Complementary and Alternative therapies in Psychiatry
Upcoming SlideShare
Loading in...5
×
 

Complementary and Alternative therapies in Psychiatry

on

  • 711 views

This is a seminar which i had presented as a part of academic activity in my department. Please comment on the seminar, so that i can make any future changes... Thank you.

This is a seminar which i had presented as a part of academic activity in my department. Please comment on the seminar, so that i can make any future changes... Thank you.

Statistics

Views

Total Views
711
Views on SlideShare
711
Embed Views
0

Actions

Likes
1
Downloads
59
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Complementary and Alternative therapies in Psychiatry Complementary and Alternative therapies in Psychiatry Presentation Transcript

  • Complementary and Alternative Therapies in Psychiatry Presenter- Dr.D.Raj Kiran Chairperson- Dr.Keshava Pai “He's the best physician that knows the worthlessness of the most medicines“ - Benjamin Franklin
  • National Centre for Complementary and Alternative Medicine (NCCAM) • It is the US Government's agency for scientific research on complementary and alternative medicine (CAM). • Mission: - Is to define, through scientific investigation, the usefulness and safety of CAM interventions and their roles in improving health and health care. • In India, it is Indian Board for Alternative Medicine (IBAM). • IBAM- A Internationally Recognized Government Institution of CAM providing world-wide research in the field of complementary and alternative medicines.
  • • 1. CAM: - Group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine. • 2. Complementary medicine: - It is used together with conventional medicine. • 3. Alternative medicine: - It is used in place of conventional medicine. • 4. Integrative medicine: - It combines mainstream medical therapies and CAM therapies for which there is some highquality scientific evidence of safety and effectiveness.
  • National Health Interview Survey by CDC in USA in 2007 • In adults- 4 /10 use CAM, most commonly used are non-vitamin, nonmineral, natural products (17.7%) and deep breathing exercises (12.7%). • In children- 1/ 9 use CAM, most commonly used are non-vitamin, nonmineral, natural products (3.9%) and chiropractic or osteopathic manipulation (2.8%). • Children whose parent used CAM were almost 5x as likely (23.9%) to use CAM. • When worry about cost delayed receipt of conventional care, individuals were more likely to use CAM.
  • NCCAM classifies CAM therapies into: •Alternative Medical Systems: – Built upon complete systems of theory and practice. Examples- Ayurveda, Homeopathy, Acupuncture and Chinese medicine. •Mind-Body Interventions: - Techniques designed to enhance the mind’s capacity to affect bodily function and symptoms. Examples - Meditation, Spirituality, Creative therapies. •Biologically Based Therapies: - Substances found in nature are used. Examples- Dietary supplements, Herbal products, vitamins. •Manipulative and Body based methods: - Based on manipulation and/or movement of one or more parts of the body. ExamplesYoga, Massage. •Energy Therapies: - Involves the use of energy fields. Two types: – a)Bio field therapies: - Qigong, Reiki, Therapeutic Touch. – b)Bio electromagnetic therapies- pulsed fields, magnetic fields, or alternating-current or direct-current fields.
  • • 5000 year old Indian system of healing. • Derived from Vedic concepts of health and healing . • Charaka Samhita is important compilation. • Focuses on prevention of illness rather than treatment. • Causes– Improper diet, – Actions committed in this birth, – Bad deeds done in the last birth, – Physical illnesses and overindulgence, – Severe mental or physical stress, – Un favourable -personal, familial and social environment
  • • Mental Disorders described in Ayurveda– Unmada - Insanity, – Apasmara- Epilepsy, – Avasada- Depression, – Citto Udvega- Anxiety neurosis, – Manasa Mandata- Mental Retardation, – Atatva abhinevisha- Obsessive Disorders, – Madatyaya - Intoxication. • Describes three ‘guna’ of Mind (manas) -> Satwa , Raja &Tama. • Disease is due to imbalance of the ‘tamas’ or ‘rajas’ in the mind. • Rajas and Tamas are termed as ‘Doshas of mind’.
  • • Tridosha- Vata, Pitta and Kapha. • They literally mean the darkness and brightness of the mind or negative thoughts in the mind. • These impurities or imbalances are called ‘doshas’. • It concentrates on the aspect of mind, body and soul and thus moulds the treating process combining both mind and body. • It declares that health is the result of pure body, happy soul and selfless mind.
  • • Methods of healing• 1. Daivavyaprashya Chikitsa– Mantra- Chanting of Hymns, – Gems- Auspicious Stones, – Mangala- Auspicious offerings, – Homa- Yajna, – Niyama- Regulations, – Prayaschita-Atonement, – Upavasa-Fasting. • 2. Yukti Vyapashraya (Medicines)• a. Antah Parimarjana – (a) Shodhana: Cleansing (Panchkarma & Mild purgation , therapeutic Emesis & Purgation in Pitta & Kaphja type). – (b) Shamana: Palliative (Medhya Rasayanas, Diet etc.)
  • • 2. Yukti Vyapashraya (Medicines)• b. Bahir Parimarjnana- Murdha Taila, Ahyanga, Shirodhara. • 3. Satvavajaya Cikitsa (Psychotherapy)– Aim is to augment the sattva guna in order to correct the imbalance in state of rajas (passion) and tamas (inertia).” • NCCAM research- Most clinical trials were small, problems with research designs, or lacked control groups. Researchers have studied Ayurvedic approaches for schizophrenia; however, scientific evidence for its effectiveness is inconclusive.
  • • Developed in Germany by Samuel Hahnemann at the end of the 18th century. • Three unconventional theories: – "Like cures like“- disease can be cured by a substance that produces similar symptoms in healthy people. – "Law of minimum dose“- lower dose of medication, has greater effectiveness. – Remedies are effective when they are selected on the “total” characteristic set of symptoms, not just those of the disease. • Remedies are derived from plants, minerals, or animals, such as red onion, arnica, crushed whole bees, white arsenic, poison ivy, belladonna. • Formulated as sugar pellets.
  • • Widely used to self-treat generalized anxiety and other anxiety symptoms. • Case reports of homeopathic remedies in PTSD, social phobia, panic disorder, and OCD were published. However, findings of placebo-controlled studies were negative or equivocal. • NCCAM research on Homeopathy– Little evidence to support homeopathy as an effective treatment for any specific condition. – Key concepts are not consistent with fundamental concepts of chemistry and physics. For example, it is not possible to explain how a remedy containing little or no active ingredient can have any effect. – There is no uniform prescribing standard for practitioners.
  • • It is an ancient Chinese treatment & central to Traditional Chinese Medicine (TCM). • TCM promotes a holistic, energy-based approach to wellbeing, as opposed to the disease-oriented approach of Western medicine. • Acupuncture incorporates use of ultra-fine needles, inserted into specific points on the skin (acupoints). • Concept- The body’s energy/ Qi, flows along series of points called meridians. Each of the internal organs has a corresponding meridian, and applying pressure, heat or needles to relevant acupoints is believed to influence each of the internal organs and harmonize the body’s Qi.
  • • Exact mechanism is unclear. • Research shows that it results in local and systemic effects, such as an increased release of pituitary betaendorphins and ACTH. • Endorphins- Analgesic property, ACTH→ ↑Cortisol→ Anti inflammatory effects. • It also leads to accelerated synthesis & release of 5-HT & NA in CNS.
  • • Luo et al (1998) & Yang et al (1994) found electro-acupuncture to be as effective as amitriptyline for depressive symptoms. • Acupuncture is also a promising treatment for depression during pregnancy. • Wang et al (2001) found that pts treated with acupuncture reported significantly lower levels of anxiety than did controls. • Reports from the Chinese literature suggest that different acupuncture protocols are beneficial in the management of anxiety disorders. • Inconclusive evidence in treatment of Psychotic disorders and Substance use disorders.
  • • “It is a psychological state of active passivity and creative quiescence”. • Meditator purposefully and nonjudgmentally pays attention to the present moment. • Focus is on the process, or flow of psychic content, rather than on the content itself. • There are many types of meditation, most have originated in ancient religious and spiritual traditions. • Meditator generally uses certain techniques, such as a specific posture, focused attention, and an open attitude toward distractions.
  • • Two common forms- Mindfulness meditation and Transcendental meditation (TM). • Mindfulness- essential component of Buddhism. • The meditator is taught to bring attention to the sensation of the flow of the breath in and out of the body. • Helps the meditator learn to experience thoughts and emotions in normal life with greater balance and acceptance. • TM- derived from Hindu traditions. • Uses a mantra to prevent distracting thoughts from entering the mind. The goal of TM is to achieve a state of relaxed awareness.
  • • Davidson et al (2000)- meditation increases left-sided anterior activation → reductions in anxiety and negative affect and increases in positive affect. • Other physiological effects include – ↓ Oxygen consumption, – ↓ Respiratory rate, – ↓ BP, – EEG changes associated with decreased autonomic arousal. • RCTs- consistent practice of mindfulness meditation significantly reduces generalized anxiety and other anxiety symptoms. • NCCAM finds the common use of meditation in health problems like anxiety, pain, depression, stress, insomnia, physical symptoms associated with chronic illnesses.
  • • Religion: - Organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent. • Spirituality: - Personal quest for understanding answers to the ultimate questions about life. • In medieval ages most mental disorders were considered as witchcraft or demonic possession, when natural causes was not considered to mental disorders. • Most of the Physicians like Charcot, Maudslay, Sigmond Freud, Albert Ellis had anti religious stance based on their personal experiences. • David Larson, Jeffrey Levin, Harold Koenig have conducted a series of studies looking at the relationship between religious involvement and mental health.
  • • Levin & Chatters (1998) stated that “the existing research has shown that religious involvement has protective effects over psychological well-being related outcomes”. • Koenig et al (1998) found out that intrinsic religious motivation was associated with faster remission from depression. • Kendler et al (2003) found a strong association between religion and lower prevalence rates of nicotine, alcohol and drug abuse or dependence. • Koenig et al (2001) found lower rates of suicide or more objections to suicide among the more religious subjects • Koenig et al (2001) “Research has shown that medical patients have religious and spiritual needs that are intimately related to their physical health conditions, and that religious and spiritual beliefs and practices can often be important for emotional healing”
  • • Reasons ??? – Feelings of social connectedness, – Messages of healthy living, – Reduced drug-seeking behaviour, – Beliefs that justice prevails at the end, – Belief that adverse events always have a message and a meaning, – That there is a caring ever-present God. • Faith and Religion play important roles in the lives of many patients and physicians, but such concepts are yet to be incorporated into routine clinical care.
  • • Def: - It is based on the premise that when someone works creatively under the guidance of a qualified therapist, they become more expressive and communicative. • Music therapy: - It is use of music to accomplish individualized goals within a therapeutic relationship by a professional. • Art therapy: - It is a mental health profession who uses the creative process of art making to improve and enhance the physical, mental, and emotional wellbeing of individual. • Drama therapy: - It is the intentional use of drama and/or theatre processes to achieve therapeutic goals. • Dance therapy: - The psychotherapeutic use of movement to further the emotional, cognitive, physical and social integration of the individual.
  • • Others- Poetry therapy, Play therapy, Sand-play therapy, Multi-modal therapy. • Compared to others they have– Self expression, – Active participation, – Imagination, – Mind body connections. • Music therapy is the most widely researched modality, because physiological and behavioural reactions to music can be quantified.
  • • Beneficial effects- effects on endorphins and other neurotransmitters that mediate improvements in depressed mood. • A Cochrane review (2005)- concluded that Music therapy as an adjunct in schizophrenia was found to improve their global state and may also improve mental state and functioning. • A meta-analysis in dementia concluded that regular singing, engaging in dance therapy, listening to music, and participating in musical games improve cognitive and behavioural functioning in individuals with severe dementia. • They also experienced reduced agitation, irritability & wandering, enhanced social interaction mood & cooperative behaviour.
  • modifications • ↓ refined sugar and caffeine→ improves mood in some depressed patients. • Caffeine→ ↑ serum Adr, NA, and cortisol→ general feelings of “nervousness” / ↑ risk of panic attacks in predisposed individuals. • Consumption of high fat & calorie diet→ ↑ developing Alzheimer's disease compared to those who take moderate fat & calories. • Excess caloric & fat intake→ promote formation of damaging free radicals→ diffuse neuropathological changes in the brain. • Moderate but not heavy consumption of wine→ ↓ risk of Alzheimer's disease.
  • • Deficiencies: – Causative role in mental illness and exacerbate symptoms. – Symptoms can result in poor nutrition. – May compromise patient recovery. • B1 (Thiamine)– Chronic Alcoholism, Eating disorders. – Wernick’s encephalopathy, Korsakoff’s psychosis. • B2 (Riboflavin)– Excess Alcohol – Depression (Glutathione def) • B6 (Pyridoxine)– Hemodialysis, OCP’s. – Depression
  • • B9 (folate)– Required for synthesis of 5 HT, NA, DA. – Mood disorders, Depression, Psychosis. – Augmentation with L-Methylfolate in antidepressant rx. • B12 (Cobalamin)– Associated with ↑ Homocysteine. – Depression, Irritability, Agitation, Psychosis, Obsessive symptoms, Cognitive decline, Alzheimer’s dis. – Compromises antidepressant efficacy. • C (Ascorbic acid)– Drug/ Alcohol abuse, Eating disorders. – Depression, Schizophrenia. • A– Excess- Aggression, Depression, Psychosis, Suicide.
  • • D– Role in brain function and development. – Depression, Cognitive dysfunction, Seasonal Affective disorder. • Supplementation of Folate (1 to 15mg), Thiamine (50mg), Inositol (up to 20gm/ d)→ ↑ Efficacy of conventional antidepressants. • ↑ Serum Homocysteine is a marker for folate, B6, and B12 deficiencies→ risk factor for Alzheimer's disease and other neurodegenerative diseases. • Supplementation of Folate, Choline, Phosphatidylcholine → ↑ efficacy of lithium in acute mania. • In Schizophrenia, daily Folate & Niacin + antipsychotic→ fewer +ve & -ve symptoms and respond more rapidly.
  • • Mg – Rapid recovery from severe depressed mood, – Ameliorate symptoms of anxiety, irritability, insomnia, postpartum depression and short-term memory, – Improve neuropsychological deficits, – Low in ADHD and supplementation can help inattention. • Studies→ high copper levels may be a causative factor in the pathogenesis of Alzheimer's disease. • Deficiencies in Zinc, Manganese and Iron are common in alcoholics and worsen with chronic heavy use.
  • • In psychiatric symptoms→ SAMe (S Adenosyl l Methionine), L-tryptophan, 5-hydroxytryptophan, L-taurine, tyrosine, acetyl-L-carnitine & glycine. • SAMe– Efficacy in treatment of depression along with antidepressants. – ↓ SAMe→ may lead to depression in Alcoholics. • L-tryptophan – Effective in treatment of moderate depression and as adjuvant in treatment resistant depression. – Combined with antidepressant→ rapid response in insomnia. – ↓ levels → BPAD in genetic predisposed.
  • • Acetyl L Carnitine– Treat cognitive impairments related to dementia and other neurodegenerative disorders. – May improve mood in depression. • L-Theanine– Found in green tea – Treat symptoms of anxiety and depressed mood. – ↑ brain 5-HT, DA and GABA levels and may have neuro-protective effects. • Glycine– Some efficacy in treatment of -ve symptoms of schizophrenia in addition to antipsychotics.
  • • 2 main omega-3 FA - Eicosapentaenoic acid (EPA) & docosahexaenoic acid (DHA). • Studies suggest that PUFA’s- EPA and DHAAmeliorate symptoms associated with many psychiatric disorders. • Studies→ Association b/n depression and low omega-3 FA. • Studies → Therapeutic benefit when EPA is added on to existing psychotropic medication in depression & schizophrenia. • Individual trials→ Benefits of EPA treatment in BPD • Trails→ combined omega-3 and omega-6 fatty acid treatment for ADHD showed some evidence.
  • • EPA supplementation→ effective augmentation strategy for the management of MDD. • No definitive conclusions about the preventive or therapeutic role as a standalone treatment of MDD, BPAD, schizophrenia, ADHD, borderline personality disorder and other psychiatric disorders. • MOA- antidepressant efficacy include – ↑ CNS serotonin activity, – Anti-inflammatory effects, – Suppression of PIP second messenger activity, – ↑ Heart rate variability.
  • • Hypericum perforatum aka St John's wort, is a flowering plant. • Called so because traditional flowering and harvesting takes place on St John's day, 24 June. • Constituents (Hyperforin) function as – SRIs, – ↓ binding to BZD receptors, – Weakly inhibit MAO, – Possibly bind to NMDA receptors. • Current evidence→ treatment of mild to moderate depression and Somatisation disorder with tentative support in Seasonal affective disorder. • Studies were conducted to explore its use in other psychiatric disorders like ADHD, Dysthymia, OCD, GAD, Social phobia etc.., but the evidence is not conclusive.
  • • The ginkgo is a living fossil, with fossils recognisably dating back 270 million years. • It is one of the most frequently prescribed herbal preparation in Germany and over the counter herbal preparation in US. • MOA- Antioxidant and Anti PAF activity • Induces→ Modulatory effects on CerebroVasculature tone, receptor activity and EEG activity. • Indications- Alzheimer’s age associated dementia, Traumatic brain injury, Multi infarct dementia, Cerebral edema etc.., • Lack of evidence- autism, ADHD, addiction, GAD, and tardive dyskinesia. • Adverse effects- Bleeding tendencies.
  • • Yoga is a Sanskrit word, meaning “to join”. • Mahabharata- The experience of uniting the individual “Ātman” with the universal “Brahman” that pervades all things. • Early indications of yogic postures are seen in remains of Indus valley civilisation. • Early texts such as Patanjali’s yoga sutras describe the basic principles of yoga. • Sub-types and incorporates physical postures (asanas), controlled breathing (pranayama), deep relaxation and meditation. • Effects in mental illness- Calming effects, increasing awareness, increasing the attention span, Acceptance and adaptability and a sense of security.
  • • Sivakumar et al (2013)- following yoga significant improvement in cognitive function, QOL, sleep quality in elderly. • Gangadhar et al (2013)- in depression yoga had better efficacy than pharmacotherapy and devoid of side-effects. • Manjunath et al (2013)- found yoga with pharmacotherapy better than physical exercise in-patients with psychosis. • Varambally et al & Thirthalli et al (2013)demonstrated increase in serum BDNF & ↓ Cortisol following yoga in depression. • Good evidence as an adjunct treatment in depression, schizophrenia and ADHD. • Fair evidence in treatment of sleep disorders and eating disorders.
  • • Def- “The manipulation of the soft tissue of the body to bring about generalised improvements in health”. • Variety of strokes- effleurage, petrissage and kneading. • Touch- thought to be therapeutic in those with less physical contact like those without intimate friends or family or who have painful physical conditions. • Different ways- Lower stress, Increase immune function, Boost mental health and wellness, Manage pain and Improve physical fitness. • Increasingly being used as supplement to pharmacotherapy to counteract anxiety, agitated behaviour, and depression. • Its efficacy however, is contested.
  • Energy therapies • Believes healer can channel healing energy into the person seeking help by different methods. • Edzard Ernst (Prof of CAM)- "healing continues to be promoted despite the absence of biological plausibility or convincing clinical evidence ... that these methods work therapeutically and plenty to demonstrate that they do not." • These are controversial to conventional health care providers and policymakers for two main reasons: – The dearth of rigorous scientific data that support or refute their efficacy. – Because bio-fields currently cannot be measured, so their scientific method of action remains questionable.
  • • Provides healing energy to recharge and rebalance the human energy fields, creating optimal conditions needed by the body’s natural healing system. • Japanese term for ‘‘universal life energy,’’. • Originated thousands of years ago in Tibet and reestablished in the 1800s. • Administered through a gentle lying of hands. • Practitioner maintains a meditative presence and allows the Reiki energy to flow to where the patient needs it. • Studies- reduces anxiety and depression and increases relaxation and comfort. • Widely used outside of mainstream medicine, to relieve pain, especially postoperative pain and to facilitate patient recovery.
  • • Traditional Chinese exercises widely practised for health benefits. • Involves sequences of flowing movements coupled with changes in mental focus, breathing coordination and relaxation. • Relatively safe, non-pharmacological practices which can be used for treatment and proven benefit for psychosomatic diseases with few adverse events reported. • Showed improvement in immune function, vaccine response, increased endorphins and baroreceptor sensitivity, decreased inflammatory markers, ACTH and cortisol. • Most logical clinical application is for stress reduction.
  • Why people use Complementary and Alternative therapies? • Three theories have been proposed to explain the use of CAM • 1.Dissatisfaction: - Dissatisfied with conventional treatment because it has been ineffective, has produced adverse effects, or too costly. • 2.Need for personal contact: - They see them less authoritarian, more empowering, offering them offer personal autonomy over their health care decisions. • 3.Philosophical congruence: - More attractable because they are seen as more compatible with patients’ values, spiritual/ religious philosophy, or beliefs.
  • Take Home Message… • Whenever required using an alternative therapy may be helpful. • Usage of alternative therapies based on patients religious background. • To discourage the use of non evidence based therapies.
  • Refercences • 1.http://nccam.nih.gov/health/whatiscam. • 2.Barnes PM, Bloom B. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. National health statistics report. Number 12, December 10, 2008. • 3.Venkoba rao A. Mind in Ayurveda. Indian Journal of Psychiatry, 2002, 44(3)201-2. • 4.Ramu MG, Venkataram BS. Manovikara (Mental disorders) in Ayurveda. Ancient sci of life. Vol. IV, No.3 January 1985, Page 165-173. • 5.Ernat E. A systematic review of systematic reviews of homeopathy. Br J Clin Pharmacol, 54, 577–582. • 6.Acupuncture Research Resource Centre, British Acupuncture Council: Depression and anxiety: The evidence for effectiveness. Briefing paper No. 9. February 2002.Available at: http://www.acupuncture.org.uk/content/Library/doc/anxiety_bp9.pdf. • 7.McGee M. Meditation and psychiatry. Psychiatry 2008. Jan, pg 28-41. • 8.http://www.amtamassage.org/articles/1/News/detail/2885. • 9.Culliford L. Spiritual care and psychiatric treatment: an introduction. ment APT (2002), vol. 8, p. 249 Advances in Psychiatric Treatment (2002), vol. 8, pp. 249–261. • 10.Murali SR. Spirituality in psychiatry, Letters to the editor. Psychiatry 2005, sept, pg 20-3. • 11.http://www.musictherapy.org/ • 12.http://www.arttherapy.org/ • 13.http://www.adta.org/ • 14.http://www.nadta.org/ • 15.Herrmann W, Lorenzl S, Obeid R: Review of the role of hyperhomocysteinemia and B-vitamin deficiency in neurological and psychiatric disorders—Current evidence and preliminary recommendations. Fortschr Neurol Psychiatr. 2007;75(9):515. • 16.Kaplan BJ, Crawford SG, Field CJ, Simpson JS: Vitamins, minerals, and mood. Psychol Bull. 2007;133(5):747. • 17.Lakhan SE, Vieira KF: Nutritional therapies for mental disorders. Nutr J. 2008;7:2. • 18.Ross BM, Seguin J, Sieswerda LE: Omega-3 fatty acids as treatments for mental illness: Which disorder and which fatty acid? Lipids Health Dis. 2007;18(6):21. • 19.Sarris J: Herbal medicines in the treatment of psychiatric disorders: A systematic review. Phytother Res. 2007;21(8):703. • 20.Cavaye J. Does Therapeutic Massage Support Mental Well-Being?. Medical Sociology online. Volume 6, Issue 2, May 2012, pg 43- 50. • 21.Vander vaart S, Gijsen VMGJ, Wiidt SN, Koren G. A Systematic Review of the Therapeutic Effects of Reiki. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE. Volume 15, Number 11, 2009, pp. 1157–1169. • 22.Abbott R & Lavretsky H. Tai chi and Qigong for the treatment and prevention of mental disorders. In Sec 3: mind- body of Complemantary and integrative therapies for psychiatric disorders. PCNA. March 2013, vol 36, no 1, pg 109-20. • 23.Astin JA. Why patients use alternative medicine: results of a national study. JAMA, may 20, 1998, vol 279, no 19.
  • THANK YOU