Healing Arts Report Charter Issue IN THIS ISSUE DEAR READER: Welcome! Why another newsletter on alternative medicine? SCIENCE REPORT Is there research on alternatives? Acupuncture Meridian Research:   A method for detecting the health of the body by examining acupuncture meridians. HEALING ARTS The Alternative Edge of Surgery Predicting Recovery How discomfort is detected in an unconscious patient. Healer in the Operating Room Patients ask energy healer's help with surgery. HEALTH TRENDS How practitioners are becoming more holistic by integrating CAM (complementary and alternative medicine) in conventional care settings. Q & A Two resources provide you with custom research on alternative therapies for health conditions REVIEWS World Med '96 -- The World Congress on Complementary Therapies in Medicine reflects current state of health care. Dear Reader: Welcome to the charter issue of Healing Arts Report. If you are looking for information, news, and reviews about complementary and alternative health therapies, research, books, conferences, and consumer issues, Healing Arts Report is the place to find them. Friends ask me, "What are you doing now?" When I tell them I'm writing a newsletter on complementary or alternative health care and medicine, often referred to as CAM, I usually get one of two responses: • "Hey, that's great! I'm very interested in alternatives. I had good results in cutting down on colds with echinacea, but I wish I knew where to find out more." They want to be more involved in improving their health. They experiment with new options, hear many conflicting opinions, and, worst of all, can't find out more from their own doctors. • Or they say after a long silence, "Isn't that already being done?" Yes, dozens of alternative health letters already exist. I receive ads for them almost every day. Many come from highly qualified doctors and well-known universities. Some have specific diets or therapies they are promoting. Many are informative and authoritative and give useful health advice. What's Different About Healing Arts Report? I'm an interested consumer of health services, just like you. I research studies and attend conferences. I have been treated homeopathi- cally by an M.D. for over twenty years. At various times I have used chiropractic, massage, meditation, visualization, acupuncture, Gestalt therapy, and herbs. I have also experienced good conventional medical care, including surgery. These experiences have taught me that some treatments are much more appropriate than others for particular conditions. Healing Arts Report will help you understand why. Some day all the options that I've gone out of my way to find will be readily available. Tremendous changes are happening in the world of health care. I'm excited about what I'm finding out and think you will be, too. Why So Much Interest So Suddenly? In 1993, Dr. David Eisenberg and his colleagues at Beth Israel Hospital in Boston, a teaching affiliate of Harvard Medical School, published a landmark study in The New England Journal of Medicine.1 It jarred the medical world and made conventional practitioners listen to what patients had to say. The study revealed a virtual medical underground and a lack of authoritative information about alternatives. Knowledge of the study has expanded widely among physicians and health care consumers. These were its most salient points: 1. Thirty-four percent of adults surveyed used one of sixteen health care interventions, none of which are taught widely in U.S. medical schools or are generally available in hospitals. 2. Most of the interventions are not covered by insurance and are paid for out-of-pocket. 3. By extrapolation, Eisenberg estimated about 425 million visits made to unconventional therapists, far more than the 388 million visits to U.S. primary care physicians. 4. An additional surprise was that 72 percent of the patients did not inform their medical doctor, suggesting a lack of trust or, at the very least, a lack of communication. This meant that unconventional treatments were rarely supervised by a medical doctor. Some believe the study gives undue significance to the use of complementary therapies. Of those using alternatives, 88 percent were limited to three techniques -- relaxation, chiropractic, and massage. Only twelve percent used the other thirteen therapies. There are, however, reasons to believe that the researchers underestimated usage. They did not survey those who did not speak English well enough or those having too poor health to participate in the phone interview. Compared to two other national surveys, Eisenberg's study contained a much lower percentage of those who described themselves as having poor health. Yet, it is this very group who had the highest rates of using unconventional therapy. The New Health Paradigm Healing Arts Report offers a forum for the burgeoning interest in health and healing meth- ods and theories that are as culturally diverse as the world we live in. The new health model includes all therapies and involves the patient as an active participant in the healing process. The holistic approach of this newsletter reflects the understanding that lifestyle is an essential part of health; that the mind/body relationship, the culture, and the environment must not be ignored as contributors to health; and that health is well-being on all levels of human experience, not only the physical. In addition, science is beginning to uncover proof of energy systems that support bioenergetic or vibrational medical models. There is a growing interest in finding the common path to all healing systems, and having each of them accessible when they are well-suited to a particular individual's temperament or condition. In Healing Arts Report, you will find a variety of articles about health, health-related topics, and people -- health care providers as well as patients -- who are changing the medical paradigm. The best news is that this is good news and we think you'll enjoy it. Healing Arts Report welcomes your suggestions. Please read this charter issue and let us know what you like and what you'd like to read in future issues. Top of Page SCIENCE REPORT Are Scientists Studying CAM? Medical professionals wishing to protect the public from fraud have promoted research on CAM (complementary or alternative medicine). For practitioners and patients who experience the success of complementary therapies, however, research means getting help out to those who can benefit from it. Research is being sponsored within conventional settings as well as by private foundations such as the Institute of Noetic Sciences, Bastyr University, and The Fetzer Institute. The federal government has also recognized the need for research and formed the National Institutes of Health Office of Alternative Medicine (OAM) in 1992. Its stated purpose is to facilitate the evaluation of alternative medical treatments and help integrate effective ones into mainstream medical practice. The OAM is funding research grants to selected projects proposed by institutions around the country. The International Society for the Study of Subtle Energies and Energy Medicine (ISSSEEM) is an organization that publicizes research on subtle energies. They publish a peer-reviewed scientific journal and sponsor an annual conference which includes the presentation of papers. Presenters there named several international organizations of scientists, such as the Institute of HeartMath and the Dove Health Alliance, that are devoted, as ISSSEEM is, to bridging the gap between objective and subjective experience. More about these organizations in future issues of Healing Arts Report. Summaries of two studies and one report presented at ISSSEEM's annual conference can be found in this issue. The following study is an exemplary use of alternative means for achieving both speedy diagnoses and possibly preventing the development of pathological conditions. Measurements of Acupuncture Meridians Provide Early Warning A comprehensive cost-effective physical checkup measuring energy in the acupuncture meridians is already in wide use in Japan, according to Gaetan Chevalier, Ph.D. Chevalier discussed how the test, given by a trained technician using an AMI (Apparatus for Meridian Identification) takes only ten minutes to perform. Individuals whose tests deviate from the norm can be referred to specialists. They can then undergo in-depth traditional testing and therapy to strengthen their systems long before pathology becomes apparent. In traditional Chinese medicine, acupuncture meridians are thought of as paths of energy that lie just below the skin. They reflect the health of specific physiological systems, such as digestion or heart/lungs. Research has already shown AMI tests correlate with western medicine in: (1) assessing immune function, which is an early predictor of cancer; and (2) in degree of liver disease. Not the Nervous System The acupuncture points have been shown clearly to be unrelated to the nervous system. Chevalier mentioned another scientist's research on chickens which shows that the meridian energy system exists before the nervous system is even formed. Chevalier believes it is a different type of energy than genetic material. The meridians appear to be electrical paths that interface with or precede physical manifestation. In 1971, Dr. Hiroshi Motoyama, then living in Japan, invented the AMI technology to measure meridian activity. Using the AMI, he mapped the electrical impulses of the acupuncture meridians of many healthy people in order to form a concept of normal ranges. Now he and Gaetan Chevalier are finding the normal meridian readings for people living in California. Humidity of the environment is a factor in changing the measurements. Gaetan Chevalier, Ph.D. is Laboratory Director and Assistant Professor at the Graduate School and Research Center of the California Institute for Human Science. Chevalier is replicating and expanding on Dr. Motoyama's work. Hiroshi Motoyama, Ph.D., is Director of the Institute for Religious Psychology and President of the California Institute for Human Science. Both can be reached at 701 Garden View Court, Encinitas, CA 92024, 619-634-1771 ext. 108. Fax: 619-634-1772, e-mail: lab@cihs.edu Top of Page HEALING ARTS Can Surgery Be Alternative? New techniques blur the edge between traditional and complementary or alternative medicine. The following articles illustrate two of many possible gradations. Both are occurring in traditional surgical settings. In the first section below, electromyography is used for measuring subtle muscle movement. In the second section, Julie Motz is using an alternative -- energy healing -- that has not, according to conventional science, been proven to even exist. Reactions in Anesthetized Patients Predict Recovery There is evidence that patients have emotional reactions while undergoing surgery although they may have no memory of it. Through research, Henry L. Bennett, Ph.D., has shown that "grimacing" microexpressions during surgery predicts stressful or difficult recovery. Likewise, lack of facial muscle movement has been correlated with an uneventful recovery. Therefore, making sure that the patient is comfortable during surgery prepares the way for a more satisfactory recovery. Electromyography At a presentation at the ISSSEEM conference, Dr. Bennett discussed how he has been using electromyography during surgery. Electromyography is a method for testing and recording nerve and muscle function. Through electrodes placed on the skin or with a needle electrode inserted in a muscle, the apparatus detects electrical impulses that pass through a muscle as it contracts and relaxes. He finds that movement in the facial muscles provides a way of monitoring adequacy of anesthesia. Facial expressions have autonomic qualities and, therefore, function somewhat independently. Monitoring Difficulties Finding a way to monitor adequacy of anesthesia has been challenging to the physician. When a patient is anesthetized, doctors cannot tell if the person is conscious or feeling pain. Patients have, on occasion, reported after surgery that they were conscious. Brain waves do not reflect consciousness nor can the patient indicate awareness to the surgeon because his muscles are paralyzed by the anesthesia. Although the muscles are paralyzed, they still fire. This is picked up by the very sensitive electromyography technology which can measure millionths of a volt. The facial skin moves because, unlike most muscles, certain facial muscles are not attached to bone. Energy Healing in the Operating Room In November 1994, Julie Motz, M.A., M.P.H., at a patient's request, began doing energy healing in the operating room at Columbia Presbyterian Medical Center in New York City. Energy healing is based upon the concept that one person's vital force can affect another's. It can be done through touch, visualization, or touching the aura around a person. During an operation, Motz describes herself as standing "at the feet, sending energy into the liver and kidney meridians to support the function of these organs during the operation." When the patient is anesthetized, the energy field tends to leave the body and collect around the head. She brings it back down to the feet by placing her hands on the ankles, knees, and hip joints. During the operation, she may also stand at the patient's head with her hands supporting it or touching the temples. She talks to the patient, explaining what is going on and helping the patient deal with remembered or current trauma. Previous to working in the operating room, Motz had worked with heart and lung transplant patients -- pre- and post-operatively -- until they requested her assistance during surgery. Motz says that patient records show the results of her work, which include: "absence of post operative depression for all patients, no organ rejection on first biopsy and lower than normal rejection rates on subsequent biopsies for heart transplant patients, lower post-operative heart rates for transplant patients, no leg pain and leg weakness for spasms patients and quicker recovery times, including use of the arm on the affected side, for breast cancer patients." She also described excellent results reducing anxiety, depression, and pain. In addition, her patients had increased kidney function and blood oxygen levels, normalized blood pressure and heart rate, and relief from insomnia. Cases In a presentation at the ISSSEEM conference, Motz told of how often she has seen a patient's emotional history influence how their surgery goes. Fears of abandonment or childhood abuse can effect a person long after the original events. She told of a heart transplant patient whose heart the surgeon couldn't find because of the tremendous amount of scar tissue. When the surgeon finally did touch the heart, it seemed to cringe. An image came to her of a young boy flailing his arms about as if to ward off blows. She sensed and later confirmed that the patient had been struck often as a child. Motz works to alter the flow of energy to various parts of the body or speaks to the patient about the surgical process or about what she senses about them. Even though the patient may be under anesthesia, what she does often facilitates emotional release. In another incident, Motz described an emergency mechanical heart implant patient. He had been rushed to the hospital and brought immediately into the operating room. During surgery, she sensed his extreme depression. At that point the surgeon mentioned that the patient's vital signs were exceptionally low. She wondered if he wanted to die. She talked quietly into his ear and told him, "Mr. Smith, you don't owe us your life. If you want to live we're here to make that option available to you." As if he were responding to not feeling pressured any more, he began to stabilize. The doctor then asked Motz what she had been saying to the patient. She replied, "Oh, I was telling him it was all right if he wanted to go." "You did what?!" To a doctor committed to saving lives, this was a shocking thing to say. He began yelling, "Mr. Smith, you come back here right now. I've got things I need to talk to you about!" The patient's vital signs immediately shot higher. To Motz, it was a clear indication about the power of having someone care. The doctor's communicating wanting contact with him was almost as powerful as the surgery itself. Standard of Care Motz says that in surgery the body is well cared for but the person is not. She told of research published in the Journal of the American Medical Association that indicated patients do better in a warmer operating room. Nevertheless, surgeons still haven't turned up the temperature. She believes change will come only through publicity and consumer demand. Bennett studied with Dr.Charles Tart at U.C. - Davis and Ernest Hilgard at Stanford. He is Associate Professor, Department of Anesthesia, Pennsylvania State University School of Medicine, Hershey, Pennsylvania. Dr. Bennett can be reached at Milton S. Hershey Medical Center, Department of Anesthesia, P.O. Box 850, Hershey, PA 17031. Julie Motz's work has been reported in The New York Times Magazine and on CNN. She has developed energy healing protocols for bypass and transplant surgery and breast cancer surgery. She trains operating room and cardiac care nursing staffs. Contact her at Health's Angels, P.O. Box 75, Lake Peekskill, NY 10537, 914-528-4018. Top of Page HEALTH TRENDS Are Conventionally Trained Providers Interested in Alternatives? You bet! All over the country, practitioners are experimenting with different forms of care. Many doctors are dissatisfied with short-term solutions and the side effects of drugs and are doing something about it. Some spend more time with their patients so that communication can contribute to their treatment. Others know that different kinds of treatments may address the source of patients' problems better than conventional practices. Some have learned alternative therapies themselves. Others are integrating forms of care by joining forces with alternative or complementary therapists. Patients have more options, including classes for learning new ways to take care of themselves. Nurses have formally included Therapeutic Touch as part of their nursing protocol. Subtle energy healing is being used in the operating rooms and new and more sensitive equipment is helping make surgery safer and more responsive to patients' comfort. At the World Med '96 Conference, in a symposium led by Elliott Dacher, a number of practitioners described their efforts to be more holistic. Four of their stories follow. Doctor Sets Example Elliott Dacher, M.D., once physician-in-chief of Kaiser Permanente in Reston, Virginia, was expected to see so many patients that he couldn't remember who they were. He wanted better treatment for them and a healthier lifestyle for himself. In 1983, Dacher fired his staff, began answering the phone himself, and reorganized his time doing things he loved -- seeing patients, writing books, speaking and teaching about holistic medicine, and reading poetry. According to Dacher, science has focused so single-mindedly on knowledge of manipulating the physical world that we have suffered an unhealthy separation from intuition, art, poetry, and human consciousness. This need for holism affects our health. He said the word 'holistic' was created as far back as 1922 and refers to nature's tendency to create wholes. By contrast, man has a "tendency to create parts." The emerging post- modern world view is characterized by our "reanimating nature and recovering a major second source of knowledge, (our) intuition." Our regained sense of wholeness is part of this new world view. The individual needs conscious development to improve health. Illness can help us become better people. He reminded his audience that, "Symptoms are the gateway to a larger life," and that "Health is a verb, a lifelong artistic growth grounded in the individual." To find out more, Dr. Elliott S. Dacher, M.D. is author of Intentional Healing, republished by Marlowe, 1996 and Whole Healing, soon to be released by Dutton. He practices in Reston, Virginia. M.D. Seen as the Alternative A remarkably robust eighty-year-old man came to David Edelberg, M.D., for hernia surgery. All this patient's life, he had practiced the careful dietary and exercise regimens now thought of as alternative. Only because his hernia required a surgeon's skills was he seeing a conventional physician. To the snappy senior, Edelberg was the alternative. The doctor was humbled by this perspective. He had been seeing himself as the mainstay of the clinic, generously recruiting alternative practitioners. The program Dr. Edelberg helped found includes two clinics in Chicago and a third in Colorado. A variety of alternative practitioners, with credentials from their respective specialties, work out of the clinics. Patients refer themselves or are referred. The Chicago clinics served 6,500 patients in 1995 and have been well-received. At Edelberg's American Holistic Center in Chicago, typical approaches to low back pain include exploration of mind-body interactions, chiropractic evaluation, Alexander or Felden- krais lessons, and group t'ai chi or yoga classes. According to Dr. Edelberg, the most obvious difference in this practice is the active role patients play in their own care. When they first come to the clinic they learn about tapes, books, and other forms of self-education. They are given the book, Optimal Wellness by Ralph Golan. When asked whether patients get addicted to more attentive treatment, Edelberg said, " We have the greatest patients! They know that if they call me at two in the morning I'm going to open the same book and read it to them, so they may as well read it themselves, do what they can for themselves, and call us at the clinic the next day." Dr. Edelberg is Section Chief of Holistic Medicine at Columbia-Grant Hospital in Chicago and can be reached at the American Holistic Center, 990 W. Fullerton, Chicago, IL 606611, 312-296-6700. Medicine = Science + Emotion Steve Horowitz, M.D., told the story of a previously energetic seventy-year-old female patient who showed up looking suddenly old and bent. "What's wrong?" he asked. She'd had a lumpectomy and it was found to be cancerous. "I've got cancer," she said gloomily. He checked with her surgeon. It had indeed been cancerous but the tissue around it was clear and the surgeon had no concerns about her. Dr. Horowitz, after talking with the woman further, found out that her golf instructor had moved away. She missed him and golf terribly. The doctor found her a new instructor and the next time he saw her, she had become her old spirited self. Damage is done to health by ignoring emotion, even among medical students and doctors. He described meeting new students and seeing them filled with enthusiasm and interest, but by the fourth year, they are depressed. Three changes would make a difference in the practice of medicine for medical staff and for patients: Humanize the hospital experience Refocus on patient needs Empower patients with information The Planetree program, which Dr. Horowitz directs, does this so well that they often find "difficult" cases from the rest of the hospital being referred to them. The unit is decorated in a less sterile way. Patients have access to their medical charts, a library about community resources and alternative therapies, and a kitchen in which to make themselves food. They are encouraged to participate in their own care, so that the hospital stay can be a learning experience. Dr. Steve Horowitz is Director of the Planetree Program at Beth Israel Hospital in New York (attention: Planetree 8 Silver), 212-420-2000. Nurses Influence Growing Use of Complementary Therapies Denise F. Rankin-Box described how the Centre for Complementary Care operates in Great Britain. The center does not have an actual building but instead fulfills requests made by patients and doctors to send alternative practitioners to supplement treatments provided by the National Health Service. She also discussed the influence nurses have on the delivery of health care. Of the nineteen university programs in Great Britain offering training in complementary medicine over the last four years, twelve were designed or managed by nurses. Some programs are modular and others are part of diploma courses. Because of nurses' close contact with patients, they see the need for and results of patient-centered care. This is reflected in the growing interest in aiming education toward values rather than knowledge. Nurse and Doctors' Surveys In Rankin-Box's recent research survey of nurses, it was revealed that an increasing range of complementary therapies are being used for greater lengths of time for more medical condi- tions in more clinical settings. Nurses appear to be stimulating the shift of care toward comple- mentary medicine. The nurses' own interest in further training focused on massage, aromather- apy, reflexology, visualization, and Therapeutic Touch. They used these therapies in private practice to alleviate pain and provide palliation. Rankin-Box also surveyed doctors who took a course in homeopathy; a year later 70 percent were still using it. The course also resulted in many of the doctors employing the homeopathic method of case-taking, which is very thorough and makes use of careful listening on the doctor's part. Both surveys and the course revealed a more humane attitude developing around care, trust, responsibility, respect, confidentiality, and compassion. Denise Rankin-Box is editor of Complementary Therapies in Nursing and Midwifery, author of The Nurse's Handbook of Complementary Therapies, and consults with the U.K. government on complementary medicine. Her address is Centre for Complementary Medicine, P.O. Box 10, Macclesfield, Cheshire SK10 4HW, United Kingdom. Top of Page REVIEW World Congress in Complementary Medicine WorldMed '96 billed itself as "the first major peer-reviewed conference of its kind and the most comprehensive international conference to date on complementary medicine." It took place in Washington, D.C. at the Renaissance Washington Hotel. C. Everett Koop, M.D., former Surgeon General, and Marc S. Micozzi, M.D., Ph.D., Executive Director of the College of Physicians of Philadelphia, co-chaired the event. There were some recognizable names at the conference, even to people who do not practice medicine -- Dean Ornish, M.D., developer of the heart program shown to reverse heart disease; Wayne Jonas, Director of the Office of Alternative Medicine; and Dana Ullman, popular spokesperson for homeopathy. Strengths It was heartening to participate in a gathering of so many distinguished medical practitioners and educators who are actively working to improve health care options. The breadth of the program was wide. Homeopathy, Ayurveda, naturopathy, indigenous, chiropractic, and Chinese traditions were all represented. Topics such as integrated practice, mind-body medicine, medical education, pharmacy, nutrition, and economics were covered, too. Many participants were doctors, nurses, medical educators, and insurance company representatives. For a few that I spoke with, this was their introduction to complementary/alternative medicine in a scientific setting they felt was trustworthy. The atmosphere, though formal, was unequivocally friendly. WorldMed '96 was a forum of significant value in which to exchange ideas. The spirit conveyed was that inspiring efforts are being made by many people to integrate therapies, make health care more affordable, and educate consumers and health providers about increased options and improvements in delivery. Uneven Quality It would be surprising if an event of this breadth were not of uneven quality. It seemed to reflect the bumpy transition our culture is experiencing as we feel our way from the old medical paradigm to a more holistic orientation. Speakers presenting research on alternative therapies or on how they use alternatives in their own practices were invaluable. One speaker was clearly intent on selling a product he developed. He belonged in the exhibit hall, which in itself might better be eliminated if at all financially feasible. The speaking voice of one Indian doctor who had good material on Ayurvedic medicine (I could tell by the slides) was almost impossible to understand. At the same time, he seemed to be betraying his own venerable mode of healing in an effort to present it in a format that western science would consider legitimate. Next year? Designing three consistent tracks of presentations was apparently a challenge. I would like to have seen the tracks divided according to physicians new/physicians experienced in complementary medicine; or practitioner-educator-administrator-researcher concerns on one day and treatment modalities, experiential workshops, and integrated care for specific conditions on another. Fewer speakers offered more than once and on different topics in different tracks might increase the chance of hearing them. Lastly, there were no participant evaluation forms in the otherwise helpful program packet. I hope this was not a signal that Churchill Livingstone is not committed to sponsoring this event next year. It would be a loss to health practitioners and health care consumers, alike. For information about the next WorldMed conference, call Ms. Radley at 212-206-5056. Tapes can be ordered for $10 each from Audio Recording Services, Inc. in Chester, MD, 410-643-4220 or fax 410-643-3463. Top of Page Q & A Two Foundation Resources Provide Custom Research Q. Where can I find alternative information about treating a particular condition before I seek out professional advice? A. Two organizations that provide re-search for alternative therapies are worth noting. The World Research Foundation (WRF) has health information library packets on approximately 180 diseases or conditions. Each packet "contains data dealing with complementary, alternative, nontraditional and natural diagnostic and therapeutic approaches to the specific illness or disease which it addresses." It might include data on acupuncture, homeopathy, visualization, and other therapies. It averages about 150 pages, gathered mostly from books written by medical professionals. The packet costs $67.50 including shipping. A list of the topics available is included in the WRF introductory packet which costs $2.00. Mail your order to: WRF, 20501 Ventura Blvd., Suite 100, Woodland Hills, CA 91364. Phone 818-999-5483 or fax 818-227-6484. he Herb Research Foundation is an internationally recognized center for herbal research and education. They do not sell herbs and therefore can provide frank and unbiased answers. They draw from a library of over 100,000 scientific articles and an international network of contacts. For $7-$15 the foundation has ready-made packets of information on either specific herbs or particular conditions, including attention deficit disorder, cancer, colitis, heart disease, hypoglycemia, immunity/AIDS, and menopause. They publish their own Herb Safety Report by herbal specialists. This includes the government GRAS (generally recognized as safe) List and a list of herbs for which caution is advised. In addition, they provide custom research on any aspect of herbs, spices, medicinal plants, and essential oils. They will search by disease, condition, plant, or plant constituent. The fee is $50 for the first hour and $30 for each additional hour. You can set a budget limit. Phone Margaret Blank at 303-449-2265 for more information. There is a membership discount of ten percent on all materials. Membership is $35 a year and includes a subscription to Herbalgram or Herbs For Health. Herbalgram is a more technical industry-oriented quarterly with news on legislation and manufacturing. Herbs For Health is published bimonthly and is more of a consumers' magazine. Top of Page Best wishes, Barbara June Appelgren END NOTES 1. David M. Eisenberg, M.D. et al., The New England Journal of Medicine 328 (January 28, 1993): 246-252.