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Izumi Makino, Young-Chang P Arai,
Shuichi Aono,
Kazuhiro Hayashi,
Atsuko Morimoto,
Makoto Nishihara,
Tatsunori Ikemoto,
Shinsuke Inoue,
Miyuki Mizutani,
Takako Matsubara,
Takahiro Ushida
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ABSTRACT: PURPOSE: Apparent organic abnormalities are sometimes not identified among patients suffering from chronic pain in the craniocervical region. In some cases, parafunctional activities (PAs) are recognized. PAs are nonfunctional oromandibular activities that include jaw clenching and bruxism, but are considered as factors that contribute to craniomandibular disorders (CMDs). It is now recognized that PAs and CMDs influence musculoskeletal conditions of the upper quarter. Exercise therapy (ET) to improve jaw movement and psychological intervention (PI) to reduce PAs are useful for PAs and CMDs. We hypothesized that ET and PI would be effective for craniocervical pain without organic abnormalities. METHODS: Thirty-nine subjects suffering from craniocervical chronic pain were allocated into 3 groups: The control group received only pharmacological treatment; the ET group received jaw movement exercise (JME); and the ET-PI group received JME and PI. Pain and jaw movement were evaluated using a numerical rating scale (NRS). RESULTS: After interventions, the NRS scores were significantly lower in the ET-PI group, compared with those in the other groups. Jaw movement improved 100% in the ET group, 92% in the ET-PI group, and 0% in the control group. CONCLUSION: A combination of jaw exercise and psychological intervention to reduce parafunctional activities is more effective than jaw exercise alone for the improvement of craniocervical pain without apparent organic abnormalities.
Pain Practice 05/2013; · 2.21 Impact Factor
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ABSTRACT: We report on the use of pulsed radiofrequency (RF) within the plexus for the management of intractable pain in three patients with metastatic or invasive plexopathy. The patients were a 38-year-old woman with a history of breast cancer 6 years earlier whose computed tomography (CT) scans revealed a mass lesion at the infraclavicular part of the right brachial plexus, a 68-year-old man diagnosed with advanced lung cancer whose CT scans revealed a bone metastasis in the right humerus invading the axillary region of the right brachial plexus, and a 67-year-old woman diagnosed with advanced lung cancer whose CT scans revealed a bone metastasis in the left humerus invading the axillary region of the left brachial plexus. Ultrasound-guided pulsed RF was performed within the interscalene brachial plexus. During the follow-up period, their intractable pain was moderately controlled.
Journal of Anesthesia 10/2012; · 0.83 Impact Factor
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Young-Chang P Arai,
Makoto Nishihara,
Kunio Kobayashi,
Tamotsu Kanazawa,
Nobuhiko Hayashi,
Yukio Tohyama,
Kikuyo Nishida,
Maki Arakawa,
Chiharu Suzuki,
Akiko Kinoshita,
Miki Kondo,
Satuki Matsubara,
Nami Yokoe,
Ruiko Hayashi,
Aya Ohta,
Jun Sato,
Takahiro Ushida
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ABSTRACT: PURPOSE: WHO's three step ladder sometimes cannot provide adequate pain relief for pancreatic cancer. Some patients develop terminal delirium (TD). The aim of this study was to test if the addition of a celiac plexus block (CPB) to pharmacotherapy could reduce the incidence of TD. METHODS: Pancreatic cancer patients under the care of our palliative-care team were investigated with regard to the duration and occurrence of TD, pain scores [numerical rating score (NRS)] and daily opioid dose. Between August 2007 to September 2008, 17 patients received only pharmacotherapy (control group). Then, we modified our guideline for analgesia, performing CPB 7 days after the first intervention of our team. Between October 2008 to September 2009, 19 patients received CPB. RESULTS: The opioid doses in CPB group were significantly lower both at 10 days after the first intervention (3 days after CPB) (27 ± 11 vs. 66 ± 82 mg; p = 0.029) and 2 days before death (37 ± 25 vs. 124 ± 117 mg; p = 0.009). NRS in the CPB group were significantly lower both at 10 days after the first intervention (0 [0-2] vs. 3 [2-5], p < 0.0001) and 2 days before death (1 [0-2] vs. 3 [1-4.5], p = 0.018). The occurrence and duration of TD in CPB group were both reduced (42 vs. 94 %, p = 0.019; and 1.8 ± 2.9 vs. 10.4 ± 7.5 days, p = 0.0003). CONCLUSION: The duration and occurrence of TD and the pain severity were significantly less in pancreatic cancer patients who underwent neurolytic CPB.
Journal of Anesthesia 09/2012; · 0.83 Impact Factor
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Young-Chang P Arai,
Atsuko Morimoto,
Hiroki Sakurai,
Yusuke Ohmichi,
Shuichi Aono,
Makoto Nishihara,
Jun Sato,
Takahiro Ushida,
Shinsuke Inoue,
Makoto Kurisuno,
Yuji Kobayashi
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ABSTRACT: BACKGROUND: Celiac plexus block (CPB) can be used for treating intra-abdominal visceral pain syndromes. The celiac plexus is the largest plexus of the sympathetic nervous system. Several nerve blocks have a marked effect on autonomic nervous activity. Furthermore, stellate ganglion block changes cardiac autonomic nervous activity. Thus, CPB could influence the sympathetic activity of the cardiac plexus. The aim of the present study was to see whether CPB modulated heart rate variability (HRV) in patients with pancreatic cancer. METHODS: Twelve patients received neurolytic CPB using 14 ml absolute alcohol. Data recorded in a palm-sized electrocardiographic unit were analyzed for HRV. RESULTS: CPB using a neurolytic solution did not induce any significant changes in the low-frequency (LF)/high-frequency (HF) ratio of HRV (LF/HF, P = 0.4642). Furthermore, the procedure did not induce any significant changes in blood pressure (systolic, P = 0.5051; diastolic, P = 0.5180). CONCLUSION: CPB did not induce any significant changes in HRV or hemodynamics.
Journal of Anesthesia 08/2012; · 0.83 Impact Factor
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ABSTRACT: BACKGROUND: Sympathetic nervous activity contributes to the maintenance of muscle oxygenation. However, patients with chronic pain may suffer from autonomic dysfunction. Furthermore, insufficient muscle oxygenation is observed among workers with chronic neck and shoulder pain. The aim of our study was to investigate how muscle load tasks affect sympathetic nervous activity and changes in oxygenation of the trapezius muscles in subjects with chronic neck and shoulder pain. METHODS: Thirty females were assigned to two groups: a pain group consisting of subjects with chronic neck and shoulder pain and a control group consisting of asymptomatic subjects. The participants performed three sets of isometric exercise in an upright position; they contracted their trapezius muscles with maximum effort and let the muscles relax (Relax). Autonomic nervous activity and oxygenation of the trapezius muscles were measured by heart rate variability (HRV) and Near-Infrared Spectroscopy. RESULTS: Oxyhemoglobin and total hemoglobin of the trapezius muscles in the pain group were lower during the Relax period compared with the control group. In addition, the low frequency / high frequency (LF/HF) ratio of HRV significantly increased during isometric exercise in the control group, whereas there were no significant changes in the pain group. CONCLUSIONS: Subjects with neck and shoulder pain showed lower oxygenation and blood flow of the trapezius muscles responding to isometric exercise, compared with asymptomatic subjects. Subjects with neck and shoulder pain also showed no significant changes in the LF/HF ratio of HRV responding to isometric exercise, which would imply a reduction in sympathetic nervous activity.
BMC Musculoskeletal Disorders 08/2012; 13(1):146. · 1.58 Impact Factor
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Young-Chang P Arai,
Akihiro Ito,
Kenji Ohshima,
Soki Hibino,
Sinnosuke Niwa,
Jun Kawanishi,
Hiroki Numanami,
Yoshikazu Sakakima,
Shouji Mizuno,
Yusuke Tawada,
Yuki Maruyama,
Jun Sato,
Makoto Nishihara,
Shinsuke Inoue,
Takahiro Ushida
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ABSTRACT: Neuraxial blockade causes arterial hypotension. Transcutaneous electrical nerve stimulation (TENS) at the Neiguan (PC-6) and Jianshi (PC-5) reduces the severity of hypotension after spinal anaesthesia, but did not clarify the optimal stimulus frequency. We hypothesized that the stimulus frequency of TENS at the PC-6 and PC-5 points would influence the severity of hypotension after epidural anaesthesia. 65 ASA I or II male patients presenting for inguinal hernia repair were randomized to five groups: the control group received no treatment; the 2 Hz, 10 Hz, 20 Hz, and 40 Hz groups received TENS at a frequency of 2 Hz, 10 Hz, 20 Hz, and 40 Hz, respectively. The lowest SBP was significantly higher in the 40 Hz group [the control, 84 (74-110) mmHg; the 2 Hz, 96 (62-116) mmHg; the 10 Hz, 100 (68-110) mmHg; the 20 Hz, 96 (64-115) mmHg; the 40 Hz, 104 (75-140) mmHg: P = 0.004]. Significantly less patients experienced hypotension in the 40 Hz group [the control, 78%; the 2 Hz, 43%; the 10 Hz, 38%; the 20 Hz, 38%; the 40 Hz, 8%: P = 0.008]. TENS on the PC-6 and PC-5 points reduced the severity and incidence of hypotension after epidural anaesthesia, depending on the stimulus frequency.
Evidence-based Complementary and Alternative Medicine 01/2012; 2012:727121. · 4.77 Impact Factor
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ABSTRACT: Acupressure on local and distal acupuncture points might result in sedation and relaxation, thereby reducing chronic neck pain. The aim was to investigate the effect of acupressure at local (LP) and distal acupuncture points (DP) in females with chronic neck pain. Thirty-three females were assigned to three groups: the control group did not receive any stimuli, the LP group received acupressure at local acupuncture points, GB 21, SI 14 and SI 15, and the DP group received acupressure at distal acupuncture points, LI 4, LI 10 and LI 11. Verbal rating scale (VRS), Neck Disability Index (NDI), State-Trait Anxiety Inventory (STAI), muscle hardness (MH), salivary alpha-amylase (sAA) activity, heart rate (HR), heart rate variability (HRV) values and satisfaction due to acupressure were assessed. VRS, NDI, STAI and MH values decreased after acupressure in the LP and the DP group. HR decreased and the power of high frequency (HF) component of HRV increased after acupressure in only the LP group. Although acupressure on not only the LP but also the DP significantly improved pain conditions, acupressure on only the LP affected the autonomic nervous system while acupuncture points per se have different physical effects according to location.
Evidence-based Complementary and Alternative Medicine 01/2011; 2011. · 4.77 Impact Factor
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Young-Chang P Arai,
Takako Matsubara,
Kazuhiro Shimo,
Katsutoshi Suetomi,
Makoto Nishihara,
Takahiro Ushida,
Kunio Kobayashi,
Chiharu Suzuki,
Akiko Kinoshita,
Miki Kondo,
Satuki Matsubara,
Ruiko Hayashi,
Yukio Tohyama,
Kikuyo Nishida,
Maki Arakawa
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ABSTRACT: Painful neuropathic conditions of cancer pain often show little response to nonopioid and opioid analgesics but may be eased by antidepressants and anticonvulsants. Although gabapentin is effective in the treatment of neuropathic pain in patients with cancer, some patients experience intolerable side effects sufficient to warrant discontinuation. The aim of this study was to see whether low-dose gabapentin is effective in treating cancer-related neuropathic pain when combined with low-dose imipramine.
Fifty-two cancer patients diagnosed as having neuropathic pain were allocated into four groups: G400-I group took gabapentin 200 mg and imipramine 10 mg every 12 h orally; G400 group took gabapentin 200 mg every 12 h orally; G800 group took gabapentin 400 mg every 12 h orally; I group took imipramine 10 mg every 12 h orally.
Low-dose gabapentin-imipramine significantly decreased the total pain score and daily paroxysmal pain episodes. Several patients developed mild adverse symptoms in the four groups, and three patients discontinued treatment due to severe adverse events in the G800 group.
Low-dose gabapentin-antidepressant combination with opioids was effective in managing neuropathic cancer pain without severe adverse effects.
Journal of Anesthesia 03/2010; 24(3):407-10. · 0.83 Impact Factor
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Journal of Anesthesia 02/2010; 24(2):317-8. · 0.83 Impact Factor
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Takahiro Ushida,
Takeshi Yokoyama,
Yasuyo Kishida,
Mika Hosokawa,
Shinichirou Taniguchi,
Shinsuke Inoue,
Ryuichi Takemasa,
Katsutoshi Suetomi, Young-Chang P Arai,
Matthew McLaughlin,
Toshikazu Tani
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ABSTRACT: Retrospective clinical review and prospective report of postoperative delirium after cervical spine surgeries.
To investigate factors contributing to the development of delirium after cervical surgery and see whether amended therapeutic protocols could improve or alter postoperative outcomes.
Important consequences of postoperative delirium for the orthopedic patients include impaired recovery and increased morbidity and mortality. Although its risk factors have been reported in orthopedic surgery, there are a very few reports regarding postoperative delirium in spine surgery.
Eighty-one cervical myelopathy patients were retrospectively examined about the incidence of postoperative delirium and the risk factors. Similarly, 41 patients who received postoperative care under modified protocols were prospectively examined.
Postoperative delirium occurred more commonly in patients over 70 years and those with hearing impairment. Patients who received high-dose methylprednisolone (>1000 mg) demonstrated an increased incidence of postoperative delirium. Under modified protocol, we reduced the usage of methylprednisolone and encouraged free body movement with cervical orthosis immediately after surgery. The incidence of postoperative delirium was significantly lower under the modified protocol.
Early commencement of mobilization after cervical spine surgery would be crucial to the prevention of postoperative delirium in the elderly.
Spine 11/2009; 34(23):2500-4. · 2.08 Impact Factor
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ABSTRACT: Postoperative cognitive problems and delirium are not uncommon in the elderly. We reported four cases in which auricular acupunctures on the 'Shenmen' and 'Point Zero' points successfully managed postoperative problematic behaviors of the three patients with dementia and the one patient postoperatively demonstrating an agitated behavior.
Evidence-based Complementary and Alternative Medicine 10/2009; 7(3):383-6. · 4.77 Impact Factor
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ABSTRACT: Acupressure applied on the Extra 1 acupuncture point results in sedation, thereby reducing bispectral index (BIS) values. Mental status and hypnotic agents influence the autonomic nervous system. We hypothesized that acupressure at the Extra 1 point would induce sedation and change sympatho-parasympathetic nerve balance. We investigated the effect of acupressure at the Extra 1 point on the EEG spectral entropy values and heart rate variability (HRV). Forty-eight volunteers (24 males and 24 females) were randomly assigned to the control or Extra 1 group. The control group received acupressure at a sham point and the Extra 1 group received acupressure at the Extra 1 point. Acupressure was applied for 5 min. The record of the EEG spectral entropy values and HRV started 5 min before acupressure and stopped 5 min after acupressure. Acupressure significantly reduced the EEG spectral entropy values in both groups, but the values of the Extra 1 group were significantly smaller than those of the control group (P < .01). Acupressure significantly decreased the LF/HF ratio of HRV in both groups (P < .05). When divided upon gender, although acupressure tended to decrease the LF/HF ratio, the ratio significantly decreased during and after acupressure only in females of the Extra 1 group (P < .05). We concluded that acupressure on the Extra 1 point significantly reduced the EEG spectral entropy in both the genders, but affected the LF/HF ratio of HRV only in females.
Evidence-based Complementary and Alternative Medicine 09/2008; 2011:503698. · 4.77 Impact Factor
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ABSTRACT: Psychological factors are known to play an extremely important role in the maintenance and development of chronic pain conditions. However, it is unclear how such factors relate to the central neural processing of nociceptive transmission in healthy individuals. To investigate this issue, the activation of the brain was studied in 30 healthy volunteers responding to virtual pain stimuli by fMRI. In the first series of the study (non-preconditioned study), 15 participants were shown a digital video demonstrating an injection needle puncturing the right palm. In the second series of the study (pre-conditioned study), same-task paradigms were used for another 15 participants. Prior to the fMRI session, real needle punctuate stimuli were applied to the right palm of participants for pre-conditioning. fMRI analysis revealed that bilateral activations in anterior insula (BA45), parietal operculum (S2: BA40), premotor area, medial globus pallidus, inferior occipital gyrus (BA18), left temporal association cortex, right fusiform gyrus, right parietal association cortex and cerebellum occurred due to the task in the preconditioned group. On the other hand, right parietal operculum (S2: BA40), premotor area, parietal association cortex, left inferior frontal gyrus and bilateral temporal association cortex were activated in the non-preconditioned group. In addition, activation of anterior insula, inferior frontal gyrus, precentral gyrus and cerebellum significantly increased in the preconditioned group compared with the non-preconditioned group. These results suggest that the virtual needle puncture task caused memory retrieval of unpleasant experiences which is possibly related to empathy for pain, resulting in the activation of specific brain areas.
Neuroscience Letters 08/2008; 439(1):7-12. · 2.11 Impact Factor
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Young-Chang P Arai,
Takahiro Ushida,
Tomoaki Osuga,
Takako Matsubara,
Kahori Oshima,
Kana Kawaguchi,
Chiaki Kuwabara,
Sigeya Nakao,
Atsushi Hara,
Chihiro Furuta,
Erina Aida,
Shugyoku Ra,
Yui Takagi,
Kyoko Watakabe
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ABSTRACT: Premedication with sedatives can decrease the discomfort associated with invasive anesthetic procedures. Some researchers have shown that acupressure on the acupuncture extra 1 point is effective for sedation. We investigated whether acupressure on the extra 1 point could alleviate the pain of needle insertion.
We investigated the effect of acupressure at the extra 1 point or a sham point on needle insertion using verbal rating scale (VRS) pain scores and heart rate variability (HRV). Twenty-two healthy female volunteers were randomly allocated to two groups: the extra 1 group received acupressure at the extra 1 point, and the sham group received acupressure at a sham point. After starting the electrocardiogram record, a 27-gauge needle was inserted into the skin of a forearm. Thereafter, another needle was inserted into the skin of the other forearm during acupressure.
Acupressure at the extra 1 point significantly reduced the VRS, but acupressure at the sham increased the VRS. Acupressure at the extra 1 significantly reduced the low frequency/high frequency ratio of HRV responding to needle insertion.
Acupressure at the extra 1 point significantly reduced needle insertion pain compared with acupressure at the sham point. Also, acupressure at the extra 1 point significantly reduced the low frequency/high frequency ratio of HRV responding to needle insertion, which implies a reduction in sympathetic nervous system activity.
Anesthesia and analgesia 08/2008; 107(2):661-4. · 3.08 Impact Factor
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ABSTRACT: Emergence agitation in pediatric anesthesia is associated with preanesthesia child anxiety, which is strongly influenced by maternal mental conditions. Mental stress affects the autonomic nervous system, thereby influencing heart rate variability (HRV). The present study tested the correlations between preanesthesia maternal HRV and perioperative child behavior.
A total of 27 pairs of mothers and children were analyzed in the present study. Maternal HRV was recorded from the night before the child's surgery to arrival to the operation room and thereafter recorded data were analyzed. The children underwent minor plastic surgery under general anesthesia, and induction and emergence behavior were assessed.
Quality of mask induction did not correlate with the ratio of low-frequency (LF) components to high-frequency (HF) components (LF/HF ratio) of preanesthesia maternal HRV either obtained during 21:00-06:00 (stage I) or 06:00-08:00 (stage II). Scores of the child's emergence behavior did not correlate with the LF/HF ratio of maternal HRV of stage I; however, the LF/HF ratio of maternal HRV of stage II significantly correlated with emergence behavior.
Two-hour maternal HRV just before surgery significantly correlated with emergence behavior of children undergoing general anesthesia.
Pediatric Anesthesia 03/2008; 18(2):167-71. · 2.10 Impact Factor
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ABSTRACT: Airway obstruction occurs in anesthetized children with obstructive sleep apnea syndrome (OSAS). The inspiratory attempts against the occluded airway lead to an increased sympathetic activity. Heart rate variability (HRV) analysis provides information about the autonomic nervous system. The low-frequency component/high-frequency component ratio of HRV is considered to be an index of sympatho-parasympathetic balance.
We investigated the effects of general anesthesia, the neutral neck position, and jaw thrust in the supine and lateral positions on HRV in 20 children (aged 3-9 yr), with OSAS. HRV was recorded before and after anesthesia induction, at the neutral neck position and with jaw thrust maneuver in the supine and lateral positions with the patients breathing 5% sevoflurane.
General anesthesia with the patient in the neutral neck position increased airway obstruction. The patients' stridor scores improved with the airway maneuver of jaw thrust and lateral position. The low-frequency component/high-frequency component ratio and heart rate increased at the postinduction measurement and reached the highest value with the patient in the neutral neck position. The values significantly decreased with the jaw thrust maneuver and with the patient in the supine and lateral positions. Ultra-short-term entropy of HRV decreased after anesthetic induction and reached the lowest value with the patient in the neutral neck position. The values increased during jaw thrust and with patients in the supine and lateral positions.
Changes of HRV induced by inhaled anesthesia, jaw thrust, and lateral positioning procedures corresponded to changes in the stridor score of children with OSAS.
Anesthesia and analgesia 07/2007; 104(6):1352-5, table of contents. · 3.08 Impact Factor
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ABSTRACT: The distribution of spinal anesthesia is affected by the density and viscosity of the local anesthetic solution that, in turn, may be influenced by the temperature of the injectate. Our hypothesis in the present study was that the temperature of the injectate influences its distribution into the subarachnoid space. We measured the density and viscosity of hyperbaric 0.5% bupivacaine at 25 degrees C and 37 degrees C and tested the onset and extent of spinal anesthesia achieved by these solutions in 36 patients. The densities of the two solutions were similar (mean [sd]): 25 degrees C, 1.028 [0.000], versus 37 degrees C, 1.028 [0.000] (g/mL), but the viscosity was more at 25 degrees C than at 37 degrees C (0.01116 [0.00003] versus 0.00843 [0.00002] g x cm(-1) x s(-1); P < 0.001). The maximum cephalad extent of loss of pinprick sensation was significantly higher with 37 degrees C (T2 with 37 degrees C versus T5 with 25 degrees C; P < 0.001), but the time to achieve peak block height was similar. In conclusion, we showed a consistent, but modest, increase in the cephalad level of spinal anesthesia by warming hyperbaric bupivacaine 0.5% from 25 degrees C to 37 degrees C. Viscosity was reduced in the warmed solution, but it is unclear if this or other factors led to the difference in spinal anesthetic level.
Anesthesia and analgesia 02/2006; 102(1):272-5. · 3.08 Impact Factor
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ABSTRACT: Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing children with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers such as chin lift and jaw thrust on airway patency (stridor score and upper airway dimensions by endoscopy) in anesthetized children scheduled for adenotonsillectomy. Eighteen children aged 1-11 yr were anesthetized with sevoflurane. During spontaneous breathing with 5% sevoflurane and 100% oxygen, upper airway dimensions and stridor score were recorded. After baseline recording, chin lift and jaw thrust were performed in both the supine and the lateral decubitus position. Chin lift, jaw thrust, and lateral position increased the airway dimensions and improved the stridor score. Moreover, lateral positioning enhanced the effects of these airway maneuvers on airway patency. We concluded that lateral positioning combined with airway maneuvers provided better airway patency for anesthetized children with adenotonsillar hypertrophy.
Anesthesia & Analgesia 05/2005; 100(4):949-52. · 3.29 Impact Factor
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ABSTRACT: Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing patients, especially in pediatric anesthesia with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea and also decreases collapsibility of the pharynx in anesthetized adults with obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers, such as chin lift and jaw thrust, on airway patency (stridor score) in anesthetized children scheduled for adenotonsillectomy. Thirty children aged 1-10 yr were anesthetized with sevoflurane. During spontaneous breathing of 5% sevoflurane, stridor score was recorded. After baseline recording, chin lift and jaw thrust were performed on patients in both the supine and the lateral decubitus positions. Chin lift and jaw thrust improved the stridor score. Furthermore, lateral positioning dramatically enhanced the effects of these airway maneuvers on airway patency. Jaw thrust combined with lateral positioning provided easy airway management for the anesthesiologists. We conclude that lateral positioning combined with airway maneuvers significantly improved airway patency compared with the airway maneuvers alone for patients in the supine position.
Anesthesia & Analgesia 01/2005; 99(6):1638-41, table of contents. · 3.29 Impact Factor
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Anesthesia & Analgesia 10/2004; 99(3):951-2. · 3.29 Impact Factor
