Effect of impaired cognition on hypertension outcomes in older urban African Americans.
As the number of elders in the United States continues to grow, health care resources to manage the effects of aging and hypertension on cognitive decline are becoming more limited (HHS, 2003). Cognitive decline places people with hypertension at risk for inadequate blood pressure control because successful management may be dependent on cognitive ability to sustain self-care behaviors (Chobanian et al., 2003). Historically, a substantial number of studies supported the negative relationship between hypertension and cognitive function, but few were conducted with African-American samples (Elias, Robbins, Elias, & Streeten, 1998; Elias, Wolf, D'Agostino, Cobb, & White, 1993; Farmer et al., 1987; Glynn et al., 1999; Harrington, Saxby, McKeith, Wesnes, & Ford, 2000). More recently, investigators have expanded the study of the relationship of cognition and hypertension to African-American elders with hypertension; however, but few, if any, have explored the effect of cognitive difficulties in hypertension-related self-care (Goldstein et al., 2005; Insel, Morrow, Brewer, & Figueredo, 2006; Robbins, Elias, Elias, & Budge, 2005). The purpose of this pilot study was to examine the prevalence of selected cognitive impairments and explore the relationships among cognitive function, hypertension-related self-care, and blood pressure (BP) in African-American older adults.
The triarchic theory of human intelligence is a useful guide for understanding the cognitive components required to execute hypertension-related self-care. Because Sternberg (1988) developed the theory to circumvent prior culturally dependent models of intelligence, it was believed to have utility in application to African-Americans elders with varied educational and socioeconomic characteristics. In the triarchic theory, intelligence is viewed in terms of its information-processing components that allow adaptation and shaping of the environment by the individual. The individual adjusts his or her self-care actions within the personal environment in order to manage hypertension-related self-care for BP regulation. Such adjustments require intact information-processing functioning. Sternberg's triarchic model suggests that self-care actions require intact functioning in dimensions of cognition (memory, fluency, and orientation) considered to be critical in information processing. These cognitive dimensions were used to guide the selection of cognitive function measures in this study and also to examine the relationships among cognitive function, hypertension-related self-care, and blood pressure in African-American elders.
Design and sample. A descriptive and correlational design was used to examine cognitive function at baseline and hypertension-related self-care behaviors and BP at a 3-month follow up. Following approval by the Wayne State University Internal Review Board, African-American men and women age 60 and older were recruited from a larger clinical trial testing the effects of a home BP telemonitoring/telecounseling intervention on BP (Artinian et al., 2007). The clinical trial included a convenience sample of otherwise healthy African Americans with hypertension. The sample was recruited through free BP screenings offered at community centers, drug stores, and grocery stores in a large midwestern United States city.
Data collection procedures. To make arrangements for cognitive screening, the first author contacted participants by telephone after they completed the baseline interview of the parent study. Using a private room, two trained graduate psychology students administered cognitive testing at one of the study's affiliated community centers or at the participant's home. Testing took approximately 20 minutes. The first author was present at all locations during cognitive testing of participants. Baseline demographic data and 3-month data for hypertension self-care measures were obtained from the larger clinical trial and were collected according to the clinical trial protocol.
Cognitive function. For this study, cognitive function comprised three components: semantic fluency, memory, and temporal orientation. Each component was measured separately. Semantic fluency, as an index of frontal lobe function, is demonstrated by saying words from a particular semantic category (e.g., animals) (Brady, Spiro, McGlinchey-Berroth, Milberg, & Gaziano, 2001). Semantic fluency was measured with subscales from two instruments: (a) the rapid verbal retrieval subscale of the Fuld Object Memory Evaluation [FOME] (Fuld, 1982), and (b) the animal-naming subscale of the MacNeil Lichtenberg Decision Tree [MLDT] (MacNeill & Lichtenberg, 2000). The FOME uses rapid verbal retrieval to provide a composite score of timed recall of names, food, and vegetables. Participants are asked to pull 10 common household objects from a bag, indentify them, and then are given five opportunities to recall the items with subsequent reminders of items missed. Each opportunity to recall the items in the bag is separated by a 1-minute distraction trial that requires the participant to name items in different categories (e.g., names, foods, vegetables, "things that make you happy," and "things that make you sad"). Because women have higher normative scores, results for the rapid verbal retrieval subtest were compared against gender-based norms (Fuld, 1982). Validity and reliability of the FOME has been established in a similar African-American population (Mast, Fitzgerald, Steinberg, MacNeill, & Lichtenberg, 2001). The FOME is internally consistent (alpha coefficient = 0.84) and demonstrates adequate alternate forms reliability (r = 0.71) (Fuld, 1982).
The animal-naming test, a subscale of the MLDT, was used as an alternative measure of semantic fluency. Participants were asked to name as many different animals as they could, as fast as they could, for a period of 1 minute. A cut-off score of fewer than 10 animals named for persons with 12 years of education and less, and fewer than 14 animals named for persons with more than 12 years of education, was used to determine the presence of impairment (MacNeill & Lichtenberg, 2000). The MLDT has high levels of sensitivity (82%) and specificity (83%), with a high positive predictive value (85%) and a high negative predictive power (80%) (Bank, MacNeill, & Lichtenberg, 2000).
The different component abilities of memory functioning (e.g., storage and retrieval) also were assessed with the FOME, using scores from four additional subtests named storage, ineffective reminders, retrieval, and repeated retrieval. Storage was measured using a total score from the storage and ineffective reminders subtests; the storage subtest score represented a summation of the cumulative score of items remembered by the end of each recall trial, with a possible total score ranging from 0-50. The ineffective reminders subtest score represented the number of times there was an inability to recall an item on two consecutive trials despite selective reminding, with a possible total score ranging from 0 to 40. Both the FOME and the MLDT were scored according to the standards developed by the instruments' authors.
Retrieval was measured by total scores on the two subtests identified as retrieval and repeated retrieval. The retrieval subtest score represents a summation of the number of items correctly recalled on each of the five recall trials, with a possible total score ranging from 0-50. The repeated retrieval subtest score represented a summation of the number of items recalled on two consecutive trials, with a possible total score ranging from 0-40.
Orientation was defined as temporal orientation to the day of week, day of month, month, year, and time of day. Orientation was measured with the MLDT subtest known as the Benton temporal orientation test (BTOT), which provides a sum of error points for incorrect responses. The BTOT penalizes incorrect responses to time of day less heavily than incorrect responses to the year and month. A cutoff of greater than 3 error points has been cited as indicating moderate impairment and was used as a cutoff for this study (Benton, Sivan, Hamsher, Varney, & Spreen, 1994). MacNeill and Lichtenberg (2000) reported acceptable levels of validity and reliability of the BTOT in samples of elder urban African Americans.
Hypertension self-care. Hypertension-related self-care referred to the lifestyle behaviors of dietary intake, physical activity, and medication-taking required to control BP. Diet was assessed using three 24-hour food recalls translated into nutrient intakes using the Food Processor computer software (ESHA Research, Salem, OR). A rate of adherence to a dietary intake consistent with reducing blood pressure (JNC, 2003) was calculated by dividing the number of reported food servings or milligrams of sodium by the recommended number of servings or milligrams. A composite diet score was calculated by averaging the rates of adherence for each individual food category and sodium.
Assessment of physical activity was determined by two single-item measures. The first item asked participants to report whether, in the last 3 months, they had performed physical activity or exercise in their leisure time of at least 20 minutes without stopping, enough to make them breathe hard and/or sweat. The second item asked participants to think about activities in the last 7 days that were at least moderate-level intensity, then report how many days they performed moderate-intensity activity and exercise that added up to at least 30 minutes each day. To answer this last question, participants were shown cards listing various examples of moderate-level activity and the interviewer demonstrated moderate-intensity walking.
Medication-taking was measured using a medication electronic monitoring system (MEMS-R) which tracks patients' patterns of drug intake (AARDEX Ltd., Zug, Switzerland). A MEMS monitor is designed to compile the dosing histories of ambulatory patients' prescribed oral medications. It records each opening of the bottle cap as a presumptive dose, listing the date, time, and duration of each opening for later retrieval on a computer. Only one anti-hypertension drug for each participant was monitored. AARDEX software was used to calculate two rates of medication-taking: (a) percent prescribed number of doses taken, calculated by dividing the number of doses taken in 30 days by the number of prescribed doses for that period, and (b) percent days correct number of doses taken, calculated by dividing the number of days in a month that the correct dose was taken by 30 days.
Blood pressure was measured using an electronic BP monitor (Omron HEM-737 Intellisense) that has been validated in accordance with criteria of the British Hypertension Society and the Association for the Advancement of Medical Instrumentation. Blood pressure was measured following a 5-minute rest period; at least two BPs were measured and their average was used for analyses. Participants wore unrestrictive clothing and sat next to the interviewer's table, with their feet on the floor, their backs supported, their arms abducted and slightly flexed, and supported at heart level by the smooth, firm surface of a table.
Data analysis. The Statistical Package for the Social Sciences (SPSS) version 11.0 software (Chicago, IL) was used for all analyses. Descriptive statistics and correlation coefficients were used to address the research aims. Because of the small sample size, a probability level of p < 0.05 was used. As defined by Cohen (1992), correlations of a least moderate magnitude also will be noted.
Sample characteristics. Participants in the final sample (n = 39) were ages 60-82 (mean age 70, SD = 6.34). The majority were women (69%, n = 26) and almost half were told they had hypertension by age 50 (46%, n = 18). A history of heart failure, stroke, or poor kidney function was reported by 11 (28%) participants, and 17 (44%) reported feeling depressed a little to most of the time.
Twenty-seven (69%) participants were widowed or separated, ten (26%) were married, and two (5%) were single. Even though the majority of the sample was unpartnered, only 28% of individuals (n = 11) reported living alone and 69% (n = 2T) reported having someone to help with household chores.
Despite a mean education level of 12.44 years (range 3-12 or more years), 24 participants (62%) reported a median annual household income of less than $5,000-$19,999. Only 10 participants were employed, and 34 participants reported having health insurance. Thirty-five participants (90%) reported receiving regular medical care from a physician, with the majority stating they follow their physicians' recommendations most or all of the time.
Data screening resulted in exclusion of 13 participants from the total number of participants prescribed antihypertensive medication (n = 31; 7 participants from the cognitively intact group, and 6 participants from the cognitively impaired group due to their discontinuation of use of the eDEM within the first 30 days or the use of only one medication dose (n = 1).
Cognitive function. Cognitive function by gender and age is described in Table 1, with the highest percentage of cognitively impaired persons found in participants ages 70-79. Using cut-off scores of one SD below the mean of norm referenced tests, participants with no subtest failures on the FOME and MLDT tests were grouped as cognitively intact (54%, n = 21), and participants with one or more subtest failures were grouped as cognitively impaired (46%, n = 18). Within the cognitively impaired group, 13 participants had one to two subtest failures, and 5 participants had four to six subtest failures.
Semantic fluency. Difficulties in semantic fluency were present in 9% of males (n = 1) and 28% of females (n = 7), with scores on the rapid verbal retrieval subtest one SD below Fuld's (1982) established mean (males < 17.44, females < 31.97). Among participants ages 60-79, 25% also failed the animal naming test. In the group age 80 or older (n = 3), none had difficulty with animal naming.
Memory. Mean scores on the four memory subtests of the FOME, along with normative values established by Fuld (1982), are presented in Table 2. Using one SD as the cut-off score from Fuld's normative values, 25% of the group ages 60-79 (n = 9) had responses consistent with at least one subtest failure in storage or retrieval skills. All three participants age 80 or older functioned well above the mean for all categories. Testing for one participant was halted during the fifth distraction trial on the FOME due to evidence of emotional distress. The test administrator, a doctoral student in psychology, offered emotional support and subsequent referral to the university psychological counseling services. This participant was excluded from the sample.
Orientation. Using three error points as the cut-off score for borderline function on the orientation test of the MLDT, 8% (n = 3) of those ages 60-79 were at least borderline, and 6% (n = 2) severely defective in orientation (greater than eight errors). One participant greater than age 80 committed more than eight errors, thereby scoring in the defective classification range of the test.
Relationship of Cognitive Functions and Hypertension-Related Self-Care
Semantic fluency and hypertension self-care. Correlations between the semantic fluency indicators of rapid verbal retrieval and animal naming and the hypertension self-care measures of diet, physical activity, and medication adherence were not significant (see Table 3).
Memory and hypertension self-care. The strongest relationship between cognition and hypertension-related self-care was between memory storage on the FOME and the percent of days in a month that the correct number of medication doses was taken (r = 0.59, p < 0.05), with better storage scores associated with an increase in the correct number of medication doses taken (see Table 3). None of the other correlations between indices of memory functioning and hypertension self-care were significant statistically. However, consistent with triarchic theory, scores on storage and retrieval were associated positively with correct medication dosing.
Orientation and hypertension self-care. The correlations between orientation and measures of hypertension self-care were not significant statistically. However, better orientation scores were associated with higher levels of physical activity and lower levels of dietary adherence (see Table 3).
Relationship of cognitive functions and blood pressure. No statistically significant correlations between any of the measures of cognitive function and BP were obtained (see Table 4).
Despite a small sample size (n = 39), this convenience sample of community-residing African-American elders had a high prevalence (46%) of clinically significant cognitive impairments and co-morbidities, supporting the growing body of knowledge on the association of aging and hypertension with cognitive impairment and comorbidities (Artinian, Washington, Flack, Hockman, & Jen, 2006). A substantial percentage (28%) of the women in this study had difficulty with an executive functioning task, supporting Singh-Manoux and Marmot's (2005) finding of the stronger effect of BP on decline in executive cognitive function in women. The ominous nature of this finding is noteworthy for Elkins and colleagues (2005), who found that women age 65 and older with pre-existing hypertension were more likely to experience a greater adverse impact of stroke on cognitive function.
Of particular interest is the finding of strong positive association between cognition (memory) and hypertension-related self-care (correct use of medication); this paralleled the findings of Insel and colleagues (2006) in their convenience and community-residing sample of elders with hypertension. Although their sample included only a small number of African-American elders (n = 9), they did find that a composite score of executive function and working memory measures were related significantly to medication adherence.
The evidence supporting the importance of cognitive function in self-care has important implications for nurses who provide education on medication administration to eiders with hypertension. Elders experiencing even minimal cognitive difficulties may be at risk for incorrect use of medications that affects their hypertension management. This supports the need for nurses to conduct cognitive assessment prior to instructing elders with hypertension in medication administration. When cognitive difficulty is confirmed, alternative plans to support successful medication administration may need to be considered (Bergman-Evans, 2006; Klymko, 2005).
The FOME and MLDT cognitive screening tools were useful in this study to detect cognitive difficulties that may have a significant effect on decision-making and problem-solving behaviors associated with self-care. The screening tools were inexpensive, easily administered in multiple settings, and acceptable to the elders in this study. Nurses may want to consider using these cognitive assessment tools prior to engaging elders with culturally diverse backgrounds in self-care education programs.
Study limitations. The small sample size may have contributed to the inability to detect statistically significant relationships between selected cognitive functions and BP regulation. The participants' psychosocial and economic personal characteristics, hypertension self-care, and co-morbid medical conditions may have created a restricted range on important characteristics, resulting in less variability in the analyses. This convenience sample of community-residing elders limits the representativeness of individuals with similar conditions. Further study is warranted using a nursing model to support testing of the relationships of cognition, self-care, and BP regulation while controlling for such individual factors as depression and co- morbidity that were clinically significant in this pilot study.
Assisting older adult patients with hypertension in planning, implementing, and evaluating their hypertension-related self-care will continue to be a challenge for nurses as the United States population ages and the burden of chronic diseases continues to grow. The prevalence of cognitive impairment found in this study, coupled with the association of cognition and hypertension self-care, adds to the growing body of research literature that suggests the need for nurses to consider cognitive assessment when providing patient education in areas of self-care.
Artinian, N.T., Flack, J.M., Nordstom, C.K., Hockman, E.M., Washington, O.G.M., Jen, K-L.C., et al. (2007). Effects of nurse-managed telemonitoring on blood pressure at 12-month follow-up among urban African Americans. Nursing Research, 56(5), 312-322.
Artinian, N.T., Washington, O.G.M., Flack, J.M., Hockman, E.M., & Jen, K-L.C. (2006). Depression, stress, and blood pressure in urban African-American women. Progress in Cardiovascular Nursing, 21, 68-75.
Bank, A., MacNeill, S., & Lichtenberg, P. (2000). Cross validation of the MacNeill Lichtenberg decision tree: Triaging mental health problems in geriatric rehabilitation patients. Rehabilitation Psychology, 45(2), 193-204.
Benton, A.L., Sivan, A.B., Hamsher, K.D., Varney, N.R., & Spreen, O. (1994). Assessment: A clinical manual (2nd ed.). New York: Oxford University Press.
Bergman-Evans, B. (2006). Evidence-based guideline: Improving medication management for older adult clients. Journal of Gerontological Nursing, 32(7), 6-14.
Brady, C.B., Spiro, A., McGlinchey-Berroth, R., Milberg, W., & Gaziano, J.M. (2001). Stroke risk predicts verbal fluency decline in healthy older men: Evidence from the normative aging study. Journal of Gerontology: Psychological Sciences, 56B(6), 340-346.
Chobanian, A., Bakris, G., Black, H., Cushman, W., Green, L., Izzo, J., et al. (2003). Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 42, 1206-1252.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1), 155-159.
Douglas, J., Bakris, G., Epstein, M., Ferdinand, K., Ferrario, C., Flack, J., et al. (2003). Management of high blood pressure in African Americans. Archives of Internal Medicine, 163, 525-541.
Elias, M.G., Robbins, M.A., Elias, P.K., & Streeten, D.H. (1998). A longitudinal study of blood pressure in relation to performance on the Wechsler Adult Intelligence Scale. Health Psychology, 17(6), 486-493.
Elias, M.E, Wolf, EA., D'Agostino, R.B., Cobb, J., & White, L.R. (1993). Untreated blood pressure level is inversely related to cognitive functioning: The Framingham study. American Journal of Epidemiology, 138(6), 353-364.
Elkins, J.S., Yaffe, K., Cauley, J.A., Fink, H.A., Hillier, T.A., & Johnston, S.C. (2005). Pre-existing hypertension and the impact of stroke on cognitive function. Annals of Neurology, 58(1), 68-74.
Farmer, M.E., White, L.R., Abbott, R.D., Kittner, S.J., Kaplan, S.J., Kaplan, E., et al. (1987). Blood pressure and cognitive performance: The Framingham study. American Journal of Epidemiology, 126(6), 1103-1114.
Fuld, P. (1982). Fuld Object-Memory Evaluation: Instructional manual (Catalog No. 33925M). Department of Neurology. Bronx, NY: Albert Einstein College of Medicine.
Fields, L., Burt, V., Cutler, J., Hughes, J., Roccella, E., & Sorlie, P. (2004). The burden of adult hypertension in the United States 1999 to 2000: A rising tide. Hypertension, 44, 1-7.
Glynn, R.J., Beckett, L.A., Herbert, L.E., Morris, M.C., Scherr, P.A., & Evans, D.A. (1999). Current and remote blood pressure and cognitive decline. Journal of the American Medical Association, 281(5), 438-445.
Goldstein, EC., Ashley, A.V., Freedman, L.J., Penix, L., Lah, J.J., Hanfelt, J., et al. (2005). Hypertension and cognitive performance in African Americans with Alzheimer disease. Neurology, 64(5), 899-901.
Harrington, G., Saxby, B.K., McKeith, I.G., Wesnes, K., & Ford, G.A. (2000). Cognitive performance in hypertensive and normotensive older subjects. Hypertension, 36(6), 1079-1082.
Insel, K., Morrow, D., Brewer, B., & Figueredo, A. (2006). Executive function, working memory, and medication adherence among older adults. Journal of Gerontology: Psychological Sciences, 61B(2), P102-P107.
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC). (2003). The seventh report of the National Committee on the prevention, detection, evaluation, and treatment of high blood pressure (NIH Publication No. 03-5233). Bethesda, MD: National Institutes of Health.
Klymko, K.W. (2005). Cognitive assessment in elderly African American hypertensives. Journal of Gerontological Nursing, 31(11), 15-20.
MacNeill, S.E., & Lichtenberg, P.A. (2000). The MacNeill-Lichtenberg decision tree: A unique method of triaging mental health problems in older medical rehabilitation patients. Archives of Physical Medical Rehabilitation, 81, 618-622.
Mast, B.T., Fitzgerald, J., Steinberg, J., MacNeill, S.E., & Lichtenberg, P.A. (2001). Effective screening for Alzheimer's disease among older African Americans. The Clinical Neuropsychologist, 15(2), 196-202.
Robbins, M.A., Elias, M.B., Elias, EK., & Budge, M.M. (2005). Blood pressure and cognitive function in an African-American and a Caucasian-American sample: The Maine-Syracuse study. Psychosomatic Medicine, 67(5), 707-714.
Roma'n, G. (2003). Vascular dementia: Changing the paradigm. Current Opinion in Psychiatry, 16(6), 635-641.
Singh-Manoux, A., & Marmot, M. (2005). High blood pressure was associated with cognitive function in middle-age in the Whitehall II study. Journal of Clinical Epidemiology, 58(12), 1308-1315.
Sternberg, R.J. (1988). The triarchic mind. New York: Viking.
United States Department of Health and Human Services, Center for Disease Control and Prevention, & National Center for Health Statistics (HHS). (2003). Health, United States, 2003, Special Excerpt: Trend tables on 65 and older population (DHHS Publication No. 2004-0152). Washington, DC: Author.
Kay W. Klymko, PhD, FNP-BC, MSN, is an Assistant Professor (Clinical), College of Nursing, Wayne State University, Detroit, MI, and a Family Nurse Practitioner, Physicians Healthcare Network, Port Huron, MI.
Nancy T. Artinian, PhD, MSN, RN, BC, FAHA, is a Professor, College of Nursing, Wayne State University, Detroit, MI.
Olivia G.M. Washington, PhD, APRN, BC, NP, LPC, is an Associate Professor, College of Nursing and Institute of Gerontology, Wayne State University, Detroit, MI.
Peter A. Lichtenberg, PhD, ABPP, is a Professor and Director, Institute of Gerontology, Wayne State University, Detroit, MI.
Jillon S. Vander Wal, PhD, is an Assistant Professor, Department of Psychology, Saint Louis University, St. Louis, MO.
Acknowledgments: This pilot study was partially supported by Sigma Theta Tan International, Lambda Chapter, NIH/NRSA 1 F31 NR008472-01 and NIN/NINR R01 NR07682-03. The authors acknowledge the assistance of Kristen Kennedy and Amanda Schafer for their support in this research.
Table 1. Cognitive Function Group by Gender and Age Intact Impaired n % n % Total 21 54 18 46 Gender Male 7 33 6 33 Female 14 67 12 67 Age 60-69 12 57 8 44 70-79 7 33 9 50 80-82 2 10 1 6 Table 2. Comparison of Mean FOME Memory Subtest Scores to Normative Observations Normed Group, Study Sample, Ages 70-79 Ages 60-79 Fuld (1982) Standard Standard Test Mean Deviation Mean Deviation Storage 45.7 2 45.4 4 Retrieval 38.7 4 39.4 6 Repeated retrieval 25.8 5 25.9 6 Ineffective reminder 2.1 2 2.5 4 Table 3. Correlations Between Cognition and Hypertension Self-Care Outcomes % Prescribed Number of % Days Correct Physical Medication Number of Diet Activity Doses Taken Doses Taken Storage -0.03 -0.10 0.42 0.59 * Retrieval -0.11 -0.01 0.31 0.26 Repeated -0.11 -0.01 -0.32 -0.15 retrieval Ineffective -0.02 0.02 -0.09 0.03 reminders Rapid verbal 0.28 0.01 -0.18 0.14 retrieval Animal -0.22 -0.02 -0.17 -0.24 naming Orientation -0.42 0.11 0.04 0.28 * p<0.05 Table 4. Correlations Between Cognition and Blood Pressure Cognition Average Systolic BP Average Diastolic BP Storage -0.06 -0.19 Retrieval -0.04 -0.21 Repeated retrieval 0.02 0.18 Ineffective reminders 0.02 -0.01 Rapid verbal retrieval 0.16 0.09 Animal naming 0.07 0.03 Orientation 0.01 -0.08
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Research for Practice|
|Author:||Klymko, Kay W.; Artinian, Nancy T.; Washington, Oliva G.M.; Lichtenberg, Peter A.; Vander Wal, Jillo|
|Date:||Dec 1, 2008|
|Previous Article:||Hereditary non-polyposis colon cancer: change the name to protect the innocent.|
|Next Article:||Pilot studies.|