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Elyasi F, Sadati S, Heydari F. The management challenges of a case with Flupentixol-induced neuroleptic malignant syndrome. Neuropsychopharmacol Rep 2023; 43:154-159. [PMID: 36585735 PMCID: PMC10009412 DOI: 10.1002/npr2.12315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a rare and life-threatening reaction. The incidence rate of NMS has dropped because of the higher use of atypical antipsychotics, compared with the typical ones. The mortality rate in patients taking injectable antipsychotics has been also by 38%. AIM Here, a case developing the NMS symptoms following Flupentixol (FPX) use was reported. CASE PRESENTATION The patient was a 46-year-old man with the history of schizoaffective disorder (SAD) and recently on six-weekly doses of long-acting (LA) typical antipsychotic drugs. He was referred with a fever, sweating, a food intolerance, mutism, and disorientation in 2019. He was presented with generalized rigidity, negativism, and neck stiffness. The patient's initial creatine phosphokinase (CPK) level was 1476 IU/L, which gradually elevated to 3997 IU/L on Day 26. NMS was further diagnosed, in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, and the score 9+ in the Naranjo Algorithm as the adverse drug reaction probability scale. Afterward, the patient was treated with bromocriptine at a dose of 5 mg 3 times a day, which progressively reached a maximum of 50 mg. He experienced sepsis and resistant respiratory infection several times. The case was finally discharged after 66 days of hospitalization, with a high level of consciousness, but limited verbal communication, in a fever-free condition with the oral administration of bromocriptine and lorazepam. CONCLUSION In conclusion, there were suggestions for the management challenges of NMS in patients receiving LA injectable antipsychotic agents.
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Affiliation(s)
- Forouzan Elyasi
- Sexual and Reproductive Health Research Center, Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran.,Department of Psychiatry, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Seyedehnasibeh Sadati
- Department of Psychiatry, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fateme Heydari
- Department of Anesthesiology and Critical Care Medicine, Imam Khomeini Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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Abstract
SummaryPresence of fever in psychiatric patients may signify a number of potentially fatal conditions. Several of these are related to treatments (e.g. neuroleptic malignant syndrome with antipsychotics, serotonin syndrome with serotonergic antidepressants, and malignant hyperpyrexia with anaesthesia used for administration of electroconvulsive therapy) or exacerbated by them (e.g. malignant catatonia with antipsychotics). New classes of drug treatment may be changing the epidemiology of these disorders. We suggest that an initial diagnosis of hyperthermia syndrome is clinically useful as there are some important commonalities in treatment. We outline a systematic approach to identify a particular subtype of hyperthermia syndrome and the indications for more specific treatments where available.
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Ali M, Das S, Thirthalli J, Sastry NLS. Olanzapine induced neuroleptic malignant syndrome, treated with electroconvulsive therapy (ECT)-A case report. Asian J Psychiatr 2017; 30:230-231. [PMID: 28736031 DOI: 10.1016/j.ajp.2017.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 07/03/2017] [Indexed: 01/28/2023]
Affiliation(s)
- Mustafa Ali
- NIMHANS, Bengaluru, India; Professor of Psychiatry and I/C Head of Psychiatric Rehabilitation Services, National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru 560029, India; NIMHANS, Bengaluru, India.
| | - Soumitra Das
- NIMHANS, Bengaluru, India; Professor of Psychiatry and I/C Head of Psychiatric Rehabilitation Services, National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru 560029, India; NIMHANS, Bengaluru, India.
| | - Jagadisha Thirthalli
- NIMHANS, Bengaluru, India; Professor of Psychiatry and I/C Head of Psychiatric Rehabilitation Services, National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru 560029, India; NIMHANS, Bengaluru, India.
| | - Nagavarapu Leela Shankar Sastry
- NIMHANS, Bengaluru, India; Professor of Psychiatry and I/C Head of Psychiatric Rehabilitation Services, National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru 560029, India; NIMHANS, Bengaluru, India.
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Velamoor R. Neuroleptic malignant syndrome: A neuro-psychiatric emergency: Recognition, prevention, and management. Asian J Psychiatr 2017; 29:106-109. [PMID: 29061403 DOI: 10.1016/j.ajp.2017.05.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 11/17/2022]
Abstract
Neuroleptic Malignant Syndrome (NMS) is a life threatening complication of antipsychotic therapy. It is often assumed to be rare. Observations suggest that rather than overestimating its frequency, we are more likely to underestimate it (Pope et al., 1986). It is a rare but potentially fatal disorder characterized by four principal symptoms. These are mental status changes, muscle rigidity, hyperthermia, and autonomic dysfunction. The diagnosis of NMS often presents a challenge because several medical conditions generate similar symptoms. Although less common now than in the past, thanks to greater awareness, it remains a risk in susceptible patients receiving conventional or atypical neuroleptics. Reducing the risk factors, early recognition of suspected cases, and prompt management can significantly reduce morbidity and mortality of this dangerous condition. Collaboration between psychiatry and other medical specialities may be the key to a successful outcome.
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Affiliation(s)
- Raj Velamoor
- Professor Psychiatry, Northern Ontario School of Medicine, Laurentian and Lakehead University, Ontario, Canada; Emeritus Professor Psychiatry, Schulich School of Medicine, Western University, Ontario, Canada.
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Gurrera RJ. A systematic review of sex and age factors in neuroleptic malignant syndrome diagnosis frequency. Acta Psychiatr Scand 2017; 135:398-408. [PMID: 28144982 DOI: 10.1111/acps.12694] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To examine sex and age distributions in neuroleptic malignant syndrome (NMS) patients based on a systematic literature review. METHOD EMBASE and PubMed databases were searched to identify any observation of NMS published from January 1, 1998 through November 1, 2014 that was accessible and interpretable (using language translation software). Redundant and equivocal reports were excluded. Sex ratio and age distributions were examined using standard graphical techniques and measures of association. RESULTS Twenty-eight independent sex ratio estimates were included. Males predominated in most (75%) estimates with an overall median sex ratio of 1.47 (95% CI, 1.20-1.80). NMS incidence peaked at age 20-25 years and declined steadily thereafter, with males consistently outnumbering females at all but the oldest age intervals. CONCLUSION NMS patients are 50% more likely to be males, and NMS is most likely to occur in young adulthood.
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Affiliation(s)
- Ronald J Gurrera
- Veteran Affairs Boston Healthcare System, Boston MA and Harvard Medical School Department of Psychiatry, Boston, MA, USA
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Atypical Neuroleptic Malignant Syndrome Associated with Use of Clozapine. Case Rep Emerg Med 2017; 2017:2174379. [PMID: 28303200 PMCID: PMC5337851 DOI: 10.1155/2017/2174379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/31/2016] [Accepted: 01/10/2017] [Indexed: 11/24/2022] Open
Abstract
The Neuroleptic Malignant Syndrome (NMS) is a medical emergency of infrequent presentation in the emergency department, which is associated with the use of psychiatric drugs, such as typical and atypical antipsychotics. Our case addresses a 55-year-old patient diagnosed with undifferentiated schizophrenia for 10 years, who had been receiving clozapine and clonazepam as part of their treatment. This patient presents the symptoms of Neuroleptic Malignant Syndrome without fever, which improves with treatment especially with the withdrawal of clozapine. In the absence of fever and clinical improvement, the patient is considered to have an atypical presentation of this disease.
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Abstract
Neuroleptic malignant syndrome (NMS) is a life-threatening emergency that is often seen as a complication of antipsychotic agents. It is characterized by a tetrad of motor, behavioral, autonomic, and laboratory abnormalities. We report a case of a 34-year-old man with a history of newly diagnosed Type 2 diabetes mellitus, mental retardation, and behavioral abnormalities who developed NMS after starting on antipsychotic agents. He presented with high temperature, muscle rigidity, tachycardia, and elevated blood pressure. After a week of hospital treatment in the general ward of a secondary care unit, he was discharged in a hemodynamically and mentally stable state.
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Affiliation(s)
- Bino Rajamani
- Low-Cost Effective Care Unit, CMC, Vellore, Tamil Nadu, India
| | - Yashwant Kumar
- Department of Family Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sajitha M F Rahman
- Department of Family Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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Ahuja N, Cole A. Practical approach to management of catatonia. FUTURE NEUROLOGY 2015. [DOI: 10.2217/fnl.15.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this article, we discuss important issues in the management of catatonic symptoms in busy clinical settings. Catatonic symptoms are common among inpatients, not only in psychiatry but also in acute medicine and neurology. Prompt recognition of these symptoms is easy if clinicians maintain a high index of suspicion. Early diagnosis and treatment can reduce the significant morbidity and mortality associated with these cases. Speedy investigation to rule out organic catatonia and identify dangerous complications forms an important part of management. Early treatment with benzodiazepines can aid diagnosis and shorten the duration of catatonia, thereby improving outcomes. Electroconvulsive therapy has an important role where benzodiazepines have been ineffective, but antipsychotics can be potentially harmful. There are a number of other treatment options that are less robustly evidence-based, but supportive management is essential in all cases.
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Affiliation(s)
- Niraj Ahuja
- Northumberland, Tyne & Wear NHS Foundation Trust, Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Andrew Cole
- Northumberland, Tyne & Wear NHS Foundation Trust, Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
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Dixit S, Dutta MK, Namdeo M. A Rare Case of Myxedema Coma with Neuroleptic Malignant Syndrome (NMS). J Clin Diagn Res 2015; 9:VD01-VD03. [PMID: 26155541 PMCID: PMC4484133 DOI: 10.7860/jcdr/2015/13008.5868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/07/2015] [Indexed: 11/24/2022]
Abstract
Myxedema coma or hypothyroid crisis is an endocrine emergency and needs ICU management. Neuroleptic malignant syndrome (NMS) is another medical emergency which needs high degree of clinical suspicion else mortality can be high. There is a paradox in co existence of myxedema coma and NMS. While one is hypometabolic state another is hypermetabolic state and both can be precipitated by antipsychotics use. Hypothermia and flaccidity commonly expected in myxedema coma may mask fever and rigidity of classical NMS contributing to diagnostic problem and treatment delay. Scientific literature on coexistance of myxedema coma and NMS is sparse. We hereby report first case with coexisting myxedema coma and NMS in a patient of schizophrenia treated with antipsychotic, where classical symptoms of NMS were masked by myxedema coma. Prompt diagnosis and effective management by a team resulted in favourable outcome in our patient. This case is reported to alert intensive care physicians to atypical manifestations of NMS in presence of hypothyroidism.
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Affiliation(s)
- Siddharth Dixit
- Classified Specialist Psychiatry, Department of Psychiatry, Base Hospital, Delhi Cantt, Assistant Professor, Department of Psychiatry, Army College of Medical Science, New Delhi, India
| | - Manoj Kumar Dutta
- Classified Specialist Endocrinology, Base Hospital Delhi Cantt. Assistant Professor, Army College of Medical Science, New Delhi, India
| | - Mayank Namdeo
- DNB Resident, Department of Psychiatry, Base Hospital, Delhi Cantt, India
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Zou D, Shao Y, Qin Z, Zhang J, Liu N, Li Z, Huang P, Chen Y. Death due to fulminant neuroleptic malignant syndrome induced by low doses of haloperidol: A rare case. J Forensic Leg Med 2014; 24:12-4. [DOI: 10.1016/j.jflm.2014.02.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 01/29/2014] [Accepted: 02/25/2014] [Indexed: 11/29/2022]
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Lithium toxicity and neurologic effects: probable neuroleptic malignant syndrome resulting from lithium toxicity. Case Rep Psychiatry 2012; 2012:271858. [PMID: 22953147 PMCID: PMC3420417 DOI: 10.1155/2012/271858] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 02/28/2012] [Indexed: 12/02/2022] Open
Abstract
Introduction. We present the case of a patient who developed lithium toxicity with normal therapeutic levels, as a result of pharmacokinetic interaction with Valsartan, and probable Neuroleptic Malignant Syndrome from the ensuing lithium toxicity. Case Presentation. A 59-year old black male with bipolar disorder maintained on lithium and fluphenazine therapy presented with a 2 week history of worsening confusion, tremor, and gait abnormality. He recently had his dose of Valsartan increased. At presentation, patient had signs of autonomic instability, he was confused, dehydrated, and had rigidity of upper extremities. Significant labs on admission were lithium level-1.2, elevated CK-6008, leukocytosis WBC-22, and renal impairment; Creatinine-4.1, BUN-35, HCO3-20.1, and blood glucose 145. CT/MRI brain showed old cerebral infarcts, and there was no evidence of an infective process. Lithium and fluphenazine were discontinued, his lithium levels gradually decreased, and he improved with supportive treatment including rehydration and correction of electrolyte imbalance. Conclusions. This case illustrates that lithium toxicity can occur within therapeutic levels, and the neurotoxic effect of lithium can include Neuroleptic Malignant Syndrome. Clinicians should be aware of the risk associated with drug interactions with lithium.
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Liu PY, Wu PC, Chen CY, Chen YC. Potentiating effect of fluphenazine decanoate and risperidone on development of neuroleptic malignant syndrome. Gen Hosp Psychiatry 2011; 33:84.e5-7. [PMID: 21353143 DOI: 10.1016/j.genhosppsych.2010.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 10/24/2010] [Accepted: 10/26/2010] [Indexed: 11/24/2022]
Abstract
We present the case of a woman with paranoid schizophrenia who was receiving oral risperidone. She developed neuroleptic malignant syndrome (NMS) following the addition of depot fluphenazine for the treatment of refractory delusions. NMS subsided and psychotic features were controlled after both antipsychotics were discontinued and the patient was treated instead with olanzapine.
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Affiliation(s)
- Pang-Yen Liu
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
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Tural U, Onder E. Clinical and pharmacologic risk factors for neuroleptic malignant syndrome and their association with death. Psychiatry Clin Neurosci 2010; 64:79-87. [PMID: 20416027 DOI: 10.1111/j.1440-1819.2009.02042.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM The aim of the present study was to evaluate demographics, clinical features, psychiatric diagnoses and prognosis of neuroleptic malignant syndrome (NMS) reported in Turkey, and to assess their association with mortality. METHODS Data on all reported cases of NMS in the Turkish Psychiatric Index between 1985 and 2005 were collected. The type, dosage and administration period of neuroleptics, the clinical and laboratory findings; and prognosis were compared in terms of mortality. RESULTS Thirty-six patients with a mean age of 33.67 +/- 16.98 years were identified. Fifteen (41.7%) were diagnosed as having schizophrenia or other psychotic disorders and the same number were diagnosed as having affective disorder. Remaining five (13.9%) were diagnosed with other psychiatric disorders and 1 (2.7%) had no psychiatric diagnosis. Twenty-two (61.1%) of the NMS cases were associated with high potency typical neuroleptics. Association between an atypical antipsychotic and NMS has been reported in one case. NMS appeared within 7 days after initiation of the antipsychotic medication in the majority of samples (n = 19, 52.8%). Several combinations of rescue treatments were used in the majority of cases (n = 19, 52.8%), although bromocriptine (n = 22, 61.1%) was the most frequently preferred rescue treatment for NMS. Benzodiazepines were significantly better than the other treatment options in preventing mortality. Five out of the 36 patients (13.9%) with NMS had died. Age was the only significant independent factor that was associated with mortality. CONCLUSIONS Benzodiazepines may be included in the treatment of NMS. The mortality rate due to NMS in Turkey was lower than the previously reported rates from other developing countries.
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Affiliation(s)
- Umit Tural
- Department of Psychiatry, Medical Faculty, Kocaeli University, Kocaeli, Turkey.
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Abstract
Antipsychotic as a class of medications became available for treatment of various psychiatric disorders in the early 1950's. Over the last 60 years many antipsychotics have become available. In line with the west, Indian researchers have evaluated the efficacy of antipsychotics in various conditions. Additionally, researchers have also evaluated the important safety and tolerability issues. Here, we review data originating from India in the form of drug trials, effectiveness, usefulness, safety and tolerability of antipsychotics. Additionally, data with respect to other important treatment related issues is discussed.
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Affiliation(s)
- Ajit Avasthi
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Munish Aggarwal
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Gurrera RJ, Simpson JC, Tsuang MT. Meta-analytic evidence of systematic bias in estimates of neuroleptic malignant syndrome incidence. Compr Psychiatry 2007; 48:205-11. [PMID: 17292713 DOI: 10.1016/j.comppsych.2006.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The aim of this study was to examine published reports for sources of excessive variance in neuroleptic malignant syndrome (NMS) incidence estimates. DATA SOURCES An unrestricted computerized MEDLINE search was conducted with a comprehensive search logic and supplemented by secondary references and a manual search of an extensive personal library. STUDY SELECTION Studies were analyzed if they presented original data and provided at least 2 of the following: number of NMS cases, number of patients at risk, or ratio of cases to patients at risk. Twenty-six of the 28 candidate studies met these minimal criteria. DATA EXTRACTION Variables included incidence, year of study publication, mean year of NMS occurrence, patient population at risk, study design, diagnostic criteria, and country of origin. DATA SYNTHESIS Standard error, which reflects study size, accounted for 90.8% of the variance (beta = .953, P < .001) in this international series of 26 NMS incidence estimates. Incidence was significantly lower in 7 studies the time end points of which were set in advance of case identification (chi(2) = 71.08, P < .001). No other variable was significantly related to incidence. CONCLUSIONS Neuroleptic malignant syndrome incidence estimates to date are non-trivially biased such that larger study size (patients at risk) is strongly related to lower observed incidence. Future studies can minimize the contribution of this and other sources of experimental error by incorporating several very feasible recommendations.
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Affiliation(s)
- Ronald J Gurrera
- Department of Psychiatry and VA Boston Healthcare System, Harvard Medical School, Boston, MA 02115, USA.
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