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Lopez G, Eddy C, Liu W, Li Y, Chen M, Bruera E, Cohen L. Physical Therapist-Led Exercise Assessment and Counseling in Integrative Cancer Care: Effects on Patient Self-reported Symptoms and Quality of Life. Integr Cancer Ther 2019; 18:1534735419832360. [PMID: 30862209 PMCID: PMC6416745 DOI: 10.1177/1534735419832360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Exercise - contributes to improved treatment-related outcomes. We reviewed characteristics of cancer patients referred for physical therapist-led exercise counseling at a comprehensive cancer center and its effects on self-reported symptoms and quality of life. METHODS Patients presenting for outpatient exercise counseling from February 2016 to May 2017 completed the Edmonton Symptom Assessment Scale (ESAS; 0-10 scale, 10 most severe) pre-encounter/post-encounter and Patient-Reported Outcomes Measurement Information System (PROMIS10) global health assessment pre-encounter. Counseling included assessment and education. ESAS individual items and subscales of physical distress (PHS), psychological distress, and global distress (GDS) were analyzed. We used paired t-tests to compare (1) ESAS symptoms pre-encounter/post-encounter and (2) ESAS and PROMIS10 scores at baseline (pre-encounter) and first follow-up. RESULTS Of 350 participants, most were female (77.7%), Caucasian (66.3%), and had breast cancer (43%). Baseline (pre-encounter) symptom scores (frequency; mean) included poor sleep (68.2%; 3.5), poor well-being (67.4%; 3.2), and fatigue (64.7%; 3.1). Comparing pre-encounter/postencounter ESAS outcomes, we observed statistically and clinically significant reduction in GDS (-3.32; SD = 6.52; P < .001). On follow-up, statistically and clinically significant improvements were observed for fatigue (-1.22; P = .01), GDS (-4.81; P = .01), PHS (-3.1; P = .03) and PROMIS10 global health, mental health, and physical health scores (all P <.05). CONCLUSION Patients presenting for exercise counseling had a low to moderate symptom burden and experienced significant improvement in GDS. Longitudinal evaluation revealed improvement in global health and fatigue. Additional research is needed to learn more about patient selection and timing of exercise counseling.
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Affiliation(s)
- Gabriel Lopez
- Department of Palliative Care,
Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer
Center, Houston, TX, USA
| | - Carol Eddy
- Department of Palliative Care,
Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer
Center, Houston, TX, USA
| | - Wenli Liu
- Department of Palliative Care,
Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer
Center, Houston, TX, USA
| | - Yisheng Li
- Department of Biostatistics, The
University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Minxing Chen
- Department of Biostatistics, The
University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care,
Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer
Center, Houston, TX, USA
| | - Lorenzo Cohen
- Department of Palliative Care,
Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer
Center, Houston, TX, USA
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Hardcastle SJ, Galliott M, Lynch BM, Nguyen NH, Cohen PA, Mohan GR, Johansen NJ, Saunders C. Acceptability and utility of, and preference for wearable activity trackers amongst non-metropolitan cancer survivors. PLoS One 2018; 13:e0210039. [PMID: 30596781 PMCID: PMC6312256 DOI: 10.1371/journal.pone.0210039] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/14/2018] [Indexed: 01/14/2023] Open
Abstract
Purpose The study purpose was to investigate the acceptability and utility of, and preference for, wearable activity trackers (WATs) amongst cancer survivors living in regional and remote areas of Western Australia. Methods Twenty participants were recruited (Mean age = 63 years, SD = 13) to test two to three trackers from five available models (Fitbit Alta, Garmin Vivofit 2, Garmin Vivosmart, Polar loop 2 and Polar A300). Participants wore each device for two weeks, followed by a one-week washout period between devices. Interviews were conducted with participants to explore user perceptions and experiences. Interview transcripts were analysed using thematic analysis. Results Four main themes emerged: (i) Consciousness raising; (ii) Prompts and Feedback; (iii) Accuracy and registry of activities; and, (iv) WAT preferences and features. Conclusions WATs were acceptable and useful to cancer survivors. WATs increased self-awareness of physical activity, provided real time feedback in relation to step goals, and reinforced progress and efforts towards goals. The aesthetics of the WATs were deemed crucial in determining preference and likelihood of use. Implications for cancer survivors Future interventions may do well to have two different WATs available for participants to choose from, according to activity preferences, aesthetic preferences, and display size.
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Affiliation(s)
- Sarah J. Hardcastle
- School of Psychology, Curtin University, Perth, WA, Australia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
- * E-mail:
| | | | | | | | - Paul A. Cohen
- School of Medicine, University of Western Australia, Crawley, WA, Australia
- St John of God Hospital, Subiaco, WA, Australia
| | | | | | - Christobel Saunders
- School of Medicine, University of Western Australia, Crawley, WA, Australia
- Hollywood Private Hospital, Nedlands, WA, Australia
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Martínez N, Herrera M, Frías L, Provencio M, Pérez-Carrión R, Díaz V, Morse M, Crespo MC. A combination of hydroxytyrosol, omega-3 fatty acids and curcumin improves pain and inflammation among early stage breast cancer patients receiving adjuvant hormonal therapy: results of a pilot study. Clin Transl Oncol 2018; 21:489-498. [PMID: 30293230 DOI: 10.1007/s12094-018-1950-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 09/07/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Breast cancer patients receiving hormonal therapies face risks of relapse, increased rates of cardiovascular events, and toxicities of therapy such as aromatase inhibitor (AI)-associated musculoskeletal symptoms (AIMSS). C-reactive protein (CRP), a marker for inflammation, is associated with breast cancer outcomes. We evaluated whether the olive-derived polyphenol hydroxytyrosol combined with omega-3 fatty acids and curcumin would reduce CRP and musculoskeletal symptoms in breast cancer patients receiving adjuvant hormonal therapies. EXPERIMENTAL DESIGN This prospective, multicenter, open-label, single arm, clinical trial enrolled post-menopausal breast cancer patients (n = 45) with elevated C-reactive protein (CRP) taking predominantly aromatase inhibitors to receive a combination of hydroxytyrosol, omega-3 fatty acids, and curcumin for 1 month. CRP, other inflammation-associated cytokines, and pain scores on the Brief Pain Inventory were measured before therapy, at the end of therapy and 1 month after completion of therapy. RESULTS CRP levels declined during the therapy [from 8.2 ± 6.4 mg/L at baseline to 5.3 ± 3.2 mg/L (p = 0.014) at 30 days of treatment], and remained decreased during the additional 1 month off therapy. Subjects with the highest baseline CRP levels had the greatest decrease with the therapy. Pain scores also decreased during the therapy. There were no significant adverse events. CONCLUSIONS The combination of hydroxytyrosol, omega-3 fatty acids, and curcumin reduced inflammation as indicated by a reduction in CRP and reduced pain in patients with aromatase-induced musculoskeletal symptoms. Longer studies comparing this combination to other anti-inflammatories in larger groups of patients with clinical outcome endpoints are warranted.
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Affiliation(s)
- N Martínez
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Herrera
- Hospital Clínico San Carlos, Madrid, Spain
| | - L Frías
- Hospital Universitario La Paz, Madrid, Spain
| | - M Provencio
- Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | - V Díaz
- Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | - M C Crespo
- IMDEA-Food, CEI UAM + CSIC, Madrid, Spain
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Bodai BI, Nakata TE, Wong WT, Clark DR, Lawenda S, Tsou C, Liu R, Shiue L, Cooper N, Rehbein M, Ha BP, Mckeirnan A, Misquitta R, Vij P, Klonecke A, Mejia CS, Dionysian E, Hashmi S, Greger M, Stoll S, Campbell TM. Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival. Perm J 2018; 22:17-025. [PMID: 29035175 DOI: 10.7812/tpp/17-025] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
By ignoring the root causes of disease and neglecting to prioritize lifestyle measures for prevention, the medical community is placing people at harm. Advanced nations, influenced by a Western lifestyle, are in the midst of a health crisis, resulting largely from poor lifestyle choices. Epidemiologic, ecologic, and interventional studies have repeatedly indicated that most chronic illnesses, including cardiovascular disease, cancer, and type 2 diabetes, are the result of lifestyles fueled by poor nutrition and physical inactivity.In this article, we describe the practice of lifestyle medicine and its powerful effect on these modern instigators of premature disability and death. We address the economic benefits of prevention-based lifestyle medicine and its effect on our health care system: A system on the verge of bankruptcy. We recommend vital changes to a disastrous course. Many deaths and many causes of pain, suffering, and disability could be circumvented if the medical community could effectively implement and share the power of healthy lifestyle choices. We believe that lifestyle medicine should become the primary approach to the management of chronic conditions and, more importantly, their prevention. For future generations, for our own health, and for the Hippocratic Oath we swore to uphold ("First do no harm"), the medical community must take action. It is our hope that the information presented will inspire our colleagues to pursue lifestyle medicine research and incorporate such practices into their daily care of patients. The time to make this change is now.
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Affiliation(s)
- Balazs I Bodai
- Director of The Breast Cancer Survivorship Institute in Sacramento, CA.
| | - Therese E Nakata
- Program Manager of The Breast Cancer Survivorship Institute in Sacramento, CA.
| | | | - Dawn R Clark
- Chief Facilitator of the Physician Wellness Program and an Obstetrician/Gynecologist at the San Dimas-Baldwin Park Medical Center in San Dimas, CA.
| | - Steven Lawenda
- Internist at the Antelope Valley Medical Center in Lancaster, CA.
| | | | - Raymond Liu
- Chief of Hematology-Oncology at the San Francisco Medical Center in CA.
| | - Linda Shiue
- Internist and the Director of Culinary Medicine at the San Francisco Medical Center in CA.
| | - Neil Cooper
- Radiologist at the Glenlake Medical Center in Atlanta, GA.
| | - Michael Rehbein
- Pediatrician and Assistant Physician-in-Charge for Outpatient Service at the Stockton Medical Office in CA.
| | - Benjamin P Ha
- Associate Area Medical Director for Family Medicine at the Bakersfield Medical Center in CA.
| | - Anne Mckeirnan
- Obstetrician/Gynecologist at the San Diego Medical Center in CA.
| | - Rajiv Misquitta
- Primary Care Physician at the South Sacramento Medical Center in CA. He is also an Elected Representative on The Permanente Medical Group Board of Directors.
| | - Pankaj Vij
- Medical Director of the Kaiser Permanente Weight Management Program in Pleasanton, CA.
| | - Andrew Klonecke
- Nuclear Medicine Specialist at the Sacramento Medical Center and at the Roseville Medical Center in CA.
| | | | - Emil Dionysian
- Orthopedic Surgeon at the Lakeview Medical Offices and at the Orange County Medical Center in Anaheim, CA.
| | - Sean Hashmi
- Internist at the Woodland Hills Medical Center in CA.
| | - Michael Greger
- Physician and Founder of NutritionFacts.org in Kensington, MD.
| | - Scott Stoll
- Co-Founder and Chairman of the Plantrician Project in Rieglesville, PA.
| | - Thomas M Campbell
- Instructor of Clinical Family Medicine at the University of Rochester School of Medicine and Dentistry and the Co-Founder and Clinical Director of the University of Rochester Program for Nutrition in Medicine in NY.
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Chapman J, Fletcher C, Flight I, Wilson C. Pilot randomized trial of a volitional help sheet‐based tool to increase leisure time physical activity in breast cancer survivors. Br J Health Psychol 2018; 23:723-740. [DOI: 10.1111/bjhp.12313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/04/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Janine Chapman
- Flinders Centre for Innovation in Cancer College of Medicine and Public Health Flinders University Bedford Park South Australia Australia
| | - Chloe Fletcher
- Flinders Centre for Innovation in Cancer College of Medicine and Public Health Flinders University Bedford Park South Australia Australia
| | - Ingrid Flight
- Flinders Centre for Innovation in Cancer College of Medicine and Public Health Flinders University Bedford Park South Australia Australia
| | - Carlene Wilson
- Flinders Centre for Innovation in Cancer College of Medicine and Public Health Flinders University Bedford Park South Australia Australia
- Olivia Newton John Cancer Wellness and Research Centre Heidelberg Victoria Australia
- School of Psychology and Public Health La Trobe University Bundoora Victoria Australia
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Knowledge, attitudes, and practice of oncologists and oncology health care providers in promoting physical activity to cancer survivors: an international survey. Support Care Cancer 2018; 26:3711-3719. [PMID: 29740694 DOI: 10.1007/s00520-018-4230-1] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 04/26/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To investigate knowledge, attitudes, and practices of oncologists towards physical activity (PA) in cancer survivors, and the association between oncologists' own PA behavior and PA promotion. METHODS Oncologists (n = 123) completed a survey based on the Theory of Planned Behavior (TPB). Participants reported PA promotion behavior, PA involvement, attitudes, intentions, social norm, perceived behavioral control (PBC), and confidence and knowledge of exercise prescription. Structural equation modeling (SEM) evaluated these associations. RESULTS Less than half of oncologists reported regularly promoting PA to patients (46%), with 20% providing written information and 23% referrals. Only 26% were physically active. TPB SEM pathways explained 54.6% of the variance in PA promotion (comparative fit index (CFI) = 0.905, standardized root mean square residual (SRMR) = 0.040). Social norm was not only the significant pathway to intention but also a significant indirect pathway to PA promotion (p = 0.007). Confidence to promote PA, PBC, and intentions were direct significant pathways to PA promotion (p < 0.05). Exploratory SEM pathways explained 19.6% of the variance of PA behavior, which in turn explained 13.1% social norm, 10.7% attitude, 10.0% confidence to recommend, and 17.8% PA promotion behavior (CFI = 0.921, SRMR = 0.076). Instrumental attitude was a direct significant pathway to PA behavior (p = 0.001). PA behavior was a direct significant pathway to social norms, attitude, confidence to recommend, and PA promotion (p < 0.05). CONCLUSIONS Oncologists reported a modest ability to promote PA, low PA promotion rates, and limited knowledge of exercise prescription. Patient physical activity promotion may be improved through strategies that increase oncologists' PBC, confidence, and their own personal PA participation.
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Maxwell-Smith C, Cohen PA, Platell C, Tan P, Levitt M, Salama P, Makin GB, Tan J, Salfinger S, Kader Ali Mohan GR, Kane RT, Hince D, Jiménez-Castuera R, Hardcastle SJ. Wearable Activity Technology And Action-Planning (WATAAP) to promote physical activity in cancer survivors: Randomised controlled trial protocol. Int J Clin Health Psychol 2018; 18:124-132. [PMID: 30487917 PMCID: PMC6225057 DOI: 10.1016/j.ijchp.2018.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/23/2018] [Indexed: 11/28/2022] Open
Abstract
Background/Objective: Colorectal and gynecologic cancer survivors are at cardiovascular risk due to comorbidities and sedentary behaviour, warranting a feasible intervention to increase physical activity. The Health Action Process Approach (HAPA) is a promising theoretical framework for health behaviour change, and wearable physical activity trackers offer a novel means of self-monitoring physical activity for cancer survivors. Method: Sixty-eight survivors of colorectal and gynecologic cancer will be randomised into 12-week intervention and control groups. Intervention group participants will receive: a Fitbit Alta™ to monitor physical activity, HAPA-based group sessions, booklet, and support phone-call. Participants in the control group will only receive the HAPA-based booklet. Physical activity (using accelerometers), blood pressure, BMI, and HAPA constructs will be assessed at baseline, 12-weeks (post-intervention) and 24-weeks (follow-up). Data analysis will use the Group x Time interaction from a General Linear Mixed Model analysis. Conclusions: Physical activity interventions that are acceptable and have robust theoretical underpinnings show promise for improving the health of cancer survivors.
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Affiliation(s)
| | - Paul A. Cohen
- Bendat Comprehensive Cancer Centre, Salvado Road, Subiaco, Australia
- School of Medicine, University of Western Australia, Stirling Highway, Crawley, Australia
- Institute for Health Research, University of Notre Dame, Fremantle, Australia
- Women Centre, McCourt street, West Leederville, Australia
| | - Cameron Platell
- St John of God Subiaco Hospital, Salvado Road, Subiaco, Australia
- University of Western Australia, Stirling Highway, Crawley, Australia
| | - Patrick Tan
- St John of God Subiaco Hospital, Salvado Road, Subiaco, Australia
| | - Michael Levitt
- St John of God Subiaco Hospital, Salvado Road, Subiaco, Australia
| | - Paul Salama
- St John of God Subiaco Hospital, Salvado Road, Subiaco, Australia
| | - Gregory B. Makin
- St John of God Murdoch Hospital, Murdoch Drive, Murdoch, Australia
| | - Jason Tan
- Women Centre, McCourt street, West Leederville, Australia
| | - Stuart Salfinger
- St John of God Subiaco Hospital, Salvado Road, Subiaco, Australia
| | | | - Robert T. Kane
- School of Psychology, Curtin University, Kent Street, Bentley, Australia
| | - Dana Hince
- Institute for Health Research, University of Notre Dame, Fremantle, Australia
| | | | - Sarah J. Hardcastle
- School of Psychology, Curtin University, Kent Street, Bentley, Australia
- School of Medicine, University of Western Australia, Stirling Highway, Crawley, Australia
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Weigl J, Hauner H, Hauner D. Can Nutrition Lower the Risk of Recurrence in Breast Cancer? Breast Care (Basel) 2018; 13:86-91. [PMID: 29887784 PMCID: PMC5981678 DOI: 10.1159/000488718] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The impact of diet on breast cancer prognosis is poorly understood. Therefore, we conducted a literature search summarizing the current evidence on the effect of diet on breast cancer recurrence and mortality. METHODS The PubMed database was searched for original studies, reviews, and meta-analyses published between 2010 and 2017. Studies related to diet, dietary patterns, special diets or specific dietary factors, and breast cancer recurrence or mortality were included. RESULTS Adherence to high diet quality indices (relative risk (RR) 0.74, 95% confidence interval (CI) 0.60-0.90) and a prudent/healthy dietary pattern (RR 0.76, 95% CI 0.60-0.95) may have a beneficial effect on breast cancer prognosis, whereas a Western/unhealthy diet is associated with poorer overall mortality (RR 1.44, 95% CI 1.17-1.77). For low-fat diets, the findings are inconsistent. A positive effect of the Mediterranean Diet was found for all-cause mortality, but no beneficial effect from other diets such as low-carbohydrate, ketogenic or vegetarian/vegan diets was observed. Alcohol consumption was associated with an increased risk for breast cancer recurrence. No general recommendation for soy exists, but occasional intake seems to be acceptable, whereas the use of other supplements is not justified. CONCLUSION Adherence to high-quality diets and a prudent/healthy dietary pattern seem to be beneficial for breast cancer prognosis. No clear evidence for a benefit from special diets, soy products, or other supplements was found.
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Affiliation(s)
| | - Hans Hauner
- Institute for Nutritional Medicine, Else Kröner-Fresenius-Center for Nutritional Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Seiler A, Chen MA, Brown RL, Fagundes CP. Obesity, Dietary Factors, Nutrition, and Breast Cancer Risk. CURRENT BREAST CANCER REPORTS 2018; 10:14-27. [PMID: 30662586 PMCID: PMC6335046 DOI: 10.1007/s12609-018-0264-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW To synthesize the critical role of obesity-associated inflammation, dietary factors, and nutrition in determining breast cancer risk. RECENT FINDINGS Obesity-associated inflammation is strongly linked to breast cancer risk and progression, largely via two processes: inflammatory pathways and dysregulated metabolism. Cytokine production in excess adipose tissues creates a chronic inflammatory microenvironment, which favors tumor development. Lifestyle factors, including diet, have long been recognized as important determinants of breast cancer risk and mortality. SUMMARY Obesity increases the risk of developing breast cancer in both pre- and postmenopausal women and also negatively affects breast cancer recurrence and survival. Poor dietary habits characterized by the high intake of refined starches, sugar, and both saturated and trans-saturated fats, as well as the low intake of omega-3 fatty acids, natural antioxidants, and fiber, modulate inflammation and, thereby, appear to be linked to increased risk of breast cancer and mortality.
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Affiliation(s)
- Annina Seiler
- Department of Consultation-Liaison-Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Haldenbachstrasse 18, 8091 Zurich, Switzerland
| | | | - Ryan L Brown
- Department of Psychology, Rice University, Houston, TX, USA
| | - Christopher P Fagundes
- Department of Psychology, Rice University, Houston, TX, USA
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Hardcastle SJ, Cohen PA. Effective Physical Activity Promotion to Survivors of Cancer Is Likely to Be Home Based and to Require Oncologist Participation. J Clin Oncol 2017; 35:3635-3637. [PMID: 28915086 DOI: 10.1200/jco.2017.74.6032] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Sarah J Hardcastle
- Sarah J. Hardcastle, Curtin University, Perth; and University of Western Australia, Crawley, Western Australia, Australia; and Paul A. Cohen, St John of God Subiaco Hospital, Subiaco; University of Western Australia, Crawley; University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Paul A Cohen
- Sarah J. Hardcastle, Curtin University, Perth; and University of Western Australia, Crawley, Western Australia, Australia; and Paul A. Cohen, St John of God Subiaco Hospital, Subiaco; University of Western Australia, Crawley; University of Notre Dame Australia, Fremantle, Western Australia, Australia
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