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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

This article has ignored one potential confounding factor. Older physicians are more experienced, and are therefore more likely to be assigned the more challenging and difficult patients, who are likely to have a greater mortality rate regardless of who is treating them. Also, if they have been treating their patients for a number of years, the average age of these patients may be older than the group treated by younger physicians.

Additionally, those treating large numbers of patients tend to be running day clinics with relatively well patients, and are likely to be dealing with a group which is on the whole not as sick as those treated by the older consultants. and therefore less likely to die.

Until this article is rewritten to account for these potential differences in the type of patients treated, the findings should at best be regarded as unproven.

Competing interests: No competing interests

18 May 2017
Merle Wigeson
Diagnostic radiologist
Kenmore Hills, Queensland, Australia.
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Re: GPs use pen and paper after IT systems are shut down as precaution Ingrid Torjesen. 357:doi 10.1136/bmj.j2377

Using pen and paper to issue prescriptions without having access to the medical records may have acted as a powerful reminder to all of us of the dangers of polypharmacy. Over the last 15 years, we have assisted in a significant increase in the number of repeat prescriptions, particularly in the over 60s. I have counted more than 20 medications on repeat prescription for one patient, and it is not unusual to count 10 or more. With each added drug, the risk of side effects increases.

IT software helps the prescriber to remain aware of the several possible interactions. Furthermore, it does limit without eliminating, the risk of prescribing errors in the several forms they may take place, including handwriting misunderstanding. It is common for patients with polypharmacy not to be fully aware of the name of all the medications they are taking and the reasons for which they had been prescribed. I cannot refrain from wondering if the introduction of electronic medical records may have facilitated the growth of polypharmacy. Mindful that other IT crashes are more likely than not, besides limiting where possible polypharmacy, perhaps we could print for each patient a list of their medications, their posology and the problem they have been advised for.

Competing interests: No competing interests

17 May 2017
Edoardo Cervoni
Locumdoctor4u Ltd.
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Re: The hackers holding hospitals to ransom Krishna Chinthapalli. 357:doi 10.1136/bmj.j2214

This is regarding a possible suggestion for a future direction the NHS could take regarding its databases, information security etc. to not only potentially improve efficiency but also security and privacy concerns. This is adapted from a short article I wrote on Blockchain technology for the JIPMER (Jawaharlal Institute of Postgraduate Medical Education and Research in India) 2017 alumni reunion in the UK (the author's mother being an alumnus of JIPMER).

** Main Body of Article/Response begins here **

This is aimed at those of you who are either decision-makers, in the position to influence them, or who are looking to advocate solutions for healthcare reform either within your own trusts or across the NHS more broadly. Essentially, NHS databases and data-sharing arrangements are generally inefficient, impede effective service-delivery, and prevents optimal utilisation of data. Some of you may or may not have heard of Blockchain technology and this might be something worth exploring.

Applications of Blockchain technology are not just limited to crypto-currencies and the financial services industry. A Blockchain is a database that maintains a continuously a growing set of records. It is a distributed database, which means there is no central authority that holds the entire ‘chain’. Instead, each participating ‘node’ has a copy of the ‘chain’. It’s also ever-growing – data records are only added to the chain (so the records cannot be tampered with or modified – thereby ensuring their integrity). Fundamentally:

1. Transactions are the actions created by the participants in the system.
2. Blocks record these transactions and make sure they are in the correct sequence and have not been tampered with. Blocks also record a time stamp when the transactions were added.

Blockchain technology can, therefore, be used in tracking billions of connected devices, patient records and information, etc; it can enable the processing of transactions, and ensure the integrity of data (so that it is verifiable) whilst the cryptographic algorithms ensure peoples’ privacy. In this sense, it is secure, efficiently accessible, and enables privacy (so much so that many people use Bitcoin – which uses Blockchain technology – to illegally buy drugs, weapons, and so on, because they are confident of their anonymity being preserved).

Recently, the US Department of Health and Human Services (a Federal Government agency) sponsored a blockchain research contest (the ‘Blockchain Challenge’) and the Chamber of Digital Commerce (a leading trade association representing the digital asset and blockchain industry) provided an executive overview of “over 70 white papers from industry and academics” within its report: ‘Blockchain Healthcare & Policy Synopsis’. Amongst “the main areas for the application of blockchain in healthcare were thought to be: real item verification of doctor’s license status, drug delivery supply chain auditability, insurance claim fraud detection, continuing education validation, and digital wallets could be used to store a set of medical records, allowing the patient to have their records in digital form, giving them control of who sees their medical information.”

There is also the potential to ensure that the Blockchain can help secure the Internet of Things (IoT) as it pertains to healthcare because, according to an article entitled “Inside Risks: The Future of the Internet of Things” by Ulf Lindqvist and Peter Neumann, healthcare establishments already use devices that are remotely-controlled and accessible; this includes patient monitors, body scanners, pacemakers, defibrillators, infusion pumps, main and auxiliary power, lighting, and air conditioning. If compromised, people could literally be killed through malicious software and actors remotely – Blockchain technology can, therefore, help ensure security, integrity, human safety and health.

Ideas can be spread through both top-down and bottom-up approaches – indeed, an idea often only materialises effectively in large organisations when a combination of both is used (at least to some degree). If you think this is something your practice, your trust, or the NHS could benefit from more broadly, it is worth investigating and speaking to others, raising it in various fora and seeing whether the idea gains traction. I don’t proclaim to have significant expertise but there is a lot of research going into Blockchain technology – Guardtime is the world’s largest Blockchain company by revenue (and they have implemented Blockchain solutions in many contexts) whilst, in the UK, University College London hosts the UCL Research Centre for Blockchain.

As Doctors, you have the opportunity to make recommendations about improving healthcare services that are taken more seriously by service-users than your ordinary policymakers and NHS management. Data-sharing and NHS databases are a source of major inefficiency throughout our healthcare system – it can be dealt with. Now, the need for improving the NHS Cyber Security apparatus presents a potential opportunity to kill two birds with one stone.

Competing interests: No competing interests

17 May 2017
Vishal Wilde
Incoming Civil Service Fast Streamer, Masters Student, Researcher, Journalist, Politician and Creative Writer.
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Re: Red meat: another inconvenient truth Fiona Godlee. 357:doi 10.1136/bmj.j2278

You ask what doctors can do, and suggest lobbying for better research to support evidence based dietary guidelines.

Would this be the same profession that espouses and promotes the wholly arbitrary "5 a day"?

Competing interests: No competing interests

17 May 2017
Bart J Maguire
Retired (IT Network Engineeer)
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Re: Measles outbreak in Somali American community follows anti-vaccine talks Owen Dyer. 357:doi 10.1136/bmj.j2378

Scientist F and colleagues tell us that vaccination on the day of exposure or within three days of exposure is effective. "Circumwent" is the word they used.

If they were advocating passive immunisation with globulins, one couid readily accept. But, when they are talking about a live attenuated vaccine, I for one would like to see the evidence from field trials.
And who better to provide such evidence than the Indian Council of Medical Research? They have a very large population to study.

I hope to see their reply.

Competing interests: No competing interests

17 May 2017
JK Anand
Retire doctor
Free spirit
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Re: Mortality from different causes associated with meat, heme iron, nitrates, and nitrites in the NIH-AARP Diet and Health Study: population based cohort study Maki Inoue-Choi, Sanford M Dawsey, Christian C Abnet, et al. 357:doi 10.1136/bmj.j1957

The study by Etemadi and colleagues [1], the comment by John Potter [2] and the editorial by Fiona Godlee [3] all add to the negative publicity heaped on the red meat industry in recent years. This has already forced thousands of traditional livestock producers out of business in the UK [4], to be replaced, ironically, by more intensive ones who cut costs through increased scale and medication, and less natural diets. If the associations the authors find are robust then the criticism is fully justified, but they show signs of siloed thinking, appear to be unaware of differences between feeding systems and could be accused of throwing out the grass-fed ruminant baby with the bath water of intensive, grain-fed, beef. As such, they may inadvertently give yet another twist to the spiral of agricultural intensification.

At first glance, cutting meat consumption, or switching from beef to chicken, look like ways to reduce both greenhouse gas emissions (GHGs) and diet-related diseases. Potter tells us unequivocally that “Overconsumption of meat is bad for health and for the health of our planet”. Few people would deny that overconsumption of anything is bad, yet Etamadi’s study finds increased mortality at every stage from very low to excessively high red meat consumption. Are these perfectly graded associations credible for all nine diseases they cover?

It may be relevant that Etemadi’s study was undertaken in the US where most beef is finished in feedlots on diets based on corn and soya – not natural feeds for ruminants. While a proportion of beef cattle are fed grain-based diets in most parts of the world, many of these receive only modest amounts of grain and others are exclusively fed on grass. But cattle fed some grain are far better able than poultry to utilise arable crop residues, Brewers’ and Distillers’ grains, sugar beet pulp, Miller’s offal and most oilseed bi-products [5] all of which we cannot eat - the exception being soyabean meal, widely included in poultry feed.
There are two key reasons why this could make a difference to the health impact of the meat. First, studies in the UK [6] [7], US [8] and Australia [9] have found that meat from grass-fed cattle has an omega-6 to omega-3 ratio of well under 2:1, while grain-fed beef typically has a ratio of between 8:1 and 11:1 and was found to be 20:1 in one trial. Grass-fed beef was also higher in conjugated linoleic acid and lower in trans fats. Omega-6 breaks down into arachidonic acid which has pro-inflammatory effects which can be counteracted by the long chain omega-3 fatty acids [10]. The consumption of oily fish is recommended for this reason, but there are no longer enough fish in the sea for everyone and for the significant proportion of the population who do not eat oily fish, grass-fed beef or lamb provides an important, if modest, contribution to omega-3 intake in a healthy balance with omega-6.

Second, several studies have noted a pro-oxidant effect from haem iron, which Etemadi and colleagues identify as the key source of higher mortality in red meat consumers. However, some studies [8] have also found higher levels of antioxidants including vitamin E and beta-carotene in grass-fed beef. Zinc is another important antioxidant. While beef is a good source of zinc, liver is much higher still in zinc. There has been a dramatic reduction in ox liver consumption in recent decades. This could mean that some red meat consumers who eat only grain-fed beef and no ox liver do not take in enough antioxidants to counteract the pro-oxidant effect of the haem iron in beef. This would apply particularly to those with below average fruit and vegetable intake, something which characterised the higher red meat consumers in Etemadi and colleagues’ study.

The UN report [11] Potter cites on the environmental side told us that livestock are responsible for 18 per cent of GHS. Almost half (48 per cent) of this related to rainforest clearance for cattle and soya. However, the team only analysed such trends in South America. They did not include regions where grazing land was being converted to forest, or where rainforest was being cleared for palm oil.

In 2013, some of the same authors published a further report [12] with the revised figure of 14.5 per cent. Yet in a third and even less well-known accompanying report [13] they acknowledged that even this was a significant over-estimate, because they based their analysis on rainforest destruction in 2005, which by 2013 had declined significantly.

Grass is the only major crop that restores degraded soil while producing food for humans, albeit indirectly. One major European study [14] has found that up to 1.2 adults cattle grazing per hectare can be carbon neutral – the carbon sequestered and stored by the grass compensates for all their GHGs. Such high levels of sequestration will not continue indefinitely but the importance of not ploughing the grassland to keep this carbon in the ground cannot be over-emphasised.

Grass covers 70 per cent of global farmland, mostly for sound agronomic or environmental reasons. Plough this land for continuous cropping to feed chicken, intensive beef cattle or humans and over a decade or so you release GHGs typically equivalent to 250 tonnes of CO2 per hectare [15], making the land more vulnerable to droughts, floods and soil erosion. Chicken is promoted by many people because the birds convert grain to protein much faster than cattle, but cattle are the most efficient converters of non-human edible feeds to protein.

The evidence suggests to me that the only sustainable way to get human edible food from existing grassland is to graze it with livestock, and where appropriate, grow arable crops in rotation with grass, not in continuous monocultures.

Perhaps the next team of researchers to address the red meat issue could consider the relative impacts of beef and lamb from different production systems?

[1] Etemadi A, Sinha R, Ward MH, Graubard BI, Inoue-Choi M, Dawsey SM, Abnet CC. Mortality from different causes associated with meat, heme iron, nitrates, and nitrites in the NIH-AARP Diet and Health Study: population based cohort study. BMJ 2017; 357.

2] Potter, JD. Red and processed meat, and human and planetary health. BMJ 2017; 357.

[3] Godlee, F. Red meat: another inconvenient truth. BMJ; 357.

[4] Cross J. In the Balance. The Future of the English Beef Industry. EBLEX 2009 pp2-3.

[5] Wilkinson JM. ‘Re-defining efficiency of feed use by livestock’, Animal 2011; 5:1014–1022.

[6] Enser M, Hallett KG, Hewett B, Fursey GAJ, Wood JD and Harrington G. Fatty acid content and composition of UK beef and lamb muscle in relation to production system and implications for human nutrition. Meat Science; 1998, 49:329–341.

[7] Elmore JS, Warren H, Mottram DS, Scollan ND, Enser M, Richardson RI and Wood JD. A comparison of aroma volatile and fatty acid compositions of grilled beef muscle from Aberdeen Angus and Holstein-Friesian steers fed diets based on silage or concentrates. Meat Science; 2004, 68:27–33.

[8] Daley CA, Abbott A, Doyle PS, Nader GA and Larson S. A review of fatty acid profiles and antioxidant content in grass-fed and grain-fed beef. Nutrition Journal; 2010, 9:1–12.

[9] Ponnampalam EN, Mann NJ and Sinclair AJ. Effect of feeding systems on omega-3 fatty acids, conjugated linoleic acid and trans fatty acids in Australian beef cuts: potential impact on human health. Asia Pacific Journal of Clinical Nutrition; 2006, 15:21-29.

[10] Calder PC. n-3 Polyunsaturated fatty acids, inflammation, and inflammatory diseases. Americian Society for Clinical Nutrition; 2006, 83:S1505–S15195.

[11] Steinfeld H, Gerber PJ, Wassenaar T and De Haan C. Livestock’s Long Shadow: Environmental Issues and Options, United Nations Food and Agriculture Organization, 2006, Rome.

[12] Gerber, PJ, Steinfeld, H, Henderson B, Mottet A, Opio C, Dijkman J, Falcucci A and Tempio, G. Tackling Climate Change through Livestock – A Global Assessment of Emissions and Mitigation Opportunities, Food and Agriculture Organization of the United Nations, FAO 2013, Rome.

[13] Opio, C., Gerber, P., Mottet, A., Falcucci, A., Tempio, G., MacLeod, M., Vellinga, T., Henderson, B. and Steinfeld, H. (2013) Greenhouse Gas Emissions from Ruminant Supply Chains – A Global Life Cycle Assessment. Food and Agriculture Organization of the United Nations (FAO), Rome.

[14] Sousanna J.-F, Klumpp K. and Ehrhardt F. (2014) The role of grassland in mitigating climate change, book chapter in EGF at 50 The Future of European Grasslands’, Proceedings of the 25th European Grasslands Federation (ed Hopkins A, Collins RP, Fraser MD, King VR, Lloyd DC, Moorby IM and Robson PRH), Aberystwyth, Wales, 7–11 September, 2014.

[15] Vellinga, T, van den Pol-van Dasselaar, A. & Kuikman, P. Nutrient Cycling in Agroecosystems; 2004, 70:33

Competing interests: In addition to my work for the Sustainable Food Trust, which is a registered charity, I am also a partner in a family organic beef cattle and sheep farm which has its own retail butchers shop.

17 May 2017
Richard H Young
Policy Director of the Sustainable Food Trust; Beef cattle and sheep farmer
Sustainable Food Trust
38 Richmond Street, Bristol BS3 4TQ
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Re: Critical thinking in healthcare and education Sandy Oliver, Kevan Collins, Astrid Austvoll-Dahlgren, Tammy Hoffmann, et al. 357:doi 10.1136/bmj.j2234

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation,1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals.

Oh dear! I am not surprised to see this statement because the current system of medical Directives (aka guidelines and possible suit for negligence) effectively limits the possibility of “Critical thinking” and leads to the so-called “defensive medicine” which at best, leads to second best treatment.

On top of this is the problem of the 10 minute appointment. To be able to think critically in such a limited time to sort out all the potential and relevant signs and syptoms of an “atypical” case is just not feasible even for the most brilliant GP. It is in this area that the “experts” on time management/clinical diagnosis will have to develop a system of, say, nurse lead triage to ensure the GP gets the time to do what he/she has been trained to do. Such a procedure would also re-invigorate the professionalism and interest in the job.

That the UK regulator and GMC were apparently unaware/uninterested in “critical thinking” comes as no surprised. These bodies are unfortunately steeped in the past and relying on research such as the Ancel Keys flawed Seven Countries Study

Competing interests: No competing interests

17 May 2017
Michael J. Hope Cawdery
Retired Veterinary Researcher
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Re: Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data Arja Helin-Salmivaara, Edeltraut Garbe, James M Brophy, et al. 357:doi 10.1136/bmj.j1909

That antiinflammatory drugs increase the risk of coronary heart disease (CHD) is a strong argument against the idea that CHD is caused by inflammation. It is true that the coronary arteries in patients with CHD are inflamed, but if antiinflammatory drugs increase the risk of CHD, the inflammation is evidently protective, which is in accordance with our hypothesis, that the commonest cause of atherosclerosis and CHD is acute and chronic infections.1,2

1. Ravnskov U, McCully KS. Vulnerable plaque formation from obstruction of vasa vasorum by homocysteinylated and oxidized lipoprotein aggregates complexed with microbial remnants and LDL autoantibodies. Ann Clin Lab Sci 2009;39:3-16.
2. Ravnskov U, McCully KS. Infections may be causal in the pathogenesis of atherosclerosis. Am J Med Sci 2012;344:391-4. doi: 10.1097/MAJ.0b013e31824ba6e0.

Competing interests: No competing interests

17 May 2017
Uffe Ravnskov
Independent researcher
Kilmer S. McCully
22350, Lund, Sweden
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Re: Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data Arja Helin-Salmivaara, Edeltraut Garbe, James M Brophy, et al. 357:doi 10.1136/bmj.j1909

In Italy, a wide range of NSAIDs is used, and most of it includes self-medication. It is known that NSAIDs increase cardiovascular risk, but it is also true that they are useful in reducing the local inflammatory component.

Systemic administration, high doses, and prolonged treatment periods can increase the disadvantages of this class of medications. Intra-dermic (mesotherapy) administration, for localized pain management, is a useful option for treating patients with systemic NSAID contraindications (1). With a series of microinjections in the surface layers of the skin, corresponding to localized pain, and with a smaller dose, a slower spread of the drug is obtained as compared to deeper or systemic administration (2). This technique has several advantages, including the drug-saving effect, a prolonged analgesic effect, and a lower risk of adverse events.

Mesotherapy can be applied to patients with several localized musculoskeletal types of pain and may synergize with other therapeutic strategies (3). The use of anti-inflammatory drugs should be regulated by medical staff, and the local administration route could be a useful tool to exploit the pros of NSAIDs and reduce systemic cons. It is the task of pharmacological research to take advantage of this opportunity for proper use of this class of medications. Regulatory authorities and pharmacompanies should consider this possibility. Of course, it is crucial to diagnose the type of pain and choice the appropriate therapeutic strategy in the individual patient and its involvement (informed consent) in the care plan (4). Can this strategy help to reduce the inappropriate use of systemic NSAIDs?

1. Mammucari M, Gatti A, Maggiori S, Bartoletti CA, Sabato AF. Mesotherapy, definition, rationale and clinical role: A consensus report from the Italian Society of Mesotherapy. Eur Rev Med Pharmacol Sci 2011; 15(6): 682-694
2. Mammucari M., Gatti A., Maggiori S., Sabato A.F. Role of mesotherapy in musculoskeletal pain: Opinions from the Italian Society of Mesotherapy. Evidence-based Complementary and Alternative Medicine 2012; Article N. 436959
3. Mammucari M, Maggiori E, Natoli S. Should the general practitioner consider mesotherapy (intradermal therapy) to manage localized pain? Pain Ther. 2016; 5:123–126
4. Mammucari M, Lazzari M, Maggiori E, Gafforio P, Tufaro G, Baffni S, Maggiori S, Sabato AF. Role of the informed consent, from mesotherapy to opioid therapy. Eur Rev Med Pharmacol Sci. 2014; 18(4):566-74.

Competing interests: No competing interests

17 May 2017
Massimo Mammucari
General Practitioner
Primary Care Unit, ASL RM 1, Rome
Via Aurlia 784, Rome - Italy
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Re: Mortality from different causes associated with meat, heme iron, nitrates, and nitrites in the NIH-AARP Diet and Health Study: population based cohort study Maki Inoue-Choi, Sanford M Dawsey, Christian C Abnet, et al. 357:doi 10.1136/bmj.j1957

Dear Dr Mann,
Thank YOU for your reply. The topic of the main paper was to determine the association of different types of meat and associated compounds with mortality. The problem of this population based cohort study is the known confusion between association, correlation and causality. The mediation analysis remains unclear. The interdependent interaction between interactions between factors and co-factors doesn’t allow a subgroup analysis. I see the same critical points in your opinion about a possible addiction of Hitler.

I take the problems of addiction very serious. As a psychiatrist I try to treat every day many patients suffering from alcohol and /or drug dependency (DSM-5 criteria). I use the term “substance use disorder”, abuse and addiction are not the same. Until now, I cannot serious assess the personality, personality disorder, possible psychiatric disorders and the drug consumption of Hitler (Goldwater rule, American Psychiatric Association's code of ethics, which states that it's unethical for psychiatrists to make public statements about a public figure they have not evaluated). I have read literature and medical records of excellent, medium and poor quality. It´s evident that his physician, Dr Morell, treated Hitler with an uncommon, heavy polypharmacy, including methamphetamine (crystal methamphetamine is only a form of this drug that looks like glass fragments) and oxycodone, Hitler got local cocaine solution from his otorhinolaryngologist. There are no criteria for a dependency, but maybe an abuse. The book of Norman Ohler is a typical mixture of real facts, legends and incorrect interpretations. It`s well written but unserious with lurid headlines, sorry. I don’t think that Germany lost the war because of any abuse or a dependency of Hitler or the German army.

The problem of alcohol dependency cannot be solved by alcohol prohibition. People with love and peace movement ideas have not beaten Nazi Germany. The points were strong weapons against Krupp Stahl, men like Sir Winston Churchill, who liked Cuban cigars and Whiskey, not men like Chamberlain or the weak, ill President Roosevelt.

I´m afraid of intolerant, dogmatic, idealistic ideologists. Vegetarianism implicates no peace per se. It´s dangerous to believe this.

By the way, beer contains 1.828 mg niacin, 0.164 mg B6, 0.146 mg Pantothenic Acid, 0.018 mg thiamin, 0.07 micrograms B12, 21 micrograms folate /12-oz. glass (United States Department of Agriculture's national nutrient database).

Competing interests: No competing interests

17 May 2017
Detlef Degner
Department of Psychiatry, University hspital Göttingen, Germany
Von-Siebold-Str . D- 37085 Göttingen, Germany
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