Posts Tagged ‘AHA’

@MaharishiU’s Dr. Robert Schneider presents @TMmeditation research to @uiowa Hospitals and Clinics medical staff

January 9, 2014

Doctor touts health benefits of Transcendental Meditation
Written by Sara Agnew, Iowa City Press-Citizen
Jan. 7, 2014 8:55 PM

Dr. Francois Abboud, left, talks with Dr. Robert H. Schneider, who spoke with medical staff at University of Iowa Hospitals and Clinics Tuesday about how the practice of Transcendental Meditation can reduce the risk of heart disease and lower blood pressure. / Sara Agnew / Iowa City Press-Citizen

Dr. Francois Abboud, left, talks with Dr. Robert H. Schneider, who spoke with medical staff at University of Iowa Hospitals and Clinics Tuesday about how the practice of Transcendental Meditation can reduce the risk of heart disease and lower blood pressure. / Sara Agnew / Iowa City Press-Citizen

If you want to reduce your risk of cardiovascular disease and lower your blood pressure without taking medication, Dr. Robert H. Schneider has a suggestion: Transcendental Meditation.

Schneider says he has been involved in studies that show this type of meditation can reduce the rate of death from cardiovascular disease by 30 percent and from cancer by 40 percent.

The key is you need to know the “techniques” of Transcendental Meditation to experience the benefits — sitting with your eyes closed for 10 minutes won’t cut it.

That’s the message Schneider shared with about 40 hospital personnel Tuesday during an hourlong presentation called MIND-BODY-HEART: Evidence for Meditation in Hypertension and Cardiovascular Disease at University of Iowa Hospitals and Clinics. It was his first visit with staff and doctors at UIHC.

“It was breakthrough,” he said of his visit.

Schneider is director of the Institute for Natural Medicine and Prevention and dean of medical programs at Maharishi University of Management in Fairfield. As a physician and scientist, Schneider has spent the past 30 years researching evidence-based natural approaches for treating heart disease, high blood pressure, stress and other cardiovascular factors. Over the past 20 years, he has received more than $20 million in research grants from the National Institutes of Health for his natural approaches to treating heart disease.

Much of his work centers on the benefits of Transcendental Meditation.

Schneider said TM is an effortless technique for “automatic self-transcending.” It allows your mind to settle inward beyond thought to experience the source of thought — pure awareness. This is the most silent and peaceful level of consciousness and what many who practice TM call your innermost self.

“It takes a technique that you learn in an eight-hour course,” Schneider said. “Once you have the technique, it happens quite easily.”

Schneider said humans have an “inborn ability” to practice this type of meditation.

“But we have lost this simple and natural technique,” he said.

Schneider said much of his research about the correlation between mind and body were affirmed last June when the American Heart Association announced that Transcendental Meditation is the only meditation practice that has shown to lower blood pressure. In addition, AHA reported lower blood pressure through TM is associated with substantially reduced rates of death, heart attack and stroke.

Ultimately, Schneider said the AHA recommended that TM be recommended for consideration as an alternative treatment for individuals with blood pressure greater than 120/80 mm Hg.

Schneider said he learned about TM 40 years ago as a college student.

“I was always interested in how we can tap into the body’s own cell repair and healing abilities,” he said. “I thought I’d try it and see if it works.”

He read the research and gave TM a try.

“I found I could study better and learn better and had more energy,” Schneider said.

Later, when he was a fellow in hypertension at the University of Michigan Medical School, Schneider took an interest in the connection between the brain and heart.

“I thought maybe we could use the brain to lower blood pressure,” he said.

Schneider believes his years of research on managing the mind-body connection is paying off as organizations such as the AHA begin recognizing the benefits of TM.

During his presentation at UIHC, Schneider highlighted a 2012 study that showed blacks with heart disease who practiced TM regularly were 48 percent less likely to have a heart attack, stroke or die from all causes compared with blacks who attended a health education class over more than five years.

Those practicing TM also “lowered their blood pressure and reported less stress and anger,” Schneider said.

Schneider is interested in researching how TM can be used to help military veterans recover from post-traumatic stress disorder.

Dr. Francois Abboud, the namesake of UI’s Cardiovascular Research Center, asked, “How will I know if I am meditating correctly?”

Linda Rainforth, a certified TM teacher from Iowa City, said people who are practicing TM reach a “deep, deep level of silence and stillness” in which they experience an “expansion of the mind.”

One listener wondered whether men or women followed through most consistently in practicing TM during research studies.

“Men and women both get results,” Schneider said. “But in some of our studies, there was slightly more compliance with the women.”

If you go

Learn more about Transcendental Meditation by attending one of the following presentations by certified teachers in TM. All presentations will be at the Iowa City Public Library, meeting room E.
• 7:30 to 8:30 p.m. Thursday.
• 3 to 5 p.m. Saturday.
• 6:30 p.m. Jan. 16.
TM sessions also can be by appointment by calling Iowa City Transcendental Meditation Program at 936-1986, 641-472-0827 or 641-919-7282. For more information, go to www.tm.org.

MUM's Dr. Robert Schneider presenting research at UIMC

Dr. Robert Schneider was also interviewed by Steve Smith on KMCD’s MUM Spotlight Show about the American Heart Association’s recommendation of Transcendental Meditation to lower high blood pressure. He also reported on his visit to UI’s Medical Center. Steve asked some great questions. It was a lively discussion. Listen here: http://fairfieldiowaradio.com/audio/spotlight%201-9.mp3. (20:45)

See Dr. Schneider on New Zealand Television’s Breakfast ONE News describing the value of TM for heart health. http://tvnz.co.nz/breakfast-news/meditating-your-heart-video-5602306

Iowa Senator Tom Harkin inspires M.U.M.’s Class of 2013 with his Top Ten Rules to Live By

June 2, 2013

Iowa Senator Tom Harkin Inspired M.U.M.’s Class of 2013 with his Top Ten Rules To Live By at the University’s largest graduating class.

In true David Letterman-style, Iowa Senator Tom Harkin presented the M.U.M. Class of 2013 with his top-10 list—Harkin’s Top Ten Rules To Live By. Senator Harkin gave the Commencement Address after receiving an honorary doctorate from the University and inspired everyone with his humorous wit and down-to-earth wisdom.

Senator Tom Harkin receives an honorary doctoral degree from M.U.M. President Dr. Bevan Morris.

Senator Tom Harkin receives an honorary doctoral degree from M.U.M. President Dr. Bevan Morris. / Ken West Photography

Iowa Senator Tom Harkin received an honorary Ph.D. from Maharishi University of Management before delivering the Commencement Address at the start of M.U.M.’s Graduation exercises, which took place last Saturday, May 25, 2013, in the Maharishi Patanjali Golden Dome of Pure Knowledge.

The University’s 38th Commencement graduated its largest class ever of 334 students from 54 countries, out of the 88 represented on campus. The Class of 2013 included 251 graduates and 83 undergraduates. Check this link to see a menu of videos from M.U.M.’s Commencement 2013 http://www.mum.edu/commencement-2013. See the full PRWeb press release here bit.ly/17bxT6k for more details.

Senator Harkin was awarded a Doctor of Laws Honoris Causa degree for his extraordinary lifelong service and compassionate and progressive leadership for the state of Iowa and the United States of America. He has served in the Senate since 1985 and also served in the House of Representatives from 1975–1985. He is chairman of the Senate Committee on Health, Education, Labor and Pensions and is the seventh most senior Senator overall.

In his introduction, M.U.M. president Dr. Bevan Morris said, “We honor you for a lifetime of service to the State of Iowa and the United States of America, and your compassionate and progressive leadership. You have recognized that the quality of American life is shaped by the quality of American education.”

He said that Senator Harkin has been a very good friend of the University and greatly enjoyed all his visits here. “He has given us advice and encouragement for all the University’s programs—for natural methods of prevention of disease, organic agriculture, sustainable living, our Sustainable Living Center, as well as to our town, which is rising to being one of the greenest in the nation, under the leadership of Mayor Ed Malloy.”

Senator Harkin began his commencement address on a humorous note. He thanked the University for this distinguished award and said, “I come before you with a measure of humility. I realize I was probably selected to be your speaker today because Oprah wasn’t available.” This elicited a lot of laughter as he was referring to Oprah’s visit to Fairfield last year, which she aired, including a profile of the Maharishi School on the M.U.M. campus.

He then went on to say, “But I do want you to know of my highest respect and admiration that I have for this university, for what you have done, what you have become here, in Iowa, the nation, and the world, and especially for what I consider to be the best holistic approach to education and wellness in life at any university anywhere on the globe.”

He was referring to Maharishi University’s unique system of Consciousness-Based education and leadership role in wellness research and sustainability. M.U.M. was designated as a Center for Natural Medicine and Prevention and has received over $25 million from the NCCAM and NHLBI over the past 20 years to conduct collaborative medical research on the use of Transcendental Meditation as a complementary alternative approach to treat hypertension and cardiovascular disease in underserved minority populations, the results of which have been published in top peer-reviewed scientific journals.

The most recent study was published and publicized by the American Heart Association. Last year the AHA Journal Circulation published a long-term study showing a 48% lower risk of heart attack, stroke and death in a group already afflicted by heart disease that learned the practice of Transcendental Meditation. And this year the AHA published a paper recommending Transcendental Meditation as the only meditation practice that has been shown to lower blood pressure.

“Graduation,” Harkin said, “is one of the five great milestones in life; the others being birth, marriage, death, and the day you finally pay off your student loans.”

“I know exactly what you’re thinking. You’re wondering, ‘How long is that guy gonna talk?’ The answer is not long.”

To answer he quoted advice from Father John Ryan, the Irish priest in his hometown when he was first asked to give a commencement address. The role of a commencement speaker is like the body at an old-fashioned Irish wake: “They need you in order to have the party but they don’t expect you to say very much.”

Senator Harkin said he chose a method for the day’s occasion that has imparted wisdom to millions of people throughout the years—“I speak of course, not of the Ten Commandments, but of David Letterman’s top ten list.” But his were more like suggestions for students to choose, depending on which ones they liked.

Harkin’s Top Ten Rules To Live By

10. Don’t panic. You will find a job. Don’t worry. “My confidence is based on one thing — because you came to the right school. I have nothing, as I said, but admiration for what this university has accomplished in such a short period of time. In a unique way you have put the ‘higher’ in higher education.”

“You folks would agree with William Butler Yeats who said that education is not about filling up a bucket but lighting a fire. And you carry that one step further. At this university education is also about training, focusing, freeing the mind. It’s about raising consciousness. Here you have been beautifully prepared intellectually and spiritually for all the challenges you will face in the world out there, so you should go forth with confidence.” He encouraged students to move to smaller Iowa towns to make a contribution.

(more…)

Excellent article by Tom Jacobs on Meditation: Strong Preventative Medicine for Heart Patients

November 14, 2012

Meditation: Strong Preventative Medicine for Heart Patients

New research finds major health benefits of meditation for African Americans with heart disease.

November 13, 2012 • By for Pacific Standard

Meditation is usually thought of as a practice of healthy, well-off white people and Asians. But newly published research suggests it can produce hugely significant health benefits in a very different demographic group: African Americans with heart disease.

A study of that followed 201 African Americans for an average of five years found those who meditated regularly were far more likely to avoid three extremely unwelcome outcomes. Compared to peers participating in a health-education program, meditators were, in that period, 48 percent less likely to die, have a heart attack, or suffer a stroke.

“It appears that Transcendental Meditation is a technique that turns on the body’s own pharmacy—to repair and maintain itself,” said Dr. Robert Schneider, the paper’s lead author and director of the Institute for National Medicine and Prevention at the Maharishi University of Management in Fairfield, Iowa. His research is published in the American Heart Association journal Circulation: Cardiovascular Quality and Outcomes.

The paper was originally scheduled to be published in 2011 in the journal Archives of Internal Medicine, but was withdrawn just before being posted “to allow time for review and statistical analysis of additional data.” The AHA’s Maggie Francis reports that the paper “went through peer review, statistical review, editorial discussions, and the authors of the article were responsive to the review process.”

While, two decades ago, research from Maharishi University was often regarded with skepticism, the institution is now well-regarded for its scholarly work.

Schneider and his co-authors undertook this research in part because African Americans “suffer from disproportionately high rates” of mortality due to cardiovascular disease. As we have reported, this may in part reflect high stress levels, the result of living in a society where racial prejudice continues to linger.

The study was conducted at the Medical College of Wisconsin in two phases: From 1998 to 2003, and from 2004 to 2007. Participants were African Americans whose blood flow to the heart was seriously obstructed. Specifically, at least one of their coronary arteries had been narrowed by at least 50 percent.

The patients’ mean age was 59; almost half reported an income of under $10,000. Males slightly outnumbered females. Around 40 percent were cigarette smokers; their mean body mass index was just over 32, making them, on average, clinically obese.

They were randomly divided into two groups. Half took part in a cardiovascular health education program, in which they “were advised to spent at least 20 minutes a day at home practicing heart-healthy behaviors,” including exercise and eating healthy food.

The others were taught the technique of Transcendental Meditation, and encouraged to engage in this activity for 20 minutes each day. “Follow-up and maintenance meetings were held weekly for the first month, biweekly for the next two months, and monthly thereafter,” the researchers write.

The researchers followed up on the participants an average of 5.4 years after they initially joined the experiment. They found those in the meditation group were 48 percent less likely than their peers to have suffered one of three negative outcomes: a heart attack, a stroke, or death from any cause.

“There was a significant association between regularity of home (meditation) practice and survival,” the researchers report. “The subgroup of subjects who were regular in their TM practice had a 66 percent risk reduction, compared with the overall sample risk reduction of 48 percent.”

Regular meditators also reduced their blood pressure, on average, and reported feeling less anger than they did before beginning the experiment.

“This trial did not address the effects of other mind-body, meditation-type interventions on clinical events,” the researchers note. So it’s not clear if these apparent health benefits were the result of some specific aspect of Transcendental Meditation, or would apply to any regimen involving deep breathing and clearing one’s mind.

Nevertheless, as the researchers note, this appears to be the first randomized, controlled trial to find the risk of mortality, heart attack and stroke declined “with the individual practice of a relatively simple mind-body intervention.”

It’s some of the clearest evidence yet that reducing stress through regular meditation can have a positive effect on one’s physical health.

About Tom Jacobs
Staff writer Tom Jacobs is a veteran journalist with more than 20 years experience at daily newspapers. He has served as a staff writer for The Los Angeles Daily News and the Santa Barbara News-Press. His work has also appeared in The Los Angeles Times, Chicago Tribune and Ventura County Star.
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Transcendental Meditation May Lower Heart Risk: WebMD Heart Disease Health Center

November 13, 2012

Heart Disease Health Center

Transcendental Meditation May Lower Heart Risk

By 
WebMD Health News
Reviewed by Louise Chang, MD

Nov. 13, 2012 — Transcendental Meditation is good for the heart, according to a new study.

The study was funded by the National Institutes of Health. It found that African-Americans with heart disease who regularly practiced TM reduced their risk of death, heart attack, and stroke by 48%.

Researcher Robert Schneider, MD, says those results should apply to the general population. Schneider is director of the Institute for Natural Medicine and Prevention at the Maharishi University of Management (MUM) in Fairfield, Iowa.

“This taps into a universal physical phenomenon that is not related to race, age, culture, etc.,” Schneider says. “This state of restful alertness has restorative benefits for everyone. It’s a way to utilize the body’s own internal pharmacy.”

TM is a trademarked form of meditation. It requires training by a certified teacher to “settle inward” to a place called “transcendental consciousness.” The technique is one of the two pillars underlying education at the Maharishi University of Management, according to the school’s web site.

Health Benefits of TM

The study was a collaboration between MUM and the Medical College of Wisconsin in Milwaukee. Researchers recruited 201 African-American men and women whose average age was 59 and who were generally considered obese.

All of the participants previously had been diagnosed with heart disease. Many of them were current smokers. African-Americans, says Schneider, have a 35% higher risk of dying from heart disease than the general population.

The people in the study were divided into two groups. While both groups continued to receive standard care and medication for heart disease, the study group attended a seven-step course in TM. The people in that group were then instructed to meditate twice a day for 20 minutes for the duration of the study.

Schneider says that the program was standard for TM practitioners and had not been modified for the study.

The comparison group received conventional health education. The people in that group were told to spend at least 20 minutes a day on heart-healthy activities.

Members of both groups were followed for as long as nine years.

In addition to reducing the risk of death, heart attack, and stroke by nearly half, TM also significantly lowered systolic blood pressure, the top number in a blood pressure reading.

Anger control and overall anger also improved. Those who entered the study with either high blood pressure or high stress benefited the most from meditation.

“What this is saying is that mind-body interventions can have an effect as big as conventional medications, such as statins,” says Schneider.

The TM group was expected to meditate 14 times per week. But the researchers found that on average participants only practiced the technique 8.5 times.

They would have done well to stick to their instructions. Those who followed the study guidelines more strictly, Schneider says, had even greater benefits. Their risk reduction was 66%.

Second Opinion

“In cardiology, we are always impressed when we see any effective intervention,” says cardiologist Michael Shapiro, DO, of Oregon Health and Science University in Portland. “But to actually show a reduction in overall mortality — that is really impressive.”

Shapiro, who reviewed the study for WebMD, says that its design appears scientifically rigorous and that its results are likely valid. But he says the study was too small to draw any definite conclusions.

“I am enthusiastic and cautiously optimistic,” says Shapiro. “Overall, I like the study, and it provides justification for a much larger study.”

Shapiro, who practices a different form of meditation, also says that more needs to be learned about what drives these results. He says the reduction in blood pressure, while significant, is likely not enough to account for all of the study’s positive outcomes.

“Meditation can do a whole host of positive things: reduce anger and stress, encourage happiness,” he says. “Who is to say that these are not the most important factors? This study can’t get at the mechanism involved. We don’t know how it works.”

A Cost-Effective Means of Prevention

Transcendental Meditation, says Schneider, is “a simple, effortless, and natural way to settle down to a quiet state of mind.”

But it is not free. According to the Maharishi Foundation USA’s web site, the seven-part introductory TM course that the study participants attended costs $1,500. Financial aid and sliding scale fees are available to those who can’t afford the full amount.

To Schneider, this study shows that TM is a cost-effective means of prevention.

“This is the strongest study ever done on meditation or any mind-body intervention for cardiovascular disease,” he says.

In July 2011, the study was pulled from publication in Archives of Internal Medicine, a last-minute decision made when one of the journal’s reviewers raised questions about the data. Schneider says that in the intervening time, the data was re-analyzed. Also, new data was added and the study underwent an independent review.

“This is the new and improved version,” Schneider says. It appears in the current issue of Circulation: Cardiovascular Quality and Outcomes.

Note: Check November 20 when the next issue comes out in print: http://circoutcomes.ahajournals.org.

Also see: Transcendental Meditation may reduce death, heart attack and stroke in heart patients—AHA

Science Codex: Meditation may reduce death, heart attack and stroke in heart patients

Meditation could slash the risk of heart attack and stroke (and make you less angry) — Daily Mail

Transcendental Meditation may reduce death, heart attack and stroke in heart patients—AHA

November 13, 2012

Meditation may reduce death, heart attack and stroke in heart patients

November 13, 2012

Study Highlights:

  • Twice-a-day Transcendental Meditation helped African Americans with heart disease reduce risk of death, heart attack and stroke.
  • Meditation helped patients lower their blood pressure, stress and anger compared with patients who attended a health education class.
  • Regular Transcendental Meditation may improve long-term heart health.

DALLAS, Nov. 13, 2012 — African Americans with heart disease who practiced Transcendental Meditation regularly were 48 percent less likely to have a heart attack, stroke or die from all causes compared with African Americans who attended a health education class over more than five years, according to new research published in the American Heart Association journal Circulation: Cardiovascular Quality and Outcomes.

Those practicing meditation also lowered their blood pressure and reported less stress and anger. And the more regularly patients meditated, the greater their survival, said researchers who conducted the study at the Medical College of Wisconsin in Milwaukee.

Robert Schneider, M.D., director of the Institute for Natural Medicine and Prevention and dean of Maharishi College of Perfect Health in Fairfield, Iowa. Courtesy MAPI

“We hypothesized that reducing stress by managing the mind-body connection would help improve rates of this epidemic disease,” said Robert Schneider, M.D., lead researcher and director of the Institute for Natural Medicine and Prevention in Fairfield, Iowa. “It appears that Transcendental Meditation is a technique that turns on the body’s own pharmacy — to repair and maintain itself.”

For the study, researchers randomly assigned 201 people to participate in a Transcendental Meditation stress-reducing program or a health education class about lifestyle modification for diet and exercise.

  • Forty-two percent of the participants were women, average age 59, and half reported earning less than $10,000 per year.
  • Average body mass index was about 32, which is clinically obese.
  • Nearly 60 percent in both treatment groups took cholesterol-lowering drugs; 41 percent of the meditation group and 31 percent of the health education group took aspirin; and 38 percent of the meditation group and 43 percent of the health education group smoked.

Those in the meditation program sat with eyes closed for about 20 minutes twice a day practicing the technique, allowing their minds and bodies to rest deeply while remaining alert.

 Participants in the health education group were advised, under the instruction of professional health educators, to spend at least 20 minutes a day at home practicing heart-healthy behaviors such as exercise, healthy meal preparation and nonspecific relaxation.
Researchers evaluated participants at the start of the study, at three months and every six months thereafter for body mass index, diet, program adherence, blood pressure and cardiovascular hospitalizations. They found:
  • There were 52 primary end point events, which included death, heart attack or stroke. Of these, 20 events occurred in the meditation group and 32 in the health education group.
  • Blood pressure was reduced by 5 mm Hg and anger decreased significantly among Transcendental Meditation participants compared to controls.
  • Both groups showed beneficial changes in exercise and alcohol consumption, and the meditation group showed a trend towards reduced smoking. Although, there were no significant differences between the groups in weight, exercise or diet.
  • Regular meditation was correlated with reduced death, heart attack and stroke.

Cardiovascular disease is the leading cause of death worldwide. Death from heart disease is about 50 percent higher in black adults compared to whites in the United States. Researchers focused on African Americans because of health disparities in America.

“Transcendental Meditation may reduce heart disease risks for both healthy people and those with diagnosed heart conditions,” said Schneider, who is also dean of Maharishi College of Perfect Health in Fairfield, Iowa.

“The research on Transcendental Meditation and cardiovascular disease is established well enough that physicians may safely and routinely prescribe stress reduction for their patients with this easy to implement, standardized and practical program,” he said.

Co-authors are: Theodore Kotchen, M.D.; John W. Salerno, Ph.D.; Clarence E. Grim, M.D.; Sanford I. Nidich, Ed.D.; Jane Morley Kotchen, M.D., M.P.H.; Maxwell V. Rainforth, Ph.D.; Carolyn Gaylord-King, Ph.D.; and Charles N. Alexander, Ph.D. Author disclosures are available on the manuscript.

The National Heart, Lung and Blood Institute funded the study.

Follow @HeartNews on Twitter for the latest heart and stroke news.

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Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association’s policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and device corporations are available at www.heart.org/corporatefunding .

Circulation: Cardiovascular Quality and Outcomes. 2012; 5: 750-758. Published online before print November 13, 2012, doi: 10.1161/ CIRCOUTCOMES.112.967406. November 2012 issue. Stress Reduction in the Secondary Prevention of Cardiovascular Disease: Randomized, Controlled Trial of Transcendental Meditation and Health Education in Blacks. Abstract | Full Text | PDF

Also posted on EurekAlert! http://www.eurekalert.org/pub_releases/2012-11/aha-mmr110812.php

Also see: Transcendental Meditation May Lower Heart Risk: WebMD Heart Disease Health Center

Science Codex: Meditation may reduce death, heart attack and stroke in heart patients

Meditation could slash the risk of heart attack and stroke (and make you less angry) — Daily Mail

TIME Strongest Study Yet Shows Meditation Can Lower Risk of Heart Attack and Stroke

Excellent article by Tom Jacobs on Meditation: Strong Preventative Medicine for Heart Patients

AHA Newsletter: News from the Heart: Update from CEO Nancy Brown for AHA Volunteers (11/15/12) features Dr. Schneider’s study, “meditation reduces cardiovascular risk”

And many major articles around the world, including reports by CNN, CBS, ABC, and NBC.

I also included a review of some of the global news coverage and the report in our university paper the Review: New Study Shows Reduced Mortality, Heart Attack, Stroke (Vol. 28, #6, November 28, 2012). You can also read it in this news post: Results of American Heart Association publishing landmark TM study.


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