Shorts

briefed by Jule Klotter

Electrodermal Screening

Device Reliability

Electrodermal screening (EDS) devices measure electrical conductivity of points on the skin. The devices were initially used to authenticate the existence of acupuncture points and meridians. These acupoints and meridians conduct electrical energy more readily and show less resistance than other skin tissue. Resistance at acupuncture points measures about 0.8 MOhms while surrounding tissue measures 1.4 MOhms, according to K.T. Yung (Turner et al.). Is EDS reliable enough to use in medical practice?

L. Turner and colleagues at the University of British Columbia’s psychology department (Vancouver, Canada) tested the Prognos Machine, an ohmmeter made by the German company MedPrevent. Turner et al. needed to show reliability as part of a larger study designed to test the Prognos’s ability to distinguish between people with chronic pain and those without pain. The Canadians hoped to verify the results of earlier work conducted by A.P. Colbert and colleagues at Kaiser-Permanente Center for Health Research (Portland, Oregon). In 2004, Colbert and colleagues documented a mean reliability for the Prognos of .96 (range .89–.99) after marking acupoint locations with washable ink and taking four quick measurements in a row. Colbert also led a 2006 study that documented a sizable increase in skin resistance during sleep and corresponding decrease upon waking. Because of this variability, Turner and colleagues chose to test their subjects between 8 a.m. and noon.

Like the Colbert group, Turner and colleagues found that marking the test points, located on fingers and toes at the corner of the nail bed, greatly improved measurement consistency. They, however, chose to use colored reinforcers for three-hole punch notebook paper after learning from MedPrevent that ink could affect skin conductivity. Like Colbert’s team, the Canadian group found that taking multiple measurements in quick succession improved the reliability coefficient, but they report that averaging five quick measurements produced the best results. (Three measurements produced the same reliability as four.) Turner’s team also verified Colbert’s observation that measuring acupoints located on the left side of the body produced more reliable results than those on the right. The Canadians were puzzled that one acupoint, “the ‘Right Triple Heater’ displayed low reliability…consistently.” They wonder if others have observed the same pattern.

Prognos is not the only EDS device to undergo reliability testing. Other devices, including the AcuGraph system, have also shown the ability to measure skin resistance accurately. As researchers document the relationship between EDS readings and physiologically processes and illnesses, EDS will gain respect as a noninvasive tool for biological assessment.

Chamberlin S. Colbert AP, Larsen A. Skin conductance at 24 Source (Yuan) acupoints in 8637 patients: influence of age, gender and time of day (abstract). J Acupunct Meridian Stud. March 2011;4(1):14–23. Available at www.ncbi.nlm.nih.gov/pubmed/21440876. Accessed November 11, 2011.

Colbert AP, Hammerschlag R, Aickin M, McNames J. Reliability of the Prognos electrodermal device for measurements of electrical skin resistance at acupuncture points. (abstract). J. Altern Complement Med. August 2004;10(4):610-616. Available at www.ncbi.nlm.nih.gov/pubmed/15353016. Accessed November 11, 2011.

Colbert AP, Hayes M, Aickin M, Hammerschlag R. Physiological variability of electrical skin resistance measurements at the ting acupuncture points. Medical Acupunct. 2006;17(2):1–10. Available at www.medicalacupuncture.org/aama_marf/journal/vol17_2/article_1.html. Accessed November 11, 2011.

Mist SD, Aickin M, Kalnins P, et al. Reliability of AcuGraph system for measuring skin conductance at acupoints [abstract]. Acupunct Med. September 2011; 29(3):221–226. Available at www.ncbi.nlm.nih.gov/pubmed/21602233. Accessed November 11, 2011.

Turner L, Linden W, Talbot Ellis A, Millman R. Measurement reliability for acupoint activity determined with the Prognos Ohmmeter. Appl Psychophysiol Biofeedback. September 2010; 35(3):251–256. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC2903710. Accessed November 11, 2011.

Electrodermal Screening for Allergy/Sensitivity Patients

Electrodermal screening (EDS) devices, originally developed in the 1950s to measure effects of acupuncture treatment, are also being used to treat as well as diagnose allergies and sensitivities. EDS uses a metal probe to transmit a small electrical current to specific acupuncture points located on the hands and feet. The probe connects to a computer, which measures electrical resistance and stores collected data. Acupuncture points have high conductivity/lower electrical resistance than surrounding skin tissue. Building on Traditional Chinese Medicine and its use of acupuncture, EDS users have correlated electrical measurements at specific points with organs and tissue systems. More recently, EDS has become a means of diagnosing and treating allergies and environmental sensitivities.

From 1994 to 1998, Konrad Kail, ND, director of the Southwest College Research Institute, conducted a Level 2 outcome study to test the effectiveness of an EDS allergy diagnosis and treatment protocol (Natural Elimination of Allergy Therapy). He enrolled 96 patients, and 90 completed the study. As part of the pre- and posttreatment assessment, Kail developed the Allergy Symptom Severity Index that asked participants to rate 41 possible symptoms of allergy/sensitivity on a five point scale: 1= no problem; 2 = rarely (once a month) or minimal; 3=occasional (once a week) or mild; 4=frequent (several times a week) or moderate; 5=daily or severe. Patients with the most severe symptoms had the highest scores.

In addition to the symptom survey, Kail used EDS to assess the number of substances that produced reactions in a patient. When a person reacts to an item (or its energy signature stored in the EDS device), the device shows a peak reading of 58 or less and an indicator drop greater than two. The peak reading represents overall energy, while the indicator drop signifies resistance in current flow. A peak reading of about 50 with an indicator drop less than 2 indicates a balanced system. Kail tested each participant for sensitivity to over 1500 generic and specific items (taken from the individual’s environment).

After assessment, Kail gave each participant supplements to support and help repair digestion, gut barrier integrity, mucus membrane integrity, and skin health. Weaknesses in these “barrier” systems allow foreign substances to infiltrate the bloodstream and incite sensitivity reactions. He then neutralized allergic/sensitivity reactions using electromagnetic homeopathics, consisting of lactose pellets “imprinted” with the energy signature of antigens affecting each patient. Instead of consuming these homeopathics, patients simply held the remedy while Kail applied acupressure therapy to specific meridians in order to “creat[e] a new ‘default setting’ for the brain, which no longer sees the antigens as a threat and stops future attacks as long as barrier functions are repaired and maintained.” Patients were then instructed to avoid exposure to the antigens for 24 hours so that the new setting could strengthen. Those who did not avoid exposure often needed to repeat treatment. The Natural Elimination of Allergy Therapy protocol consisted of four EDS treatments, one per week. The first week focused on inhalant antigens (pollens, danders, smoke, smog, etc.). The second week dealt with contact allergens. The third looked at food allergens, and the fourth treatment retested all items to “clean up” anything remaining.

Posttreatment evaluation revealed several improvements. The allergy survey total scores declined: “Median score was 82.32 before treatment with the desensitization protocol and 54.25 after treatment, a statistically significant change (p<0.01).” (A score of 41 indicated no allergic symptoms.) Symptom reduction persisted at that level for at least two years. In addition, 46.7% of the patients rated the protocol’s effect as excellent and 42.1% rated it as good. Patients also reported a decreased need for medication and fewer visits to their allergists. EDS conductance measurements normalized, and indicator drop became less pronounced as treatment progressed. The sole negative effect was mild to moderate symptom aggravation, which often occurred (54.2% of the time) after treatment. Symptom aggravation lasted an average of 33.6 hours.

“The procedure is natural, noninvasive, does not require long periods of abstinence, is safe, and free from long-term side effects,” Kail writes. “Perhaps the most interesting finding is that these changes were accomplished with the application of acupressure, and use of homeopathic remedies which were never ingested by the participants. All changes occurred purely from an energy therapy.”

I would love to see a blinded, controlled study of this therapy or, better yet, a well-designed study that compares it with conventional allergy testing.

Kail K. Clinical outcomes of a diagnostic and treatment protocol in allergy/sensitivity patients. Altern Med Rev. 2001;6(2):188–202. Available at www.lewisnaturalhealth.com/conditionshelped/pdf/AllergiesEDSAltMedReviewArticle.pdf. Accessed November 10, 2011.

Lewis Family Natural Health. Electrodermal Screening and Allergy Desensitization [Web page]. Available at www.lewisnaturalhealth.com. Accessed October 15, 2011.

Laboratory Testing

In medicine, standardized laboratory tests, performed by machine, take a very complicated biological system that is constantly striving for homeostasis and translate its actions into numbers. We learn at an early age that numbers equate precision; either the answer is right or it’s wrong. Do laboratory tests deserve the same confidence? If patients have followed instructions, such as fasting before a blood test, and lab technicians handle, label, and store the sample correctly – in other words, if these types of common human errors have been avoided – are laboratory tests worthy of the authority we give to them?

To determine a clinical laboratory test’s reliability, American Association for Clinical Chemistry (AACC) cites four indicators: accuracy, precision, sensitivity, and specificity. A laboratory’s personnel are responsible for ensuring both a test’s accuracy, which refers to the test’s ability to measure what it is supposed to measure, and its precision, which refers to reproducibility of results. Personnel check accuracy by having laboratory equipment assess control samples and comparing the results to “the best testing standards available.” Evaluating a test’s precision involves multiple analyses of the same sample; each analysis should produce a “similar” result. “Although a test that is 100% accurate and 100% precise is ideal, in practice, test methodology, instrumentation, and laboratory operations all contribute to small but measurable variations in results,” according to AACC’s informative website Lab Tests Online.

The other two indicators, specificity and sensitivity, are derived from clinical research. Specificity refers to the number of false-positive results produced by a test: how well can it exclude healthy people? For example, the standard prostate-specific antigen (PSA) cut-off of 4 ng/mL has a specificity of 93.6%, according to a 2006 study from the University of Texas Health Science Center (San Antonio, TX). Therefore, about 6 out of 100 healthy men with a PSA value of 4 ng/mL or greater will be told that they have prostate cancer (false positive). Specificity is particularly important when a positive test result leads to diagnosis of a serious disease involving prolonged, debilitating, and expensive treatment.

Sensitivity, the final indicator, refers to a test’s ability to correctly identify people with a disease or condition. The 4 ng/mL PSA cut-off sensitivity is 20.5%, using biopsy verification. Out of 100 men with prostate cancer, about 80 of them will be told they do not have the disease (false negatives).

No matter how accurate a test, a person’s results will vary. Some analytes (substances being measured) can ebb and surge according to daily, monthly, seasonal or even lifetime cycles such as puberty or menopause. “Knowledge of these cycles is vital for good patient care,” according to Dr. Callum Fraser, an internationally recognized expert on biologic variation. More often, an analyte’s level fluctuates around a mean (homeostatic setting point), derived from several samples taken during the same session. The homeostatic setting point for an analyte varies from person to person.

While laboratory tests provide useful information, they do not have the precision of a mathematical equation. Do practitioners keep in mind all the possible variables that can affect a blood test’s results? Are these tests being used skillfully as a tool or as a crutch used so automatically, so habitually that we no longer think about them or question their accuracy?

American Association for Clinical Chemistry. How reliable is laboratory testing ? [online article]. June 7, 2010. Available at www.labtestsonline.org. Accessed October 19, 2010.

Ankerst DP, Thompson IM. Sensitivity and specificity of prostate-specific antigen for prostate cancer detection with high rates of biopsy verification [abstract]. December 2006; 78(4):125–129. Available at www.ncbi.nlm.nih.gov/pubmed/17269614. Accessed November 9, 2011.

Fraser C. Biological Variation: From Principles to Practice. Washington, DC: AACC Press; 2001. Foreword available at www.westgard.com/biologic-variation-principles-and-practice.htm. Accessed November 9, 2011.

Houben PHH, Winkens RAG, Van Der Weijden T, Vossen RCRM, Naus AJM, Grol RPTM. Reasons for ordering laboratory tests and relationship with frequency of abnormal results. Scand J Prim Health Care. 2010;28:18–23. Available at www.informahealthcare.com/doi/pdf/10.3109/02813430903281758. Accessed November 12, 2011.

Singh H, Thomas EJ, Sittig DF et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? [abstract] Am J Med. March 2010;123(3):238–244. Available at www.sciencedirect.com/science/article/pii/S0002934309009565. Accessed October 18, 2011.

Medical Study Retractions

As the number of medical studies increases, it is not unexpected that retractions have also increased. Most retracted studies are withdrawn because of authors’ unintentional errors, but an increasing number result from deliberate fraud. R. Grant Steen, PhD, identified 742 retracted papers, written in English between 2000 and 2010, in the PubMed database. Fraud (intentional error) was cited as the reason for 26.6% of the retractions. Moreover, Steen found evidence that “authors of fraudulent retracted papers appear to target journals with a high [impact factor], often have several other retracted papers, tend to diffuse responsibility across [four or more] co-authors, delay retracting fraudulent papers, and collaborate with co-authors who also have other retracted papers.”

Editors’ and publishers’ slow, sometimes absent, response to flawed studies dismays bioethicists. Retracted studies continue to be cited in medical studies, partly because publishers do not always make it clear that a study has been withdrawn. Journals often post notes on their websites and/or use watermarks or append notices on PDF versions of retracted studies; but “31.8 % of retracted papers were not noted as retracted in any way,” according to Steen’s April 2011 study. Bioethicist Barbara Redman found 315 retracted articles from English-language journals between 1995 and 2004, just 0.0065% of over 5 million PubMed articles published during that period. Those 315 articles, however, were cited 3942 times before retraction and 4501 times after being withdrawn; scientists were using these flawed, withdrawn studies to support their own research. “Unless researchers take it upon themselves to double-check all their citations or are compelled to do so by journals as a condition of publication, retracted studies will continue to propagate through scientific literature,” writes Roger Collier in Canadian Medical Association Journal.

Collier R. Shedding light on retractions. Can Med Assoc J. April 19, 2011;183(7):E385–E386. Available at http://ecmaj.ca/content/183/7/E385.full. Accessed October 18, 2011.

Steen RG. Retractions in the scientific literature: do authors deliberately commit research fraud? J Med Ethics. 2011;37:113–117. Available at http://bioon.com/trends/UploadFiles/201011/2010111618294149.pdf. Accessed November 10, 2011.

———. Retractions in the scientific literature: is the incidence of research fraud increasing? [abstract] J Med Ethics. 2011;37:249–253. Available at http://jme.bmj.com. Accessed October 18, 2011.

Wager E, Williams P. Why and how do journals retract articles? An analysis of Medline retractions 1988-2008 [abstract]. J Med Ethics. 2011;37:567–570. Available at http://jme.bmj.com. Accessed October 18, 2011.

Nutrient Testing

Nutrient laboratory testing was the subject of a roundtable discussion recently published in Alternative and Complementary Therapies (June 2011). Participants included Ron Hunninghake, MD, chief medical officer at the Riordan Clinic (Wichita, Kansas); Todd LePine, MD, clinical medical director of Metametrix Clinical Laboratory (Duluth, Georgia); Richard S. Lord, PhD, chief science officer at Metametrix; and Jonathan E. Prousky, MSc, ND, chief naturopathic medical officer and a professor of clinical nutrition at the Canadian College of Naturopathic Medicine (North York, Ontario, Canada).

Functional nutritional testing is far more complex than simply identifying excess or deficient nutrient levels that can be remedied by adjusting supplement intake. Practitioners need to recognize that serum levels of a nutrient may be normal, but coenzyme/enzyme deficiencies or abnormalities (due to genetic variations) can prevent its use. Such biological individuality can cause a body to need far more of a nutrient than what is considered normal. Prousky uses serum nutrient levels as “a starting point.” He refers to a study in which patients with psychological and cognitive changes had normal B12 levels in blood samples but deficient levels in their cerebrospinal fluid. Prousky says, “… even if the laboratory testing does not show a serum deficiency, the patient may not have an organ sufficiency. This is an important clinical concept to remember when using nutrient laboratory test results.”

As with other laboratory tests, nutritional testing accuracy depends upon correct patient preparation (i.e., fasting), correct handling and storage of the specimen, and quality-controlled laboratory practices. However, even when a laboratory maintains excellent standards of accuracy and precision, results will differ because of biological variability. Biochemistry isn’t static. The body continually adjusts; and some compounds, such as cholesterol, vary significantly – up to 51% – even when samples are taken at the same sitting. “As you move into the realm of physiological compounds,” Lord says, “the clinical question is: ‘Does a given measurement represent the patient’s true average?’ … You may have to measure cholesterol in three different specimens before you know the true average value [for that patient].”

Prousky advocates careful physical examination and prudent use of nutrient testing. “We have to be very rational and ethical, while considering the costs,” he states. “Will the outcome of the test actually change the anticipated treatment? Patients can be highly motivated not only by numbers but also by the interactions they have with their doctors.”

Hunninghake R, LePine T, Prousky JE, Lord RS. Roundtable discussion: the value of nutrient laboratory testing. Altern Complement Ther. June 2011;17(3):142–148. Available at CINAHL Plus with Full Text. Accessed November 10, 2011.

Nutrients and Organic Produce

The majority of studies that compare organically grown with conventionally grown produce find more nutrients and less pesticide residue in organic food; yet, a widely publicized 2009 systematic review led by A.D. Dangour found “no evidence of a difference in nutrient quality between organically and conventionally produced foodstuffs.” In a letter to American Journal of Clinical Nutrition, Charles Benbrook, Donald R. Davis, and Preston K. Andrews commented on methodologic flaws in the Dangour review, including the team’s exclusion of well-designed studies and the review’s conclusion, which ignored positive data presented in reviewed studies. In their letter, the three authors add: “Since 2008, some 15 new studies have been published, most of which use superior experimental designs and analytic methods, and most often show organic foods as being higher or equal, but rarely lower, in phytonutrients.”

“Determining the potential nutritional superiority of organic food is not a simple task,” says Walter Crinnion, ND in an article for Alternative Medicine Review. Crinnion chairs the Environmental Medicine Program at Southwest College of Naturopathic Medicine (Tempe, Arizona). To produce an accurate comparison between organic farming practices and conventional chemical practices, researchers must control for microclimates, soil conditions, and seed variety. All of these factors affect a crop’s vitamin, mineral, and phytochemical content. Crinnion also states that the number of years that a plot of land has been farmed organically affects nutrient levels. According to US regulation, land must be farmed organically for just three years in order to become certified. However, a 10-year University of California-Davis study showed that “… while the flavonoid levels in tomatoes from conventional plots stayed relatively constant over 10 years, those from organic plots kept increasing each year. The increase in flavonoid levels corresponded with increasing levels of organic matter in the soil and the reduction of manure application after the plots became rich in organic matter.” Studies that compare crops grown on recently certified organic land with conventional crops may be less likely to find a difference in nutrient levels, says Crinnion.

Few studies have looked at organically grown food’s effect on human health. Crinnion says that performing a literature review on the topic is difficult because PubMed does not have a Medical Subject Heading (MeSH) for “organic food.” He found one article involving 815 2-year-olds that showed a 35% reduction in eczema risk among children given organic, rather than conventional, milk and milk products. More carefully designed studies on the health effects of eating organic are needed.

Benbrook C, Davis DR, Andrews PK. Methodologic flaws in selecting studies and comparing nutrient concentrations led Dangour et al to miss the emerging forest amid the trees. Am J Clin Nutr. December 2009;90(6):1700–1701. Available at www.ajcn.org/content/90/6/1700.full. Accessed October 18, 2011.

Crinnion WJ. Organic foods contain higher levels of certain nutrients, lower levels of pesticides, and may provide health benefits for the consumer. Altern Med Rev. 2010;15(1):4–12. Available at www.thorne.com/altmedrev/.fulltext/15/1/4.pdf. Accessed October 17, 2011.

Measuring Nutrition’s Effect on Cognition

While studies, particularly with infants and children, indicate that nutrition affects brain function and development, no long-term randomized controlled studies that show specific causal effects on cognition exist. Following the diets of large groups of people in utero to the grave is costly and time-consuming. Individual variations in diet, as well as differences in environmental, lifestyle, socioeconomic factors, and genetic/individual biochemistry, complicate the task of designing and conducting a RCT nutrition study. “Given the multiplicity of transacting factors influencing the development of cognitive abilities, teasing out independent effects of nutrition presents a daunting methodological challenge and requires careful experimental design,” state E. Isaacs and J. Oates. Measuring cognitive function is more subjective than measuring blood levels of a nutrient or tracking cause of death. In their 2008 article for European Journal of Nutrition, Isaacs and Oates explain cognitive assessment principles so that nutritionists can evaluate the quality of nutrition-cognition studies and/or design solid research themselves.

Although the brain retains its ability to adapt throughout life, nutrition has its greatest effect during periods of rapid development in the central nervous system (CNS). CNS development is particularly rapid during the third trimester before birth and the first few months after delivery. Other CNS “growth spurts” occur between ages 2 and 4, 6 and 8, 10 and 12, and 14 and 16. “Because neural development is a cascade of events,” write Isaacs and Oates, “even a small change early in the sequence may have a large and diffuse impact on future development.”

In their article, Isaacs and Oates discuss a variety of tests that measure cognitive function in children. Until recently, most medical studies have used an overall assessment of cognitive function, such as an IQ test; but these global assessments measure general function rather than specific abilities. As a result, the authors encourage nutritionists and researchers to use tests that have been successfully used in drug trials to measure small changes in cognitive performance. If no standardized assessment for a particular outcome is available, researchers can develop their own and conduct a pilot study to evaluate their test’s sensitivity. Experimenters need to beware of using tests that have not been standardized for their test population’s culture. For example, translating words used in a standardized memory test into another language does not have the same validity as the original test; the translated words may be unfamiliar or used less often in the culture, making them harder to remember. In addition to performance assessment, researchers now have the advantage of using brain imaging technology to map nutrients’ effects.

As Isaacs and Oates wisely advise, “… the more thought that goes into planning the study before data collection starts, the better the outcome will almost certainly be. This means articulating very specifically what the aim of the study is and choosing a design that will allow the question to be answered. It is a good idea to plan the way that the data will be analyzed ahead of time to ensure that the appropriate data are collected to allow the statistical analysis.”

Isaacs E, Oates J. Nutrition and cognition: assessing cognitive abilities in children and young people. Eur J Nutr. August 2008;47(Suppl 3):4–24. Available at EBSCOHealth Source Nursing/Academic Edition Database. Accessed October 19, 2011.

The Physical Exam

Abraham Verghese, MD, with the help of colleagues at Stanford University’s medical school (California) is campaigning for a revival of “the lost art” of the physical exam. “The new era of health care reform will probably bring with it a new level of accountability,” write Verghese and colleague John Kugler, MD. “It is unlikely that the promiscuous ordering of imaging and other lab tests can continue to conceal the problem of poor physical exam skills.” Verghese and Kugler contend that emphasizing physical exam skills would make doctors more observant, able to make quicker and more accurate diagnoses, and less likely to order unnecessary (and costly) tests.

Although medical students are still taught how to use stethoscopes and reflex hammers to perform a physical exam, those skills are never fully developed. Interns and residents spend more time writing orders for tests and clicking on drop-down boxes in electronic medical records. Because of this, Verghese, who is the senior associate chair for the theory and practice of medicine at Stanford, designed “The Stanford Medicine 25 Program” for the school’s first-year residents (interns). The hands-on practice sessions of 25 diagnostic skills have also become popular with the school’s second- and third-year residents. As the program grows, Verghese hopes that the school’s residents will act as mentors to each year’s new group of interns. The list of diagnostic techniques is available at http://stanmed.stanford.edu/2010summer/article3a.html.

In addition to providing medical data, a skilled physical exam creates a “ritual,” says Verghese, a ritual that creates a bond between doctor and patient. When performed with skill and respect, a physical exam engenders trust and has a healing power of its own. In “A Touch of Sense,” Verghese writes:

I can recall occasions when my visit with a difficult or aggrieved patient, or with a garrulous and hypochondriac patient, changed course as I performed a detailed examination. On those occasions, I had a sense that the exam had flowed, it had become almost a dance, one in which the patient was an active participant, and that it had quieted and reassured my patient, the exam itself bringing about this change. Indeed, in those moments, I became aware that I’d changed, too, as though both of us – doctor and patient – had entered some sacred space by virtue of this ritual and had been transformed.

No matter how sophisticated medical tests become, they will never be able to create the healing magic that occurs between two people.

Kugler J, Verghese A. The physical exam and other forms of fiction. J Gen Intern Med. 2010;25(8):756–757. Available at www.stanford25.wordpress.com. Accessed October 25, 2011.

The Stanford Medicine 25: Exam techniques every doctor should know. Summer 2010. Available at http://stanmed.stanford.edu/2010summer/article3a.html. Accessed October 25, 2011.

Verghese A. A touch of sense. Health Affairs. 2009;28(4):1177–1182. Available at http://content.healthaffairs.org/content/28/4/1177.full.html. Accessed October 25, 2011.