Colonoscopy results - i'd like some input please!

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Jam300

Jam300

Joined
Oct 18, 2012
Messages
210
Hello Everybody,

Just some quick background so everybody can be brought up to speed.

I was diagnosed with CD in 2007 by Colonoscopy which found inflammation in my TI. The only syptom I displayed was Orofacial Granulamatosis (a swelling of the lip), no GI problems. I was put on a two month course of Modulen IBD and then followed an elimination diet, my lips swelling went down a bit, but not entirely. I went back to eating whatever I wanted about four years ago. No meds or anything since the modulen.

I had a scope yesterday (I began to worry what years unmedicated may have done to me after casually browsing this forum 6 or so months ago). The scope found nothing and i'll quote from the report (for David's benefit :D):

'A digital rectal examination was performed. The Colonoscope was inserted via the anus to the terminal ileum. The caecum was identified by ileal intubation. The scope was retroflexed into the rectum. The examination to the point of insertion was normal. No abnormalities detected.

Normal ileocolonoscopy. Normal ileal appearances. Biopsies taken.'

My follow up isn't until the 28th of March when the histology comes back from my biopsies. This is obviously very good news but i'm baffled if i'm honest and so it seems were the doctors. The guy doing the scope even said that had I not been diagnosed with Crohn's previously he would have said I didn't have it.

I presented swollen lips for three years before my diagnosis, so in total i've supposedly had CD for ten years. Yet i'm somehow in a full remission, despite years of poor diet, no lifestyle changes, drinking and smoking regularly and heavily. It sounds like i'm boasting, I really do not mean to, I know people on here struggle daily with this dreadful illness. But how is this possible? Is it all possible that I was misdiagnosed when I was young? I don't see how I can go ten years with Crohn's only presenting one superficial syptom (which is in itself barely noticeable anymore).

Can someone give me some more informed insight on this please? I can't wait until March to find out!
 
The thing is with crohn's is that in remission, you can have normal scopes.
It does seem to me strange that you were diagnosed with crohn's from not many symptoms, but as you said you were diagnosed with a colonoscopy you must have shown some signs of it for them to diagnose you with it.
It is a hard thing to diagnose and some people go through years trying to get diagnosed and don't show the signs for the doctors to clearly say it is IBD.
So maybe you have just been very lucky, in that they were able to diagnose it in the first place on very little symptoms, and that you have managed to be in remission for such a long time with very little symptoms.
Everyone is different and some people will have the disease more severely than others. I imagine there are a lot of people that live with crohn's their whole lives undiagnosed because their symptoms are not very bad.
I suppose there is always the chance that one day you will get worse symptoms. But no one knows what is around the corner!
Enjoy being symptom free is what I say! :)
I think you were right to want to get checked out from not having treatment for a long time though. I think that things can get worse without you really feeling it as I have developed fistulas while apparently being in remission.
Don't know if I have really answered your questions or not?
 
Hey, Jordan!

May I ask why they decided to do a colonoscopy when you were showing no GI symptoms? Did they suspect Crohn's based on the orofacial granulamatosis?

I wouldn't assume right away that you were misdiagnosed. Did they take biopsies that confirmed Crohn's (when they did the first colonoscopy)? Is the lip swelling still occurring?
 
Sounds like you are in remission but i don tthink anyone will be able to help until the biospsy comes back, It should be back already so i would call your GI and see if he can give you the results over the phone x
 
SarahBear said:
Hey, Jordan!

May I ask why they decided to do a colonoscopy when you were showing no GI symptoms? Did they suspect Crohn's based on the orofacial granulamatosis?
Click to expand...

Yeah they did, after a fair few years of trying to work out what it was that was causing it, they gave me a colonoscopy and decided Crohn's.

SarahBear said:
I wouldn't assume right away that you were misdiagnosed. Did they take biopsies that confirmed Crohn's (when they did the first colonoscopy)? Is the lip swelling still occurring?
Click to expand...

I'm not sure if they took biopsies in the first one, all I know is that there was in inflammation in my TI. I still have swollen lips, but they aren't anywhere near as bad as they used to be, and haven't been for years.

I'm not assuming I don't have Crohn's, but I am very suprised that my scope shows nothing, having never been medicated. To me, from everything i've read on this forum, that just doesn't make any sense.
 
If I were you, I'd ask at the next appointment if biopsies were taken when you were diagnosed. If so, it's very unlikely your diagnosis was wrong.

I'm just making guesses and assumptions here, so don't hold me to any of this or take it as fact, but... I think a lot of people with CD seem to have it for a while before showing symptoms. It seems that there is some trigger that sets the dormant disease off (often times stress, food poisoning, etc.). Personally, I experienced constipation as a small child then mild stomach pains for years before my symptoms got bad and really seemed to indicate Crohn's. The change in severity of symptoms happened when my home life became extremely stressful.

It might be possible that you have caught it before the disease has really come to the surface. It's also possible that it just is a mild and somewhat unusual case.

Are you planning or hoping to start a medication to maintain remission (assuming the biopsies come back positive)?

Also, when I was diagnosed I had ulcers and inflammation throughout my entire small intestine. I took medication for about a year and a half maybe, and still had Crohn's symptoms during that time. I had to stop my medication when I lost my medical insurance, and went without for another year or so. When I had a colonoscopy and a pill cam done over the summer, there was no evidence of Crohn's. My diagnosis was fairly definite, though - biopsies, blood work, and what was seen by the pill cam all confirmed. So it can happen. :)
 
Well I had intended to take medication accordingly, expecting fullwell to get a colonoscopy that showed inflammtion ect. Now I don't know what to do, because i'm not sure what to expect. My heads going round in circles right now. But yeah if the biopsies come back positive I will most probably go on to some sort of medication to stay this way, although i'll be very hesitant to try something like Azathioprine for something as unproblematic as my case. I'll most likely go on LDN. Do you have any suggestions.

I really am completely baffled right now.
 
Pentasa / Asacol / the other mesalamine medications might be a good option for you. They're the most gentle medications used for CD/UC (you can read about these medications in the mesalamine section of the Treatment forum here). Usually they're used along with another medication when treating Crohn's (as they're best for UC), but since your case is a little different, I don't know if another medication would be needed or wanted. Might be worth bringing up with your doctor, if they don't mention it themselves.
 
I was under the impression that Pentasa was recently proved to have a success rate similar to that of placebo? Medications a bit of a minefield really isn't it :)
 
Hmmm, I haven't heard that one. The issue might be that it's used to treat Crohn's when it shouldn't be. It's approved only for UC, because it works by coating the top layer of the intestine in the medication. As UC only affects this layer, it works for that, but Crohn's can go deeper, so in many cases it just isn't enough. I'm looking it up now.

You're probably better off reading through the forum, but I found this: http://www.askapatient.com/viewrating.asp?drug=20049&name=PENTASA It's nothing scientific or anything, just people who have been on Pentasa offering their opinions. What I found interesting about it is that the vast majority have Crohn's disease.
 
Yeah, a Cochrane review of 1400 patients with Crohn's on mesalamine (the active ingredient in Pentasa) found it to be no better than placebo.

I think step one is waiting for the biopsy results to come back. If they come back normal, based upon everything you've said, I would question the original Crohn's diagnosis especially considering that if you do indeed have Orofacial Granulomatosis and they weren't using the term loosely (many do), then that should EXCLUDE Crohn's disease as a diagnosis.
 
David said:
Yeah, a Cochrane review of 1400 patients with Crohn's on mesalamine (the active ingredient in Pentasa) found it to be no better than placebo.
Click to expand...

I guess now I know why it didn't work for me! :p

I didn't see that when looking it up (I'm at work and have to limit my googling). Does anyone happen to have a link to this information? I'd like to check it out. Thanks!
 
Hi David, thanks for commenting!

I'm confused (had to work an incredibly early shift this morning). When you say using the term loosely, what exactly do you mean? From what I gather, OFG is a rather loose term and covers a lot of other conditions that aren't technically OFG is that what you meant?

So if I truely have OFG that excludes CD? But if I have an inflammation reffered to as OFG that isn't actually then I could have Crohn's, is that the jist?

Thank you for your patience :)
 
Ok, when you say you were diagnosed with crohns due to swollen lips, did you also have intestinal issues as well?? How did they diagnose you, was it through colonoscopy and biopseis?

I mean if you are saying that the ONLY symptom you had was lip swelling, well A lot of things can cause this besides crohns disease. How were you originally diagnosed?









Jam300 said:
Hello Everybody,

Just some quick background so everybody can be brought up to speed.

I was diagnosed with CD in 2007 by Colonoscopy which found inflammation in my TI. The only syptom I displayed was Orofacial Granulamatosis (a swelling of the lip), no GI problems. I was put on a two month course of Modulen IBD and then followed an elimination diet, my lips swelling went down a bit, but not entirely. I went back to eating whatever I wanted about four years ago. No meds or anything since the modulen.

I had a scope yesterday (I began to worry what years unmedicated may have done to me after casually browsing this forum 6 or so months ago). The scope found nothing and i'll quote from the report (for David's benefit :D):

'A digital rectal examination was performed. The Colonoscope was inserted via the anus to the terminal ileum. The caecum was identified by ileal intubation. The scope was retroflexed into the rectum. The examination to the point of insertion was normal. No abnormalities detected.

Normal ileocolonoscopy. Normal ileal appearances. Biopsies taken.'

My follow up isn't until the 28th of March when the histology comes back from my biopsies. This is obviously very good news but i'm baffled if i'm honest and so it seems were the doctors. The guy doing the scope even said that had I not been diagnosed with Crohn's previously he would have said I didn't have it.

I presented swollen lips for three years before my diagnosis, so in total i've supposedly had CD for ten years. Yet i'm somehow in a full remission, despite years of poor diet, no lifestyle changes, drinking and smoking regularly and heavily. It sounds like i'm boasting, I really do not mean to, I know people on here struggle daily with this dreadful illness. But how is this possible? Is it all possible that I was misdiagnosed when I was young? I don't see how I can go ten years with Crohn's only presenting one superficial syptom (which is in itself barely noticeable anymore).

Can someone give me some more informed insight on this please? I can't wait until March to find out!
Click to expand...
 
Hi Ihurt,

Think i've already answered your questions in my OP!


Jam300 said:
Hello Everybody,

I was diagnosed with CD in 2007 by Colonoscopy which found inflammation in my TI. The only syptom I displayed was Orofacial Granulamatosis (a swelling of the lip), no GI problems. I was put on a two month course of Modulen IBD and then followed an elimination diet, my lips swelling went down a bit, but not entirely. I went back to eating whatever I wanted about four years ago. No meds or anything since the modulen.
Click to expand...

I'll happily answer anything else you have to ask?
 
David said:
You nailed it on all counts. Sorry for not being more clear.
Click to expand...

You were perfectly clear David, it was me being a dope that meant I couldn't quite figure what you meant!

I know that a biopsy was taken from my lip when I was first diagnosed, is that helpful?

What do the biopsies actually show? If they do indicate Crohn's still, what would that mean, that i'm not actually in remission?
 
Biopsies from the intestine show how deep the inflammation goes. In crohn's disease the inflammation can go the full thickness of the intestine. So if the biopsy is showing inflammation fairly deep, then that is an indication of crohn's disease.
I feel like I haven't explained that very well!
I'm not sure if they test for anything else. Just done a quick search online but could only find "distinctive cell changes known to occur in crohn's disease"
 
Ahh, so i'm not sure to be in remission then? Didn't realise how important these biopsies were to the overall findings of the scope!
 
Jam300,
Of course you need the info from the biopsies from your scopes;however, I believe that from the info that you have given here that you did have Crohn's disease and that the treatment regime of Enteral Nutrition (the Modulen) followed by the elimination diet is what put you into remission.

Dr. John Hunter at Addenbrooke's Hospital in the U.K. advocates for this treatment program: http://www.crohns.org.uk/crohns_disease/nutritional_therapy

I also use this treatment approach and I also have achieved remission, however I still must follow a restricted diet.

My understanding is that for some people after they achieve remission and stay on the diet for a year or more, they can resume a full diet without any problems. Some relapse in the future, some do not.

I suggest that you continue to be monitored periodically no matter what the current biopsies show as the inflammation can return and cause scarring without you being aware of it immediately.

May you enjoy your good health and long may it last. :)
 
An update:

Just got a call from the hospital, my MRI results are in and have been looked over by my doctor. Everything was completely normal.

Only after I got off the phone did I begin to wonder what exactly they'd be looking for in a Small Bowel Study? I'd imagine stricturing ect? Can inflammation show up on an MRI?

Still got a few more days for my histology, fingers crossed!
 
Thats great news!
I expect they would be looking for any abnormalities, so yes strictures, maybe fistulas. And yes inflammation can show on an MRI. The first one I had was instead of a colonoscopy as it was thought it would be less invasive.
 
Well that's good then, i'd imagine it was also to check that my CD hadn't progressed up the tract, without doing an endoscopy unless it was needed.

2/3 tests clear, just to find out what the big one will tell me now.
 
I've had very good news so far Sarah, and I know i'm being silly, but I seem to go on cycles of four of five days feeling good followed by two being utterly miserable. On those days, I just can't do anything other than think about Crohn's and how it may affect my life, medicatiosn, food, supplements, travel, work... its just too much some times and it scares me so much.

It's wierd, I know this isn't the end of the world. But sometimes I just can't help but look at it that way. Melodramatic, eh?
 
I'm so sorry, Jam. I know you're worried, but try to think about how mild a case it is, if it even is Crohn's. It seems unlikely that you would have to make any major lifestyle changes if you don't want to. :)

:hug: I think you're allowed to be melodramatic in this situation!
 
You're a sweetheart Sarah, thank you. Funnily enough you're saying everything the sensible part of my brain says, but you know when you just can't listen to that part even though you know it makes sense?

For everytime I tell myself 'you're mild i'm sure you'll be fine' I get a 'but for how long?' from the back of my mind. I go cold and start panicking and googling.

I'm going to go out for a bit, I need some air. Thank you for replying Sarah, you've been a great help over the last few weeks.
 
I'm glad I can help! :)

And stop googling, that's how you're scaring yourself. :p I'm joking - it really is useful, but google also has a tendency to tell you that you have the flu when you ask about cold symptoms, if you get what I mean. :)
 
I know that googlings terrible (although it helped me find this place, which is a plus) but its wierdly addictive. I think the last four or so months are just starting to get to me, four months of wondering and worrying can start to take their toll.
 
I think everything your feeling is normal!
But as sarah said, your case is very mild so make the most of it! :)
Of course things could change and its good that you are aware of what could happen, but it isn't worth stressing over, stress will only make it worse!
I realised a long time ago that the best thing to do it just take each day at a time. It makes it a lot easier to deal with. Why worry about something that hasn't happened yet and may not even happen?
 
Another update!

I've just got back from a meeting with the head IBD nurse at my hospital, to go through my biopsy results, which 'support a diagnosis of Crohn's Disease' as a result of superficial granuloma. I know a lot of people said this was likely the case from the off but I was (understandably, I think :ytongue:) resistant to this idea. For the first time in my life I can now admit in true AA fashion.... My name is Jordan Gold and I have Crohn's Disease.

This is surprisingly relieving. While it sucks that I do have Crohn's, I at least have a confirmed diagnosis, which is paradise in comparison to the five month self inflicted purgatory i've just come out of. So in this sense, I consider the diagnosis a positive experience, hurrah!

However this leads me to my questions and the overall point of this post. I know i've banged on an awful lot on here, but I ask for your collective inputs one last time, your informed opinions really do matter to me. I'm at a loss with where to go from here, my doc's recommendation is Aza. The nurse asked me how i'd feel about this, my response was that i'm not a fan of the idea. Though I do have Crohn's, I don't seem overly symptomatic and in a macroscopic sense, my bowel looks good. My overall understanding of Aza is that while it does present several side effects, these are generally thought to be worth it as they are outweighed by the benefits of the medicine. In my case I consider this to be less applicable. Also from what anecdotal evidence i've read on this forum, generally it would seem that Aza is a way of delaying a rather grim looking path. Seeing as it's not recommended for long term use it seems like i'll most likely get four or five years out of Aza before i'll then have to move onto biologics, which themselves carry a host of side effects and long term use issues. At the age of the 21 this doesn't seem a very discursive or well conceived treatment plan. I should point out that i'm not all that well informed, this is simply an observation of mine and if anyone disagree's with anything i've said, well that's the point of this post, i'm looking for advice on how to progress.

The nurse did say that plenty of patients they've treated have incurred muccosal healing as a result of Aza and have subsequently been able to go med-free, or downgrade to Pentasa/sporadic steroid courses to bring remission back. I didn't realise this was possible, does anyone know if this is actually possible?

I was then asked what I would want, I asked how they'd feel about me trialling myself on LDN. They said while they can't ethically prescribe me it, if that's how I choose to treat myself they would happily oversee me, which weirdly made me feel very affectionate both towards the doctor and nurse, bless em. I also had my bloods taken for B12 deficiency, the nurse apparently couldn't send for any more vitamin tests without the doctors consent so they'll have to be done at another date.

In short then I suppose my quandary is how to advance from here now that I finally have a diagnosis. LDN of course is a promising and seemingly 'safer' medicine, especially in terms of side effects, but its trickier to get hold of and can't be monitored by my current doctor so will require to me to seek expensive private sessions. Aza is easily available, but i'm pretty terrified of it, not because of the side effects as much more because I don't fancy the long term prognosis. I do wonder whether I should take advantage of my position and attempt diet therapy, though once again i'm unsure. One final question, is which supplements should I be looking at? This is specifically aimed at something David has been talking about recently (though anyone who can answer, feel free). I noticed David said it's very hard to test for deficiency, how then do you recommend working out if you need the extra, is it just a case of taking a supplement and seeing if you feel better?

Apologies for the marathon post, though i'm sure many of you can relate. 5+ months of if's and but's will do that to you I suppose. Anyway, I look forward to hearing ANYTHING that ANYONE has to advise. All the best gang.
 
Jam, I'm so glad you're able to look at this so positively. :hug:

As for your questions about medication, I think I'll have to leave that to someone else. Normally, I'd advise you stick with it because of the potential risks of going untreated, but it does seem like your case is different.

Jam300 said:
The nurse did say that plenty of patients they've treated have incurred muccosal healing as a result of Aza and have subsequently been able to go med-free, or downgrade to Pentasa/sporadic steroid courses to bring remission back. I didn't realise this was possible, does anyone know if this is actually possible?
Click to expand...

That makes sense to me. I'm curious though - do they advise this in more typical Crohn's cases? It seems a little risky for most people.
 
I believe its on a case by case basis, but must of happened enough times for the nurse to consider it worth mentioning, god knows to be honest. I'm just very undecided on whether or not I want to step up the pyramid of drugs for the next 30 years =\

PS, I like your new picture Sarah, your dog is adorable!
 
Hmm. It was probably for very mild cases, then. Have you asked if they have had any cases similar to yours?

I'm sorry I can't offer much insight on either Aza or LDN. Have you taken a look through their sections in the treatment forum? Sounds like you have. :)

Thanks! He's just a teeny little thing. A bit longer than that now, but not much taller. :p
 
Hi Jam,

I don't believe your case is any different as you have Crohn's disease. I hate the term, "Mild Crohn's Disease" or "Severe Crohn's Disease" as it leads to a whole host of potential issues. I prefer, "Crohn's disease with mild activity" or, "Crohn's disease with severe activity" at present or something along those lines. Let me use a metaphor. Think of inflammation in your intestines as a wild fire. Sometimes wild fires are minor but firefighters don't say, "Meh, we'll just keep an eye on it and see if it burns out" because the next thing they know, that minor wild fire could turn into an inferno. You may have mild inflammation at present, but that mild inflammation is still damaging your bowel. You want ZERO inflammation and full mucosal healing. Nothing less.

Which is better, Aza or LDN? Azathioprine is certainly more proven but I'm a big fan of LDN as well. How about both? From what I've read, they can be taken together. Then if you get a clean bill of health a couple years from now, you can try going off the azathioprine and be closely monitored. But for now, do everything in your power to get that inflammation down and promote mucosal healing. Western meds, alternative meds, diet, lifestyle changes, etc etc.

As for testing for deficiency, I was alluding to magnesium deficiency being hard to test for because the serum magnesium test isn't that good. Other deficiencies such as B12, vitamin D, and zinc which Crohnies are commonly deficient in are much easier to test for though I don't agree with all their reference ranges.
 
Thanks for the input David, my concern just remains that Azathioprine is not recommended for long term use thus i'd have to step up in a few years. I'm not sure how okay with that I am. It probably sounds silly, but it really is a big concern of mine.

How then do you recommend discovering Magnesium deficiency? Is it just a case of taking the supplement and seeing if you feel better?
 
Is it possible to go from Aza to 6MP, they are similar drugs so it wouldn't be a step up. Or can you not go from one to the other for the same reason you can't stay on Aza for too long?
 
I was really sick with Crohn's disease that was symptomatic but undiagnosed for years. I eventually had surgery and have been in remission for years now, so long that I have often questioned my initial diagnosis many times. But having reviewed my history, it is clear, I do have it....there is no cure....and I am fortunate to have remained in remission for so long without medication. This illness has always been a mystery to me and I just treat every day as a gift and enjoy my life to the fullest. In the meantime, I have colonoscopies every five years and follow up with my GI doc every year with full blood work. I hope and pray for a cure or better medications in case my remission ends in the future.
 
Jam300 said:
Thanks for the input David, my concern just remains that Azathioprine is not recommended for long term use thus i'd have to step up in a few years. I'm not sure how okay with that I am. It probably sounds silly, but it really is a big concern of mine.

How then do you recommend discovering Magnesium deficiency? Is it just a case of taking the supplement and seeing if you feel better?
Click to expand...
I've noticed you mention azathioprine not being for long term use. Where are you getting that from? It's actually one of the best long term maintenance medications there are in my opinion. Your concerns, however, are NOT silly and I think it's good you're doing your research :)

I need to do a writeup for magnesium. First step is go here http://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/ and total up how much magnesium you get per day based upon those magnesium rich foods. Let me know when you figure it out :)
 
My info is from here http://www.nacc.org.uk/downloads/factsheets/drugAzathioprine6MP.pdf
which was suggested by my nurse. As I said, I don't have a problem with Aza as such, I understand that everything has a chance of side effects. I'm just concerned that it would mean that five years from now i'm on one of the biologics before i'm even close to thirty, which is a prognosis I don't fancy.

I'll give that link a go as soon as possible David, i'm at my girlfriends at the moment and her internet isn't agreeing with the link. I'm considering getting my vitamins taken by my GP, just so I can get it done and out the way, although I think should my GI send for them the results will come back quicker, hmmm, decisions decisions. Fortunately though food doesn't seem to affect me as much as other Crohns sufferers so from a dietary perspective (assuming i'm having no problems from malabsorption) I should be getting a decent level of vitamins.
 
I think I see what you're saying. This .pdf said this:
How long will I be taking azathioprine or mercaptopurine?
If you respond well to azathioprine or mercaptopurine you should be able to keep taking it for some years, provided the results of your monitoring blood tests are satisfactory and you do not develop any serious adverse reactions. Research suggests that for some people azathioprine or mercaptopurine can continue to be effective for at least five years and possibly longer.
Click to expand...
And you're worried that in 3-5 years it will no longer be working and you'll have to move on to a biologic? Not so much that it isn't recommended for long term use?
 
Well assuming that I don't have any problems with absorption (is this likely with a macroscopically sound Colon?) I should be ok in terms of magnesium... my diet appears to be very high in it as I eat bran, raisins, seeds ect daily. Still, i'll wait and see how my other vitamin tests fare in order to see if i'm absorbing well.

David, I must apologise, it appears i've misread the .pdf! You know when you misread something and then that sort of stores itself as a memory, so when you next read that paragraph you read it as you did before again? I was under the impression that it was recommended patients do not stay on Aza for more than five years (that being the maximum)! I'm certain I picked up that information from that .pdf so clearly i've misread it! In that case then yes my worry would be as you described, do you know if it regularly lasts for a longer period of time than that?
 
Magnesium is primarily absorbed in the terminal ileum, not the colon. If you had inflammation (or resection) of the terminal ileum, that could affect absorption. In addition, diarrhea and vomiting lower levels as well. And most of us don't get enough in our diet. If you do, you're definitely an exception.

Like most things with Crohn's disease, you don't know how you're going to fare on azathioprine. Some just plain can't tolerate it and are off it very quickly. It doesn't lead to remission for others so the next best thing is tried. And others still might be on it for 10+ years and do fantastic. It's a case by case basis so I really can't say how you'll fare. What I can say is that your doctor can play a big role in your success. Prior to starting azathioprine they can conduct a TPMT genetics or enzyme test to help determine optimal dosing. And then later on they can utilize thiopurine metabolite testing to make sure that the dose you're on is getting you to therapeutic levels. Optimization of azathioprine dosage is critical to its long term success.
 

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