (64% of 18 to 24-year-olds) (Truth Initiative e-cigarettes were second only to those for conventional cig 2015). Using proprietary data from Nielsen, Duke and arettes and higher than the numbers for moist snuff, cigars, colleagues (2014) estimated that 50% of U. Eighty-fve percent of the content in e-cigarette were exposed to e-cigarette ads on television in 2013 ads focused more on a theme of logos. On average, those exposed In examining persuasive themes, the study found saw 21 ads between October 2012 and September 2013. In terms of images, 100% of the ads included the brand the most widely aired ad was for blu, featuring a celeb name and an image of the product. After the Master Settlement Agreement in 1998, A different content analysis of magazine ads for sponsorship of events with a signifcant youth audi e-cigarettes, this one for a 3-month period in 2012 ence, such as concerts and athletic events, was banned (Richardson et al. Additionally, blu has handed out free Activities of the E-Cigarette Companies 159 A Report of the Surgeon General Figure 4. Activities of the E-Cigarette Companies 161 A Report of the Surgeon General Figure 4. Further, conservative estimates indicate that in 2012 and Although the marketers of e-cigarettes have made 2013, free samples were provided by six companies at claims that differ from those made for conventional ciga 348 events, most of these events having high participa rettes (such as use for smoking cessation, which is illegal tion by youth (Durbin et al. Under the deeming rule without being an approved cessation drug or device), published in May 2016 (currently under litigation), free a content analysis of e-cigarette marketing (Grana and samples were banned (Federal Register 2016). Ling 2014) and the observations of tobacco marketing sur veillance systems point to several similarities, including Digital Landscape for E-Cigarettes the use of young, attractive models; lifestyle claims; and celebrities. In claims (Federal Register 2016) (although this provision 2015, a study conducted by the Truth Initiative indicated has been challenged in pending lawsuits). The study by Grana and Ling (2014) analyzed claims brick-and-mortar stores; they are also offered by online from 59 English-language websites over a 2-month period stores and through social media. Grana and Ling (2014) in 2011 and found four major thematic content areas: found that 80% of websites indicated a sale price or dis health and cessation-related benefts, avoiding smokefree count, while Huang and colleagues (2014a) found that policies, lifestyle benefts, and product-engineering claims. However, under the e-cigarette use as a means of circumventing clean air poli deeming rule, websites cannot sell e-cigarettes to youth cies. Websites social media websites (including Facebook, Twitter, and also pointed to social advantages for users of their par YouTube). Claims Tobacco industry analysts estimate that online sales of increased social status, opportunity, and romance as accounted for approximately 30% of e-cigarette sales well as the use of celebrities may resonate especially with volume in the frst quarter of 2015 (Wells Fargo Securities youth and young adults (Grana et al. Some Internet vendors sell their own brands A different content analysis, this one of the mar exclusively. Brands analyzed from 2012 were signifcantly problems with the website or the payment system, all of more likely than those in the later period to (a) claim that which were unrelated to age verifcation. Of the remaining their products were healthier and less expensive than con 80 orders, 75 (93. Five vendors claimed to ventional cigarettes and could be used where smoking is use a service offered by shipping companies to verify age prohibited and (b) indirectly claim their products were at delivery, but none actually did. Although data are not effective for smoking cessation through testimonials and available on the proportion of youth who purchase their other methods (Zhu et al. The study also found an e-cigarettes online versus buying them at retail outlets, increase from one period to the next in the number of this study suggests that youth would have ready access if branded retail websites and the number of favors per brand they tried to purchase e-cigarettes online. The Prevent All advertised on a website, as well as the likelihood of a web Cigarette Traffcking Act of 2009 requires Internet sellers site offering e-cigarette hardware and such other products of cigarettes and smokeless tobacco to , among other provi as e-liquids and e-hookahs or other products that did not sions, verify age of customers at the time of purchase and resemble cigalikes (Zhu et al. However, there dardized search strategy employed in their earlier study are currently no federal requirements for Internet vendors of websites selling cigarettes (Ribisl 2003) to identify of e-cigarettes to check identifcation upon delivery or pay 995 English-language websites selling e-cigarettes in applicable taxes (Campaign for Tobacco Free Kids 2016). The authors performed a content analysis on the the marketing of candy and fruit favors may be one 281 most popular websites, as judged by data on traffc. Zhu and col Most offered favors, with the most popular being fruit leagues (2014), who used three search engines (Google, (79. Physicians and e-cigarette retail websites, Grana and Ling (2014) found other health professionals provided endorsements as well. Further, favors were being sold under brand forensic analysis of websites that sold e-cigarettes and par names similar to cereal and candy products that appeal to ticipated in affliate advertising on the Internet. Three categories of e-cigarette brands have emerged Research suggests Internet e-cigarette vendors have within the U. However, after August 8, 164 Chapter 4 E-Cigarette Use Among Youth and Young Adults by cigarette manufacturers. A content analysis that access to websites of brands developed by cigarette of websites for these three types of brands suggested that manufacturers (or a subsidiary) was restricted to users those developed by cigarette manufacturers may be mar 21 years of age and older (MarkTen), and user registra keted more cautiously than brands acquired by cigarette tion was required. Activities of the E-Cigarette Companies 165 A Report of the Surgeon General with a cigarette manufacturer and those acquired by ciga well (Seidenberg et al. The Green Smoke website rette manufacturers were accessible to users 18 years of even provided a link to guide customers in fnding the age and older via self-reporting of age, with the exception proper nicotine level for their cartridges (Green Smoke of 21st Century Smoke. YouTube is the most popular video having an affliation with a cigarette manufacturer or sharing website globally and features many e-cigarette that were acquired by a cigarette manufacturer, all brands videos. Luo and colleagues (2014) used various search except Logic offered fruit, candy, or other favors. Further, terms to identify 196 unique videos in February 2013 all of the unaffliated brand websites sold e-cigarettes that were portraying e-cigarettes and found that 94% of online and offered multiple nicotine levels. Online sales All brands can be purchased Both brands can be purchased MarkTen can be purchased online; online. Multiple levels of Among all brands, the level Among both brands, the level of For MarkTen, the level of nicotine nicotine of nicotine varies by product. Flavors (other than All brands offer a variety of Both brands offer a variety of MarkTen offers two favors: fusion and tobacco and/or favors, such as fruit and candy. Source: Unless cited otherwise, information was obtained from the companieswebsites (January 2016). For example, persons 18 years of age and older can browse the website, but those younger than 18 cannot. Those authors found that Sponsored Online and Video Advertising the three most common genres were advertising of prod the study by Richardson and colleagues (2015) ucts, user sharing, and product reviews. E-cigarette ads were often some time from June 2007 to June 2011, estimated that placed on music or entertainment (39. Just 16% of the videos were formal or environmentally friendly than conventional cigarettes advertisements or news clips, and 79. Interestingly, videos sponsored by marketers ConventionalTobacco Retailers (Convenience contained a signifcantly lower level of health claims than Stores, Pharmacies,Tobacco Shops) did those from laypeople (users) and, not surprisingly, As of December 2015, 48 of the 50 states prohibited contained a higher level of information cues. State Legislatures 2015), but compliance of retailers with A cross-sectional study of Twitter, a microblogging youth-access laws has not yet been studied. As of through a licensed Twitter data provider over a 2-month August 8, 2016, the federal deeming rule bans the sale of period in 2012, found extensive marketing of e-cigarettes e-cigarettes to minors under the age of 18 and requires (Huang et al. The majority of e-cigarette con photo identifcation for those under age 27 (Federal tent during this period was advertising and promotion. For example, after hyperlinks to commercial websites), and only 11% iden Lorillard acquired blu in 2012, the number of retailers tifed as being non-sponsored or independent, refecting selling this brand increased from 13,000 to 127,000 in individual opinions or experiences, or being linked to non just 1 year (Esterl 2012; Bannon 2013). Commercial tweets most commonly the proportion of licensed tobacco retailers that sold contained price promotions and discounts (34. E-cigarettes are widely available in convenience Jo and colleagues (2016), in a study of 2,847 tobacco stores, a type of establishment that 4. The tweets also touted the relatively low price were sold in more than half of convenience stores, phar of e-cigarettes and made comparative claims about the macies, and liquor stores and in nearly all tobacco shops health risks of the product. Activities of the E-Cigarette Companies 167 A Report of the Surgeon General (California Department of Public Health and California studies, which used data collected in two studies that used Tobacco Control Program 2014). In a 2012 nationally with weaker smokefree air policies, even after control representative sample of tobacco retailers, the presence of ling for store type, price of conventional cigarettes, and a public school within 1,000 feet was not related to the neighborhood demographics (Rose et al. In a study inverse relationship was found between sales of dispos that examined a much larger buffer zone in Kentucky, able e-cigarettes (as measured by retail scanner data in 88% of schools in two counties were located within 1 mile 52 U. As of the population protected by 100% smokefree policies for colleges, disposable and/or rechargeable e-cigarettes covering all indoor areas of bars, restaurants, and work were available at 60% of tobacco retailers near campuses places (Huang et al. Taken together, these results in North Carolina and Virginia in 2013, a more than two suggest that e-cigarettes are, at least initially, more likely fold increase from the previous year (Wagoner et al. A pilot study examining tobacco point-of-sale adver Few retail surveillance studies have characterized tising and promotion in the central Harlem neighborhood promotion, placement, or price for e-cigarettes (Hsu et al.

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The lens matter is elastic in nature but it gradually loses its elasticity with age impotence caused by diabetes cheap 100 mg kamagra gold visa. Metabolic disorders of the foetus or infant like galactosaemia erectile dysfunction caused by nicotine order generic kamagra gold on line, galactokinase deficiency iii erectile dysfunction statistics us purchase 100mg kamagra gold with amex. If the opacity is large and central in position erectile dysfunction more causes risk factors generic kamagra gold 100 mg fast delivery, there is marked visual impairment erectile dysfunction los angeles buy kamagra gold 100mg line. The opacity is sharply demarked and the area of the lens within and around the opacity is clear erectile dysfunction age at onset buy kamagra gold 100mg free shipping. There are multiple club-shaped opacities near the periphery of the lens usually hidden by the iris. Anterior capsular cataract It is due to the delayed formation of Coronary cataract the anterior chamber. It may occur following perforation of a corneal ulcer in ophthalmia neonatorum cases. It may project forwards into the anterior chamber like a pyramid (anterior pyramidal cataract). The underlying cortex may become opaque (anterior cortical cataract) occasionally. Posterior capsular cataract It is often due to persistence of posterior part of vascular sheath. Lens Aspiration the child should be operated earlier as the fixation reflex develops between 2-4 months of age. Technique Aspiration of lens matter can be done by limbal route, (either single incision or two-port bimanual technique) or corneo scleral tunnel technique. A subconjunctival injection of gentamicin and dexamethasone is given postoperatively. The incidence is reduced when posterior capsulorhexis is combined with vitrectomy. Proliferation of lens epithelium is common but may not be visually significant if visual axis is not involved. Lensectomy In this operation, the lens including anterior and posterior capsule along with anterior vitreous are removed with the help of vitreous cutter, infusion and suction device. Abnormal product of metabolism, drugs or metals can be deposited in storage diseases (Fabry), metabolic diseases (Wilson) and toxic reactions (siderosis). The Lens 213 Classification Morphologically, the senile cataract occurs in two forms: 1. It is common to find cortical and nuclear senile cataracts co-existing together in one eye. In general, the relative frequency of cunieform cataract is 70%, nuclear 25% and cupuliform cataract is 5% approximately. Any physical or chemical factor which disturbs the intra and extracellular equilibrium of water and electrolytes causes opacification of lens. Frequent changes of glasses occur due to rapid change in the refractive index of lens. Coloured halos around light are seen due to presence of irregular refractive index in different parts of the lens. Cupuliform cataract Clinical Stages In senile cortical cataract presenile changes are the rule. Progressive hydration causes swelling of the lens, making the anterior chamber shallow. The iris shadow is absent as iris is separated by only lens capsule from the opaque lens. Later on fluid cortex may get absorbed due to leakage Hypermature morgagnian cataract resulting in the formation of membranous cataract with a very small nucleus. Phacolytic glaucoma may occur due to leakage of lens protein which is ingested by the phagocytes. These large Hypermature cataract phagocytes obstruct the angle of anterior chamber. There is dense aggregation of opacities just beneath the capsule usually in the posterior cortex. There is marked impairment of vision due to the opacity being near the nodal point of the eye. There is loss of ability to see objects in bright sunlight or being blinded by light when driving at night. Etiology There is slow sclerosis of the nucleus due to long-term effect of the ultraviolet irradiation. It may become brown, dusky red or black occasionally due to deposition of melanin pigment derived from amino acids in the lens. There is change in refractive index of the nucleus which causes index myopia, resulting in improvement of near vision. Etiology There is disturbance to the nutrition of the lens due to the inflammatory or degenerative diseases of the other parts of the eye. Symptom There is markedly impaired vision due to presence of opacity near the nodal point in the posterior cortex. True diabetic cataract is a rare condition occurring typically in young persons due to acute diabetes. When blood sugar levels are elevated beyond 200 mg per ml, excess glucose is converted to sorbitol. Clouds of small discrete opacities appear in the cortex, separated from the capsule by a clear zone. It causes bilateral cataract typical (oil drop cataract) due to inborn inability to metabolize galactose. Chlorpromazine, Busulphan, Amiodarone, Gold and Allopurinol are the other drugs associated with cataract. Early or late Rosette-shapedcataract is formed usually in the posterior cortex or at times in the anterior cortex or both. It is the excessive awareness of light, such as direct sunlight or headlights of an oncoming motor vehicle. Commonly occurs with posterior subcapsular cataract due to excessive irregular scattering of light. They can be easily differentiated from muscae volitantes in the vitreous which are mobile. Coloured halos are seen due to hydration of the lens which results in irregularity in the refractive index of different parts of the lens. These may act as antigens and induce antigen-antibody reaction leading to uveitis. Subluxation and dislocation of lens may occur due to degeneration of zonules in hypermature stage. Examination of the eye is done carefully specially in cases of complicated cataract. Systemic examination is done for diabetes, hypertension, ischaemic heart disease and gross focal sepsis. When fundus cannot be seen, the following tests are done to find out the condition of posterior segment, I. Light is thrown from various directions and the patient points the correct direction.

In his presentation to the Group does erectile dysfunction get worse with age order kamagra gold on line, Joe Smyser made a compelling case for just this kind of countermovement erectile dysfunction in a young male order kamagra gold american express. First most effective erectile dysfunction drugs purchase discount kamagra gold on-line, if the fundamental goal of any pro vaccination efort is to increase rates of inoculation erectile dysfunction muse cheap kamagra gold master card, it is not at all clear that even an efective efort to counter the narrative of diehard anti-vaccination activists and bloggers will move the needle very much erectile dysfunction treatment in kuala lumpur generic kamagra gold 100mg free shipping. More worrisome erectile dysfunction video buy on line kamagra gold, perhaps, is the very real possibility that the counternarrative will prove inefective, or worse, backfre and grant more visibility and legitimacy to the anti-vaccination activists. Second, quite apart from the resonance of the competing narratives, we should also worry about the institutional identities associated with the typical pro-vaccination spokespersons. In an era of rising anti-government, anti-science, anti-elite sentiment, one can imagine pronouncements by leading public health or other government ofcials reinforcing, rather than allaying, the fears and suspicions of those inclined toward anti-vaccination views. Somewhat counterintuitively, movement scholars have amassed considerable evidence that a movement benefts from having a highly visible extremist wing. While one might think that an extremist wing would serve to discredit the movement as a whole, studies of the phenomenon have found something diferent. Radical fank efects occur when the actions of radical groups work to the beneft of the moderate core of the movement. For instance, disruptive tactics or infammatory rhetoric employed by radicals may attract greater public attention to issues that moderate actors have sought to address with limited success. The presence of a radical fank may also allow moderates to portray themselves as the reasonable and responsible voices within the larger movement (Connor & Epstein, 2007; Elsbach & Sutton, 1992; Hofman & Bertels, 2009). And by enhancing the reputation of the moderates in this manner, the radical fank may also increase their attractiveness to potential funders and political allies. The fear is that a highly public, sustained efort to counter the narrative of extreme anti-vaccination groups or individuals will actually enhance their visibility and usher in the efects described here. To be efective, the movement would need to enlist a broad coalition of institutional allies from the worlds of public health, medicine, philanthropy, and health-related non-profts. One component of the movement might involve conventional public health education campaigns targeting specifc communities with especially low vaccination rates. For this to work, however, the current trend of health care providers denying service to those who hesitate or choose not to be vaccinated would have to be reversed. Instead of sharpening the boundary between those who do and do not get vaccinated by pushing fence-sitters toward providers willing to cater to them, the goal would be to continue providing care to those who are hesitating. The hope is that with repeated eforts at persuasion, their fears and misconceptions can be overcome. Finally, to maximize the benefts of the campaign, I would suggest it be designed not only as a proactive efort to increase vaccination rates, but also as a systematic research project to determine which clinical approaches are most efective in transforming fence-sitters into those who get vaccinated. By doing so, pro-vaccination researchers and advocates should be able, over time, to devise increasingly efective clinical practices to overcome vaccine hesitancy. Based on the successful legislative lobbying eforts in California and elsewhere, another promising form of mobilization would seem to be coordinated top-down and bottom-up eforts to press legislators to pass vaccine mandates or other pro-vaccination measures. While member movements often succeed in the absence of signifcant grassroots activism, insider reform combined with pressure from grassroots groups would certainly increase the chances of movement success. This seems to be the formula that worked well in California and several other states. One caution: I would restrict these legislative movements to the most receptive states or other jurisdictions. Achieving legislative gains in even a limited set of states would create policy models for others and pressure them to at least engage the issue. On the other hand, creating a visible pro-vaccination grassroots movement in hostile states would almost certainly trigger reactive mobilization by anti-vaccination groups, without any chance of achieving legislative success. Better to leave sleeping dogs lie in non receptive states, while concentrating pro-vaccination eforts in states reliably committed to immunization. While most theories and popular accounts of social movements persist in depicting their beginnings as a predictable response to some objective threat or opportunity, such threats or opportunities generally fail to trigger collective action. Rather, the origin of a movement refects the subjective signifcance attached to that threat or opportunity by a specifc group, which then begins to engage in sustained collective action in response to their shared perception. The vaccine hesitancy movement did not emerge because of an increase in the objective risk posed by vaccines, but because specifc groups constructed an account of increased risk and began acting collectively to counter that perceived threat. While the characteristic features and typical dynamics of insider and outsider movements tend to be quite diferent, the long-term success of either generally refects the interaction of two factors. On the one hand, the prospects for movement success are powerfully shaped by the environments in which they are embedded. As we have seen, successful movements typically beneft from prior, destabilizing change processes that render their opponents more receptive to movement infuence. And they also depend critically on the capacity of movement actors to recognize and respond strategically to the evolving opportunities and constraints aforded them by environmental changes. This ongoing interaction between movement groups and the broader strategic environment ultimately shapes the relative impact of the movement. Doug McAdam, Ray Lyman Wilbur Professor of Sociology at Stanford University; Former Director, Center for Advanced Study in the Behavioral Sciences Doug McAdam, Ph. Wright Mills Award; and Dynamics of Contention (Cambridge University Press, 2001), with Sid Tarrow and Charles Tilly. His most recent book is Deeply Divided: Racial Politics and Social Movements in Postwar America (Oxford University Press, 2014). The structure of political opportunities and peasant mobilization in Central America. Acquiring organizational legitimacy through illegitimate actions: A marriage of institutional and impression management theories. But for Birmingham: the local and national movements in the civil rights struggle. Structural opportunity and perceived opportunity in social movement theory: the Iranian revolution of 1979. The origins of the civil rights movement: Black communities organizing for change. The three main propositions are that vaccination results from: (1) what people think and feel, (2) social processes, and (3) direct behavior change Figure 1). Colleagues and I previously reviewed the evidence for these propositions and put forward what has become known as the Increasing Vaccination Model (Brewer, Chapman, Rothman, Leask, & Kempe, 2017). However, its length and complexity have been barriers to its use by some practitioners. Globally, 86% of children have received a measles vaccine, and that percentage is higher in North America and Europe as of 2018 (World Health Organization, 2018). These high rates have caused the incidence of many infectious diseases to plummet in the decades since relevant vaccines have been introduced. Such successes have led to calls for complete eradication of polio and regional elimination or control of other diseases through vaccination. Inadequate coverage is the uptake of vaccination that fails to meet an agreed-on quality marker. While global vaccination coverage rates have steadily drifted upwards, they have stalled in some regions and even slipped backwards in a few countries. Delay is getting vaccines after the recommended age or While global vaccination coverage spreading the doses out over time. Despite rates have steadily drifted upwards, clear fndings that the current vaccination they have stalled in some regions schedule is safe, parents are increasingly and even slipped backwards in a choosing to spread out or delay vaccines in few countries. Some countries with generally high vaccination coverage have experienced periods of dramatic instability. Denmark had a similar issue that it was able to turn around, but only after coverage had fallen by half (Hansen, Schmidtblaicher, & Brewer, 2020). The model presented here is about what works to increase vaccination uptake, which results from a series of behaviors by various actors. A family may talk about vaccines with friends, search for information online, schedule an appointment, travel to a clinic, consent to vaccination, return for any needed follow-up doses, and pay any related costs, such as an administration fee or travel expenses. Providers stock vaccines, recommend them, track their use in medical records, fag who is due and overdue, and manage their vaccine stock. In sum, vaccination uptake results from a web of interconnected players, resources, and behaviors, all of which follow predictable patterns. On the left side of the fgure, disease risk appraisals are thoughts and feelings about potential health problems caused by infectious agents (perceived risk and fear); vaccine confdence is the attitude that vaccines are good (efective) or bad (unsafe). Risk appraisals and confdence motivate people to vaccinate or not to do so, as shown in the middle. Getting vaccinated can lower some appraisals of disease risk and increase vaccine confdence, as shown by the arrows going from the far right back to the left (Brewer, Weinstein, Cuite, & Herrington, 2004). Vaccine uptake is associated with higher disease risk appraisals, including thinking infectious diseases are likely, serious, and regrettable (Brewer et al. Similarly, vaccine uptake is associated with higher vaccine confdence, as shown by believing that vaccines are important, save lives, and have few side efects. However, experimental evidence from randomized trials generally does not support the thoughts and feelings proposition. This stronger body of evidence better answers the question of whether interventions focused on thoughts and feelings can increase vaccine uptake. Risk communication interventions do not appreciably increase vaccine uptake, according to a recent meta-analysis of 16 studies, although the interventions somewhat increased the belief that infectious diseases are likely (Parsons, Newby, & French, 2018). An older meta-analysis, restricted to fve risk communication interventions that increased risk appraisals, did fnd increases in vaccine uptake (Sheeran, Harris, & Epton, 2014). While some intervention studies have increased vaccine confdence, including beliefs that vaccines are safe and efective (Horne, Powell, Hummel, & Holyoak, 2015; Shah et al. Finally, interventions to increase motivation to vaccinate have not shown reliably that they can infuence hesitant people, despite success at increasing motivation for other behaviors (Webb & Sheeran, 2006). Motivational interviewing, while promising, has yet to be shown efective in a randomized trial, although it has been included as one component of several efective multicomponent interventions (Dempsey et al. In sum, while thoughts and feelings motivate While thoughts and feelings people to get vaccinated, interventions motivate people to get vaccinated, targeting thoughts and feelings have shown interventions targeting thoughts little promise for reliably increasing vaccine and feelings have shown little uptake. Furthermore, there is no apparent promise for reliably increasing logic as to when interventions boost vaccine vaccine uptake. I return later to the question of whether thoughts and feelings interventions might generate support for vaccination policies and programs, an important outcome that is distinct from vaccination uptake. The social network, the collection of connections among people, is shown on the left side of the fgure. Finally, social norms and preferences about vaccination lead to vaccination uptake, as shown on the right. Social networks are well characterized and show robust clustering of people with similar ideas about vaccination in social spaces (Dunn et al. Social norms are reliably associated with vaccine uptake (Schmid, Rauber, Betsch, Lidolt, & Denker, 2017), with somewhat less evidence showing smaller associations for social preferences. I return later to the question of whether thoughts No published randomized trials to date have When experts bring research papers and feelings interventions might generate support for vaccination policies and programs, an established that social process interventions to a frefght, they have lost before important outcome that is distinct from vaccination uptake. The social network, the collection of connections among people, is shown on the where thoughts and feelings interventions fail. Finally, social norms and preferences about vaccination lead to vaccination (Reyna, 2012). The consequence is that anti-vaccine activists had, for a while, locked down many social media Figure 3. More recently, citizen and scientist activists have fought back with increasingly efective tools. Shots Heard Round the World has developed a rapid-response collective of volunteers to defend health care providers attacked for their vaccine advocacy. Quantifying the impact of anti and pro vaccine activism and tools is an important area for new research.

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