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Letters to the Editor Issue 293
listed in letters to the editor, originally published in issue 293 - March 2024
British Dentists Welcome Proposed EU Ban on Mercury Amalgam Fillings
A growing number of British dentists welcome the EU’s proposed ban on the use of mercury dental amalgam and prohibition on manufacture and export of this toxic product.
Amalgam which is 50% mercury, causes adverse effects on health and the environment.
The EU – N. Ireland agreement means that the UK will be affected by the EU’s ban.
“We are pleased that the EU is working to protect the public’s health and environment from amalgam’s mercury. As health professionals, dentists should be leading the push for a mercury free future for our profession in order to protect our patients, our communities and our planet.” Says Dr Graeme Munro-Hall, Chief Dental Officer of the World Alliance for Mercury Free Dentistry
The EU’s proposed amalgam ban is feasible because there are many mercury-free filling materials that are effective, available and affordable today. Thanks to these mercury-free fillings amalgam bans and partial bans have begun in great force. As shown in the “Global Amalgam Tracker”, https://environmentalmedicine.eu/mercury-free-dentistry-for-planet-earth/, and other reliable sources, more than 70 countries have adopted major measures that ban or restrict amalgam use – either a full ban, or a phase out date, or a ban for children, or a ban on imports, or a ban in government programs. These countries include Albania, Armenia, Azerbaijan, Bahrain, Bangladesh, Bolivia, Colombia, Cuba, Ecuador, El Salvador, Gabon, Georgia, Guyana, Iceland, India, Indonesia, Japan, Kazakhstan, Kuwait, Liechtenstein, Mauritius, Moldova, Mongolia, Mozambique, Nepal, New Caledonia, Norway, Pakistan, Panama, Paraguay, Peru, Philippines, Qatar, Russia, Saint Kitts & Nevis, Saint Lucia, Saudi Arabia, Surinam, Switzerland, Tanzania, Thailand, Tunisia, United Arab Emirates, Uruguay, Vietnam, Zambia—plus each country in the 27-nation European Union.
It is just as feasible to end amalgam use in the UK. As former UK Chief Dental Officer Barry Cockcroft wrote in 2012 “the UK should support the EU Strategy to reduce the environmental impact of mercury and could support a ban in the use of dental amalgam from 2016 with agreed exemptions.”
Despite the damage amalgam caused to patients and the environment and the fact that the rest of the world is moving away from amalgam use, the British Dental Association defends the use of mercury as per their open letter to the Chief Dental Officers of the UK. The BDA clearly does not represent the many dentists who embrace mercury free dentistry – nor does it represent the interests of our patients and our planet.
“Now is the time for the UK to end its use mercury amalgam use,” says Dr Munro-Hall.
Contact:
Dr Graeme Munro-Hall
Chief Dental Officer of the World Alliance for Mercury Free Dentistry.
Email: wafmfd-uk@steeps.net
The Cause of Long Covid has been Identified – And It’s Our Own Immune System
New research has that revealed changes in our blood proteins caused by our body’s own immune defences are the likely cause of long Covid. A leading medical expert says we can now develop simple blood tests to identify people with the debilitating condition.
Almost four years after it was first reported, the likely cause of long Covid has been identified. Pinpointing the cause of the debilitating condition could now lead to new treatments.
Long Covid is a life-changing condition that causes chronic fatigue, breathlessness, ‘brain fog’, anxiety and stress, leading to significant impact on our daily life. Around 1.9 million Brits suffer from it and around 1 in 20 people who contract Covid-19 go on to develop long Covid. Concerningly, 41% of long Covid patients report serious health issues lasting at least two years. There are currently no diagnostic tests and few therapeutic solutions for affected patients.
Dr Avinash Hari Narayanan MBChB, Clinical Lead at London Medical Laboratory (LML) says: “It has long been hypothesised that immune dysfunction underlines long Covid, and now research has determined it is due to increased activation of the ‘complement system’. The complement system is major part of the body’s immune defences that normally helps to clear infections and clean up damaged cells. Ironically, in long Covid cases, it is causing the problems.
“A new report, published in Science last week, found patients experiencing long Covid symptoms exhibited changes to their blood serum proteins. These changes indicated that the complement system was abnormally activated, altering blood coagulation and causing tissue injury. Medical professionals call this “thrombo-inflammation”.
“Together with changes at a cellular level to blood platelets, these results show potential new biomarkers for diagnosis of long Covid and will inform research for future treatments.
“For many months after the first Covid patients began to report debilitating, persistent symptoms, long Covid was regarded with scepticism by some employers and even health professionals. The crux of the problem was its distinct pattern of presentation, with no identifiable cause.
“Now the cause of the condition has potentially been recognised after pioneering research by scientists from the UK, Switzerland, the USA and Sweden. The team followed 39 healthy controls and 113 Covid-19 patients for up to a year after initial confirmation of acute Covid infection. At six months, 40 patients had developed long Covid symptoms.
“They found several differences in the blood of people with long Covid compared to those without it, including an imbalance in proteins involved in blood clotting and inflammation. This was linked to increased activation of the complement system.
“People with long Covid symptoms lasting six months or more had reduced levels of some proteins involved in the complement system and elevated levels of others, compared with fully recovered or healthy participants. Interestingly, those patients who initially had long Covid but whose symptoms ended within six months found their complement systems returned to normal.
“In addition to offering a basis for easily diagnosing the condition, the study will help clinical researchers find ways to modulate and regulate the complement systems of patients suffering from long Covid, potentially offering an opportunity to understand and manage the condition.
“Already, “off-the-shelf” blood tests can easily identify inflammation in the body and that can be used to indicate the likelihood of long Covid. A heart health profile test measures “C-Reactive protein” (CRP) that indicates inflammatory burden and cardiovascular risk. It is also an excellent indicator of high cholesterol and other issues.
“London Medical Laboratory’s Heart Health Profile test is already widely used to identify a number of conditions. The simple, finger-prick blood test indicates risks to heart health and includes a full cholesterol profile, as well as testing for inflammation. It also tests for diabetes, showing how well the body is controlling blood sugar.
“The Heart Health Profile test can be taken at home through the post, or at one of the many drop-in clinics that offer these tests across London and nationwide in over 120 selected pharmacies and health stores.”
For full details see: https://www.londonmedicallaboratory.com/product/heart-health-profile
Further Information
London Medical Laboratory’s Clinical Lead, Dr Avinash Hari Narayanan, is available to supply exclusive written comment or for interview. To contact Dr Hari Narayanan, or for more information, please email London Medical Laboratory’s Head of Public Relations, David Jinks MILT at david.jinks@londonmedicallaboratory.co.uk
The Pin Prick Blood Test that Predicts Dementia Risk from Middle Age
A new pinprick blood test that not only aims to predict your future risk for dementia, but tells you how to reduce it, is launched today as part of a global prevention research study aiming to involve a million people worldwide.
The home-test kit, from the charity FoodfortheBrain.org, measures your blood sugar, vitamin D, omega-3 and B vitamin status which account for more than half the modifiable risks for dementia. The results show how a person can reduce their risk with specific diet changes.
“Alzheimer’s is a preventable, but not reversible disease. Less than one in a hundred cases are directly caused by genes. Prevention is entirely possible if you can identify who is at risk early enough and encourage the right diet and lifestyle changes.” says Patrick Holford, founder of FoodfortheBrain.org, the UK’s leading dementia prevention charity which is running the prevention project together with Dr Tommy Wood, Assistant Professor at the University of Washington.
“By tracking a person’s blood sugar, vitamin B, D and omega-3 status against changes in cognitive function over time, in addition to lifestyle factors such as sleep and physical activity, we can learn what really helps prevent cognitive decline.” says Dr Wood, the principal investigator for the study.
The charity has already tested over 410,000 people with their free Cognitive Function Test at FoodfortheBrain.org, and hopes to enrol a million people, making this the largest ‘citizen science’ global prevention initiative.
“Subtle changes in cognition occur at least 30 years before a diagnosis, which is why we screen people online with a free Cognitive Function Test. And there are four simple blood tests that are not only predictive, but can help a person to understand how to drive down that risk. I call them the four horsemen of the mental health apocalypse because they also drive depression and ADHD. The incidence of both of these are on the increase” says Holford.
The four tests, called DRIfT [the Dementia Risk Index functional Test] carried out using a simple home-test kit and a single pin prick of blood, add further predictive capability, and help guide the individual to make diet changes to reduce future risk.
Blood sugar (HbA1c) - Even raised blood sugar levels from age 35, but within ‘reference’ ranges, predict a 15 per cent increased risk of Alzheimer’s disease 35 years later, according to research by Boston University School of Medicine.[1] This confirms other research from the University of Washington showing an 18% increased risk with raised sugar levels in older people seven years later and a 40% increased risk in those with diabetes.[2] Even better than your blood sugar level, which varies across the day, is a long-term measure of blood sugar, called HbA1c, used to predict diabetes, which is what this test measures.
B vitamins (Homocysteine) – Low levels of B12, found in animal products, and folate, found in greens, raise blood levels of homocysteine. Raised homocysteine is considered a top marker for dementia risk, and is a causative driver of the disease process.[3] Studies lowering homocysteine with B vitamins have more than halved the rate of age-related brain shrinkage. A Swedish study, started in 1968, found that those in the top third of homocysteine scores in their 40’s had double the risk for Alzheimer’s almost 35 years later.[4] When homocysteine goes up memory gets worse and when it goes down memory gets better, according to a six-year study in Norway.[5]
About half of all people over 60 have homocysteine levels above 11mcmol/l,[6] which is the level associated with increased brain shrinkage. A study in Italy found that those with a homocysteine above 15mcmol/l have five times the risk of developing Alzheimer’s, compared to those with a level below 10.[7]
Last year, a study in China showed that raised homocysteine increases risk of cognitive decline by ten times.[8] Homocysteine is easily lowered by supplementing vitamin B6, B12 and folate but at levels higher than achievable from diet because many older people do not absorb B12 well.
Oxford University’s health economist Dr Apostolos Tsiachristas estimates “Screening for homocysteine in people over 60 in the UK and treating those with raised levels with B vitamins could save the UK economy approximately £60 million per year.”
Omega-3 – Increased intake of omega-3, either from diet or supplements, and having a higher omega-3 blood level, is associated with cutting risk for dementia by a fifth (20%), according to a study of 48 studies involving over 100,000 people.[9]
Supplementing fish oils[10] cuts risk of dementia by 9%, according to research from the UK Bio Bank. Being in the top third for omega-3 blood levels, compared to the lowest third, reduced the rate of brain shrinkage in a year by more than two thirds in those given B vitamins with mild cognitive impairment.[11]
The omega-3 index, which is what the DRIfT test measures, predicts both brain size and cognitive function.[12] This Oxford University research establishes that the brain needs both sufficient B vitamins and omega-3 to stay healthy.
Vitamin D – Having a higher vitamin D above 75nmol/l (25 ng/ml) cuts risk for Alzheimer’s and dementia by a third.[13] In turn, those with a vitamin D level below 50nmol/l, increase their risk for Alzheimer’s and dementia by a third.[14]
Six out of 10 adults in the UK[15] and three out of 10 in the US[16] have a vitamin D level below this. Taking vitamin D supplements may help ward off dementia, according to a 2023 study involving over twelve thousand dementia-free 70+ year olds in the US. Those taking vitamin D supplements had 40% lower incidence of dementia during a ten-year period. Vitamin D is essential to supplement during winter months.
These four risk factors, measured in the DRIfT test, are thought to account for over half the modifiable risk for Alzheimer’s disease and dementia.[17] Having an active lifestyle, both physically, socially and intellectually further reduces risk substantially.
To take the free online Cognitive Function Test, the pin prick DRIfT test and join the global prevention study go to https://www.foodforthebrain.org/
About The Food For The Brain Foundation
The Food for the Brain Foundation (FoodfortheBrain.org) is an educational and research charity, focussing on dementia prevention. It’s free online validated Cognitive Function Test, followed by the Dementia Risk Index questionnaire assessing eight drivers of dementia, including ‘brain fats’ and ‘low carbs & GL’ thus identifying those eating too many carbs and not enough brain fats, then advising them what to do. www.foodforthebrain.org/tests
References
- Zhang X, Tong T, Chang A, Ang TFA, Tao Q, Auerbach S, Devine S, Qiu WQ, Mez J, Massaro J, Lunetta KL, Au R, Farrer LA. Midlife lipid and glucose levels are associated with Alzheimer's disease. Alzheimers Dement ;19(1):181-193. doi: 10.1002/alz.12641. Epub Mar 23 2022 . PMID: 35319157; PMCID: PMC10078665. Jan 2023.
- P.K. Crane et al., ‘Glucose levels and risk of dementia’, New England Journal of Medicine: 369(6): 540–548. 2013.
- Smith AD, Refsum H, Bottiglieri T, Fenech M, Hooshmand B, McCaddon A, Miller JW, Rosenberg IH, Obeid R. Homocysteine and Dementia: An International Consensus Statement. J Alzheimers Dis.;62(2): 561-570. doi: 10.3233/JAD-171042. PMID: 29480200; PMCID: PMC5836397. 2018.
- Zylberstein DE, Lissner L, Bjorkelund C, Mehlig K, Thelle DS, Gustafson D, Ostling S, Waern M, Guo X, Skoog I Midlife homocysteine and late-life dementia in women. A prospective population study. Neurobiol Aging 32: 380-386. 2011,
- Nurk E, Refsum H, Tell GS, Engedal K, Vollset SE, Ueland PM, Nygaard HA, Smith AD Plasma total homocysteine and memory in the elderly: The Hordaland Homocysteine study. Ann Neurol 58, 847-857. 2005.
- Pfeiffer CM, Osterloh JD, Kennedy-Stephenson J, Picciano MF, Yetley EA, Rader JI, Johnson CL. Trends in circulating concentrations of total homocysteine among US adolescents and adults: findings from the 1991-1994 and 1999-2004 National Health and Nutrition Examination Surveys. Clin Chem;54(5):801-13. doi: 10.1373/clinchem.2007.100214. Epub Mar 28 2008 . PMID: 18375482. May 2008.
- Ravaglia G, Forti P, Maioli F, Martelli M, Servadei L, Brunetti N, Porcellini E, Licastro F Homocysteine and folate as risk factors for dementia and Alzheimer disease. Am J Clin Nutr 82, 636-643. 2005.
- Teng Z, Feng J, Liu R, Ji Y, Xu J, Jiang X, Chen H, Dong Y, Meng N, Xiao Y, Xie X and Lv P Cerebral small vessel disease mediates the association between homocysteine and cognitive function. Front. Aging Neurosci. 14:868777. doi: 10.3389/fnagi.2022.868777. 2022.
- Wei BZ, Li L, Dong CW, Tan CC; Alzheimer’s Disease Neuroimaging Initiative; Xu W. The Relationship of Omega-3 Fatty Acids with Dementia and Cognitive Decline: Evidence from Perspective Cohort Studies of Supplementation, Dietary Intake, and Blood Markers. Am J Clin Nutr.:S0002-9165(23)46320-4. doi: 10.1016/j.ajcnut.2023.04.001. Epub ahead of print. PMID: 37028557. 5 Apr 2023.
- Huang Y, Deng Y, Zhang P, Lin J, Guo D, Yang L, Liu D, Xu B, Huang C and Zhang H Associations of fish oil supplementation with incident dementia: Evidence from the UK Biobank cohort study.Front. Neurosci. 16:910977.doi: 10.3389/fnins.2022.910977. 2022.
- Jernerén F, Elshorbagy AK, Oulhaj A, Smith SM, Refsum H, Smith AD. Brain atrophy in cognitively impaired elderly: the importance of long-chain ω-3 fatty acids and B vitamin status in a randomized controlled trial. Am J Clin Nutr. 2015 Jul;102(1):215-21. doi: 10.3945/ajcn.114.103283. PMID: 25877495. Epub Apr 15 2015.
- Loong, S.; Barnes, S.; Gatto, N.M.; Chowdhury, S.; Lee, G.J. Omega-3 Fatty Acids, Cognition, and Brain Volume in Older Adults. Brain Sci.13,1278. https://doi.org/10.3390/brainsci13091278 2023.
- https://foodforthebrain.org/the-role-of-vitamin-d-in-reducing-risk-of-alzheimers-diseasewilliam-b-grant-ph-d/
- Chai et al. BMC Neurology19:284 https://doi.org/10.1186/s12883-019-1500-6 2019.
- Calame W, Street L, Hulshof T. Vitamin D Serum Levels in the UK Population, including a Mathematical Approach to Evaluate the Impact of Vitamin D Fortified Ready-to-Eat Breakfast Cereals: Application of the NDNS Database. Nutrients.;12(6):1868. doi: 10.3390/nu12061868. PMID: 32585847; PMCID: PMC7353432. Jun 23 2020.
- Liu X, Baylin A, Levy PD. Vitamin D deficiency and insufficiency among US adults: prevalence, predictors and clinical implications. Br J Nutr;119(8):928-936. doi: 10.1017/S0007114518000491. PMID: 29644951. Apr 2018.
- https://foodforthebrain.org/what-is-the-scientific-basis-of-the-cft-dri-cog-nition/
Source and Media Contact
For media enquiries please contact Sophie at Panpathic Communications: Sophie@panpathic.com / 07815 860 082.
Sahmyook University Researchers Develop a Light-Responsive Novel Drug Delivery System Against Skin Cancer
The layer-by-layer assembled nanofibers target skin cancer through a controlled and sequential drug release mechanism. Nanotechnology-based drug delivery systems (DDS) offer several advantages, such as enhanced bioavailability and controlled drug release with reduced dosage. Recently, Sahmyook University researchers have developed a light-responsive DDS to treat skin cancer. By incorporating gold nanorods into the matrix of nanofibers, the study demonstrates external control over the release of anticancer drugs in a sequential and controlled method. This innovative DDS holds promise for future real-life nanotech-based applications in healthcare.
Treating complex diseases such as skin cancer often requires simultaneous administration of multiple anticancer drugs. The delivery of such life-saving therapeutic drugs has evolved with the rise of nanotechnology-based drug carriers. Nanoplatforms offer numerous advantages, including increased bioavailability, lowered dosages, and improved biodistribution.
In this light, a team of researchers led by Professor Myoung-Hwan Park from Sahmyook University in South Korea has developed a light-responsive nanofiber-based novel drug delivery system (DDS) targeting skin cancer. The DDS was studied in a detailed manner, beginning with its synthesis and characterization to its biocompatibility, drug release profile, and efficacy against skin cancer. These research findings were made available online on 1 September 2023 and was published in Volume 88 of the Journal of Drug Delivery Science and Technology on 1 October 2023.[1]
Explaining the motivation behind the present research, Dr Park explains,
“Conventional drugs can be efficiently delivered in a controlled manner through nano-engineered platforms and such an approach increases the overall effectiveness of the treatment. This approach improves outcomes in cancer drug therapy by ensuring precise delivery at optimal dosages.”
The researchers employed various innovative research methods in developing a smart DDS against skin cancer. Overcoming the solubility barrier of anticancer drugs is crucial and is achieved by coating them with suitable materials for better release. They created camptothecin (CPT)-contained nanofibers (NFs), using electrospinning. The sequential and controlled drug release from NFs was achieved by using a layer-by-layer assembly process involving poly-ionic coatings to load doxorubicin (DOX). At pH 7.4, DOX was initially released to a lesser extent, and at pH 6, a substantially larger release was noted. To externally control the drug release profile of CPT, gold nanorods (GNRs) were used. Upon near-infrared (NIR) exposure, the GNRs present in the nanofibers facilitated localized heating, which, in turn, triggered the sequential and controlled release of CPT by causing the thermosensitive polymer to shrink and swell.
Envisioning the long-term applications of their work, Dr Park speculates,
“Our nanoplatform show significant potential for real-life practical applications in the form of topical drug products for various skin disorders, such as psoriasis, skin cancer, skin wounds, bacterial and fungal infections. Accordingly, the integration of nanofibers with on-demand drug delivery systems can open up new possibilities for drug therapy.”
Indeed, the development of a multi-stimuli-triggered smart DDS against skin cancer emphasizes the immense potential of nanoplatforms in the advancement of healthcare.
Reference
- Baljinder Singh, Sunyoung Yun and Myuoung-Hwan Park. Light-responsive layer-by-layer assembled nanofibers for sequential drug release. Journal of Drug Delivery Science and Technology: 88. Oct 2023. https://www.sciencedirect.com/science/article/pii/S1773224723007621 DOI: https://doi.org/10.1016/j.jddst.2023.104910.
About the Institute
Sahmyook University is situated in metropolitan Seoul, South Korea. The university is renowned for its pristine campus, earning the title of "Korea's most beautiful university." Its commitment to environmental sustainability is reflected in its eco-friendly construction. The university prides itself on its unique holistic academic counselling system in which students and professors organically work together in receiving and giving guidance. Comprising six colleges, including the College of Theology, Humanities & Social Science, and Health Science & Social Welfare, as well as four graduate schools, Sahmyook University provides a comprehensive educational experience. https://www.syu.ac.kr/eng/
About the Author
Myoung-Hwan Park is an Associate Professor of Chemistry and Life Science and Director of Research Center for NanoBioMaterials Lab. at Sahmyook University, Korea. His group is developing novel approaches and versatile materials for applications in drug delivery systems and industrial devices. He is also the founder and current CEO of NtoB Co., Ltd., which develops drug delivery platforms for brain cancer and cosmetics, and NBChem Co., Ltd., which manufactures low-friction coating composites for mobile machines. Before coming to Sahmyook University, he completed the Postdoctoral training at Paula Hammond’s lab at department of chemical engineering of MIT. In 2012, he received his PhD under the supervision of Prof. Vincent Rotello of Chemistry from University of Massachusetts at Amherst.
Source and Media Contact:
Rishita Sachan rishita.sachan1@cactusglobal.com Public Relations Team of Sahmyook University
Can Magnesium Reduce Risks Of Diabetes Complications?
Researchers have launched a multi-centre clinical trial to investigate a new treatment for preventing diabetes complications in people with type 1 diabetes.
The collaboration between the University of Sunderland, in partnership with St Andrews University and the University of Leeds, pulls together world-leading expertise from across the UK to uncover key biological mechanisms underpinning the origins of blood vessel disease and to test new innovative treatments to halt their progression.
The study has received £400K from national charity Diabetes UK and will start to recruit research participants this year.
People living with type 1 diabetes are at a higher risk of developing vascular problems where blockages (blood clots) in the blood vessels limit the flow of blood causing heart attacks and strokes. The research team have previously shown that reduced breakdown of blood clots in people increases the risk of heart attacks and strokes. The team’s preliminary research, in part funded by Sunderland’s Quality-Related (QR) research funding, has identified that lower blood magnesium levels are associated with reduced blood clot breakdown and that low levels of blood magnesium are common in people with type 1 diabetes.
Dr Matthew Campbell, Principal Investigator in Human Metabolism in the Faculty of Health Sciences and Wellbeing is leading the University of Sunderland component of the study and explained:
“Although we know that low blood magnesium levels are linked to blood vessel disease we don’t yet know why. This study will help to expose the mechanisms linking blood magnesium levels and blood vessel disease and establish whether prescribing magnesium supplements can help to reduce the risk of this disease. This bench-to-bedside research has the potential to accelerate the development of new low-cost and safe treatments for people with type 1 diabetes.”
Dr Campbell who has published extensively in the area of diabetes and vascular disease says that if the work shows that magnesium supplementation reduces the risk of blood clot formation by making the clot easier to break down, testing blood magnesium status and providing supplements to those with low magnesium levels could become part of routine clinical care in the near future.
He added:
“We are delighted that Diabetes UK have funded this study which acknowledges the urgent unmet clinical need we intend to address and illustrates a significant return on University investment”.
Dr Faye Riley, Research Communications Manager at Diabetes UK, said:
“Every week in the UK, diabetes leads to 590 heart attacks and 770 strokes, stressing the urgent need for new and improved treatments to protect people with diabetes from its devastating complications.
“We’re proud to be funding this important trial, which could help us find a novel and simple treatment that tackles blood clots in people with type 1 diabetes, to help prevent heart attacks and strokes and save lives.”
About the University of Sunderland
The University of Sunderland is a life-changing institution. It welcomes all with talent into higher education and supports students in reaching their potential through its strategic ambitions to be student-focused, professions-facing and society-shaping. The University has around 25,600 students based at campuses in Sunderland, London and Hong Kong, as well as through global learning partnerships in 15 countries and online learning. The University is proud of its positive contribution to economic and social change. Its graduates leave equipped with the knowledge, skills, confidence and connections to make a positive difference in the wider world. Find out how the University of Sunderland can change lives at www.sunderland.ac.uk
Source and Media Contact
Please contact: Helen Franks on Tel: 07786 807586; helen.franks@sunderland.ac.uk / Ruth Aiken on Tel: 07910 230258 ruth.aiken@sunderland.ac.uk / pressoffice@sunderland.ac.uk
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