Saturday, December 19, 2009

Surgery For Life: How Romanticism and Religion Are Working With Science To Improve Medicine



Is medicine a life-saving endeavor? Is it the art of healing, combined with the science of life? Or is it a statistical exercise--just an offshoot of utilitarian economics, the most dismal branch of the dismal science? If it’s the former, then medicine should be celebrated. If it’s the latter, then “healthcare,” a concept borrowed mostly from social science, should dethrone medicine and all is lore, and we should all die at the most economically opportune time. The choice is ours. Unless, of course, Washington-based bean-counters make the choice for us. As they fully intend to do: cue up the current debate over Obamacare.

And as we shall see, the power of these reigning social-science bean-counters--these “sophists, economists, and calculators,” to use Edmund Burke’s famous phrase--is so strong that even the most heroic of doctors feel defensive about their life-saving work. And that’s a sad state of affairs.

On December 14, The New York Times’ Denise Grady published a genuinely inspiring chronicle of the heroic effort to save the life of one Robert Collison, a 59-year-old Wisconsin man of no great importance--except to his wife and family, his friends, and to God. Which is to say, Collison is, in fact, important. As are all of us.

But since he was suffering from a rare form of seemingly inoperable cancer that had surrounded his liver and other internal organs, Collison faced quick death earlier this month. But Dr. Tomoaki Kato, a surgeon at New York-Presbyterian Hospital/Columbia University Medical Center, was willing and able to perform an ex vivo resection--Collison’s cancer-strangled organs were removed, the tumor sliced away, and the organs restored to his body.

Here’s how reporter Grady described some of Kato’s efforts:

Surgery is a stunning blend of finesse and brute force. The incision was a huge, cross-shaped cut that ran from Mr. Collison’s breastbone to his pubic bone, then across his belly near the navel. Metal retractors needed to hold open the wound looked like tools from a hardware store, and it took three people to wrestle them into place. Electrocautery pens that did much of the cutting sparked, smoked and sent up a stench of burning flesh. Suction probes like bigger versions of the ones that dentists use gurgled as they vacuumed blood from the incisions.

The finesse is in the hands. Dr. Kato’s moved with confidence and grace that became all the more apparent when he worked across the operating table from someone less deft. An anesthesiologist said Dr. Kato had “soft hands,” reflected in the monitors tracking the patient’s pulse, breathing, electrocardiogram and blood pressure. When soft hands cut, stitched and moved organs around, the monitor readings held steady, but they spiked up and down when rough hands took over.

Surgeons tie knots in every single stitch. Dr. Kato said he made anywhere from 3 to 10 knots per stitch, depending on the type of suture material and the tissue being sewn. Nylon takes more knots than silk, arteries more than veins. Looking over his shoulder was like watching a magician: with a wave of his fingers, a knot would form, and it was possible to see the trick over and over without quite knowing how it was done. For Mr. Collison’s operation, he would ultimately tie 5,000 knots.

And they had to be tied just so. When a surgeon still in training pulled a knot too tight, Dr. Kato said, softly but insistent, “Don’t break the tissue, please.” At times, if helping hands fumbled, he would gently brush them away and say, “No, let me do it.”

When the liver finally came out, the tumor hanging from it was a dense, meaty-looking mass the size of a football. Embedded in the tumor were segments of Mr. Collison’s stomach, pancreas and intestines. Dr. Kato handed it to Dr. Jean C. Emond, the hospital’s director of transplantation, who cradled it in a purple towel like a grotesque baby. He estimated that the whole reddish-brown slab — tumor, liver and parts of other organs — weighed about 15 pounds. Ten of which were tumor.

Then Dr. Emond and Dr. Benjamin Samstein slid the grisly thing into a basin of icy salt water and went to work on it. The idea was to strip away the tumor, with minimal damage to the liver and its blood vessels and ducts, and then reimplant the liver.


And so Collison’s life was saved by Serious Medicine. Nobody knows for how long, but we know for sure that Collison would have had no chance were it not for Dr. Kato and his team.

But reporter Grady takes note of concerns that the New York City doctors harbor, even as they fulfill their Hippocratic duties:
 
A 43-hour operation inevitably raises questions about the best way to use medical resources.

Dr. Emond, who eagerly hired Dr. Kato as a rising star who could push the envelope in transplant surgery, said that even he was somewhat conflicted about operations that he called “extravaganzas.”

“What does this mean for medicine, doing these incredibly complex procedures to save individual lives?” Dr. Emond asked. “It’s an important philosophical question.”

He referred to the Talmudic teaching, that whoever saves one life saves an entire world. But he added, “That’s not a very health-policy, quantitative way of looking at it.”

Another argument for the surgery is like the rationale for sending people to the Moon, Dr. Emond said: “Understanding things better or extending the limits of care in these extreme situations somehow moves the whole field of medicine forward.”

Both he and Dr. Kato likened ex vivo operations to the early days of liver transplants, which originally took twice as long as they do now and met with harsh criticism. Hopefully, we’ll get more efficient and make the surgery better,” Dr. Emond said. He noted that surgeons had a saying: “The great surgeon invents an operation that only he can do, and the truly great surgeon invents an operation that everyone can do.”

 
Thus we come to the ethical and political crux of the Times story: Was all this effort on behalf of Collison worth it? Was it a worthwhile expenditure compared to other possible priorities? Let’s take a second look at a key sentence from the passage above:

[Dr. Emond] referred to the Talmudic teaching, that whoever saves one life saves an entire world. But he added, “That’s not a very health-policy, quantitative way of looking at it.”


Indeed, a 43-hour operation to save a single life is “not a very health-policy, quantitative way of looking it.” For one thing, such an operation is qualitative, not quantitative. It’s about the quality of mercy, and that’s hard, if not impossible, to quantify.

And yet it’s interesting, and revealing that Dr. Emond, a distinguished doctor, feels defensive about his own profession and what he does to save lives--that he feels that he has to explain himself to social science.  

Medicine, from at least the time of Hippocrates, is naturally focused on the patient. And because of that personal focus, the overall romance and mystique of medicine is inherently qualitative--save one life, goes the Hippocratic argument, and you save the world. Saving people, one by one.

And that's why civilization has so revered medicine through most of human history.  Not only is there the life-saving aspect, not only the religious element--do God's merciful work here on earth--but there's also a romantic element. That’s “romantic” with a small “r,” as in, say, “Magnificent Obsession,” but also romantic with a capital “r”: dueling with death, battling fate, taking on long odds, stealing Promethean fire. So yes, there are many good and valid reasons why medicine has been mostly privileged over the millennia, seen as a higher calling that ledgering and bean-counting.

But medicine has not been so privileged lately, at least among the dominant policy classes.  These days, “healthcare policy” in Washington DC is seen mostly as a battle between social scientists, financiers and pseudo-financiers, waged not by doctors, but by ideologues--the sophists, economists, and calculators that Burke derided in an earlier era. And yet ironically, that policy battle, bitter as it is, is actually more of a conflation, because both "left" and "right" seem to agree that non-medical ideology and belief is more important than medicine. Thus the two disputant sides have disappeared into a ball, an indistinguishable blur of quant-talk that does nothing for, say, Robert Collison.

Picking up on Dr. Emond's comment, not only is “health care policy” the antonym of medicine--and to the idea that there’s a value in so many people working so hard to save a single life--but “healthcare policy” was, in fact, intended to be the antonym, or at least the antidote, to the exaltation of medicine.  Back in the 70s and 80s, the chattering policy classes decided that “medicine” was too cold and technological; and besides, “medicine” was too closely associated with the American Medical Association, a leading bete noire of the left in those days.   And so “medicine” beame “healthcare policy.” (And the AMA has been dethroned, shrunken, and substantially proletarianized.)

Yet even so, real people, as they live their lives, are reflexively romantic and qualitative.  They'll drop everything, for example, to try to save the life of a child who falls down a well.  Yes, from a Kennedy School point of view, such strenuous effort might be deemed a poor investment.  But there's a reason why nobody gets elected to public office from the Kennedy School--the folks out there see these life-and-death issues differently.

Because ranged against every wonk is a Wordsworth. Indeed, those who think in the mode of William Wordsworth, rejecting “bottom line” thinking in favor of romantic thinking, vastly outnumbering the nerds. As the great English poet lyricized back in 1807: Getting and spending, we lay waste our powers...We have given our hearts away, a sordid boon!

Not everyone can quote Wordsworth, of course, but almost everyone thinks that morality matters more than money--we all have, or like to think we have, that spark of that celestial fire within us. And such instinctive romanticism is an ongoing rebuke to those who would smother and freeze personal feeling and compassion under the ice of cost/benefit analysis.

But there is another reason why medicine is celebrated: In addition to the romantic element, there’s also the religious dimension, which has inspired so many, over the ages, to go into the healing arts.

Having been reminded, above, about the Talmud, we are also reminded of the story about Jesus in Bethany, the House of Suffering, as recorded in Matthew 26:

 6 Now when Jesus was in Bethany, in the house of Simon the leper,
 7 There came unto him a woman having an alabaster box of very precious ointment, and poured it on his head, as he sat at meat.
 8 But when his disciples saw it, they had indignation, saying, To what purpose is this waste?
 9 For this ointment might have been sold for much, and given to the poor.
 10 When Jesus understood it, he said unto them, Why trouble ye the woman? for she hath wrought a good work upon me.
 11 For ye have the poor always with you; but me ye have not always.
 12 For in that she hath poured this ointment on my body, she did it for my burial.
 13 Verily I say unto you, Wheresoever this gospel shall be preached in the whole world, there shall also this, that this woman hath done, be told for a memorial of her.


One lesson to take away from these verses is that the Moment, if that’s the right word, can be more important than the broader Context. A single highly specific Good Work matters more than larger, vaguer Good Works. From a Christian point of view, it was more important to illustrate, for all time, in a vivid story, the importance of devotion to Jesus. By anointing Him in anticipation of His death, Christians were subsequently reminded that some things are even more important than aiding the poor. A controversial position, perhaps, but so be it. Religion is always controversial.

And speaking of controversy, one might note the role that conservative religion has played in reshaping the healthcare debate in the last 35 years. Religious conservatives have been at the forefront of the battle against “modernism” in healthcare--modernism defined as Benthamite utilitarianism, using numbers to justify “hard choices” about who lives and who dies.

In the middle of the last century, experts deemed it inevitable, as well as desirable, that we should all be moving toward a more secular calculus about life and death--just as we saw in Western Europe, where assisted suicide and euthanasia seemed to be the confident wave of the future. (In such a “progressive” intellectual context, the Supreme Court’s 1973 Roe v. Wade decision was regarded as just another milestone in the long march to social rationalization.)

From a “numbers” point of view, it makes little or no sense to preserve the life of a 90-year-old in a coma. But history suggests that if we concede that it doesn't make sense to protect the lives of the senescent elderly, then we soon find ourselves slippery-sloping our way to the point where “experts” assert that it's not worth doing too much to save the life of a one-year-old, or a 30-year-old.   Medicine and healthcare are, after all, expensive.

So the Right To Lifers, and those who argue for a “seamless garment,” and for “a consistent ethic of life,” have played an historic and decisive role in turning around greatest-good-for-the-greatest-number-type arguments.

Indeed, in 2009, the Republican Party, historically associated with efforts to cut entitlements, found itself playing the role of chief defender of Medicare. An uncomfortable feeling for many libertarians, but nonetheless a decisive triumph for religious (and romantic) sentiment-- a victory for feeling over budget-consciousness.

But can we afford such heroic medicine? That’s one argument of the utilitarians that can’t just be waved away. Heroic medicine, critics say, is expensive medicine, especially when it is expended on “futile care” for “vegetables.” President Barack Obama himself said, just this week, that unchecked medical expenses would “bankrupt” the federal government.

No responsible policymaker can ignore fiscal concerns, and neither religious nor romantic sentiment should blind people to other realities, including economic realities. As Martin Luther declared, our lives must be lit by the light of faith, and by the light of reason.

But as Dr. Emond said to the Times, in the long run, doctors will find a way to streamline even ex vivo surgical “extravaganzas.” And yet history tells us that such streamlining can only occur as the result of repetition--doing the same procedure over and over again, until better and more efficient techniques are identified and applied. Through such a process, streamlining leads to assembly-lining. And assembly-lining is the key to making things better and cheaper.

It’s somewhat paradoxical that we would have to spend more to ultimately spend less, but that’s an obvious lesson of the industrial revolution over the last three centuries. You have to bear the expense of building the factory, and all the costs associated with climbing up the learning curve, before you can get the benefit of mass production. (And the jobs, and the wealth.)

But when you do reach the level of mass production, the expensive boutique item becomes the inexpensive routine item--and also, a much better item. Today, the humblest and cheapest cell phone is a vastly superior machine than the bulky portable phones that presidents and generals were using just a few decades ago.

That’s how Serious Medicine becomes Routine Medicine.  And so, for example, if we put our minds to it, not only will ex vivo surgery get cheaper--performed, laparoscopically, perhaps, by robots--but one fine day, tumors will be eliminated non-invasively, through some new and better technique.

That's the story of technology, and it has its own kind of romance to it. The evidence on this score is so overwhelming that those who choose to ignore that evidence--pushing instead policies of scarcity and rationing--qualify as a category of Romantic themselves. As Luddites, peddling an alleged realism that is really pessimism, or even nihilism.

Luddites are entitled to their opinions, however wrong they might be. But when confronted by Luddism in the political and policy sphere, the rest of us are required, for our own sake, to vote against them and to keep them away from our medicine our healthcare, and our loved ones.

135 comments:

  1. Excellent. Thanks for the education.

    ReplyDelete
  2. One of the best columns you ever wrote Jim. Thank you. As Roberta said "Beautiful! " It gives us readers an insight into your heart.

    You poised: "Is medicine .... the art of healing, combined with the science of life?"
    I think of Medicine as the science of healing combined with the art of living and doing no harm. But, maybe I'm being picky because it's like seeing the glass as half empty or half full.

    ".....almost everyone thinks that morality matters more than money"
    Good! I think this is true, for I think it sinful to wonder how much it cost to rehab Helen Keller, Gov. David Paterson, Lance Armstrong or Stephen Hawking to name just a few...............

    Yes, Luddites are wrong. We must vote against them thus keeping them away from our Medicine, Healthcare and loved ones.

    For Life is worth living and we should never do harm.

    ReplyDelete
  3. The crux of the healthcare debate is how much the health plan administrators can skim off the torrent of money that goes to health care. People who have their fingers deep in the pie don't want to pull their fingers out, not even just a tiny fraction. Everything else is a smoke screen.

    ReplyDelete
  4. A great informative blog.Keep posting articles like.Your have a great knowledge of the subject.Thanks for sharing such an article where education of people matters the most.You way of expressing articles through words is excellent.he way of expressing things is best and informative.Keep sharing articles like this.A great article with best possible effects.I am great fan of your blog.Every time i come here i see something very new.Thanks for sharing the information.


    Kamagra | Edegra

    ReplyDelete
  5. I've seen a documentary about those technics. It seems it's working

    ReplyDelete
  6. I suggest this site to my friends so it could be useful & informative for them also. Great effort.thanks to share very informative blog

    ReplyDelete
  7. Hey great stuff, thank you for sharing this useful information and i will let know my friends as well.

    ReplyDelete
  8. I appreciate these people
    thanks a lot for sharing this
    news.



    .....Alex

    ReplyDelete
  9. http://www.bestpenisproducts.com is an all-natural Penis Enlargement, safe, and guaranteed alternative to painful and dangerous Penis enlargement methods such as surgery, straps, or rings.
    penis enlargement pills or male enhancement pills will immediately boost your performance, improve your orgasms, and increase the size of your penis within just a few weeks!
    VISIT OUR BEST PENIS ENLARGEMENT PILLS PRODUCTS:

    VIGRX PLUS PILLS
    VIMAX PILLS
    MALE EXTRA PILLS
    MALE ENHANCEMENT PILLS

    ReplyDelete
  10. Really science medicine and technology has gone way ahead of time and getting to see various new experiments, thanks for sharing this great post.

    ReplyDelete
  11. For men who want bigger, harder, longer-lasting erections, there's now VigRX Plus™, a fresh twist on the already popular VigRX™, but designed to further enhance men's sexual functioning with the addition of three exciting new ingredients: Damiana, Tribulus, and Bioperin. Doctor endorsed and rated #1 for results by clients of penis enlargement consumers. rated two penis pills is vimax. if you find about male enhancement this products is the best and proven to work, there products have money-back guarantee in effectiveness and result.

    ReplyDelete
  12. I agree with author. It is very hard to understand both factors. Thanks for sharing this.

    ReplyDelete
  13. People who have their fingers deep in the pie don't want to pull their fingers out, not even just a tiny fraction. Everything else is a smoke screen.

    ReplyDelete
  14. I am thoroughly convinced in this said post. I am currently searching for ways in which I could enhance my knowledge in this said topic you have posted here. It does help me a lot knowing that you have shared this information here freely. I love the way the people here interact and shared their opinions too. I would love to track your future posts pertaining to the said topic we are able to read.

    ReplyDelete
  15. It is a very nice thing to see your excellent work and I like your article very much. With your rich knowledge, we can learn more from your wonderful post. Thanks so much.

    ReplyDelete
  16. Excellently written article, if only all bloggers offered the same level of content as you, the internet would be a much better place. Please keep it up!

    ReplyDelete
  17. Indeed a very interesting blog. Read a pleasure. Cognitive information that is very good.

    ReplyDelete
  18. Really great post, Thank you for sharing This knowledge.

    ReplyDelete
  19. Great post has been shared here. Nice article and thanks for sharing this lovely post.

    ReplyDelete
  20. Vaccines are one of the most important and controversial achievements in public health. Washington-based journalist Allen explores in depth this dark horse

    ReplyDelete
  21. Hey,
    Really Amazing information found on your blog. Excellent work! Just Keep it up.

    Thanks very much for the share....

    ReplyDelete
  22. Nice post, I would like to request you to one more post about that Keep it up

    ReplyDelete
  23. I believe this blog post is one of the most informative thing not only for the technique learner but also for necessary for all stage people.

    ReplyDelete
  24. Wow, nice post,there are many person searching about that now they will find enough resources by your post.Thank you for sharing to us.Please one more post about that.

    ReplyDelete
  25. Really you have done great job,There are may person searching about that now they will find enough resources by your post.I like this blog..
    Blogger how when you visit my site,
    My Site created for men's health,
    Here the best method for you and get the best Penis Enlargement Pills today.

    ReplyDelete
  26. The blog posting is nice & appreciative.Thanks for sharing.

    ReplyDelete
  27. Please continue to write more because it’s unusual that someone has something interesting to say about this. Will be waiting for more…

    ReplyDelete
  28. Thanks for sharing this informative post.

    ReplyDelete
  29. Skönt att vara besöka din blogg igen, har det varit månader för mig. Väl här artikeln som jag har väntat så länge. Jag behöver den här artikeln för att slutföra mitt uppdrag i kollegiet, och den har samma tema med din artikel. Tack, bra aktie.

    ReplyDelete
  30. The obvious problem is what is "moral" behaviour . Authoritarian states will love these drugs. On a slightly different tack, I have often speculated on the possibility of directly recording and playing back human emotions, which would surely be the perfect punishment, far better than incarceration. Murderers would get to experience the anguish of the loved ones of their victims.

    ReplyDelete
  31. I believe this blog post is one of the most informative thing not only for the technique learner but also for necessary for all stage people.

    ReplyDelete
  32. Interesting post and thanks for sharing. Some things in here I had never thought about before.Thanks for making such a nice post which is really very well written. Will be referring this to a lot of friends. Thanks a lot.

    ReplyDelete
  33. The Louboutin 2011 is planned using the ladies. offered the fact that pumps was born, the ladies lifestyle turn into colorful. The christian Louboutin 2011 Pumps
    will be the god's masterwork. Who invited the Christian Louboutin Wedges ? Seldom people knew, but I think each and every and every lady will be grateful for him. between the countless pumps,the Christian Louboutin Shoes
    could be probably the most exceptional ones. The stylish pattern, the delicate design all mold the ladies perfect leg profile. Flowers inside the spring of 2011 creeping, up from frizzy hair to outfits hold on to footwear, have experienced a brilliant up. on this type of the glamor, spring and summer time flowers now here. Romance is really a woman's mood, exquisite flowers just appropriate of expression within our gestures, the woman, how can we not adore the romantic temperament to make certain which they distributed the flowers do? 2011 flowers bloom will get satisfaction from numerous poses! The Christian Louboutin New Sandalsalso can adds the hright in the ladies, it hold shock toward short lady. especially the red-colored lone in the louboutin heels, beauty and sexy, different ladies are crazy. The red-colored sole, the earliest attribute in the Sale Louboutin stroe.

    ReplyDelete
  34. Want to be the fashionable person?Sexy and beautiful women are always men's favor. Now come to Louboutin UK store! We will change you into a gorgeous girl! Here provides Christian Louboutin Fashion,Louboutin 2011,Christian Louboutin Wedding,louboutin platforms,Louboutin Wedges and so on.The unique and well-Designed shoes favored by the world, signed with the Christian Louboutin red soles of the mark, giving high heels and covetable accessories, system pumps and elegant luxury Christian Louboutin clutch has to be available almost all fashion only. We now provide Christian Louboutin shoes with free shipping and save 60% off! Hurry up! Christian Louboutin UK store is your first choice!

    ReplyDelete
  35. nike air maxes have been issued and on the basis air max by better improvement It will be the most popular shoes of the world. discount nike air max are created a visual landmark and has greatly enhanced cushioning and stability. Nike Air max sale has been a big hit this spring with its neutral colorway a suitable match to a variety of fits.nike air max shoes have excellent materials and production.Cheap Nike Air max is made of multiple materials fused together for incredibly lightweight, breathable durability.Nike Air Griffey Max is very popular as Nike Air Max 2010 ,We sell nike air max 2011 and nike air zoom kobe, also sellnike air max tn, nike air max bwand cheap air max
    .Buy cheap discount nike air max ltd and nike shoes us online with 40-70% off and Free shipping!We also sell for nike air max skyline ,nike air max shoes, nike collection,nike air max 1, nike air max 95, nike air max 180 and so on.High quality, incredible comfort and fashion are nike air max 24 7 and nike air max 87, It is worth to own nike air max 90 and nike air max 91.Welcome and happy purchasing online in nike air maxes.

    ReplyDelete
  36. Skönt att vara besöka din blogg igen, har det varit månader för mig. Väl här artikeln som jag har väntat så länge. Jag behöver den här artikeln för att slutföra mitt uppdrag i kollegiet, och den har samma tema med din artikel. Tack, bra aktie.

    ReplyDelete
  37. This is good site to spent time on .I just stumbled upon your informative blog and wanted to say that I have really enjoyed reading your very well written blog posts. I will be your frequent visitor, that's for sure.

    ReplyDelete
  38. Wow, nice post,there are many person searching about that now they will find enough resources by your post

    ReplyDelete
  39. I need this article to complete my assignment in the college, and it has same topic with your article. Thanks, great share.

    ReplyDelete
  40. I wonder how you got so good. This is really a fascinating blog, lots of stuff that I can get into. One thing I just want to say is that your Blog is so perfect!

    ReplyDelete
  41. I really enjoy reding your posts as I learn a lot from them. I also broaden my thinking as far as what I can use and do with things

    ReplyDelete
  42. Wow, nice post,there are many person searching about that now they will find enough resources by your post

    ReplyDelete
  43. Jauki, apmeklējot savu blogu atkal, tas ir mēnešiem par mani. Nu šajā rakstā, ka es esmu gaidījis tik ilgi. Man vajag šo rakstu, lai pabeigtu savu uzdevumu in koledžā, un tas ir to pašu tēmu ar savu rakstu. Paldies, liels īpatsvars

    ReplyDelete
  44. ehi amico, questo è uno dei migliori post che io abbia mai visto, si possono comprendere le idee ancora un po 'nel tema stesso. Sto ancora aspettando alcune interessanti riflessioni da parte vostra nel prossimo post.

    ReplyDelete
  45. Masaya akong maging ng pagbisita sa iyong blog muli, ito ay nai-buwan para sa akin. Well artikulong ito na ako naghintay para sa kaya mahaba. Kailangan ko ang artikulong ito upang makumpleto ang aking assignment sa kolehiyo, at ito ay may parehong topic sa iyong artikulo. Salamat, mahusay na ibahagi.

    ReplyDelete
  46. I really enjoy reding your posts as I learn a lot from them. I also broaden my thinking as far as what I can use and do with things

    ReplyDelete
  47. Thank you for sharing to usThank you for sharing to us.Please one more post about that..

    ReplyDelete
  48. Wow, nice post,there are many person searching about that now they will find enough resources by your post

    ReplyDelete
  49. Nice post. Great blog. Thanks for sharing. It was very interesting and meaningful. Keep posting. I follow you.
    Fiverr clone script| airbnb clone| Fiverr clone script|

    ReplyDelete
  50. It was very interesting to read.
    serve as a reference
    creditcard cash creditcard shopping, shopping cash creditcard shopping, creditcard cash creditcard shopping, shopping cash creditcard shopping, creditcard cash

    ReplyDelete
  51. Christian Louboutin Store is commonly a European shoe. Artist who promoted his collection of luxury women's Christian louboutin pumps sale in earlier 90s. Christian Louboutin Tall Boots can disregard the existence in the style world, World-famous red-colored soles and Christian louboutin sale discount are shaped features. However, you can by no means overlook the beautiful Christian louboutin classic shoes. You do not even need to go inside environment, as well as your slim, gorgeous and graceful legs may be effortlessly discovered in people's eyes for Discount louboutins.

    ReplyDelete
  52. The low-pitched luxurious style of cheap louboutin shoes on hot sale!The clean design lines and the signature red sole become a classic.Wear christian louboutin shoes with any basic outfit to add a little bit of fun and flirtiness to your outfit.Don't hesitate to buy cheap louboutin shoes with free shipping and no tax at Christian Louboutin sale.

    ReplyDelete
  53. The 1995 model was extremely popular Nike Outlets for a long time and saw many colors introduced. 2011 Cheap Nike Air Max Online Store Its popularity has waned, but many people still love the shoe. Originally it was met with some skepticism due to its suede construction, UGG Outlet Store. high price tag and neon accent color. International collectors quickly came to love the Air Max 2011 shoe and eventually it became popular in the United States as well.

    ReplyDelete
  54. Hi! This is my first visit to your blog! We are a team of volunteers and starting a new initiative in a community in the same niche. Your blog provided us useful information to work on. You have done a extraordinary job!

    ReplyDelete
  55. This Nike soccer cleats ultra vibrant New nike soccer shoes ...The Nike soccer cleats has a huge army of fans across the globe, and if you're one of them we know you love them to be bright, flashy and in-your-face colours. Checking out these nike mercurial vapor superfly III fg versions, part of Nike's Fall seasonal releases, we're sure you're going to love these Nike Football Cleats too, they combine Laser technology and Nike Mercurial Vapor Superfly with the Vapor series!especially once they start appearing en masse on pitch. You can click "VIEW MORE" for more detailed pictures. New levels of performance after nike mercurial vapor superfly III new levels of performance after.

    ReplyDelete
  56. Very significant article for us ,I think the representation of this article is actually superb one. This is my first visit to your site

    ReplyDelete
  57. Thanks for the informative writing. Would mind updating some good tips about it. I still wait your next place. ;)



    buy vicodin online

    ReplyDelete
  58. I like your blog post. Keep on writing this type of great stuff. I'll make sure to follow up on your blog in the future.

    ReplyDelete
  59. Thanks for not only taking the time to write this, but to even improve the information by Online Pharmacy making it easy to read and understand.

    ReplyDelete
  60. Your blog is just not only helpful but also incredibly artistic too. There usually are extremely couple of individuals who can write not simple posts that creatively. Maintain the great posting !!

    ReplyDelete
  61. Good article. Well written! Keep them coming. Love to know more from you!

    ReplyDelete
  62. I just wanted to comment your blog and say that I really enjoyed reading your blog post here. It was very informative and I also digg the way you write! Keep it up and I’ll be back to read more soon mate

    ReplyDelete
  63. Thanks for the informative writing. Would mind updating some good tips about it. I still wait your next place. ;)


    buy online vicodin es

    ReplyDelete
  64. Hi , i got this Article , i was searching some thing relevant to this, And i am feeling lucky, as its the perfect one for what i am looking for. I will share this link on face book

    ReplyDelete
  65. Hi there, nice information provided. thanks for that. keep posting of blogs in the future. thanks once again..
    Kamagra

    ReplyDelete
  66. You are focused on realizing all you possibly can about this. We're completely satisfied you discovered us.

    On this site, we have introduced collectively an unlimited array of data and sources on this.

    Accountants in London

    ReplyDelete
  67. Thanks to a brilliant effort in publishing your article. One can be more informative as this. There are many things I can know only after reading your wonderful article.



    the best seo company

    ReplyDelete
  68. The creativity of your blogs is best.This is something very best on your part..keep sharing..

    ReplyDelete
  69. This site is excellent and so is how the subject matter was explained. I also like some of the comments too.Waiting for next post.

    ReplyDelete
  70. Very good customer service, prompt delivery (lol...prompt for coming from so far away!), and good products.


    maquinas de coser
    maquinas de bordar

    ReplyDelete
  71. i just wanna thank you for sharing your information and your site or
    blog this is simple but nice article I've ever seen like it i learn something today...

    ReplyDelete
  72. Now that surprised me as i really never had an outlook on the subject like that.

    ReplyDelete
  73. Yes, the post is very interesting and I really like.

    ReplyDelete
  74. Really a nice and wonderful post. Keep posting.

    ReplyDelete
  75. I would like to thank you for the efforts you have made in writing this post. I am hoping the same best work from you in the future as well.


    Cuscowilla on lake oconee

    ReplyDelete
  76. Good to know someone I could share my ideas. Looking forward to know and learn some more from you.

    ReplyDelete
  77. If you want to buy xanax online then I think you are at right place mycare pharmacy is one of the best pharmacy . Here you can buy medicines at very cheap rates as like buy ritalin online and many more .

    ReplyDelete
  78. He was very well written and easy to understand. Unlike other blogs I’ve read that are not really good. I also found interesting your blogs.


    Houston Electrician

    ReplyDelete
  79. Your Escort Agency offers exclusive and most beautiful London escort girls of various nationalities.

    ReplyDelete
  80. Details are very true and factual, I do really learned something new upon reading this interesting post.

    Good job! and Thanks!


    Houston Electrician

    ReplyDelete
  81. I really enjoyed it to be honest. Thanks.

    ReplyDelete
  82. I have no words to appreciate this post ..... I'm really impressed with this post .... the person who created this post was a big thank you man .. for sharing with us.

    ReplyDelete
  83. Healthcare can use all the help it can get most important is for people to practice healthy lifestyles.

    ReplyDelete
  84. Interesting post. I have been wondering about this issue, so thanks for posting.

    ReplyDelete
  85. Brilliant post and useful information…I think this is what I read somewhere…but
    I don’t know with your experience...

    ReplyDelete
  86. Nice information,Ankara escort
    many thanks to the author.Ankara escort
    It is incomprehensible to me nowAnkara escort
    , but in general,Escort ankara bayan
    the usefulness and significance is overwhelming.Ankara escort
    Thanks again and good luck!
    Ankara escort
    became the first designer in Wimbledon's 133-year history to create official uniforms for the tournamentescort bayan ankara
    As part of this year's event, which starts next week.
    will introduces the first ...Escort ankara
    determinationEscort ankara
    to maintain and enhance the values for which our two brands are famous throughout the world.Escort ankara
    The rugby ralph lauren brand brings to Wimbledon the look of timeless elegance,Escort ankara
    drawing on our rich history and traditionsEscort ankara
    expert and i like your blog and the information you have
    mentioned in this post about the Google tools is really great!
    escort bayan
    escort
    escort istanbul
    Bayan Escort
    escort bayan ankara
    escort bayan ankara
    escort bayan ankara kızılay
    Escort ankara bayan
    escort bayan ankara çankaya
    Ankara escort bayan
    Ankara escort bayan
    Ankara Escort
    Ankara Escort


    Thanks for sharing. Very impressive

    ReplyDelete
  87. WAO its totally indifferent i'm so impressed the way you presented this

    ReplyDelete
  88. It does help me a lot knowing that you have shared this information here freely. We are constantly Study, a total of enjoyment of information and work together to improve their lives.


    buy curcumin

    ReplyDelete
  89. If you only know where to buy

    adderall online
    We promise that you wont suffer from any anxiety or pain. See more stuff as well

    ReplyDelete
  90. This site is excellent and so is how the subject matter was explained. I also like some of the comments too.Waiting for next post.

    ReplyDelete
  91. Glimpse out promotional
    Roofing Orlando FL on youngster swimwear
    LongBeach Plumbing dunes the online
    Plumbing Milwaukee prices.With on top
    Westfield Locksmiths 100 long period
    Brentwood Plumber together airport security
    Tampa Locksmith our franchise of
    Reno Roofing and security reasons
    Naperville Roofing get on these
    Inglewood Locksmith comprehending to help
    Pasadena Carpet Cleaning subject.
    Exclusively a bit
    Las Vegas Plumbing section of the

    ReplyDelete
  92. I’m still not really certain how much I agree with you on it all. I subscribed to your rss feed though and will certainly keep following your writing and possibly down the road I may chime in once again in much more detail.



    natural suppliments

    ReplyDelete
  93. Your blog article is very interesting and fantastic, at the same time the blog theme is unique and perfect, great job. To your success. One of the more impressive blogs I’ve seen. Thanks so much for keeping the internet classy for a change.
    buy watson

    ReplyDelete
  94. If you want to make you free website I think you need free flash templates .

    Free flash intos is one of the best free flash effects that you need.

    ReplyDelete
  95. Some people really make difference. Blog carries great informative material. One should read this one and appreciate. Thanks.

    ReplyDelete
  96. Nice stuff you got, very interesting to read.Well, I do have also in my sleeves, if you have

    time don't forget to visit

    Spring Electrician

    ReplyDelete
  97. Interesting subject and well written. Seems interesting. Thanks for sharing such kind of post.

    ReplyDelete
  98. There Is Obviously a lot to know about this. I suppose you made Some Amazing points in the Feature also.

    reseller hosting

    ReplyDelete
    Replies
    1. I am inspired by your work and obviously this blog is perfect. satellite internet .

      Delete
  99. What an amazing post that I have ever come through. Well, this is the best i have see so far ! Great stuff, just great!

    ReplyDelete
  100. Increase credit score and save money. Your credit score largely determines the lenders available and the interest rate at which they will lend. Fix credit and expand the number of lenders willing to compete for your loan.

    ReplyDelete
  101. Thank you for sharing your new site. Keep up the great work.

    Manufacturing Logo

    ReplyDelete
  102. London escorts directory London Crumpet is created to expose Independent escorts and escort agencies in London. Everybody can post their advert on this directory for FREE.

    ReplyDelete
  103. London Asian Escorts is an Asian and Oriental escort agency operating in Central London. The agency provides escort service for a true gentlemen. Our escort models are carefully selected and are genuine.

    ReplyDelete
  104. "Thanks for taking the time to discuss this, I feel strongly about it and love learning more on this topic. If possible, as you gain expertise, would you mind updating your blog with more information? It is extremely helpful for me."

    ReplyDelete
  105. I really like and appreciate your article post.Really looking forward to read more. Really Cool.taxis in w2 | minicab to airport | airport drop w2

    ReplyDelete
  106. Great, thanks for sharing this article post.Really looking forward to read more. Awesome.cabs in w2 | cab w2 | w2 taxis

    ReplyDelete
  107. very nice post, i certainly love this website, keep on it.mirza maqbool | Maqbool mirza

    ReplyDelete
  108. Really appreciate your professional approach. These are pieces of very useful information that will be of great use for me in future.

    Mumbai Escort

    ReplyDelete
  109. You really make it seem so easy with your presentation but I find this topic to be really something which I think I would never understand. It seems too complicated and very broad for me. I am looking forward for your next post.

    ReplyDelete
  110. " Interesting and helpful, I liked all the articles posted by you.
    ""http://www.trustpharmarx.com/mens_health.php/""

    ReplyDelete