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Al-Wandi, A., Landén, M. & Nordenskjöld, A. (2024). Antipsychotics in the maintenance phase for psychotic depression. Acta Psychiatrica Scandinavica, 149(1), 6-17
Open this publication in new window or tab >>Antipsychotics in the maintenance phase for psychotic depression
2024 (English)In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 149, no 1, p. 6-17Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: This study aimed to associate antidepressants with versus without antipsychotics with readmission and suicide in patients with psychotic unipolar depression.

METHODS: Swedish national registers were used to identify inpatients with psychotic unipolar depression, treated 2007-2016. The participants collected antidepressants with or without antipsychotics from a pharmacy within 14 days after discharge and were followed up for 2 years. The primary outcome was hospital readmission due to any psychiatric disorder, suicide attempt, or completed suicide. Cox regression was used to analyze the data, which were adjusted for sex, age, prior admissions, comorbidity, electroconvulsive therapy, and other pharmacological treatments.

RESULTS: We identified 4391 patients, of which 2972 were in the antidepressant + antipsychotic combination therapy group, and 1419 were in the antidepressant monotherapy group. After 2 years, 42.3% and 36.6% of patients were readmitted or committed suicide in the combination therapy and monotherapy group, respectively. Monotherapy was significantly associated with a lower risk of reaching the outcome in the main analysis (hazard ratio = 0.86; 95% confidence interval: 0.77-0.95). The results went in the same direction in all sensitivity analyses.

CONCLUSION: Our findings do not indicate any advantage of adding antipsychotics as adjunctive to antidepressants as maintenance treatment. Considering the wide use, known side effects, and the current lack of evidence supporting the benefit, further studies on the effect of antipsychotics in the maintenance phase of psychotic unipolar depression are urgently warranted.

Place, publisher, year, edition, pages
John Wiley & Sons, 2024
Keywords
Antidepressants, antipsychotics, psychotic depression, readmission, relapse
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-109607 (URN)10.1111/acps.13628 (DOI)001099887800001 ()37932158 (PubMedID)2-s2.0-85176095605 (Scopus ID)
Funder
Region Örebro County
Available from: 2023-11-07 Created: 2023-11-07 Last updated: 2024-01-22Bibliographically approved
Ekstrand, J., Takamiya, A., Nordenskjöld, A., Kirov, G., Sienaert, P., Kellner, C. & Movahed Rad, P. (2024). Ketamine or ECT? What have we learned from the KetECT and ELEKT-D trials?. International Journal of Neuropsychopharmacology, 27(1), Article ID pyad065.
Open this publication in new window or tab >>Ketamine or ECT? What have we learned from the KetECT and ELEKT-D trials?
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2024 (English)In: International Journal of Neuropsychopharmacology, ISSN 1461-1457, E-ISSN 1469-5111, Vol. 27, no 1, article id pyad065Article in journal (Refereed) Published
Abstract [en]

Two recent clinical trials, KetECT and ELEKT-D, compared the effectiveness of ketamine and electroconvulsive therapy (ECT) for major depressive disorder. Notably, these trials reported marked differences in ECT's clinical outcomes of, with remission rates of 63% for KetECT and a strikingly lower rate of 22% for ELEKT-D, while the remission rates for ketamine were 46% and 38%, respectively. Considering that the primary objective of both trials was to compare the standard treatment (ECT) with an experimental intervention (ketamine), it is crucial to highlight the pronounced disparities in ECT's clinical outcomes. This article offers a comprehensive comparison of these trials while also exploring how patient characteristics, treatment protocols, and study designs may contribute to such pronounced outcome discrepancies. These differences highlight the heterogeneous nature of depression and underscore the need for personalized treatments. These studies also provide valuable insights into identifying the most suitable candidates for ketamine and ECT.

Place, publisher, year, edition, pages
Oxford University Press, 2024
Keywords
Clinical trials, Electroconvulsive therapy, Major depressive disorder, Racemic Ketamine
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-110457 (URN)10.1093/ijnp/pyad065 (DOI)001153591700001 ()38114073 (PubMedID)2-s2.0-85184037882 (Scopus ID)
Available from: 2023-12-21 Created: 2023-12-21 Last updated: 2024-02-14Bibliographically approved
Brus, O., Cao, Y., Carlborg, A., Engström, I., von Knorring, L. & Nordenskjöld, A. (2024). Long-Term Effect of Maintenance Electroconvulsive Therapy in Patients With Depression-Data From a Small Randomized Controlled Trial. Journal of ECT
Open this publication in new window or tab >>Long-Term Effect of Maintenance Electroconvulsive Therapy in Patients With Depression-Data From a Small Randomized Controlled Trial
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2024 (English)In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112Article in journal (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVES: This study aimed to compare the long-term effects of maintenance electroconvulsive therapy (M-ECT) with medication and medication only in patients with depression.

METHODS: A randomized controlled trial of 1 year of M-ECT with medication or medication only investigated relapse/recurrence among 56 patients in remission after electroconvulsive therapy (ECT) for depression was conducted. The results of the first year are published already and showed a significant advantage of M-ECT with medication.The current study was a long-term follow-up. When the randomized treatment allocation ended, medication was continued in both groups but M-ECT was terminated. Patients were followed for up to 10 years via Swedish national registers until the study endpoint of a new psychiatric diagnosis as an inpatient, suicide, suspected suicide, or death of another cause. Time to relapse was compared between the M-ECT with medication group and the medication-only group using Kaplan-Meier estimates.

RESULTS: The median follow-up time was 6.5 years for the M-ECT and medication group and 3.1 years for the medication-only group. One year after randomization 22 patients remained in the M-ECT and medication group, and 14 patients remained in the medication-only group. Relapse patterns between the treatment groups after the completion of M-ECT seemed to be similar according to visual inspection.

CONCLUSIONS: This long-term follow-up study suggests that most of the benefit achieved during the treatment period with M-ECT is maintained over several years, but the small sample size, with accompanying large statistical imprecision, makes the results uncertain. More long-term studies of M-ECT are required.Trial registration: ClinicalTrials.gov identifier: NCT00627887.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2024
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-111028 (URN)10.1097/YCT.0000000000000983 (DOI)38232249 (PubMedID)
Funder
Region Örebro County
Note

Uppsala-Örebro Regional Research Council and Research Committee of Örebro County Council, Örebro, Sweden, supported the research

Available from: 2024-01-30 Created: 2024-01-30 Last updated: 2024-01-30Bibliographically approved
Sellevåg, K., Bartz-Johannessen, C. A., Oedegaard, K. J., Nordenskjöld, A., Mohn, C., Bjørke, J. S. & Kessler, U. (2024). Unmasking Patient Diversity: Exploring Cognitive and Antidepressive Effects of Electroconvulsive Therapy. European psychiatry, 67(1), Article ID e12.
Open this publication in new window or tab >>Unmasking Patient Diversity: Exploring Cognitive and Antidepressive Effects of Electroconvulsive Therapy
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2024 (English)In: European psychiatry, ISSN 0924-9338, E-ISSN 1778-3585, Vol. 67, no 1, article id e12Article in journal (Refereed) Published
Abstract [en]

Background: Electroconvulsive therapy (ECT) is an established treatment for depression, but more data on effectiveness and safety in clinical practice is needed. The aim of this register-based study was to investigate short-term effectiveness and cognitive safety after ECT, evaluated by clinicians and patients. Secondary, we investigated predictors for remission and cognitive decline.

Methods: The study included 392 patients from the Regional Register for Neurostimulation Treatment in Western Norway. Depressive symptoms and cognitive function were assessed with Montgomery-angstrom sberg Depression Rating Scale and Mini-Mental State Examination (clinician-rated) and Beck Depression Inventory and Everyday Memory Questionnaire (patient-rated). Assessments were done prior to ECT-series and a mean of 1.7 days after (range 6 days before and 12 days after) end of ECT-series. Paired samples t-tests were extended by detailed, clinically relevant subgroups. Predictors were examined using logistic regression.

Results: Clinician- and patient-rated remission rates were 49.5 and 41.0%, respectively. There was a large reduction in depressive symptoms and a small improvement in cognition after ECT, but we also identified subgroups with non-response of ECT in combination with cognitive decline (4.6% clinician-rated, 15.7% patient-rated). Positive predictors for patient- and clinician-rated remission were increasing age, shorter duration of depressive episode, and psychotic features. Antipsychotic medication at the commencement of treatment and previous ECT-treatment gave higher odds of clinician-rated remission, whereas higher pretreatment subjective depression level was associated with lower odds for patient-rated remission. Clinician-rated cognitive decline was predicted by higher pretreatment MMSE scores, whereas psychotic features, increasing age, and greater pretreatment subjective memory concerns were associated with lower odds for patient-rated cognitive decline.

Conclusions: Our study supports ECT as an effective and safe treatment, although subgroups have a less favorable outcome. ECT should be considered at an early stage for older patients suffering from depression with psychotic features. Providing comprehensive and balanced information from clinicians and patients perspectives on effects and side effects, may assist in a joint consent process.

Place, publisher, year, edition, pages
Cambridge University Press, 2024
Keywords
Psychiatry, Depression, Neurostimulation treatment, Electroconvulsive therapy, ECT effectiveness, ECT cognitive outcomes
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-110699 (URN)10.1192/j.eurpsy.2024.1 (DOI)001160538800001 ()38214065 (PubMedID)
Note

The study was supported by Norwegian Health West (project F-12169).

Available from: 2024-01-12 Created: 2024-01-12 Last updated: 2024-02-26Bibliographically approved
Göteson, A., Clements, C. C., Juréus, A., Joas, E., Holmén Larsson, J., Karlsson, R., . . . Landén, M. (2023). Alterations in the Serum Proteome Following Electroconvulsive Therapy for a Major Depressive Episode: A Longitudinal Multicenter Study. Biological psychiatry global open science, 3(4), 884-892
Open this publication in new window or tab >>Alterations in the Serum Proteome Following Electroconvulsive Therapy for a Major Depressive Episode: A Longitudinal Multicenter Study
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2023 (English)In: Biological psychiatry global open science, E-ISSN 2667-1743, Vol. 3, no 4, p. 884-892Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Electroconvulsive therapy (ECT) is the most effective treatment for severe depression, but the biological changes induced by ECT remain poorly understood.

METHODS: This study investigated alterations in blood serum proteins in 309 patients receiving ECT for a major depressive episode. We analyzed 201 proteins in samples collected at 3 time points (T): just before the first ECT treatment session (T0), within 30 minutes after the first ECT session (T1), and just before the sixth ECT session (T2).

RESULTS: Using statistical models to account for repeated sampling, we identified 152 and 70 significantly (<5% false discovery rate) altered proteins at T1 and T2, respectively. The most pronounced alterations at T1 were transiently increased levels of prolactin, myoglobin, and kallikrein-6. However, most proteins had decreased levels at T1, with the largest effects observed for pro-epidermal growth factor, proto-oncogene tyrosine-protein kinase Src, tumor necrosis factor ligand superfamily member 14, sulfotransferase 1A1, early activation antigen CD69, and CD40 ligand. The change of several acutely altered proteins correlated with electric current and pulse frequency in a dose-response-like manner. Over a 5-session course of ECT, some acutely altered levels were sustained while others increased, e.g., serine protease 8 and chitinase-3-like protein 1. None of the studied protein biomarkers were associated with clinical response to ECT.

CONCLUSIONS: We report experimental data on alterations in the circulating proteome triggered by ECT in a clinical setting. The findings implicate hormonal signaling, immune response, apoptotic processes, and more. None of the findings were associated with clinical response to ECT.

Place, publisher, year, edition, pages
Society of Biological Psychiatry, 2023
Keywords
Biomarker, Depression, ECT, Longitudinal, Major depressive episode, Proteomics
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-109500 (URN)10.1016/j.bpsgos.2022.11.005 (DOI)001094462700001 ()37881534 (PubMedID)2-s2.0-85149895725 (Scopus ID)
Funder
Swedish Research Council, 2018-02653Swedish Foundation for Strategic Research, KF10-0039Wenner-Gren Foundations, SSv2019-0008
Note

Funding Agency:

Fulbright US Student Program (to CCC)

Available from: 2023-10-31 Created: 2023-10-31 Last updated: 2023-11-29Bibliographically approved
Ernstsson, O., Heintz, E., Nordenskjöld, A., Johnson, J. A., Korkmaz, S. & Zethraeus, N. (2023). Association between pulse width and health-related quality of life after electroconvulsive therapy in patients with unipolar or bipolar depression: an observational register-based study. Nordic Journal of Psychiatry
Open this publication in new window or tab >>Association between pulse width and health-related quality of life after electroconvulsive therapy in patients with unipolar or bipolar depression: an observational register-based study
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2023 (English)In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725Article in journal (Refereed) Epub ahead of print
Abstract [en]

AIMS: To examine the association between pulse width and HRQoL measured within one week after electroconvulsive therapy (ECT) and at six-month follow-up in patients with unipolar or bipolar depression.

METHODS: This was an observational register study using data from the Swedish National Quality Registry for ECT (2011-2019). Inclusion criteria were: age ≥18 years; index treatment for unipolar/bipolar depression; unilateral electrode placement; information on pulse width; EQ-5D measurements before and after ECT. Multiple linear regressions were performed to investigate the association between pulse width (<0.5 ms; 0.5 ms; >0.5 ms) and HRQoL (EQ-5D-3L index; EQ VAS) one week after ECT (primary outcome) and six months after ECT (secondary outcome).

RESULTS: The sample included 5,046 patients with unipolar (82%) or bipolar (18%) depression. At first ECT session, 741 patients (14.7%) had pulse width <0.5 ms, 3,639 (72.1%) had 0.5 ms, and 666 (13.2%) had >0.5 ms. There were no statistically significant associations between pulse width and HRQoL one week after ECT. In the subsample of patients with an EQ-5D index recorded six months after ECT (n = 730), patients receiving 0.5 ms had significantly lower HRQoL (-0.089) compared to <0.5 ms, after adjusting for demographic and clinical characteristics (p = .011). The corresponding analysis for EQ VAS did not show any statistically significant associations.

CONCLUSION: No robust associations were observed between pulse width and HRQoL after ECT. On average, significant improvements in HRQoL were observed one week and six months after ECT for patients with unipolar or bipolar disease, independent of the pulse width received.

Place, publisher, year, edition, pages
Taylor & Francis, 2023
Keywords
Depressive disorders, electroconvulsive therapy, eq-5d, pulse width, quality of life
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-110371 (URN)10.1080/08039488.2023.2289915 (DOI)001124132000001 ()38079191 (PubMedID)2-s2.0-85180181665 (Scopus ID)
Funder
Region Stockholm
Note

Funding Agencies:

Region Stockholm

uroQol Research Foundation

Available from: 2023-12-18 Created: 2023-12-18 Last updated: 2024-02-05Bibliographically approved
Rask, O., Nordenskjöld, A., Johansson, B. A. & Movahed Rad, P. (2023). Electroconvulsive therapy in children and adolescents: results from a population‑based study utilising the Swedish National Quality Register. European Child and Adolescent Psychiatry, 32(11), 2649-2656
Open this publication in new window or tab >>Electroconvulsive therapy in children and adolescents: results from a population‑based study utilising the Swedish National Quality Register
2023 (English)In: European Child and Adolescent Psychiatry, ISSN 1018-8827, E-ISSN 1435-165X, Vol. 32, no 11, p. 2649-2656Article in journal (Refereed) Published
Abstract [en]

Electroconvulsive therapy (ECT) is effective and safe for adults with severe depression, but less studied in adolescents. Here, we examined the indications, prevalence, practice, response and remission rates, and side effects in young people treated with ECT in Sweden. We also examined the usage of ECT in the transition to adult psychiatry. Using data from national patient registers and the Swedish National Quality Register for ECT (Q-ECT), we identified patients aged up to 19 years treated with ECT over a 5-year study period. Response and remission rates were analysed using the Clinical Global Impression (7-point scale)-Improvement (CGI-I) and Severity (CGI-S). A total of 118 individuals were identified, of which 105 were also enrolled in the Q-ECT. The most common indication for ECT was depression (68%; n = 80). Adolescents aged < 18 years were more severely ill before treatment than those aged 18 years (P < 0.01). Three of the hospitals in Sweden treated the majority of adolescents < 18 years old. The median number of sessions in each ECT series was seven. Unilateral placement of the electrodes was the most common (88%; n = 99). Fifty-seven percent (n = 54) of the patients responded (CGI-I, 1-2) to the treatment; remission (CGI-S, 1-2) was achieved by 32% (n = 30). Psychotic symptoms were associated with a higher response rate in patients with depression (P = 0.038). A deterioration of memory compared to pre-treatment was reported in six patients. ECT was associated with high response and remission rates in adolescents with severe psychiatric disorders after non-response to medication.

Place, publisher, year, edition, pages
Springer, 2023
Keywords
Adolescents, Children, Depression, Electroconvulsive therapy, Epidemiology, Neuropsychiatric illness
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-102754 (URN)10.1007/s00787-022-02123-2 (DOI)000898703700001 ()36513894 (PubMedID)2-s2.0-85143906782 (Scopus ID)
Funder
Lund University
Available from: 2022-12-16 Created: 2022-12-16 Last updated: 2024-01-12Bibliographically approved
Strandberg, P., Nordenskjöld, A., Bodén, R., Ekman, C. J., Lundberg, J. & Popiolek, K. (2023). Electroconvulsive Therapy Versus Repetitive Transcranial Magnetic Stimulation in Patients With a Depressive Episode: A Register-Based Study. Journal of ECT
Open this publication in new window or tab >>Electroconvulsive Therapy Versus Repetitive Transcranial Magnetic Stimulation in Patients With a Depressive Episode: A Register-Based Study
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2023 (English)In: Journal of ECT, ISSN 1095-0680, E-ISSN 1533-4112Article in journal (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVES: Electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) are both effective in treating depression. Although rTMS induces fewer adverse effects, its effectiveness relative to ECT is not well established. The aim of this study was to investigate the treatment outcomes of ECT and rTMS in patients who have received both interventions.

METHODS: This was a register-based observational crossover study in patients with depression who had undergone ECT and rTMS in Sweden between 2012 and 2021. Primary outcome was reduction in the Montgomery-Åsberg Depression Rating Scale-Self-report (MADRS-S) score. Secondary outcome was response defined as a 50% or greater decrease in the MADRS-S score. Subgroup analyses were performed to identify factors that predicted differential responses between rTMS and ECT. Continuous and categorical variables were analyzed using paired-samples t tests and McNemar tests, respectively.

RESULTS: In total, 138 patients across 19 hospitals were included. The MADRS-S score after ECT and rTMS was reduced by 15.0 and 5.6 (P = 0.0001) points, respectively. Response rates to ECT and rTMS were 38% and 15% (P = 0.0001), respectively. Electroconvulsive therapy was superior across all subgroups classified according to age and severity of depression.

CONCLUSIONS: Our results suggest that ECT is more effective than rTMS in treating depression among patients who have received both interventions. Age and baseline depression severity did not predict who would similarly benefit from rTMS and ECT.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2023
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-110020 (URN)10.1097/YCT.0000000000000971 (DOI)38048154 (PubMedID)
Funder
NyckelfondenRegion Örebro County
Available from: 2023-12-05 Created: 2023-12-05 Last updated: 2023-12-05Bibliographically approved
Movahed, P., Nordenskjöld, A. & Kellner, C. H. (2023). Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression [Letter to the editor]. New England Journal of Medicine, 389(10), 960-961
Open this publication in new window or tab >>Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression
2023 (English)In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 389, no 10, p. 960-961Article in journal, Letter (Refereed) Published
Place, publisher, year, edition, pages
Massachusetts Medical Society, 2023
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-108120 (URN)10.1056/NEJMc2308757 (DOI)37672704 (PubMedID)
Available from: 2023-09-07 Created: 2023-09-07 Last updated: 2023-09-07Bibliographically approved
Ekman, C. J., Popiolek, K., Bodén, R., Nordenskjöld, A. & Lundberg, J. (2023). Outcome of transcranial magnetic intermittent theta-burst stimulation in the treatment of depression - A Swedish register-based study. Journal of Affective Disorders, 329, 50-54
Open this publication in new window or tab >>Outcome of transcranial magnetic intermittent theta-burst stimulation in the treatment of depression - A Swedish register-based study
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2023 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 329, p. 50-54Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is an established treatment of depression. The more recently introduced intermittent Theta-burst stimulation (iTBS) has shown significant superiority over sham-stimulation and equal effect sizes to a 10 Hz protocol in one clinical trial. The aim of the current study was to investigate the effectiveness and tolerability of iTBS in a naturalistic, clinical setting. Further, we explored demographical and clinical predictors of response.

METHODS: Data was collected from seventeen rTMS-sites in Sweden between January 2018 and May 2021, through the Swedish National Quality register for repetitive Transcranial Magnetic Stimulation (Q-rTMS). We included 542 iTBS-treated patients with unipolar or bipolar depression. Outcome was assessed with Clinical Global Impression Severity and Improvement scores in an intention to treat analysis.

RESULTS: The response rate was 42.1 % and 16.1 % reached remission. The response rate was significantly larger in the oldest age group compared to the youngest (odds ratio 3.46, 95 % confidence interval 1.65-7.22). Less severe level of depression (Montgomery-Åsberg depression rating scale self-assessment < 36) at baseline predicted response and remission. Only <1 % were much or very much worse after treatment. Drop-out rate was 10.9 %. No serious adverse events were reported.

LIMITATIONS: Retrospective analysis of register data. No comparison group.

CONCLUSIONS: In a clinical setting, iTBS was shown to be safe and tolerable and the response rate was similar to that reported from clinical trials. Older age-group and less severe illness predicted response.

Place, publisher, year, edition, pages
Elsevier, 2023
Keywords
Bipolar disorder, Depression, Theta-burst stimulation, Transcranial magnetic stimulation
National Category
Psychiatry
Identifiers
urn:nbn:se:oru:diva-104528 (URN)10.1016/j.jad.2023.02.098 (DOI)000952976200001 ()36841303 (PubMedID)2-s2.0-85149260353 (Scopus ID)
Available from: 2023-02-27 Created: 2023-02-27 Last updated: 2023-04-12Bibliographically approved
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Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-7454-3065

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