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Suzy McHale’s Diary: 2018

Events of note for this year: Michele and Chris visited us (parents and I at home) on Thursday 18 January; they were staying in Melbourne for a few days. I got a bad foot tendon injury in February which hampered my exercise for a few weeks. Our telephone (landline and ADSL internet connection) cut out on Thursday 12/4. In May I developed plantar fasciitis, a painful and disabling inflammation of tendons in both my heels which left me unable to walk without pain. This healed, but in August I managed to partly tear my left adductor groin muscle! This healed, but I then developed bad constipation in September (20/9), which saw a panicked visit to Sandringham Hospital ER department! This resolved, but I still don’t know what caused it. And to top all this off, in a very unwelcome health development, my rectal prolapse returned, though not quite as severely as the first time. Margaret Perona visited us in July and stayed for a week. Michele and Chris holidayed in New Zealand’s South Island from 19/11 to 30/11. Michele also passed her Occupational Therapy degree. For Christmas I received a new iPad!

January

Tuesday 17/1

Over halfway into the month. I have not felt much like writing. Michele and Chris are coming to visit tomorrow (they are staying in Melbourne briefly). My cousin (Dad’s nephew) Kevin Reilly came to visit us on Monday 18 December, just for dinner – he had already booked a hotel in Melbourne, so he did not end up staying overnight here (to my admitted relief). I barely recognized him as he has changed in appearance so much, not for the better – he looked a bit unkempt and is a bit overweight in the belly. He and his brother Ian have never married or had children. I only spoke to him briefly to greet him; I did not feel at ease around him for some reason. He was going to see his mother, Aunty Hilda, in Tasmania (Uncle John has dementia and is in a nursing home there).

February

Wednesday 14/2

Michele and Chris visited on Thursday 18/1. I took some photos:

Mum, Dad and Michele Suzanne and Michele Mum and Dad

Weather was unpleasantly hot and humid at the end of January. Monday 29/1 saw power cuts across Victoria due to the extreme weather conditions (humid, hot). Fortunately my parents’ home missed out. The power was to be turned off from 8 a.m. to 3:30 p.m. on Tuesday 30/1 for planned maintenance, but this was postponed due to the power company (Energy United) having to do repairs in various areas. We got another notice for the power off on Thursday 22/2.

Mum turned 80 on Sunday 4/2 (Uncle Brian turned 91).

Our only toilet developed a leak from the cistern feeder pipe last Sunday 11/2, so Dad had to fix that rather than go to church. I did find I could use a chamberpot – a bright orange one that we used as toddlers and went to England with us! I emptied the waste down the outside sewer vent and flushed this with some water from a bucket. So not enjoyable, but I know I can resort to this if the toilet is non-functioning again.

Thursday 15/2

1:25 PM: Mum developed a bad toothache yesterday, so she is going to the dentist at Southland tomorrow to have it looked at. I also made a dentist appointment for myself on Tuesday 13 March.

April

Friday 13/4

I haven’t written for a while! I have been having trouble with minor injuries, and am now off the Internet for the weekend at least, so a quick summary:

Monday 30/4

Mum and Dad left for Kyneton Bushland Resort last Thursday 26/4, so I am on my own until next Thursday 3/5. I have walked to Southland on Friday 27/4 and today, so my foot is a bit sore again, frustratingly. I will have to avoid that walking. I got the 822 bus to Chadstone on both occasions to get two trips in; I only had time for a coffee (latté) at Southland. Saturday I rode my bicycle to Southland and back. I am quite tired afterwards.

The weather has still been mostly fine and sunny, though a change is coming through on Thursday, with some rain, unfortunately.

A notice arrived in the mail today that the “NBN (National Broadband Network) construction is commencing in your area … you will be contacted as soon as your property is ready for connection to the NBN network.” The rollout of the NBN has been very trouble-plagued, no thanks to the Liberal Government deliberately and spitefully sabotaging it from its original design under the previous Labour Government (Kevin Rudd).

May

Monday 7/5

3:28 PM: I spoke too soon regarding my feet as my heels have now been very sore since late last week, to the point where I can barely walk – I shuffle like an old woman. Very frustrating. I probably overdid the exercise last week – I rode my bicycle to Chadstone and back last Wednesday, which was at the limit of my endurance, and walking to Southland probably exacerbated the injury. I went to the city on Saturday (got the train from the new Southland Station) and could barely walk around. So I am hobbled again, and have moderated my exercise to walking on the spot and some cycling.

A young black-and-white cat with yellow eyes has been hanging around our garden for a few weeks. Dad caught it today. It was very thin and starving, and gobbled down some minced meat Mum cooked for it. It (don’t know its sex) is timid but not feral as it now approaches us for pats (and food). Dad called the local council, who are sending an officer tomorrow afternoon to look at it. It does not have a collar, but it might be microchipped, so will be scanned tomorrow. If it turns out to have no owner – not be a lost/missing cat – I am not sure what we will do; a pet is not a responsibility I really want, though the cat seems nice enough.

Wednesday 16/5

I visited a doctor on Monday. The GP (Dr Lucy Buchanan) confirmed what I had feared: I have plantar fasciitis, an inflamation of the tendon under the heels. I cannot walk without pain – each step is like getting spikes stuck in, or an electric shock in my heels. Walking is my main form of exercise, so that is now out for I don’t know how long. I shuffle and hobble along slowly like an old woman. The only activity I can do without pain is bicycling, but that is very unpleasant when the weather is bad (rain and wind). I try to do half an hour or so most days on my old bicycle. The condition could take weeks or even months to heal, if it ever does. Realistically I cannot stop walking anywhere – if I want to go places I have to walk, however painfully. I am in despair and pain and nothing seems to relieve it.

July

Monday 30/7

Two months gone! My feet seem to have healed, though I am still being careful, and I have eased back into walking again. My right hip was hurting for a couple of weeks up to last week, though that seems to have mostly gone. I seem to have had one usage injury after another this year, so in that respect it has not been good. My weight is still around 41-43 kg (depending on what scales I use). My veins pop up all over my body and I seem to have little subcutaneous body fat, so I suffer from the cold not surprisingly. Am looking forward to the warmer weather!

Michele’s 46th birthday is this Wednesday 1/8, so for a couple of months she will be 1 year behind me in age.

Her eldest daughter Margaret came to stay from Monday 9 July to Monday 16; she drove down from Queensland with a girlfriend. It was a bit stressful for me and my food routines, though I managed to adjust somewhat.

We heard no more about that cat from May (7/5 entry), so it was either adopted or euthanized. Just having it for one night confirmed that I do not want another pet; cleaning up after it was stressful and an extra hassle.

September

Thursday 6/9

Oops, haven’t written in a while! Unfortunately I got another debilitating injury, this time after carrying some heavy loads of books to charity shops in early August. Pain flared up in my left groin adductor muscle the following week (from around Monday 8/8), rendering me unable to walk without extreme pain. I gave in and went to the GP (Dr Lucy Buchanan again) on Tuesday 14/8; she gave me a referral for an ultrasound, which I had done the next day at a clinic opposite Moorabbin Hospital. As I had my Health Care Card, I was bulk-billed and did not have to pay (I could not have afforded it otherwise). A partly-torn muscle was diagnosed, which only time and rest would heal. So daily walks were out, and I was back to square one. I resorted to buying a walking stick, which has helped me with getting around (takes off some of the weight on that side). The acutely painful phase has now passed, and I have been able to walk more normally for a couple of weeks, but I still get soreness there if I overdo it, so I will have to be careful for a few more weeks. I also have a sore lower back for some reason. This year has been a bad one for injuries!

My Health Care Card expires in 2 weeks (Saturday 22/9); I managed to botch the online renewal process. On Saturday 25/8, I initially filled in the digital form on my MyGov Centrelink account and submitted it, but then realized I wanted to make a correction and withdrew the claim. But there was now no option to resend that renewal, or make a new claim! So I tried to ring Centrelink, and the wait times now are really excessive. Finally got through on Wednesday; the lady I spoke to said she would send out a paper renewal form, which I would then mail back in, as well as scan the pages and documents in and upload them to my account. Received the form Tuesday; filled it in and mailed and uploaded it yesterday. I had to ring Centrelink again (groan!) to tell them I had completed this task; managed to get through to another lady after an hour. (Both were nice and helpful.) She confirmed the form had uploaded, and said my claim would now go into the processing queue. If no new card were mailed within a week and a half, then to contact them again. Hopefully I will get my new card in time?

So after all that, I am quite exhausted.

Update: I just fetched our mail and my new card (expires 22/9/2019) was posted! Amazingly quickly this time. So I am greatly relieved.

October

Sunday 7/10

My injuries – the torn left adductor – seem to have healed up, but my health travails are not over yet! A little over two weeks ago, on Thursday 20/9, I became constipated, at the same time as developing a soreness in my lower back, left side. I will copy-and-paste from my online website Journal:

28/9: I am still alive! But more health woes, so I have not felt like posting here at all. This time it is … bowel problems! I had a bout of constipation from last Thursday 20/9, which I have not experienced like that before (I am usually regular, at least once a day), to the point where I went to the emergency department at Sandringham Hospital on Sunday 23/9 to see what they could find! By that time I was in much discomfort and panicking that I had some sort of blockage. They took a blood sample and did an x-ray, but nothing abnormal showed up. I was given both laxatives and an enema, and they cleared me out after a bit of a wait. Messy and embarrassing, but a relief! (The nurses are saints.) I was there around 6 hours; Mum came with me (bless her). I then went to my local GP at the East Bentleigh Medical Group where I got another blood sample, an ultrasound scan at the nearby Moorabbin Hospital (I was full of gas, which was remarked upon a few times!) and she suggested I get a colonoscopy, but I will cancel the last; I doubt that anything specific will be found. My diet is healthy (lots of fruit and vegetables, no processed foods, meats, sweets) and I do all the suggested remedies (exercise, etc.) so that was an aberration. I am now functioning more-or-less normally again, though I still get bloated and uncomfortable after eating, so it will take my body a while to settle.

I also developed an irritating soreness in my lower left abdomen and back from that Thursday, which I still have. I am sure that is related to the bowel issues. I was reading through this forum post on the Irritable Bowel Syndrome forum, and quite a few others have had the same odd problem! I do believe I have IBS, and this latest ordeal was a new manifestation of it. Remember I had surgery for a rectal prolapse back in December 2008 and May 2009 (the second one as the first attempt was unsuccessful), both at Sandringham Hospital also, so my bowel issues have been ongoing.

4/10: I am still not recovered from my latest health drama. I saw my GP on Tuesday 2/10. She wanted an extended session as she is very concerned for my physical and mental health. The tests I had (blood, ultrasound) were mostly normal, though I have a low white blood cell count and elevated lipase level. I have somehow lost 3 kilograms since my last weight check in August (now measured at 40.3 kg and 158.5 cm height). I am to see her again next Tuesday. She wanted very strongly to contact a mental health team from Monash Hospital. I deferred but have the feeling I am being “herded” towards things I don’t want to do. She was concerned that I seemed mentally “flat” and that I was obviously unwell. I don’t want to make any decisions and the only help I want is to continue as I am and otherwise be left alone. I suppose I am undertaking a form of passive suicide (I have no courage to actively attempt it) in that my body will eventually fail (physcially I resemble a concentration camp survivor). I have no future to look forward to, no career, no skills, no money, am reliant upon my aging parents, and so on. The outside world is too daunting for me and I have given up.

I seem to be pooping more-or-less normally again (several times a day), though I still have the odd back soreness. I am going to see Dr Lucy Buchanan again next Tuesday 9/10 at 2 p.m. Dr Andrew Batty also came in to talk to me briefly during that appointment last week.

Mum and Dad booked a new stay at the Kyneton Bushland Reserve, from Friday 26/10 for one week (they canceled the initial second visit from 23 August).

Daylight Savings began today. The weather is slowly warming up; the mornings are not bitterly cold. Today was very sunny and glorious. I can function better in warm weather.

Monday 29/10

I am … OK. No more injuries (so far), pooping mostly normally (for me!). Mum and Dad are currently away in Kyneton, at their usual stay (Kyneton Bushland Resort), to return this coming Friday. The weather is warming up; into the low 30s later this week! The awful freezing mornings have abated and we are on Daylight Savings time. I am tired and weak, though, and have to get around on my old and heavy bicycle, or use public transport (and pay fares – these add up, even with a concession card).

I went to Bentleigh Safeway this morning for some shopping – a place I have no fond memories of! A lady minding the self-serve registers named Cathy recognized me as one who used to work there; she is plumpish, with short red hair and is quite nice. I vaguely recognized her, but have no real recollection of who she was (embarrassingly). We chatted a bit; not surprisingly, most people who were there when I was have left (presumably for better jobs). I am very long-term unemployed – I left Safeway on 26/10/2001 (see that entry), 17 years ago! I have literally done nothing since then to further employment, but become a recluse living with her parents. I am almost non-functional now – I really should be on a disability pension, but the government has deliberately made this very difficult to get, frustratingly. There are a lot of highly-qualified young people who cannot find work.

I visited the optometrist at long last on Thursday 18/10 (Family Eyecare in Bentleigh as usual) – my last visit was in November 2014 – and got a new pair of glasses – these with a green frame. I am not entirely happy with them (as usual) but will stick with them. Cost with lenses was $245 (frames were $77).

November

Friday 30/11

In a very unwelcome development, it appears my rectal prolapse has returned (see my 2009 Journal for the last occurrence of this condition). I went to see the GP, today, Dr Lucy Buchanan, who sent off a fax referral to Dr Paul Sitzler at Sandringham Hospital; they will mail an appointment letter to me. So the whole wearisome process appears as if it will be repeated for a third time, and who knows when I may have surgery, as I will have to go on the public hospital waiting list again, not to mention getting to see the specialist surgeon in the first place. I wonder what his reaction will be on seeing me again (probably not positive). I had a look at the area in a mirror yesterday and noticed the ominous bulging out when I pushed – despair and dismay were my obvious reactions.

Googling search showed up this research article: “Rectal prolapse associated with anorexia nervosa: a case report and review of the literature” (and an Archive.org link) – I have also reproduced the body of the report below:

Abstract

Anorexia nervosa is one of a few mental health diagnoses that affects every organ system. Patients with AN often present with multiple secondary effects of starvation at the time of first assessment, including gastrointestinal (GI) complaints. In extreme cases, severe GI complications such as rectal prolapse may be encountered as a consequence of the illness although formal studies investigating the frequency of such occurrences are lacking. We present the case of a 16 year old female previously diagnosed with anorexia nervosa that developed a rectal prolapse as a consequence of her disease as well as a detailed literature review investigating the frequency and prevalence of such occurrences in this population.

Background

Anorexia nervosa (AN) is a potentially devastating disease that carries high rates of psychological and medical morbidity. Recognized as having the highest mortality rate among psychiatric diagnoses, AN is characterized by a pronounced state of starvation coupled with an intense fear of becoming fat or gaining weight. Despite being under-weight, patients are uniformly distorted in their thoughts and feelings surrounding body image. The prevalence of AN is approximately 1% in industrialized society with an overwhelming female predominance. Although multiple etiological underpinnings have been implicated in disease origins, prevailing wisdom points to a multi-factorial cause implicating biological, psychological, social and environmental influences in vulnerable individuals.

Anorexia nervosa is one of a few mental health diagnoses that affects every organ system. If left untreated, severe medical morbidity and complications become the rule not the exception. Patients with AN often present with multiple secondary effects of starvation at the time of first assessment, including gastrointestinal (GI) complaints. In almost all cases, gut symptoms improve as patients are renourished and re-establish healthy weights. In extreme cases, severe GI complications such as rectal prolapse may be encountered as a consequence of the illness although formal study investigating the relative frequency of such occurrences is non-existent. The objective of the following article is to present a case-report on a young woman diagnosed with AN that developed rectal prolapse as a consequence of her disease and to conduct a formal review of all published literature investigating the frequency and prevalence of such occurrences in this population cohort. Method

A comprehensive literature review using Pubmed, Ovid and Medline databases examining articles relating to AN and rectal prolapse published between January 1st, 1969 and December 31st, 2011 was completed. A total of five medical subject headings (MeSH) were used in different groupings. These included AN, eating disorder (ED), bulimia nervosa (BN), rectal prolapse, and constipation. Relevant abstracts published in the English language were reviewed in depth along with corresponding reference sets.

Results

A total of 83 abstracts were reviewed, of which 16 matched the objective of the study and were examined in-depth. Articles which focused on the finding of rectal prolapse and BN were more common than those with AN, although only 12 patients across all ED diagnoses were identified. In 1997 Malik et al. published a case series on seven patients with BN and hypothesized that chronically high intra-abdominal pressure associated with vomiting and straining, prolonged gut transit time, and constipation contributed to the rectal prolapse observed. Guerdjikova and colleagues published a case history of another BN patient that experienced rectal prolapse although in this case, rectal purging (repeated finger evacuation of feces in the rectum) was suspected to be the primary contributor. In 2001 Dreznik et al. published a case series describing three young women with AN and rectal prolapse. The three women described were all diagnosed with AN at a young age, suffered from chronic constipation requiring routine laxatives or enemas, and experienced rectal prolapse four to seven years into the course of their respective eating disorder. Ravneet and Paradiso also presented a brief report describing a patient with AN that developed rectal prolapse following long-term laxative abuse.

Case report

A 16 year old female diagnosed three years prior with anorexia nervosa binge-purge subtype presented to the emergency department (ER) of a tertiary care hospital with a chief complaint of constipation. The patient’s eating disorder history was significant for regular binging and purging in the six months prior to presenting, although at the time of initial diagnosis her eating disorder was restrictive in nature. At the time of the emergency visit, the patient’s weight was 47.3 kilograms, and her body mass index (BMI) was 18.5 kg/m2. At triage, the patient reported being unable to have a bowel movement in the week prior to presentation. The patient reported the need to severely “strain” to try and pass stool but in doing so, had experienced a rectal prolapse. The patient was able to digitally correct the prolapse without issue but became nauseated in the moments thereafter and subsequently vomited. The patient informed her mother of the prolapse and they presented to the ER given her general state of feeling unwell. On the way to hospital, the patient also developed a severe headache. Her vital signs at triage showed a heart rate (HR) of 72 beats per minute (bpm), temperature of 35.5 degrees Celcius oral, and lying blood pressure of 94/63 mm HG. The patient reportedly looked unwell and complained of dizziness. Over the course of the next 60 minutes, the patient’s headache worsened, prompting the emergency physician to complete bloodwork and start an IV. Her bloodwork revealed a low potassium level (3.2 mmol/L, lower limit normal 3.5 mmol/L). An electrocardiogram was completed which revealed normal sinus rhythm and no arrhythmia. The patient’s headache was treated with a single dose of IV toradol 15 mg and her potassium was replenished via IV supplementation. No further history or mention was made of her rectal prolapse during the ER visit, and she was subsequently discharged home twelve hours later with parents after reportedly feeling much better.

The patient followed up in the eating disorder outpatient clinic within the week. The events of the emergency visit were reviewed, and the patient reported ongoing issues with rectal prolapse with bowel movements. It was at this point that she revealed that the prolapse had occurred for the first time shortly after beginning treatment in the ED day treatment hospital. This correlated with an increase in her weight given improved nutritional delivery, a decrease in eating disorder symptoms, but also a stooling pattern which occurred on average once weekly. Historically, the patient had disclosed issues relating to her constipation (but not the prolapse) and had been treated with a combination of increased fluid and fiber, as well as docusate sodium 200 mg daily and eventually a trial of PEG 3350 which provided relief. Over the next 2–3 months her constipation (and prolapse) gradually improved. The patient noted increased anxiety at the time of her discharge from intensive ED services, and relayed part of her fear to worries that the constipation and prolapse would recur. As a result of this fear, the patient consciously began restricting and purging in an attempt to limit the amount of nutrition that passed through her gut and bowel. In doing so, her weight dropped and unfortunately she once again became constipated, which ultimately resulted in a recurrence of the prolapse.

The patient was referred to the division of general surgery. Physical examination confirmed the presence of the prolapse (evident with abdominal straining) and the patient was counselled on the need to restart her fiber supplement as well as reinitiate PEG 3350 daily. She was also taught Kegal exercises as a means of strengthening her pelvic floor muscles (thought weakened as a result of her overall malnourished state). Gradually, over the next six months the patient once again became symptom free from her eating disorder and her constipation and prolapse resolved completely. She has remained at a healthy weight over the last twelve months and has not experienced any further recurrences of her prolapse.

Discussion

Rectal prolapse manifests as protrusion of the full-thickness of the rectal wall through the anal canal and may occur as a result of a variety of risk factors in patients with severe eating disorders (EDs). It has a bimodal peak and is more commonly seen in extreme ages. In the pediatric population it usually presents before age four, has no sex predilection, and is associated with chronic constipation, cystic fibrosis, and other medical conditions. In contrast, in the adult population the elderly are more vulnerable and peak incidence occurs in the seventh decade. Women are six times as likely as men to have rectal prolapse. A consensus among experts in regards to a theory detailing the exact pathophysiology of rectal prolapse remains elusive. However, it has been proposed that the anatomical basis for rectal prolapse involves pelvic floor muscle weakness allowing the rectum to herniate through. Diastasis of levator ani, dilatation of the anal sphincter and detachment of rectal sacral ligament have also been implicated as exacerbating factors.

Predisposing risk factors for rectal prolapse typically include previous pelvic surgeries, obstetric trauma, elevated intra-abdominal pressure, advanced age and chronic constipation. It is thought that the descending bowel into the rectum may cause a mechanical blockage that is worsened with persistent straining, pelvic floor muscle incoordination and colonic dysmotility. Associated symptoms of rectal prolapse can be particularly worrisome as they include reducible protruding mass with bowel movements, mucous discharge, feeling of incomplete evacuation, rectal bleeding, change in bowel habits and fecal and/or urinary incontinence.

The association with EDs and chronic constipation has been well-documented. Risk factors for constipation that pertain to young women with eating disorders include female gender, low caloric intake, low-fiber diet and potential polypharmacy. Slowed colonic transit time is more common in women, and this is particularly characteristic of women with eating disorders. Medications and/or organic medical conditions can also contribute to secondary constipation. Eating disorder patients are often prescribed medications that worsen constipation, such as, antipsychotics, antidepressants, and diuretics. Also, they are predisposed to co-morbid conditions, including depression, irritable bowel syndrome, and cognitive impairment. In 2004 Marceau and colleagues illustrated that young patients with chronic psychiatric disorders receiving long-term medications had an increased incidence of rectal prolapse with markedly poor prognosis.

Although the relation between chronic constipation and AN has been documented previously, its underlying etiology is not yet clearly understood. Increased defecatory perception thresholds and altered expulsion dynamics has been theorized. Chronic constipation may lead to bloating, abdominal distension, and early satiety leading to pervasive “feelings of being fat” rendering AN remarkably resistant to weight restoration. These symptoms may promote laxative and diuretic abuse resulting in electrolyte abnormalities.

Delayed solid gastric emptying witnessed in AN may worsen chronic constipation and its associated symptoms. It has been proposed that the delay in gastric emptying may be due to starvation, protein malnutrition resulting in smooth muscle atrophy of intestinal mucosa, gastric dysrhythmias or lack of peristalsis, or that rectal distension leads to reflexive inhibition of gastric emptying. Appropriate nutrition improves gastric motility.

In an effort to quantitatively describe constipation severity, numerous studies have examined colonic transit times using radio-opaque marker technique in patients with AN compared with healthy controls. Research consistently showed significant delayed intestinal transit times in patients with AN. Subsequent re-testing after re-feeding had occurred revealed normal colonic transit times, resulting in the conclusion that re-feeding and weight restoration ameliorate constipation in affected individuals.

In the case of our patient, a number of indirect risk factors likely predisposed her to developing the prolapse as opposed to any one obvious cause. She had complained previously of constipation and had over the course of the preceding 4–6 weeks been started on a regular progressive feeding plan which resulted in a significant increase in oral intake, along with a stated reduction in ED symptoms. Although not measured, she would almost certainly have continued to experience decreased intestinal transit time in the early course which would have exacerbated her constipation. She acknowledged the need to constantly strain in order to have a bowel movement and this, along with her history of purging would almost certainly have resulted in increased intra-abdominal pressures. Finally, her history of malnourishment likely weakened her pelvic floor muscles (among other muscles) which would have also elevated her risk. Clearly, these risk factors are present in countless patients that present for and progress through intensive treatment. Our patient’s case highlights the need for health care providers to pay particular attention to patient’s medical symptoms as they make their way through treatment and to continue to ask pointed questions even in cases where treatment appears to be progressing without issue.

Conclusion

Rectal prolapse is a rare occurrence in young women, and appears to be an infrequent secondary GI complication of eating disorders. Witnessed in patients with BN and AN, rectal prolapse likely results as a consequence of a number of different factors some of which are related to malnutrition and others as a consequence of regular purging and constipation. It is possible that greater numbers of women experience this condition, but do not bring it to their health care provider’s attention given their angst and anxiety associated with the problem. This was certainly the case with our own patient. We would recommend that treatment providers include basic screening questions related to rectal prolapse as part of their ongoing review of GI symptoms to ensure that patients feel comfortable in relaying all their concerns at the time of initial assessment but also at regular points throughout treatment. Also, given the fact that prolapse is such a rare occurrence in adolescents, we would suggest that any young women presenting with gastrointestinal complaints, chronic constipation and a history of rectal prolapse be also screened for ED behaviours.

Michele and Chris flew to New Zealand’s South Island last Monday 19/11 for a holiday. They are flying back today. Michele found out that she passed her Occupational Therapy degree on Wednesday.

My birthday was on Friday 9/11. As well as my new glasses, I received a much-needed new office chair from Officeworks, this one blue in color.

December

Thursday 27/12

Christmas Day turned out a bit better than expected for me as I received a new iPad! (2018 model, 9.7-inch screen, Generation 6, gold in color – actually more of a rose gold, which I like better.) It has 32 GB of storage (the iPad2 has 16 GB) and is much faster. So I am happy that one of my two wishes was granted! (The other is for a new bicycle, or a refurbished 2nd-hand one, as my old mountain bicycle is really past its best, is heavy, worn-out and barely-rideable – I bought it in 1991 for around $400.)

3:38 PM Thursday, 27 December 2018