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Schwarzbach CJ, Eichner FA, Rücker V, Hofmann AL, Keller M, Audebert HJ, von Bandemer S, Engelter ST, Geis D, Gröschel K, Haeusler KG, Hamann GF, Meisel A, Sander D, Schutzmeier M, Veltkamp R, Heuschmann PU, Grau AJ. The structured ambulatory post-stroke care program for outpatient aftercare in patients with ischaemic stroke in Germany (SANO): an open-label, cluster-randomised controlled trial. Lancet Neurol 2023; 22:787-799. [PMID: 37459876 DOI: 10.1016/s1474-4422(23)00216-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Patients with ischaemic stroke are at risk of recurrent stroke. In this study, we aimed to compare the effect of a structured ambulatory post-stroke care programme versus usual care on recurrent vascular events and death and control of cardiovascular risk factors. METHODS We did a prospective, open-label, cluster-randomised controlled trial (SANO) at stroke centres in regions of Germany. A cluster was defined as a region in which acute stroke care is provided by a participating stroke centre. Patients were eligible for participation if they were aged 18 years or older, had no severe disabilities before the index stroke (modified Rankin scale 0-1), had at least one modifiable cardiovascular risk factor, and presented within 14 days of symptom onset of their first ischaemic stroke. The participating regions were randomly assigned (1:1) to the intervention and control group (usual care) by the statistician using block randomisation (block sizes of six), stratified by rural and urban regions. In intervention regions, a cross-sectoral multidisciplinary network was established to provide a 1-year organisational and patient-centred intervention. Due to the type of intervention, masking of participants and study physicians was not possible. Endpoint adjudication was performed by an independent endpoint adjudication committee who were masked to cluster allocation. The primary endpoint was a composite of recurrent stroke, myocardial infarction, and all-cause death within 12 months after baseline assessment, assessed in the modified intention-to-treat (mITT) population, which included all patients who did not withdraw consent and completed the primary endpoint assessment at 12 months. This study was registered with the German Clinical Trials Register, DRKS00015322. FINDINGS Between Jan 1, 2019 and Dec 22, 2020, 36 clusters were assessed for eligibility, of which 30 were randomly assigned to the intervention group (n=15 clusters) or control group (n=15 clusters). No clusters dropped out of the study. 1203 (86%) of 1396 enrolled patients in the intervention group and 1283 (92%) of 1395 enrolled patients in the control group were included in the mITT population. The primary endpoint was confirmed in 64 (5·3%) of 1203 patients in the intervention group and 80 (6·2%) of 1283 patients in the control group (unadjusted odds ratio [OR] 0·80 [95% CI 0·49-1·30]; adjusted OR [aOR] 0·95 [95% CI 0·54-1·67]). All-cause deaths occurred in 31 (2·4%) of 1203 patients in the intervention group and 12 (1·0%) of 1283 patients in the control group. The incidence of serious adverse events was higher in the intervention group (266 [23·1%] of 1151) than the control group (106 [9·2%] of 1152). Falls (134 [11·4%] of 1203 patients in the intervention group; 39 [3·3%] of 1152 patients in the control group), hypertensive crisis (55 [4·7%]; 34 [2·8%]), and diagnosis of depression (51 [4·3%]; 13 [1·1%]) were the most frequent adverse events in both groups. No differences were identified in the rate of readmission to hospital between groups. INTERPRETATION No differences were identified between patients with ischaemic stroke in the intervention group and control group with regard to the incidence of vascular events 1 year after baseline assessment, despite positive effects with regard to the control of some cardiovascular risk factors. Longer-term effects and other potentially favourable effects on stroke-related sequelae and quality of life require further evaluation. FUNDING Innovation Fund of the Federal Joint Committee.
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Affiliation(s)
| | - Felizitas Anna Eichner
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Viktoria Rücker
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Anna-Lena Hofmann
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Moritz Keller
- Department of Neurology, Catholic Hospital Koblenz-Montabaur, Koblenz, Germany
| | - Heinrich J Audebert
- Department of Neurology with Experimental Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Stefan T Engelter
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Dieter Geis
- Bavarian General Practitioners̓ Association, München, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Gerhard F Hamann
- Clinic for Neurology and Neurological Rehabilitation, District Hospital Günzburg, Günzburg, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk Sander
- Department of Neurology, Benedictus Hospital, Tutzing, Germany
| | - Martha Schutzmeier
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital Rüttenscheid, Essen, Germany; Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Ulrich Heuschmann
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-University Würzburg, Würzburg, Germany; Clinical Trial Centre Würzburg, University Hospital Würzburg, Würzburg, Germany; Institute for Medical Data Science, University Hospital Würzburg, Würzburg, Germany
| | - Armin J Grau
- Department of Neurology, Ludwigshafen Municipal Hospital, Ludwigshafen, Germany
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Eichner FA, Reis JM, Dores J, Pavlovic V, Kreß L, Daneshkhah N, Weinhardt R, Grau A, Mühler J, Soda H, Schwarzbach CJ, Schuler M, Häusler KG, Heuschmann PU. Cross-sectional study on patients' understanding and views of the informed consent procedure of a secondary stroke prevention trial. Eur J Neurol 2021; 28:2639-2647. [PMID: 33988886 DOI: 10.1111/ene.14917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Improving understanding of study contents and procedures might enhance recruitment into studies and retention during follow-up. However, data in stroke patients on understanding of the informed consent (IC) procedure are sparse. METHODS We conducted a cross-sectional study among ischemic stroke patients taking part in the IC procedure of an ongoing cluster-randomized secondary prevention trial. All aspects of the IC procedure were assessed in an interview using a standardized 20-item questionnaire. Responses were collected within 72 h after the IC procedure and analyzed quantitatively and qualitatively. Participants were also asked their main reasons for participation. RESULTS A total of 146 stroke patients (65 ± 12 years old, 38% female) were enrolled. On average, patients recalled 66.4% (95% confidence interval = 65.2%-67.5%) of the content of the IC procedure. Most patients understood that participation was voluntary (99.3%) and that they had the right to withdraw consent (97.1%); 79.1% of the patients recalled the study duration and 56.1% the goal. Only 40.3% could clearly state a benefit of participation, and 28.8% knew their group allocation. Younger age, higher graduation, and allocation to the intervention group were associated with better understanding. Of all patients, 53% exclusively stated a personal and 22% an altruistic reason for participation. CONCLUSIONS Whereas understanding of patient rights was high, many patients were unable to recall other important aspects of study content and procedures. Increased attention to older and less educated patients may help to enhance understanding in this patient population. Actual recruitment and retention benefit of an improved IC procedure remains to be tested in a randomized trial.
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Affiliation(s)
- Felizitas A Eichner
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Joschua M Reis
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Joaquim Dores
- Department of Neurology, Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | - Vladimir Pavlovic
- Neurological Clinic, Leopoldina Krankenhaus Schweinfurt, Schweinfurt, Germany
| | - Luisa Kreß
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Naeimeh Daneshkhah
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Renate Weinhardt
- Neurological Clinic, Rhön-Klinikum Campus Bad Neustadt an der Saale, Bad Neustadt, Germany
| | - Armin Grau
- Department of Neurology, Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | - Johannes Mühler
- Neurological Clinic, Leopoldina Krankenhaus Schweinfurt, Schweinfurt, Germany
| | - Hassan Soda
- Neurological Clinic, Rhön-Klinikum Campus Bad Neustadt an der Saale, Bad Neustadt, Germany
| | | | - Michael Schuler
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Peter U Heuschmann
- Institute for Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Center Würzburg, Universitätsklinikum Würzburg, Würzburg, Germany
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Schwarzbach CJ, Grau AJ. [Arguments for a structured outpatient poststroke care]. Nervenarzt 2021; 92:168. [PMID: 33464362 DOI: 10.1007/s00115-020-01054-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 11/24/2022]
Affiliation(s)
- C J Schwarzbach
- Neurologische Klinik, Klinikum der Stadt Ludwigshafen am Rhein, Bremserstr. 79, 67063, Ludwigshafen, Deutschland.
| | - A J Grau
- Neurologische Klinik, Klinikum der Stadt Ludwigshafen am Rhein, Bremserstr. 79, 67063, Ludwigshafen, Deutschland
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Schwarzbach CJ, Eichner FA, Pankert A, Schutzmeier M, Heuschmann PU, Grau AJ. [Stroke aftercare : Treatment reality, challenges and future perspectives]. Nervenarzt 2020; 91:477-483. [PMID: 32361775 DOI: 10.1007/s00115-020-00909-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Registry data demonstrate a high risk of recurrent stroke and rehospitalization rates after first-time stroke in Germany compared to the international level. Meanwhile, a report of the Institute for Applied Quality Assurance in the Healthcare System (aQua institute) pointed out the potential for improvement of post-stroke care in Germany. OBJECTIVE To establish perspectives for improvement of outpatient post-stroke care in Germany. METHODS Critical discussion of important aspects of post-stroke care, presentation of the current structures of healthcare provision and possibilities for improvement of post-stroke care. RESULTS Post-stroke care in Germany is predominantly carried out by general practitioners. Currently, standard healthcare procedures do not provide a comprehensive supportive system of structured and cross-sectoral aftercare after ischemic stroke. Special attention must be paid to the treatment of cardiovascular risk factors according to the guidelines, a specific and rapid provision of assist devices and physiotherapy as well as prevention and treatment of stroke-associated complications. Previous investigations have revealed sometimes clear deficits in the provision of treatment. The reasons include but are not limited to sectoral barriers that are difficult to overcome. New concepts of post-stroke care for improvement of these deficits are currently undergoing clinical testing. CONCLUSION Ischemic stroke should be considered as a complex chronic disease and should be treated accordingly after discharge from acute inpatient treatment. Emphasis should be placed on the optimization of interdisciplinary and cross-sectoral cooperation and support for general practitioners in the outpatient post-stroke care. New concepts of post-stroke care have the potential for improvement of the current healthcare structures.
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Affiliation(s)
- C J Schwarzbach
- Neurologische Klinik, Klinikum der Stadt Ludwigshafen, Bremserstr. 79, 67063, Ludwigshafen, Deutschland.
| | - F A Eichner
- Institut für Klinische Epidemiologie und Biometrie, Universität Würzburg, Würzburg, Deutschland
| | - A Pankert
- Neurologische Klinik, Klinikum der Stadt Ludwigshafen, Bremserstr. 79, 67063, Ludwigshafen, Deutschland
| | - M Schutzmeier
- Institut für Klinische Epidemiologie und Biometrie, Universität Würzburg, Würzburg, Deutschland
| | - P U Heuschmann
- Institut für Klinische Epidemiologie und Biometrie, Universität Würzburg, Würzburg, Deutschland.,Zentrale für Klinische Studien, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - A J Grau
- Neurologische Klinik, Klinikum der Stadt Ludwigshafen, Bremserstr. 79, 67063, Ludwigshafen, Deutschland
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Eichner FA, Schwarzbach CJ, Keller M, Haeusler KG, Hamann GF, Sander D, Audebert HJ, Gröschel K, Geis D, von Bandemer S, Rücker V, Schutzmeier M, Heuschmann PU, Grau A. Trial design and pilot phase results of a cluster-randomised intervention trial to improve stroke care after hospital discharge - The structured ambulatory post-stroke care program (SANO). Eur Stroke J 2020; 6:213-221. [PMID: 34414297 PMCID: PMC8370073 DOI: 10.1177/2396987320910596] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/09/2020] [Indexed: 01/22/2023] Open
Abstract
Introduction Previous studies showed insufficient control of cardiovascular risk factors (CVRF) and high stroke recurrence rates among ischemic stroke patients in Germany. Currently, no structured secondary prevention program exists in clinical routine. We present the trial design and pilot phase results of a complex intervention to improve stroke care after hospital discharge in Germany. Patients and methods SANO is a cluster-randomized trial with 30 participating regions across Germany aiming to enrol 2,790 patients (drks.de, DRKS00015322). Study intervention combines both structural and patient-centred elements. Study development was based on the Medical Research Council framework for complex interventions. In 15 intervention regions, a cross-sectoral multidisciplinary network is established to enhance CVRF control as well as detection and treatment of post-stroke complications. Recommendations on CVRF are based on high-quality secondary prevention guidelines. Study physicians use motivational interviewing and agree with patients on therapeutic targets. While hospitalised, patients also receive dietary counselling and a health-passport to track their progress. During regular visits, CVRF management and potential complications are monitored. The intervention is compared to 15 regions providing usual care. The primary endpoint is the combination of recurrent stroke, myocardial infarction and death assessed 12 months after enrolment and adjudicated in a blinded manner. Results Eighteen patients were enrolled in a pilot phase that demonstrated feasibility of patient recruitment and study procedures. Conclusion SANO is investigating a program to reduce outcome events after ischemic stroke by implementing a complex intervention. If successful, the program may be implemented in routine care on national level in Germany.
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Affiliation(s)
- Felizitas A Eichner
- Institute for Clinical Epidemiology and Biometry, Universität Würzburg, Würzburg, Germany
- Felizitas A Eichner, Josef-Schneider-Straße 2, 97080 Würzburg, Germany.
| | | | - Moritz Keller
- Department of Neurology, Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | | | - Gerhard F Hamann
- Clinic for Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Dirk Sander
- Department of Neurology, Benedictus Krankenhaus Tutzing, Tutzing, Germany
| | - Heinrich J Audebert
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, Universitätsmedizin Mainz, Mainz, Germany
| | - Dieter Geis
- Bayrischer Hausärzteverband, München, Germany
| | | | - Viktoria Rücker
- Institute for Clinical Epidemiology and Biometry, Universität Würzburg, Würzburg, Germany
| | - Martha Schutzmeier
- Institute for Clinical Epidemiology and Biometry, Universität Würzburg, Würzburg, Germany
| | - Peter Ulrich Heuschmann
- Institute for Clinical Epidemiology and Biometry, Universität Würzburg, Würzburg, Germany
- Clinical Trial Center Würzburg, Universitätsklinikum Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Center Würzburg, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Armin Grau
- Department of Neurology, Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
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Schwarzbach CJ, Schmitt WH, Szabo K, Bäzner H, Hennerici MG, Blahak C. Chorea in a patient with cryopyrin-associated periodic syndrome. Neurology 2015; 86:241-4. [DOI: 10.1212/wnl.0000000000002300] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 09/15/2015] [Indexed: 11/15/2022] Open
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Tepest R, Schwarzbach CJ, Krug B, Klosterkötter J, Ruhrmann S, Vogeley K. Morphometry of structural disconnectivity indicators in subjects at risk and in age-matched patients with schizophrenia. Eur Arch Psychiatry Clin Neurosci 2013; 263:15-24. [PMID: 22821623 DOI: 10.1007/s00406-012-0343-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 06/30/2012] [Indexed: 01/13/2023]
Abstract
Structural disconnectivity has been hypothesized as being accountable for the pathophysiology of schizophrenia. Morphometric variables suitable for the empirical study of disconnectivity were studied aiming at the research question whether empirical indicators for disconnectivity are already informative in subjects at risk (SAR) and in young matched patients diagnosed with schizophrenia (SZ). In MRI data of subjects of the two diagnostic groups SZ and SAR, the size of the corpus callosum (CC) as indicator for interhemispherical long distance connections and the gyrification index (GI) as indicator for cortico-cortical connections were analyzed compared to a healthy controls (HC). Each subgroup consists of 21 subjects matched for sex and age. Measurements of the CC and GI were estimated in manually performed tracing procedures. GI data revealed significant differences between the diagnostic groups of both SAR and SZ as compared to HC in the frontal and parietal cortices. Measurements of total CC yielded no significant differences between diagnostic groups. The results are suggestive for impaired cortico-cortical connections as indicated by gyrification changes in SZ and also in SAR, whereas interhemispherical connectivity at the same time appears to be unaffected.
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Affiliation(s)
- Ralf Tepest
- Klinik für Psychiatrie und Psychotherapie, Uniklinik Köln, Cologne, Germany.
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Schwarzbach CJ, Schaefer A, Ebert A, Held V, Bolognese M, Kablau M, Hennerici MG, Fatar M. Stroke and cancer: the importance of cancer-associated hypercoagulation as a possible stroke etiology. Stroke 2012; 43:3029-34. [PMID: 22996958 DOI: 10.1161/strokeaha.112.658625] [Citation(s) in RCA: 188] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE The importance of cancer-associated hypercoagulability as a possible stroke etiology in patients with cancer has received relatively little attention to date. A recent study has suggested that cancer-associated hypercoagulation may be of special importance in the absence of conventional stroke mechanisms. METHODS We identified patients with ischemic stroke sequentially admitted to our stroke center with the additional diagnosis of active and malignant cancer from 2002 to 2011. By using our prospectively collected stroke, MRI, and laboratory data banks, the etiology and risk factors of stroke, types of cancer, deep vein thrombosis/pulmonary embolism, d-dimer levels, and diffusion-weighted imaging lesion patterns were compared to an age- and sex-matched control group. Patients with cancer with a conventional stroke etiology and patients with an unidentified and/or cancer-associated stroke etiology were analyzed separately. RESULTS One hundred forty patients with cancer and 140 control subjects were included. Unidentified stroke (P<0.001) and infarction in multiple vascular territories (P<0.001) were significantly more frequent and d-dimer levels significantly higher (P<0.05) in patients with cancer. Vice versa, risk factors such as hypertension (P<0.05) and hyperlipidemia (P<0.01) were more prevalent in control subjects. Deep vein thrombosis and pulmonary embolism were more frequent (P<0.01) and d-dimer levels higher (P<0.01) in the patients with unidentified and/or cancer-associated stroke etiology compared to the patients with cancer with a conventional stroke etiology. Lung and pancreatic cancer were significantly overrepresented and d-dimer levels higher in these patients compared with other patients with cancer (P<0.01). CONCLUSIONS Our data confirm the concept of cancer-associated hypercoagulation as a widely underestimated important stroke risk factor in patients with cancer, especially in those with severely elevated d-dimer levels and in the absence of conventional risk factors.
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Affiliation(s)
- Christopher J Schwarzbach
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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