Mark Corson

By X. Hanson. Purdue University North Central.

Neverthe- less cheap malegra dxt 130 mg fast delivery erectile dysfunction incidence age, pregnant women in these countries can at least be conWdent that their oVspring can escape infection discount malegra dxt 130mg with mastercard erectile dysfunction doctor dallas, and buy malegra dxt 130 mg amex erectile dysfunction gene therapy treatment, that if they accept treatment, they themselves may beneWt from earlier diagnosis (de Cock and Johnson, 1998). Studies in the early 1990s in Kenya and other African countries have shown that the epidemic has had little impact on attitudes and subsequent child- bearing (Ryder et al. In addition, some countries, such as Uganda and Senegal, have managed to reduce transmission by vigorous public health education programmes (Anonymous, 2000b). Pregnant women are considered an ‘epi- demiological useful’ group because they represent a stable sub-group of the heterosexually active population at ‘normal risk’. I shall now consider the potential implications of a positive result, the nature of the relationship between the health professional and the pregnant woman, and the process of consent, as these are all relevant to a discussion about the ethics of anonymized and named testing. The implications of a positive result A pregnant woman is likely to experience considerable distress on discovery of her positive status (Manuel, 1999), particularly as she may feel more vulnerable and dependent on others, and she has the added responsibility of motherhood ahead of her. Once born, however, the interests of the child are paramount, and parental views may be overridden if they are seen to conXict with the child’s welfare. Babies can still gain protection from infection if given antiviral treatment within 48 hours of birth, even if the mother has refused to take medication or have a Caesarean section (Wade et al. It is beyond the scope of this discussion to consider the poignant dilemma for parents of whether or not to disclose to their child his or her incurable infection and uncertain life expectancy, or to explore the burden of imposing life-long unpleasant treatment on a child, and of protect- ing him or her from stigma. It is evident from the case above, however, that women may Wnd that breast-feeding causes disapprobation, and may even result in their infants being considered ‘at risk’. Abstention from breast-feeding creates particular diYculties in countries and cultures where breast-feeding is the norm, and bottle-feeding stigmatizes a woman (Graham and Newell, 1999). The relationship between the health professional and the patient As I have discussed elsewhere (de Zulueta, 2000a), the relationship between a health professional and a patient can be characterized as a Wduciary one. The health professional is therefore entrusted to put the patient’s interests Wrst, and to hold certain things (such as conWdential information) ‘in trust’. As Brazier succinctly expresses this: ‘It is trite to describe the health profes- sional’s relationship with his or her patient as a relationship of trust, yet the description encapsulates the very heart of the relationship’ (Brazier and Lobjoit, 1999: p. The health professional has a duty to promote the well-being of both the mother and the unborn child, but should only provide care that the mother agrees to. Failure to seek the patient’s consent is not only a moral failure, but, in English law, also leaves the doctor liable to the tort or crime of battery or to the tort of negligence. The information required is such that the patient understands in broad terms the nature and purpose of the procedure, and the principal risks, beneWts and alternatives (Chatterton v Gerson, 1981). Consent is a process, not an event, and involves a continuing dialogue between the health care professional and the patient, such that there is genuine shared decision-making. I submit that in the case of anonymized testing, and in the case of ‘routine’ voluntary named testing, consent is often vitiated by a lack of understanding and information, and sometimes by coercion. This may be justiWed in countries where the resources are not available to oVer counselling or treatment, and where the data may be used to galvanize the developed world into providing aid. These Wgures, it is argued, can then be used to provide the justiWcation for allocating more resources to the treatment and prevention of the disease, particularly in areas of high prevalence. But I would counter-argue that it is unprofessional and unethical to encourage individuals to relinquish beneWts that may aVect third parties (human fetuses), even if these are not ‘legal persons’. Finally, it could be argued that if an informed mother agrees to anony- mized testing, she does not intend to deprive the fetus of beneWt, as she does not know if she harbours the virus. This argument is also used to justify the health professional’s behaviour – no harm is intended, and there is no responsibility to act upon the result since it is unobtainable. A woman attending an antenatal clinic carries the reasonable expecta- tion that all tests and procedures are done either directly to beneWt her or her unborn child (de Zulueta, 2000a). The case for abuse of trust is even stronger than with anonymized testing of pregnant women, as the mothers are even more likely to assume that all tests are for the baby’s beneWt. Since the baby relies entirely on others to protect his interests, it is arguably even more unethical to use the baby ‘merely as a means, rather than as an end in himself’, to paraphrase Kant. In order to make an informed choice, the woman needs to understand the nature of the test itself, as well as the advantages and disadvantages of not receiving the result should it be positive. They cite a case when a doctor was found in breach of duty for failing to inform a woman of the potential consequences of not agreeing to a cervical smear. In addition, the leaXet issued by the Department of Health, in circulation after 1994, does not refer to treatments available for reducing vertical transmission. In any case, the notion of passive consent, that is to say that consent is implied unless there is a verbal refusal, is ethically unsound and ‘a concept quite alien in English law’ (Brazier and Lobjoit, 1999: p. In clinics that pro- vide universal testing (see later), the women should have received the relevant information from a pre-test discussion with the midwife, and the 70 P. In one study only Wve per cent fully understood the nature of the testing, and a signiWcant proportion believed that they would be informed should the result be positive (Chrystie et al. The principle of autonomy is frequently infringed by the process of anonymized testing, and, as Brazier says, ‘Consent truly is a myth’ (Brazier and Lobjoit, 1999: p. The ethics of named testing The Department of Health’s Unlinked Anonymous Surveys Steering Group in 1989 rejected mass voluntary testing as an alternative to anonymized testing. As argued above, the beneWts of named testing, and the arguments in favour of truth-telling are further strengthened, particularly as third parties are placed at risk by non-disclosure. The majority of industrialized countries adopted a universal testing policy (whereby all women were oVered the test), and developed their own guide- lines. Women at high risk in ‘low-prevalence areas’ may well miss out; this resource allocation dilemma is one well known to all screening programmes, and diYcult to resolve.

For this reason buy malegra dxt 130mg low price drugs for erectile dysfunction ppt, people who remain close to you for prolonged times may be exposed to unnecessary and avoidable radiation discount malegra dxt 130 mg overnight delivery erectile dysfunction treatment pumps. Besides the above mentioned radiation buy malegra dxt 130mg visa erectile dysfunction pump surgery, there is the possibility that other people close to you may directly ingest small quantities of radioactive iodine eliminated by your body in the saliva or sweat. The three principles to avoid unnecessary radiation exposure are: (1) Distance: Do not get too close to any other person. Because most of the iodine is excreted in the urine it is very important that you wash your hands thoroughly after going to the toilet. Avoid close and prolonged contact with other people, especially children and pregnant women, who are more sensitive to radiation than the rest of the population. If you have a small child or you are in charge of one, request special instructions from your doctor. If you are breast feeding, you must stop before therapy begins because the iodine is excreted into breast milk. Men are advised to urinate sitting down to avoid splashing urine outside the toilet bowl or in its borders. Eat sweets or drink lemon juice to produce more saliva and in this way prevent iodine retention within your salivary glands. Wash your underwear and bed linen separately from those of the rest of the family and rinse several times. Clinical benefits The aim of radionuclide therapy for metastatic bone pain is to ameliorate pain, reduce the intake of analgesics and improve quality of life. The requirement for such treatment is the demonstration of good focal uptake of 99mTc bone-seeking radiopharmaceuticals in bone scintigraphy at sites corre- sponding to the bone pain. Between 60 and 75% of patients normally show a good response to such treatments; the duration of response lasts between 6 and 24 weeks (with a mean of 12 weeks) and is independent of the radioisotope used. A significant proportion (40–50%) of responders do not require analgesics, while the rest require only mild doses of oral analgesics in order to remain free of pain. Studies have also demonstrated that there is significantly delayed onset of new bone pain following therapy. Mild to moderate myelosuppression (thrombocytopenia, leucopoenia and rarely anaemia) is sometimes observed. Physiological basis Bone metastases have local effects resulting in increased bone destruction (osteolysis), increased bone formation (osteosclerosis) or both. Osteolytic metastases are the predominant types of lesions in most cancers, but a sclerotic appearance is seen in the majority of metastases from prostate cancer, in about 10% of metastases from breast cancer, as well as in those from other cancers. In the majority of skeletal metastases, new bone formation develops simultaneously with bone destruction, and the radiological appearance reflects the process that predominates. Systemic administration provides a means of delivering radiation systemically to the sites of disseminated bone metastases. They may be used as adjuncts and/or alternatives to external beam radiotherapy for the palliation of metastatic bone pain. Relative: Impending cord compression may require concurrent external beam –3 therapy. Procedure The regulations and guidelines for the therapeutic administration of radiopharmaceuticals described in Sections 6. Pretreatment investigations The following pretreatment investigations are carried out: (a) Haematological screening, to ensure adequacy of platelets and granulo- cytes; (b) Bone scans, to ensure that skeletal lesions are positive on scintigraphy; (c) Radiographs of skeletal lesions, when necessary, to rule out impending cord compression or fracture. Patient information Before administering therapy, the patients should be informed that: (a) The treatment has an 80% probability of reducing their bone pain, although the chance of complete pain relief is low. Strontium-89 is administered intravenously as the soluble salt strontium chloride. Higher doses may increase side effects without any significant gain in pain palliation. Evaluation of palliative efficacy On average, all the three above cited radiopharmaceuticals produce pain relief in between 60 and 75% of patients suffering from painful bone metastases. The effect usually shows between one and three weeks after dose administration and generally lasts between 6 and 24 weeks. The response starts with a slight improvement, increases with time to a plateau, then slowly declines with the recurrence of pain. About 25–35% of patients may have a complete pain free phase for a certain period of time, but most patients experience a varying effect day-to-day throughout the course. The platelet and white cell counts may drop by 30–50% of the baseline values one to four weeks after treatment. The side effects are not usually severe, and patients will recover spontaneously in most instances. Follow-up All patients should be followed up for at least five or six weeks with weekly or bi-weekly clinical, biochemical and haematological examinations. It is believed that 50% of patients who fail the first dose may benefit from another dose. This uptake is blocked competitively by noradrenalin analogues including Ephedrine and pseudoephedrine, which occur frequently in cough lozenges and drops, some antidepressants and related compounds. Contraindications Absolute: pregnancy, continued breast feeding, severe myelosuppression, severe renal failure; Relative: unstable patient condition not allowing isolation therapy. Serum markers return to normal in about 10%, with a reduction of more than 50% in a further 30% and no change in about 45%.

Tests Useful in the Differential Diagnosis of Amylase-Rich Pleural Effusions Tests Acute Pancreatitis Chronic Pancreatic Effusion Esophageal Rupture Malignancy Pleural fluid amylase Moderate Extremely elevated Minimal Minimal concentration Pleural fluid /serum amylase 10:1 20:1 (mean 63 cheap malegra dxt 130mg without prescription impotence due to alcohol,000) 5:1 3:1 Pleural fluid amylase Pancreatic Pancreatic Salivary Salivary isoenzyme Pleural fluid pH 7 order 130 mg malegra dxt fast delivery drugs for erectile dysfunction ppt. Causes of Amylase-Rich Pleural Effusions Diagnosis Type of Amylase Isoenzyme Pancreatitis discount malegra dxt 130mg without a prescription erectile dysfunction cleveland clinic, pancreaticopleural fistula Pancreatic Carcinoma of the lung (usually adenocarcinoma) Salivary (most common cause of salivary amylase-rich effusion) Adenocarcinoma of ovary Salivary Lymphoma Macroamylase/salivary Esophageal rupture Salivary Chronic lymphatic leukemia Salivary Pneumonia Salivary Ruptured ectopic pregnancy Probably salivary chest pain and dyspnea or may be asymptomatic, appearance suggests that the patient has long- usually without fever. The chest radiograph typically shows a if there is an unexpandable lung without active small-to-moderate unilateral effusion with a nor- disease, up to 15,000 mostly neutrophils/ L in mal cardiac silhouette. However, in one third of acute rheumatoid pleurisy or with a cholesterol patients, another manifestation of rheumatoid lung effusion with chronic inflammation. There are anecdotal tomatic with pleuritic chest pain (86 to 100%), reports of responses to corticosteroids; however, pleural rub (71%), cough (65%), dyspnea (50%), the course is variable, and it is uncommon for the and fever. Pleural thickening may be a residual in sions; however, unilateral massive pleural effu- some patients evolving into a trapped lung that sions have been reported. In refractory cases, Patients usually require antiinflammatory immunosuppressive agents, such as azathioprine, therapy for relief of symptoms, including predni- added to corticosteroids are sometimes but not sone in some cases. However, persistent pleuritic pain corticosteroids because their withdrawal often appears to be an adverse prognostic marker with results in recurrence. The chest radio- elevated left hemidiaphragm in the early postop- graph is abnormal in 95% of patients, with pleural erative period associated with phrenic nerve injury. A trapped lung may develop after 6 increased cardiac silhouette, most likely from a months and typically is a small, unilateral effusion pericardial effusion. In contrast, medium-chain triglycerides (con- Lymphocytic effusion of taining 12 carbon units) are directly absorbed uncertain origin into the portal vein without entering intestinal Constrictive pericarditis lymphatics. Approximately 60% of the dietary fat Lung entrapment enters the lymphatics, and 1,500 to 2,500 mL of Persistent ( 6 mo) Trapped lung chyle travels daily through these vessels. If the mediastinal pleura remain intact, node hyperplasia), sarcoidosis, Kaposi sarcoma, chyle fills the mediastinum and forms a “chyloma” yellow nail syndrome, Noonan syndrome, multiple over the next several days before rupturing into myeloma, Waldenström macroglobulinemia after the pleural space, usually on the right at the base thoracic radiation, and goiter. The thoracic duct, Patients with chylothorax present with sub- which has its origin in the cisterna chyli, is situated acute or insidious onset of dyspnea. The thoracic duct travels through tion, a number of chylothoraces are termed idio- the aortic hiatus of the diaphragm approximately pathic; these are most likely caused by innocuous at the level of the tenth to twelfth thoracic vertebrae hyperextension of the spine or an occult malig- to the right of the aorta. Patients with chylothorax are usually not to sixth thoracic vertebrae, the duct enters the left febrile and do not have chest pain because chyle posterior mediastinum and eventually joins the does not tend to invoke an inflammatory response. Sputum triglyceride concentrations have below T5 to T6 causes a right-sided chylothorax, been reported to range from 662 to 2,600 mg/dL, whereas injury to the duct above this level re- which is greater than concurrent serum values. Second, pro- opalescent if fat is present; however, the fluid can longed drainage of a chylothorax should be be clear and yellow in the adult who has not eaten avoided to prevent immunosuppression and mal- for 12 h or hemorrhagic if there is concomitant nutrition. The primary cells in chyle bowel rest, and parenteral nutrition to minimize are T lymphocytes, which typically represent 80% the flow of chyle and maintenance of fluid and of the cellular population. If In contrast to a cholesterol pleural effusion, the drainage is persistent after 2 weeks, 1,500 mL for cholesterol levels in chyle are substantially lower 5 days, or if the patient develops significant weight and range from 65 to 220 mg/dL. Conversely, if the There are recent reports of percutaneous catheter- triglyceride level is 50 mg/dL, it is highly ization and embolization of the thoracic duct in unlikely that a chylothorax is present. If have been reported to decrease chyle production chylomicrons are present, the diagnosis is estab- in postoperative chylothorax in small case lished definitively. There are studies recurrences were ipsilateral (71%) and contralateral that have evaluated the outcomes of lung trans- (74%), occurring at an average of 21. Thirteen (38%) of Foundation study identified 8 (4%) of 193 patients 34 patients had previous pleurectomy or pleurode- who developed bilateral simultaneous pneumo- sis. Also, 18 (53%) of 34 patients had extensive thorax during the course of their disease, with pleural adhesions that were judged to be of moder- several patients experiencing recurrent bilateral ate severity and severe intent. After esophageal-mediastinal perforation, a “crunch” The three distinct types of esophageal perfora- may be auscultated over the left heart synchro- tion are (1) traumatic (iatrogenic and barogenic), nous with the cardiac cycle. Mediastinitis and sepsis are responsible Mediastinal emphysema virtually never appears for the rates of high morbidity and mortality in this before 1 h after perforation and never occurs in syndrome. With intrathoracic The pathogenesis of esophageal rupture esophageal perforation, mediastinal changes are includes the following: (1) the esophageal tear more likely to occur. The presence and timing of always occurs longitudinally, (2) the tear always pleural changes are linked to the integrity of the occurs in the lower half of the esophagus, (3) the mediastinal parietal pleura. Most left-sided the upper esophagus is buttressed by striated pleural lesions occur because 70% of barogenic smooth muscle fibers, whereas the lower esopha- esophageal ruptures develop in the left posterior gus contains only unsupported smooth muscle. How- When esophageal rupture is suspected, a con- ever, perforation of the cervical esophagus usually trast study of the esophagus should be performed does not involve the pleural space. The choice of contrast is limited to a The most dramatic presentation of esophageal water-soluble iodinated compound and barium rupture is associated with barogenic perforation. Barium has the advantage of increased This entity is seen most commonly in men in their radiographic density and better mucosal adher- fourth-sixth decades of life with a history of alco- ence. Therefore, aspiration of these thoracentesis, absence of another disease related compounds into the tracheobronchial tree can cre- to the pleural effusion, and no development of a ate significant inflammation and precipitate pul- malignant tumor within 3 years. The latency of these effu- tesis can establish the diagnosis once the medias- sions was shorter than for other asbestos-related tinal pleura have ruptured. After mediastinal parietal pleural ifestation within 10 years, and it was the most rupture, the patient develops an anaerobic empy- common abnormality during the first 20 years after ema. Recurrent effusions develop the diagnosis, which may not be detected on in approximately 30% of patients, sometimes ipsi- Gram stain and wet preparations. Other reported that if primary closure was achieved cells in the effusion were predominantly lympho- within 24 h of rupture the outcome was excellent, cytes with varying numbers of neutrophils and with a 92% survival rate. An unusual variant of pleural fibrosis, called Immediate primary repair of barogenic esophageal rounded atelectasis, can result directly from a pleu- rupture includes mediastinal and pleural space ral effusion and often can be confused with possible drainage and prompt treatment with antibiotics tumor. The edema could be culous pleural effusion because of the high risk of confined to the fingertips alone but was often more tuberculosis in this patient population.

Winter and Krämer (2012) investigate several factors that influ- ence readers’ selection of user-generated content on participatory websites cheap 130 mg malegra dxt free shipping erectile dysfunction injections videos, adapting research on persuasion buy malegra dxt 130 mg online erectile dysfunction injection drugs. A two-sided summary buy malegra dxt 130 mg with amex erectile dysfunction drugs stendra, which indicates that both positions on a controversial issue are being considered, may appear more attractive to readers who are motivated to reach an informed position. Construction and legitimization of roles in online health communities In d/p sites’ framework, the interaction of net users (willing to show and tell their health issues) and doctors (with their sympathetic authority), as well as the silent readers (those who read the posts without actually participating in the discussion) have a relationship in which net users contribute to the formation of medical knowledge and forge a modern sense of appropriation of health information and of doctor/patient exchange. In laymen-to-laymen forums, knowledge communication is practiced in communities in which knowledge and experience are shared to create new knowledge (Wenger 1999). Such digital environments allow people to play the roles of both information source and receiver, as they give, share and critique the content of forum posts. This game has profound implications for how people construct and evaluate credibility, in particular when it comes to their limited ability to discern quality information due to a stressed emotional state, which is often the background to an online health fact search. According to Fage-Butler and Nisbeth Jensen (2014), in online health forums p-p communication has striking similarities with aspects of d-p Credibility and Responsibility in User-generated Health Posts 201 communication, as it includes the sharing of biomedical information on diagnosis, suggesting treatment action and giving treatment advice. See for example: (1) 1st User: [asks for some details] 2nd User: […] strong vasoconstrictors and not to anything that regulates neu- ronal excitability or neurotransmitters, they think nortriptyline worked only because serotonin is a vasoconstrictor […]; Moderator: Hi, Christine, and welcome! In addition, people also take up position towards their utterances and in extreme case they even question doctors’ treatments: (3) Macca, 100 mg a day was your starting dose? Not to play doc- tor, but the usual starting dose is 25 mg, to be increased in 25 mg increments every 1-2 weeks or even longer depending on patient tolerance. However, the study also illustrates that respondents use disclaimers which are expressed when acknowledging lay status and which, in a way, downgrade their position to semi-experts. However, if authority implies expertise and experience, the forum respondents may increase their credibility, since “patient-patient communication clearly com- 202 Marianna Lya Zummo prises aspects that cannot be found in traditional doctor-patient com- munication, as it incorporates experiential knowledge, empathetic support drawn from common experience and ‘we-ness’ or group solidarity” (Fage-Butler/Nisbeth Jensen 2013: 35). Responsibility in the communication of information The legitimization of the role of the writer, when assessing credibility in a forum post, comes from their perceived expertise, which means the way they express certainty (and commitment) in their posts. Assuming that the use of the first person pronoun expresses credibility (as a role marker of authorial presence and investment to personally get behind the statements) and helps the writer to establish commitment to their words, the frequency and role of first person pronouns I and we in their various forms (subject, object and possessive) are studied as role markers and authorial presence, together with adjectives and grading adverbs. Writer visibility in exchanges is mostly concerned with the function of stating sympathy whereas func- tions related to the expression of commitment toward information have very low percentage values. The categorisation of discourse Credibility and Responsibility in User-generated Health Posts 203 functions of personal pronouns in healthcare forum exchanges shows an increasing loss of authority expressed by the authorial presence. In other words, it seems that comment users adopt their own visibility for the purpose of sharing personal stories and show sympathy without using themselves as references to influence or persuade their readers. It could be hypothesized that the writers of the posts choose not to adopt authorial stances because they are conscious of a lack of expertise and of a reluctance to commit themselves explicitly to their claims. On the other hand, it is true that elaborating a sentence without explicitly expressing the subject, increases the perception of the neutral objective truth of the utterance (Gotti 2011). Results suggest that users know the limitations of their own medical knowledge and may perceive the importance of their suggestions when offering help, limiting the expression of authorship and certainty, as in these comments: (4) As for the meds and their side effects you’re experiencing, perhaps you might talk to your doctor about ramping the dose up a bit more slowly. Following Marín Arrese (2004), direct evidence (perceptual markers and beliefs) and indirect evidence (inference and reasoning) jointly express the speaker’s commitment to the truth of the utterance, both cognitively and perceptually, since references to sources of information have been linked closely to references to reliability of knowledge (Dendale/ Tasmowski 2001) Evidentiality markers are considered to be ‘percep- tual’ (expressed by verbs such as hear, see, etc. Another subdivision is provided by De Haan (2001), who puts forward the classifications of direct/indirect and first hand / second hand evidence, where indirect evidence incorporates that which is quoted, while inferential refers to personal but indirect access to information. Evidentiary validity and degree of certainty are two parameters to be analysed in order to find the dimension of author commitment to the validity of the information. Epistemic modality (Nuyts 2001) refers to the possibility or necessity of the truth of the utterance, and consequently indicates the speaker’s degree of commitment to his/her proposition in relation to his/her knowledge or belief within a high degree of certainty (one possible conclusion to be drawn from facts), and a low degree of certainty (facts lead to speculation). Markers of possibility are found in utterances like: “All of the symptoms you have could be a migraine”; markers of certainty can be found in expressions such as: “I’d definitely suggest […]”. The results indicate that users offer suggestions that are drawn from mental processes and general knowledge, as in the following examples: (8) I actually read once that B vitamins should be taken as a balanced thing, so if you’re taking one, you could balance it by taking a B-complex with it, so you get some of each. Credibility and Responsibility in User-generated Health Posts 205 (9) I assume there is a trigger in your food or combinations of food that combined with body rhythms trigger the migraines. In some (rare) occasions, in fact, the members report information obtained by their own doctors for other users’ specific health problem: (10) User1: I’ve read somewhere that the hormones in birth control pills mimic early pregnancy hormones. He said that multiple studies show that while natural menopause can make migraines either better or worse (just like estrogen-containing birth control) surgical menopause in 99% of the cases makes migraines much, much worse. As suggested by Fitneva (2001), cognitive resources cannot provide a solid certain background, so users tend towards a dimension based on possibility and probability. Use of health forums and negotiation of trust Health forums are a particularly intriguing space to consider with regard to information and source credibility, for several reasons. Although net users may be comfortable with technology and good at using it, they may lack the tools and abilities needed to effectively evaluate medical information. Such strategies are ‘analytic’ (people analyse information carefully), ‘heuristic’ (they use a more intuitive approach), or ‘social’ (they ask their social circle for advice). This section presents the findings of a small-scale survey of people in Italy aged 18-33 examining young adults’ beliefs about the credibility of information available on Italian health forums, and the reason why they choose to evaluate information as credible. Findings for the second research Credibility and Responsibility in User-generated Health Posts 207 question indicate that 75% of respondents use health forums but, among them, only 14. When asked why they do not trust information they find on health fo- rums, 75% of young adults reported doubts about the source of the in- formation (Table 3). In other words, as the analysis of these posts shows, the authorial presence is expressed only for support and is limited when expressing certainty and authority. Mental processes and general background knowledge, as well as mediated data, do not constitute a solid certain background on which the information may be expressed. To validate this, when people were asked why they do not trust information they find on health forums, 75% of young adults reported doubts about the source of the information. Final considerations The Internet offers confidential and convenient access to an unprece- dented level of information about a diverse range of subjects, and over time it has increased its perceived credibility. However, analysis of web pages raises significant questions about the relevance, coverage, and legitimacy of a lot of Internet health information (Rice/ Katz 2001: 31). Although content providers are expected to take steps to help control the most extreme content (Williams/Calow/Lee 2011), user agreements in the form of ‘terms of use’ are treated as membership contracts and in fact only protect one side’s rights, without assuming any responsibility for the content, for which the Credibility and Responsibility in User-generated Health Posts 209 users assume all the risk (Sözeri 2013).