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In a first, Veterans Affairs centers use genetic testing to treat depression

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Catherine Ho reports in the San Francisco Chronicle:

Kewchang Lee, a psychiatrist who oversees mental health consultations at the San Francisco Veterans Affairs Medical Center, is not used to being studied.

But in recent weeks, Lee signed up to be part of a first-of-its-kind experiment that is playing out in 21 VA health centers around the country, including San Francisco and Palo Alto.

For the first time since he began practicing medicine in 1992, Lee is asking a small number of his patients to take a cheek swab for a genetic test analyzing their ability to metabolize commonly prescribed antidepressants. Lee uses the information to help decide which and how much of an antidepressant to prescribe. And he’s allowing other psychiatrists to observe, during the course of the two-year VA study, whether his knowledge of the genetic information will ultimately lead to better recovery and remission rates among his patients with major depressive disorder.

It is the first study in the VA health system to examine whether doctors gaining knowledge of their patients’ genomic composition can help shape more precise treatment plans for depression.

“Different people for genetic reasons metabolize things differently,” said Lee, who is also a clinical professor of psychiatry at UCSF. “With fast metabolizers, I might not necessarily change the antidepressant, but might target a higher dose. If a patient is a slow metabolizer, I might consider changing the antidepressant itself depending on the side-effect profile of that drug.”

Depression, post-traumatic stress disorder and other mental health disorders are prevalent among combat veterans. Up to 25 percent of returning troops experience depression — compared to 8 percent among the U.S. adult population. In one recent survey of 700 San Francisco veterans, 58 percent had probable depression, based on their answers to a health questionnaire, according to a 2017 report by the USC Center for Innovation and Research on Veterans & Military Families, part of the university’s Suzanne Dworak-Peck School of Social Work.

The recent tragedy at Yountville’s Pathway Home, where Army infantryman Albert Wong fatally shot two Pathway staff members, a VA clinical psychologist and himself, highlights the need to advance research to improve mental health treatment.

Wong had been undergoing PTSD treatment at Pathway, a treatment center for troubled veterans of the post-Sept. 11 wars, and had been asked to leave the program two weeks before the shooting.

“When things like this happen, we all think about ways that we can improve mental health care and access to mental health care,” Lee said. “It does speak to the need for funding for research and studies to improve the treatment of conditions like PTSD and depression.”

The VA depression study, funded by $12 million from the Department of Veterans Affairs, seeks to enroll 2,000 pairs of doctors and veterans who have not responded well to previous treatment for depression. . .

Continue reading. More at the link.

Written by LeisureGuy

17 March 2018 at 8:02 pm

People are dying because we misunderstand how those with addiction think

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Brendan de Kenessey, a fellow-in-residence at the Edmond J. Safra Center for Ethics at Harvard University and (as of this fall) a member of the faculty of the philosophy department at the University of Toronto, writes in Vox:

The American opioid epidemic claimed 42,300 lives in 2016 alone. While the public policy challenge is daunting, the problem isn’t that we lack any effective treatment options. The data shows that we could save many lives by expanding medication-assisted treatments and adopting harm reduction policies like needle exchange programs. Yet neither of these policies has been widely embraced.

Why? Because these treatments are seen as indulging an addict’s weakness rather than “curing” it. Methadone and buprenorphine, the most effective medication-assisted treatments, are “crutches,” in the words of felony treatment court judge Frank Gulotta Jr. [see note below – LG]; they are “just substituting one opioid for another,” according to former Health and Human Services Secretary Tom Price.

And as county Commissioner Rodney Fish voted to block a needle exchange program in Lawrence County, Indiana, he quoted the Bible: “If my people … shall humble themselves … and turn from their wicked ways; then will I hear from heaven, and will forgive their sin.”

Most of us have been trained to use more forgiving language when talking about addiction. We call it a disease. We say that people with addiction should be helped, not blamed. But deep down, many of us still have trouble avoiding the thought that they could stop using if they just tried harder.

Surely would do better in their situation, we think to ourselves. We may not endorse the idea — we may think it is flat-out wrong — but there’s a part of us that can’t help but see addiction as a symptom of weak character and bad judgment.

Latent or explicit, the view of addiction as a moral failure is doing real damage. The stigma against addiction is “the single biggest reason America is failing in its response to the opioid epidemic,” Vox’s German Lopez concluded after a year of reporting on the crisis. To overcome this stigma, we need to first understand it. Why is it so easy to see addiction as a sign of flawed character?

We tend to view addiction as a moral failure because we are in the grip of a simple but misleading answer to one of the oldest questions of philosophy: Do people always do what they think is best? In other words, do our actions always reflect our beliefs and values? When someone with addiction chooses to take drugs, does this show us what she truly cares about — or might something more complicated be going on?

These questions are not merely academic: Lives depend on where we come down. The stigma against addiction owes its stubborn tenacity to a specific, and flawed, philosophical view of the mind, a misconception so seductive that it ensnared Socrates in the fifth century BC.

Do our actions always reflect our preferences?

In a dialogue called the Protagoras, Plato describes a debate between Socrates and a popular teacher named (wait for it) Protagoras. At one point their discussion turns to the topic of what the Greeks called akrasia: acting against one’s best judgment.

Akrasia is a fancy name for an all-too-common experience. I know I should go to the gym, but I watch Netflix instead. You know you’ll enjoy dinner more if you stop eating the bottomless chips, but you keep munching nevertheless.

This disconnect between judgment and action is made all the more vivid by addiction. Here’s the testimony of one person with addiction, reported in Maia Szalavitz’s book Unbroken Brain: “I can remember many, many times driving down to the projects telling myself, ‘You don’t want to do this! You don’t want to do this!’ But I’d do it anyway.”

As pervasive as the experience of akrasia is, Socrates thought it didn’t make sense. I may think I value exercise more than TV, but, assuming no one is pressuring me, my behavior reveals that when it comes down to it, I, in fact, care more about catching up on Black Mirror. As Socrates puts it: “No one who knows or believes there is something else better than what he is doing, something possible, will go on doing what he had been doing when he could be doing what is better.”

Now, you might be thinking: Socrates clearly never went to a restaurant with unlimited chips. But he has a point. To figure out what a person’s true priorities are, we usually look to the choices they make. (“Actions speak louder than words.”) When a person binges on TV, munches chips, or gets high despite the consequences, Socrates would infer that they must care more about indulging now than about avoiding those consequences — whatever they may say to the contrary.

(He isn’t alone: Both the behaviorism movement in 20th-century psychology and the “revealed preference” doctrine in economics are based on the idea that you can best learn what people desire by looking at what they do.)

So for Socrates, there’s no such thing as acting against one’s best judgment: There’s only bad judgment. He draws an analogy with optical illusions. Like a child who thinks her thumb is bigger than the moon, we overestimate the value of nearby pleasures and underestimate the severity of their faraway consequences.

Through this Socratic lens, it’s hard not to see addiction as a failure. Imagine a father, addicted to heroin, who misses picking up his children from school because he’s shooting up at home. In Socrates’s view, the father must be doing what he believes to be best. But how could the father possibly think that?

I see two possibilities. As Socrates’s illusion analogy suggests, the father could be grievously mistaken about the consequences of his actions. Perhaps he has convinced himself that his kids can get home on their own, or that he’ll be able to pick them up while high. But if the father has seen the damaging effects of his behavior time and again — as happens often to long-term addicts — it becomes harder to see how he is not complicit in this illusion. If he really believes his choice will be harmless, he must be willfully, and condemnably, self-deceived.

Which leads us to the second, even more damning possibility: Perhaps the father knows the consequences shooting up will have on his children, but he doesn’t care. If his choice cannot be ascribed to ignorance, it must reveal his preferences: The father must care more about getting high than he cares about his children’s well-being.

If Socrates’s model of the mind is right, these are the only available explanations for addictive behavior: The person must have bad judgment, bad priorities, or some combination of the two.

Our philosophy of addiction shapes our treatment of it — whether we realize it or not

It’s not exactly a sympathetic picture. But I suspect it underlies much of our thinking about addiction. Consider the popular idea that someone with addiction has to hit “rock bottom” before she can begin true recovery. In the Socratic view, this makes perfect sense. If addiction is due to a failure to appreciate the bad consequences of getting high, then the best route to recovery might be for the person to experience firsthand how bad those consequences really are. A straight dose of the harshest reality might be the only cure for the addict’s self-deceived beliefs and shortsighted preferences.

We could give a similar Socratic rationale for punishing drug possession with decades in jail: If we make the consequences of using bad enough, people with addiction will finally realize that it’s better to be sober, the thought goes. Once again, we are correcting their flawed judgment and priorities, albeit with a heavy hand.

Socrates’s view also makes sense of our reluctance to adopt medication-assisted treatment and needle exchange programs. These methods might temporarily mitigate the damage caused by addiction, but on the Socratic view, they leave the underlying problem untouched.

By giving out clean needles or substituting methadone for heroin, we may prevent some deaths in the short term, but we won’t change the skewed priorities that caused the addictive behavior in the first place. Worse, we may “enable” someone’s bad judgment by shielding her from the worst effects of her actions. In the long run, the only way to save addicts from themselves is to make it harder, not easier, to pursue the lifestyle they so clearly prefer.

Is Socrates right? Or can we find a better, more sympathetic way of thinking about addiction?

To see things differently, we need to question the fundamental picture of the mind on which Socrates’s view rests. It is natural to think of the mind as a unified whole and identify ourselves with that whole. But this monolithic view of the mind leads to the Socratic view of addiction. Whatever I choose must be what my mind wants most, and so what want most. The key to escaping the Socratic view, then, is to realize that the mind has different parts — and that some parts of my mind are more me than others.

The “self” is not a single, unitary thing

This “divided mind” view has become popular in both philosophy and psychology over the past 50 years. In psychology, we see it in the rise of “dual process” theories of the mind, the most famous of which comes from Nobel laureate Daniel Kahneman, who divides the mind into a part that makes judgments quickly, intuitively, and unconsciously (“System I”) and a part that thinks more slowly, rationally, and consciously (“System II”).

More pertinent for our purposes is research on what University of Michigan neuroscientist Kent Berridge calls the “wanting system,” which regulates our cravings for things like food, sex, and drugs using signals based in the neurotransmitter dopamine. The wanting system has powerful control over behavior, and its cravings are insensitive to long-term consequences.

Berridge’s research indicates that addictive drugs can “hijack” the wanting system, manipulating dopamine directly to generate cravings that are far stronger than those the rest of us experience. The result is that the conscious part of a person’s mind might want one thing (say, to pick his kids up from school) but be overruled by the wanting system’s desire for something else (to get high). . .

Continue reading.

Note: I wonder whether Judge Gulotta wears glasses (an obvious “crutch”). If he breaks his leg, will he refuse to use a crutch because it’s just a crutch? I wear hearing aids—obviously a crutch. I think Judge Gulotta is a moron.

Written by LeisureGuy

17 March 2018 at 1:48 pm

White House Tells Idaho to Sabotage Obamacare More Subtly

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Eric Levitz writes in New York magazine:

In January, Republicans in Idaho decided that if Congress wasn’t going to repeal the Affordable Care Act, they would just have to repeal it themselves. Governor C.L. “Butch” Otter signed an executive order that nullified a whole host of ACA regulations: Insurers in the Gem State would now be able to sell health-care plans that didn’t cover maternity care, mental illness, or other “essential health benefits“; to charge higher premiums to people with preexisting conditions, and deny them coverage outright if they had failed to maintain “continuous coverage”; and set a dollar limit on the amount of benefits that consumers could draw on (which is to say, sneak in a provision that renders the insurance plan useless if an enrollee happens to develop an exorbitantly expensive medical condition).

The one catch was that insurers who sold such skimpy plans would be required to also sell at least one Obamacare-compliant option over the exchanges. This arrangement would allow (temporarily) healthy people to get (junky) insurance at a very cheap price — while rendering the risk pool for Obamacare-compliant plans exceptionally sickly, thereby causing premiums to skyrocket for people who required comprehensive coverage.

This all constituted a flagrant violation of federal law. But responsibility for enforcing said law lay with Trump’s Health and Human Services Department, which has been flagrantly violating the spirit of Obamacare for more than a year now. For weeks, the White House refused to say whether Idaho would be allowed to pick and choose which federal laws it wished to follow. In the interim, Blue Cross of Idaho announced that it would gladly sell terrible insurance plans to the good people of the Gem State — and other conservative states began seeing the virtues of simply pretending that Obamacare no longer existed.

But on Thursday night, Trump’s Health Department (somewhat apologetically) announced that it would not allow Idaho to comport itself as a sovereign nation. In a letter to Governor Otter, Seema Verma, administrator of the Centers for Medicare and Medicaid Services (CMS), wrote, “CMS is committed to working with states to give them as much flexibility as permissible under the law to provide their citizens the best possible access to healthcare. However, the Affordable Care Act remains the law[.]”

Verma encouraged Idaho to try a subtler approach to nullifying Obamacare, noting that its proposal could have passed legal muster “with certain modifications.”

And it’s true that the Trump administration has already provided conservative states with a blueprint for ending Obamacare in practice, if not law. Specifically, the White House has alerted red states to a loophole in the ACA: The law does not impose essential health benefit requirements on short-term insurance plans.

The reasoning behind this exemption was fairly simple:  . . .

Continue reading.

Written by LeisureGuy

9 March 2018 at 1:48 pm

America Is Giving Away the $30 Billion Medical Marijuana Industry

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The subhead is good:

Why? Because the feds are bogarting the weed, while Israel and Canada are grabbing market share

Josh Dean reports in Bloomberg Businessweek:

Lyle Craker is an unlikely advocate for any political cause, let alone one as touchy as marijuana law, and that’s precisely why Rick Doblin sought him out almost two decades ago. Craker, Doblin likes to say, is the perfect flag bearer for the cause of medical marijuana production—not remotely controversial and thus the ideal partner in a long and frustrating effort to loosen the Drug Enforcement Administration’s chokehold on cannabis research. There are no counterculture skeletons in Craker’s closet; only dirty boots and botany books. He’s never smoked pot in his life, nor has he tasted liquor. “I have Coca-Cola every once in a while,” says the quiet, white-haired Craker, from a rolling chair in his basement office at the University of Massachusetts at Amherst, where he’s served as a professor in the Stockbridge School of Agriculture since 1967, specializing in medicinal and aromatic plants. He and his students do things such as subject basil plants to high temperatures to study the effects of climate change on what plant people call the constituents, or active elements.

Craker first applied for a license to grow marijuana for medicinal research in 2001, at the urging of Doblin, the founder and executive director of the Multidisciplinary Association for Psychedelic Studies(MAPS), a nonprofit that advocates for research on therapeutic uses for LSD, MDMA (aka Ecstasy), marijuana, and other psychedelic drugs. Doblin, who has a doctorate in public policy, makes no secret of his own prior drug use. He’s been lobbying since the 1980s for federal approval for clinical research trials on various psychedelics, and he saw marijuana as both a promising potential medicine and an important front in the public-relations war. Since 1970 marijuana has been a DEA Schedule I substance, meaning that in the view of the federal government, it’s as dangerous as LSD, heroin, and Ecstasy, and has “no currently accepted medical use and a high potential for abuse.”

By that definition, pot—now legal for medicinal use by prescription in 29 states and for recreational use in eight—is more dangerous and less efficacious in the federal government’s estimation than cocaine, oxycodone, or methamphetamine, all of which are classified Schedule II. Scientists and physicians are free to apply to the Food and Drug Administration and DEA for trials on Schedule I substances, and there are labs with licenses to produce LSD and Ecstasy for that purpose, but anyone who seeks to do FDA-approved research with marijuana is forced to obtain the plants from a single source: Uncle Sam. Specifically, since 1968 the DEA has allowed only one facility to legally cultivate marijuana for research studies, on a 10-acre plot at the University of Mississippi, funded by the National Institute on Drug Abuse and managed by the Ole Miss School of Pharmacy.

The NIDA license, Doblin says, is a “monopoly” on the supply and has starved legitimate research toward understanding cannabinoids, terpenes, and other constituents of marijuana that seem to quell pain, stimulate hunger, and perhaps even fight cancer. Twice in the late 1990s, Doblin provided funding, PR, and lobbying support for physicians who wanted to study marijuana—one sought a treatment for AIDS-related wasting syndrome, the other wanted to see if it helped migraines—and was so frustrated by the experience that he vowed to break the monopoly. That’s what led him to Craker.

In June 2001, Craker filed an application for a license to cultivate “research-grade” marijuana at UMass, with the goal of staging FDA-approved studies. Six months later he was told his application had been lost. He reapplied in 2002 and then, after an additional two years of no action, sued the DEA, backed by MAPS. By this point, both U.S. senators from Massachusetts had publicly supported his application, and a federal court of appeals ordered the DEA to respond, which it finally did, denying the application in 2004.

Craker appealed that decision with backing from a powerful bench of allies, including 40 members of Congress, and finally, in February 2007, a DEA administrative law judge ruled that his application for a license should be granted. The decision was not binding, however; it was merely a recommendation to the DEA leadership. Almost two years later, in the last week of the Bush administration, the application was rejected. Craker threw up his hands. He firmly believed marijuana should be more widely grown and studied, but he’d lost any hope that it would happen in his lifetime. And he had basil to attend to. . .

Continue reading.

Written by LeisureGuy

8 March 2018 at 2:21 pm

Hundreds of Canadian doctors demand lower salaries. (Yes, lower.)

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And that’s what I like about the North. (Apologies to Phil Harris—see below.) Amy Wang reports in the Washington Post:

In a move that can only be described as utterly Canadian, hundreds of doctors in Quebec are protesting their pay raises, saying they already make too much money.

As of Wednesday afternoon, more than 700 physicians, residents and medical students from the Canadian province had signed an online petition asking for their pay raises to be canceled. A group named Médecins Québécois Pour le Régime Public (MQRP), which represents Quebec doctors and advocates for public health, started the petition Feb. 25.

“We, Quebec doctors who believe in a strong public system, oppose the recent salary increases negotiated by our medical federations,” the petition reads in French.

The physicians group said it could not in good conscience accept pay raises when working conditions remained difficult for others in their profession — including nurses and clerks — and while patients “live with the lack of access to required services because of drastic cuts in recent years.”

A nurses union in Quebec has in recent months pushed the government to address a nursing shortage, seeking a law that would cap the number of patients a nurse could see. The union said its members were increasingly being overworked, and nurses across the province have held several sit-ins in recent months to push for better working conditions.

In January, the situation was encapsulated in a viral Facebook post by a nurse in Quebec named Émilie Ricard, who posted a photo of herself, teary-eyed, after what she said had been an exhausting night shift. Ricard said she had been the only nurse to care for more than 70 patients on her floor; she was so stressed that she had cramps that prevented her from sleeping, she added.

“This is the face of nursing,” Ricard wrote, criticizing Quebec Health Minister Gaétan Barrette, who had deemed recent health-care system changes a success.

“I don’t know where you’re going to get your information, but it’s not in the reality of nursing,” the nurse wrote. She later added: “I am broken by my profession, I am ashamed of the poverty of the care that I provide as far as possible. My Health system is sick and dying.”

Ricard’s post has since been shared more than 55,000 times.

“There’s always money for doctors, she says, but what about the others who take care of patients?” said Nancy Bédard, president of Quebec’s nurses union, according to Global News.

Meanwhile, in February, Quebec’s federation of medical specialists reached a deal with the government to increase the annual salaries of  . . .

Continue reading.

And the Phil Harris reference:

Written by LeisureGuy

8 March 2018 at 2:16 pm

Doctors Said Immunotherapy Would Not Cure Her Cancer. They Were Wrong.

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Gina Kolata reports in the NY Times:

No one expected the four young women to live much longer. They had an extremely rare, aggressive and fatal form of ovarian cancer. There was no standard treatment.

The women, strangers to one another living in different countries, asked their doctors to try new immunotherapy drugs that had revolutionized treatment of cancer. At first, they were told the drugs were out of the question — they would not work against ovarian cancer.

Now it looks as if the doctors were wrong. The women managed to get immunotherapy, and their cancers went into remission. They returned to work; their lives returned to normalcy.

The tale has befuddled scientists, who are struggling to understand why the drugs worked when they should not have. If researchers can figure out what happened here, they may open the door to new treatments for a wide variety of other cancers thought not to respond to immunotherapy.

“What we are seeing here is that we have not yet learned the whole story of what it takes for tumors to be recognized by the immune system,” said Dr. Jedd Wolchok, chief of the melanoma and immunotherapeutics service at Memorial Sloan Kettering Cancer Center in New York.

“We need to study the people who have a biology that goes against the conventional generalizations.”

Four women hardly constitutes a clinical trial. Still, “it is the exceptions that give you the best insights,” said Dr. Drew Pardoll, who directs the Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins Medicine in Baltimore.

The cancer that struck the young women was hypercalcemic small cell ovarian cancer, which typically occurs in a woman’s teens or 20s. It is so rare that most oncologists never see a single patient with it.

But Dr. Douglas Levine, director of gynecologic oncology at New York University Langone Medical Center, specialized in this disease. A few years ago, he discovered that the cancer was driven by a single gene mutation. The finding was of little use to patients — there was no drug on the horizon that could help.

Women with this form of ovarian cancer were sharing news and tips online in a closed Yahoo group. Dr. Levine asked to become part of the group and began joining the discussions. There he discovered patients who had persuaded doctors to give them an immunotherapy drug, even though there was no reason to think it would work.

The women reported that their tumors shrank immediately.

The idea behind immunotherapy is to dismantle a molecular shield that some tumors use to avoid an attack by the body’s white blood cells.

The immune system sees these tumors as foreign — they are fueled by hundreds of genetic mutations, which drive their growth and are recognized by the body. But when white blood cells swarm in to attack the cancer cells, they bounce back, rebuffed.

Immunotherapy drugs pierce that protective shield, allowing the immune system to recognize and demolish tumor cells. But the new drugs do not work against many common cancers. . .

Continue reading.

Written by LeisureGuy

23 February 2018 at 12:24 pm

Ants injured while hunting for termites get help from paramedic-style triage system

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Amina Khan reports in the LA Times:

Move over, ant farms — ant hospitals are where the real action is. Scientists studying the behavior of African Matabele ants in Ivory Coast have found that the insects act like paramedics in a crisis, triaging and treating the wounds of their injured peers.

The discovery, described in the Proceedings of the Royal Society B, documents a surprisingly sophisticated system that helps determine which ants are most likely to survive a combat injury.

Ants are often thought to live in systems where the life or death of an individual worker doesn’t matter much. That’s because many ant species live in giant colonies whose workers usually have very short life spans relative to the queen, and because the queen can lay eggs for new workers at a fast rate.

“The benefit from helping injured ants in this scenario is small, because replacing them should be easier,” the scientists wrote. “At the same time, if injuries were mainly fatal, the benefit of a rescue behavior focused on injured individuals would again be marginal.”

That’s not the case for ants like Megaponera analis, which venture out in raiding parties of 200 to 600 individuals, attack termites and carry their unfortunate prey back home. The hard-headed termites don’t go without a fight, though. Many invading ants lose legs or end up with termite mandibles dug into their bodies.

Surprisingly, the returning ants don’t abandon all their casualties: Before returning home they look for their injured comrades, which send out a ‘distress signal’ pheromone. Within 24 hours of being taken back to the nest and treated, maimed ants can switch to a four-legged or five-legged gait that lets them run almost as fast as their six-legged peers.

Because these injured ants can still do almost the same things as their healthy peers, it makes sense to bring them home and treat them — especially since roughly a third of the small-sized ants that run these termite raids have lost a leg at some point in their life.

Gravely injured peers are usually left behind. And open wounds from severed legs could easily become infected and spread disease in the ant nest, given that there’s a lot of interaction and very low diversity within a single colony.

So for this paper, scientists from Universität Würzburg in Bavaria, Germany, wanted to learn how the ants providing medical aid make decisions about which wounded ants to save — or whether it’s their decision to make at all.

“While the benefit for the colony of leaving behind fatally injured ants is clear, the mechanism that regulates this behavior remains unknown: is the decision to rescue made by the helper or the fatally injured ant?” the study authors wrote.

To find out,  . . .

Continue reading.

Written by LeisureGuy

23 February 2018 at 10:53 am

Posted in Healthcare, Medical, Science

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