Your barbecue and pancreatic cancer

How do you like your meat? Rare or well-done?

The barbecue season has opened in many parts of the world. And meat is the staple of most barbecues. Meat that is well-done, sometimes even slightly burnt. Researchers from the University of Minnesota is warning us that regular consumption of meat, especially when well-done and charred, can increase our risk for pancreatic cancer by 60%. How does this happen?

According to the American Cancer Society

Cooking meats at very high temperatures creates chemicals (heterocyclic amines, or HAs) that might increase cancer risk. Heterocyclic amines (HAs) are created by the burning of amino acids and other substances in meats cooked at particularly high temperatures and that are particularly well-done. HAs turn up in grilled and barbecued meat as well as broiled and pan-fried meat.

The study surveyed more than 62,000 people and their eating habits, e.g. meat consumption, preference in meat preparation and “doneness”. The study participants were followed up for about 9 years as part of the Prostate, Lung, Colorectal and Ovarian (PLO) screening trial.

Choose lean cuts of meat and trim any excess fat. Fat dripping onto hot coals causes smoke that contains potential carcinogens. Less fat means less smoke.

Line the grill with foil and poke small holes in it so the fat can still drip off, but the amount of smoke coming back onto the meat is lower.

Avoid charring meat or eating parts that are especially burned and black - they have the highest concentrations of HAs.

Add colorful vegetables and fruit to the grill. Many of the chemicals that are created when meat is grilled are not formed during the grilling of vegetables or fruits, so you can enjoy grilled flavor worry-free. Red, yellow, and green peppers, yellow squash, mushrooms, red onions, and pineapple all grill well and make healthy additions to your plate.

This is not the first study to indicate that meat consumption can have some detrimental effects on our health, regardless of food preparation. According to the National Institutes of Health, four ounces of red meat per day is the limit for the average adult. However, most Americans consume more than that. Or any barbecue loving people for that matter.

Red meat, be it as steak, burger, or sausage, not only increases your risk for cancer, but for cardiovascular disease as well. It is rich in saturated fat and cholesterol. You can also check out some tips on how to make your barbecue more heart-friendly at Battling Heart Disease and Stroke.

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Cancer disparity: your ethnicity and your risk

Next week is US National Minority Cancer Awareness Week. You may be wondering why should there be a week specially dedicated to cancer among ethnic minorities. This special week has been observed since April 1987 when the US Congress declared every 3^rd week of April to focus on “an unfortunate, but extremely important fact about cancer. While cancer affects men and women of every age, race, ethnic background, and economic class, the disease has a disproportionately severe impact on minorities and the economically disadvantaged.”

Some statistics about cancer and ethnic disparities are:

• African Americans are more likely to die of cancer than any other ethnic group.
• New cancer cases and cancer mortality rates for men are highest among African Americans.
• Among men, the number of new cases of lung cancer is more than 2 times higher among African Americans than among Asian/Pacific Islanders.
• Twice as many African American men die of prostate cancer than white men.
• Among women, the number of new cases of lung cancer is more than 2 times higher among whites than among Asian/Pacific Islanders.
• Cancer mortality rates for women are highest among African Americans, followed by whites, Hispanics, and Asian/Pacific Islanders.
• African-American women have a lower risk to develop breast cancer than white women but when they do, they have a much higher likelihood to die from it.
• Aside from African Americans, other minority groups that face higher risk of developing and dying from cancer compared to the rest of the population are women immigrants from Vietnam and Mexicano women living near the border.

(Sources of above statistics: Centers for Disease Control and Prevention (CDC), Michigan Cancer Consortium, American Cancer Society).

All people are created equal. But apparently, their susceptibility to certain diseases, especially cancer is not the same. Indeed it is true that cancer burden varies between ethnic groups. But why is this so?

Besides the genetics behind cancer, there is another significant factor: poor access of minorities to health care. This is of course followed by the question “why do this people do not have full access to health care?”

According to the American Cancer Society (ACS) special report on cancer disparities

“….members of racial and ethnic minority groups are more likely to be poor, to have lower education levels, and not to have health care coverage or a source of primary care.”

The goal of the National Minority Cancer Awareness Week is to promote “increased awareness of prevention and treatment among those segments of the populations that are at greater risk of developing cancer. The week’s emphasis gives social workers, physicians, nurses, health care professionals and researchers an opportunity to focus on high-risk populations and to develop creative approaches to battling cancer problems unique to these communities.”

This campaign, however, shouldn’t stop after the week is over. Because cancer is a year-round problem that needs to be looked into. And, as the ACS rightly declares, “cancer is a burden, finding help shouldn’t be.”

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Traffic exposure can trigger a heart attack

We are exposed to traffic everyday, whether as a commuter or as a driver. Some of us are even exposed as part of our jobs, e.g. as traffic policemen, bus drivers, tec. This post explores the link between traffic exposure and cardiovascular health.

Previous studies have shown that heart attacks may be triggered by strenuous activities. This recent study by German researchers suggest that exposure to traffic can have some serious consequences on people’s heart health. The researchers looked at time spent on any form of traffic exposure by using some form of transport, be it by car, by public transport, or by bicycle and its triggering effect on heart attacks. However, driving a car was the most common source of traffic exposure among the 1,454 study participants. The results of the study indicate that people exposed to any form traffic exposure have a 3.2 times higher risk of having a heart attack than those without exposure. For those exposed, there is a small but significant increase in the likelihood that a heart attack can occur with 6 hours of exposure. Those who were especially at risk were

• women
• elderly men
• people who are unemployed
• people who have a history of angina pectoris (chest pains)

According to lead author Dr. Annette Peters

“Driving or riding in heavy traffic poses an additional risk of eliciting a heart attack in persons already at elevated risk. In this study, underlying vulnerable coronary artery disease increased the risk of having a heart attack after driving in traffic… one potential factor could be the exhaust and air pollution coming from other cars. But we can’t exclude the synergy between stress and air pollution that could tip the balance.”

This isn’t the first study to find a link between cardiovascular disorder and air pollution. British and Swedish researchers found that diesel exhaust increased the rate of blood clot formation as well as blood platelet activity even in healthy people - leading to increased risk of having heart attack and stroke. The increased cardiac event risk due to traffic pollution is evident even when fine particulate matter concentrations are considered low or safe.

In a previous resource post, I have reviewed the most recent medical evidence that linked air pollution to cardiac events. In one study, it was shown that fine particulate matter can interfere with the heart’s electrical functioning.

In the same way, stress can be a triggering factor towards a cardiac event. In a previous post, I discussed about the effect of stress on driving and vice versa.

We all need some form of transport to get somewhere and many of us are on the move to get to our jobs 5 days a week. What would be interesting to find out is a risk comparison between drivers and public transport commuters, e.g. which form of traffic exposure has the least adverse effect on our cardiovascular health.

Phot credit: stock.xchng

               

How anger and hostility affect your heart health

Negative feelings can have adverse effects on your cardiovascular health. We know that depression and stress are not good for the health. But what about anger and hostility? In many films we see, anger is classically featured as an emotion that triggers heart attacks. However, research studies over the years have actually failed to provide conclusive evidence to support this. Until now.

Researchers from the University College London, UK performed a meta-analysis of studies that looked at the link between heart disease and the mind states anger and hostility. The studies covered almost 80,000 participants both healthy as well as those with pre-existing coronary heart disease (CHD) in Australasia, Europe, and America.

The results of the meta-analysis show that

“anger and hostility were associated with a 19% increase in coronary heart disease (CHD) events in healthy individuals and a 24% increase in risk among those with preexisting CHD.”

The results of the analysis have been published in the most recent issue of the Journal of the American College of Cardiology.

Other notable findings are:

• The association between hostility and anger and increased CHD risk is stronger in men than in women.
• CHD risk appeared to be mediated through high-risk behaviors, with the association between anger/hostility and CHD becoming no longer significant after full adjustment for behavioral factors such as smoking, physical activity, body-mass index, or socioeconomic status.

The findings indicate that symptoms of anger and hostility should be taken serious when diagnosing and treating cardiovascular disease. However, suppression of these negative emotions does not actually lead to prevention but actually to the worsening of the problem.

To reduce the problem, the authors recommend the following:

• Clinicians may consider referring their coronary patients with high levels of anger for behavioral intervention.
• Future research should more often focus on the interplay between negative emotions and emotion-regulation strategies as a determinant of major coronary events.

The authors add that anger is not necessarily bad for the heart because it is a natural emotion that may have some evolutionary significance (e.g. warning signal, self-preservation, protection of the young, etc.). Instead the emotion should be “regulated and used in a socially meaningful and adaptive way.”

               

The birth size - breast cancer link

Do you know that your size at birth may actually tell you whether you are susceptible to breast cancer later in life? Yes, new findings showed that birth size, particularly birth length, may be related to risk of breast cancer in adulthood and this information can be used as an indicator for susceptibility to this type of cancer for women.

This is based on the association study led by Isabel dos Santos, a professor of Epidemiology at the London School of Hygiene and Tropical Medicine. In this study, the researchers reviewed 32 published and unpublished studies, comprising of 22,058 cases of breast cancer among 600,000 women from developed countries. They re-analysed the data to determine the relationship between birth size and risk of breast cancer in adult women. The information on birth size was based on birth records of all participants. The three birth size measures that were examined were birth weight, birth length and head circumference.

The researchers found that women with higher birth weight tended to have higher risk for breast cancer. The analysed data showed that 0.5 kg increase in birth weight may increase the risk of breast cancer by 7%. Birth length and head circumference are also found to be indicators of breast cancer risk. Birth length was especially found to be the strongest predictor for breast cancer.

According to dos Santos Silva,

‘Our study indicates that birth size is a marker of susceptibility to breast cancer in adulthood, at least in developed countries. The birth size - breast cancer association appeared to be largely independent of known risk factors. Little is known on how the pre-natal environment may affect breast cancer risk later in life. Further research is needed to unravel the biological mechanisms underlying the birth size - breast cancer association’.

Specifically, the women who were found to be at higher risk were:

• those with birth length of 51 cm or more.
• those whose head circumference was 35 cm or more.
• those who weighed more than 4 kg at birth.

The results are especially relevant considering the trend of many babies being overweight at birth due to maternal health factors.

According to experts at the Harvard University School of Public Health who were not part of the research, the new study provides “the strongest evidence yet that birth size is a critical determinant of breast cancer risk in adult life.”

Unfortunately, the study cannot explain the reason behind this birth size - breast cancer association. Let us hope that future research will bring some clarifications.

Photo credit: bimsan at stock.xchng

               

Does your waistline predict your risk for heart disease?

If you are female and have a waistline circumference measuring 35 inches (about 89 cm), then you are advised to have a detailed risk assessment of your cardiovascular health. This is according to Dr. Erin Michos, a cardiologist of Johns Hopkins Medicine.

This statement was based on a US-wide study which screened 8,936 women aged 35 to 63 years old for risk factors of heart disease. For the risk assessment, the women from 14 cities underwent physical check-ups and filled out a health questionnaire. The results of the screening were as follows:

• 39% of the study participants were overweight (body mass index is between 25 and 30).
• 35% were considered obese (body mass index is over 30).
• 55% of these women, taking into account waistlines of 35 inches or more, have increased risk for heart disease.

Dr. Michos laments the fact that traditional risk factor assessment for heart disease do not take into account weight, body mass index and waistline size. Based on the Framingham Risk Assessment, this risk factor scoring system for heart disease only assesses the 10-year risk of heart disease and includes:

• age
• blood pressure
• blood cholesterol levels
• smoking
• diabetes

Based on this system, 85% of the women had low risk profiles. Taken into account the study findings on weight and waistline, 59% of the low-risk participants had 1 or 2 more risk factors not previously considered. 41% of those with intermediate risk profiles had 3 or more risk factors overlooked.

“These women have a high lifetime risk of cardiovascular disease even though their 10-year risk may be predicted as low… Our results really emphasize the growing epidemic of obesity in America and showcase its potential for misreading or masking future harm to women’s heart health, “

according to Dr Michos. Therefore, even if no health problems are evident now, early screening is important.

The cardiologist goes on to say that awareness of the problem should be increased so that preventive measures can then be taken as early as possible. Losing weight early enough can drastically lower the risks.

However, the screening study also found out that many women are not aware of the health risks that even slightly overweight people are facing. Doctors in the US are so used “well-built” people that excess weight is often overseen during health assessments.

The author goes on to say that although the study was specific to women, it “also bear significance for men, for whom a waistline greater than 40 inches is considered obese.”

               

Carcinoid Cancer

Carcinoid Cancer as defined by the American Cancer Society: “carcinoid tumors or carcinoids: tumors that develop from neuroendocrine cells, usually in the digestive tract, lung, or ovary. The cancer cells from these tumors release certain hormones into the bloodstream. In about 10% of people, the hormone levels are high enough to cause facial flushing, wheezing, diarrhea, a fast heartbeat, and other symptoms throughout the body.” These symptoms are referred to as Carcinoid Syndrome.

The causes of carcinoid cancer are unclear. This type of cancer is very slow growing and has no early signs or symptoms. It is often detected while evaluating other unrelated symptoms.

Risk Factors per the Mayo Clinic:

Sex: Affect women more often than men.

Family history: Children who have a parent with carcinoid tumors or a family history of multiple endocrine neoplasia type 1 (MEN 1) syndrome.

Smoking: Linked to some atypical lung carcinoids.

Other medical conditions. Those that affect the stomach’s ability to produce acid may be linked to some gastrointestinal carcinoids.

Diagnosis can be difficult and is usually done through:

• A blood test evaluating for high levels of the protein chromogranin A.
• A urine test for the presence of 5-HIAA.
• A CT scan
• A fine needle biopsy

Treatment is truly individualized depending on the location and staging. If the tumor has not metastasized, surgery may be the treatment option.

Other treatment options:

• Chemotherapy
• Radiofrequency Ablation
• Injections of Sandostatin to slow tumor growth
• Hepatic Artery Embolization-cutting off the blood supply to the tumor

Resources:

The Carcinoid Cancer Foundation offers not only information on carcinoid cancer but online discussion groups and seek to increase awareness.

Together We Make a Difference

Carcinoid. com is the Novartis website which offers information on carcinoid cancer and managment of the symptoms of Carcinoid Syndrome.

Carcinoid Cancer Awareness Network: CCAN.: A non-profit organization whose mission is to intensify awareness of carcinoid cancer and to assist support groups around the world in providing patients and caregivers access to important information about carcinoid disease.

Battling Books:

Carcinoid Cancer, Zebras and Stardust: My Sister’s Cancer Battle by Mary Girsch-Bock

(May 2008)

               

Stroke rates: Europe wins over US

When it comes to stroke rates, Europeans are way better off than Americans, according to a Dutch study.

The researchers looked at data from 2004 on 13,667 Americans and 30,120 Europeans from 11 countries. Their analysis shows that American men have 61% higher likelihood of suffering from stroke than their European counterparts. Also, American women were almost twice more likely to suffer from stroke than European women. This difference in stroke rates in the two sides of the Atlantic is most evident among the poor segment of the two regions’ population but less visible among the rich.

“….Poor Americans …were much more likely to have a stroke than poor Europeans, whereas the gap in stroke prevalence is less marked between rich Americans and rich Europeans.”

according study author Mauricio Avendano, of the Erasmus Medical Center in Rotterdam, the Netherlands. This is the same group who reported the research results showing that rich Americans are less likely to suffer from stroke at an early age than Americans in the low income group.

Higher stroke rate was associated with lower socioeconomic status as measured by wealth, income and education in both the US and Europe. However, the link between socioeconomic status and stroke prevalence is much more evident in the US than in most European countries.

The researchers speculate that the big difference between stroke rates in the US and Europe may be due to the following:

• Europe offers universal health care which is accessible to every one. In the US, over 40 million people have no health insurance, according to the CDC.

“Some European health systems emphasize tackling stroke risk factors, as opposed to the US health-care system, which focuses more on treatment and may actually be more successful in keeping stroke cases alive.”

• Europeans also tend to be more physically active than Americans, partly because of differences in the public transportation system.
• European diet tends to be healthier. When looking at individual countries, the lowest stroke prevalence was observed in the southern Mediterranean countries of Spain, Italy and Greece, but also in Switzerland.

“Southern Mediterranean countries have a diet rich in vegetables, fruits and fish, and lower in fats, which partly explains why heart disease is so much lower in these populations than in northern Europe and the United States.”

In conclusion,

“a higher rate of risk factors and more barriers to health care may be among the reasons why stroke is more common in the United States than in Europe.”

 

Photo credit

               

The Ovarian Cancer Battle

Ovaries are the small almond shaped glands that attach to the uterus via the fallopian tubes. They produce eggs and hormones.

According to the American Cancer Society, a woman’s risk of getting ovarian cancer in her lifetime is 1 in 71. The National Cancer Institute estimates that in 2008 there will be 21,250 new cases diagnosed and 15,520 deaths.

Most Ovarian Cancer develops from:

Epithelial Cells: surface cells covering the ovary, the most commonly diagnosed ovarian cancer
Germ Cells: the egg producing cells

While the cause of ovarian cancer is unknown, it is known what may reduce or increase your risk.

Ovarian Cancer Risk Factors:

• Your risk of getting ovarian cancer is reduced if you have had a hysterectomy or a tubal ligation (fallopian tubes are ‘tied’)
• Your risk is lower if you have had children, and lower with each pregnancy
• Women who have breast fed have a lower risk
• Women who take birth control pills have a lower risk
• The use of male hormones to treat endometriosis may increase your risk
• Obesity may increase your risk
• A family history of ovarian cancer, breast cancer or colorectal cancer increases your risk
• A personal history of breast cancer increases your risk
• Use of estrogen therapy alone may increase your risk
• Most ovarian cancers occur in women who are in menopause.

Please visit the American Cancer Society site for a complete discussion of these risk factors.
Ovarian cancer may be detected with a pelvic exam. By that time it may be advanced. Women with high risk factors and a family history should be extra diligent to maintain routine gynecologic exams and be very observant for possible symptoms.

Symptoms May Include:

Simple acronyms shared by the Ovarian Cancer National Alliance are:

B for Bloating
P for Pelvic or abdominal Pain
D for Difficulty eating or feeling full quickly
U for Urinary symptoms (urgency or frequency)

It’s obvious these symptoms may be indicative of other diseases. Per the American Cancer Society, “If you have symptoms that you can’t explain nearly every day for more than a few weeks, talk to your doctor right away. “

The BRCA1 and BRCA2 (or Breast Cancer 1 and 2) genes are responsible for many cases of familial ovarian cancer and familial breast cancer. Women with a familial link to ovarian cancer should consult their physicians about this test. Source: The Gilda Radner Familial Ovarian Cancer Registry at Roswell Park Cancer Institute in Buffalo, N.Y.

As part of diagnosis, your physician may order a blood test. A CA-125 will show higher levels in women who have ovarian cancer. Other tests may include various radiographic imaging exams and possibly a biopsy, colonoscopy and or laparoscopy.

Treatment:

Currently a combination of surgery, chemotherapy and radiation are the modalities for ovarian cancer treatment. Early diagnosis is the key.

For up-to-date treatment options for ovarian cancer see the National Cancer Institute pages which includes information on antiogenisis, the process of reducing the blood supply to tumors.

Ovarian Cancer Initiatives and Resources:

One of the strongest voices in the battle against ovarian cancer is the The Ovarian Cancer National Alliance. Their National Agenda has three initiatives:

1. Advance Ovarian Cancer Research
2. Improve Health Care Practice for Ovarian Cancer, and
3. Expand the National Advocacy Movement for Ovarian Cancer

February 13, 2008, a Yale University Phase II clinical trial released the following information: ” Researchers at Yale School of Medicine have developed a blood test with enough sensitivity and specificity to detect early stage ovarian cancer with 99 percent accuracy. ”

For more information on clinical trials for ovarian cancer see the American Cancer Society Clinical Trials Matching Service, the National Cancer Institute or The Ovarian Cancer National Alliance Clinicial Trials Matching Service.

The Gynecologic Cancer Foundation (GCF) offers support and advocacy. Upcoming classes include: 2008 Ovarian Cancer Survivors Course.

Ovarian Cancer Canada, and the Winners Walk of Hope: ” Join thousands of people in 14 cities across Canada on Sunday, September 7th to help commemorate September as Ovarian Cancer Awareness Month.”

Conversations! The International Newsletter for those Fighting Ovarian Cancer.

SHARE: Self-help for Women with Breast or Ovarian Cancer: hotlines, support groups, education and advocacy.

Battling Books:

100 Questions & Answers About Ovarian Cancer, Second Edition by Don S. Dizon (2006)

A Guide to Survivorship for Women With Ovarian Cancer by F. J. Montz, Robert E. Bristow, and Paula J. Anastasia (2005)

It’s My Ovaries, Stupid! by Elizabeth Lee Vliet (2003)

Tomorrow is your last day–comment on any blog post through Friday May 9th, for a chance to win a free pound of Bald Lady coffee.

               

Cervical Cancer

Cervical cancer will be diagnosed in more than 11,000 women in the U.S. in 2008 and more than 3,000 women will die of the disease this year.

Worldwide it is third leading cause of cancer death in women.

What is the cervix?

The cervix is the lower portion of the uterus. It connects the uterus to the birth canal (vagina) and is the area of the uterus where a fetus will grow and develop.

There are two types of cervical cancer:

• squamous cell carcinoma
• adenocarcinoma
  

Per the American Cancer Society, 80 to 90 percent of all diagnosed cases of cervical cancer are squamous cell carcinoma.
A diagnosis of cervical ‘pre-cancerous tissue’ is treated the same as cancer, though these abnormal cells do not always become cancerous. This is because often the symptoms of cervical cancer are silent until the cancer is at advanced stages.

The HPV and Cervical Cancer Connection:

Human Pappillomavirus is connected to 90% of all diagnosed cervical cancer cases. Many people have this common virus which is passed to another person during sex. A healthy immune system generally protects the HPV virus from doing any harm. However in some women it can cause pre-cancerous cellular changes that may continue to slowly change the cells to cancerous tissue.

The HPV vaccine will protect women from 4 types of human papillomavirus. Per the CDC: “If you are 11–26 years old, you can help prevent cervical cancer by getting the HPV vaccine. It protects against the types of HPV that most often cause cervical, vaginal, and vulvar cancers, and is given in a series of three shots.”

For detailed information on the HPV virus see the Mayo Clinic site.

Risk Factors:

• HPV infection (early sex, unprotected sex)
• Smoking
• Multiple full-term pregnancies
• Immune suppression diseases
• Birth control pills
• Other sexually transmitted diseases
• Family history
• Diets low in fruits and vegetables
• Socio-economic (no access to health care and regular PAP screenings)
• Age-most often occurs in women over the age of 40

These risk factors are discussed in more detail at the American Cancer Institute site.

Symptoms:

Cervical cancer begins on the cellular level which causes silent symptoms. Symptoms such as pelvic pain, bloody discharge or pain during intercourse may not appear until the cancer is no longer in the early stages.

Prevention:

• Reduce risk factors as appropriate
• Ask your physician if the HPV vaccine is right for you
• Schedule regular PAP tests

What is a PAP test?

The name PAP comes from one of the inventors George Papanikolaou.

A PAP test is done during your routine gynecological pelvic exam. Cell scrapings of the cervix are put on slides which are then examined for cellular changes or abnormalities.

Detailed information on PAP screenings can be found in the National Cancer Institute fact sheet.

Diagnosis and Treatment:

Diagnosis begins with a physical exam and history. The level of diagnostic testing will be determined by the stage of your disease. 78% of all cervical cancer cases are diagnosed in the early stage.

If it is suspected that the cancer is not in the early stage, your physician may order detailed testing to check the lymph nodes, urinary system, rectal and vaginal areas for spread of the disease. Detailed testing information can be found at the The M.D. Anderson Cancer Center site.

Treatment may include, surgery, chemotherapy and radiation. Per The M.D. Anderson Cancer Center, treatment options also include the following:

• The stage of the cancer
• The size of the tumor
• The patient’s desire to have children
• The patient’s overall health and age

Terminology for diagnosis and/or treatment:

Cone biopsy: a surgical procedure where a cone shaped piece of tissue is removed from the cervix.

Cryosurgery: a surgical procedure that uses an instrument to freeze and destroy precancerous tissue.

LEEP : Loop Electrical Excision Procedure- treatment done under local anesthesia, an electrical current passed through a thin wire hook to remove abnormal tissue.

Laser surgery: a surgical procedure that uses a laser beam to remove surface lesions.

Resources:

For more detailed information on cervical cancer, the CDC (Center for Disease Control) offers a downloadable pdf fact sheet and a cervical cancer podcast.

Eyes on the Prize.org offers support and information for gynecological cancer.

Women’s Health Cancer Centres (Canada) is a huge network of resources.

Battling Books:

100 Questions & Answers About Cervical Cancer by Don S., M.D. Dizon (2008).

Women at risk: The HPV epidemic and Your Cervical Health by Gregory Henderson M.D. Ph.D and Batya Swift Yasgur (2002).

               

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