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1.
J Dairy Sci ; 102(5): 4002-4013, 2019 May.
Article in English | MEDLINE | ID: mdl-30827539

ABSTRACT

Our aim was to compare the energy balance estimated (EBest) according to equations published by various energy feeding systems (German Society for Nutrition Physiology, French National Institute for Agricultural Research, and US National Research Council) and the EB calculated by use of calorimetrically measured heat production (EBhp) of 20 high-yielding (≥10,000 kg/305 d) German Holstein cows at -4 (pregnant, nonlactating) and 2 wk (early lactation) relative to parturition. In addition to heat production, feed and water intake, physical activity (including standing-lying behavior), body weight, body condition score, body temperature, plasma concentrations of fatty acids and ß-hydroxybutyrate, milk yield, and milk composition were measured to characterize the metabolic status. The EBhp was balanced [2.74 ± 4.09 MJ of metabolizable energy (ME)/d; ±standard error] before calving, but strongly negative (-84.7 ± 7.48 MJ of ME/d) at wk 2 of lactation. At both time points, EBhp and EBest differed significantly. On average, the equations overestimated the antepartum EB by 33 MJ of ME/d and underestimated the postpartum negative EB by 67 MJ of ME/d, respectively. Because the same ME intake and energy-corrected milk values were used for calculation of EBest and EBhp in our study, we considered that the factors (0.488 to 0.534 MJ of ME/kg0.75) currently used to calculate the ME requirements for maintenance probably underestimate the needs of high-yielding dairy cows, particularly during early lactation. In accord, heat production values determined under standard conditions of thermoneutrality and locomotion restriction amounted to 0.76 ± 0.02 MJ of ME/kg0.75 (4 wk antepartum) and 1.02 ± 0.02 MJ of ME/kg0.75 (2 wk postpartum), respectively. The expected positive correlation between EBhp and DMI was observed in pregnant cows only; however, a bias of 26 MJ of ME/d between mean actual energy intake and ME intake predicted according to German Society for Nutrition Physiology was found in cows at wk 4 antepartum. At both investigated time points, mobilization of tissue energy reserves (reflected by plasma fatty acid concentration) was related to EBhp. In early lactating cows, metabolic body weight (kg0.75) and the percentage of milk fat showed the strongest correlation (correlation coefficient = -0.70 and -0.73) to EBhp. Our findings must be taken into account when experimental data are interpreted because the true energy status might be significantly overestimated when EBest is used.


Subject(s)
Cattle/metabolism , Dairying , Energy Metabolism , Milk , 3-Hydroxybutyric Acid/blood , Animals , Body Weight , Calorimetry/veterinary , Diet/veterinary , Energy Intake , Female , Lactation/physiology , Milk/metabolism , Parturition , Postpartum Period , Pregnancy , Thermogenesis
2.
Animal ; 12(7): 1451-1461, 2018 Jul.
Article in English | MEDLINE | ID: mdl-29065950

ABSTRACT

High performing dairy cows experience distinct metabolic stress during periods of negative energy balance. Subclinical disorders of the cow's energy metabolism facilitate failure of adaptational responses resulting in health problems and reduced performance. The autonomic nervous system (ANS) with its sympathetic and parasympathetic branches plays a predominant role in adaption to inadequate energy and/or fuel availability and mediation of the stress response. Therefore, we hypothesize that indices of heart rate variability (HRV) that reflect ANS activity and sympatho-vagal balance could be early markers of metabolic stress, and possibly useful to predict cows with compromised regulatory capacity. In this study we analysed the autonomic regulation and stress level of 10 pregnant dried-off German Holstein cows before, during and after a 10-h fasting period by using a wide range of HRV parameters. In addition heat production (HP), energy balance, feed intake, rumen fermentative activity, physical activity, non-esterified fatty acids, ß-hydroxybutyric acid, cortisol and total ghrelin plasma concentrations, and body temperature (BT) were measured. In all cows fasting induced immediate regulatory adjustments including increased lipolysis (84%) and total ghrelin levels (179%), reduction of HP (-16%), standing time (-38%) and heart rate (-15%). However, by analysing frequency domain parameters of HRV (high-frequency (HF) and low-frequency (LF) components, ratio LF/HF) cows could be retrospectively assigned to groups reacting to food removal with increased or decreased activity of the parasympathetic branch of the ANS. Regression analysis reveals that under control conditions (feeding ad libitum) group differences were best predicted by the nonlinear domain HRV component Maxline (L MAX, R 2=0.76, threshold; TS=258). Compared with cows having L MAX values above TS (>L MAX: 348±17), those with L MAX values below TS (L MAX cows (18.5±0.4 and 47.3 kg/day). From the present study, it seems conceivable that L MAX can be used as a predictive marker to discover alterations in central autonomic regulation that might precede metabolic disturbances.


Subject(s)
Cattle , Energy Metabolism , Heart Rate , Milk , Stress, Physiological , Animals , Cattle/physiology , Diet , Female , Lactation , Pregnancy , Retrospective Studies
3.
J Dairy Sci ; 100(2): 1507-1520, 2017 Feb.
Article in English | MEDLINE | ID: mdl-28012622

ABSTRACT

The liver plays a central role in adaptation for energy requirements around calving, and changes in the effects of insulin on hepatic energy metabolism contribute to metabolic adaptation in dairy cows. Hepatic insulin effects may depend on body fat mobilization. The objective of this study was to investigate the effects of insulin on the hepatic gene expression of enzymes involved in energy metabolism and factors related to nutrition partitioning in cows with high and low total liver fat concentration (LFC) after calving. Holstein cows were retrospectively grouped according to their LFC after calving as a proxy for body fat mobilization. Cows were classified as low (LLFC; LFC <24% fat/dry matter; n = 9) and high (HLFC; LFC >24.4% fat/dry matter; n = 10) fat-mobilizing after calving. Euglycemic-hyperinsulinemic clamps [6 mU/(kg × min) of insulin for 6 h] were performed in wk 5 antepartum (ap) and wk 3 postpartum (pp). Before and at the end of the euglycemic-hyperinsulinemic clamps, liver biopsies were taken to measure the mRNA abundance of enzymes involved in carbohydrate and lipid metabolism, expression related to the somatotropic axis, and adrenergic and glucocorticoid receptors. The mRNA abundance of pyruvate carboxylase, cytosolic phosphoenolpyruvate carboxykinase (PEPCK; PCK1), acyl-CoA-dehydrogenase very long chain (ACADVL), and hydroxyl-methyl-glutaryl-CoA-synthase 1 increased, but the mRNA abundance of solute carrier family 2 (SLC2A2 and SLC2A4), growth hormone receptor 1A (GHR1A), insulin-like growth factor 1 (IGF1), sterol regulatory element binding factor 1, adrenoceptor α 1A, and glucocorticoid receptor decreased from ap to pp. Insulin treatment was associated with decreased PCK1, mitochondrial PEPCK, glucose-6-phosphatase, propionyl-CoA-carboxylase α, carnitine-palmitoyl-transferase 1A, ACADVL, and insulin receptor mRNA, but increased IGF1 and SLC2A4 mRNA ap and pp and GHR1A mRNA pp. The mRNA abundance of SLC2A4 was greater, and the mRNA abundance of GHR1A and IGF1 tended to be lower in LLFC than in HLFC. Administration of insulin, albeit at a supraphysiological dose, was associated with inhibition of gene expression related to glucose production and ß-oxidation, but we observed variable effects in the degree of insulin depression of individual genes. Insulin status is important for regulation of nutrient partitioning, but different LFC pp had very little influence on changes in hepatic gene expression following administration of insulin.


Subject(s)
Adipose Tissue/metabolism , Cattle , Energy Metabolism/genetics , Gene Expression/drug effects , Insulin/pharmacology , Liver/metabolism , Adipose Tissue/drug effects , Animals , Blood Glucose/analysis , Carbohydrate Metabolism/genetics , Energy Metabolism/drug effects , Energy Metabolism/physiology , Fatty Acids, Nonesterified/blood , Female , Gene Expression Regulation , Growth Hormone/physiology , Insulin/blood , Lactation/physiology , Lipid Metabolism/genetics , Liver/chemistry , Postpartum Period/physiology
4.
J Dairy Sci ; 99(8): 6665-6679, 2016 Aug.
Article in English | MEDLINE | ID: mdl-27179866

ABSTRACT

Dairy cows undergo significant metabolic and endocrine changes during the transition from pregnancy to lactation, and impaired insulin action influences nutrient partitioning toward the fetus and the mammary gland. Because impaired insulin action during transition is thought to be related to elevated body condition and body fat mobilization, we hypothesized that over-conditioned cows with excessive body fat mobilization around calving may have impaired insulin metabolism compared with cows with low fat mobilization. Nineteen dairy cows were grouped according to their average concentration of total liver fat (LFC) after calving in low [LLFC; LFC <24% total fat/dry matter (DM); n=9] and high (HLFC; LFC >24.4% total fat/DM; n=10) fat-mobilizing cows. Blood samples were taken from wk 7 antepartum (ap) to wk 5 postpartum (pp) to determine plasma concentrations of glucose, insulin, glucagon, and adiponectin. We applied euglycemic-hyperinsulinemic (EGHIC) and hyperglycemic clamps (HGC) in wk 5 ap and wk 3 pp to measure insulin responsiveness in peripheral tissue and pancreatic insulin secretion during the transition period. Before and during the pp EGHIC, [(13)C6] glucose was infused to determine the rate of glucose appearance (GlucRa) and glucose oxidation (GOx). Body condition, back fat thickness, and energy-corrected milk were greater, but energy balance was lower in HLFC than in LLFC. Plasma concentrations of glucose, insulin, glucagon, and adiponectin decreased at calving, and this was followed by an immediate increase of glucagon and adiponectin after calving. Insulin concentrations ap were higher in HLFC than in LLFC cows, but the EGHIC indicated no differences in peripheral insulin responsiveness among cows ap and pp. However, GlucRa and GOx:GlucRa during the pp EGHIC were greater in HLFC than in LLFC cows. During HGC, pancreatic insulin secretion was lower, but the glucose infusion rate was higher pp than ap in both groups. Plasma concentrations of nonesterified fatty acids decreased during HGC and EGHIC, but in both clamps, pp nonesterified fatty acid concentrations did not reach the ap levels. The study demonstrated a minor influence of different degrees of body fat mobilization on insulin metabolism in cows during the transition period. The distinct decrease in the glucose-dependent release of insulin pp is the most striking finding that explains the impaired insulin action after calving, but does not explain differences in body fat mobilization between HLFC and LLFC cows.


Subject(s)
Glucose/metabolism , Insulin/blood , Parturition , Animals , Blood Glucose/metabolism , Cattle , Diet/veterinary , Energy Metabolism , Fatty Acids, Nonesterified/blood , Female , Lactation/metabolism , Milk/metabolism , Pregnancy
5.
J Dairy Sci ; 96(10): 6449-60, 2013 Oct.
Article in English | MEDLINE | ID: mdl-23910553

ABSTRACT

The beginning of lactation requires huge metabolic adaptations to meet increased energy demands for milk production of dairy cows. One of the adaptations is the mobilization of body reserves mainly from adipose tissue as reflected by increased plasma nonesterified fatty acid (NEFA) concentrations. The capacity of the liver for complete oxidation of NEFA is limited, leading to an increased formation of ketone bodies, reesterification, and accumulation of triglycerides in the liver. As the skeletal muscle also may oxidize fatty acids, it may help to decrease the fatty acid load on the liver. To test this hypothesis, 19 German Holstein cows were weekly blood sampled from 7 wk before until 5 wk after parturition to analyze plasma NEFA concentrations. Liver biopsies were obtained at d 3, 18, and 30 after parturition and, based on the mean liver fat content, cows were grouped to the 10 highest (HI) and 9 lowest (LO). In addition, muscle biopsies were obtained at d -17, 3, and 30 relative to parturition and used to quantify mRNA abundance of genes involved in fatty acid degradation. Plasma NEFA concentrations peaked after parturition and were 1.5-fold higher in HI than LO cows. Muscle carnitine palmitoyltransferase 1α and ß mRNA was upregulated in early lactation. The mRNA abundance of muscle peroxisome proliferator-activated receptor γ (PPARG) increased in early lactation and was higher in HI than in LO cows, whereas the abundance of PPARA continuously decreased after parturition. The mRNA abundance of muscle PPARD, uncoupling protein 3, and the ß-oxidative enzymes 3-hydroxyacyl-coenzyme A (CoA) dehydrogenase, very long-chain acyl-CoA dehydrogenase, and 3-ketoacyl-CoA was greatest at d 3 after parturition, whereas the abundance of PPARγ coactivator 1α decreased after parturition. Our results indicate that around parturition, oxidation of fatty acids in skeletal muscle is highly activated, which may contribute to diminish the fatty acid load on the liver. The decline in muscle fatty acid oxidation within the first 4 wk of lactation accompanied with increased feed intake refer to greater supply of ruminally derived acetate, which as the preferred fuel of the muscle, saves long-chain fatty acids for milk fat production.


Subject(s)
Adipose Tissue/metabolism , Fatty Acids, Nonesterified/metabolism , Lactation/physiology , Muscle, Skeletal/metabolism , Acyl-CoA Dehydrogenase, Long-Chain/genetics , Acyl-CoA Dehydrogenase, Long-Chain/metabolism , Animals , Cattle , Fatty Acids, Nonesterified/blood , Female , Gene Expression , Lipid Metabolism/physiology , Lipolysis , Liver/metabolism , Oxidation-Reduction , PPAR gamma/genetics , PPAR gamma/metabolism , Parturition , RNA, Messenger/genetics , RNA, Messenger/metabolism , Triglycerides/metabolism
6.
Nuklearmedizin ; 49(3): 97-105, 2010.
Article in English | MEDLINE | ID: mdl-20126826

ABSTRACT

OBJECTIVES: Comparison of the binding affinity to a CD30-positive Hodgkin lymphoma (HL) cell line and biodistribution in HL bearing mice of new anti-CD30 radioimmunoconjugates (RICs) of varying structure and labelling nuclides. METHODS: The antibodies Ki-4 and 5F11 were radioiodinated by the chloramine T method or labelled with (111)In via p-NCS-Benzyl-DOTA. In addition, the Ki-4-dimer was investigated in the iodinated form. The RICs were analyzed for retained immunoreactivity by immunochromatography. In-vitro binding studies were performed on CD30-positive L540 cell lines. For in-vivo biodistribution studies, SCID mice bearing human HL xenografts were injected with the various radioimmunoconjugates. After 24 h, activities in the organs and tumour were measured for all 5 RICs. Tumour-free animals were studied in the same way with (131)I- Ki-4 24 h p. i. The three RICs with the highest tumour/background ratios 24 h p.i. ((131)I-Ki-4, (131)I-5F11, (111)In-bz-DOTA-Ki-4) were analysed further at 48 h and 72 h. RESULTS: All the RICs were successfully labelled with high specific activities (28-47 TBq/mmol) and sufficient radiochemical yields (>80%). Scatchard plot analysis proved high tumour affinity (KD = 20-220 nmol/l). In-vivo tumour accumulation in % of injected dose per g tissue (%ID/g) lay between 2.6 ((131)I-5F11) and 12.3 % ID/g ((131)I-Ki-4) with permanently high background in blood. Tumour/blood-ratios of all RICs were below one at all time points. CONCLUSIONS: In-vitro tumour cell affinities of all RICs were promising. However, in-vivo biokinetics tested in the mouse model did not meet expectations. This highlights the importance of developing and testing further new anti-CD30 conjugates.


Subject(s)
Hodgkin Disease/radiotherapy , Indium Radioisotopes/pharmacokinetics , Iodine Radioisotopes/pharmacokinetics , Ki-1 Antigen/antagonists & inhibitors , Animals , Antibodies, Monoclonal/immunology , Antibodies, Monoclonal/therapeutic use , Cell Division , Cell Line, Tumor , Hodgkin Disease/pathology , Humans , Indium Radioisotopes/therapeutic use , Iodine Radioisotopes/therapeutic use , Ki-1 Antigen/immunology , Mice , Radiotherapy/adverse effects , Radiotherapy Dosage , Tissue Distribution
7.
J AOAC Int ; 78(5): 1153-60, 1995.
Article in English | MEDLINE | ID: mdl-7549530

ABSTRACT

Determination of chloramphenicol (CAP) residues in egg by gas chromatography/high-resolution mass spectrometry (GC/HRMS) with negative chemical ionization and gas chromatography with electron capture detection (GC-ECD) is described. A cleanup based on acetonitrile extraction followed by solid-phase extraction with silica gel and gel filtration columns was developed for extraction of CAP residues from whole egg. For quantitation, the internal standards used were the meta isomer of CAP (m-CAP) for GC-ECD and both m-CAP and deuterium-labeled CAP (D5-CAP) for GC/HRMS. For GC/HRMS, evaluation was performed by selecting characteristic ions at m/z 466 for CAP and m-CAP and at m/z 471 for D5-CAP. Both methods were validated with egg samples fortified at 0.4-2.0 micrograms/kg and lyophilized egg samples from animals treated at the 1 microgram/kg concentration level. The coefficient of variation was below 10%. Limits of detection and quantitation of both methods were about 0.3 and 0.5 microgram/kg, respectively. For confirmation of CAP residues, the relative ion abundance (m/z 466 and 468) was calculated. Further confidence was obtained by comparison of accurate monoisotopic masses from a spectrum library.


Subject(s)
Anti-Bacterial Agents/analysis , Chloramphenicol/analysis , Chromatography, Gas , Eggs/analysis , Food Contamination , Gas Chromatography-Mass Spectrometry , Chromatography, Gas/methods , Chromatography, Gas/statistics & numerical data , Gas Chromatography-Mass Spectrometry/statistics & numerical data , Regression Analysis , Sensitivity and Specificity
8.
Analyst ; 119(12): 2687-90, 1994 Dec.
Article in English | MEDLINE | ID: mdl-7879876

ABSTRACT

Amperozide 4-[4,4-bis(4-fluorophenyl)butyl]-N-ethylpiperazine-1- carboxamide) is used in veterinary medicine because of its sedative effect on pigs. A method developed for the detection of amperozide residues in porcine liver using liquid chromatography with thermospray mass spectrometry (LC-MS) is described and compared with LC with electrochemical detection (LC-ED). For LC-ED analysis, the samples were extracted with acetonitrile and cleaned up on a Sep-Pak C18 cartridge. The residues of amperozide were separated on a C8 polymer-based reversed-phase column and determined by using amperometric detection at +1050 mV. For LC-MS analysis, the samples were extracted with ethanol and cleaned using liquid-liquid extraction. After separation on a C8 polymer-based reversed-phase column, the residues were detected by discharge-assisted ionization with positive ion detection MS using single-ion monitoring. The positive discharge ionization produced typical [M+H]+ molecular ions of amperozide (m/z 403) and the internal standard (m/z 431). The limit of quantification for both methods, determined by using spiked blank liver in the concentration range 20-100 micrograms kg-1, was found to be below 70 micrograms kg-1.


Subject(s)
Drug Residues/analysis , Liver/chemistry , Piperazines/analysis , Serotonin Antagonists/analysis , Animals , Chromatography, High Pressure Liquid/methods , Chromatography, Liquid/methods , Mass Spectrometry/methods , Piperazines/metabolism , Sensitivity and Specificity , Swine
9.
J Chromatogr B Biomed Appl ; 661(1): 75-84, 1994 Nov 04.
Article in English | MEDLINE | ID: mdl-7866555

ABSTRACT

A discharge-assisted LC-MS method has been developed and validated for the analysis of four sulphonamides (sulphathiazole, sulphadiazine, sulphamerazine and sulphadimidine) and their N4-acetyl metabolites in the muscle of swine treated with Polysulpha-Complex, which contains all four drugs. The clean-up procedure developed involved chloroform-acetone extraction followed by Sep-Pak silica solid-phase extraction. In parallel a LC-UV method was validated using the same clean-up procedure. Blank tissue was fortified at levels between 20 and 100 micrograms/kg. [13C]sulphadimidine was used as internal standard. The samples were analysed with thermospray LC-MS. The [M + H]+ ion was the major ion in all cases and was employed for single-ion monitoring. The limits of detection (LOD) were below 25 micrograms/kg and the limits of quantification (LOQ) for most sulphonamides were ca. 100 micrograms/kg. Incurred muscle tissues were measured by both LC methods and the concentrations of the sulphonamides were found to be similar. However, the LC-MS procedure is more suitable for confirmatory analysis due to its specificity.


Subject(s)
Chromatography, Liquid/methods , Muscles/chemistry , Sulfonamides/analysis , Sulfonamides/metabolism , Swine/metabolism , Acetylation , Animals , Drug Residues/analysis , Drug Residues/metabolism , Gas Chromatography-Mass Spectrometry , Mass Spectrometry , Meat/analysis , Muscles/metabolism , Sulfadiazine/analysis , Sulfadiazine/metabolism , Sulfamerazine/analysis , Sulfamerazine/metabolism , Sulfamethazine/analysis , Sulfamethazine/metabolism , Sulfathiazole , Sulfathiazoles/analysis , Sulfathiazoles/metabolism , Ultraviolet Rays
10.
Padiatr Grenzgeb ; 29(3): K4-6, 1990.
Article in German | MEDLINE | ID: mdl-2377372

ABSTRACT

2 case reports regarding patients with a psychosocial dwarfism. Both children showed clinical and endocrinological signs of "idiopathic" hypopituitarism. Both patients came from economically well situated families of the upper middle-class. Disturbances in eating and sleeping behaviour are important hints that there might be a psychosocial etiology.


Subject(s)
Dwarfism, Pituitary/psychology , Growth Hormone/deficiency , Psychophysiologic Disorders/psychology , Psychosocial Deprivation , Adolescent , Child , Child, Preschool , Diagnosis, Differential , Dwarfism, Pituitary/diagnosis , Female , Follow-Up Studies , Humans , Male , Psychophysiologic Disorders/diagnosis
13.
Monatsschr Kinderheilkd (1902) ; 127(3): 139-43, 1979 Mar.
Article in German | MEDLINE | ID: mdl-423902

ABSTRACT

Correlations between clinical status and psychological variables in 56 juvenile diabetics were studied. Intelligence was only partly associated with clinical status. Among personality variables extraversion proved to be correlated with insufficient clinical control. This result is significant, both from a theoretical and from a practical point of view. There were no correlations of parental personality and clinical control.


Subject(s)
Diabetes Mellitus, Type 1/psychology , Adolescent , Child , Extraversion, Psychological , Female , Humans , Intelligence , Male , Parents , Personality
14.
Monatsschr Kinderheilkd (1902) ; 125(4): 190-4, 1977 Apr.
Article in German | MEDLINE | ID: mdl-857145

ABSTRACT

In addition to earlier reports findings of a psychological five-year-follow-up of PKU-children are presented. Intelligence and motor development of these children depend significantly on age at onset of therapy and quality of dietary control. After dietary treatment over several years older PKU-children with late onset of therapy display no structural change as far as cognitive and motor development are concerned. Furthermore, a psychodiagnostic approach is presented to predict quality of dietary control. Although this approach did not yet yeald positive results because of insufficient sample-size it should be applied to further studies in the future.


Subject(s)
Phenylketonurias/diagnosis , Age Factors , Analysis of Variance , Child, Preschool , Humans , Infant , Intelligence , Motor Skills , Phenylketonurias/diet therapy , Psychological Tests
15.
Klin Padiatr ; 187(5): 407-12, 1975 Sep.
Article in German | MEDLINE | ID: mdl-126331

ABSTRACT

This first out of three articles reviews general psychological aspects and problems of the child with chronic illness and handicap and of his parents and healthy siblings.


Subject(s)
Child Development , Chronic Disease , Disabled Persons , Intellectual Disability , Child , Germany, West , Humans , Parent-Child Relations , Sibling Relations
16.
Klin Padiatr ; 187(5): 413-23, 1975 Sep.
Article in German | MEDLINE | ID: mdl-126332

ABSTRACT

This second out of three articles deals with some specific psychological problems of chronic illness and handicap in childhood, i.e. epilepsy, physical handicap, diabetes mellitus, congenital heartdisease, hemophilia, dwarfism, hemodialysis and renal transplantation, and malignant disease.


Subject(s)
Child Development , Disabled Persons , Intellectual Disability , Child , Chronic Disease , Diabetes Mellitus, Type 1 , Dwarfism , Education, Special , Epilepsy , Female , Germany, West , Heart Defects, Congenital , Hemophilia A , Humans , Kidney Transplantation , Male , Neoplasms , Renal Dialysis
17.
Klin Padiatr ; 187(5): 424-31, 1975 Sep.
Article in German | MEDLINE | ID: mdl-126333

ABSTRACT

This third and last paper on psychological aspects of chronic illness is childhood discusses tasks of the physician and the parents as well as aspects of social medicine.


Subject(s)
Chronic Disease , Disabled Persons , Intellectual Disability , Psychotherapy , Child , Counseling , Germany, West , Humans , Physician-Patient Relations , State Medicine
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