1
|
Gimbel LA, Zimmermann M, Byatt N, Moore Simas TA, Hoffman MC. Screening, Assessment, and Treatment of Perinatal Mental Health in Obstetrical Settings. Clin Obstet Gynecol 2024; 67:134-153. [PMID: 38281173 DOI: 10.1097/grf.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Perinatal mood and anxiety disorders (PMADs) are common, yet obstetricians receive little training prior to independent practice on screening, assessing, diagnosing, and treating patients with depression and anxiety. Untreated PMADs lead to adverse pregnancy and fetal outcomes. Obstetricians are in a unique position to address PMADs. The following serves as a resource for addressing PMADs in obstetric practice.
Collapse
Affiliation(s)
- Lauren A Gimbel
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Martha Zimmermann
- Department of Psychiatry, UMass Chan Medical School, Shrewsbury, Massachusetts
| | - Nancy Byatt
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Tiffany A Moore Simas
- Department of Obstetrics & Gynecology, UMass Chan Medical School/UMass Memorial Health, Worcester, Mssachusetts
| | - M Camille Hoffman
- Departments of Obstetrics & Gynecology and Psychiatry, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
2
|
Weingarten SJ, Osborne LM. Review of the Assessment and Management of Perinatal Mood and Anxiety Disorders. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:16-24. [PMID: 38694149 PMCID: PMC11058917 DOI: 10.1176/appi.focus.20230023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth. When poorly controlled, they are associated with worse obstetric outcomes, such as higher rates of preterm birth and unplanned cesarean delivery. They are also associated with suicide, a leading cause of perinatal maternal death. This article provides an overview of evidence-based recommendations for screening, assessment, and management of PMADs, including suicide risk assessment and management and pharmacological and nonpharmacological treatment options compatible with pregnancy and lactation. Although specialized reproductive psychiatrists can provide expert guidance for the management of PMADs, their scarcity means that most patients will not have access to this expert care and instead will seek guidance from general psychiatrists. This article provides a clinical guide for generalists that is based on the best current evidence, including recently released treatment guidelines.
Collapse
Affiliation(s)
- Sarah J Weingarten
- Department of Obstetrics and Gynecology (Weingarten, Osborne) and Department of Psychiatry (Osborne), Weill Cornell Medicine at NewYork-Presbyterian Hospital, New York, NY
| | - Lauren M Osborne
- Department of Obstetrics and Gynecology (Weingarten, Osborne) and Department of Psychiatry (Osborne), Weill Cornell Medicine at NewYork-Presbyterian Hospital, New York, NY
| |
Collapse
|
3
|
Kinser PA, Bodnar-Deren S, Amstadter AB, Lapato DM, Thacker LR, Johnson JA, Aubry C, Johnson A, Gault C, Hill-Thomas A, Russell S, Lanni S, Freeman A. Study protocol for the Mindful Moms Study: A randomized controlled trial evaluating a mindful movement intervention for marginalized pregnant people experiencing depression. Contemp Clin Trials 2023; 132:107302. [PMID: 37500008 PMCID: PMC10529983 DOI: 10.1016/j.cct.2023.107302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/22/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023]
Abstract
More than 1 in 5 pregnant people in the United States experience depressive symptoms. Although treatments exist, many people remain under- or un-treated due to concerns about stigma, side effects, and costs of medications or psychotherapy, particularly those who are marginalized (defined as those who are minoritized, low-income, or with low-educational attainment). Further, the standard depression treatments do not address social connectedness, which is a potentially modifiable factor involved in depressive symptom etiology. This protocol presents the rationale, design, and status of the two-arm longitudinal parallel group randomized controlled trial - the Mindful Moms Study - which aims to evaluate the effects and mechanisms of a group-based mindful physical activity (yoga) intervention in marginalized pregnant people with depressive symptoms (n = 200) compared to a prenatal education control group. The primary aim is to evaluate effects of group assignment on depressive symptom severity, anxiety, and perceived stress over time from baseline to six weeks postpartum. Secondary aims include understanding the role of social connectedness as a moderator of the effects and to identify genome-wide DNA methylation patterns associated with depressive symptoms and perceived social connectedness at postpartum. A focus on adequate symptom management through non-pharmacologic, accessible therapies that address social connectedness during pregnancy in marginalized women is an urgent clinical and research priority. The successful completion of this study will provide important insights into social connectedness as a mechanism to decrease depressive symptoms in a largely understudied population. Trial registration: NCT04886856.
Collapse
Affiliation(s)
- Patricia A Kinser
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA; Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA.
| | - Susan Bodnar-Deren
- Department of Sociology, Virginia Commonwealth University, Richmond, VA, USA
| | - Ananda B Amstadter
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA; Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
| | - Dana M Lapato
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA; Department of Human and Molecular Genetics, Virginia Commonwealth University, Richmond, VA, USA
| | - Leroy R Thacker
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Jennifer A Johnson
- Department of Sociology, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Christine Aubry
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA
| | - Anisa Johnson
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA
| | - Candice Gault
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA
| | - Ariel Hill-Thomas
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA
| | - Sally Russell
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA
| | - Susan Lanni
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | | |
Collapse
|
4
|
Paz Fernández N, González González Y, Alonso Calvete A, Da Cuña Carrera I. Efectos del ejercicio en la depresión durante el embarazo y el posparto. Una revisión sistemática. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2021.100683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
5
|
Russell S, Aubry C, Rider A, Mazzeo SE, Kinser PA. Mindful Moms: Motivation to Self-Manage Depression Symptoms. MCN Am J Matern Child Nurs 2021; 45:233-239. [PMID: 32604182 PMCID: PMC7338034 DOI: 10.1097/nmc.0000000000000625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Nearly 20% of women in the United States experience depressive symptoms during the perinatal period, with known detrimental effects for the mother, child, and family. Depressive symptoms affect motivation to engage in healthy behaviors and self-management of symptoms. PURPOSE The purpose of this study was to explore the experiences of women with depressive symptoms who participated in a 12-week mindful physical activity intervention (Mindful Moms) throughout their pregnancy. STUDY DESIGN In this qualitative study, we explore the lived experience of women with depressive symptoms who participated in Mindful Moms, a self-management intervention involving nurse-led motivational sessions and group-based mindful physical activity (yoga). METHODS Semistructured interviews conducted at approximately 6 weeks postpartum provided rich qualitative data that was analyzed using a phenomenological approach. RESULTS Twenty-five women participated. Findings suggest that participants in Mindful Moms felt empowered to manage their depressive symptoms through the combination of four key factors: a newly recognized need for help, a felt sense of physical and emotional benefit from participation, the power of shared safe space with other pregnant women, support from study staff, and an overall sense of empowerment. CLINICAL IMPLICATIONS Mindful Moms appears to be a feasible and acceptable approach to enhancing motivation to self-manage depressive symptoms in pregnant women. Nurses working with childbearing women should be aware of the potential benefits of self-management strategies, such as mindful physical activity and motivational interviewing, for women facing perinatal depressive symptoms.
Collapse
Affiliation(s)
- Sasha Russell
- Sasha Russell is a Registered Nurse and Research Assistant, School of Nursing, Virginia Commonwealth University, Richmond, VA. Christine Aubry is a Registered Nurse and Research Assistant, School of Nursing, Virginia Commonwealth University, Richmond, VA. Amy Rider is a Research Nurse and Project Coordinator, School of Nursing, Virginia Commonwealth University, Richmond, VA. Dr. Suzanne E. Mazzeo is a Professor, Department of Psychology, Virginia Commonwealth University, Richmond, VA. Dr. Patricia A. Kinser is an Associate Professor, Department of Family and Community Health Nursing, Virginia Commonwealth University School of Nursing, Richmond, VA. Dr. Kinser can be reached via email at
| | | | | | | | | |
Collapse
|
6
|
Kinser P, Jallo N, Huberty J, Jones E, Thacker L, Moyer S, Laird B, Rider A, Lanni S, Drozd F, Haga S. Study protocol for a multisite randomized controlled trial of an internet and mobile-based intervention for preventing and reducing perinatal depressive symptoms. Res Nurs Health 2021; 44:13-23. [PMID: 33319443 PMCID: PMC7856295 DOI: 10.1002/nur.22092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/02/2020] [Accepted: 11/29/2020] [Indexed: 01/07/2023]
Abstract
Nearly 20% of women in the United States experience clinically significant depressive symptoms during pregnancy or the postpartum period. These women may benefit from easily accessible, nonpharmacologic, and inexpensive self-management approaches, such as via internet and mobile-based interventions, to prevent development of symptoms and/or intervene with current symptoms. This paper summarizes the research protocol of a nationally-funded large-scale randomized controlled study to evaluate "Mamma Mia," a self-guided program with 44 modules that women use throughout pregnancy to 6 months postpartum. The program contains a novel combination of components designed to enable women to enhance self-efficacy, emotional self-regulation, and perceived social support. The overall goal of this three-arm longitudinal randomized controlled trial is to evaluate the effects and mechanisms of this self-management approach in diverse women in the U.S. (n = 1950). Enrolled pregnant women will be randomly assigned to one of three groups: (1) "Mamma Mia" alone, which is self-guided; (2) "Mamma Mia Plus" in which participants engage in the "Mamma Mia" modules plus receive brief guided support from a registered nurse; or (3) usual prenatal/postpartum care. The first specific aim is to evaluate effects by group on the primary outcome of interest, depressive symptoms, over time. The second aim is to evaluate effects by group on subjective well-being, anxiety, and stress. Using a conceptual framework based upon Individual and Family Self-Management Theory, the third aim is to evaluate possible mediators (self-efficacy, emotion self-regulation, perceived support) and possible moderators (e.g., race/ethnicity, type of healthcare clinician) of this self-management approach.
Collapse
Affiliation(s)
| | - Nancy Jallo
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer Huberty
- College of Health Solutions, Arizona State University, Tempe, Arizona, USA
| | - Evelyn Jones
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Leroy Thacker
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sara Moyer
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Breanne Laird
- College of Health Solutions, Arizona State University, Tempe, Arizona, USA
| | - Amy Rider
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Susan Lanni
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Filip Drozd
- Regional Centre for Child and Adolescent Mental Health, Oslo, Norway
| | - Silje Haga
- Regional Centre for Child and Adolescent Mental Health, Oslo, Norway
| |
Collapse
|
7
|
Dagher RK, Bruckheim HE, Colpe LJ, Edwards E, White DB. Perinatal Depression: Challenges and Opportunities. J Womens Health (Larchmt) 2021; 30:154-159. [PMID: 33156730 PMCID: PMC7891219 DOI: 10.1089/jwh.2020.8862] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Perinatal depression (PND) is a major depressive episode during pregnancy or within 4 weeks after childbirth up to a year. Risk factors for PND include stressful life events, history of depression, poor social support, unplanned and unwanted pregnancies, poor relationship quality, current or previous abuse, and low socioeconomic status. This mental disorder has been shown to have negative effects on mothers' quality of life and their intimate relationships, birth outcomes, and breastfeeding likelihood, as well as long-term effects on children's cognitive and emotional development. To date, no nationally representative study has examined whether there are socioeconomic and/or racial/ethnic differences in PND. This study discusses the prevalence and risk factors for PND, as well as its health consequences for mothers and children, the reasons for its underreporting and undertreatment, the evidence for different screening instruments and different treatment options, and the existing supportive policies to address this disorder in the United States. We conclude with outlining next steps in addressing the gaps in the literature on PND.
Collapse
Affiliation(s)
- Rada K. Dagher
- Division of Scientific Programs, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Lisa J. Colpe
- National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Emmeline Edwards
- Division of Extramural Research, National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Della B. White
- Division of Extramural Research, National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
8
|
Mediterranean Diet for the Prevention of Gestational Diabetes in the Covid-19 Era: Implications of Il-6 In Diabesity. Int J Mol Sci 2021; 22:ijms22031213. [PMID: 33530554 PMCID: PMC7866163 DOI: 10.3390/ijms22031213] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 02/07/2023] Open
Abstract
The aim of this review is to highlight the influence of the Mediterranean Diet (MedDiet) on Gestational Diabetes Mellitus (GDM) and Gestational Weight Gain (GWG) during the COVID-19 pandemic era and the specific role of interleukin (IL)-6 in diabesity. It is known that diabetes, high body mass index, high glycated hemoglobin and raised serum IL-6 levels are predictive of poor outcomes in coronavirus disease 2019 (COVID-19). The immunopathological mechanisms of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection include rising levels of several cytokines and in particular IL-6. The latter is associated with hyperglycemia and insulin resistance and could be useful for predicting the development of GDM. Rich in omega-3 polyunsaturated fatty acids, vitamins, and minerals, MedDiet improves the immune system and could modulate IL-6, C reactive protein and Nuclear Factor (NF)-κB. Moreover, polyphenols could modulate microbiota composition, inhibit the NF-κB pathway, lower IL-6, and upregulate antioxidant enzymes. Finally, adhering to the MedDiet prior to and during pregnancy could have a protective effect, reducing GWG and the risk of GDM, as well as improving the immune response to viral infections such as COVID-19.
Collapse
|
9
|
de Campos EA, Narchi NZ, Moreno G. Meanings and perceptions of women regarding the practice of yoga in pregnancy: A qualitative study. Complement Ther Clin Pract 2020; 39:101099. [PMID: 32379641 DOI: 10.1016/j.ctcp.2020.101099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/10/2019] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Considering that pregnancy triggers profound transformations in the life experience of women, among them the need to adapt to a body in a constant process of physiological, psychic, social and emotional change, it is important to identify to what extent yoga can contribute to this process. For this reason, the present study aimed to comprehend the meanings and perceptions of women regarding the practice of yoga during pregnancy. MATERIALS AND METHODS A qualitative and descriptive study was carried out with nine women at different gestational ages who were practicing yoga in places with alternative and integrative therapies for pregnant women located in São Paulo, Brazil. Data collection was performed through semi-structured interviews and the women's statements were transcribed, analysed and grouped into three thematic categories. RESULTS The analysis of the interviews allowed the identification of three categories 'Benefits of practicing yoga', 'Self-knowledge, autonomy and self-care' and 'Empowerment for the moment of the birth'. These findings allowed us to understand how the women perceived the practice of yoga in the pregnancy and considered it fundamental to the recognition that they were competent and skilled to manage and control their bodies during childbirth. CONCLUSION It was concluded that the practice of yoga provided physical and psychosocial benefits for the women of this study, including strengthening of the pelvic floor, pain relief, improvement of breathing, reduction of stress and anxiety, and strengthening of self-confidence, self-esteem and autonomy in the management of the pregnancy and in caring for themselves.
Collapse
Affiliation(s)
- Edemilson Antunes de Campos
- Direct-entry Midwifery Program of the School of Arts, Sciences and Humanities of the University of Sao Paulo, Av. Arlindo Bettio, 1000 - Ermelino Matarazzo, 03828-000, São Paulo, São Paulo, Brazil.
| | - Nádia Zanon Narchi
- Direct-entry Midwifery Program of the School of Arts, Sciences and Humanities of the University of Sao Paulo, Av. Arlindo Bettio, 1000 - Ermelino Matarazzo, 03828-000, São Paulo, São Paulo, Brazil.
| | - Gabriela Moreno
- Direct-entry Midwifery Program of the School of Arts, Sciences and Humanities of the University of Sao Paulo, Av. Arlindo Bettio, 1000 - Ermelino Matarazzo, 03828-000, São Paulo, São Paulo, Brazil.
| |
Collapse
|
10
|
Innovations in the Treatment of Perinatal Depression: the Role of Yoga and Physical Activity Interventions During Pregnancy and Postpartum. Curr Psychiatry Rep 2019; 21:133. [PMID: 31802268 DOI: 10.1007/s11920-019-1121-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW We review evidence for physical activity and yoga as interventions for depressed pregnant and postpartum women. RECENT FINDINGS Results from existing trials have generally indicated that physical activity and yoga interventions are acceptable to women during the perinatal period, and that these interventions can be effective in reducing depression. However, some studies have not found significant differences between intervention and control conditions. In addition, symptom improvements were not always maintained. The available research on physical activity and yoga as interventions for perinatal depression is encouraging with regard to feasibility, acceptability, patient safety, and preliminary efficacy. These interventions have the ability to reach a large number of women who may not engage in traditional treatment. Additional high quality, rigorous, randomized controlled trials are needed. Future research is also needed to examine the optimal dose of these interventions and how to best increase sustained engagement.
Collapse
|
11
|
Frieder A, Fersh M, Hainline R, Deligiannidis KM. Pharmacotherapy of Postpartum Depression: Current Approaches and Novel Drug Development. CNS Drugs 2019; 33:265-282. [PMID: 30790145 PMCID: PMC6424603 DOI: 10.1007/s40263-019-00605-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Postpartum depression is one of the most common complications of childbirth. Untreated postpartum depression can have substantial adverse effects on the well-being of the mother and child, negatively impacting child cognitive, behavioral, and emotional development with lasting consequences. There are a number of therapeutic interventions for postpartum depression including pharmacotherapy, psychotherapy, neuromodulation, and hormonal therapy among others, most of which have been adapted from the treatment of major depressive disorder outside of the peripartum period. Current evidence of antidepressant treatment for postpartum depression is limited by the small number of randomized clinical trials, underpowered samples, and the lack of long-term follow-up. The peripartum period is characterized by rapid and significant physiological change in plasma levels of endocrine hormones, peptides, and neuroactive steroids. Evidence supporting the role of neuroactive steroids and γ-aminobutyric acid (GABA) in the pathophysiology of postpartum depression led to the investigation of synthetic neuroactive steroids and their analogs as potential treatment for postpartum depression. Brexanolone, a soluble proprietary intravenous preparation of synthetic allopregnanolone, has been developed. A recent series of open-label and placebo-controlled randomized clinical trials of brexanolone in postpartum depression demonstrated a rapid reduction in depressive symptoms, and has led to the submission for regulatory approval to the US Food and Drug Administration (decision due in March 2019). SAGE-217, an allopregnanolone analog, with oral bioavailability, was recently tested in a randomized, double-blind, placebo-controlled phase III study in severe postpartum depression, with reportedly positive results. Finally, a 3β-methylated synthetic analog of allopregnanolone, ganaxolone, is being tested in both intravenous and oral forms, in randomized, double-blind, placebo-controlled phase II studies in severe postpartum depression.
Collapse
Affiliation(s)
- Ariela Frieder
- Department of Psychiatry, Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, New York, NY, 11004, USA
| | - Madeleine Fersh
- Department of Psychiatry, Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, New York, NY, 11004, USA
| | - Rachel Hainline
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Kristina M Deligiannidis
- Department of Psychiatry, Women's Behavioral Health, Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, New York, NY, 11004, USA.
- Departments of Psychiatry and Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
- Feinstein Institute for Medical Research, Manhasset, NY, USA.
| |
Collapse
|