FULL TITLE: Characteristics and predictors of short-term outcomes in individuals self-selecting yoga or physical therapy for treatment of chronic low back pain.

OBJECTIVE: To compare clinical and demographic characteristics of individuals self-selecting yoga or physical therapy (PT) for treatment of chronic low back pain (cLBP) and to examine predictors of short-term pain and functional outcomes. DESIGN: Descriptive, longitudinal study. SETTINGS: A hospital-based clinic that offers modified integral yoga classes for cLBP and 2 outpatient PT clinics that offer exercise-based PT. PARTICIPANTS: Adults (n=53) with cLBP?12 weeks: yoga (n=27), PT (n=26). METHODS: Yoga participants attended a 6-week, once weekly, 2-hour yoga class. PT participants underwent twice weekly, 1-hour individualized PT. Data were collected at baseline and at 6 weeks. Groups were compared by using ?2 and independent samples t-tests. Hierarchical linear regression was used to predict treatment outcomes. MAIN OUTCOME MEASURES: Disability (Roland Morris Disability Questionnaire), health status (Rand Short Form 36 Health Survey 1.0), pain bothersomeness (numerical rating scale), back pain self-efficacy (Back Pain Self-Efficacy Scale), and treatment satisfaction. RESULTS: At baseline, yoga participants were significantly less disabled (P=.013), had higher health status (P=.023), greater pain self-efficacy (P=.012), and less average pain bothersomeness (P=.001) compared with PT participants. At 6 weeks, when controlling for baseline group differences, greater pain self-efficacy was the strongest predictor for reduced pain and higher function for the entire sample. A significant group interaction by baseline pain self-efficacy predicted disability at 6 weeks. PT participants with low pain self-efficacy reported significantly greater disability than those with high pain self-efficacy. Yoga participants with low and high pain self-efficacy had similar disability outcomes. CONCLUSION: These findings strengthen evidence that self-efficacy is associated with cLBP outcomes, especially in individuals self-selecting PT. Further research to evaluate outcomes after yoga and PT in participants with low pain self-efficacy is needed.

PM R. 2010 Nov;2(11):1006-15. Evans DD, Carter M, Panico R, Kimble L, Morlock JT, Spears MJ. Family and Community Nursing, Emory University Nell Hodgson Woodruff School of Nursing, 1520 Clifton Rd, Atlanta, GA 30322, USA. dian.evans@emoryhealthcare.org

Prostatitis ranges from a straightforward clinical entity in its acute form to a complex, debilitating condition when chronic. It is often a source of frustration for the treating physician and patient. There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic. Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage. The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, urinary tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract. The mainstay of therapy is an antimicrobial regimen. Chronic pelvic pain syndrome is a more challenging entity, in part because its pathology is poorly understood. Diagnosis is often based on exclusion of other urologic conditions (e.g., voiding dysfunction, bladder cancer) in association with its presentation. Commonly used medications include antimicrobials, alpha blockers, and anti-inflammatory agents, but the effectiveness of these agents has not been supported in clinical trials. Small studies provide limited support for the use of nonpharmacologic modalities. Asymptomatic prostatitis is an incidental finding in a patient being evaluated for other urologic problems.

Am Fam Physician. 2010 Aug 15;82(4):397-406. Sharp VJ, Takacs EB, Powell CR. University of Iowa Health Care, Iowa City, 52242-1089, USA. victoria-sharp@uiowa.edu

This article is part of an occasional series profiling editors of the American Journal of Clinical Hypnosis (AJCH). William E. Edmonston was the second editor, succeeding Milton H. Erickson. His research focused on the use of conditioning paradigms and psychophysiological measures to explore a wide variety of hypnotic phenomena, leading to a "neo-Pavlovian" theory of neutral hypnosis as physiological relaxation (anesis). A longtime professor of psychology at Colgate University, he created an interdisciplinary undergraduate major in neuroscience, and was named New York State College Professor of the Year in 1988. He gave the Journal a new look, and a greater balance of clinical and experimental papers. The article also provides background on George Barton Cutten, George H. Estabrooks, and Frank A. Pattie, pioneers of hypnosis who were linked to Edmonston.

Am J Clin Hypn. 2010 Oct;53(2):81-91. Kihlstrom JF, Frischholz EJ. Department of Psychology, University of California, Berkeley 94720-1650, USA. jfkihlstrom@berkeley.edu

FULL TITLE: Trends and predictors of publicly subsidized chiropractic service use among adults age 50+.

OBJECTIVES: This article examines trends in and predictors of publicly subsidized chiropractic use from 1991 to 2000, a decade characterized by health care system reforms throughout North America. SAMPLE: The sample included adults age 50+ who visited a publicly subsidized chiropractor in the Canadian province of British Columbia during the study period. DESIGN: Administrative claims data for chiropractic service use were drawn from the Medical Services Plan (MSP) Master file in the British Columbia Linked Health Data resource. The MSP Master file contains claims reported for every provincially insured medical service and supplementary health benefit including chiropractic visits. RESULTS: Joinpoint regression analyses demonstrate that while annual rates of chiropractic users did not change over the decade, visit rates decreased during this period. Predictors of a greater number of chiropractic visits include increasing age, female gender, urban residence, low to moderate income, and use of chiropractic services earlier in the decade. CONCLUSIONS: The trend toward decreasing visit rates over the 1990s both conflicts with and is consistent with findings from other North American chiropractic studies using similar time periods. Results indicating that low and moderate income and advancing age predict more frequent chiropractic service are novel. However, given that lower income and older individuals were exempted from chiropractic service limits during this period, these results suggest support for the responsive nature of chiropractic use to financial barriers.

J Altern Complement Med. 2010 Sep;16(9):995-1001. Votova K, Penning MJ, Zheng C, Brackley ME. Department of Sociology and Centre on Aging, University of Victoria, Victoria, BC, Canada.

FULL TITLE: Could chiropractors screen for adverse drug events in the community? Survey of US chiropractors.

BACKGROUND: The "Put Prevention into Practice" campaign of the US Public Health Service (USPHS) was launched with the dissemination of the Clinician's Handbook of Preventive Services that recommended standards of clinical care for various prevention activities, including preventive clinical strategies to reduce the risk of adverse drug events. We explored whether nonprescribing clinicians such as chiropractors may contribute to advancing drug safety initiatives by identifying potential adverse drug events in their chiropractic patients, and by bringing suspected adverse drug events to the attention of the prescribing clinicians. METHODS: Mail survey of US chiropractors about their detection of potential adverse drug events in their chiropractic patients. RESULTS: Over half of responding chiropractors (62%) reported having identified a suspected adverse drug event occurring in one of their chiropractic patients. The severity of suspected drug-related events detected ranged from mild to severe. CONCLUSIONS: Chiropractors or other nonprescribing clinicians may be in a position to detect potential adverse drug events in the community. These detection and reporting mechanisms should be standardized and policies related to clinical case management of suspected adverse drug events occurring in their patients should be developed.

Chiropr Osteopat. 2010 Nov 17;18:30. Smith M, Bero L, Carber L. Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, USA. monica.smith@palmer.edu.

Some environmental toxins like DDT and other chlorinated compounds accumulate in the body because of their fat-soluble nature. Other compounds do not stay long in the body, but still cause toxic effects during the time they are present. For serious health problems to arise, exposure to these rapidly-clearing compounds must occur on a daily basis. Two such classes of compounds are the phthalate plasticizers and parabens, both of which are used in many personal care products, some medications, and even foods and food preservation. The phthalates are commonly found in foods and household dust. Even though they have relatively short half-lives in humans, phthalates have been associated with a number of serious health problems, including infertility, testicular dysgenesis, obesity, asthma, and allergies, as well as leiomyomas and breast cancer. Parabens, which can be dermally absorbed, are present in many cosmetic products, including antiperspirants. Their estrogenicity and tissue presence are a cause for concern regarding breast cancer. Fortunately, these compounds are relatively easy to avoid and such steps can result in dramatic reductions of urinary levels of these compounds.

Altern Med Rev. 2010 Sep;15(3):190-6. Crinnion WJ. Environmental Medicine, Southwest College of Naturopathic Medicine, Tempe, AZ, USA. w.crinnion@scnm.edu

Pain is one of the most prevalent conditions for which patients seek medical attention. Additionally, the number of patients who utilize complementary and alternative medicine as a treatment of pain either in lieu of, or concurrent with, standard conventional treatments continues to grow. While research into the mechanisms, side effect profiles, and efficacies of these alternative therapies has increased in recent years, much more remains unknown and untested. Herein, we review the literature on complementary and alternative medicine for pain, with particular emphasis on evidence-based assessments pertinent to the most common alternative therapies, including acupuncture, herbal therapy, massage therapy, hypnosis, tai chi, and biofeedback.

Curr Pain Headache Rep. 2010 Nov 10. Dhanani NM, Caruso TJ, Carinci AJ. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114, USA.

Acupuncture is often advocated as a treatment for depression, and several trials have tested its effectiveness. Their results are contradictory and even systematic reviews of these data do not arrive at uniform conclusions. The aim of this review is to critically evaluate all systematic reviews of the subject with a view of assisting clinical decisions. Thirteen electronic databases were searched to identify all relevant articles. Data of these systematic reviews and the primary studies they included were extracted independently by the two authors according to predefined criteria. Eight systematic reviews including seventy-one primary studies were found. Five of the reviews arrived at positive conclusions and three did not. All the positive reviews and most of the positive primary studies originated from China. There are reasons to believe that these reviews are less than reliable. In conclusion, the effectiveness of acupuncture as a treatment of depression remains unproven and the authors' findings are consistent with acupuncture effects in depression being indistinguishable from placebo effects.

Eval Health Prof. 2010 Dec 7. Ernst E, Lee MS, Choi TY.

OBJECTIVE: To observe clinical therapeutic effect of acupuncture plus cupping for treating insomnia in college students. METHODS: Ninety two college students suffering from insomnia were randomly divided into a treatment group (52 cases) and a control group (40 cases). Acupuncture plus cupping was used for profiting the brain and tranquilizing the mind in the treatment group, and conventional differentiation of symptoms and signs was used in the control group. Therapeutic effect, number of treatment, self-rating sleeping scaling (SRSS), and subtracted rate were evaluated after one month of treatment. RESULTS: There was a significant difference in effective rate between the two groups (P < 0.05). For the cases with moderate insomnia, the effective rate was obviously better in the treatment group than that in the control group (P < 0.05), and for the cases with slight and moderate insomnia, the average treatment number was remarkably less in the former than that in the latter (P < 0.01). SRSS was reduced in both groups (P < 0.01, P < 0.05) with a significant difference between the two groups (P < 0.05). The subtracted rate in the former was more than that in the latter (P < 0.05). Conclusion: The therapeutic effect in the treatment group was better than that in the control group, showing superiority in the cases with moderate insomnia with less treatments and more improved and cured rates.

J Tradit Chin Med. 2010 Sep;30(3):185-9. Zhang YF, Ren GF, Zhang XC. Hospital of Liaocheng University, Liaocheng, Shandong 252059, China.

FULL TITLE: Intentions to use hypnosis to control the side effects of cancer and its treatment.

Evidence suggests that hypnosis is an effective intervention for reducing distress, pain and other side effects associated with cancer and its treatment. However, hypnosis has failed to be adopted into standard clinical practice. This study (n = 115) investigated overall intentions to use hypnosis to control side effects of cancer and its treatment, as well as demographic predictors of such intentions among healthy volunteers. Results suggest that the vast majority of participants (89%) would be willing to use hypnosis to control side effects associated with cancer treatment. Mean intention levels did not differ by gender, ethnicity, education or age. These results indicate that in the general public, there is a willingness to consider the use of hypnosis, and that willingness is not determined by demographic factors. This broad acceptance of hypnosis argues for more widespread dissemination.

Am J Clin Hypn. 2010 Oct;53(2):93-100. Sohl SJ, Stossel L, Schnur JB, Tatrow K, Gherman A, Montgomery GH. Dept. of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Piedmont Plaza 11, 2nd Fl, Winston-Salem, NC 27157-1063, USA. ssohl@wfubmc.edu

BACKGROUND: Medical Informatics in India is still in its infancy. Although the Indian Association for Medical Informatics (IAMI) was founded in 1993, proposed by major healthcare delivery institutions, the absence of independent career options in medical informatics in India has resulted either in the exodus of the needed faculty members for supporting education in the field. However, this situation may have been changing in the past few years, but a large gap exists which needs to be filled up quickly. The purpose of this report is to provide an assessment of the present situation of research and training in medical informatics in India, and its implications for future development of the field. OBJECTIVES: To assess the current situation regarding the opportunities for research and education in Medical Informatics in India and related issues like availability of career options. METHODS: A survey questionnaire was sent by postal mail to well-known Indian institutions engaged in medical informatics training and research. In addition, key stakeholders working towards imparting education and awareness on the principles and practice of medical informatics were contacted to provide information about training and research in medical informatics in India. This was a purposive sampling based on prior knowledge. The responses were thematically analyzed. RESULTS: A total of six courses were identified in the survey. These were administered through face to face (F2F), e-learning and other modes of distance learning. In general, most of the students are graduates in medicine (allopathic, homeopathic, ayurvedic), allied sciences (nursing, physiotherapy) and medical administrators or graduates in engineering or library and information sciences. Most of them are also working, thus, the majority of the courses are for part-timers and act as on-job value addition. Most of the courses however do not directly train for jobs. Therefore, as most of the participants are already working somewhere, the question of placement due to the course may not be measurable directly. Since most of the students from India are already employed, by attending this course they gain further insights into health informatics that they want to pursue as a career.

Sarbadhikari SN, Gogia SB. Yearb Med Inform. 2010:106-8. Immediate Past President IAMI, 28/31 Old Rajinder Nagar, New Delhi 110060, India. Tel.: (L) +91 11 2585 2291, (M) +91 981 0126 883, E-mail gogia7@gmail.com, http://www.iami.org.in.

FULL TITLE: Effect of "developmental speech and language training through music" on speech production in children with autism spectrum disorders.

The study compared the effect of music training, speech training and no-training on the verbal production of children with Autism Spectrum Disorders (ASD). Participants were 50 children with ASD, age range 3 to 5 years, who had previously been evaluated on standard tests of language and level of functioning. They were randomly assigned to one of three 3-day conditions. Participants in music training (n = 18) watched a music video containing 6 songs and pictures of the 36 target words; those in speech training (n = 18) watched a speech video containing 6 stories and pictures, and those in the control condition (n = 14) received no treatment. Participants' verbal production including semantics, phonology, pragmatics, and prosody was measured by an experimenter designed verbal production evaluation scale. Results showed that participants in both music and speech training significantly increased their pre to posttest verbal production. Results also indicated that both high and low functioning participants improved their speech production after receiving either music or speech training; however, low functioning participants showed a greater improvement after the music training than the speech training. Children with ASD perceive important linguistic information embedded in music stimuli organized by principles of pattern perception, and produce the functional speech.

J Music Ther. 2010 Spring;47(1):2-26. Lim HA. Sam Houston State University, USA.

FULL TITLE: Efficacy of bolus lukewarm saline and yoga postures as colonoscopy preparation: a pilot study.

BACKGROUND: Colonoscopy is now the gold standard for colon cancer screening and a vital diagnostic and therapeutic tool in 21st century medical practice. Although advances have been swift since colonoscopy came into wide use a generation ago, its effectiveness can be compromised by patients' ability to adequately prepare for the procedure. Many patients dread this task more than the procedure itself. While no prep regimen can be ideal for all patients, the authors present a novel approach that represents a potential time-saving improvement for younger, healthier patients. It is a modern version of an Indian practice called shankh prakshalana, in which lukewarm saline is used in combination with five yoga postures to cleanse the bowel. OBJECTIVE: The objective of this study was to examine the safety, efficacy, and tolerability of lukewarm saline and yoga (LWS/yoga) as a colonoscopy preparation in comparison with NuLytely(®) (PEG-3350, sodium chloride, sodium bicarbonate, and potassium chloride solution) used according to the manufacturer's instructions. RESEARCH DESIGN: This was a pilot study comprising 54 healthy adults, ages 18-65, equally divided into two groups: Group A preparing with lukewarm saline and yoga postures (LWS/yoga); and Group B preparing with NuLytely(®) as directed on the label. MEASUREMENTS: Data were collected on the quality of bowel preparation, patient safety, patient tolerability, and side-effects. The setting was a Joint Commission accredited outpatient endoscopy clinic. INTERVENTIONS: Patients performed the series of five yoga postures known as shankh prakshalana, interrupting the exercises at regular intervals to consume 480?mL of lukewarm saline. The solution was prepared by adding 9?g of sodium chloride per liter of lukewarm water (99°F-102°F/37.2°C-38.9°C). RESULTS: The mean total score was significantly better in Group A versus Group B (20.63?±?5.09 versus 16.48?±?5.18, p? J Altern Complement Med. 2010 Dec;16(12):1269-77. Arya V, Gupta KA, Arya SV. Weill Cornell Medical College and Endoscopy Unit, Wyckoff Heights Medical Center, Middle Village, NY, USA. varyamd@yahoo.com

FULL TITLE: The effectiveness of clinical hypnosis in the digestive endoscopy: a multiple case report.

The aim of this study is to evaluate the efficacy and viability of hypnosis before and during a gastrointestinal endoscopy. Six Gastroscopies and 22 colonoscopies were carried out under hypnosis in a group of patients. The patients ranged in age from 20 and 67 years and have a history of previously incomplete and poorly tolerated examinations or expressed an active demand for sedation. For 6 of the patients who underwent a gastroscopy under hypnosis, the procedure was successfully completed, reaching the second part of the duodenum without difficulty for the endoscopist. Colonoscopy of the cecum was completed in 19 of 20 patients. All patients, except 1, considered their tolerance level as "good." Hypnosis facilitated an adequate endoscopy intervention without any discomfort in 85% of the cases examined. Avoidance of anaesthesia reduces risk to the patient. Hence, hypnosis for gastrointestinal endoscopy appears to provide a promising strategy.

Am J Clin Hypn. 2010 Oct;53(2):101-7. Domínguez-Ortega L, Rodríguez-Muñoz S. Internal Medicine Department, Sleep and Hypnosis Unit, Hospital 12 de Octubre. luis.dominguez@clinicaludor.com

A Book Review by Tim Bruson PhD

Few books on psychotherapeutic topics have given me as much intellectual and emotional satisfaction as Bill O'Hanlon's new book, Quick Steps to Resolving Trauma. With surprising thoroughness and compelling clarity, he presents a four step process that helps therapists understand this pervasive problem. Unlike many therapist books, it is written in a way, which non-therapists can both easily fathom and benefit. I was pleasantly shocked that the book was only 123 pages and could quickly be consumed in one sitting.

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Lavenders and their essential oils have been used in alternative medicine for several centuries. The volatile compounds that comprise lavender essential oils, including linalool and linalyl acetate, have demonstrative therapeutic properties, and the relative abundance of these metabolites is greatly influenced by the genetics and environment of the developing plants. With the rapid progress of molecular biology and the genomic sciences, our understanding of essential oil biosynthesis has greatly improved over the past few decades. At the same time, there is a recent surge of interest in the use of natural remedies, including lavender essential oils, in alternative medicine and aromatherapy. This article provides a review of recent developments related to the biosynthesis and medicinal properties of lavender essential oils.

Planta Med. 2011 Jan;77(1):7-15. Woronuk G, Demissie Z, Rheault M, Mahmoud S. Irving K. Barber School of Arts & Sciences Unit 2, University of British Columbia - Okanagan, Kelowna, Canada.

FULL TITLE: Nurses' use of non-pharmacological methods in children's postoperative pain management: educational intervention study.

AIM: This paper is a report of study of the impact of an educational intervention in pain management on nurses' self-reported use of non-pharmacological methods for children's postoperative pain relief and their perceptions of barriers that limited their use of these methods. BACKGROUND: Non-pharmacological methods have been shown to be effective in relieving pain; however, many barriers, including lack of knowledge, limit nurses' use of these methods. Pain education is a promising strategy for changing nursing practice, but only a few authors have examined the effectiveness of educational interventions for nurses to help relieve children's postoperative pain. METHODS: A quasi-experimental one-group pre- and post-test design was used. Questionnaire surveys were conducted with a convenience sample of 108 Registered Nurses in two public hospitals in Singapore in 2008. RESULTS: Statistically significant increases were found in nurses' self-reported use of imagery, positive reinforcement, thermal regulation, massage and positioning in the postintervention survey. Before the intervention, these methods were less frequently used compared to other methods. Heavy workload/lack of time and the child's inability to cooperate were the most commonly reported barriers at pre- and post-test. CONCLUSION: The educational intervention had a positive effect on nurses' use of several non-pharmacological methods. Regular dissemination of updated information to nurses on these pain management methods is recommended to maintain the positive changes. Nevertheless, education alone was not sufficient to optimize nurses' use of these methods, as various barriers limited their practice.

J Adv Nurs. 2010 Nov;66(11):2398-409. doi: 10.1111/j.1365-2648.2010.05402.x. He HG, Jahja R, Lee TL, Ang EN, Sinnappan R, Vehviläinen-Julkunen K, Chan MF. Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. nurhhg@nus.edu.sg

FULL TITLE: Nurses' use of non-pharmacological methods in children's postoperative pain management: educational intervention study.

AIM: This paper is a report of study of the impact of an educational intervention in pain management on nurses' self-reported use of non-pharmacological methods for children's postoperative pain relief and their perceptions of barriers that limited their use of these methods. BACKGROUND: Non-pharmacological methods have been shown to be effective in relieving pain; however, many barriers, including lack of knowledge, limit nurses' use of these methods. Pain education is a promising strategy for changing nursing practice, but only a few authors have examined the effectiveness of educational interventions for nurses to help relieve children's postoperative pain. METHODS: A quasi-experimental one-group pre- and post-test design was used. Questionnaire surveys were conducted with a convenience sample of 108 Registered Nurses in two public hospitals in Singapore in 2008. RESULTS: Statistically significant increases were found in nurses' self-reported use of imagery, positive reinforcement, thermal regulation, massage and positioning in the postintervention survey. Before the intervention, these methods were less frequently used compared to other methods. Heavy workload/lack of time and the child's inability to cooperate were the most commonly reported barriers at pre- and post-test. CONCLUSION: The educational intervention had a positive effect on nurses' use of several non-pharmacological methods. Regular dissemination of updated information to nurses on these pain management methods is recommended to maintain the positive changes. Nevertheless, education alone was not sufficient to optimize nurses' use of these methods, as various barriers limited their practice.

J Adv Nurs. 2010 Nov;66(11):2398-409. doi: 10.1111/j.1365-2648.2010.05402.x. He HG, Jahja R, Lee TL, Ang EN, Sinnappan R, Vehviläinen-Julkunen K, Chan MF. Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. nurhhg@nus.edu.sg

Most medical treatments of Parkinson's disease (PD) are aimed at the reduction of motor symptoms. However, even when motor improvements are evident, patients often report a deterioration of their daily lives. Thus, to achieve a global improvement in personal well-being, not only drugs, but also complementary therapies, such as physical exercise, occupational and speech therapy, and active music therapy, have been used. We hypothesized that theater could reduce clinical disability and improve the quality of life of PD patients (primary end points) more efficiently than other complementary therapies because (1) in order to impersonate a character, patients are forced to regain the control of their bodies; and (2) while being part of a group, patients have a high degree of social interaction. The need to regain the control of their bodies and their social functioning is very likely to deeply motivate patients. To assess this hypothesis, we ran a randomized, controlled, and single-blinded study that lasted 3 years, on 20 subjects affected by a moderate form of idiopathic PD, in stable treatment with L-dopa and L-dopa agonists, and without severe sensory deficits. Ten patients were randomly assigned to an active theater program (in which patients were required to participate), while the others underwent physiotherapy (control group), the most common nonpharmacological treatment for PD rehabilitation. Patients of both groups were evaluated at the beginning of each year, using five clinical rating scales (Unified Parkinson's Disease Rating Scale [UPDRS], Schwab and England Scale, Parkinson's Disease Quality of Life [PDQ39] Scale, Epworth Sleepiness Scale, and Hamilton Depression Rating Scale). The theater patients showed progressive improvements and, at the end of the third year, they showed significant improvements in all clinical scales. Conversely, the control patients did not exhibit significant ameliorations with time. Thus, the present study provides the first scientific evidence that active theater, coupled with conventional medical treatments, represents a valid complementary therapeutic intervention for PD treatment.

ScientificWorldJournal. 2010 Nov 16;10:2301-13. Modugno N, Iaconelli S, Fiorlli M, Lena F, Kusch I, Mirabella G. IRCCS Neuromed, Pozzilli (IS), Italy.

FULL TITLE: Large ethnic variations in recommended physical activity according to activity domains in amsterdam, the netherlands.

PURPOSE: The level of recommended physical activity (PA) is met less frequently by people from some ethnic minorities than others. We explored whether these differences in recommended PA between ethnic minority groups and the general population varied by domain and type of culturally-specific activity. METHODS: Participants were sampled from the population based SUNSET study and were from ethnic Dutch (n = 567), Hindustani-Surinamese (n = 370) and African-Surinamese (n = 689) descent. The validated SQUASH-questionnaire measured PA for the following domains: commuting, occupation, household, leisure time. Culturally-specific activities were added as extra question within the leisure time domain. The effect of each domain on ethnic differences in recommended PA prevalence was examined by odds-ratio (OR) analysis through recalculating recommended PA, while, in turn, excluding the contribution of each domain. RESULTS: In the ethnic Dutch population, more vigorous PA in commuting and leisure time was reported compared to the Surinamese groups. The Hindustani-Surinamese and African-Surinamese reported more walking as commuting activity, while the Dutch group reported cycling more frequently. Ethnic differences in recommended PA became smaller in both Surinamese groups compared with the Dutch after removing commuting activity, for example, in Hindustani-Surinamese men (OR = 0.92, 95%CI: 0.62-1.37 vs. OR = 1.33, 0.89-2.00) and women (OR = 1.61, 1.12-2.32 vs. OR = 2.03, 1.41-2.92). Removing occupational activity resulted in larger ethnic differences in both groups compared with the Dutch. Smaller effects were found for yoga and dancing, leisure time and household activities. CONCLUSION: This study shows that differences in PA between ethnic minority groups and the general population vary according to the activity domain. The results indicate that including all relevant domains and activities is essential for assessment of ethnic differences in recommended PA.

Int J Behav Nutr Phys Act. 2010 Nov 29;7:85. de Munter JS, van Valkengoed IG, Agyemang C, Kunst AE, Stronks K. Academic Medical Center, Dept, of Public Health, University of Amsterdam, Amsterdam. j.s.demunter@amc.uva.nl.

FULL TITLE: "An Object of Vulgar Curiosity": Legitimizing Medical Hypnosis in Imperial Germany.

During the late nineteenth and early twentieth centuries, German medical hypnotists sought to gain a therapeutic and epistemological monopoly over hypnosis. In order to do this, however, these physicians were required to engage in a complex multi-dimensional form of boundary-work, which was intended on the one hand to convince the medical community of the legitimacy and efficacy of hypnosis and on the other to demarcate their use of suggestion from that of stage hypnotists, magnetic healers, and occultists. While the epistemological, professional, and legal boundaries that medical hypnotists erected helped both exclude lay practitioners from this field and sanitize the medical use of hypnosis, the esoteric interests, and sensational public experiments of some of these researchers, which mimicked the theatricality and occult interests of their lay competitors, blurred the distinctions that these professionals were attempting to draw between their "legitimate" medical use of hypnosis and the "illegitimate" lay and occult use of it.

J Hist Med Allied Sci. 2010 Nov 9. Wolffram H.

FULL TITLE: Attitudes of non-practicing chiropractors: a pilot survey concerning factors related to attrition.

BACKGROUND: Research into attitudes about chiropractors who are no longer engaged in active clinical practice is non-existent. Yet non-practicing chiropractors (NPCs) represent a valid sub-group worthy of study. AIM: The purpose of this research was to assess attrition attitudes of NPCs about the chiropractic profession and develop a scale to assess such attitudes. METHODS: A 48 item survey was developed using the PsychData software. This survey included 35 Likert-style items assessing various aspects of the profession namely financial, educational, psychosocial and political. An internet discussion site where NPCs may be members was accessed for recruitment purposes. RESULTS: A total of 70 valid responses were received for analysis. A majority of respondents were male with 66% being in non-practice status for 3 to 5 years and less with 43% indicating that they had graduated since the year 2000. Most respondents were employed either in other healthcare professions and non-chiropractic education. A majority of NPCs believed that business ethics in chiropractic were questionable and that overhead expense and student loans were factors in practice success. A majority of NPCs were in associate practice at one time with many believing that associates were encouraged to prolong the care of patients and that associate salaries were not fair. Most NPCs surveyed believed that chiropractic was not a good career choice and would not recommend someone to become a chiropractor. From this survey, a 12 item scale was developed called the "chiropractor attrition attitude scale" for future research. Reliability analysis of this novel scale demonstrated a coefficient alpha of 0.90. CONCLUSION: The low response rate indicates that findings cannot be generalized to the NPC population. This study nonetheless demonstrates that NPCs attrition attitudes can be assessed. The lack of a central database of NPCs is a challenge to future research. Appropriate investigation of attrition within the chiropractic profession would be helpful in the analysis of attitudes regarding both chiropractic education and practice. Further research is needed in this area.

Chiropr Osteopat. 2010 Nov 4;18:29. Mirtz TA, Hebert JJ, Wyatt LH. Division of Health, Physical Education and Recreation, 414 East Clark Street--Dome 221B, University of South Dakota, Vermillion, South Dakota, 57069, USA. timothy.mirtz@usd.edu.

In recent years so-called Complementary and Alternative Medicine (CAM) practices have made significant political and professional advances particularly in the United Kingdom (UK): osteopathy and chiropractic were granted statutory self-regulation in the 1990s effectively giving them more professional autonomy and independence than health care professions supplementary to medicine; the practice of acupuncture is widespread within the National Health Service (NHS) for pain control; and homoeopathy is offered to patients by a few General Practitioners alongside conventional treatments. These developments have had a number of consequences: one is that both CAM and Conventional and Orthodox Medical (COM) professions have had to reappraise their professional identity. In manual therapy for example, questions have been asked about the differences between physiotherapy, osteopathy and chiropractic, and what the justification is for having separate professions. A wider question concerns the relationship between CAM and COM; are CAM distinct professions or should they, as has happened to a limited extent in the UK, be absorbed into the broader field of 'Medicine' or 'Health Care' as adjunctive therapies. CAM professions have also had to develop, implement and enforce codes of practice for practitioners and clarify the scope of practice within a profession. At the heart of these issues lies the need to identify and clarify professional values. A key claim of CAM professions is that their practice is distinct and the outcome of treatment at least as effective and in many cases more effective than with conventional therapies. In addition, what counts as effective outcome is often different from conventional medical understanding, involving more subtle humanitarian considerations, for example. Three values are identified as being commonly held across CAM professions. These are: offering 'natural' treatment; being patient rather than disease focussed; and being holistic. However, these may not be as distinctive of CAM as is claimed either because the meaning is unclear or because COM professions claim similar values. The paper argues that the values that inform 'good practice' and 'effective outcome' should be seen as distinct components of professional competence. This has implications for establishing professional identity and codes of practice.

Med Health Care Philos. 2010 Nov 23. Tyreman S. Dean of Osteopathic Education Development at the British School of Osteopathy (BSO), 275 Borough High Street, London, SE1 1JE, UK, S.Tyreman@bso.ac.uk.

FULL TITLE: Nonpharmacologic Treatments for Migraine and Tension-Type Headache: How to Choose and When to Use.

OPINION STATEMENT: There are a variety of nonpharmacologic treatments for headache. Educating patients about headache and its management, identifying and managing triggers (via diaries), modifying lifestyles, and understanding the importance of adopting and adhering to interventions (either pharmacologic or nonpharmacologic) are relevant to all persons with headache. In addition, specific nonpharmacologic treatments can be used either alone or in conjunction with ongoing pharmacologic intervention. Strong candidates for nonpharmacologic treatment include individuals with significant headache-related disability, comorbid mood or anxiety disorders, difficulty managing stress or other triggers, medication overuse, and patients who prefer a specific treatment. Behavioral treatments (relaxation, biofeedback, and cognitive-behavioral therapy) possess the most evidence for successful headache management. They have a long history of randomized trials showing efficacy and are considered first-line preventive options. Among complementary and alternative treatments, recent positive findings from randomized trials using acupuncture provide evidence of its potential as a first-line intervention. Other complementary and alternative techniques do not have a consistent base of research to recommend them for headache prevention, but they may be used if the patient prefers this approach or when other first-line interventions (nonpharmacologic or pharmacologic) have not provided adequate results. Among "natural" treatments, both butterbur extract and vitamin B2 have shown efficacy in more than one randomized trial and are thus potentially useful first-line preventive interventions.

Curr Treat Options Neurol. 2010 Nov 16. Nicholson RA, Buse DC, Andrasik F, Lipton RB. Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1402 S. Grand Blvd. Monteleone Hall, St. Louis, MO, 63104, USA, nicholra@slu.edu.

Full Title: Acupuncture effect on thermal tolerance and electrical pain threshold: a randomised controlled trial.

OBJECTIVE: The aim of this study was to test whether acupuncture could modify the threshold of tolerance to thermal and electrical stimuli. METHODS: A randomised placebo-controlled single-blind trial was conducted in 36 healthy volunteers randomly distributed to control (no treatment), conventional acupuncture and sham acupuncture groups. The subjects were blind to the group allocation. The authors measured before and after treatment the pain threshold with the Painmatcher (Cefar Medical AB, Lund, Sweden) and the cold tolerance with the cold pressor test, together with the Visual Analogue Scale pain score. RESULTS: Electrical stimulation threshold and cold pressor tolerance both increased significantly in the control and the true acupuncture groups, but not the sham group. The changes in the true acupuncture group were highly statistically significant and amounted to 24% (pain threshold) and 44% (cold tolerance) increases in threshold. The changes in the true group were significantly greater than the control group but not significantly different from the sham group. The changes in the sham and control groups were not significantly different from each other. CONCLUSION: Acupuncture at true, appropriate points was more effective than no intervention in raising pain threshold and tolerance in volunteers, and acupuncture at inappropriate points had an intermediate effect which was not significantly different from either. Thus acupuncture analgesia may not be a point specific effect.

Acupunct Med. 2010 Dec 7. Amand M, Nguyen-Huu F, Balestra C. Department of Environmental & Occupational Physiology, Haute École Paul-Henri Spaak, I.S.E.K. (Institut Supérieur d'Ergothérapie et de Kinésithérapie), Brussels, Belgium.

Metabolomics represent a global understanding of metabolite complement of integrated living systems and dynamic responses to the changes of both endogenous and exogenous factors and has many potential applications and advantages for the research of complex systems. As a systemic approach, metabolomics adopts a "top-down" strategy to reflect the function of organisms from the end products of the metabolic network and to understand metabolic changes of a complete system caused by interventions in a holistic context. This property agrees with the holistic thinking of Traditional Chinese Medicine (TCM), a complex medical science, suggesting that metabolomics has the potential to impact our understanding of the theory behind the evidence-based Chinese medicine. Consequently, the development of robust metabolomic platforms will greatly facilitate, for example, the understanding of the action mechanisms of TCM formulae and the analysis of Chinese herbal (CHM) and mineral medicine, acupuncture, and Chinese medicine syndromes. This review summarizes some of the applications of metabolomics in special TCM issues with an emphasis on metabolic biomarker discovery.

Planta Med. 2010 Dec;76(17):2026-35. Zhang A, Sun H, Wang Z, Sun W, Wang P, Wang X. National TCM Key Lab of Serum Pharmacochemistry, Heilongjiang University of Chinese Medicine, Heping Road 24, Harbin, China.

FULL TITLE: Management of menopause-associated vasomotor symptoms: Current treatment options, challenges and future directions.

Hot flashes are one of the most common and distressing symptoms associated with menopause, occurring in more than 75% of postmenopausal women. They are especially problematic in breast cancer patients since some breast cancer therapies can induce hot flashes. For mild hot flashes, it is proposed that behavioral modifications are the first step in management. Hormonal therapies, including estrogens and progestogens, are the most well known effective agents in relieving hot flashes; however, the safety of these agents is controversial. There is an increasing amount of literature on nonhormonal agents for the treatment of hot flashes. The most promising data regard newer antidepressant agents such as venlafaxine, which reduces hot flashes by about 60%. Gabapentin is another nonhormonal agent that is effective in reducing hot flashes. While many complimentary therapies, including phytoestrogens, black cohosh, and dehydroepiandrosterone, have been explored for the treatment of hot flashes; none can be recommended at this time. Furthermore, there is a lack of strong evidence to support exercise, yoga, or relaxation for the treatment of hot flashes. Paced respirations and hypnosis appear to be promising enough to warrant further investigation. Another promising nonpharmacological therapy, currently under investigation, involves a stellate ganglion block.

Int J Womens Health. 2010 Aug 9;2:123-35. Pachman DR, Jones JM, Loprinzi CL. Internal Medicine, Mayo Clinic, Rochester, MN, USA;

Full Title: International cooperation in support of homeopathy and complementary medicine in developing countries: the Tuscan experience.

Health is a fundamental human right which contributes to reducing poverty, and encourages social development, human safety, and economic growth. International initiatives have fallen far short of their goals. This paper describes collaboration between the region of Tuscany and Cuba, Western Sahara, Senegal and Serbia. These have introduced various forms of Complementary and Alternative Medicine, including homeopathy and Traditional Chinese Medicine into primary healthcare particularly obstetrics, and into veterinary medicine. Complementary and traditional medicine can represent a useful and sustainable resource in various fields of health care. Inclusion in the public health system must go hand in hand with scientific evaluation.

Homeopathy. 2010 Oct;99(4):278-83. Rossi E, Di Stefano M, Baccetti S, Firenzuoli F, Verdone M, Facchini M, Stambolovich V, Viña MP, Caldés MJ. Homeopathic Clinic, Campo di Marte Hospital, Lucca, Tuscany Network for Integrative Medicine, Italy. omeopatia@usl2.toscana.it

FULL TITLE: Effect of group music activity as an adjunctive therapy on psychotic symptoms in patients with acute schizophrenia.

The effect of group music activity as an adjunctive therapy on psychotic symptoms was evaluated in 67 patients with schizophrenia from an acute psychiatric ward of a regional hospital in south Taiwan. A pretest-posttest, two-group repeated measures design was used. The experimental group received 50-minute sessions of group musical activity five times a week for 2 weeks in addition to standard care. The severity of psychotic symptoms was assessed using the Brief Psychiatric Rating Scale (BPRS). Group music activity significantly reduced the scores in total and subscales of the BPRS in patients with acute schizophrenia.

Arch Psychiatr Nurs. 2010 Dec;24(6):429-34. Peng SM, Koo M, Kuo JC. Department of Psychiatry, Dalin Tzu Chi General Hospital, Dalin, Chiayi, Taiwan.

FULL TITLE: Hypnosis and Alopecia Areata: Long-term Beneficial Effects on Psychological Well-being.

Although there often exists important psychological comorbidity in patients with alopecia areata, few studies have investigated the role of psychotherapeutic interventions. The aim of this prospective cohort study was to investigate the long-term evolution of psychological symptoms in twenty-one patients with refractory alopecia areata. Patients received 10 individual sessions of hypnosis during an approximate 6-month period. Before treatment, patients presented a pathological psychological comorbidity. After treatment, a significant amelioration of alexithymia, anxiety, depression and mental well-being was observed. These improvements were maintained up to 6 months after the end of treatment. Important limitations of this study include the recruitment of highly motivated patients and a non-controlled study design. In summary, hypnotherapy may be effective for significantly improving and maintaining psychological well-being and quality of life in patients with refractory alopecia areata.

Acta Derm Venereol. 2010 Nov 22. doi: 10.2340/00015555-1012. Willemsen R, Haentjens P, Roseeuw D, Vanderlinden J. Department of Dermatology, Universitair Ziekenhuis Brussel, Vrije University Brussel, Jette, Belgium.

by Joyce-Anne Locking

What greater pleasure can be experienced than to feel the warmth of the sun in winter or the cool refreshing breeze of summer? The beauty of a bush or a flower can only be reproduced as an imitation. The original nature of the fresh flower is available to us for such a short time. Life is full of so many stimulating colours and sights. We want to see the beauty around us and absorb its lasting benefits.

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Objectives The objective of this review is to systematically review the evidence for the effectiveness of aromatherapy in the treatment of high blood pressure. Methods Twelve databases were searched from their inception through December 2009. Controlled trials testing aromatherapy in patients with hypertension of any origin that assessed blood pressure were considered. The selection of studies, data extraction and validations were performed independently by two reviewers. Results One randomized clinical trial (RCT) and four non-randomized controlled clinical trials (CCTs) met our inclusion criteria. The one RCT included tested the effects of aromatherapy as compared with placebo and showed significant reduction of systolic blood pressure and diastolic blood pressure. All of the four CCTs showed favourable effects of aromatherapy. However, all of the CCTs also had a high risk of bias. Conclusion The existing trial evidence does not show convincingly that aromatherapy is effective for hypertension. Future studies should be of high quality with a particular emphasis on designing an adequate control intervention.

J Eval Clin Pract. 2010 Jul 29. Hur MH, Lee MS, Kim C, Ernst E. Professor, School of Nursing, Eulji University, Daejeon, South Korea.

FULL TITLE: Piloting tailored teaching on nonpharmacologic enhancements for postoperative pain management in older adults.

Despite many advances in the pharmacologic treatment of pain, the issue of unresolved postoperative pain continues to plague patients and health care professionals. Little seems to be known about the reasons why nonpharmacologic methods are not more widely used, particularly as they are commonly low in cost, easy to use, and largely free of adverse side effects. A central question has to do with what patients are taught about nonpharmacologic methods and how a novel mode of teaching can be embedded in practice. A seven-step pre-posttest teaching intervention pilot study was deployed with older joint replacement patients within the context of a translational research model. Results of the teaching pilot showed significant post-teaching changes in subjects' knowledge and attitudes about nonpharmacologic methods for pain management, high satisfaction with the nonpharmacologic methods they chose, and incrementally greater use of the nonpharmacologic methods over the course of the hospital stay. A randomized controlled trial of the study is now in the early planning stages in an effort to obtain generalizable results that will help solidify evidence of the impact of music, imagery, and slow-stroke massage on pain management and confirm the value of patient teaching as an important means of offering patients more options for managing their own pain.

Pain Manag Nurs. 2010 Sep;11(3):148-58. Tracy SM. University of New Hampshire, Durham, NH, USA. s.tracy@unh.edu

By Coach Cary Bayer

I've met countless alternative healers whose office files belong more in the 20th century than in the 21st. I'm not suggesting that therapists should have paperless offices. I am suggesting, however, that electronic data be incorporated, as well.

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FULL TITLE: Ethnic differences in complementary and alternative medicine use among patients with diabetes.

OBJECTIVE: To evaluate the effect of ethnicity as a predictor of the use of complementary and alternative medicine (CAM) among patients with diabetes. DESIGN AND SETTINGS: A 16-item questionnaire investigating CAM use was distributed among patients attending the Taking Control of Your Diabetes (TCOYD) educational conferences during 2004-2006. Six TCOYD were held across the United States. Information of diabetes status and sociodemographic data was collected. CAM use was identified as pharmacologic (herbs and vitamins) and nonpharmacologic CAMs (e.g., prayer, yoga, and acupuncture). RESULTS: The prevalence of pharmacologic and non-pharmacologic CAMs among 806 participants with diabetes patients was 81.9% and 80.3%, respectively. Overall, CAM prevalence was similar for Caucasians (94.2%), African Americans (95.5%), Hispanics (95.6%) and Native Americans (95.2%) and lower in Pacific Islanders/others (83.9%) and Asians (87.8%). Pharmacologic CAM prevalence was positively associated with education (p=0.001). The presence of diabetes was a powerful predictor of CAM use. Several significant ethnic differences were observed in specific forms of CAM use. Hispanics reported using frequently prickly pear (nopal) to complement their diabetes treatment while Caucasians more commonly used multivitamins. CONCLUSIONS: Treatment with CAM widely used in persons with diabetes. Ethnic group differences determine a variety of practices, reflecting groups' cultural preferences. Future research is needed to clarify the perceived reasons for CAM use among patients with diabetes in clinical practice and the health belief system associated with diabetes by ethnic group.

Complement Ther Med. 2010 Dec;18(6):241-8. Villa-Caballero L, Morello CM, Chynoweth ME, Prieto-Rosinol A, Polonsky WH, Palinkas LA, Edelman SV. Family and Preventative Medicine Department, School of Medicine, University of California, San Diego, CA, United States.

FULL TITLE: A stranger in the looking glass: developing and challenging a hypnotic mirrored-self misidentification delusion.

This article describes a study that used hypnosis to temporarily re-create mirrored-self misidentification, which is the delusional belief that the person one sees in the mirror is a stranger. Following a hypnotic suggestion to see a stranger in the mirror, high hypnotizable subjects described seeing a stranger with physical characteristics different to their own. Whereas subjects' beliefs about seeing a stranger were clearly false, they had no difficulty generating sensible reasons to explain the stranger's presence. The authors tested the resilience of this belief with clinically inspired challenges. Although visual challenges (e.g., the hypnotist appearing in the mirror alongside the subject) were most likely to breach the delusion, some subjects maintained the delusion across all challenges. Findings are discussed in light of the dominant theory of delusions and highlight the advantages of using hypnosis to explore delusional beliefs.

Int J Clin Exp Hypn. 2011 Jan;59(1):1-26. Barnier AJ, Cox RE, Connors M, Langdon R, Coltheart M. Macquarie University, Sydney, Australia.

FULL TITLE: Health promotion practices in two chiropractic teaching clinics: does a review of patient files reflect advice on health promotion?

PURPOSE: To retrospectively review patient files in two teaching clinics in the United States and to assess the documented attempts to deliver health promotion messages when a chart indicated a need for health promotion or a red-flag condition that could be helped with positive behavioral changes. METHODS: Approximately 100 patient files were randomly selected from each of two separate chiropractic teaching clinics, for patients seen after January 2007. Files were assessed for pertinent family history of diseases, personal medical history, and red-flag conditions of patients that would warrant intervention with health promotion. RESULTS: Health promotion advice on at least one occasion was noted in 108 (53.7%) patient charts. Only 7 of 98 overweight or obese patients and none of those with family history of obesity were advised on weight management. Among 23 hypertensive patients, only 5 were advised and 17 of the 97 patients with risk of cardiovascular disease were advised. CONCLUSION: Chiropractic teaching clinics should assess what they are doing to help Americans reach their health goals. There is an opportunity to shape future practitioners so they include primary prevention as a part of what they do if the profession cares to move in that direction. Future research should look at mechanisms of delivery for health promotion, including better tracking of patients who need it and how staff doctors are trained to deliver oversight to interns in the area of primary prevention.

J Chiropr Educ. 2010 Fall;24(2):159-64. Ndetan H, Evans MW, Lo K, Walters D, Ramcharan M, Brandon P, Evans C, Rupert R. Parker College of Chiropractic.

OBJECTIVE: The purpose of this systematic review is to discuss the evidence for manipulative methods of management of shoulder pain and chiropractic management techniques used within the literature. METHODS: A literature search of MEDLINE, CINAHL, MANTIS, the Cochrane Musculoskeletal Group trials register and the Cochrane Controlled Trials Register was conducted. Search terms included chiropractic or manipulative therapy and shoulder pain, impingement, rotator cuff, shoulder instability, shoulder joint, treatment or rehabilitation exercises. Publications were included if they contained shoulder pain or contained a specific clinical diagnosis of a shoulder pain syndrome in the title; a detailed description of the treatment intervention which was typical of the profession; treatment performed by a registered practitioner and outcome measures were included in the studies. Exclusion criteria included the diagnosis of adhesive capsultis or referred/pathological pain. The articles were reviewed and clinical trials ranked on the Physiotherapy Evidence Database scale. RESULTS: From a total of 913 retrieved publications, 22 case reports, 4 case series and 4 randomized, controlled trials met the inclusion and exclusion criteria for this review. CONCLUSIONS: The literature contains 2 articles of reasonably sound methodology. The evidence for chiropractic management of shoulder pain is limited to low level evidence in the form of case reports and case series and 1 small controlled trial. There is a need for more well-designed, trials investigating multi-modal chiropractic management for shoulder pain.

J Manipulative Physiol Ther. 2010 Nov-Dec;33(9):679-89. Pribicevic M, Pollard H, Bonello R, de Luca K. mariochiro@optusnet.com.au