depression pregnancy

Infant sleep duration associated with mother's level of education and prenatal depression

Findings show greater support for mothers who experience prenatal depression or cesarean delivery may be warranted

February 27, 2019

Science Daily/University of Alberta Faculty of Medicine & Dentistry

A new study analyzing data from Canadian parents has found that babies sleep less at three months of age if their mothers do not have a university degree, experienced depression during pregnancy or had an emergency cesarean-section delivery.

 

The study, which examined associations between a mother's level of education, prenatal depression, method of delivery and her infant's sleep duration, was published this month in Sleep Medicine. It found that infants born to mothers without a university degree slept an average of 13.94 hours per day -- 23 minutes less than infants born to mothers with a university degree, and just short of the National Sleep Foundation guidelines of an average of 14-17 hours of sleep per day at three months of age.

 

The researchers analyzed data from 619 infants and their mothers participating in AllerGen's CHILD Cohort Study -- a national birth cohort study collecting a wide range of health, lifestyle, genetic and environmental exposure information from nearly 3,500 children and their families from pregnancy to adolescence.

 

"Sleep affects a baby's growth, learning and emotional development, and is one of the most common concerns of new parents," said Piush Mandhane, an associate professor of pediatrics at the University of Alberta and one of the study's lead authors.

 

"While earlier research has linked a mother's socioeconomic status, including level of education, to shorter infant sleep duration, we have not really understood the factors at play. Our study revealed that 30 per cent of the effect of maternal education on infant sleep duration is actually mediated by a mother's prenatal depression, as well as the type of delivery."

 

Specifically, the researchers found mothers without a university degree to be at significantly higher risk of having symptoms of depression during both the prenatal and postnatal periods, or the prenatal period alone, compared to women with a university degree.

 

There are several possible explanations for the association between maternal depression and infant sleep, according to co-lead author Anita Kozyrskyj, also a professor of pediatrics at the U of A. "Mothers in distress tend to have sleep problems during pregnancy, which can be 'transmitted' to the fetus via the mother's circadian clock and melatonin levels," she said. "Maternal depression and emergency cesarean section also both lead to elevated free cortisol levels, which, in turn, may cause an exaggerated stress response in infants that negatively impacts their sleep."

 

Further, the researchers found that the method of delivery independently predicted infant sleep duration, with infants delivered by emergency cesarean section sleeping approximately one hour less per day than infants born by vaginal delivery.

 

"This was an interesting finding, as we did not observe an association between shorter infant sleep and scheduled cesarean sections or vaginal deliveries," commented first author Brittany Matenchuk, an AllerGen trainee and a former Master's student at the U of A.

 

"While we are still at an early stage of unravelling the underlying biologic mechanisms, our study suggests that prenatal depression and birth mode are potential targets for health-care professionals and policy makers to improve infant sleep duration. Mothers who experience prenatal depression or an emergency cesarean delivery may benefit from support so that infant sleep problems do not persist into childhood."

 

According to the team, previous studies have shown that sleep has a large impact on infant emotional and behavioural development. It may also affect how they perform cognitively later in life.

 

"We need to support moms before the child is born," added Mandhane. "And if we can start to promote healthy sleep early on, three months of age onward, I think that just is better for families in general."

https://www.sciencedaily.com/releases/2019/02/190227140010.htm

Sixty-four percent of women suffer from insomnia in late pregnancy

January 29, 2018

Science Daily/University of Granada

A new study warns that health systems need to address the problem of insomnia in pregnancy systematically, since as well as affecting the quality of life of pregnant women, insomnia is a risk factor for high blood pressure and pre-eclampsia, gestational diabetes mellitus, depression, preterm birth and unplanned caesarean sections.

 

The research study was recently published in the European Journal of Obstetrics & Gynecology and Reproductive Biology. 486 healthy pregnant women from Granada, Jaen, Huelva and Seville who had attended the Andalusian Health Service (SAS) before the 14th week of pregnancy (first trimester) participated in the study. The effects of pregnancy on these women were monitored throughout all three trimesters.

 

The results reveal that 44% of pregnant women suffer from insomnia in the first trimester of pregnancy, which increases to 46% in the second trimester and 64% in the third trimester. These are very high figures which, according to the authors of the research, justify the need for a "systematic approach to this problem."

 

Dr. María del Carmen Amezcua Prieto, one of the researchers behind the study and a lecturer at the Department of Preventive Medicine and Public Health of the University of Granada, explains that: "Although it is well known that pre-existing sleep problems worsen and new issues frequently arise during pregnancy, there is a tendency to assume that difficulties related to getting to sleep and maintaining restorative sleep are characteristic phenomena of pregnancy and that they must be endured."

 

However, Dr. Amezcua Prieto points out that: "This probably occurs because the health system does not give importance to the issue during the monitoring of pregnancies, to the point where the World Health Organization (WHO) does not even address the issue of sleep in its guidelines on providing care to pregnant women."

 

Insomnia-related problems

 

Insomnia causes numerous problems. It affects the quality of life of pregnant women, which apart from being of great importance per se, is also a risk factor for high blood pressure and pre-eclampsia, gestational diabetes, depression, premature birth and unplanned caesarean sections. Consequently, the issue must be tackled systematically.

 

María del Rosario Román Gálvez, one of the other researchers behind this ambitious project, warns that every single aspect of night-time sleep and its impact on daytime functioning must be addressed in order to study insomnia effectively.

 

"The results of our study show significant alterations in sleep fragmentation (the times women wake up during the night and how long they stay awake), as well as in daytime sleepiness. It also demonstrates that the frequency and intensity of sleep fragmentation continue to increase as the pregnancy progresses. Likewise, pregnancy also complicates sleep induction (the time it takes for an individual to fall asleep) and sleep duration. It is important to take into account these aspects to properly address the problem using non-pharmacological treatments," the UGR researcher notes.

 

Factors associated with insomnia were also analysed as part of the project. Prof. Aurora Bueno Cavanillas highlights that: "Although it may seem obvious, the most important factor is pre-gestational insomnia, given that it is fundamental to prevention and underscores the importance of detecting insomnia before pregnancy and throughout all stages of it." The study also revealed that other factors, such as obesity and whether or not the women have already had children, can have an impact on sleeping patterns.

 

Lastly, the study illustrates that the regular practice of moderate or intense physical exercise during pregnancy protects women against pregnancy-related insomnia, "so this is yet another reason for promoting physical activity during pregnancy."

https://www.sciencedaily.com/releases/2018/01/180129131340.htm

 

Postpartum depression least severe form of depression in mothers

Time frame when pregnant woman first develops depression determines severity, treatment of it

June 15, 2016

Science Daily/Northwestern University

Postpartum depression -- a household term since actress Brooke Shields went public in 2005 about her struggle with it -- is indeed serious. But depression that begins before or during pregnancy is often more severe because it lasts longer and usually goes undetected until the doctor screens for it after the birth of the baby, according to a new study.

 

Deciphering the onset time can impact how the doctor treats the woman's depression, such as intervening earlier with psychiatric help, if needed, said Sheehan Fisher, the study's corresponding author and an instructor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine.

 

"There's a difference between postpartum depression and depression that started before or during the pregnancy. It's not a homogenous disorder, " Fisher said. "When clinicians see a mother during the postpartum period and diagnose her with depression, it's important for them to ask how long this depression has been an issue so they can assess the longevity and severity."

 

The study, recently published in the Journal of Affective Disorders, is one of the first to evaluate the rate of depression in mothers at the three onset time points: 24.9 percent of participants developed depression pre-pregnancy, 36.7 percent developed it during pregnancy (prenatal) and 38.4 percent developed depression during the postpartum period.

 

Mothers who develop depression during the postpartum period are more likely to be Caucasian, older, educated, married or cohabitating, and have private health insurance than mothers whose depression begins before or during pregnancy, the study found.

 

"Mothers who develop postpartum depression often experience protective risk factors such as better access to resources, fewer children and are more mature, which helps them adapt to the stress of pregnancy," Fisher said. "Once their babies are born, they show more obsessive-compulsive symptoms--like over-worrying about their baby's health--than mothers who developed depression before or during pregnancy."

 

Women who had depression before they became pregnant were more likely to experience hypersomnia or difficulty falling asleep. They also experienced more symptoms of paranoia, such as a psychotic episode, than women who developed depression during or after pregnancy. And they had a higher severity of postpartum depression than the other onset periods.

 

The proportion of mothers who had a bipolar disorder, which Fisher said is more severe than unipolar depression, was significantly higher among mothers whose depression onset was during the pre-pregnancy period (38.7 percent), compared with prenatal (22.6 percent) and postpartum (17.9 percent).

 

Agitation was the distinctive factor that differentiated mothers with unipolar and bipolar depression in the study. Mothers who had a bipolar disorder and developed depression during her pregnancy exhibited the highest amount of agitation.

 

The study evaluated depression symptoms during the four- to six-week postpartum period for 727 women from an urban women's hospital in Pittsburgh, Penn. This period was chosen because women typically visit their doctors for post-birth evaluations six weeks after birth, and the four- to six-week epoch is associated with the highest depression onset.

https://www.sciencedaily.com/releases/2016/06/160615142624.htm

 

 

Prenatal stress could enhance protective mechanisms of babies

May 13, 2016

Science Daily/Universität Basel

Maternal stress and depression during pregnancy may activate certain protective mechanisms in babies. Psychologists from the University of Basel together with international colleagues report that certain epigenetic adaptations in newborns suggest this conclusion. Their results have been published in the journal Social Cognitive and Affective Neuroscience.

 

In their study, the researchers observed that increased concentrations of maternal stress hormones, depressive symptoms and general adversities during pregnancy were accompanied by epigenetic changes in the child. As a result of these changes the oxytocin receptor gene, which is important for social behavior and stress adaptations, is activated more easily. This mechanism could indicate that in these cases, the babies adapt to develop more resilience to cope with future challenges and adversities.

 

Switch reprogrammed

 

Whether a gene can be activated or not also depends on methyl groups that attach to the DNA and function as a switch. The researchers found that children from mothers with increased stress and depressive symptoms show a reduced methylation of the oxytocin receptor gene at birth. This results in the gene becoming more easily activated, which leads to a facilitated production of oxytocin receptors for oxytocin to react with and unfold its effects. Oxytocin not only has an important function in mother-child bonding and in induction of labor and lactation, it also influences social behavior.

 

For their study, the team of Prof. Gunther Meinlschmidt from the Faculty of Psychology at the University of Basel examined 100 mothers and their babies during and after pregnancy. They collected umbilical cord blood from 39 newborns and assessed the stress hormone cortisol in saliva samples of the mothers. In addition, the researchers evaluated stressful life events and mental health of the mothers via questionnaires. Since the data were only analyzed up to the newborn phase, no conclusions were drawn with regard to the long-term consequences that the epigenetic programming of oxytocin receptors might have for the children.

 

"Resilience research only at the beginning"

 

Researchers from the University of Basel, Ruhr University Bochum, Exeter University, McGill University Montreal, Ludwig Maximilian University of Munich, University of Trier, Zurich University of Applied Sciences and the Stress Center Trier were involved in this study funded by the Swiss National Science Foundation. Previous studies have shown, that adversities during pregnancy can increase the risk for mental disorders and physical diseases in the mother's offspring. However, science has so far dedicated much less attention to potential protective mechanisms of the child.

 

"Resilience research in this area is only at the beginning," explains Meinlschmidt. The observations made provide first evidence that an adverse environment during pregnancy could also activate protective mechanisms. "We need a comprehensive understanding of the psychological processes that allow humans to sustain long-term health even over generations despite adversities," says Meinlschmidt. Based on this knowledge, resilience processes could be promoted in order to try preventing the development of mental disorders and physical illnesses.

https://www.sciencedaily.com/releases/2016/05/160513084542.htm

Screening for depression recommended for adults, including pregnant and postpartum women

January 26, 2016

Science Daily/The JAMA Network Journals

The US Preventive Services Task Force is recommending screening for depression in the general adult population, including pregnant and postpartum women, and that screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

 

This recommendation is a USPSTF grade B recommendation, meaning that there is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.

 

Depression is among the leading causes of disability in persons 15 years and older. It affects individuals, families, businesses, and society and is common in patients seeking care in the primary care setting, and also common in postpartum and pregnant women. The U.S. Preventive Services Task Force (USPSTF) reviewed the evidence in the medical literature on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations. The USPSTF is an independent, volunteer panel of experts that makes recommendations about the effectiveness of specific preventive care services such as screenings, counseling services, and preventive medications. This report is an update of a 2009 USPSTF recommendation statement. The USPSTF continues to recommend that adults 18 and older be screened for depression.

 

Detection, and Benefits of Early Detection, Intervention and Treatment

 

The USPSTF found convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women, and found adequate evidence that programs combining depression screening with adequate support systems in place improve clinical outcomes (i.e., reduction or remission of depression symptoms) in adults, including pregnant and postpartum women. The USPSTF found convincing evidence that treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity. The USPSTF also found adequate evidence that treatment with cognitive behavioral therapy (CBT) improves clinical outcomes in pregnant and postpartum women with depression.

 

Harms of Early Detection, Intervention and Treatment

 

The USPSTF found adequate evidence that the magnitude of harms of screening for depression in adults is small to none and that the magnitude of harms of treatment with CBT in postpartum and pregnant women is small to none. The USPSTF found that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) are associated with some harms, such as an increase in suicidal behaviors in adults age 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 years, with risk increasing with age; however, the magnitude of these risks is, on average, small. The USPSTF also found evidence of potential serious fetal harms from pharmacologic treatment of depression in pregnant women, but the likelihood of these serious harms is low. Therefore, the USPSTF concludes that the overall magnitude of harms is small to moderate.

 

Screening

 

The optimal timing and interval for screening for depression is not known. A pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted. Positive screening results should lead to additional assessment that considers severity of depression and comorbid psychological problems, alternate diagnoses, and medical conditions.

 

Treatment and Interventions

 

Effective treatment of depression in adults generally includes antidepressants or specific psychotherapy approaches, alone or in combination. Given the potential harms to the fetus and newborn child from certain pharmacologic agents, clinicians are encouraged to consider evidence-based counseling interventions when managing depression in pregnant or breastfeeding women.

 

USPSTF Assessment

 

The USPSTF concludes with at least moderate certainty that there is a moderate net benefit to screening for depression in adults 18 years and older, including older adults, who receive care in clinical practices that have adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up after screening. The USPSTF also concludes with at least moderate certainty that there is a moderate net benefit to screening for depression in pregnant and postpartum women who receive care in clinical practices that have CBT or other evidence-based counseling available after screening.

 

Editorial: Recommendations for Screening for Depression in Adults

 

Michael E. Thase, M.D., of the University of Pennsylvania, Philadelphia, comments on the USPSTF recommendations in an accompanying editorial.

 

"Until there are better methods to match patients with specific forms of treatment, the best hope to improve on a B grade for patients with depression may be to adapt care systems to respond more flexibly and decisively to key events that are associated with nonadherence or treatment failure. For example, if the clinicians working within a collaborative care model could rapidly incorporate the information that an initial prescription was not filled or was not refilled, it may be possible to diminish the chances that nonadherence will compromise treatment outcome."

 

"Likewise, given evidence that nonresponse is predicted by a lack of symptom improvement during the first 14 days of therapy, web-based monitoring of symptoms early in the course of therapy may enable physicians and other mental health professionals to intervene more rapidly and reduce the chances of treatment failure. The same approach to ongoing care could be used to facilitate a more timely transition through treatment algorithms and more expeditious referral to specialty care."

http://www.sciencedaily.com/releases/2016/01/160126125228.htm

Depression in early pregnancy linked to gestational diabetes

September 19, 2016

Science Daily/National Institutes of Health
A two-way link between depression and gestational diabetes has been uncovered by researchers. Women who reported feeling depressed during the first two trimesters of pregnancy were nearly twice as likely to develop gestational diabetes, according to an analysis of pregnancy records. Conversely, a separate analysis found that women who developed gestational diabetes were more likely to report postpartum depression six weeks after giving birth, compared to a similar group of women who did not develop gestational diabetes.
https://images.sciencedaily.com/2016/09/160919094450_1_540x360.jpg
Pregnant woman having her blood sugar/ glucose checked.
Credit: © Mediteraneo / Fotolia

Gestational diabetes is a form of diabetes (high blood sugar level) occurring only in pregnancy, which if untreated may cause serious health problems for mother and infant.

"Our data suggest that depression and gestational diabetes may occur together," said the study's first author, Stefanie Hinkle, Ph.D., staff scientist in the Division of Intramural Population Health Research at the NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). "Until we learn more, physicians may want to consider observing pregnant women with depressive symptoms for signs of gestational diabetes. They also may want to monitor women who have had gestational diabetes for signs of postpartum depression."

Although obesity is known to increase the risk for gestational diabetes, the likelihood of gestational diabetes was higher for non-obese women reporting depression than for obese women with depression.

The researchers analyzed pregnancy records from the NICHD Fetal Growth Studies-Singleton Cohort, which tracked the progress of thousands of pregnancies, to understand the patterns of fetal growth. The study enrolled 2,334 non-obese and 468 obese women in weeks eight to 13 of pregnancy. The women responded to questionnaires on symptoms of depression when they enrolled in the study, again between the 16th and 22nd week of pregnancy, and then six weeks after giving birth. The researchers also reviewed the women's records to identify who had developed gestational diabetes.

"Of particular note, persistent depression from the first to second trimester set women at even greater risk for gestational diabetes" said the study's senior author, Cuilin Zhang, M.D., Ph.D, in the Division of Intramural Population Health Research at NICHD. Women who had the highest scores for depression in the first and second trimesters -- about 17 percent -- had nearly triple the risk for gestational diabetes when compared to women who had lower depression scores.

"Our results suggest it would be a good idea for clinicians to pay particular attention to women with high depression scores when evaluating the risk of gestational diabetes," Dr. Zhang added.

Although obesity increases the risk for gestational diabetes, non-obese women with high depression scores had nearly triple the risk for gestational diabetes than the other women in the study. Depression did not appear to increase the risk for gestational diabetes among obese women.

Currently, the American College of Obstetricians and Gynecologists recommends (link is external) that physicians screen patients at least once for depression during the perinatal period (link is external) (22 weeks of pregnancy through 7 days after birth.)

The researchers also found a higher risk for postpartum depression among the women who had gestational diabetes. Of the women who developed gestational diabetes, nearly 15 percent experienced depressive symptoms after birth, which was more than four times that of women who had not had gestational diabetes.

Dr. Hinkle stressed that the study was not able to prove a cause and effect relationship between symptoms of depression and gestational diabetes. The researchers added that earlier studies have shown that depression is associated with impaired glucose metabolism that may lead to higher blood sugar levels. Similarly, high blood sugar levels may lead to inflammation, hormonal, and other changes that could lead to symptoms of depression.Gestational diabetes is a form of diabetes (high blood sugar level) occurring only in pregnancy, which if untreated may cause serious health problems for mother and infant.

"Our data suggest that depression and gestational diabetes may occur together," said the study's first author, Stefanie Hinkle, Ph.D., staff scientist in the Division of Intramural Population Health Research at the NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). "Until we learn more, physicians may want to consider observing pregnant women with depressive symptoms for signs of gestational diabetes. They also may want to monitor women who have had gestational diabetes for signs of postpartum depression."

Although obesity is known to increase the risk for gestational diabetes, the likelihood of gestational diabetes was higher for non-obese women reporting depression than for obese women with depression.

The researchers analyzed pregnancy records from the NICHD Fetal Growth Studies-Singleton Cohort, which tracked the progress of thousands of pregnancies, to understand the patterns of fetal growth. The study enrolled 2,334 non-obese and 468 obese women in weeks eight to 13 of pregnancy. The women responded to questionnaires on symptoms of depression when they enrolled in the study, again between the 16th and 22nd week of pregnancy, and then six weeks after giving birth. The researchers also reviewed the women's records to identify who had developed gestational diabetes.

"Of particular note, persistent depression from the first to second trimester set women at even greater risk for gestational diabetes" said the study's senior author, Cuilin Zhang, M.D., Ph.D, in the Division of Intramural Population Health Research at NICHD. Women who had the highest scores for depression in the first and second trimesters -- about 17 percent -- had nearly triple the risk for gestational diabetes when compared to women who had lower depression scores.

"Our results suggest it would be a good idea for clinicians to pay particular attention to women with high depression scores when evaluating the risk of gestational diabetes," Dr. Zhang added.

Although obesity increases the risk for gestational diabetes, non-obese women with high depression scores had nearly triple the risk for gestational diabetes than the other women in the study. Depression did not appear to increase the risk for gestational diabetes among obese women.

Currently, the American College of Obstetricians and Gynecologists recommends (link is external) that physicians screen patients at least once for depression during the perinatal period (link is external) (22 weeks of pregnancy through 7 days after birth.)

The researchers also found a higher risk for postpartum depression among the women who had gestational diabetes. Of the women who developed gestational diabetes, nearly 15 percent experienced depressive symptoms after birth, which was more than four times that of women who had not had gestational diabetes.

Dr. Hinkle stressed that the study was not able to prove a cause and effect relationship between symptoms of depression and gestational diabetes. The researchers added that earlier studies have shown that depression is associated with impaired glucose metabolism that may lead to higher blood sugar levels. Similarly, high blood sugar levels may lead to inflammation, hormonal, and other changes that could lead to symptoms of depression.

Science Daily/SOURCE :https://www.sciencedaily.com/releases/2016/09/160919094450.htm

Depression during pregnancy is associated with abnormal brain structure in children

November 15, 2016

Science Daily/Elsevier
Depressive symptoms in women during and after pregnancy are associated with reduced thickness of the cortex -- the outer layer of the brain responsible for complex thought and behavior -- in preschool-age kids, according to a new study. The findings suggest that a mother's mood may affect her child's brain development at critical stages in life.

"Mothers generally want to do everything they can to give their offspring the best possible chance of success in life. They often make sure to eat well and to take special vitamins," said John Krystal, Editor of Biological Psychiatry. "This new study now suggests that another thing they may be able to do is to make sure that they are treated for their depression."

Eighteen percent of women experience depression some time during pregnancy, and both perinatal and postpartum depression have been associated with negative outcomes in children. The new study, led by Catherine Lebel of the University of Calgary in Alberta, is the first to report associations between maternal depression and abnormal brain structure in kids at this age.

The researchers screened 52 women for depressive symptoms during each trimester of pregnancy and a few months after the child was born. The women ranged in the presence of symptoms, some with no or few symptoms, and some meeting the screening criteria for depression. When the children reached about 2.5 to 5 years old, the researchers used magnetic resonance imaging to measure their brain structure.

Women with higher depressive symptoms tended to have children with thinner frontal and temporal areas, cortical regions implicated in tasks involving inhibition and attention control. The researchers also found an association between depressive symptoms and abnormal white matter in the frontal area, the fiber tracts connecting the region to other areas in the brain.

These associations were only found when symptoms occurred during the second trimester and postpartum, suggesting these periods are particularly critical times for child brain development.

Cortical thinning is a normal aspect of brain development during early childhood, so Lebel says the findings suggest that the brain may be developing prematurely in children whose mothers experience more depressive symptoms.

Abnormalities in brain structure during critical periods in development have often been associated with negative outcomes, such as learning disabilities and behavioral disorders. Additionally, the brain structure abnormalities identified in this study reflect those found in children with depression or at high risk for developing the disorder, suggesting that these alterations may be why children of mothers with perinatal depression are more vulnerable to depression later in life.

Although the mechanism behind the association remains a mystery, the findings may have implications for minimizing risks of atypical brain development in children.

"Our findings underscore the importance of monitoring and supporting mental health in mothers not just in the postpartum period, but also during pregnancy," said Lebel.

Science Daily/SOURCE :https://www.sciencedaily.com/releases/2016/11/161115123323.htm

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