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Please explain what and when the procedure was performed. Has the patient been seen since surgery by the physician? What was the reason provided for not seeing the patient?There is a patient abandonment issue. The person doing the surgery should do follow up for any complication related to the procedure he/she performed. Is it because of noncompliance, schedule conflict, non-payment etc?[Edit: Per additional history provided in the Comments section. The article below addresses medical management after bariatric surgery. The physician has tried to work up surgical complications. This is the section regarding nausea and vomiting. The authors mention antiemetic unless there are other issues. I hesitate to second guess what the surgeon’s train of thought is. I do think there should be response to the patient’s communications. I understand the frustration and the cost of repeat emergency room visits. Someone here has suggested contacting the chief of surgery. Post bariatric surgery recuperation can be problematic and I hope the symptoms resolve in time.Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].]World J Gastrointest Surg. 2014 Nov 27; 6(11): 220–228.Published online 2014 Nov 27. doi: 10.4240/wjgs.v6.i11.220PMCID: PMC4241489Medical management of patients after bariatric surgery: Principles and guidelinesAbd Elrazek Mohammad Ali Abd Elrazek, Abduh Elsayed Mohamed Elbanna, and Shymaa E BilasyAuthor information ► Article notes ► Copyright and License information ►This article has been cited by other articles in PMC.Go to:AbstractObesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index (BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity. Being overweight was also associated with decreased survival in several studies. Unfortunately, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. All obese patients (BMI ≥ 30 kg/m) should receive counseling on diet, lifestyle, exercise and goals for weight management. Individuals with BMI ≥ 40 kg/m and those with BMI > 35 kg/m with obesity-related comorbidities; who failed diet, exercise, and drug therapy, should be considered for bariatric surgery. In current review article, we will shed light on important medical principles that each surgeon/gastroenterologist needs to know about bariatric surgical procedure, with special concern to the early post operative period. Additionally, we will explain the common complications that usually follow bariatric surgery and elucidate medical guidelines in their management. For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation. Patients maintain a low calorie liquid diet for the first few postoperative days that is gradually changed to soft solid food diet within two or three weeks following the bariatric surgery. Later, patients should be monitored for postoperative complications. Hypertension, diabetes, dumping syndrome, gastrointestinal and psychosomatic disorders are among the most important medical conditions discussed in this review.Keywords: Obesity, Bariatric surgery, Postoperative care, Body-mass index, El bannaCore tip: Obesity is a growing health concern worldwide that impacts the life of individuals both physically and psychologically. There are several well-established health hazards associated with obesity. Additionally, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. Bariatric surgery is one of the definite solutions for obesity. In this review, we will briefly discuss the general guidelines that should be considered before bariatric surgery. Also, we discuss the protocols of patients’ postoperative care and the management of medical disorders that must be considered after bariatric surgery.Go to:INTRODUCTIONObesity is a chronic disease that impairs health-related quality of life in adolescents and children. In 2010, overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life loss, and 3.8% of disability-adjusted life-years worldwide. Obesity is increasing in prevalence, currently, the proportion of adults with a body-mass index (BMI) of 25 kg/m or greater is 36.9% in men and 38.0% in women worldwide[1]. Attempts to explain the large increase in obesity in the past 30 years focused on several potential contributors including increase in caloric intake, changes in the composition of diet, decrease in the levels of physical activity and changes in the gut microbiome. More than 50% of the obese individuals in the world are located in ten countries (listed in order of number of obese individuals): United States, China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan and Indonesia. Although age-standardized rates were lower in developing than in developed countries overall, 62% of the world’s obese individuals live in developing countries. Recently, United States accounted for 13% of obese people worldwide, the prevalence of obesity was 31.7% and 33.9% among adult men and women, respectively. In Canada 21.9% of men and 20.5% of women are obese. Reported prevalence rates of obesity include: 27.5% of men and 29.8% of women in Australia, 24.5% of men and 25.4% of women in the United Kingdom, in Germany 21.9% of men and 22.5% of women, in Mexico 20.6% of men and 32.7% of women, in South Africa 13.5% of men and 42% of women, in Egypt 26.4% of men and 48.4% of women, in Saudi Arabia 30% of men and 44.4% of women and in Kuwait 43.4% of men and 58.6% of women Figure ​Figure11)[2].There are several well-established health hazards associated with obesity, e.g., nonalcoholic steatohepatitis (NASH), type 2 diabetes, heart disease, chronic kidney disease, gastroesophageal reflux disease, gastrointestinal motility disorders, sexual disorders, cerebrovascular stroke, certain cancers, osteoarthritis, depression and others[3-10]. The risk of development of such complications rises with the increase of adiposity, while weight loss can reduce the risk. Bariatric surgery could be the definitive clue in many situations[11-15]. Bariatric surgery is one of the fastest growing operative procedures performed worldwide, with an estimated > 340000 operations performed in 2011. While the absolute growth rate of bariatric surgery in Asia was 44.9% between 2005 and 2009, the numbers of procedures performed in the United States plateaued at approximately 200000 operations per year[16,17]. Starting in 2006, the Center for Medicare and Medicaid Services, United States, restricted the coverage of bariatric surgery to hospitals designated as “Centers of Excellence” by two major professional organizations[18]. Medical management and follow up of patients who have undergone bariatric surgery is a challenge due to post operative complications.GENERAL GUIDELINES FOR SURGEONS/GASTROENTEROLOGISTSA well skilled physician or a surgeon has to consider the followings:(1) as the prevalence of obesity increases so does the prevalence of the comorbidities associated with obesity. Losing weight means overcoming illness at the present, complications in future and alleviating the economic burden in the present and future;(2) Overweight; BMI between 25 and 30, technically refers to excessive body weight, whereas “obesity” BMI ≥ 30 kg/m refers excessive body fat, “Severe obesity”, BMI ≥ 35 kg/m, or “morbid obesity” refers to individuals with obesity-related comorbidities. Furthermore, severe obesity and morbid obesity groups who failed dietary and medical regimens are candidates for bariatric surgery;(3) Children obesity; refers to children with BMI > 95th percentile for their age and sex and “overweight” refers to children with BMI between the 85th and 95th percentile for their age and sex;(4) Patients undergoing a bariatric operation should have a nutritional assessment for deficiencies in macro and micronutrients, also with no contraindication for such a major operation;(5) Most of bariatric procedures are performed in women (> 80%) and approximately half of these (> 40% of all bariatric procedures) are performed in reproductive aged women, accordingly, pregnancy planning and contraception options should be discussed in details with women who will undergo bariatric procedures. Fertility improves soon after bariatric surgery, particularly in middle-aged women, who were anovulatory. Additionally, oral contraceptives may be less effective in women who have undergone malabsorptive bariatric procedure. Therefore, it is better to delay pregnancy for 6-12 mo following bariatric surgery. Risk of preeclampsia, gestational diabetes, and macrosomia significantly decrease post bariatric surgery, but the risk of intrauterine growth restriction/small infants for their gestational age may increase. Body contouring surgery is in high demand following bariatric surgery;(6) All bariatric operations are accompanied with restrictive and/or malabsorption maneuvers; less food intake and malabsorption concepts;(7) The most common types of bariatric surgeries performed worldwide are Sleeve gastrectomy (SG): This procedure involves the longitudinal excision of the stomach and thus shaping the remaining part of the stomach into a tube or a “sleeve” like structure. SG removes almost 85% of the stomach (Figure ​(Figure2);2); Roux-en-Y gastric bypass (RYGB): It reduces the size of the stomach to the size of a small pouch that is directly surgically attached to the lower part of the small intestine. In this procedure, most of the stomach and the duodenum are surgically stapled and therefore, bypassed (Figure ​(Figure3);3); The laparoscopic adjustable gastric band (AGB): This is one of the least invasive procedures, where the surgeon inserts an adjustable band around a portion of the stomach and therefore, patients feel fuller after eating smaller food portions (Figure ​(Figure4).4). Bariatric surgical procedures, particularly RYGB, plus medical therapy, are effective interventions for treating type 2 diabetes. Improvement in metabolic control is often evident within days to weeks following RYGB; and(8) Complications reported following bariatric surgery vary based upon the procedure performed. Cholilithiasis, renal stone formation and incisional hernia could be the delayed phase complications; on the other hand, bleeding, leaking, infection and pulmonary embolism could be the early phase complications following the bariatric procedure. The overall 30-d mortality for bariatric surgical procedures worldwide is less than 1%.Roux-in Y Gastrectomy, sleeve gastrectomy. and adjustable gastric band.POST OPERATIVE CARE AND FOLLOW UPEarly post operative period; (1-3) d post bariatric surgeryPatients undergoing a bariatric operation are admitted to the post-anesthesia care unit (PACU) immediately at the conclusion of the operation. Usually, on postoperative day (POD) one, we begin oral therapy in tablet or crushed-tablet and liquid form if there is a naso-gastric tube after the gastrografin leak test. A basic metabolic profile (e.g., complete blood count, electrolytes, renal function, liver function, prothrombin time and partial thromboplastin time) should be obtained every 12 h for the successive two PODs, then every 24 h for another 3 d. Oxygen is administered by nasal cannula and weaned thereafter. The likelihood that, early specific complication, will arise for a given patient is determined by the nature of the procedure, the anesthetic techniques used, and the patient’s preoperative diseases. Respiratory problems are common complication in the early postoperative period following bariatric surgery. Patients with significant comorbidities, particularly neuromuscular, pulmonary, or cardiac problems are at a higher risk for respiratory compromise, but any patient can develop hypoxemia following bariatric surgery. For prophylaxis against Deep Venous Thrombosis (DVT) following bariatric surgeries, ultrasound evaluation is recommended for all patients, D-dimer test should be applied for suspected patients with DVT, especially after long operative time, repeat ultrasound or venography may be required for those with suspected calf vein DVT and a negative initial ultrasound investigation[19,20].Late post operative monitoringAfter the PACU period, most patients are transferred to the inpatient surgical postoperative unit. For the next 24-72 h, the postoperative priorities include ruling out an anastomotic leak following laparoscopic RYGB or laparoscopic SG. If no leak is observed, patients are allowed to start a clear liquid diet and soft drinks. The postoperative care team cares for the following: control of pain, care of the wound, continuous monitoring of blood pressure, intravenous fluid management, pulmonary hygiene, and ambulation. Post-bariatric nausea and vomiting is directly correlated with the length of the surgery; it also increases in females, non-smokers, and those patients with prior history of vomiting or motion sickness. Prophylaxis with pharmacologic treatment before the development of post operative nausea and vomiting significantly reduces its incidence after surgery[21-23].After hospital dischargeDiet: Usually patients are discharged 4-6 d after surgery. Most patients are typically discharged from the hospital on a full liquid diet, patients should be taught to keep monitoring their hydration and urine output. Approximately two-three weeks after surgery, the diet is gradually changed to soft, solid foods. The average caloric intake ranges from (400) to (800) kcal/d for the first month, and thus the daily glycemic load is greatly reduced. We encourage patients to consume a diet consisting of salads, fruits, vegetables and soft protein daily.To control the epigastric pain and vomiting, patients should be taught to eat slowly, to stop eating as soon as they reach satiety and not to consume food and beverages at the same time. For most patients suffering chronic vomiting, prokinetic therapy and proton-pump inhibitors (PPIs) should be considered. Patients, who underwent SG, LAGB or RYGB, benefit from a well-planned dietary advancement. Patients should understand that the surgery has changed their body but not the environment, they have to choose healthy foods, do not skip meals and to visit the dietitian regularly in the first 12 mo after surgery. However, if food intolerance develops, patients may choose a more vegetarian-based diet. Nevertheless, fresh fruits and vegetables are usually tolerated without a problem. The daily protein intake should be between 1.0 to 1.5 g/kg ideal body weight per day[24]. The biliopancreatic diversion/duodenal switch (BPD/DS) is a malabsorptive procedure for both macro- and micronutrients. Hence, we encourage higher protein intake of 1.5 g to 2.0 g of protein/kg ideal body weight per day, making the average protein requirement per day approximately 90 g/d[25,26]. Alcohol is better prevented in the first 6-12 mo after surgery[27].Monitoring: Patients should generally have their weight and blood pressure measured weekly until the rapid weight loss phase diminishes, usually within 4-6 mo, then again at 8, 10 and 12 mo, and annually thereafter. Patients with diabetes are encouraged to check their blood glucose daily. Glycemic control typically improves rapidly following bariatric surgery. Patients maintained on antihypertensive or diabetic medications at discharge should be monitored closely for hypotension and hypoglycemia, respectively, and medications should be adjusted accordingly. We recommend that the following laboratory tests be performed at three, six, nine months and annually thereafter: (1) Complete Blood Count; (2) Electrolytes; (3) Glucose and Glucose Tolerance test; (4) Complete iron studies; (5) Vitamin B12; (6) Aminotransferases, alkaline phosphatase, bilirubin, GGT; (7) Total protein and Albumin; (8) Complete lipid profile; (9) 25-hydroxyvitamin D, parathyroid hormone; (10)Thiamine; (11) Folate; (12) Zinc; and (13) Copper.Complications following the surgical treatment of severe obesity vary based upon the procedure performed. Secondary hyperparathyroidism, Hypocalcemia, Gastric remnant distension, Stomal stenosis/Obstruction, Marginal ulcerations, Cholilithiasis, Ventral incisional hernia, Internal hernia, Hiatus Hernia, Short bowel syndrome, Renal failure, Gastric prolapse, infection, Esophagitis, Reflux, Vomiting, Hepatic abnormalities and dumping syndrome are common late-phase complications after bariatric surgery. However, the clinician should aware of complications specific for every bariatric procedure[28,29]. Before therapy, the clinician should understand that the impact of various bariatric surgeries on drug absorption and metabolism are scarce. On the other hand, RYGB and other malabsorptive procedures that significantly exclude the proximal part of the small intestine, decrease the surface area where most drug absorption occurs and may result in a reduction in systemic bioavailability[30-32].Go to:COMMON MEDICAL CONDITIONS FOLLOWING BARIATRIC SURGERYHypertensionHypertension is not always related to obesity, and dietary interventions do not assure the normalization of blood pressure. However weight loss, whether by an intensive lifestyle medical modification program or by a bariatric operation, improves obesity-linked hypertension. Patients should be monitored weekly until the blood pressure has stabilized, and patients may need to resume antihypertensive medications, but often at adjusted doses[33].DiabetesPatients with diabetes should have frequent monitoring of blood glucose in the early postoperative period and should be managed with sliding scale insulin. Many diabetic patients have a decreased need for insulin and oral hypoglycemic agents after bariatric surgery. Oral sulfonylureas and meglitinides should be discontinued postoperatively as these medications can lead to hypoglycemia after bariatric surgery. Metformin is the safest oral drug in the postoperative period, since it is not associated with dramatic fluctuations in blood glucose. RYGB is associated with durable remission of type 2 diabetes in many, but not all, severely obese diabetic adults. However those who underwent LAGB generally exhibit a slower improvement in glucose metabolism and diabetes as they lose weight in a gradual fashion[34,35].RefluxMedications for gastroesophageal reflux disease (GERD) may be discontinued after RYGB and Laparoscopic AGB, however, SG has been associated with an increased incidence of GERD in some procedures. Recurrent GERD symptoms after RYGB, particularly when accompanied by weight regain, should raise the possibility of a gastrogastric fistula between the gastric pouch and remnant, and should be investigated by an upper GI contrast study or CT scan and referred to the bariatric surgeon. Upper endoscopy is the best investigation to exclude other esophagogastroduodenal disorders. GERD may be associated with esophageal complications including esophagitis, peptic stricture, Barrett’s metaplasia, esophageal cancer and other pulmonary complications. Failure of the PPI treatment to resolve GERD-related symptoms has become one of the most common complications of GERD after bariatric surgery. Most patients who fail PPI treatment have Non Erosive Reflux Disease and without pathological reflux on pH testing. In patients with persistent heartburn despite of medical therapy, it is reasonable to recommend avoidance of specific lifestyle activities that have been identified by patients or physicians to trigger GERD-related symptoms[36-38].Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].Marginal ulcerationDue to increased risk of ulcer formation from nonsteroidal anti-inflammatory drugs (NSAIDs), these medications should be discontinued postoperatively, especially after RYGB. NSAID use is associated with an increased risk of bleeding. If analgesic or anti-inflammatory treatment is needed, the use of acetaminophen is preferred in a dose of 1-2 g/daily[41-45]. Other factors associated with increased risk of ulcer formation are smoking, alcohol, spicy food, gastrogastric fistulas, ischemia at the site of surgical anastomosis, poor tissue perfusion due to tension, presence of foreign material, such as staples and/or Helicobacter pylori infection. Diagnosis is established by upper endoscopy. According to our strategy, all patients should undergo diagnostic upper endoscopy to exclude congenital or GI diseases prior to bariatric procedures. Medical management is usually successful and surgical intervention is rarely needed[46-48].Go to:DUMPING SYNDROMEDumping syndrome or rapid gastric emptying is a group of symptoms that most likely occur following bariatric bypass. It occurs when the undigested contents of the stomach move too rapidly into the small intestine. Many patients who underwent bariatric bypass experienced postprandial hypoglycemia. However, the dumping syndrome usually occurs early (within one hour) after eating and is not associated with hypoglycemia. It is presumed to be caused by contraction of the plasma volume due to fluid shifts into the gastrointestinal tract. Dumping syndrome may result in tachycardia, abdominal pain, diaphoresis, nausea, vomiting, diarrhea, and sometimes, hypoglycemia. The late dumping syndrome is a result of the hyperglycemia and the subsequent insulin response leading to hypoglycemia that occurs around 2-3 h after a meal. Dumping syndrome is a common problem that occurs in patients who have undergone RYGB and when high levels of simple carbohydrates are ingested. Accordingly, patients who have experienced postgastric bypass bariatric surgery should avoid foods that are high in simple sugar content and replace them with a diet consisting of high fiber and protein rich food. Eating vegetables and salad is encouraged; beverages and alcohol consumption are better avoided[49].Go to:PSYCHOSOMATIC DISORDERS/DEPRESSIONMany patients usually experience enhanced self esteem and improved situational depression following weight loss. Depression often requires continued treatment, specially that, many patients with severe obesity often use food for emotional reasons. Therefore, when those patients experience a small gastric pouch postoperatively they may grieve the loss of food. Many studies documented the relationship between eating disorder and anxiety disorder, depression or schizophrenia[50,51]. Displaced emotions can result in somatization with symptoms of depression and psychosomatic disorders. It is important that clinicians recognize the psychological aspect of food loss after bariatric surgery, and reassure patients that the symptoms are related to the small gastric pouch size. Antidepressants often help to decrease the anxiety related to grieving associated with food loss, although the use of antidepressants needs to be approached with an empathetic style. Behavioral and emotive therapies are reported to be very helpful[52,53].Go to:OUTCOMEBariatric surgery remains the only effective sustained weight loss option for morbidly obese patients. The American Society for Metabolic and Bariatric Surgery estimated that in 2008 alone, about 220000 patients in the United States underwent a weight loss operation. The optimal choice for type of bariatric procedure, i.e., RYGB, SG, AGB or the selected surgical approach, i.e., open versus laparoscopic depends upon each individualized goals, i.e., weight loss, glycemic control, surgical skills, center experience, patient preferences, personalized risk assessment and other medical facilities. Laparoscopic sleeve gastrectomy is the most common bariatric procedure. However weight re-gain after long-term follow-up was reported[54-58]. Prospective studies and reviews report a general tendency for patients with metabolic disorders to improve or normalize after bariatric surgery. However weight loss is highly variable following each procedure. Recent studies have evaluated the potential impact of obesity on outcomes in organ-transplant recipients, for example bariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure[59-63].Go to:RECENT ADVANCES IN BARIATRIC SURGERYA modified intestinal bypass bariatric procedure (Elbanna operation), reported a novel surgical technique designed to maintain good digestion, better satiety, and selective absorption with less medical and surgical complications (Figure ​(Figure5).5). This procedure preserves the proximal duodenum and the terminal ileum and thus preserving the anatomical biliary drainage and enterohepatic circulation[64,65].Figure 5Novel ElBanna surgical procedure.Recently, a novel bariatric technique dedicated; Modified Elbanna technique in childhood bariatric, showed promising success in pediatric surgeries (non published data).Go to:CONCLUSIONThe rising prevalence of overweight and obesity in several countries has been described as a global pandemic. Obesity can be considered like the driving force towards the pre-mature deaths. It increases the like hood for the development of diabetes, hypertension and NASH. The American Heart Association identified obesity as an independent risk factor for the development of coronary heart disease. In order to minimize post-surgical cardiovascular risk, surgical weight loss may become a more frequently utilized option to address obesity. Currently, bariatric surgery passes through a plateau phase, hence medical management and follow up of patients who have undergone bariatric surgery is a challenge.Go to:FUTURE RECOMMENDATIONSChildren obesity has become one of the most important public health problems in many industrial countries. In the United States alone, 5% of children have severe obesity. It is imperative that health care providers should identify overweight and obese children so as to start early counseling and therapy. To establish a therapeutic relationship and enhance effectiveness, the communication and interventions should be supported by the entire family, society, school, public media and primary health care. Bariatric surgery could be considered in complicated cases that failed all other options.Go to:FootnotesP- Reviewer: Amiya E, Firstenberg MS, Narciso-Schiavon JL S- Editor: Tian YL L- Editor: A E- Editor: Lu YJGo to:References1. 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Pathology is a specialty not confined only to blood tests as many people believe. Its an ocean of information which is only seen as a still lake by many who do know the kind of information and insight this specialty has given to modern medicine. Pathology is at the forefront of ancient & modern diagnostics and helps the clinicians of all the specialties to diagnose, plan treatment and assess the prognosis of majority of the diseases.Pathology is study of disease and the ways in which the disease develops and manifests as a result of changes in cells and tissues due to various agents such as microorganisms, carcinogens, chemicals and many more etiological factors. It also helps in planning treatment and prognosis of diseases. To be a Pathologist, you have to undergo formal residency training program or diplomas throughout the world after finishing MBBS / Medical school.The subdivisions of Pathology are :Anatomic Pathology including Surgical HistopathologyCytopathologyBlood Banking and transfusion medicineChemical Pathology (i.e Clinical Chemistry)Clinical PathologyHaematologyImmunopathologyMolecular PathologyTelepathologyAnatomic Pathology is in true sense, the most important division of Pathology as a specialty in general. Rudolf Virchow is considered the father of Pathology. He did a lot of work in Pathology and founded the principles on which modern pathology is based. The most important contribution in my opinion was introduction of the systematic approach to autopsy which is adopted by all the pathology departments worldwide and this is what unraveled most of the mysteries of the diseases as we know it. He studied the cells after dissecting all the organs and laid the foundations for anatomic pathology. His greatest accomplishment was his observation that a whole organism does not get sick—only certain cells or groups of cells which would break the long held notion of the whole body being diseased in case a person fell sick.In 1855, at the age of 34, he published his now famous aphorism “omnis cellula e cellula” (“every cell stems from another cell”). With this approach Virchow launched the field of cellular pathology. He stated that all diseases involve changes in normal cells, that is, all pathology ultimately is cellular pathology. This insight led to major progress in the practice of medicine. It meant that disease entities could be defined much more intticately. Diseases could be characterized not merely by a group of clinical symptoms but by typical anatomic changes.(Rudolf Ludwig Carl Virchow, The Father of Pathology, 1821–1902 AD)(Rudolf Virchow’s illustration of cells in his early works)The macroscopic and microscopic study of organs & tissues leads to the diagnosis of a specific condition which can be neoplastic (benign or malignant) or non- neoplastic (inflammatory) in nature. In case of malignancies the staging of tumors is done, taking into consideration the the gross and microscopical features of the tumor. The TNM staging is helpful for solid cancers and other cancer staging systems like American joint committee on Cancer, International Federation of Gynecology and Obstetrics (FIGO) use this basis for planning treatment, expecting prognosis & evaluation of treatment in a uniform manner worldwide. The Ann Arbor staging system for Lymphomas is another example of the application of surgical histopathology. Histopathology is considered the gold standard for the diagnosis of any disease and is used extensively to study the disease.(Gross and microscopy of Bronchogenic carcinoma, a type of lung cancer)Immunohistochemistry (IHC) developed by Albert Coons uses monoclonal or polyclonal antibodies which combines anatomical, immunological and biochemical techniques to identify discrete tissue components by the interaction of target antigens with specific antibodies tagged with a visible label. IHC makes it possible to visualize the distribution and localization of specific cellular components within cells and in the proper tissue context and has revolutionized tissue diagnosis in health and disease for e.g p53, Ki 67 , E Cadherin,HER2/neu for Breast cancer and Prostate specific antigen (PSA) for Prostate cancer.(IHC staining under a microscope for positivity or negativity )Another aspect of anatomic pathology is autopsy study. The millions of autopsies performed over centuries have helped pathologists gather real knowledge of changes in tissues in various diseases and helped us differentiate and classify various diseases, their subtypes and their etiology and outcomes.The cause of death can be determined by the external examination of the dead body, gross examination of organs along with microscopy of tissues. This provides an excellent tool for research and for teaching. The gross specimens are preserved after taking sections for microscopy and these are preserved in formalin & the corresponding H & E stained slides are used to corroborate the gross changes in the tissue for teaching purposes in pathology museums for medical undergraduate and postgraduate students.(The Anatomy Lesson of Dr. Nicolaes Tulp)Surgical pathology uses gross examination of the organs sent after surgery or biopsies from various sites is fixed in formalin, zenkers fluid or other fixative, sections are taken and the tissue is drained of all the fluid with the help of alcohol and xylene (in a tissue processor) which is then embedded in paraffin. This paraffin block with the help of a microtome, cuts the tissue bit into 3 to 5 micron thin slices of tissue which are taken on a slide, ready to be stained and then observed under a microscope. The routine haematoxylin & eosin (H & E) stains are used for most of the diagnosis and special stains like the Periodic acid Schiff (PAS), Alcian blue (AB), Massons trichrome ad many others are used for detecting specific substances in tissue which may indicate the presence of a particular substance in the tissue suggestive of a specific disease. e.g macrophages, connective tissue (collagen and basement membranes) and fungi are indicated by PAS positivity. The gross finding and the microscopic examination is described in the report and any deviation from normal is the basis for a particular pathology.Cytopathology is a diagnostic technique that examines cells from various body sites to reach a diagnosis or screen for the absence or presence of a disease. It is an extension of anatomic pathology but is s sub considered a sub-specilty.The first cytopathology test developed was the Pap test Georgios Papanikolaou which has been widely utilized in the last 50 years for screening and diagnosing of cervical cancer and its precursors. The Pap test is considered the most successful screening test in medical history.Since the development of the Pap test, the practice of cytopathology has expanded to include samples from nearly all body sites. Cell samples are taken for analysis as part of many diagnostic tests such as bronchoscopy or cystoscopy. In addition, nearly any tissue mass can be sampled and diagnosed by fine needle aspiration biopsy. The aspirates are taken on a slide and stained by PAP stain, My-Grunwald-Giemsa (MGG) or Haematoxylin - Eosin stains.( Georgios Papanikolaou on Greek currency)(PAP smear microscopic view )The study of the nucleus and the cytoplasm is the key component of diagnosis by cytopathologists and is primarily used for screening and in some cases final diagnosis.microbial infections: parasitic, viral or bacterialreactive changes (e.g Lymph nodes)immune reactionsamyloidosisautoimmune diseases (e.g. Hashimotos Thyroiditis)Malignant and non-malignant tumours (e.g soft tissue tumours)Blood banking and transfusion medicineKarl Landsteiner discovered the ABO blood group system in 1900 and later with Weiner found the Rhesus blood group system, both of which are clinically the most important blood group systems. (Trivia : he also discovered the polio virus & received the Nobel prize). He is known as the father of transfusion medicine( Karl Landsteiner The father of transfusion medicine )As of now there are 33 blood groups systems representing 300 antigens that are listed in the International Society of Blood Transfusion. The important ones being MNS, Kell, Duffy, Kidd, Lutheran & Lewis. The World Health Organization (WHO) is primarily involved in providing guidelines for blood banking. In India, National AIDS control program (NACO) along with National blood transfusion council (NBTC) are responsible for formulating policies whereas FDA is the license issue authority for blood and blood components.The blood banks voluntarily collect blood from healthy donors, transport, store, screen for transmissible diseases like HIV, Hepatitis B & C, Syphilis, Malaria, prepare components like platelets, fresh frozen plasma (FFP), cryoprecipitate.etc, store at the optimum temperature and issue these to patients according to the request. The blood is only issued after grouping and cross matching and any problems arising are analyzed and dealt with by the pathologist / transfusion officer in the blood bank. There is a standard of procedure (SOP) to perform almost all the activities of the blood bank and are strictly adhered to. Blood which is HIV or Hepatitis B is not always disposed, rather is used for harvesting antibodies by various manufacturers who collect this blood from the blood bank. Blood is stored as packed cells in different refrigerators for different groups and each bag of blood or component has the date of issue, expiry and serology testing.There is a transfusion committee for most of the hospitals who formulate the policies at the local level like blood ordering schedule for various departments like surgery, transplant and emergency room.Chemical Pathology Chemical pathologists receive sample of patients from healthcare professionals such as general practitioners and specialist doctors and to provide advice on which tests to use and how to interpret the results of the tests when investigating patients. This commonly includes a wide range of conditions such as liver disease, kidney disease, high cholesterol, cancer, diabetes, and hormone imbalances. In these settings, chemical pathologists interpret a wide range of metabolic disorders such as high cholesterol, diabetes, hormone imbalances, kidney stones, bone disease and nutrition imbalances. For most of the analysis, the serum sample is utilized.Chemical pathologists authorize the tests for measuring markers of liver and kidney function, hormones, drugs and tumour markers. Many of these analytes are measured on automated analyzers which perform on various principles of wet or dry chemistry. The values obtained from the serum samples are compared with established reference values for specific demographic sections and a proper formatted report is given to the patientMost of the old and modern analyzers work on the principle of Beer-Lamberts law or some modification of this law :The Beer-Lambert law states that the quantity of light absorbed by a substance dissolved in a fully transmitting solvent is directly proportional to the concentration of the substance and the path length of the light through the solution.Because Beer's law states this, it means we can both calculate the concentration of a solution by using the absorbancies, or plot a graph of various concentrations, align them to their correct absorbencies, and use a colorimeter or spectrophotometer to find the concentration of an unknown solutionThe law states that A(λ) = e(λ) l c[ WARNING TOO TECHNICAL, read at your own risk !!! ] The proportionality constant e (λ) is called the absorptivity of the substance at the wavelength λ. e (λ) is called the molar absorptivity if the concentration is measured in moles/liter. ]The absorbance is inversely proportional to the transmittance of the solutionAll the calibration and internal quality control can be performed on these machines and this keeps the results reliable. There are also external quality control programs by various manufacturers which give you a Z-score and %CV (Coeffecient of variation) of various laboratories worldwide and for a peer group and ranking to review the performance of the machine. This helps in maintaining the accuracy of the results by the analyzers and helps to maintain a good turn around time.Clinical Pathology overlaps with chemical pathology in many ways. This includes analysis of urine, stool, body fluids (CSF, Pleural, Synovial & Ascitic), semen analysis, medical microbiology, etc. The macroscopic and microscopic examination of these specimens is done and results are entered by the pathologist and a report is made and signed and sent to the clinician for interpretation and diagnosis. Analyzers are also used to get results for various samples and bacterial cultures (BacT Alert 3D) of blood, swab , urine etc are done for identifying the type of bacteria present in the sample and determine the causative organism of the infection.Haematology Is the branch of Pathology that deals with disorders of blood. It involves treating diseases that affect the blood cells coming of the bone marrow i.e RBC, WBC & platelets, haemoglobin,blood vessels, spleen & the lymphatic system, coagulation factors and blood vessels.(William Hewson, Father of Haematology)William Hewson is called as the father of Hematology. HE demonstrated that red blood cells (RBCs) were discoid and do not contain nuclei. He also isolated fibrin which is an important protein of the coagulation pathway. He is the first person to describe the lymphatic system in human beings and animals & described the concept of cell membrane.A peripheral blood smear is the oldest and still one of the widely used simple methods to diagnose haematological disorders including anemias, leukemias, thrombocytopenias, parasitic infections like Malaria, Filaria & leishmaniasis. etc.Cell counters based on the Coulter principle have modernized haematology and the complete blood count (Cbc) remains the most ordered test worldwide since it gives a lot of vital information about a disease and plan the further route of specific diagnosis of other systems. Newer cell counters have many new parameters for diagnostic purposes.Flow cytometry has truly revolutionized the diagnosis of blood cancers & stem cell transplantation by identifying CD (cluster of differentiation surface markers) markers which express differently in different malignancies and benign conditions and give highly accurate diagnosis of the disease.Immunopathology This sub-specialty deals with the immune response of the body associated with a disease. The immune system refers to a collection of cells and proteins that function to protect the skin, respiratory passages, intestinal tract and other areas from foreign antigens, such as microbes (organisms such as bacteria, fungi, and parasites), viruses, cancer cells, and toxins. Louis Pasteur is regarded of immunology but Edward Jenner who developed the first vaccine for small pox as the real father of Immunology( Louis Pasteur)(Edward Jenner)Defects or malfunctions in either the innate or adaptive immune response can result in illness or disease. Such disorders are generally caused by an overactive immune response (known as hypersensitivity reactions e.g Type I hypersensitivity reaction like anaphylaxis), an inappropriate reaction to self (known as autoimmunity e.g Myesthenia Gravis) or ineffective immune responses (known as immunodeficiency e.g. AIDS).These immune responses seen in various diseases are helpful for the purpose of diagnosis of various infections like Hepatitis C and autoimmune diseases like SLE since the antibodies and antigens are specific for diseases and can be identified by various immunoassays such as ELISA, Western blot and othersMolecular Pathology Molecular Genetic Pathology is the subspecialty of Pathology and Medical Genetics in which the principles, theory, and technologies of molecular biology and molecular genetics are applied to help to make clinical diagnoses, determine disease prognosis, monitor infections and therapies, and provide risk assessments for genetic disorders.The Human Genome project has been a key factor in research in this sector and has also given a database of all the genes and their expression and interactions. Although the father of genetics is Gregor Mendel the development of PCR in 1983 by Kary Mulis has to be one of the watershed moments in the annals of molecular pathology to usher a new era of diagnostics (He received the Nobel prize for his work).(Kary Mulis developed the polymerase chain reaction PCR )This is the fastest growing sector in Pathology and has resulted in the availability of rapid and highly sensitive and specific diagnosis of tumours, infections, genetic diseases and many more. This has led to the innovation of modern diagnostic techniques like :Fluoroscent In-situ hybridization (FISH)Polymerase chain reaction (PCR) & qPCRTissue microarrayDNA sequencingThese tests are being increasingly used for diagnosis & research around the worldTelepathology is the practice of pathology at a distance by the use of computers and internet and specialized microscopes, slide scanners, robotics, virtual slides. etc for the purpose of remote diagnosis by specialists. Ronald S. Weinstein, coined the term "telepathology" in 1986. This is applied for histopathology.Telepathology systems are divided into three major types: static image-based systems, real time systems, and virtual slide systems. Availability of a good internet connection and a good IT backend is a pre-requisite for a successfull telepathology setup.To conclude, Pathology is one of the most interesting branches in medicine and is rapidly advancing every day.

The simple answer to your question would be the people behind the curtains who pull the strings. How does one find themselves in such a position? It helps if they have almost exclusive control of something everyone wants. In this case, that thing would be money. People who do have vast hordes of money tend to become very self-important, and begin to view less fortunate people as less deserving.When Rockefeller bought control of the CFR, after Congress forced him to split his company because he had monopolized the oil industry, he did it with the idea that congress wasn’t going to tell him what to do. Instead, he would tell them what to do. And he achieved that through his network of organizations and banks. He was a megalomaniac the likes of which president Trump could never hope to be. To someone like me, who’s been around long enough to see many changes over the years, some occurring spontaneously in an evolving society, and others occurring through strategic manipulation, what the recently coined term “Deep State” refers to is quite clear. New name, same game, same money, same aspirations it began with in the year 1918.Around twenty-five years ago was when I first began observing these subtle moves they make through whatever avenue will possibly influence the highest number of people, and are clearly designed to gradually turn our country against its’ own independent existence. The fascinating thing about it, is that they've made no secret of their intentions for several years now, (I noticed an acceleration in the paradigm shift right after 9/11) yet there are millions of Americans who are enthusiastically on board with the whole agenda. My suspicion is that a great deal of them don’t actually understand what they’re signing up for.The entity in question has hijacked the democratic party disguised as liberals, (though that's definitely not what they are) managed to convince half of a free nation that freedom isn't all that great, and somehow have millions of people believing that the planets‘ wealthiest people have the best interest of the common people at heart. They believe it would be better to have a government that will make all of your choices for you right down to what you can eat, what time to go to bed, what you may or may not own. They have many convinced that the constitution which has served as our guiding light in matters of ethics, liberty, human rights, and equality while we have lead the world into the modern age, does not serve us well and shouldn't be taken seriously.In just two centuries time, we have become the most powerful, the most wealthy, the most innovative nation on the planet, based on freedom for all, using the constitution as a set of guidelines to keep us on the right course. And it has. Look around you. Where do you think all of this came from? It came from the freedom to create, express, endeavor, and achieve.So, why would anyone think that should be changed? Because they have not reached, but rather have been deceptively and quite intentionally lead to conclusions that are negative and incorrect. They have been educated in an ”America was never great” system, and they believe it.The deep state goal is one world government. When they achieve that, they will rule the world with financial power, enforce their laws with the only armed forces that exist, and micro-manage the lives of every individual using technology that already exists and is in the possession of nearly everyone.Let's take a trip back in time to where it all began. Right around a century ago, when the first world war ended, there were a few highly educated and well-to-do people who believed the world would be better managed as one population, under one set of laws, and more importantly, one currency. They formed a small group of diplomats and scholars and travelled to the Paris peace conference in 1919 to inform the attending nations of their ideas. At the conference, like minded American and British diplomats were brought together to form an Anglo (that means white) group called the Institute of International Affairs. Most nations were very proud of their independence at that time, so there were only a few people who shared their views. That being the case, they weren't well received with their ‘integrated world’ plans. But there were still those few who were brought together by the conference, and were determined to shape society to their vision.After the conference they began attending meetings in New York City with a group they learned about while attending the conference called The Council on Foreign Relations. The CFR had been holding clandestine meetings for about a year prior to that, and had similar ideas and interests about shaping the world to their preferences. The membership consisted of high-level bank officers and financiers, lawyers, and owners of manufacturing and trade industries. There were just over a hundred very ambitious, very wealthy, aspiring rulers of the world. I realize that doesn't sound very threatening. Generally when people with a lot of money and influential credentials join forces with a common goal, trust me, it's threatening. They truly believed their way was better for everyone, and that they had a sublime right to exalted ministry over the ordinary people. That belief has only strengthened over time. (generational elitism).Realistically, at this point, It looks as though they will inevitably prevail. But the election of someone who is not for sale was a big setback for them. That's why they went absolutely nuts when president Trump won the election. It set them back years in progress toward their highest aspiration. Never were they as self-revealing as they became the very moment he announced his candidacy. All pretense of neutrality in the media was instantly gone. They were definitely pissed, and they haven’t even begun getting over it.To put this into perspective, one needs to understand that Hillary was their nail in the coffin for the sovereignty of this nation. That’s how close they were to achieving a major milestone that was a full century in the making. Bill and Hillary are not only deep state, they are property of the deep state. Their success was only a small part of a big plan. They had become quite accustomed to choosing the president simply by leading the audience to the candidate of their choice with their most valuable weapon, the media. I think maybe they became a little too visible for their own good, because people came out in droves to vote for the pro-American candidate who seemed more concerned with what Americans think about the USA than people in other nations do. To their dismay, they learned that the nation is still full of Americans who care what happens to their country.Anyway, the council formally became an incorporated entity in 1921, and began publishing a foreign policy magazine shortly thereafter that was financed by the one thousand richest people in America who were all solicited for donations. As I mentioned, globalism is not what the ordinary citizen class liberals who only know what their globalist programming has indoctrinated them to know, think it is. There's a difference between those of us who have watched it all unfold, and someone who has never seen anything else. It's normal to them. They will be perfectly willing to give the nation away for the bankers’ aspirations in exchange for being accepted and admired by “the world,” because the programming through the media and education systems assigns much higher priority to the view of them from other parts of the world than their view of themselves. They have been indoctrinated to believe that is the best direction for everyone. You think Trump is a con artist? He's not even playing in the same league as these people.Moving on, the council grew and became a club of the elite in academics, law, banking, and industry who's purpose was to manipulate the government to their designs. Eventually, the Ford Foundation and the Rockefeller Foundation became involved as well as Carnegie, and they solicited prominent figures from around the nation to gain influence in communities across the country. With Rockefeller money and dedicated involvement now at the helm, over time they were able to infiltrate the government to reach a level of over 50% of the top foreign policy officials being council members under certain administrations. Eventually, what it became was the unofficial headquarters for the CIA, security advisors, foreign policy advisors, and a lot of movie stars and other entertainment figures to get together and discuss their plans for our future.They have been the ones who decided, when, why, and with who we went to war, who we would provide with weapons and finances for war, and who was not worthy of our sponsorship, mostly based on what was in for them. Orchestrating coups, waging proxy wars, and installing puppet governments around the world for profit and power. They have been the engineers of all kinds of very nasty business. This is an exclusive organization which not only still exists and is still made up of the most elite and wealthy people in the nation, but through many years of secrecy and treachery have purchased their way out of hiding and are now in control of mainstream ideology, mainstream media, and the world economy (with the exception of nations who will not allow a World Central Bank inside their borders. It shouldn't be hard to guess which ones. *hint* Any nation that refuses to turn their economy over to the global bankers is EVIL. Some are not allowed to say no, and if they do, they get what Kaddafi got. And a brand-new Central Bank branch within one week of their death, like Libya got.They've pretty much taken over everything but the half of the United States population that refuses to sign it over. They're powerless to do anything about us besides keep the propaganda and indoctrination going strong, and wait for my generation to die off. There have been many quotes over many years that make their intentions clear, and their psychopathic egos even clearer. The Rockefeller family has been at the helm for decades. David Rockefeller wrote in his memoir “We are grateful to the Washington Post, the New York Times, Time Magazine and other great publications whose directors have attended our meetings and respected their promises of discretion for almost 40 years......It would have been impossible for us to develop our plan for the world if we had been subjected to the lights of publicity during those years. But, the world is more sophisticated and prepared to march towards a world government. The supranational sovereignty of an intellectual elite and world bankers is surely preferable to the national auto-determination practiced in past centuries.” ― David Rockefeller.Now, instead of the hundred rich white men it began with, there are about 5000 members. The members include the owners of the mainstream television networks, many affluent entertainers, Bankers, CEO's, former government officials, CIA and military leaders, and even a few trust babies who inherited vast fortunes such as the Folgers and Disney families. All are people who care so much about all the refugees and immigrants that they won't let them pitch a tent on the lawns of their mansions or even through the gates, yet from the security inside the walls around them they will tell you there is no need for a wall. If they have their way, a mass influx of immigrants will arrive in overwhelming numbers so they can use our own system against us to dissolve our constitution, disarm us, and remove our borders so they can rename all of North America "Zone D".They've known for many decades that they must remove the word "united" from the United States to achieve their goal. They've been doing that at a pretty efficient pace over the last few years. "To achieve world government, it is necessary to remove from the minds of men, their individualism, loyalty to family traditions, national patriotism and religious dogmas.” _Brock Chisholm -former President of the World Health Organization, and Globalist. They're also pissed off about the tariffs because they are the ones who own the trading companies. In short, the richest people in the country, and the people they own, (movie stars, singers, news anchors, professors, etc. - people they can use for the purpose of influence) are very accustomed to telling our government what to do based on their personal finances and investments. They have completely infiltrated the government, the education systems, the information and entertainment industries, and they've owned the newspapers for decades. That is how they went from clandestine meetings with a hundred rich men, to an unofficial branch of our government with more power than any other branch. They own the media, so you will never hear about them on the news. They are not an official part of the government, so they are not subject to House oversight. They run the CIA, so most government officials are either members or afraid of them.Where did you think this whole globalism movement originated? Did you think this just happened as a result of intellectual evolution? Globalism is the brain child of the filthy rich who have bought every politician they could, and killed the ones who became a threat for a hundred years now, so they can literally shape the world the way they think it should be shaped. Why do you think everything in the media these days is about global this or world that? Why do you think "nationalist" has become a bad word? Why do you think that after a hundred years of entering buildings on the right, and exiting on the left, suddenly we now enter Walmart on the left and exit on the right? Do you think someone just put the wrong sticker on the door one day and no one noticed? That's one of the subtle moves I mentioned earlier with a strategic subliminal purpose.Why do you think they are so adamantly against a border wall? Because they care about Mexico? Wrong. Because one of their strategies is to mix all cultures so diversely and so rapidly that citizenship becomes a minority status, and therefore diminished in every sense. In rights, in ownership, in authority, in definition. In other words, when there are more Arabs in Germany than German people, is it still Germany? I don't think it is."Oh, Trump is such an embarrassment on the WORLD stage. Look how he looks to the WORLD. He's upsetting WORLD leaders. Our GLOBAL allies. "OMG those guys are nationalists!" (Yes, suddenly if you believe in an independent nation {you know, that thing George Washington's army fought the British so we could have?} that makes you a villain. This language is not spontaneous. It is scripted quite intentionally to negate national values and culture.Selective history is being taught in schools to devalue the constitution and weaken the unity of our nation. AND IT'S WORKING. The media is being used to promote political, racial, even gender division. AND IT'S WORKING. (Incidentally, CNN’s Anderson Cooper, son of Gloria Vanderbilt, of the once richest family in the US Vanderbilt’s, is also a cousin of the Rockefellers, and in the business of influence on their behalf. Just in case you thought he was someone who struggled their way to the top.) Do you think the progressive young liberals who hate their own country and place no value in their nationality are an accident? They were manufactured in the education systems of the cities quite intentionally for the same purpose. To weaken our resolve as an independent nation.Look, this response really doesn't even scratch the surface. It's only a rough sketch of one piece of a very large puzzle. I could literally write a book about it, but I'm sure you weren't looking for that. So, the simple answer is, there is nothing “mythical” about the deep state. It has been called "the shadow government" "the new world order" the "deep state" and "The Liberal Global Order" and a few other names I'm sure. But it's always been the same families with the same goals, which started with a handful of wealthy scholars who believed they were so superior to the common people that the world would be a better place if they and their kind were in charge of it. The goal is to dissolve all borders and sovereign governments and blend them into one global population so their power will become as absolute as the emperors of ancient Rome over the entire world.Their weapon of choice is money, and it has served them well. From the Council on Foreign Relations there are many branches including international (of course) extensions like the tri-lateral commission. (Founded by David Rockefeller) This is a similar and very connected group of filthy rich bankers from other countries.So, how can I put this so you will grasp the reality of what globalism really means? Maybe with some analogies? How about a couple more quotes that are quite real and well documented from our harmless global banker friends. This one is from a speech to the council by Henry Kissinger, former Secretary of State under Richard Nixon, and foreign advisor to many administrations. Also, a very close friend of the Clinton's. "Today, America would be outraged if U.N. troops entered Los Angeles to restore order (referring to the 1991 LA Riot). Tomorrow they will be grateful! This is especially true if they were told that there was an outside threat from beyond, whether real or promulgated, (climate change?) that threatened our very existence. It is then that all peoples of the world will plead to deliver them from this evil. The one thing every man fears, is the unknown. When presented with this scenario, individual rights will be willingly relinquished for the guarantee of their well-being granted to them by the World Government.” _Henry Kissinger. I think that shows a pretty clear interest in removing rights that Americans are guaranteed by our constitution.Democrats say Trump is in it for himself and cannot represent the American people because of his wealth. The people who back the democratic party and own every politician in it make Trump look like a pauper. Do you really think these people have the best interests of the average working American at heart? These are the people who decide your children are going to die 3000 miles from home so they can stay in control of the money. They made up a bullshit story about weapons of mass destruction to kill Saddam Hussein because he removed Iraqi oil sales from the Federal Reserve note. (American Dollar) We went to war and lost lives because rich people decided it was in their best interest if we do.Globalism is not about equality, and fair play, and holding hands dancing around the global camp fire. It's a plan that was conceived a century ago to integrate the world so the people who own the most of it can make the rules for everyone. They will rule with financial power and use technology to micro manage the lives of every individual. Please don't take my word for it. Research everything I have said. The information is all there, but you have to look for it. They sure as hell are not going to volunteer anything through the media.They have had complete control of our economy since the 1980's. The bailouts? Yes, same people just assuring that their empires didn't crumble, and didn't see why we should mind kicking them almost a trillion dollars to keep them in power. We all know what we know and we can only assess the world based on that. But there is even more that we don't know. So, how can our assessments be accurate when all we know is what they want us to know? One thing they didn't bargain for was the internet, and how fast it exploded into the information super highway. Suddenly, instead of just having to trust Walter Cronkite on all of the countless evenings he fed us bullshit, now we could communicate with people all around the world, just like ourselves. Ordinary people.They set about immediately to get that reigned in, but it's taken them 20 years to assume the control they have now. During those two decades a hell of a lot of information was exchanged that they would like to have kept concealed. Seeing that this could still work in their favor, they went completely in another direction. Instead of staying behind closed doors to continue effecting subtle changes, and buying people with secret pacts and lots of cash, they went full on "make our move," and took over pretty much all of the information outlets including public schools. They couldn't pull that off in rural America because constitutionalists and patriots who love this nation are by far the majority. Instead they set about creating the divide we are seeing now.The only way to defeat us is with our own system. All they have to do is trick over half the population into supporting them. And they did it. But it didn't work this time around because of the electoral college. Is the electoral college a bad thing that needs done away with because Trump won? Well of course it is. Hillary won in 487 counties. There are 3,141 counties in the U.S. If not for the electoral college, the U.S. would not be represented. Only a few cities would. They have only been able to infiltrate and indoctrinate mostly in the coastal population centers, so the next course of action will be to keep as large an influx of illegals coming across the borders as possible to try and outnumber the Americans overwhelmingly.There's a scratch in the surface for you regarding the deep state. People believe they are real because we see what they are up to as clear as you can see the sun rising in the morning. I see every move they make, subtle or bold, to turn the nation left. The Walmart thing being a perfect example of a subtle change with deliberate intent. Yes, they support globalism. Obviously. I invite and challenge anyone who wishes to prove me wrong. View Upvote